Ahmed Farhoud

Radical Resection of Fibrous Dysplasia Involving the Anterior Cranial Base

Background:Fibrous dysplasia (FD) is a non-neoplastic developmental disease of bone characterized by replacement of normal bone by immature bone and osteoid in a cellular fibrous matrix. FD affecting the cranial base is often challenging to treat because of the proximity to neurovascular and ocular structures. Methods:This is a retrospective study comprising 32 patients diagnosed with FD involving the anterior cranial base during a 9-year period. From these cases, 26 patients were surgically treated at the Department of Otorhinolaryngology, Alexandria University. The remaining 6 patients refused surgical treatment and were followed up. The follow-up period ranged from 1.5 to 9 years (mean, 4.6±2.1 y). Results:The most common symptoms were headache (75%), nasal obstruction (65.6%), and proptosis (59.4%). The most frequently involved bone was the ethmoid (93.8%), followed by the sphenoid (68.8%). Out of the 32 patients, 6 patients refused surgical treatment and were followed up. Among the 26 patients who underwent surgery, 15 underwent radical excision, and in the remaining 11 cases the resection was considered subtotal. None of the patients who had radical resection developed any regrowth of their lesions. Three of the 11 patients who had subtotal resection demonstrated radiologic evidence of regrowth. Conclusions:In most cases of FD involving the anterior cranial base, accurate preoperative radiologic planning and modern surgical techniques with immediate reconstruction allow an aggressive but definitive treatment with good functional and aesthetic results.

Role of proton magnetic resonance spectroscopy in diagnosis of pilocytic astrocytoma in children

Abstract Background Pilocytic astrocytomas are the second overall most common pediatric brain tumor. Magnetic resonance (MR) imaging is widely used in the diagnosis and follow up of pediatric patients with pilocytic astrocytomas because of its ability to provide anatomical detail. However conventional MR imaging does not provide information about tissue biochemistry. Aim of the work To study the role of proton magnetic resonance spectroscopy in diagnosis of pilocytic astrocytoma in children. Subjects and methods This study included seven pediatric patients with histopathologically proven pilocytic astrocytoma. All patients were subjected to full history taking and thorough clinical examination. Magnetic resonance (MR) imaging was performed at 1.5 Tesla MR system using a standard head coil. Imaging included conventional MRI and proton magnetic resonance spectroscopy. Proton magnetic resonance spectroscopy was done using either single or multi-voxel technique. Surgical biopsy was then performed to all patients and correlation with histopathological data was done. Results Out of the seven patients included in this study, six were females and one was male with mean age of 9.5 years, the tumor was located in five of them in the posterior fossa, located in right thalamo-peduncular region in one patient and located in the hypothalamic–chiasmatic region in one patient. MR spectroscopic study showed the same findings in all the lesions including high Cho/NAA and Cho/Cr ratios (3.53 ± 1.5) and (7.21 ± 4.2), respectively, relative low concentration of creatine with increased NAA/Cr ratio (2.32 ± 1.1). Lactate doublet was detected in all cases while no lipid peaks were detected. Conclusion Based on the findings in this study we suggest that pilocytic astrocytoma has a specific spectroscopic metabolic profile which could be diagnostic for this type of tumor.

The supracerebellar infratentorial approach in pineal region tumors: Technique and outcome in an underprivileged setting

Abstract Background Pineal region tumors represent 1.5–8.5% of the pediatric brain tumors. Management includes endoscopic third ventriculostomy and biopsy in cases presenting with hydrocephalus. In addition, surgical resection provides survival advantage in selected cases. The supracerebellar infratentorial approach is a widely preferred approach for such region. Methods After approval of the local ethics committee of Alexandria University and acquisition of the appropriate formal consents according to the committee’s standards, we have reviewed the records of fifteen cases presenting with pineal region tumors in Alexandria main university hospital from 2013 to 2016. The mean age at the diagnosis was 14 years (2–54 years). All cases had supracerebellar infratentorial approach for surgical resection. Follow up period was from 12 to 59 months. Results All 15 cases presented with hydrocephalus and increased intracranial pressure manifestations. Out of the 15 cases, 3 cases were germ-cell tumors, 2 cases were pineoblastomas, one parenchymal tumor with intermediate differentiation (PPID), one pineocytoma, 2 cases were anaplastic ependymomas and 6 cases were astrocytomas. Gross total resection (GTR) was achieved in 4 cases, subtotal resection was achieved in 7 cases and partial resection in 4 cases. Major surgical complications included severe post-operative cerebellar edema in 2 cases that required further decompression and hemorrhage in one case that has been managed conservatively. Conclusion In Alexandria university, the supracerebellar infratentorial approach is considered a safe approach with minimal morbidity and no surgery related mortality.

Surgical Resection of Cerebellopontine Epidermoid Cysts: Limitations and Outcome

Objective Epidermoid cysts are benign slowly growing tumors commonly involving the cerebellopontine angle (CPA). The aim of this study was to analyze the surgical limitations, surgical strategies, complications, and outcome of resection of these lesions. Material and Methods The clinical data and outcome of 32 cases operated for CPA epidermoid between 2007 and 2015 were retrospectively analyzed. The mean follow‐up period was 42.6 months, and all patients were followed up at least for a whole year. Results There were 15 males and 17 females. The median age was 37.6 years. Headache and cranial nerves dysfunction were the most common presenting symptoms. Surgery was performed in all patients using the standard lateral suboccipital retrosigmoid approach. In three cases, microvascular decompression of an arterial loop was performed in addition to tumor excision. Total resection was accomplished in 19 out of 32 cases (59.4%), subtotal resection in 7 cases (21.9%), and only partial excision was achieved in 6 cases (18.7%). There was no recurrence or regrowth of residual tumor during the follow‐up period. We had a single postoperative mortality due to postoperative pneumonia and septic shock. New cranial nerves deficits occurred in 15.6% of cases but were transient in most of them. Conclusion The favorable outcome of total resection of CPA epidermoids should always be weighed against the critical risks that accompany it especially in the presence of tight adhesions to vital neurovascular structures. The retrosigmoid approach is suitable for the resection of these tumors even if they were large in size.

Three-year Follow-Up Results of Lumbar Microendoscopic Discectomy (MED): A Prospective Study in 150 Patients

Background Data: The goal of all described surgical techniques to treat lumbar disc prolapse is removing the offending disc material, decompressing the nerve root, and relieving neurologic symptoms while avoiding complications. The goal of minimum invasiveness is to minimize the added morbidity of a larger exposure; including the creation of perineural scarring. Microendoscopic discectomy (MED) is a minimally invasive technique to treat lumbar disc prolapse. It is unique in that it combines open surgical principles with endoscopic technology. Follow-up will show whether MED will improve upon the long-term results of the “gold standard” procedures. Purpose: To evaluate the efficacy of lumbar MED, regarding results, safety, complications, stability of effectiveness, incidence of recurrence, instability and redo surgeries after 3 years of follow up. Study Design: A prospective clinical case study Patients and Methods: We report 150 patients with lumbar disc prolapse, admitted at the Neurosurgery Department; Alexandria Main University Hospital and operated with MED technique. Patients were followed for 3 years. Clinical and radiological data were collected preoperatively and postoperativly. The degree of pain and disability were assessed using VAS and ODI. The length of the incision, the duration of surgery, and the average operative blood loss were calculated. Patients were followed at 2 weeks, 3 months, 1 year and 3 years. Results: This study included 150 patients; with 162 levels operated. 138 patients (92 %) had single level and 12 patients (8%) had double level surgery. L4-5 was the most common level. The mean duration of surgery was 55.0 minutes. The mean blood loss was 40.0 cc. The mean duration of hospital stay was 1.3 day. 81.3% of patients returned to their work in less than four weeks. The average length of skin incision was 2.38 cm. Intraoperative complications included four dural tears (2.6%), one (0.6%) pseudomeningocele, one (0.6%) partial nerve root injury (L5 root), and 3 (2%) superficial wound infection. No patient had postoperative instability or recurrences in the follow up period. There was a statistically significant difference between preoperative and postoperative VAS and ODI in the follow up evaluations (at 2 weeks, 3 months, 1 year & 3 years) (P=<0.001). Conclusion: MED technique allowed nerve root decompression; with minimal complications and preserving normal anatomy, with faster recoveries. For surgeons accustomed to performing endoscopic surgery, the use of MED is a safe and reliable alternative to microscopic discectomy. (2017ESJ124)

Clinical Spectrum and Management of Idiopathic Intracranial Hypertension

Objective:Diagnosis of idiopathic intracranial hypertension (IIH) is a process of exclusion based on clinical, imaging, and cerebrospinal fluid (CSF) data. The appropriate treatment for this complex disease remains unknown. In this study, we analyzed a series of patients with clinical and imaging presentations of IIH correlating them with CSF pressure data and trying to identify selection criteria for best therapeutic modality. Materials and Methods:Eighty-five cases were included in the study. All patients underwent clinical, imaging, and CSF manometry evaluation. Analysis of data was conducted and parameters suggestive of therapeutic modality were identified. Results:Sixty patients presented with classic IIH. First opening CSF pressure was mild in 13.33%, moderate in 50%, severe in 16.67%, and fulminant in 20%. Among all patients, 63.33% recovered on medical treatment and 36.67% needed placement of a lumboperitoneal shunt. Twenty-five patients presented with “borderline” IIH. Data for diagnosis included: chronic headache, visual field defects, “ballooned” partial empty sella, and borderline CSF pressure (160 to 200 mm Hg in nonobese, 160 to 250 mm Hg in obese). All patients showed good recovery to medical treatment. Conclusions:For classic IIH, medical treatment is recommended for patients with acute presentation as well as mild and moderate opening CSF pressures. Surgery is indicated for patients who fail medical treatment or develop medication intolerance, for patients with subacute and chronic presentations, as well as for patients with severe and fulminant opening CSF pressures. Patients with “borderline” IIH presenting with chronic headache, visual field defects, and “ballooned” partial empty sella respond well to medical treatment.

The added value of advanced neuro-imaging (MR diffusion, perfusion and proton spectroscopy) in diagnosis of primary CNS lymphoma

Abstract Introduction Primary CNS lymphoma is difficult to diagnose with conventional imaging modalities. Magnetic resonance proton spectroscopy, dynamic susceptibility contrast DSC perfusion and diffusion weighted images have been recently investigated as a problem-solving tool for evaluation of primary CNS lymphoma with favorable results. Aim of the work To assess the value of advanced neuro-imaging (MR diffusion, perfusion and proton spectroscopy) in diagnosis of primary CNS lymphoma. Patients and methods Five adult patients with suspected primary CNS lymphoma (as suggested by clinical or conventional imaging techniques) were prospectively studied by magnetic resonance proton spectroscopy, dynamic susceptibility contrast DSC perfusion and diffusion weighted images aiming to confirm the suspected diagnosis. The examinations were done on 1.5T machines using diffusion weighted, dynamic susceptibility contrast perfusion and chemical shift CSI imaging sequences. Results Regarding DWI, all patients show low ADC values ranging from 0.61 to 0.67 × 10−3 mm2/s with a mean ADC value of 0.63 ± 0.025(SD) × 10−3 mm2/s, regarding the DSC perfusion. The max rCBV ratios are ranging from 0.23 to 1.52 with a mean ratio of 1.14 ± 0.54(SD). Regarding the MRI spectroscopy Cho/Cr ratios are ranging from 1.9 to 63 with a mean ratio of 19.16 ± 26 (SD), Cho/NAA ratios are ranging from 3.7 to 50 with a mean ratio of 14.8 ± 19.8, NAA/Cr ratios are ranging from 0.09 to 1.6 with a mean ratio of 0.72 ± 0.59, NAA/Cho ratios are ranging from 0.02 to 0.3 with a mean ratio of 0.19 ± 0.1 Lactate peak was found in three cases. Lipid peak was found in two cases. Myo inositol peak was found in one case. Conclusions Restricted diffusion, relative hypo perfusion, increased Cho/Cr, Cho/NAA, decreased NAA/Cho, NAA/Cr and presence of lactate or lipid peaks are consistent imaging finding in CNS lymphoma.

Ventriculosubgaleal shunt in the management of obstructive hydrocephalus caused by cerebellar infarction

Abstract Introduction Cerebellar infarction is relatively uncommon. Small infarctions only cause cerebellar manifestations e.g. ataxia and nystagmus and are treated medically. Large cerebellar infarctions, however, can be life threatening. It cause brain stem compression and can obstruct the cerebrospinal fluid pathway causing obstructive hydrocephalus. It has to be treated promptly and may require besides the medical treatment surgical intervention as well. This is mainly in the form of posterior fossa decompression. In this study, we studied the beneficial effect of inserting a temporary ventriculoperitoneal shunt to relieve the supratentorial hydrocephalus in addition to posterior fossa decompression on the morbidity and mortality of patients in comparison to posterior fossa decompression alone. Aim of the work The aim of this study was to evaluate the role of ventriculosubgaleal shunt in cerebellar infarction causing supratentorial ventricular dilatation. Methods This was a retrospective study that included ten patients having extensive cerebellar infarction causing spratentorial hydrocephalus. They were divided into two groups, group (1) was submitted to posterior fossa decompression alone and group (2) was submitted to posterior fossa decompression in addition to temporary ventriculosubgaleal shunt insertion. Results Group (2) which had posterior fossa decompression in addition to temporary. ventriculosubgaleal shunt had much better results than group (1) which had only posterior fossa decompression. Group (2) had a lower morbidity and mortality and a shorter hospital stay than group (1). Conclusion Temporary insertion of ventriculosubgaleal shunt is recommended in patients having extensive cerebellar infarction causing supratentorial hydrocephalus in addition to posterior fossa decompression. It results in a lower morbidity and mortality and a shorter hospital stay.