A Multidisciplinary Technique Using Endonasal Endoscopic Approach with Intrathecal Fluorescin Under Neuronavigation Guidance in Patients with Cerebrospinal Fluid Leak

Background: Cerebrospinal fluid (CSF) is contained in an anatomic space, including cerebral ventricles and subarachnoid spaces and cisterns of brain and spine. Distraction of normal anatomy of any containing parts of this system will result in CSF leakage which could be associated with morbidity and mortality with variable degrees. In this study, we aimed to present 3 patients with history of blunt head trauma, who presented with delayed CSF leak and underwent endonasal endoscopic approach under image guided surgery using neuronavigation system with fluorescein illumination.Case Presentation: Three patients were referred to neurosurgery department of Shohada Tajrish Hospital with previous history of blunt head trauma, complained from CSF rhinorrhea. They underwent thin slice Computed Tomography scan and received intrathecal fluorescein for better visualization of leakage source under live endonasal endoscopic approach, using image guided neuronavigation technology. Autologous fat tissue and fascia was used to seal the leakage site. Clinical and imaging follow up at post-operative state as well as 1st, 2nd, 4th and 8th week revealed no post-operative complications and repeated CSF leakage.Conclusion: CSF rhinorrhea indicates abnormality in bony structure of skull base and is a major threat for ascending microbial infections and subsequent meningitis. Thus, identification of leakage site(s) and accurate surgical repair is necessary. We experienced a multidisciplinary approach which showed excellent results and no post-operative complications. Multidisciplinary approach with combination of endonasal endoscopic view under neuronavigation system improves accuracy and will minimize post-operative complications.

Surgical outcome of patients with Foramen Magnum Meningioma

Purpose: In this study we aimed to investigate the benefits of far-lateral approach without partial condylectomy in patients with foramen magnum meningiomas over surgical approach with condylectomy.Methods: From 1980 to 2011, a total of 17 patients with foramen magnum meningiomas were treated surgically via far-lateral approach without condylectomy. The follow up period of this study was 6 to 24 months.Result: In this study, most of the tumor removals were done as complete resection. Operative deaths and significant complications were not noticed during procedure. Although all of the patients improved in their motor function, sensory deficits were resolved in 85% of patients by microsurgical far-lateral approach without partial condylectomy.Conclusion: Results of this study revealed that far-lateral approach without condylectomy is safe and effective in resection of foramen magnum meningiomas

Coincidence of Anterior Communicating Artery Aneurysm in a Patient With Carotid Body Tumor: A Case Report

Background: Intracranial aneurysms (IAs) are focal pathologic dilation of cerebral vasculature, which mostly affect the anterior circulation of brain. Carotid body tumors (CBTs) are the most common head and neck parasympathetic paragangliomas. These slow growing neoplasms may cause hypertension along with catecholamine release symptoms, mostly in patients in their fourth decade. This is the second reported case of simultaneous presentation of CBT and IA in a male patient.Case Presentation: A 54-year-old male with positive history of hypertension presented with isolated acute weakness of right upper extremity. Bilateral Doppler ultrasound of carotid arteries showed a mass at left carotid bifurcation, which was confirmed by vessels computed tomography (CT) – angiography. CT scan also demonstrated anterior communicating artery (A-Com) aneurysm. Digital subtraction angiography (DSA) confirmed a right sided A-com artery aneurysm. Aneurismal repair was performed prior to CBT removal.Conclusion: Although multifactorial etiologies, such as hypertension, atherosclerosis and congenital predisposition with vascular abnormalities exists; this case raises the possibility of etiologic relationship between hypertension and hypertensive crises due to catecholamine release and aneurismal development and rupture. Avoidance of possible life threatening complications of aneurismal rupture necessitates preoperative evaluation for CBT in patients with established diagnosis of IA

Effect of Local Steroid Injection on Prevertebral Soft Tissue Swelling Following Anterior Cervical Discectomy and Fusion

Background: Prevertebral soft tissue swelling (PSTS) following anterior cervical surgery, may proceed to airway compromise which is potentially lethal. We plan to evaluate the effect of local steroid injection to reduce PSTS after anterior cervical discectomy and fusion (ACDF).Methods: In a randomized clinical trial 66 patients who underwent ACDF involving one to three segments due to radiculopathy or myelopathy were enrolled and randomly divided to two groups of 38 with local injection of 80 mg methylprednisolone in operation site, and control. Prevertebral soft tissue thickness to mid anteroposterior vertebral body diameter (S/V) ratio was defined to assess PSTS. In addition, dysphagia and pain at surgery site was evaluated using Bazaz dysphagia scale and Visual Analogue Scale (VAS) respectively, at 1st, 5th and 10th post-operative days.Results: We have observed significantly lower S/V ratio in all studied vertebrae, except C6 on second postoperative day in case group. At the end of the 6th month, there was no significant difference for S/V ratio in any level in two groups. Severity of dysphagia was significantly lower in 1st, 5th and 10th post-operative day in patients in case group. (P value<0.05) Also, patients in case group experienced significantly less severe odynophagia at 1st, 5th and 10th post-operative day, which was assessed by VAS. (P value<0.05)Conclusions: The use of local methyl prednisolone in prevertebral space is a simple and effective method to reduce PSTS and severity of dysphagia and odynophagia. Furthermore, this method was not associated with any adverse effects.

Posterior Fossa Tumor in Children

How to Cite this Article: Tabatabaei SM, Seddighi A, Seddighi AS. Posterior Fossa Tumor in Children. Iran. J. Child. Neurol 2012;6(2): 19-24. Objective Primary brain tumors are the most common solid neoplasms of childhood, representing 20% of all pediatric tumors. The best current estimates place the incidence between 2.76 and 4.28/100,000 children per year. Compared with brain tumors in adults, a much higher percentage of pediatric brain tumors arise in the posterior fossa. Infratentorial tumors comprise as many as two thirds of all pediatric brain tumors in some large series. Tumor types that most often occur in the posterior fossa include medulloblastoma, ependymoma, cerebellar astrocytoma and brainstem glioma. Materials & Methods All pediatric cases of posterior fossa tumor that were considered for surgery from 1981 to 2011 were selected and the demographic data including age, gender and tumor characteristics along with the location and pathological diagnosis were recorded. The surgical outcomes were assessed according to pathological diagnosis. Results Our series consisted of 84 patients (52 males, 32 females). Cerebellar symptoms were the most common cause of presentation (80.9%) followed by headache (73.8%) and vomiting (38.1%). The most common histology was medulloblastoma (42.8%) followed by cerebellar astrocytoma (28.6%), ependymoma (14.3%), brainstem glioma (7.2%) and miscellaneous pathologies (e.g., dermoid,  andtuberculoma) (7.2%). Conclusion The diagnosis of brain tumors in the general pediatric population remains challenging. Most symptomatic children require several visits to a physician before the correct diagnosis is made. These patients are often misdiagnosed for gastrointestinal disorders. Greater understanding of the clinical presentation of these tumors and judicious use of modern neuroimaging techniques should lead to more efficacious therapies.References 1. Mehta V, Chapman A, McNeely PD, Walling S, Howes WJ. Latency between symptom onset and diagnosis of  pediatric brain tumors: an Eastern Canadian geographic study. Neurosurgery 2002 Aug;51(2):365-73. 2. Mueller B, Gurney JG. Epidemiology of pediatric brain tumors. Neurosurg Clin N Am 1992 Oct;3(4):715-21. 3. Albright A, Wisoff JH, Zeltzer PM, Deutsch M, Finlay J, Hammond D. Current neurosurgical treatment of medulloblastomas in children. A report from the Children’s Cancer Study Group. Pediatr Neurosci 1989;15(6):276-82. 4. Albright AL. Posterior fossa tumors. Neurosurg Clin N Am. 1992 Oct;3(4):881-91. 5. Healey E, Barnes PD, Kupsky WJ, Scott RM, Sallan SE, Black PM. The prognostic significance of postoperative residual tumor in ependymoma. Neurosurgery 1991 May;28(5):666-71. 6. Park T, Hoffman HJ, Hendrick EB, Humphreys RP, Becker LE. Medulloblastoma: clinical presentation and management. Experience at the hospital for sick children, Toronto, 1950-1980. J Neurosurg 1983 Apr;58(4):543-52. 7. Allen LC. Childhood brain tumors. Current status of clinical trials in newly diagnosed and recurrent disease. Pediatr Clin North Am 1985 Jun;32(3):633-51. 8. Laurent JP,Cheek WR. Brain tumors in children. J Pediatr Neurosci 1985;1:15-32. 9. O’Brien DF, Caird J, Kennedy M, Roberts GA, Marks JC, Allcutt DA. Posterior fossa tumours in childhood: evaluation of presenting clinical features. Irish Med J 2001 Feb;94(2):52-3. 10. Bronstein KS. Epidemiology and classification of brain tumours. Cri Care Nurs Clin North Am 1995;7:79-89. 11. Lannering B, Marky I, Nordborg C. Brain tumors in children and adolescence in west Sweden 1970-1984. Epidemiology and survival Cancer. l990 Aug 1;66(3):604-9. 12. Cushing H. Experiences with cerebellar astrocytomas: a critical review of 26 cases. Surg Gynae Obstet 1931;52:129-204. 13. Geissinger JD. Astrocytomas of the cerebellum in children. Long-term study. Arch Neurol 1971 Feb;24(2):125-35. 14. Pascual - Castroviejo I, Raimondi AJ, Choux M, Di Rocco C. Functional basis of posterior fossa symptoms and signs. eds. Posterior fossa tumours. New York: Springer Verlag; 1993;12-21. 15. Cohen ME, Duner PK. Tumours of the brain and spinal cord including leukemic infiltrates. In: Swaiman KF, editor. Pediatric neurology principles and practice. St. Louis: Mosby; 1991. p. 94550. 16. Bronstein KS. Epidemiology and classification of brain tumors. Crit Care Nurs Clin North Am 1995 Mar;7(1):79-89. 17. GOL A. Cerebellar astrocytomas in children. Am J Dis Child 1963 Jul;106:21-4. 18. Hojer C, Hildebrandt G, Lanfermann H, Schroder R, Haupt WF. Pilocyticastrocytomas of the posterior fossa. A follow-up study in 33 patients. Acta Neurochir (Wien) 1994;129(3-4):131-9. 19. Lassman LP, Arjona VE. Pontine gliomas of childhood. Lancet 1967 Apr 29;1(7496):913-5. 20. Reigel DH, Scarff TB, Woodford JE. Biopsy of pediatric brain stem tumors. Childs Brain. 1979;5(3):329-40. 21. Griwan MS, Sharma BS, Mahajan RK, Kak VK. Value of precraniotomy shunts in children with posterior fossa tumours. Childs Nerv Syst 1993 Dec;9(8):462-5. 22. Raimondi AJ, Tomita T. Hydrocephalus and infratentorial tumors. Incidence, clinical picture, and treatment. J Neurosurg 1981 Aug;55(2):17482. 23. Jamjoom AB, Jamjoom ZA, al-Rayess M. Intraventricular and leptomeningeal dissemination of a pilocytic cerebellar astrocytoma in a child with a ventriculoperitoneal shunt: case report Br J Neurosurg. 1998 Feb;12(1):568. 24. Vaquero J, Cabezudo JM, de Sola RG, Nombela L. Intratumoral hemorrhage in posterior fossa tumors after ventricular drainage. Report of two cases. J Neurosurg 1981 Mar;54(3):406-8. 25. Hoffman HJ, Hendrick EB, Humphreys RP. Metastasis via ventriculoperitoneal shunt in patients with medulloblastoma. J Neurosurg 1976 May;44(5):562-6. 26. Hirsch J, Renier D, Czernichow P, Benveniste L, PierreKahn A. Medulloblastoma in childhood: survival and functional results. Acta Neurochir 1979;48:1-15. 27. Abdollahzadeh-Hosseini SM, Rezaishiraz H, Allahdini F. Acta Medica Iranica 2006;44(2):89-94.

Cervical Neurinoma Encasing Vertebral Artery

Our case was a 48-year-old man with cervical pain radiatingto the upper limbs. Imaging showed an intradural tumor with extradural component encasing the vertebral artery.Thetumor diagnosed asa neurinomaand had been removed surgically.The post operationmagnetic resonance imagingshowed that the tumor was completely removed andthe vertebral arterywas intact at theentire length.The goal of surgery of neurinoma is a total removal of the tumor,however if the vertebral artery is completely encasing by the tumor, it is advisable to remove the tumor to the level that the vertebral intactness issaved

Anesthetic Management in a Patient With Surgical Excision of Spinal Cords Hydatid Cyst: A Case Report

Echinococcosis granulosus is the leading cause of spinal hydatid disease. Hydatidosis of the bone happens in 0.5%-3% of all the cases: the involvement in the vertebral column is 50%. In the endemic areas, one of the common causes of spinal cord compression is hydatid disease, and the diagnosis may remain obscure until specifying symptoms ensuing from complications due to root and cord compression. We present a case of recurrent spinal cords hydatid cyst in a 44 years old patient because it occurs rarely, and anesthetic management in such cases has never evaluated before.

Presentation of a minimally symptomatic large extradural hematoma in a patient with an arachnoid cyst: a case report and review of the literature

<p>Abstract</p> <p>Introduction</p> <p>Hemorrhagic complications of arachnoid cysts have been reported, extensively presenting with subdural or intracystic hematoma after trauma, but presentation with extradural hemorrhage is very rare. In this paper, we report the case of a patient with an arachnoid cyst who developed an extradural hematoma after a subtle head injury. Our patient presented with very mild symptoms in spite of the very large size of the hematoma.</p> <p>Case presentation</p> <p>Our patient was a 23-year-old Iranian man who complained of diffuse progressive headache and vomiting after mild head trauma. A brain computerized scan showed a very large extradural hematoma in the left frontotemporoparietal convexity over a large arachnoid cyst.</p> <p>Conclusion</p> <p>Brain parenchyma containing an arachnoid cyst is vulnerable to trauma and increases the risk of serious hemorrhagic complications. We also suggest that the abnormal shape of the head should be considered as an indication for a computerized tomography scan in cases of mild head injury.</p

Neuropathic Pain: Mechanism, Representation, Management and Treatment

&nbsp; &nbsp;Despite the development of screening tests and diagnostic tools, neuropathic pain is still identified as an underdiagnosed condition lacking proper epidemiological studies. It is difficult to estimate its incidence and prevalence the population. The objective of this narrative review is to summarize current knowledge concerning complications. The underlying mechanisms have also been reviewed in the development of diagnostic or treatment strategies in patients with neuropathic pain to investigate its unique symptoms. The main focus is concentrated on expansion of possible therapeutic options for neuropathic pain treatment. Many therapies are not effective and this often leads to a significant deterioration in the patients’ quality of life. So, the crucial and strategic role of therapeutics in guiding patients in the right direction should not be overlooked. The existing knowledge is so limited and has safety risks. It is truly important to provide alternative treatment strategies in selected patients with refractory neuropathic pain. Interventional therapies include different types of effective treatments for reducing neuropathic pain. Giving insight into recent findings on mechanisms of neuropathic pain may help understand and further develop strategies for correct diagnosis and successful treatment.&nbsp

Drug Interactions in Iranian Veterans With Chronic Spinal Cord Injury - A Descriptive Study

Background: Veterans with chronic spinal cord injury usually have various comorbidities. They are, therefore, visited by different doctors and use different medications. It is necessary to monitor the health of these veterans. One of the important issues in this regard is the attention to drug interactions. The purpose of this study was to investigate the drugs used and their interactions.Methods: This descriptive study of the cross-sectional studies was carried out retrospectively in 2015 under the Shefa Neuroscience Research Center’s supervision, examining the medical records of veterans with spinal cord injury participating in the health screening program at Khatam Alanbiya hospital in Tehran. Demographic data, comorbidities, used drugs, and the level of involvement collected. According to the FDA, drug interactions among the drugs used for each patient has evaluated and classified into three severe, moderate, and weak groups. SPSS v. 21 analyzed data.Results: The study population consisted of 404 men, ranging in age from 41 to 74, with a mean of 51.6 ± 6.4 years. One hundred forty-two of them (35.1%) had a complete injury, and 262 veterans (64.8%) had an incomplete injury. Only 17 veterans (4.2%) had no drug interactions. The number of drug interactions varied from 1 to 38, with an average of 5.9 ± 12.8 interactions per patient. The total number of interactions was 2856, of which 32.5% were weak, 55.3% moderate, and 12.2% severe, with a 95% confidence interval. Among the severe drug interactions in the study, the highest number belonged to the antidepressant drugs.Conclusion: This study highlights the necessity of developing a strategy for investigating and preventing drug interactions in veterans with chronic spinal cord injury. It has recommended that physicians pay more attention to other medications used by the patient and prescribe as little as possible of the drug and the drug with the least number of interactions