Stereo electroencephalography in the kingdom of Saudi Arabia.

Epilepsy surgery and intracranial monitoring have a long history in the Kingdom of Saudi Arabia, spanning over 30 years. Stereo-EEG however, is a more recent offering. In this short communication, we discuss how Stereo-EEG has grown in the context of the Kingdom's healthcare model and the Vision 2030 model. We discuss the various positives of this technique and methodology as well as the various challenges that the hospitals offering Stereo-EEG have faced.

Concise outline of the nervous system examination for the generalist.

Many students, residents and generalists consider examining the nervous system as one of the most difficult parts of the physical examination. Certain problems frequently face the junior physician including organizing a complete examination in a short period, and consistently eliciting the physical signs. Certainly, repeated examinations and experience play an important role, however, solid knowledge and use of proper techniques are crucial for eliciting and interpreting neurological signs. In this paper we present an outline for the examination of the nervous system based on the medical literature and author`s personal experience. Various techniques of eliciting physical signs and possible pitfalls in the examination will be discussed.

The shaken baby syndrome.

Trauma is the most common cause of death in childhood and non-accidental injury is the leading cause of death in infants between one month and one year of life. This is a newly emerging entity in Saudi Arabia. However, there is little available literature on the extent of child maltreatment in Saudi Arabia and other Arab countries. In this review, we will discuss various aspects of the central nervous system insults resulting from the inflicted trauma of child abuse. We aim to raise awareness in the region as the tragic loss of life and function is unequalled in childhood beyond the perinatal period.

The shaken baby syndrome.

Trauma is the most common cause of death in childhood and non-accidental injury is the leading cause of death in infants between one month and one year of life. This is a newly emerging entity in Saudi Arabia. However, there is little available literature on the extent of child maltreatment in Saudi Arabia and other Arab countries. In this review, we will discuss various aspects of the central nervous system insults resulting from the inflicted trauma of child abuse. We aim to raise awareness in the region as the tragic loss of life and function is unequalled in childhood beyond the perinatal period.

Solitary metastasis of breast carcinoma in the optic chiasm.

Optic chiasmatic compression from suprasellar metastatic lesions is well known, but metastasis intrinsic to the optic chiasm has not been reported. A 45-year-old woman, with treated breast carcinoma, presented with headache and chiasmatic syndrome from a large suprasellar tumour. At surgery, an exophytic chiasmatic tumour was encountered, with an appearance similar to a glioma. The pathological appearance was consistent with the primary neoplasm in the breast.

Predicting the probability of meningioma recurrence based on the quantity of peritumoral brain edema on computerized tomography scanning.

OBJECT: The goal of this study was to determine whether the quantity of peritumoral brain edema displayed on computerized tomography (CT) scanning could be correlated with brain invasion and subsequent recurrence of meningiomas. METHODS: One hundred thirty-five patients who underwent resection of intracranial meningiomas at the Ottawa Civic Hospital were followed during the period 1980 to 1998. A complete resection was defined as one in which tumor, invaded bone, and involved dura were removed. Tumors were examined microscopically for evidence of brain invasion. The mean follow-up period was 9 +/- 4 years (standard deviation [SD]) and the mean time to recurrence was 5 +/- 4 years (SD). The authors used a simple grading system based on the average thickness (in centimeters) of edema seen on an axial CT slice showing the most tumor. Edema grade was linearly related to edema volume determined by digitizing the scans (r = 0.96; 29 cases). The chance of brain invasion increased by 20% for each centimeter of edema (r(s) = 1, p < 0.0001; 124 cases). The presence of brain invasion was predictive of recurrence after complete resection with an accuracy of 83%, a sensitivity of 89%, and a specificity of 82%. The chance of recurrence within 10 years after complete resection was given by the equation: percentage chance of recurrence = (centimeter of edema)3 x 0.7, which can be used to predict the chance of recurrence based on findings on CT scans (r(s) = 1, p < 0.0001; 86 patients). Statistical significance was confirmed using Kaplan-Meier and univariate and multivariate analyses. Completeness of resection was the most powerful predictor of recurrence (p < 0.00001, r = 0.6), followed by edema grade and brain invasion (both p = 0.02, r = 0.1). Patient age and gender and tumor location, size, and histological subtype were nonsignificant factors. CONCLUSIONS: Brain invasion causes peritumoral edema. Invaded brain tissue is also the source of residual cells in cases of tumor recurrence after gross-total resection.

Epidermoid cysts of the pineal region.

Localization of epidermoid cysts to the pineal region is rare. The 7-year-old boy now reported presented with an 18-month history of progressive ataxia. CT and MRI scans demonstrated a 2.5x2.5 cm cyst at the pineal region with obstructive hydrocephalus. At surgery via an occipital transtentorial approach, a characteristic "pearly tumour" was encountered, and complete resection was achieved. We present the management of this child with pineal region epidermoid cyst and review 11 cases reported in the literature since 1968. In all, 8 of the 12 patients were males. The age at the time of diagnosis ranged from 7 years to 69 years. Parinaud's syndrome and hydrocephalus are the most common presenting findings. All but 1 patient underwent direct surgical resection; 1 had stereotactic decompression. Surgical treatment brought about complete resolution of the presenting symptoms and signs in 10 of the 12 cases. One patient had persistent upgaze palsy. One patient died from progression of the pineal region mass. This patient presented with hemiparesis, which is a marker of clinical aggressiveness. The authors advocate direct surgical attack as opposed to stereotactic diagnosis and aspiration to: (1) obtain maximal resection and thereby limit the potential for recurrence and delayed complications of the cyst; (2) possibly avoid shunt placement in patients who present with hydrocephalus; and (3) decrease the likelihood of sampling error.

Unusual association of intractable temporal lobe seizures and intracranial aneurysms in an adolescent: is it a coincidence?

Intracranial aneurysms in the pediatric age group are rare occurrences. They usually present with subarachnoid hemorrhage or mass effect. Their association with epilepsy has rarely been reported; such concurrence may not be a coincidence. We present a 16-year-old girl with a 5-year history of medically intractable complex partial seizures. Preoperative electrophysiological and neuroimaging studies demonstrated an epileptogenic focus and atrophy in the right mesial temporal lobe, and ipsilateral incidental aneurysm at the carotid artery bifurcation. The patient underwent a complete right anterior temporal lobectomy, followed by clipping of the aneurysm. We concluded that the epilepsy management in association with cerebral aneurysms is controversial, but when surgery is indicated, clipping of the aneurysm and resection of the epileptogenic focus may provide the optimal outcome. The relevant literature is reviewed and the possible mechanisms of production of epilepsy by intracranial aneurysms are discussed.

Abscedation of posterior fossa dermoid cysts.

Dermoid cysts of the posterior fossa are uncommon. When associated with a dermal sinus, these cysts are often diagnosed during early childhood. The main risk of such an association is contamination of the cyst leading to abscedation of the dermoid itself or formation of daughter abscesses within the cerebellar hemisphere. We recently treated a 20-month-old girl who had a congenital dermal sinus leading to an intradural dermoid cyst. In addition to the midline dermoid cyst, computerized tomography revealed an enhancing lesion extending into the adjacent left cerebellar hemisphere. Suboccipital craniectomy was undertaken after 2 days of external ventricular drainage, and the infected dermoid and adjacent cerebellar abscess were excised. Cultures of the operative specimen revealed Corynobacterium aquaticum, Enterobacter sakazakii and Enterobacter cloacae, requiring 6 weeks of intravenous antibiotic therapy consisting of ceftriaxone, penicillin and gentamicin. A diligent literature search revealed only 24 sporadic cases reported over a period of 56 years. All 24 cases were in children (mean age 17 months), and one-third were in infants under the age of 1 year. All but 1 of these patients underwent posterior fossa surgery, with mortality and morbidity rates of 13% and 10%, respectively. Eleven (40%) children had suppuration within the cerebellar parenchyma, while the rest had abscedation of the dermoid cyst alone. Among the cases reviewed S. aureus was the most common agent, occurring with a probability of 64%. Key issues for appropriate management of these benign lesions are discussed.

Dorsal brain stem lipomas: case report.

Intracranial lipomas are uncommon and rarely symptomatic lesions accounting for 0.06 to 0.46% of intracranial lesions. The management of symptomatic dorsal brain stem lipomas was once limited to cerebrospinal fluid diversion, but with recent advances in microsurgery, they now may be directly treated. We report three patients with dorsal brain stem lipomas, two of which involved the quadrigeminal cistern and one of which was in the cisterna magna region. Antenatal documentation by ultrasound examination in one patient represents the first reported in utero diagnosis of quadrigeminal cistern lipoma. Computed tomographic and magnetic resonance imaging scans were diagnostic. The surgical experience in two symptomatic patients is discussed. Microsurgical decompression was performed in each without neurological deficit, and clinical symptoms postoperatively subsided. No patient required a permanent cerebrospinal fluid shunt. The management of symptomatic dorsal brain stem lipomas is discussed, and an algorithm is proposed.