IRANIAN JOURNAL OF NEUROSURGERY
Year:2020 | Volume:6 | Issue:3 (22)|Papers Count:9

Cerebrovascular diseases comprise a major subspecialty in neurological surgery. Current education curriculums lack the necessary training modalities for teaching the microvascular techniques, to neurosurgery residents. We have included a 1-month micro-lab and animal lab rotation for senior residents, which can be added to their current educational program. Necessary equipment for this rotation includes an operating microscope Zeiss S8, microsurgical instruments, and animal anesthesia equipment are used to perform revascularization techniques on the aorta of a rat model (average-sized Sprague-Dawley weighing 200-250 gram). This rotation was included in previous curriculums as micro-lab. Evaluation of microvascular surgical skills following the addition of animal models to this skill lab is suggested to be considered as a part of OSCE in board certification in future studies. The addition of animal models to micro-lab rotations, provides a better understanding of tissue consistency while dealing with a microvascular surgery procedure, for neurological surgery residents.

Background and Importance: Klippel-Tré naunay syndrome is a rare congenital condition that rarely affects peripheral nerves. Median nerve involvement at the carpal tunnel level has only been reported on four occasions of this syndrome in the medical literature. Case Presentation: A 61-year-old Caucasian female patient with Klippel-Tré naunay syndrome presented with a 10-month history of paraesthesia and numbness affecting the median nerve distribution area of her left hand. The clinical and neurophysiological examination confirmed a moderately severe carpal tunnel syndrome that required surgical decompression. Conclusion: Pre-operative findings demonstrated diffuse vascular infiltration and engorgement of the median nerve. Flexor tendons had a normal appearance. The patient had a satisfactory post-operative period with full resolution of her symptoms 4 weeks after the procedure. Although peripheral nerves are rarely affected in patients with Klippel-Tré naunay syndrome, neurological symptoms could indicate nerve involvement and magnetic resonance imaging (MRI) examination should be considered to further assess the extension of the lesion.

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.

Background and Importance: Cerebral phaeohyphomycosis is a rare but frequently fatal clinical entity caused by dematiaceous fungi like Cladophialophora bantiana. Fungal brain abscess often presents with subtle clinical symptoms and signs, and present diagnostic dilemma due to its imaging appearance that may be indistinguishable from other intracranial spaceoccupying lesions. Still, certain imaging patterns on computed tomography (CT) and magnetic resonance imaging (MRI) help to narrow down the differential diagnosis and initiate prompt treatment of these infections. Case presentation: A 48-year-old immunocompetent man presented with right-sided hemiparesis and hemisensory loss and a provisional diagnosis of stroke was made. The radiological evaluation suggested the possibility of a cerebral abscess. Accordingly, surgical excision of the lesion was performed and the histopathological examination of the specimen revealed the etiology as phaeohyphomycosis. The patient was further treated with antifungals and discharged when general conditions improved. Conclusion: Fungal central nervous system (CNS) infections present diagnostic challenges and should be considered while interpreting ring-enhancing CNS lesions in immunocompetent patients. Surgical resection and antifungal treatment should be considered in all patients with cerebral phaeohyphomycosis.

Background and Aim: Previous studies have reported the important effect of age, sex, heredity, and occupational status on intervertebral degenerative disc diseases, which are among the most important causes of low back pain. However, their results are not always so conclusive. This study was performed to investigate the demographic characteristics and family history of lumbar problems in patients with lumbar degenerative disc diseases due to causes other than acute trauma. Methods and Materials/Patients: This cross-sectional descriptive study included patients without acute trauma who were candidates for surgery of lumbar degenerative disc diseases from 2017 to 2018 in the only state hospital admitting these patients in Rasht, Iran. The data related to the disease were obtained from the patients' medical records. Their demographic characteristics and family history of lumbar vertebrae diseases in their relatives were collected using a researcher-made questionnaire through face-to-face interview by the researcher. The data were analyzed using SPSS (Version 16). Descriptive statistics and the chi-square test were conducted at a significance level of 0. 05. Results: More than half of the patients were in their 4th to 6th decades of life, and the number of men was 1. 8 times as women. The frequency of herniated discs was more than that of both spinal canal stenosis and spondylolisthesis, and most people had no history of low back trauma. The duration of disease in 73% of the patients was more than 1 year and the mean duration was about 4. 5 years. More than half of the patients reported problems with the lumbar vertebrae in at least 1 of their first-degree relatives. About one-third of the patients reported a history of vertebrae surgery in their first-degree relatives and the maximum number of reported surgeries in 1 family was 5. Most of the patients were low-literate and illiterate, and about one-third of the patients were workers/farmers. More than one-third of them were housewives and the number of patients working in administrative and driving jobs was very low. There was no significant relationship between study variables and the type of degenerative problems of the lumbar vertebrae. Conclusion: These findings showed similarities with previous studies in terms of age groups, occupational status, and a history of family lumbar problems in patients with lumbar degenerative disc diseases.

Background and Aim: Diagnosing the status of the posterior ligament complex (PLC) plays an essential role in the management of patients with thoracolumbar fractures. In this study, due to the inefficiency of existing imaging modalities in the accurate detection of PLC damage, we investigated the relevance of some imaging parameters to specific guidelines for rapid PLC injury detection. Methods and Materials/Patients: In this study, 50 patients with and 50 patients without PLC injury were included. MRI, CT scan, and radiographic imaging of the thoracolumbar spine (T12-L1) were evaluated. The thoracolumbar injury classification systems such as Denis, TLICS (Thoracolumbar Injury Classification and Scoring System), and McCormack Load Sharing and radiographic parameters such as Superior Inferior Endplate Angle (SIEA), Body Height (BH), Local Kyphosis (LK), Interspinous Distance (ISD), and Interpedicular Distance (IPD) were investigated in these patients for each imaging method. Statistical analysis was performed using SPSS (Version 21). Result: The ISD and LK and BHp (Body Height Posterior) were significant predictors of PLC injury. On radiographs, the mean LK with and without PLC damage was 25. 67° and 20. 92° , respectively (p<0. 001). The ISD difference was 6. 75 mm in cases with PLC damage and 2. 84 mm in cases with an intact PLC (p<0. 0001). In CT images, the mean LK was 25. 77° in cases with PLC damage and 18. 63° in cases with an intact PLC (p<0. 037). The ISD difference was 4. 14 mm in patients with PLC damage and 2. 19 mm in patients without PLC damage (p<0. 002). The BHp difference was 9. 44 mm in cases with PLC damage and 11. 09 mm in cases without PLC damage (p<0. 002). Conclusion: The current study suggests formulating a predictive radiological index to identify PLC injury successfully. These guidelines can be very helpful in emergency room decision-makings, especially when the cost, availability, and time of performing MRI are important concerns in patients with multiple trauma.

Background and Aim: Glioblastoma multiforme (GBM) is the most common malignant and invasive tumor of the brain. The relation between prognosis and survival of GBM patients with Epidermal Growth Factor Receptor (EGFR) expression is challenging. Thus, we aimed to evaluate the prognosis and survival of patients with GBM and its relationship with EGFR expression. Materials and Methods: This single-arm cohort study was conducted on 70 patients with GBM during 2012-2018 in Shahid Rahnemoon and Mortaz hospitals. The immunohistochemistry technique was applied to paraffin blocks of brain tumors for examining EGFR expression. Other data were extracted from medical records. To determine the survival rate, the Kaplan– Meier curves were used. A chisquare test was used for the analysis of data. Statistically, p-value <0. 05 was assumed significant. Results: The mean survival of patients with GBM was 22. 3 ± 2. 5 months (95% CI=17. 41-27. 10). In addition, 1, 2-and 5-year survival rates were 90%, 30% and 5%, respectively. The mean survival of patients with negative and positive EGFR was 27. 4± 7. 3 and 20. 6± 2. 4 months, respectively. Besides, 11. 1% and 14. 3% of patients in negative and positive EGFR groups were alive. There was no significant difference in patient’ s survival in terms of EGFR expression (p=0. 36). No significant difference was seen between the two groups (EGFR positive and negative groups), regarding the frequency of age, sex, tumor’ s anatomical location, and place of living (p>0. 05). Conclusion: Based on our study, it seems that the GBM tumor was associated with poor prognosis and a low survival rate. It was also found that the expression of the EGFR gene did not affect the survival rate of patients with GBM. Therefore, its use as a predictor factor for survival and prognosis is questionable.

Background and Importance: Fungal infections of the central nervous system (CNS) usually present as subacute meningitis or intracranial space-occupying lesion with mass effect on surrounding structures and consequent focal neurological deficits. Intracranial fungal granulomas are often misdiagnosed clinically and radiologically as neoplastic lesions. Biopsy of the lesion is the only reliable technique to establish the correct diagnosis as well as to detect the causative fungal species. Voriconazole is a broadspectrum triazole antifungal agent. It can be given orally and intravenously and has lesser adverse effects. Methods and Materials: In this article, we report a series of 6 cases of biopsyproven fungal granuloma with varied clinical and radiological presentations who were given treatment with voriconazole for 6 months and demonstrated favorable response. Results: Out of 6 patients (4 males and 2 females), 1 was immunocompromised (DM with uncontrolled hyperglycemia). Headache was the most commonly observed symptom. Paranasal sinus and anterior cranial fossa were the most commonly affected site. Four patients received voriconazole therapy for 12 months and 1 received the same for 6 months before showing clinical resolution of disease. There was 1 death in the study group from non-related medical complications. Conclusion: Our series focuses on the correct diagnosis of fungal granuloma which can be achieved by biopsy and clinical evidence of the efficacy of voriconazole against intracranial fungal granuloma.

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