Iranian Journal of Neurosurgery

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.

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.

Background and Aim: Telemedicine can be considered a primary modality of patient care for non-emergent conditions in the COVID-19 era. The usage and expansion of telemedicine are important and inevitable issues. We decided to investigate the neurosurgeons’ perspective on telemedicine in the treatment and follow-up of neurosurgical patients during the COVID-19 period. Methods and Materials/Patients: This cross-sectional study was carried out in the Department of Neurosurgery, Tehran, from June 2021 to July 2021. An internet-based questionnaire was distributed among all postgraduate and assistant neurosurgeons at the Tehran University of Medical Sciences. Statistical analysis was performed using SPPS (IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp; 2016). Results: This study was performed among 74 neurosurgeons who were mainly male (89.2%). Their mean age was 33.16±5.69 years (ranging from 27 to 62 years), and telemedicine has not been used previously in 37 precipitants (50%). Most precipitants preferred telemedicine for follow-up (93.24%). The common reasons for unimplemented telemedicine were determined by insurance and repayment obstacles (58.11%). Most of the participants believed that telemedicine should first be adapted to working condition and local setting, then it can be applied more in the future. Eventually, the effectiveness of telemedicine was controversial, according to most neurosurgeons’ replies. Conclusion: This study indicated neurosurgeons’ preference for telemedicine. They considered it a comfortable alternative. However, the effectiveness of telemedicine is controversial as it should be adapted first and then used extensively for future purposes. It is also suggested that future studies compare the results of this research with those of studies performed after the COVID-19 outbreak.

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.

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.

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

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

Background and Aim: This study aims to evaluate the frequency of adjacent segment disease (ASD) and its risk factors following posterior decompression and fusion in lumbar degenerative disorders. Methods and Materials/Patients: This retrospective cohort study was performed by reviewing the records of patients with spinal degeneration disorders who underwent lumbar fusion surgery and needed reoperation from 2013 to 2019. The participants were divided into two groups, including patients with ASD and non-ASD patients, and were compared in terms of age, sex, BMI, smoking, fusion level, surgical indications, follow-up times, laminectomy, cross-link device usage, imaging findings, fusion terminating in L1, L5 and S1, and reoperation. Results: Out of a total of 277 candidates, 181 met the inclusion criteria. In terms of gender distribution, 43.3% of the participants were male and 56.7% were female. The median age was 54 years in the ASD group and 48 years in the non-ASD group. The median follow-up of the patients was six years in the ASD group and five years in the non-ASD group. Forty patients (22.1%) developed ASD during this period. The final analysis showed a significant relationship between age, sex, indication for reoperation, repeated surgery, laminectomy, cross-link device use, imaging findings, and fusion terminating in L1. Conclusion: High body mass index, aging, lumbar spinal canal stenosis, reoperation, laminectomy at the upper fusion unit, cross-link device use, lumbar canal stenosis in imaging, and fusion to L1 vertebrae are considered risk factors for ASD.

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.

Background and Importance: Medulloblastoma (MB) is regarded as a scarce primary brain neoplasm in adulthood, originating from the fourth ventricle or the cerebellum, and cerebellopontine angle (CPA)-MB has been described less often in the literature. Few cases of CPA MB have been reported in the English-written literature, most of which are intra-axial, mainly in children; adults' extra-axial CPAMB is even scarcer. To the best of the authors’ knowledge, 12 cases of extra-axial CPA MBs have been reported in the English-written literature. Case Presentation: A 23-year-old man presented to our center complaining of a generalized pulsatile headache, imbalance, swallowing impairment, and right-sided hearing loss for the past 20 days. Computed tomography (CT) scan of the brain showed a hyper-dense extra-axial mass lesion (41*37mm) in the right CPA with a significant compression effect on the fourth ventricle, causing a three ventricular obstructive hydrocephalus. Magnetic resonance imaging (MRI) showed a well-defined heterogeneous extra-axial, lobulated, dural-based mass lesion in the right CPA, hypointense on the T1 sequence, and hyperintense on the T2 sequence compared with the adjacent parenchyma, which has a bright heterogeneous enhancement during gadolinium injection. A significant mass effect was observed on the adjacent parenchyma, brain stem, and fourth ventricle without evidence of parenchymal edema. The patient underwent emergent surgery the next day regarding the mass effect and hydrocephalus. On the postoperative examination in the intensive care unit, no new neurological deficit was detected, and the swallowing and gag reflex significantly improved. Conclusion: Though rare, clinical considerations, along with early supportive radiologic measures, should be considered in subjects with suspected MB. A total tumor excision approach followed by aggregative chemotherapy/radiotherapy is designed to hinder tumor relapse.

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.

Background and Aim: Epilepsy as a neurological disorder is characterized by unpredictable and periodic seizures. In the present study, the anticonvulsant effect of different doses of salep hydroalcoholic extract on pentylenetetrazole (PTZ) induced seizures was investigated. Methods and Materials/Patients: The animal model of seizure was established by the intraperitoneal injection of pentylenetetrazole (PTZ- 85 mg/kg). Hydroalcoholic extract of salep was administered to the animals in 3 doses (80, 160, and 320 mg/kg). The parameters of the onset and duration of tonic-clonic seizure, total seizure time, balance (falling), and jumping during seizure mortality rate were measured. The results were analyzed by ANOVA test at a significant level of p≤0.05. Results: The results of the current study indicated that salep extract increased the delay in the onset of seizure in the PTZ + extract group in comparison with the PTZ group. The duration of tonic-clonic seizure and the number of falling, jumping, and total seizure times were significantly decreased by salep extract compared to the PTZ group. In the seizure + salep extract, the number and percentage of 24-hour mortality among animals decreased with increasing dosage. All changes were dose-dependent and 320 mg/kg showed the most effect. Conclusion: Extract of salep can probably have anticonvulsant properties, however, further studies are needed to clarify the exact mechanisms.

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.

Background and Aim: The extent of resection seems a solid prognostic factor in patients with high-grade gliomas (HGGs). When administered orally, 5-aminolevulinic acid (5-ALA) is exclusively converted into protoporphyrin IX (PPIX) by malignant cells and detects, identifying contrast-enhancing glial lesions under 400 nm blue light. The authors thoroughly assess the efficacy, accuracy, and safety profile of 5-ALA-guided surgery toward the maximal resection of cranial HGGs. Case Presentation: Thirty consecutive patients with HGG adjacent to the corticospinal tract (CST) met our inclusion criteria in a single-arm retrospective study. Bilateral diffusion tensor imaging (DTI)-derived corticospinal tract (CST) tractography was employed using a 1.5 Tesla magnetic resonance imaging (MRI). Oral 5-ALA was ingested with a dose of 20 mg/kg 4 hours prior to operation and was applied to qualify the margins of the local resection cavity. The clinical and volumetric assessments were postoperatively conducted. The mean preoperative tumor volume on T1 contrast-enhanced MRI and fluid-attenuated inversion recovery (FLAIR) images was 16.8 cm3 and 47.6 cm3, respectively. Complete resection of contrast-enhanced lesions was yielded in 27 of 30 patients (90%). All patients improved postoperatively regarding motor deficits and or seizures. No new permanent neurological deficits were detected in the 3-month follow-up. Conclusion: Fluorescence image-guided surgery (FIGS) using 5-ALA increases the extent of resection (EOR) with further surgical risks in eloquent regions when combined with multimodality visualization- functional mapping. It also provides pathological insights to visualize cranial HGGs and identify infiltration of functional fiber tracts.

Background and Aim: Modic changes are alterations in the spine endplates and subchondral bone shock absorption, seen by magnetic resonance imaging (MRI). No studies have investigated the effect of vitamin D and alendronate as oral drugs on reducing and modifying Modic changes after degenerative spine fusion surgery. This study aimed to evaluate the efficacy of oral vitamin D and alendronate administration in patients with low back pain, and Modic changes undergoing lumbar fusion surgery. Methods and Materials/Patients: A total of 81 middle age women with a normal range of serum vitamin d were enrolled in three groups who underwent lumbar fusion surgery according to neurosurgical criteria. Group 1 (n=27) received additional oral alendronate, group 2 (n=27) received oral vitamin D for six months postoperatively, and group 3 (n=27) received no drug (except simple analgesics and antibiotics). The patients were followed up with a visual analog scale (VAS) and Oswestry disability index (ODI). MRI was done before and six months after surgery. Results: There was no significant difference between the three groups in VAS and ODI scores (P=0.416, P=0.601, respectively), but the mean VAS and ODI in all three groups decreased over six months, which was statistically significant (P<0.001). Modic changes in all three groups changed significantly over 6 months (P<0.01). In the vitamin D and alendronate groups, Modic type 3 increased significantly, but Modic type 2 and Modic type 1 decreased significantly in the vitamin d and no medication groups, respectively. Conclusion: Oral vitamin D administration has a desirable effect not only on clinical outcomes after lumbar spinal fusion surgery because of degenerative surgery but also on vertebral endplate Modic changes compared to oral bisphosphonate.

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.

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.

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.

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.

Background and Aim: In-hospital rebleeding and early aneurysm rupture are major causes of mortality and morbidity in aneurysmal subarachnoid hemorrhage. Rebleeding may occur at the referring hospital, during transfer or at the referral neurovascular center prior to surgical or endovascular treatment. However, there has been no report regarding the rate of in-hospital rebleeding and early aneurysm rupture at the referral centers. This study aims to clarify the incidence, significance, management, and outcome of individuals who suffer in-hospital aneurysmal rebleeding and early aneurysm rupture at the referral hospital due to anterior circulation cerebral aneurysm to the time when its neck is visualized for clipping. Methods and Materials/Patients: Among 617 patients with anterior circulation cerebral aneurysms who underwent operation between September 2010 and September 2017 at Neurovascular Unit of Namazi Hospital (main referral neurovascular center in southern Iran), 22 suffered rebleeding since the time of neuroradiologic diagnosis of aneurysm to intraoperative visualization of aneurysm for neck dissection. A surgical technique for fast access and securing the aneurysm is described in this article, too. The patients’ demographics were collected via hospital records in a retrospective fashion. Six-month functional outcome was obtained via OPD records as well as phone calls. Utilizing Independent t test, 1-way ANOVA, Kruskal-Wallis and Mann-Whitney tests in SPSS22, the effect of each study variable was evaluated during 6 months follow-up period. Results: Rebleeding occurred at different venues from CT angiography to frontal lobe retraction. Anterior communicating artery was the most common aneurysm to suffer in-hospital rebleeding and male gender was found as a risk factor. These patients have significantly higher bleeding amount and longer operative time (P

Background & Aim: DBS (deep brain stimulation) is a new and successful technique in treatment of symptoms of Parkinsonism especially after drug resistance. Research in this field is mostly designed for evolution of this technique. The present study aimed at evaluating the relationship between the angle formed in midsagittal and STN (sub-thalamic nucleus) axis line and recording length in the final electrode p lacement. Methods & Materials/Patients: 46 patient candidates for DBS operation were studied in terms of demographic variables, STN nucleus length, the angle between midsagittal line and STN axis (p angle), the number of tested electrodes, force and length of final electrode registration and final coordinates of the placed electrode. The primary information was obtained from patients records and other technical information based on MRI imaging using Stereonata software and during surgery. The information were analyzed using SPSS (version 16) and descriptive analysis and linear relationship. Results: The mean force of the recording from trial microelectrodes implanted in the right side ranged from 1.49 ± 1.45 to 2.65 ± 1.42 and in the left side from 1.53 ± 1.35 to 2.65 ± 2.30. In comparative analysis, no significant statistical relationship was found between P angle of the right side and degree registered in the final electrode of the right side (Pearson correlation: 0.314, P value= 0.049). Conclusion: Not only accurate electrodes positioning in the STN can lead to improved outcome within bilateral STN DBS, but also optimizing defined P angle can have beneficial effects on intraoperative outcome after STN DBS.

Background & Aim: Conjoined nerve root is defined as two adjacent nerve roots that share a common dural envelope at some points during their course from the thecal sac. This study reports our experience of conjoined roots involving three cases in Dakar. Methods & Materials/Patients: This is a consecutive study from 2013 to 2015 involving patients supported for disc herniation and who have presented conjoined nerve root anomalie s. Results: Three patients aged 32, 35 and 55 including two men have been concerned. Clinical analysis was done on sciatica with neuropathic occurrences in one case and lumbosciatica in two cases. The Lasegue sign was present in two patients at 45°. All three patients benefited a lumbar computerized tomography (CT scan) highlighting a degenerative disc disease with two in L5S1 space and one in L4L5 space. The imaging has not objectified radicular emerging anomalies. MRI objectified only one big root. A surgical root decompression was realized through interlaminar discectomy approach; foraminotomy and full laminectomy enabling diagnosis in intraoperative period. The evolution was favourable in all three cases with full recession of sympto matology. Conclusion: This study is the first Senegalese series on the lumbo-sciatica by anomaly of root emergence and highlights especially the difficulties for the diagnosis of these anomalies like other sub-Saharan African countries where expansion of MRI for the diagnosis is low, and still very expensive. MRI provides guidance signs and a large root appearance can warn about the existence of these anomalies. A good root release improves the symptoms.

Background and Importance: Our learning curve during two decades of neurosurgical practice has been changed from an abstractive to a more meaningful and conductive state. In cases of fifth nerve neurinoma, pre-operative anatomopathologic diagnosis could lead us to a pre-planned program during and after the surgery to get the safe surgical result. Case Presentation: Representation of two complex fifth nerve neurinoma cases, untoward happenings and the way to manage patient safety. Review of literature to find a wise approach for maximum benefit is included here. Conclusion: Both of our patients have developed iatrogenic unilateral corneal anesthesia, one of them warned of it and the second one not. We have had more problems in the way of preservation of the cornea in the warned case. We have reviewed the factors influencing safe corneal preservation after the operation of fifth nerve neurinoma which are included following items: surgical approach, Anatomopathologic location of the tumor (pre-ganglionic, ganglionic or post-ganglionic), simultaneous damage of V and VII nerve including vidian nerve, preserved corneal sensation, any combination of injury to physiologic and mechanical protectors. The cornerstones to have a safe cornea following such surgeries are pre-operative exam of fifth and 7th nerve in all aspects and also early post-operative evaluation of them including the state of the tear secretion. We encounter corneal anesthesia and epithelial defect. Iatrogenic damage of vidian nerve depending to approach selected seems to be considerable. Simultaneous damage of V and VII nerve during the surgery of large neurinoma are expected and noteworthy.