Functional Outcome After Primary Decompressive Craniectomy for Acute Subdural Hematoma in Severe Traumatic Brain Injury.

AIM: To evaluate the impact of primary decompressive craniectomy (DC) on the functional outcome in patients with post traumatic acute subdural hematoma (SDH). MATERIAL AND METHODS: A retrospective cohort analysis of 92 patients with post traumatic acute SDH who underwent primary DC and evacuation of SDH. The primary outcome variable is Glasgow outcome scale at 6 months follow up, while exposure variables are demographic data (age and gender), initial Glasgow coma scale, Marshall Classification Score of traumatic brain injury, midline shift, side of the lesion, surgery related complications and time of cranioplasty. RESULTS: Out of the 92 patients in this study, 89.1% were males and the mean age was 30.2 ± 14.4 years. At admission, the mean Glasgow Coma Scale (GCS) was 5.8 ± 2 and mean Marshall score was 4.7 ± 0.7, while the average midline shift was 8.8 ± 3.5 mm. Right decompressive craniectomy was performed in 46 (50%) patients, while in 2 (2.1%) cases, bi-frontal craniectomy was performed and left decompressive craniectomy was performed in 44 (47.8%) patients. Mortality was reported in 38 patients (41.3%) and poor outcome was reported in 24 patients (26.1%), while 30 patients (32.6%) showed good outcome. During the follow up period, cranioplasty for restoration of the bone defect was completed in 52 patients. CONCLUSION: Primary decompressive craniectomy after STBI for post-traumatic acute subdural hematoma improved the favorable outcome whenever the initial GCS > 4 among adult patients.

Urinary exosomal microRNA-96-5p and microRNA-183-5p expression as potential biomarkers of bladder cancer.

Because of low sensitivity and specificity of the currently available urine biomarkers of bladder cancer (BC) detection and painful cystoscopy procedure. Our study aimed to evaluate expression of urinary exosomal miR-96-5p and miR-183-5p as probable non-invasive and accurate biomarkers for the diagnosis and follow up of BC. Using quantitative real-time polymerase chain reaction; expression of exosomal microRNA (miR)-96-5p and miR- 183-5p in the urine samples of 51 patients with BC, 21 patients with benign urinary bladder lesions and in 24 normal individuals as control group was done. Our study results showed higher expressions of both miR-96-5p and miR-183-5p in urine of BC patients in comparison with control group (P < 0.001 for each). Receiver operating characteristic curve (ROC) analysis showed that each microRNA had good sensitivity and specificity to differentiate BC from non-BC patients miR-96-5p 80.4% and 91.8% and miR-183-5p 78.4% and 81.6% respectively compared to cytology (37.3% and 100%). In addition, it was obvious that the sensitivity of combined miR-96-5p and miR-183-5p for the diagnosis of BC reached 88.2%% and specificity reached 87.8%, which were higher than each one alone. We also found that expression of miR-96-5p and miR-183-5p with high grade, and pathological stage was significantly increased. After surgery, collected urine samples showed significantly lower expression of miR-96-5p-: P < 0.001; and miR-183-5p: P = 0.002. In conclusion, urine miR-96-5p and miR-183-5p are promising tumor biomarkers of BC diagnosis; particularly, when they combined with each other or with urinary cytology.

Cerebral venous sinus thrombosis in patients with COVID-19 infection.

BACKGROUND: Despite the COVID-19 infection is more frequently related to acute respiratory distress but there is an increasing evidence of a heterogeneous spectrum of multi-system involvement including the central nervous system. Thromboembolic events after COVID-19 infection have been reported mainly in the pulmonary vasculature however; thromboembolic complications of the nervous system with subsequent cerebrovascular stroke have been increasingly reported. The most common cerebrovascular complication after COVID-19 infection is ischemic stroke however there is also reported cases of cerebral venous sinus thrombosis in such patients as well. In the current report we present two cases with extensive cerebral venous sinus thrombosis as a potential complication for COVID-19 infection. OBJECTIVE: Increase the awareness of neurological complications in patient with COVID-19 virus disease. METHODS: Reporting two cases with confirmed cerebral venous sinus obstruction in patient with confirmed COVID-19 infection. RESULTS: Two young adult males less than 30 years old have no other risk factors of hypercoagulable state apart from being COVID-19 infection victims complicated by CVST. Both of them had progressive course of deterioration in conscious level, right hemiplegia and only one seizures attack has been reported in (Case-1). Both patients in the current report died within one week of their initial symptoms in spite the aggressive medical and surgical treatment. CONCLUSION: CVST is a devastating complication when associated with COVID-19 infection and early investigations for cerebrovascular integrity by using MRA, MRV whenever there are unexplained neurological manifestations in patient with COVID-19 disease.

Management of a posterior gunshot injury with a floating pedicle and cerebrospinal fluid leak.

PURPOSE: Gunshot injury to the spine can be devastating, and it has increased in the civilian population during the last decade. METHODS: We present the case of a 30-year-old male, who received a bullet in his back after exchange of fire with the police. Initial assessment revealed paraparesis with cerebrospinal fluid leak (CSF) from the bullet entry hole, CT scan showed metal debris with two bullet fragments in the L5/S1 right foramen and lateral recess, and another fragment in the central canal posteriorly, and also it revealed two fracture lines creating a right L5 "floating pedicle". RESULTS: The patient was taken to the operating room and underwent L5/S1 posterior approach with right L5 pedicle stabilization with a pedicle screw, removal of the bullet fragments, dural repair with a patch, L5/S1 posterolateral fusion, and insertion of a lumbar CSF drain. The patient could walk with a walking frame on day 7 with a satisfactory radiological result at 1 year but with a remaining partial motor deficit of both ankles, mainly on the right side. CONCLUSION: Literature contains a lot of controversies regarding the management of spinal gunshot injuries. The current case shows that early surgical management, when partial neurological deficit with a CSF leak is noted, could improve the clinical outcome and prevent related complications.

Prolonged Physiotherapy versus Early Surgical Intervention in Patients with Lumbar Disk Herniation: Short-term Outcomes of Clinical Randomized Trial.

STUDY DESIGN: Randomized controlled trial. PURPOSE: We compared the disability and functional outcome after conservative treatment with prolonged physiotherapy versus early surgical intervention in patients with lumbar disk herniation. OVERVIEW OF LITERATURE: Lumbar disk herniation is one of the most common causes of job-related disability in individuals less than 45 years old. Conservative treatment is the initial pathway for the majority of patients but the duration of conservative treatment remains debatable and the adverse effects of prolonged conservative treatment are still unclear. Prolonged duration of symptoms before surgical intervention is associated with worse outcomes than a short period of symptoms. METHODS: From June 2011 to July 2013, 60 patients with lumbar disk herniation at our institute were randomized into two groups. Group I was treated with prolonged physiotherapy and rehabilitation for 6 months, while group II was treated with early surgical discectomy. Oswestry disability index was used to assess disability, while the Prolo economic outcome rating scale was used to assess the work status. RESULTS: Most patients were males between 21 and 45 years old (mean age, 35.88±7.15). There was significant improvement in the disability and work status in both groups without statistically significant differences in the disability score at the second or third assessment. However, the Prolo scale became significantly better in group I than in group II patients during the second and third assessments. CONCLUSIONS: A prolonged physiotherapy and rehabilitation program is a beneficial and successful treatment in patients with recently diagnosed lumbar disk herniation.

Neurosurgical wound infection at a university hospital in Egypt; prospective study of 1,181 patients for 2 years.

AIM: The aim of this study is to report the incidence rate of neurosurgical wound infection at our university as well as the predisposing risk factors. MATERIAL AND METHODS: A 2-year hospital prospective study was conducted and included 1110 patients underwent 1181 elective neurosurgical procedures, 50.3% were male. The ages ranged between 4 days and 80 year with mean age of 33.9 ± 19.679. Instrumental spinal devices were applied in 189 (16%) of patients, and 114 (9.7%) underwent shunt surgery, while aneurysmal clips were used in 5 patients only. The mean duration of follow up was 17.46 ± 3.49 months. RESULTS: 41 patients suffered surgical wound infection representing 3.47 % of the patients. Staphylococcus aureus was the commonest organism in 10 (24.39%) patients followed by the E.coli in 5 (12.19%) patients, while the culture revealed no growth in 14 (34.14%) patients. 25 patients have one or more risk factors of wound infection. 28 cases were treated surgically and 13 patients received conservative treatment. 34 wound infections occurred early during hospitalization, while 7 patients had late wound infection. We have two death-related infection from meningitis and sever septicemia. CONCLUSION: The neurosurgical wound infection rate is usually low even in developing countries and remains within the accepted rate.

Management of Brown-Sequard syndrome in cervical disc diseases.

AIM: To raise the awareness of the appropriate management of unusual clinical presentation of cervical disc herniation. MATERIAL AND METHODS: Seven patients with Brown-Sequard syndrome due to cervical disc herniation presented with Brown-Sequard syndrome had been treated surgically as one of them treated with anterior cervical discectomy and three patients treated by anterior cervical discectomy and fusion while three of them have been treated by posterior laminectomy. RESULTS: Patients were 7 three of them were female and four were males and the mean age of our patients is 45.28 ± 16.49 years ranged between 32 and 72 years. History of spinodegenerative disease in the form of chronic neck pain with or without brachialgia was found in 6/7 patients (85.7%) while history of trauma was found in 5/7 patients (71.4%). Most common affected level is C5-C6 disc Outcome after surgical treatment revealed complete recovery in 4/7 patients (57.1%) while incomplete recovery in 2 patients (28.6%) and no improvement in one patient (14.3%). CONCLUSION: Brown-Sequard syndrome is a rare presentation of cervical disc herniation but accurate diagnosis, and early anterior spinal cord decompression lead to complete recovery of these cases.

Laparoscopic revision of the distally obstructed ventriculoperitoneal shunt.

AIM: Evaluation of the laparoscopic assisted revision of the ventriculoperitoneal shunt as an alternative technique to the traditional laparotomy. MATERIAL AND METHODS: Out of 1181 elective neurosurgical procedures have been done from January 2009 to December 2010. There are 98 (8.2%) ventriculoperitoneal shunt procedures. New shunt insertion was performed 41 times (41.9%) and shunt revision performed 57 times (58.1%). Shunt-related infection was detected in 11 cases (11.22%) while mechanical failure was found in 46 cases (46.9%), proximal obstruction was diagnosed in 26 cases (26.5 %) while 20 patients (20.4%) suffered from distal obstruction. Out of the 20 patients with distal obstruction, 12 patients were treated with laparoscopic assisted revision of the peritoneal end. RESULTS: Intra operative finding revealed peritoneal adhesion in 83.3% of cases and cerebrospinal fluid pseudo cyst in 16.6% while extra peritoneal tube was found in one case. Intraoperative management included adhesiolysis in 10 patient, evacuation and marsupialization of the cyst in two cases in addition to tube repositioning in all cases. There was no procedure-related complications. CONCLUSION: Laparoscopic assisted revision of the peritoneal catheter is an alternative technique to traditional laparotomy in the revision of ventriculoperitoneal shunt.

Buccal versus lingual mucosal graft urethroplasty for complex hypospadias repair.

OBJECTIVES: To compare surgical outcomes and donor site complications of buccal and lingual mucosa used as ventral onlay graft for complex hypospadias cases. PATIENTS & METHODS: Forty four cases with complex hypospadias after failed previous surgery were prospectively included. All had severely scarred penile skin with reasonable residual urethral plate. Cases were categorized into two groups: Group I (23) where buccal mucosal graft [BMG] was used and group II (21) where lingual mucosal graft [LMG] was used. Donor site complications as well as functional and esthetic outcomes were recorded for each group. RESULTS: Mean follow up was 20.8 months (range 12-24). Average graft harvesting time was 24 min for BMG and 19 min for LMG. Donor site pain was reported with both techniques but recovery was earlier with LMG. Slurred speech and difficult tongue protrusion were reported with lingual but not buccal grafts; however mouth tightness, peri-oral numbness and persistent oral discomfort were reported only with buccal grafts. Successful urethroplasty was obtained in 78.2% of BMG compared to 76.1% of LMG. CONCLUSION: Surgical outcomes of LMG urethroplasty were comparable to those of BMG in complex hypospadias cases. Compared to buccal mucosa, LMG is easy to harvest, with minimal donor site complications.

The validity of testicular aspirate cytology and DNA image-analysis of the aspirate in the assessment of infertile men.

OBJECTIVE: To assess the possibility of using cytological examination and DNA image-analysis of testicular fine-needle aspirates instead of open surgical biopsy in the investigation of infertile men, as testicular biopsy has long been used for investigating infertility but the interpretation of histological slides is usually subjective. PATIENTS AND METHODS: Thirty-three men (aged 22-36 years) were evaluated for infertility and underwent both open biopsy and fine-needle aspiration of their testes. Subsequently, the needle aspirates were assessed histopathologically and cytologically, and by DNA image cytometry. The percentages of haploid, diploid and tetraploid cells were determined for each patient. RESULTS: The cases were divided into four categories: (1) Complete spermatogenesis, with a DNA pattern of 1n > 2n > 4n; (2) Maturation arrest, with a DNA pattern of 2n > 4n with no haploid cells; (3) Sertoli cell-only syndrome, with a DNA pattern of only 2n, with no haploid or tetraploid cells; (4) Hypospermatogenesis, with a variable DNA pattern, i.e. mild with 1n > 2n, moderate with 2n > 1n > 4n, and marked where the DNA pattern was 2n > 4n > 1n. From the cytological and DNA image-analysis of the aspirate a diagnosis was possible that had a strong correlation with the histological diagnosis of the same case. From image analysis we could exclude interstitial cells, Sertoli cells and sperms on the static image, and differentiate between spermatozoa and spermatids based on morphological characteristics in the cytological smear. This technique can therefore be used to quantitatively determine the percentages of various cell types within the seminiferous tubules. By coupling image ploidy analysis and cytological examination of a cytological smear, spermatogenesis can be assessed accurately. CONCLUSION: Image cytometry could be used to exclude interstitial cells, Sertoli cells and sperms on the static image and so produce an accurate assessment of spermatogenesis. A combination of ploidy and cell morphology characteristics in cytological smears provides an accurate, reproducible and easily used alternative to open testicular biopsy.