Iranian Journal of Neurosurgery

Published by Negah Scientific Publisher
Online ISSN: 2423-6497
Publications
Article
Background and Aim: Hydrocephalus can cause ventricular expansion, which if not treated promptly, can result in brain damage. The hydrocephalus-induced damage is not fully improved, even by means of surgical procedures, leading to permanent damages to the brain. Methods and Materials/Patients: The aim of this study was to evaluate the demographic characteristics as well as hydrocephalus in patients with head trauma in Poursina Hospital, Rasht. The information including age, sex, Glasgow Coma Scale (GCS), trauma mechanism and accompanying brain injuries on admission were recorded. Patients with hydrocephalus diagnosed by CT scan underwent further investigation and therapeutic approaches. The treatment-related results were collected based on the GOS scale. Finally, the data were entered into SPSS version 18, and the results were analyzed by Fisher’s exact test, and Independent t-test. Results: Of the 548 patients, hydrocephalus was observed in 14 patients (2.6%). The mean age of the patients was 44.07±24.48 years old. 31.1% of men (14 cases) had hydrocephalus, while none of women suffered from this complication. Car accidents (12 people) and fall (2 people) were identified as causes of incident in hydrocephalus patients. Head injury severity in most patients with hydrocephalus was mild (n=7, GCS=13-15) and moderate (n=6, GCS=9-12), and severe (n=1, GCS=3-8). Subarachnoid hemorrhage (n=5) and then epidural hematoma (n=4) and intracerebral hemorrhage (n=4) had the most severe damage to the skull. Most patients (n=11) were treated by surgery. Three patients recovered completely. Moderate disability, severe disability, vegetative state, and death occurred in 3, 2, 1, and 5 Patients, respectively. According to independent t-test, there is a statistically significant relationship between Glasgow Coma Scale and hydrocephalus (P=0.03). Fisher’s exact test also showed a statistically significant relationship between intracerebral hemorrhage (P=0.045) and intraventricular hemorrhage (P=0.013) on admission with hydrocephalic incidence. Conclusion: This complication was mostly observed in young traumatic patients (younger than 40 years of age) and in patients with mild head injury. Therefore, it is necessary to pay attention to these people in order to detect hydrocephalus, if any, as soon as possible, and these patients be treated appropriately.
 
Article
Background and Importance: SARS-CoV-2 virus causes COVID-19. The virus’s primary target is the respiratory system, but it can also affect other systems, such as the cardiovascular and the central nervous system. Case Presentation: In this study, we introduce an 83-year-old man who was referred due to a reduced level of consciousness and hemiparesis in the left part of his body without symptoms such as fever, cough, muscle aches, and fatigue. In High-Resolution Computed Tomography (HRCT) of the lung, the Ground-Glass Opacification/Opacity (GGO) view indicated COVID-19 disease, and in Computerized Tomography (CT) scans of the brain, hemorrhage was evident in the right thalamus, lateral and right ventricle. The Polymerase Chain Reaction (PCR) test performed on the upper part of the nose was also positive. This research is a case report of intracranial and intraventricular hemorrhage in an aged man with asymptomatic COVID-19. Conclusion: Low level of consciousness in the elderly can be a sign of infection with the SARS-CoV-2 virus.
 
Different types of SAH reviewed in this study
Studies reporting on different cases of subarachnoid hemorrhage in detail
Article
Background and Importance: The novel SARS-CoV-2 virus has had an undeniable effect worldwide in different aspects. Although cerebrovascular diseases, especially subarachnoid hemorrhage (SAH), have already been reported in COVID-19 patients, little is known about various types and patterns of SAH in these patients. Case Presentation: A 63-year-old woman was admitted to the emergency department with a headache. Her headache was severe (Hunt and Hess score, grade 2). She was diagnosed with COVID-19 by a positive nasopharyngeal swab PCR test. Her CT scan revealed a perimesencephalic hemorrhage, thick SAH without any signs of hydrocephalus or intraventricular hemorrhage. Conclusion: Regarding the different associations of SAH with COVID-19, the perimesencephalic hemorrhage in our case is a novel type. Although not uncommon among non-infected populations, SAH occurrence in COVID-19 patients has not been reported before and needs further investigation.
 
Article
Background and Importance: Secondary complications after SARS-CoV-2 virus infection including cardiovascular and neurological pose additional morbidity and mortality. The data on spondylodiscitis with spinal abscess after COVID-19 infection is very limited. Case Presentation: A 71-year-old man presented with tachypnea and cough since 24 hours before admission. He was febrile and his chest CT showed typical picture of bilateral covid-19 pneumonia. Nasopharyngeal swabs showed a positive PCR for COVID-19. The patient was admitted to the intensive care unit (ICU) due to low oxygen saturation. Forty-eight hours after admission, the patient started to develop paraparesis which rapidly progressed to paraplegia within a few hours. In MRI scan, multilevel spondylodiscitis and epidural abscess in the thoracic spine were observed. Urgent surgery was performed and the patient was treated medically with hydroxychloroquine and Favipiravir for COVID-19. Calculated antibiotic treatment with meropenem and vancomycin. No COVID-19 was detected in the abscess samples. The patient passed away later due to multiorgan failure. Conclusion: Spondylodiscitis with spinal abscess secondary to COVID-19 infection is a severe condition and might be a consequence of dysbalanced immune response with immunodepression after COVID-19 infection.
 
Article
Background and Aim: The viral agent in severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) is the cause of the novel coronavirus disease 2019 (COVID-19). It was first identified in December 2019 in the city of Wuhan, Hubei, China, and the World Health Organization declared it as an outbreak and a Public Health Emergency of International Concern on 30 January 2020, and a pandemic on 11 March 2020. Neurosurgeons are not prime in COVID-19 management but they continue for caring, visiting, and operating neurosurgical patients. In neurosurgical cases that need non-urgent operation, systematic SARS-CoV-2 testing of low-risk patients should be considered. In cases with positive SRAS-COV-2 testing, the procedures should be delayed until they are cured. The high-risk settings in the neurosurgical operation room are endotracheal intubation and extubation, operations in the vicinity of sinuses and/or mastoids, operations with accidental injury to respiratory or digestive tracts, and usage of aerosol-generating instruments on virioncontaminated tissues. The risk of SARS-COV-2 infection is decreased by delaying all nonemergent cases, replacing general anesthesia with other anesthesia methods, replacing neurosurgical approaches with alternative approaches that bypass the respiratory tract, and decreasing the usage of aerosol-generating instruments. Methods and Materials/Patients: This is a narrative study about COVID-19 infection in neurosurgery. Using the keywords SARS-COV2, neurosurgery, and COVID-19, all the relevant articles (about 52) were retrieved from Google Scholar, Medline, and PubMed and reviewed and critically analyzed. Results: Neurosurgeons can change neurosurgical routines in COVID-19 patients such as delaying all nonemergent cases, replacing general anesthesia with other anesthesia methods, replacing neurosurgical approaches with alternative approaches that bypass the respiratory tract, decreasing the usage of aerosol-generating instruments, and doing preoperative SRAS-COV-2 testing. Conclusion: For decreasing the risk of COVID-19 transmission in neurosurgery, we can change routine neurosurgical protocols. Without the prevention of COVID-19 transmission, all neurosurgeons, personnel, and patients will contract COVID-19.
 
Article
Background and Aim: The survival rate of brain tumors has not yet been reported in Iran. The purpose of this study, given the lack of such information, was to evaluate the 3-year survival rate in patients with all kinds of glioma tumors. Methods and Materials/Patients: This study was descriptive and retrospective, including 222 patients who had been diagnosed clinically with one type of glioma tumor and admitted to Al-Zahra hospital, Isfahan, Iran during 2001-2010. All patients (for minors, their parents) were contacted by phone. They were asked about the 3-year survival rate following their tumor resection surgery. Data such as patient’s age on admission, gender, histological diagnosis of tumor, and treatment regimen (surgical/non-surgical, radiation, and/or chemotherapy) were collected from medical records. The 3-year survival rate and frequency of each tumor based on age and gender were measured. Results: The 3-year survival rates for Glioblastoma Multiform (GBM) and anaplastic astrocytoma were 8.7% and 0%, respectively following surgery and chemo-radiation. These tumors were categorized as high-grade glioma with poor prognosis. The 3-year survival rate for diffuse astrocytoma, low-grade oligodendroglioma, low-grade ependymoma, and pilocytic astrocytoma following surgery and radiation were 100%, 95.2%, 100%, and 100%, respectively. These tumors were categorized as low-grade glioma, which has a good prognosis. Conclusion: In this study, the 3-year survival rate in patients with low-grade glioma following surgery and radiation was almost 100%. In contrast, the 3-year survival rate in patients with highgrade glioma following surgery and chemo-radiation was almost 0%.
 
Article
Background & Aim: Spondylolisthesis is a visible deformity in lumbosacral region with vertebral slip and fracture or other deformities of pars interarticularis. This study aims at investigating the characteristics of spondylolisthesis surgery in operated patients. Methods & Materials/Patients: This is a retrospective study which included all the patients who had undergone spondylolisthesis surgery by one same surgeon from 2006 to 2011. Demographic characteristics such as age, gender, and surgery information including type of spondylolisthesis, incision site, laminectomy site, foraminotomy site, fixation site of vertebra and site of vertebral disc evacuation were collected. The data were analyzed using SPSS (Version16). Results: 52 of 63 enrolled patients were women (82.5%) and 11 men (17.5%) with mean age of 49.6 years. Based on frequency, spondylolisthesis types were 60 degenerative (95.2%), 2 post-surgical (3.2%) and 1 post-traumatic (1.6%), respectively. 58 patients had spondylolisthesis only in one vertebra and 5 patients in two vertebrae. The total number of slipped vertebrae was 68, in which slip was seen in L3, L4 or L5 vertebrae. In 42 patients, laminectomy was performed only in one vertebra, in 19 patients in two vertebrae, in 1 patient in three vertebrae and in 1 patient in five vertebrae. The total number of vertebrae with foraminotomy was 106. The highest frequency of foraminotomy was seen in L5, L4, and S1 vertebrae, respectively. Except in one case, the rest 62 patients underwent fixation surgery in two or three vertebrae. Conclusion: Based on the results, the frequency of spondylolisthesis was approximately five times in women compared to men. The most common type was degenerative spondylolisthesis. Type of surgery was fixation with pedicle screw and fusion.
 
Article
Background and Aim: Cerebrovascular brain incidents especially brain aneurysm ruptures are a major cause of death and disability. Monitoring Somatosensory Evoked Potential (SSEP) and corresponding changes are used for identifying cerebral ischemia and predicting neuronal injuries during using temporary clips in brain aneurysm surgeries. This approach limits integrated performance evaluation for somatosensory and cortex paths. Methods and Materials/Patients: This clinical trial study was conducted on the patients who were candidate for anterior cerebral circulation aneurysm surgery during 2017-2018 in Rasul Akram Hospital. SSEP monitoring was performed related to the median nerve in the contralateral wrist to examine the Middle Cerebral Artery (MCA) and posterior tibialis nerve in the contralateral ankle to examine Anterior Cerebral Artery (ACA) during the surgery procedure. Incentive parameters with a power of 5 to 25 milliampere and corresponding duration of 0.2 milliseconds and waves with a frequency of 3.3 Hertz were registered. Before locating temporary clips, SSEP was extracted as a baseline from every patient and then recorded. Results: Totally 9 patients (9 aneurysms) were studied. Three of them were men and 6 patients women. The age of patients ranged 39-78 years. The clinical status of patients was assessed using the Hunt-Hess scale. Five cases were classified as grade 1, 2 cases as grade 2, and 2 cases as grade 3. Among 9 aneurysms, 7 cases were about A.com artery and 2 cases were in connection with MCA artery, having the size of 5 to 11 millimeters. Friedman test was applied to explore average latency change percentage and amplitude change percentage in 1st, 2nd, and 3rd minutes for the 1st, 2nd, and 3rd clips where the results were significantly different (P=0.050). Conclusion: Neuromonitoring can be used as an index for examining tissue perfusion level of the brain and help to prevent accidental ischemic injuries of the brain followed by temporary clipping.
 
Article
Background and Aim: The assessment of Quality of Life (QoL) as a measurement of Traumatic Brain Injury (TBI) outcome can play a key role in identifying the adverse effects of TBI. There is no study on the evaluation of psychometric properties of the Persian version of Short Form Health Survey Questionnaire (SF-36) in the TBI patient population. Therefore, the present study aimed to validate and test the reliability of the Persian version of the SF-36 in patients with TBI. Methods and Materials/Patients: In the present cross-sectional study, 185 patients with TBI were selected by non-probability and consecutive sampling. First, the construct validity of the Persian version of the SF-36 questionnaire was evaluated using the Confirmatory Factor Analysis (CFA) in AMOS-22, and then the internal consistency reliability and item-total score correlation of each subscale were assessed by SPSS V. 22. Results: Results of CFA indicated that the dimensionality of SF-29 questionnaire with eight-factor structure among the Iranian TBI patients had construct validity (GFI=0.825, CFI=0.963, NFI=0.919, TLI=0.957, RMSEA=0.06) by eliminating 6 items and freeing some of the covariance errors between items, but the two-factor dimensionality (physical and psychological components of QoL) of this questionnaire was not approved. Internal consistency of the eight-factor form of SF-29 subscales was acceptable to excellent (=α0.70 to 0.99). Correlation analysis of item-total score for determining the construct validity of SF-29 indicated that except for 2 items, all items of the questionnaire had a positive and strong correlation with their subscales (r=0.40 to 0.99, P<0.0001). Conclusion: Persian version of SF-29 with an eight-factor construct had good validity and reliability and could be used to measure health-related QoL in Iranian patients with TBI. Keywords: Brain injuries, Traumatic, Quality of Life, Surveys and questionnaires, Measurement, Reliability, Validity.
 
Article
Background and Aim: Neurovascular lesions can cause death or disability. Some of them are operable, but surgical approaches are complicated, and proper access to these lesions is crucial. A few of these surgeries occur during the residency educational program, and residents' experience in operating these lesions may be quite inadequate. Using new technologies like 3D-reconstruction of vascular lesion images may result in better training and improve residents' knowledge and understanding of these operations. Methods and Materials/Patients: Four senior neurosurgery residents were enrolled in this study. They were taught to use a 3D image rebuilding program (3D Slicer). They were then asked to rebuild a 3D image of every patient lesion, practice different surgical views, and review anatomical structures around the lesion before surgery. Results: All residents mentioned that their knowledge of surgical approaches improved, and they learned more from each operation. Two of them commented that more self-trust during surgeries led to more effective education. Their ability in surgical planning was enhanced too. Attending physicians of these residents believed that this practice improved the residents' skills and educational quality. Conclusion: New technologies can promote residency educational programs. It seems that working on 3D images of lesions before surgery can boost residents' educational attributes.
 
Article
Background and Aim: Degenerative lumbar spine disease can lead to lumbar spine instability. The patients can present with Low Back Pain (LBP), radicular pain, and motor and sensory dysfunction. Age >50, female sex and pregnancies are among prevalent risk factors. The degeneration process usually starts from the intervertebral discs progressing to involve facet joints, ligaments, and vertebral bodies leading to spinal instability and deformity. This study aims to evaluate the effect of lumbar decompression and Posterolateral Fusion (PLF) on the short- and long-term outcomes of these patients. Methods and Materials/Patients: This prospective study assessed the effect of lumbar decompression and PLF in patients with lumbar instability referred to the Neurosurgery Clinic of Chamran hospital between March 2011 and March 2013. Forty-four patients with degenerative lumbar spine instability and stenosis were eligible for participation to undergo lumbar decompression and PLF. Its clinical effect was evaluated using Visual Analogue Scale (VAS) score and Oswestry Disability Index (ODI). The change in sagittal and coronal planes was also assessed according to pre- and post-operative findings at 2-year follow-up. The statistical method of assessment was repeated using paired t-test. P
 
Characteristics of 60 patients with brain aneurysm was treated in Neurosurgery department , Poursina Hospital in 2009-2013
Article
Background and Aim: This study aimed to present the results of early and delayed operation on patients with ruptured brain aneurysms. In addition to comparing the results and rates of morbidity and mortality in the surgical procedure and identifying the effective factors, this study aimed to provide methods to improve the treatment of brain aneurysm. Methods and Materials/Patients: This was a retrospective study on 60 patients with a definitive diagnosis of brain aneurysm admitted to Neurosurgery Ward of Poursina Hospital, Rasht, Iran from 2009 to 2013. Results: 7(11.7%) patients on the first 3 days and 37(61.7%) patients on the days 4-14 and 16(26.7%) after 2 weeks and selectively underwent surgery. In total, 11.7% of patients died and 15% developed severe complications. In the group underwent surgery on the first 3 days, 2(28.5%) patients died and 2 experienced severe complications. In the second group (in 4-14 days), 4(10.8%) patients died and 5(13.5%) suffered from severe complications, and in the group (16 patients) with delayed surgeries, 1(6.2%) patient died and 2(12.5%) suffered from severe complications. Neurological grading and operation time were important factors in complications and mortality of patients. Conclusion: This study showed that Hunt and Hess neurological grading score has a direct relationship with increased morbidity and mortality rates, while delayed operation is associated with a reduction in morbidity and mortality. Given the complications of early aneurysm surgery (during the first 3 days) compared with delayed surgery, and also most of these patients die due to vasospasm or recurrent hemorrhage before the onset of a delayed phase, performing early surgery in these patients requires further evaluation. According to this study, the reduction of each episode of occlusion with temporary clipping will result in fewer complications.
 
Huge abdominal distension 
Article
Background and Aim: Ventriculoperitoneal shunt (VPS) is the most commonly used procedure for treatment of hydrocephalus in children. Abdominal cerebrospinal fluid pseudocyst is a rare complication but potentially fatal. The pathogenesis of this complication remains unclear. This complication should be considered during differential diagnosis of an abdominal mass. Our aim is to report how large and giant an abdominal cerebrospinal fluid pseudocyst can develop, and how severe the neurological damage can be. Case Presentation: A 6 year-old girl known to have a ventriculoperitoneal shunt presented with abdominal distension and signs of increased Intracranial Pressure (ICP). Ultrasonography revealed a hypoechoic intraperitoneal fluid containing cyst with a well-defined margin and septations. Abdominal computerized tomography revealed a huge cyst in the abdomen and the distal part of the peritoneal shunt tube located within the cyst. Laparotomy revealed a huge cyst extending from the upper right side of the abdomen to the pelvis. The whole cyst was excised and the catheter repositioned. Conclusion: Early diagnosis of abdominal Cerebrospinal Fluid (CSF) pseudocyst is only possible through close and periodic examination of patients after the procedure.
 
Article
Background and Aim: Lumbar Disc Degeneration (LDD) is one of the most important causes of pain in the lower back, and lack of physical activity, overweight and obesity have been regarded as the most significant factors in its occurrence. The present study was conducted with the aim of evaluation of body mass index, abdominal obesity and physical activity level in patients undergoing for lumbar disc degeneration surgery. Methods and Materials/Patients: This descriptive-analytical study was conducted on 130 adult patients (20 to 77 years old) candidates for surgery admitted to the Poursina Hospital in Rasht City, Iran in 2016 due to degenerative lumbar vertebrae diseases. After obtaining the patients' consent, their abdominal circumference, weight, and height were measured by the researcher. The Rapid Assessment of Physical Activity (RAPA) questionnaire was used to assess the level of physical activity of the subjects and questions about professional sports were asked by the researchers. SPSS 16 was used to analyze the study findings. The Chi-square test and Fisher exact test were applied to examine the relationship between qualitative data. Results: The mean±SD BMI values in males and females were 26.63±4.47 and 28.96±4.45 kg/ m2, respectively. Also, the mean±SD values of abdominal circumference in men and women were 99.8±13.35 cm and 107.44±17.58 cm, respectively. The majority of the people (88.5%), including 71.7% of men and 97.6% of women had suboptimal physical activity, and a small percentage of samples (10.8%) reported previous professional exercises Conclusion: The present study results indicate the lack of activity level, high BMI and abdominal obesity in our patients. Further study is required to investigate the significant relationship between BMI and degenerative disease types.
 
Article
Introduction: Thermal ablation by microwave (MWA) has proven efficacy in treatment of primary and metastatic cancers. Soft tissue tumors could be ablated completely using MWA. However, bony tissue metastasis particularly spinal vertebral metastasis ablation has not reported yet. Case presentation: A 50 year old male patient with primary diagnosed colon cancer undergone surgical resection of tumor. Recently, he was diagnosed with metastasis to liver and spinal vertebral bone. He was referred to pain clinic with severe non-radiating back pain. In MRI Imaging, hyperdensity lesions were identified on body of L5 and T12 and in spinal canal of L1 indicating metastatic involvement. Under fluoroscopy guidance, the metastatic tumor was ablated by MWA and the generator was powered to 20 Watt/3 minutes in the temperature control mode. Patient had no low back pain afterward. Conclusion: MWA could be used to ablate vertebral bone metastasis without any complications and with good prognosis
 
GCS in the patients with traumatic spine in motor vehicle accidents
Article
Background and Aim: Spine trauma is an important health problem. Traumatic Spinal Cord Injury (SCI) due to Motor Vehicle Accident (MVA) might have a different epidemiologic pattern in Guilan province of Iran owing to its geographical characteristics. Therefore, the present study was conducted to the study epidemiology of SCI injuries due to road accidents in a trauma referral center in Guilan. Methods and Materials/Patients: In this cross-sectional study, we used data SCI registry of Poursina Hospital. All the patients with spine trauma, due to MVA, hospitalized in the trauma center of Poursina Hospital, Rasht, Guilan, Iran between March 2015 and March 2018 were studied. Results: A total of 127 patients with spine trauma due to MVA were reviewed. The Mean±SD age of patients was 38.27±16.22 years. We observed that 93.7%, 1.6%, and 4.7% of the patients had initial Glasgow Comma Scale (GCS≥13, 9≤GCS≤12, and GCS
 
Article
Background & Aim: Using pharmaceutical agents in treatment of aphasia has caught the attention of many neurologists and neuroscientists. This short review study has sought the role of pharmacotherapy in treatment of aphasia, a linguistic impairment after acquired brain lesions. The pharmacological principles and mechanisms related to the effects of drugs used in aphasia rehabilitation are pointed. Then, some evidence of clinical trials on different drugs in this field is presented. Methods & Materials/Patients: A comprehensive search in databases including MEDLINE, Cochrane, PubMed, Scopus, EMBASE, Science Direct on experimental studies and clinical trials associated with pharmacotherapy of aphasia after neurological damages was performed. Results: Pharmacological interventions through manipulating neurochemical levels in synapses, the pre- and post-synaptic spaces and even inside neurons start to modulate the disturbed balance of neurotransmitters due to brain lesions. Pharmacotherapy is based on the principle that drugs via balancing the molecular signaling cascades triggered due to neuronal damage can restore the function of neurons, facilitate the brain plasticity process and improve the linguistic deficits in aphasic patients. Among the drugs that have been studied in treatment of aphasia, those acting on central cholinergic and glutamergic systems were more effective and led to better clinical outcomes. Conclusion: Although existing evidence has proved the pivotal role of pharmacotherapy in treatment of aphasia after acquired brain lesions in adults, further research is required to assure the clinicians in using pharmacotherapy as a standard approach in treatment of aphasia.
 
The Brain MRI T1 (A) and T2 (C and D) images Images show the sellar and suprasellar cystic lesion that contrast enhancement was present around the lesion (D).
The pathological examination It confirmed Rathke's cleft cyst with pseudostratified ciliated epithelium and compressed normal adenohypophysis around cyst
Article
Background and Importance: Symptomatic Rathke’s cleft cyst is a rare lesion that often presents without any symptoms. Case Presentation: We report a 40-year-old female with symptomatic Rathke’s cleft cyst located in the sellar and suprasellar region. She presented with visual disturbance, headache, weight gain, hypothyroidism and amenorrhea. The patient underwent surgery and the pathological examination confirmed Rathke’s cleft cyst. Conclusion: Although the symptomatic Rathke’s cleft cyst is rare, the differential diagnosis must be done with intrasellar and suprasellar lesions.
 
Article
Background & Aim: Spinal cord injury (SCI) has a very long history, and its cases form a large proportion of patients admitted to trauma centers in Iran. Studies show that repair after spinal cord injury can be done. In fact, many pharmaceutical agents, such as erythropoietin (EPO), are applied to reduce secondary injury following the initial disorder and to maintain the nerve tissue. Methods & Materials/Patients: In this clinical trial, 60 patients with acute spinal cord injury classified as A to C according to Frankel classification grading system were selected and matched with regard to the Frankel classes, the cervical and dorsal levels and then divided into two groups A and B (each containing 30 patients). Group A, in addition to receive conventional treatment, took EPO and was evaluated in terms of hospitalization period outcomes (mean length of stay, lower extremity thrombosis, intubation, bedsores) and was compared with group B (receiving conventional medicines, such as methylprednisolone). Results: Of the 60 patients, 15 patients were female and 45 were male, with the age range of 19-72 years. The mean length of stay in the case and control group was 10.6±6.52 and 13.8±10.37 days, respectively. Six patients died during hospitalization, including three patients in the case group and three patients in the control group. 12 patients were intubated during this period, including five patients in the case group and seven patients in the control group. Of the 29 patients with bedsores, 14 patients were in the case group and 15 patients were in the control group. None of the patients had lower extremity venous thrombosis during hospitalization. Conclusion: No significant difference was found between the case and control group in the hospital stay length, intubation, bedsores and lower extremities venous thrombosis.
 
Article
Background & Importance: Acute autonomic system impairment can be dangerous and life-threatening, and a clinician should be aware of its occurrence possibility. According to the anatomy of this system, spinal cord lesions could disturb its function. There are many reports of autonomic dysreflexia in spinal cord i njuries especially spinal cord trauma. Case Presentation: A 28 year-old man with an eight month history of gradual numbness in his extremities referred to our university hospital. Neurologic examination revealed mild spastic motor weakness in all limbs and increased deep tendon reflexes. Conclusion: Acute and dangerous autonomic dysreflexia during spinal cord surgery is a rare condition that neurosurgeons and anesthesiologists should be ready for immediate diagnosis and treatment of this condition.
 
Article
Background and Aim: Traumatic brain injury is one of the leading causes of mortality and disability in young adults. Epigallocatechin-3-gallate, the antioxidant compound of green tea, has been proposed to have antioxidant and anti-inflammatory properties. This study evaluates the potential effects of epigallocatechin-3-gallate on the early clinical outcome and serum S100B levels (biomarker for brain tissue damage severity) in patients with moderate to severe traumatic brain injury. Methods and Materials/Patients: Thirty patients with moderate to severe traumatic brain injury admitted to the intensive care unit were enrolled. The patients were randomly allocated to treatment with either a daily oral dose of 400 mg epigallocatechin-3-gallate or placebo (distilled water) for seven days. The main outcome measures were duration of mechanical ventilation and ICU stay, Glasgow Coma Scale, and S100B protein level. Results: The results revealed a significant improvement in consciousness level after seven days in the epigallocatechin-3-gallate group (2.93±3.9 unit improvement in GCS versus 0.14±3.05 reduction in GCS, p-value:0.033). There was also a significantly shorter duration of mechanical ventilation in the epigallocatechin-3-gallate compared to the control group (5.1 days versus 9.8 days, p-value:0.02). Reduction of the serum S100B level was slightly higher in the epigallocatechin-3-gallate group (23.96 versus 18.6 pg/ml) but the difference was not statistically significant. Conclusion: Epigallocatechin-3-gallate supplementation had beneficial effects on consciousness level of the patients with moderate to severe traumatic brain injury in the acute phase.
 
Relationship between acute lung injury and demographic and treatment variables of study patients
Article
Background and Aim: Traumatic Brain Injury (TBI) is an essential cause of morbidity and mortality worldwide. TBI patients frequently encounter lung complications, such as Acute Lung Injury (ALI) and Acute Respiratory Distress Syndrome (ARDS), which is associated with poor clinical outcome because hypoxia causes additional injury to the brain. This study aimed to evaluate the frequency of ALI in patients with TBI and its consequences. Methods and Materials/Patients: In this descriptive cross-sectional study, data from all records of patients admitted to Poursina Hospital’s ICU (emergency and neurosurgery ICU) in 20 18-2019 were used. The evaluated data included age, gender, type of head trauma mechanism, kind of brain injury based on CT scan findings, the severity of brain injury based on Glasgow Coma Scale (GCS), underlying diseases, mean head AIS score, the number of pack cell units injected, as well as bilateral pulmonary infiltration in favor of ALI and brain injury. Results: Only 81 of the 557 TBI cases met the inclusion criteria of the present study. The highest frequency of ALI following TBI was observed on the first day of hospitalization, in men (0.41%) in the age group of 40-50 years (7%) with severe brain damage (6%) and subdural hematoma (12%), following a motorcycle accident, cars, as well as on the third day of hospitalization were seen in men (43.8%) with the age group of 20-30 years (55%) with severe brain damage (42%) and intra-parenchymal bleeding (57%), following a motorcycle accident. In addition, no significant correlation was detected between the incidence of ALI and mortality, the duration of hospitalization, GCS, mean head AIS score, or the extent of received blood units in our study. Conclusion: According to the obtained findings, men aged between 20 and 30 years with severe cerebral injury, epidural hematoma and a motorcycle accident presented the highest rate of progression toward ALI in the first to third days of hospitalization.
 
Article
Background & Importance: Acute epidural hematoma is a very rare complication of ventriculoperitoneal shunt insertion. The insertion of a ventriculoperitoneal shunt can cause sudden decompression of the brain, subsequent to which epidural hematoma occurs due to CSF drainage. To our knowledge, there are only a few cases of acute epidural hematoma in the literature which required acute evacuation. Case Presentation: In this report, we present a case of epidural hematoma close to ventriculoperitoneral shunt insertion site in a 30-year-old man after failure of endoscopic surgery for opening of the wall of a suprasellar arachnoid cyst. Secondary to communication between cyst and ventricles and clinical symptoms and sings, the patient underwent the shunt insertion. The patient became comatose two hours following the insertion of the shunt, developing a voluminous right temporo-parietal epidural hematoma that had to be evacuated immediately. Here, we intend to discuss both the pathophysiology and treatment. Conclusion: Development of epidural hematoma after ventriculoperitoneal shunt surgery is a devastating complication. Dehisensce formation between the skull and dura matter, which may be facilitated by lax adhesion between the two, is a common underlying pathology. We recommend a close post-surgical observation for immediate diagnosis and reoperation of this event.
 
Article
Background and Aim: EETA (Endoscopic Endonasal Transsphenoidal Approach) is a preferred choice for pituitary tumors. EETA offers minimal invasiveness, fewer complications, and better outcomes than the sublabial or transseptal microscopic approach. EETA has three approaches: mononostril endoscopic transsphenoidal approach, binostril endoscopic transsphenoidal approach, and one and a half nostril approach. This study aims to compare three different EETAs and compare between microscopic transsphenoidal approach, transcranial approach and EETA. Methods and Materials/Patients: To provide up-to-date information, we concisely reviewed these three EETAs. Using the keywords of “neuroendoscopy”, “META” (Mononostril Endoscopic Transsphenoidal Approach), “OETA” (One and a half nostril Approach), “BETA” (Binostril Endoscopic Transsphenoidal Approach), “pituitary adenoma”, “EETA”, “endoscopy”, “transsphenoidal approach”, “transcranial approach for pituitary adenoma” and “microscopic transsphenoidal approach”. We retrieved all the relevant articles from Google Scholar, PubMed, and Medline. Then, we reviewed them and critically analyzed them. Results: In BETA there is free and easy movement of surgical instruments in the surgical field and a broader view of the sphenoid sinus and it is an excellent approach to resect large tumors. The META is suitable in tumors with limited involvement of the intra-sellar and supra-sellar area. The mononostril approach is not suitable and has some limitations for the following situations: a crowded narrow nasal cavity, a harder tumor with the invasive appearance or significant suprasellar extension, and lesions other than pituitary adenomas. The OETA provides a sufficient surgical corridor for a 2-surgeon/4 or 3-hands technique with a minimal injury of the nose and good operative results, free and easy movement of surgical instruments in the surgical field, low post-operative morbidity, and good post-operative quality of life. Conclusion: In EETA, knowing the size and consistency of tumor, general versus invasive pituitary adenoma, and the extent of parasellar and suprasellar extension, is essential. If we cannot reach a pituitary macroadenoma with a trans-sphenoidal approach, then we can use a transcranial approach for the removal of the tumor. The microscopic transsphenoidal approach is suitable for pediatric pituitary adenoma
 
MRI revealing a well-delineated round tumor 30x25x20 mm in diameter, T1W 
MRI showing a) an intrasellar lesion isointense in T1W and T2W images enhancing homogenously and mildly after contrast material injection and b) a suprasellar lesion 3x3x2cm in diameter with the same intensity in T1W and T2W images which enhanced notably after contrast material injection. 
Article
Background and Importance: The coexistence of pituitary adenoma and another type of brain tumor is a very rare clinical scenario. Even though such a presentation can be an incidental event but the possible pathogenesis of coexistence of different lesions in the sella and suprasellar region has not yet been elucidated. Case Presentation: Two cases of concomitant sellar and suprasellar region tumors are reported. A 37-year-old lady with Prolactinoma and a suprasellar meningioma and a 42-year-old Acromegalic man with suprasellar meningioma and a pituitary adenoma (PA). Conclusion: Both meningiomas were removed transcranially while the Prolactinoma could be managed medically and the growth hormone (GH) secreting adenoma was removed trans-sphenoidally. The visual problems and hormonal imbalances of both patients improved postoperatively and there has been no sign of recurrence of the lesions after a mean of five years follow up. The literature is reviewed on this topic and the possible pathogenesis and management protocol of similar lesions are discussed.
 
Article
Introduction:Early and sufficient nutritional support is vital to improve outcomes in patients with traumatic brain injury. This study aims to determine the effects of dietitian involvementin the nutritional and clinical outcomes inpatients with traumatic brain injuries admitted tothe neurosurgical ICU. Materials &Methods: Forty-eight male patients with traumatic brain injuries admitted to Poursina Hospital neurosurgical ICU were studied, retrospectively. Patients were divided to either receive dietitian intervention or without any nutritional recommendation(control). Demographic information, Glasgow Coma Scale and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, the timing of initial enteral feeding, the amount of energy and protein intakeon day 4, the duration of mechanical ventilation and ICU length of stay were recorded. Results:Patients under the dietitian recommendation had significantly lower timing of initial enteral nutrition compared to the other cases (P=0.02). The average energy or protein intake and the percentage of target energy or protein intake on day4 appeared to be significantly lower in the subjects in the control group than in those with nutritional intervention(P≤0.001). There was no statistically significant difference in the duration of mechanical ventilation and ICU length of staybetween different groups of patients. Conclusions:Instead of occasional consultations for exclusive cases, the daily attendance of dietitians during multidisciplinary rounds of ICU is required to assess the nutritional needs of patients.
 
Cause of SCI classified by Age Groups 
Incidence of Spinal Injuri in ASIA 
Article
Background & Aim: Patients with spinal cord injury (SCI) impose a heavy burden on health care system. Awareness on prevalence and incidence of SCI is important because this would show the necessity of prevention. This study aimed to investigate the epidemiology and types of traumatic spinal cord injuries in a trauma referral center in Guilan. Methods & Materials/Patients: This is a descriptive study which was conducted on patients with spinal cord trauma using a questionnaire during one year. The questionnaire included demographic information, injured spinal cord area, mechanism of injury, and type of neural damage based on ASIA scale. The data were analyzed using SPSS18 and descriptive statistics. Results: Out of 76 study patients, 68 (88.2%) were men with mean age of 35.2 ± 1.45 years. The most common cause of SCI was motor vehicle accidents (MVA) (48.7%). 34 patients (44.7%) had cervical spine injury and in 23 patients (30.3%), thoraco-lumbar injuries caused SCI. 29.7% of patients suffered from paraplegia and 10.8% quadriplegia. 25 patients (38.5%) had complete SCI. 7 patients with SCI (9.2%) died during hospitalization. In this study, increased age was identified as a risk factor for death. In 4 of these patients (57.1%) cervical SCI was the underlying cause of death. Conclusion: Young men were the group at highest risk and the most mechanism leading to SCI was motor vehicle accidents. Many of these accidents are preventable; thus, more attention should be devoted to safety policies based on needs of the vulnerable groups. Besides, comprehensive education program with clear and practical goals should be developed.
 
Article
Background & Importance: Idiopathic stenosis of the foramina of Magendie and Luschka is a rare cause of obstructive hydrocephalus involving the fourth ventricle. Case Presentation: We reported the case of a 40-year-old woman who developed headaches and vertigo for several months and more recently gait disturbance. The CT scan showed quadri-ventricular hydrocephalus involving mainly the fourth ventricle with dilated lateral recesses. Craniocervical MRI confirmed hydrocephalus and also showed the brainstem and cerebellar tonsil herniation through the foramen magnum with hydromyelia and a hyperintense signal on T2 weighted MRI of cervical spinal cord. Biological analyses were normal. She underwent endoscopic third ventriculostomy (ETV). No complication was observed. The patient became asymptomatic during the weeks following the surgical procedure and remained stable at a mean follow-up interval of 20 months. Postoperative MR images demonstrated regression of the hydrocephalus; complete disappearance of brainstem and cerebellar tonsil herniation, hydromylia and the hyperintense signal on T2 weighted MRI of cervical spinal cord. Conclusion: This case confirms the existence of hydrocephalus caused by idiopathic fourth ventricle outflows obstruction in adult and the efficacy of ETV for this rare indication.
 
Article
Background and Importance: Transorbitocranial assaults with sharp objects like a knife are rare neuro-ophthalmologic emergencies. However, they can have dramatic functional and life-threatening consequences. Our presentation aims to report the importance of an urgent multidisciplinary approach and to raise awareness among the general population on the importance of preventing violent behavior. Case Presentation: A 33-year-old man was a victim of a knife attack without obvious brain or ophthalmological lesions. The knife entered the medial part of the orbit. Neurological examination was normal, and Computed Tomography (CT) scan showed intracranial trajectory through the orbit to the frontal horn of the lateral ventricle. The knife was extracted without complications. The patient reported spectacular improvement in visual acuity without neurological or oculomotor deficit at long-term follow-up. In this case report, we will discuss the radiological diagnosis and surgical management of transorbital and orbitocranial injuries by foreign body penetration. Conclusion: Urgent multidisciplinary management in orbitocranial trauma by stabbing is mandatory to avoid life-threatening complications and irreversible damages.
 
Article
Background & Aim: Chronic subdural hematoma (CSDH) is a common neurosurgical pathology. The objective of this study was to describe the epidemiology of this pathology and the results in treating it combined from three hospital centers in Benin. Methods & Materials/Patients: From September 2010 to September 2013 a multi-center, retrospective and descriptive study was conducted in three hospital centers in Benin. Inventory was taken of all patients in whom CSDH was diagnosed. Patients were evaluated according to Markwalder classification. All patients received a brain scan. The variables studied include demographic and clinical characteristics, therapeutic modalities and post-operative follow-up. Results: 104 consecutive patients with CSDH were included in the study. The mean age was 49.66, but ranged from six months to 87 years. The M:F sex ratio was 5.11/1. Prior cranial trauma had occurred in 81 patients (77%). Pre-operative neurological Grades 1 or 2 were observed in 56.4% of cases. Surgical treatment was given to 100 patients (96.15%). Events surrounding the surgery were straightforward and results satisfactory in 94% of cases. No relapses were observed. The morbidity was 4% and the mortality among surgical patients was 3%. Conclusion: CSDH is frequently treated in the country of Benin. The mean age of patients is lower than that observed in global literature, and patients are predominantly male. Regardless of the patient condition upon hospital admission, post-operative results compare favorably with the literature.
 
Article
Background and Importance: Plasmacytoma is more likely to involve the spine with up to 50%, most commonly in the thoracic spine. Case Presentation: This study examined a patient with solitary plasmacytoma with neck pain and abnormal C1-C2 range of motion, which happened to have an osteolytic C2 lesion on CT scanning. The patient underwent a fluoroscopically guided anterior percutaneous C2 vertebroplasty without posterior fusion, leading to management of pain, maintenance of normal motions, and restoration of cervical alignment. Conclusion: This case represents fluoroscopically guided anterior percutaneous C2 vertebroplasty as an effective treatment for C2 osteolytic lesions with an abnormal range of motion, which can be considered in selected cases as an alternative approach for demanding open surgical approaches to this challenging region.
 
Article
Background and Aim: Spontaneous Intracranial Hypotension (SIH) is a rare cause of headaches. It commonly presents with newly-developed persistent postural headaches and resolves with conservative treatment but rarely becomes a life-threatening disease. We retrospectively reviewed all cases of SIH patients treated in our institution for over ten years. Their clinical and radiological findings and the treatment given were analyzed. Their outcomes were assessed at a minimum of one year of follow-up. Materials and Methods: We retrospectively reviewed all cases of SIH patients treated in our institution over ten years. Clinicoradiological aspects, as well as the treatment given, were analyzed. The outcome was assessed at a minimum of one year of follow-up. Results: Six cases of SIH were studied. The Mean±SD age of the study population was 41.6±2.87 years. Four cases (66%) were female. The most common symptom was orthostatic headache which was present in all of them. The Mean±SD duration of symptoms before the diagnosis of SIH was 3±1.78 months. Four cases were managed conservatively, while one patient was managed with surgery and the other with epidural patch repair. The exact site of the leak could be delineated in 2 cases (33%). Two patients who were managed invasively for Cerebrospinal Fluid (CSF) the leak had a subdural hematoma. All patients had a favorable outcome at one year of follow-up. Conclusion: Prompt and early identification of changes in symptom pattern and the onset of subdural hematoma are essential markers of shifting to definitive management rather than continuing conservative measures. Subdural hematoma, secondary to SIH, warrants evacuation if it causes clinical deterioration.
 
Article
Background and Aim: Indocyanine Green (ICG) angiography has become the standard of practice in many centers managing cerebrovascular diseases. Though 3D stereoscopic recording of the surgeries has received widespread attention, there is a need for a technology to display and record real-time 3D ICG angiographies. In this study, we designed and constructed an ICG angiography camera to display the real-time 3D ICG angiographies. Methods and Materials/Patients: Our project had three phases. In phase I, a handmade ICG camera was designed and constructed in our laboratory. The second phase included creating a 3D camera to display real-time images in 3D anaglyph format. In the last phase, we developed a 3D ICG camera to demonstrate 3D ICG angiographies in real-time. Results: We successfully completed all three phases of the project and could display real-time 3D ICG angiography of a mouse mesenteric arteries, recorded it, and took pictures. Conclusion: We proposed a method and proved its feasibility for producing a 3D ICG angiography camera to be mounted on the next generation of neurosurgical microscopes.
 
Changes in Severity of Pain based on VAS Score in 24 hour Follow-up in Three Groups 
Change in HR (heart rate) in Three Groups in 24 hours 
Trend of Changes in RR in Three Groups within 24 hours 
Trend of Changes in Systolic Blood Pressure within 24 hours 
Changes in Diastolic Blood Pressure within 24 hours 
Article
Background & Aim: Although most patients experience severe pain after major spinal fixation surgery, little attention has been paid to control it with a multi-modal approach. The aim of this study is to select appropriate method of pain management after spinal surgery. Methods & Materials/Patients: This study was a randomized clinically controlled trial in candidates of spondylolisthesis and spinal fixation surgery under general anesthesia. 90 patients were divided into three groups, as follows: 1) Intervention group of epidural fentanyl (F): patient-controlled analgesia (PCA) pump infused 100 µg of fentanyl and 98cc of normal saline at the rate of 3-5 ml/h in the epidural space via an epidural catheter placed by surgeon 2) Intervention group of epidural fentanyl-bupivacaine (FB): PCA pump infused 100 µg of fentanyl and bupivacaine 0.125% at the rate of 3-5 ml/h in the epidural space. 3) IV morphine group (M): No medication was received epidurally. In case of visual analog scale (VAS) score more than four, one mg of IV morphine bolus was administered to patient. The blood pressure, heart rate, respiratory rate and pain severity were recorded at the moment of patient’s transfer from recovery room to the ward and compared in three groups every six hours for 24 hours. The results of this study were analyzed by statistical tests including repeated measures ANOVA, Kruskal-Wallis, Fisher’s exact test and SPSS software 16. P values less than 0.05 were considered statistically significant. Results: The results of the study showed that VAS score in fentanyl-bupivacaine group was significantly lower than that in the two other groups during the first 18 hours. However, VAS score in all groups decreased at 24th hour postoperatively (less than three) suggesting that there was no statistically significant difference between the three groups. In this study, no serious and severe complications were observed except for a few cases of nausea in the control group. Conclusion: Epidural analgesia with fentanyl-bupivacaine is a safe and effective way to postoperative pain management in listhesis and spinal surgeries.
 
Article
Background and Importance: Anaplastic Oligodendroglioma (ODG) constitutes 24% of all pediatric ODG. The mean age of presentation of ODG is 12±6 years. They are most common in frontal and temporal lobes; however, rare cases of intraventricular ODGs are reported. Most commonly they arise from the anterior part of lateral ventricles. Third ventricle ODG is extremely rare and only a few cases of lateral and third ventricle anaplastic ODG are reported. ODGs infiltrate locally to meninges and rarely have leptomeningeal spread. Thus, ODG forms a differential diagnosis of pediatric intraventricular tumor. Case Presentation: Here we present a case of a 15-month-old male child with raised intracranial pressure due to obstructive hydrocephalus. The patient was detected to be COVID-19 RT–PCR (Reverse Transcriptase Polymerase Chain Reaction) positive in the preoperative period and underwent emergency Right-sided Ventriculo Peritoneal (VP) shunt. His contrast MRI (Magnetic Resonance Imaging) Brain showed a 50×24×39 mm heterogeneously enhancing mass epicenter at third ventricle and extending to lateral and fourth ventricle with spinal drop metastasis. Preoperative differential diagnosis of Ependymoma was made and definitive surgery was done once the child recovered from COVID-19. However, his biopsy specimen pathology and Immunohistochemistry (IHC) were suggestive of anaplastic oligodendrogliomas and the child responded well to chemotherapy. Conclusion: Intraventricular ODG is an extremely rare pediatric tumor. Patients usually present with obstructive hydrocephalus. Contrast MRI findings are nonspecific and help in detecting leptomeningeal spread to the spine. IHC and chromosomal analysis are important diagnostic and treatment prognostication tools. These tumors have a high recurrence and poor prognosis despite gross total resection.
 
Mean Gyri Number of Right and Left Insula 
Display of Insular Morphology on Sagittal MR Images
T2-weighted Sagittal MRI Sections A. Imaging Anatomy of the Normal Insula in a 15-year-old Female. The Sections Demonstrate the Anterior (1), Middle (2), and Posterior (3) Short Gyri, Anterior (4) and Posterior (5) Long Gyri. The HG (H) Lies Immediately behind the PLG (5) and Marks the Posteroinferior Border of the Insula. B. Right Insula with the ASG (1) and the ALG (2) in a 54-year-old Man. Central Sulcus (C) has Separated the Two Gyri. The HG (H) Lies behind the ALG (2). 
Article
Background and Aim: Topography of the human insula has occasionally been studied in different populations. The purpose of this study was to evaluate the morphology of human insula in Iranian population and its relationship with sex, age, and handedness via magnetic resonance imaging. Methods and Materials/Patients: In our study, 380 normal magnetic resonance imaging were enrolled. The number of short and long insular gyri, as well as their relationship with sex, age, hemispheres and handedness were assessed. Results: No significant differences were seen in number of insular gyri among right and left hemispheres, and males and females, but gyri number of left insula in right handers were significantly more than that in left handers. Maximum anterior – posterior distance of base of insula was longer in male and left insula compared to female and right insula, respectively. Younger individuals had more gyri than the older ones. The middle short insular gyrus can be absent more frequently than anterior and posterior short gyri. Conclusion: The sagittal magnetic resonance imagings in our study can be appropriate for numbering the insular gyri and help to understand the complicated anatomical structures of insula. The findings of this study demonstrate an insular gyri pattern of handedness and age-related morphology in Iranian population, with similar gyri pattern in both males and females.
 
Top-cited authors
Zahra Mohtasham-Amiri
  • Guilan University of Medical Sciences
Mohammadreza Emamhadi
  • Guilan University of Medical Sciences
Kaveh Haddadi
  • Mazandaran University of Medical Sciences
Ghomsi Nathalie
  • University "Félix Houphouët-Boigny"
Ulrick Sidney Kanmounye
  • Geisinger Health System