Supratentorial and cervical extensions of a giant middle ear cholesteatoma.

INTRODUCTION: Cholesteatomas are slowly progressive and well demarcated lesions but if not treated, they can spread to the inner ear and brain and lead to serious neurological complications. CASE REPORT: A 59-year old male was referred to our practice. His initial imaging showed that a huge intracranial mass has spread to the neck. Beyond surgical exploration, a sizable temporal bone lesion with extensive keratinisation was observed which later on histopathological exam turned out to be a cholesteatoma. CONCLUSIONS: Cholesteatomas may be aggressive lesions by rapidly growing and gross destructive features. In such cases, more attempts should be given to ruling out any malignant neoplastic tissues.

Successful microvascular decompression surgery for dolichoectatic vertebral artery compression of medulla oblongata in a patient with hypersomnia disorder.

INTRODUCTION: Hypersomnia is a condition in which a person has trouble staying awake during the day. There are several potential causes of it, including sleep apnea and sleep disorders. CASE PRESENTATION: A 43 year old male was referred to our practice with complaints of hypersomnia, snoring, slurred speech and sleep apnea for more diagnostic and therapeutic interventions. His brain MRI was significant for a vascular loop compression on medulla oblongata. The patient underwent microvascular decompression surgery subsequently and showed improvement in all of his symptoms. CONCLUSION: One of the rare causes of sleep apnea is medulla oblongata compression by a vascular loop. Vertebrobasilar dolichoectasia may cause this phenomenon probably and should be reviewed in imaging examinations more precisely. Microvascular decompression by using a synthetic Teflon patch may be helpful in management of these patients.

Endoscopic cystoventriculostomy of an arachnoid cyst using a neuroendovascular stent to maintain patency.

INTRODUCTION: Cystoventriculostomy is a surgical treatment for arachnoid cysts. We present a case using a neuroendovascular stent to maintain ostomy patency. CASE REPORT: A 6½-year-old male with symptomatic arachnoid cyst underwent endoscopic fenestration and Wingspan stent insertion. CONCLUSION: Neuroendovascular stent placement may be an adjunct to maintain patency in cystoventriculostomy.

Dural arteriovenous fistulas as a relative contraindication for lumbar puncture: brief report and literature review.

We report three patients who deteriorated after lumbar puncture (LP). Two patients were later found to have type іі (a + b) dural arteriovenous fistulas (DAVF) with high flow retrograde venous drainage on cerebral angiography. The third had a type II (a) DAVF. All patients recovered at least partially after DAVF treatment. In patients with signs and symptoms of increased intracranial pressure (ICP) but no evidence of focal mass lesion on cranial imaging, we suggest an evaluation for a DAVF before performing an LP.

Endovascular reconstruction of iatrogenic internal carotid artery injury following endonasal surgery: a systematic review.

The objective of this study is to provide an update on endovascular treatments for iatrogenic internal carotid artery (ICA) injuries following endonasal surgery. A systematic review of the literature was performed by using Medline, Cochrane library, and Scopus from 1999 to 2019. We used a combination of the MeSH terms "internal carotid artery," "iatrogenic disease," and "endovascular procedure." Twenty-six articles including 46 patients were identified for in this systematic review. The mean age of the patients was 49 years (CI: ± 4.2). The most common site of ICA injury was in cavernous segment (18 patients; 39%). The most common type of iatrogenic ICA injury was a traumatic pseudoaneurysm documented in 28 patients (60%). Endoluminal reconstruction was performed using covered stents in 28 patients, the Pipeline embolization device (PED) in 13 patients, the Surpass flow diverter device in three, the SILK flow diverter in one, and one case was treated using a combined approach of a covered stent and a PED. Flow diversion and covered stents resulted in a good clinical outcome in 94% and 89% of patients, respectively. This difference did not reach statistical significance (p = 1.0). Even though this systematic review was limited due to articles of small sample sizes and considerable heterogeneity, the results indicate that flow diverting devices and covered stents are good therapeutic options for endoluminal reconstruction of iatrogenic ICA injuries following endonasal surgery.

Percutaneous balloon kyphoplasty in the treatment of vertebral compression fractures: a single-center analysis of pain and quality of life outcomes.

BACKGROUND: Vertebral body compression fractures are one of the most common causes of disability and morbidity, especially among the elderly population. The present study was performed in order to evaluate the effect of percutaneous balloon kyphoplasty (BKP) on patients' pain and quality of life (QOL) in Iran. METHODS: The study was conducted on a consecutive series of 54 patients with symptomatic vertebral compression fractures who failed conservative management between 2014 and 2017. A quasi-experimental design was employed in which the pain severity, quality of life, and kyphotic angle were measured before and 3 and 12 months after the PBK procedure. Pain and quality of life outcomes were determined using a Visual Analogue Scale (VAS) for Pain and the 12-Item Short Form Health Survey (SF-12) for QOL. RESULTS: Excellent improvement in VAS was documented at 3 and 12 months after the BKP procedure (p = 0.001). Improvement at 3 months was maintained through the 12 months follow-up period. A statistically significant improvement in QOL was documented at 3 months after BKP that continued to improve through 12 months follow-up. The mean kyphotic angle before PBK was 19.4 ± 5.3 degrees which after 3 months improved to 12.8 ± 3.1 degrees; this reduction was significant (p < 0.001). No new fractures occurred during the follow-up period. CONCLUSION: Balloon kyphoplasty was determined to be a safe and successful method for treating symptomatic vertebral compression fractures. It leads to significant pain relief, an improvement in self-reported QOL measures, and correction in kyphotic deformity.

Craniometrical imaging and clinical findings of adult Chiari malformation type 1 before and after posterior fossa decompression surgery with duraplasty.

Background: Posterior fossa decompression both with and without duraplasty are accepted treatments for symptomatic adult patients with Chiari Malformations Type 1 (CM-1). There is still debate of the superiority of one technique over the other. The purpose of this study was to determine the clinical and craniometrical imaging outcomes of a series of patients who underwent posterior fossa decompression with duraplasty. Materials and methods: All adult patients with symptomatic CM-1 operated at a single institution with a minimum of 6 months follow-up were enrolled prospectively. Clinical outcomes and craniometrical parameters based upon MR imaging pre- and post-surgery were analyzed. Results: A series of 33 consecutive patients who met the inclusion criteria were enrolled; mean age of 33.93 ± 10 years (range 14-56 years). The most common preoperative complaint was headache. The most common clinical sign was sensory dysfunction which was relieved or improved in 63% of patients. The mean syringomyelia size had a significant reduction after the surgery (p = .01). The mean tonsillar descent also had significant reduction (p = .00). The mean McRae line length before the surgery and after that were 33.4 and 53.1 mm respectively that this change was not statistically significant (p = .42). The odontoid process parameters had no significant changes after surgery. Conclusions: Posterior fossa decompression surgery with duraplasty can improve both clinical and imaging outcomes such as syringomyelia size and tonsillar descent for patients with symptomatic CM-1. However, no significant difference was found in craniometrical parameters before and after the surgery.

Giant frontal sinus mucocele mimicked a primary brain tumor: A case report.

INTRODUCTION: Frontal sinus mucoceles commonly manifest with orbital complications. Intracranial complications, though rare, are significant in the differential diagnosis. Tumefactive and giant mucoceles can resemble intracranial tumors. CASE PRESENTATION: We present the case of a 24-year-old male patient who initially presented to our institution after experiencing a single generalized tonic-clonic seizure. Initial imaging revealed large masses in both frontal lobes. Surgical intervention revealed mucoceles originating from the frontal and paranasal sinuses. DISCUSSION: Mucoceles are often misdiagnosed due to the wide variety of symptoms they can present. In particular, the tumefactive type of mucoceles can present brain tumors both clinically and radiologically. CONCLUSION: Mucoceles can manifest as tumefactive lesions, mimicking intracranial masses, and may present as perplexing neurological conditions.

Cervical spine epidural abscess caused by brucellosis: A case report and literature review.

We report a rare case of epidural abscess at the cervical 5-cervical 6 (C5-C6) levels. The patient underwent surgery with complete abscess removal through C6 vertebral body corpectomy. The result of bacteriological culture was Brucella melitensis. Brucellosis must be considered as a possible cause of epidural abscess in patients from endemic area.

An Intraventricular Type of Chondroma: A Case Report.

Intracranial chondromas are unusual benign tumors. They commonly occur at the base of the skull, whereas an intraventricular type is very rare. We present the case of a 19-year-old female patient with a giant intraventricular chondroma detected incidentally by imaging after a car accident. The spiral head CT scan and MRI findings revealed a large solid mass with a lobular border and coarse calcified components. A wide craniotomy was performed, and a very firm tumor was observed with no internal debulking capacity. The tumor was completely removed in one piece. Differentiation of an intraventricular chondroma from other intraventricular lesions, such as choroid plexus carcinoma, meningioma, and cavernoma, is of great importance in neuroimaging and surgical planning.

Successful endoluminal reconstruction of a pseudoaneurysm of the internal carotid artery following a transorbital stab injury.

Traumatic penetrating injuries to the internal carotid artery (ICA) resulting in the formation of a traumatic pseudoaneurysm are potentially devastating injuries. Previously treatment included, open surgical occlusion of the affected vessel or endovascular embolization. However, with the advent of flow diverter stents, endoluminal reconstruction has become a viable treatment option. In this case report we describe the successful managment of an ICA pseudoaneurysm due to a transorbital stab injury. Endoluminal reconstruction in a traumatic aneurysm is a feasible option. Considering the risk of hemorrhagic complications due to dual antiplatelet therapy required after flow diverter placement, this treatment should only be chosen if insufficient collateral supply is found and occlusion of the affected vessel is not a viable option.

Flow diverter embolization device for endovascular treatment of ruptured blister and wide necked very small aneurysms.

PURPOSE: Ruptured blood blisters (BBA) and very small, wide necked aneurysms (VSA) remain challenging lesions to treat due to their small size, wide necks, and thin, fragile walls. In the present study, we reviewed our experience with these aneurysms treated by flow diversion. METHODS: A total of 18 patients with hemorrhage due to a ruptured BBAs and VSAs, treated with flow diversion between July 2014 and March 2016 were included in this study. We analyzed clinical and radiographic outcomes. RESULTS: A total of 12 (66.7%) VSAs and 6 (33.3%) BBAs were treated with flow diversion. Fifteen (83.3%) and three (16.7%) aneurysms were located on the internal carotid artery and the basilar artery, respectively. On admission, a GCS score of 15 and WFNS grade 1 were found in 14 (77.7%) patients, 3 patients had an admission GCS of 13 and WFNS grade 2, one had an admission GCS of 8 and WFNS of 4. Fisher CT grades 2, 3, and 4 were observed in 11 (61.1%), 1 (5.6%), and 6 (33.3%) patients, respectively. Flow diversion was performed on average 5.6 days after onset of hemorrhage. 6 months post-intervention angiography showed complete obliteration of the aneurysms in all patients. CONCLUSION: Our findings indicate that flow diversion in the acute and subacute phase of hemorrhage is a reliable treatment for reducing complications in patients with BBAs and VSAs. In patients with poor clinical presentation it might be reasonable to delay treatment until the first signs of recovery become apparent.

Life cycle environmental impacts of saffron production in Iran.

Saffron is regarded as an important crop in Iranian agricultural economics that needs to be investigated to produce the environmentally friendlier product. In the present study, saffron production as an important agricultural production system in Iran was evaluated thoroughly from an environmental point of view. Data were collected from saffron farmers in Southern Khorasan province of the country with face-to-face questionnaire method during cropping period of 2013-2014. The system boundary was considered from the production of raw input materials to the harvested saffron. In order to identify the main hotspot during cultivation, impact categories were considered using CML methodology and cumulative exergy demand (CExD) indicator. Based on the results, chemical fertilizers N and P were the main hotspots in abiotic depletion (AD), acidification (AC), global warming (GWP), and photochemical oxidation (PO) impact categories, while diesel fuel was the main hotspot in fresh water aquatic ecotoxicity (FE), marine aquatic ecotoxicity (ME), and terrestrial ecotoxicity (TE). Direct emission from diesel fuel combustion (saffron) was the main hotspot only in human toxicity (HT). The small farms had the highest amounts of AD, AC, EP, GWP, and PO indicators in comparison with the medium and large farms. Total CExD indicator for production of 1 kg saffron was 1894.23 MJ eq. Totally, large farms (bigger than 1 ha) had better environmental performance considering all the impact categories.