Ali Tayebi Meybodi

Capillary hemangioma of cauda equina: a case report

BackgroundCapillary hemangiomas of spinal nerve root, mostly affecting the cauda equina, are extremely rare.Case presentationA 20-year old man was presented with back pain, radiculopathy, and urogenital symptoms. Magnetic resonance images revealed an intradural extramedullary mass, isointense in T1-weighted and hyperintense in T2-weighted images, with noticeable post injection enhancement. The clinical and radiological findings simulated neurinoma.However, a pinkish lesion was removed surgically and histopathological examination revealed lobules of capillary vessels separated by fibrous tissue, suggesting capillary hemangioma.ConclusionAlthough rare and sometimes indistinguishable from more common lesion, capillary hemangioma should be in differential diagnosis of any enhancing intradural extramedullary mass at the level of cauda equina or conus medullaris.

Intracerebral atypical calcification in nongalenic pial arteriovenous fistula: a case report

Nongalenic intradural arteriovenous fistulas, although uncommon, are clinically important. Choosing the appropriate therapeutic approach has been a controversial issue within the last decade.A 15-year-old male was presented with a calcified nongalenic arteriovenous fistula in the left parietal region, supplied by the left middle cerebral artery, and draining into the left lateral sinus. The patient was managed surgically with traditional clipping the feeder artery, along with piecemeal resection of the huge calcified mass. Although endovascular methods may be the treatments of choice in similar cases, in such huge calcified lesion, non-amenable to endovascular occlusion, open surgery seems to be preferred.

Multiple extradural spinal arachnoid cysts: a case report and review of the literature

Extradural spinal arachnoid cysts are rare lesions, which may become symptomatic due to mass effect. Multiple cysts are even rarer of which few are reported to date. A 17-year-old male with acute onset urinary retention and progressive paraparesis is presented. Magnetic resonance imaging of spine revealed multiple spinal extradural arachnoid cysts located dorsal to the spinal cord, causing mass effect. The patient underwent surgery for excision of the cyst and closure of dural defects. He gained urinary continence and near normal muscle strength of lower extremities over a period of two weeks following operation. Up to date, there have been only sixteen reported cases of multiple spinal extradural arachnoid cysts in the literature and the present case appears to be the second most extensive one reported so far. Appreciation of the rarity of such lesions as well as the importance of surgical planning (especially pre-operative localization of the dural defects) is highlighted.

Delayed post-operative contralateral epidural hematoma in a patient with right-sided acute subdural hematoma: a case report

Head injury is one of the leading causes of death and disability in traumatic accidents. Post-operative contralateral epidural hematomas after surgery for acute subdural hematoma seem to be rare. In this case, expansion and spontaneous resolution of a fractural epidural hematoma contralateral to the side of acute subdural hematoma is presented. The importance of immediate post-operative computed tomography is also highlighted to detect delayed traumatic mass lesions.

EXTRACRANIAL ANEURYSM OF THE POSTERIOR INFERIOR CEREBELLAR ARTERY WITH AN ABERRANT ORIGINATIONCASE REPORT

OBJECTIVEAneurysms of the extracranially originating posterior inferior cerebellar artery are very rare. An anatomic insight of its possible course and variations is necessary when confronting such extraordinary lesions. CLINICAL PRESENTATIONA 19-year-old man presented with the sudden onset of severe headaches. A physical examination was positive only for neck rigidity. Computed tomographic scans of the brain depicted intraventricular hemorrhage. TECHNIQUE AND INTERVENTIONFour-vessel brain digital subtraction angiography revealed an extracranial posterior inferior cerebellar artery arising extradurally from the right vertebral artery between the C1 and C2 vertebrae, bearing a saccular aneurysm in an upper cervical intradural location. An anterior inferior cerebellar artery-posterior inferior cerebellar artery variant was also found on the left side. Computed tomographic angiography failed to unmask the lesion. The aneurysm was clipped through a suboccipital craniectomy and C1 laminectomy. CONCLUSIONThe patient did well after surgery and was discharged from the hospital without neurological deficit. One can conclude that a comprehensive diagnostic approach oriented to the patient history and clinical data is mandatory to preclude such lesions evading the vigilant surgeon.

Levine-Sekhar grading system for prediction of the extent of resection of cranial base meningiomas revisited: study of 124 cases

Introduction: Skull base meningiomas comprise an intricate kingdom in neurological surgery. Due to their proximity to critical neurovascular structures, these tumours impose a cumbersome burden on the surgeon regarding surgical intervention and the clinical outcome. Preoperative prediction of the meningioma resectability will help the surgeon seek a rational result from surgery. This study tries to re-examine and promote the Levine-Sekhar (LS) grading system proposed to predict the resectability of basal meningiomas. Patients and Methods: A retrospective study was performed on 124 eligible patients (90 female and 34 male) suffering from cranial base meningioma that had been operated on between April 1996 and February 2003. The patients were classified according to LS and our modified grading systems. The modified grading system deploys six groups of variables: optic apparatus involvement, cavernous sinus neural involvement, facial-auditory involvement, caudal cranial nerve dysfunction, data derived from imaging studies (multiple fossa involvement and/or vessel encasement), and history of previous radiosurgery. Each criterion scores 1 if present and the total score is the sum of scores obtained from the aforementioned criteria. Results: Amongst 124 patients, 66 (52%) underwent gross total removal of the tumour. Regression and correlation analysis were performed for both LS (r2 = 0.9683) and our modified grading systems (r2 = 0.990) to evaluate the relationship of tumour grade versus the proportion of total resection. The correlations were significantly different (P<0.01). Conclusion: Although the LS grading system is reported to be a good predictor of the extent of tumour resection, we believe that application of the six aforementioned variables will enhance the accuracy of this system, while preserving simplicity and communicability.

Burr-Hole Drainage for the Treatment of Acute Epidural Hematoma in Coagulopathic Patients: A Report of Eight Cases

Craniotomy has been accepted as the treatment of choice for the management of acute epidural hematomas (AEDH). However, in practice, it seems possible to evacuate AEDH via a single burr hole instead of the traditional craniotomy in certain circumstances. Among 160 patients with AEDH meeting criteria for evacuation admitted to the emergency and accident division of our center between 2006 and 2009, we found 8 cases of hematoma appearing isodense to brain parenchyma on computed tomography (CT), who had concomitant coagulopathy. These patients were managed by burr-hole drainage for treatment of the liquefied AEDH. A closed drainage system was then kept in the epidural space for 3 days. In all 8 patients, AEDH was evacuated successfully via burr-hole placement over the site of hematoma. The level of consciousness and other symptoms improved within the first day, and no patient required an additional routine craniotomy. For patients with slowly-developing AEDH in the context of impaired coagulation, burr-hole evacuation and drainage might be a less invasive method of treatment compared to conventional craniotomy.

Assessment of the Endoscopic Endonasal Transclival Approach for Surgical Clipping of Anterior Pontine Anterior-Inferior Cerebellar Artery Aneurysms

OBJECTIVE Aneurysms of the anterior pontine segment of the anterior-inferior cerebellar artery (AICA) are uncommon. Their treatment is challenging because critical neurovascular structures are adjacent to it and the available surgical corridors are narrow and deep. Although endoscopic endonasal approaches are accepted for treating midline skull base lesions, their role in the treatment vascular lesions remains undefined. The present study is aimed to assess the anatomic feasibility of the endoscopic endonasal transclival (EET) approach for treating anterior pontine AICA aneurysms and compare it with the subtemporal anterior transpetrosal (SAT) approach. METHODS Twelve cadaveric specimens were prepared for surgical simulation. The AICAs were exposed using both EET and SAT approaches. Surgical window area and the length of the exposed artery were measured. The distance from the origin of the artery to the clip applied for proximal control was measured. The number of AICA perforators exposed and the anatomic features of each AICA were recorded. RESULTS The EET approach provided a wider surgical window area compared with the SAT (P < 0.001). More AICA perforators were visualized using the EET approach (P < 0.05). To obtain proximal control of the AICA, an aneurysm clip could be applied closer to the origin of AICA using EET (0.2 ± 0.42 mm) compared with SAT (6.26 ± 3.4 mm) (P < 0.001). CONCLUSION Clipping anterior pontine AICA aneurysms using the EET approach is feasible. Compared with SAT, the EET approach provides advantages in surgical window area, ensuring proximal control before aneurysm dissection, visualization of perforating branches, and better proximal control.

The Lateral Triangle of the Middle Fossa: Surgical Anatomy and a Novel Technique for Transcranial Exposure of the Internal Maxillary Artery.

BACKGROUND: The challenge of locating and isolating the internal maxillary artery (IMA) hinders its potential use as an arterial donor for extracranial-to-intracranial bypass surgery. OBJECTIVE: To introduce a new approach through the middle cranial fossa for easy access and safe exposure of the IMA. METHODS: Ten specimens were prepared for surgical simulation. After the pterional craniotomy, a 2-step drilling technique was performed (lateral triangle). First, a triangular craniectomy was completed anterolateral to the foramen spinosum. By following the middle meningeal artery and dividing the lateral pterygoid muscle, the proximal part of IMA was located. Second, a bone slot was drilled in a posterior-to-anterior direction from the anterior aspect of the first craniectomy. By tracing of the proximal part, the main trunk of the IMA was obtained. The size of the 2 craniectomies, the depth of IMA from the surface of the middle fossa, and the length of exposed IMA were measured. RESULTS: Drilling within the lateral triangle allowed safe exposure of both the trunk and the branches of the mandibular nerve of the IMA. The total craniectomy measured 27.8 ± 4.2 mm in the anterior-posterior direction, and the posterior portion measured 13.3 ± 1.5 mm in the lateral-medial direction. The depth from the middle fossa to the IMA (16.8 ± 3.2 mm, mean ± SD) was equal to the length of IMA exposed (17.6 ± 3.3 mm, mean ± SD; P > .05). CONCLUSION: This new approach provides an efficient and safe method to consistently find and isolate a segment of the IMA suitable for extracranial-to-intracranial bypass. ABBREVIATIONS: IMA, internal maxillary artery LP, lateral pterygoid MMA, middle meningeal artery

Primary intraosseous osteolytic meningioma of the skull: a case report

Primary intraosseous meningiomas are uncommon. The osteolytic variants of these tumors are even rarer. When one reviews a bony skull lesion, the differential diagnosis is very wide and includes both malignant and benign diseases. In case of primary skull meningioma, correct diagnosis and total resection of the lesion ensures curative therapy. Presented is a case of osteolytic skull lesion not invading the dura that was proved to be a fibrillary meningioma with regions of syncitial pattern.