Comparison of Efficacy and Safety of Levetiracetam Versus Phenytoin for Post-craniotomy Seizure Prophylaxis.

Background: Superiority of levetiracetam over phenytoin for postcraniotomy seizure prophylaxis in patients with a supratentorial brain tumor is controversial. We aimed to evaluate the efficacy of levetiracetam versus phenytoin for postcraniotomy seizure prophylaxis in supratentorial brain tumor. Methods: In a randomized controlled trial study, 80 patients with a supratentorial brain tumor who underwent craniotomy were allocated to levetiracetam or phenytoin group, 40 patients each. Seizure prophylaxis was started 5 days before the surgery and continued until 90 days after surgery. Phenytoin group received 100 mg oral phenytoin 3 times a day. The levetiracetam group received 500 mg oral levetiracetam 2 times a day. The primary outcome was the incidence of postcraniotomy seizures. The secondary outcome measure was the safety profile of the drugs. Results: All patients of the phenytoin group and 39 patients of levetiracetam completed the study. Two seizures developed in the study population, 1 in the phenytoin group (2.5%) and 1 in the levetiracetam group (2.6%) (P = 0.710). Renal or hepatic dysfunction was not observed in any patients. Wound hematoma was seen in 5 patients (12.5%) of the phenytoin and 6 patients (15.4%) of the levetiracetam group (P = 0.481). Skin rash developed in 3 patients (7.5%) of the phenytoin group and no patient of the levetiracetam group (P = 0.132). Thrombocytopenia was detected in 1 patient of the phenytoin group (2.5%) and no patient of the levetiracetam group (P = 0.511). None of the adverse events led to drug withdrawal. Conclusion: These results reveal no superiority of levetiracetam over phenytoin for postcraniotomy seizure prophylaxis in supratentorial brain tumor.

Surgical management of a thoracic extradural arachnoid cyst with communication to subarachnoid space through nerve root: a case report.

Spinal extradural cysts are uncommon and may cause cord and nerve root compression. The cysts usually appear in thoracic spine. We report a 29-year-old man with an extradural arachnoid cyst from T4 to T6. The cyst was communicated to the subarachnoid space through a fistula at the left T6 nerve root. To access the fistula, we had to unroof the foramen of left T6 nerve root which could lead to spinal instability. We decided to save the bony and soft tissue elements of the foramen at the mentioned thoracic spine level. Therefore, the cyst walls were excised and then the ostia of the cyst at the cystic side of the fistula was tightly closed.

Correction to: Comparison of cervical sagittal parameters among patients with neck pain and healthy controls: a comparative cross-sectional study.

Unfortunately, the affiliation of the second author (Jean Charles Le Huec) was incorrectly published in the original publication.

Comparison of cervical sagittal parameters among patients with neck pain and healthy controls: a comparative cross-sectional study.

INTRODUCTION: Previous studies have shown poor health-related outcomes among patients with spinal sagittal malalignment of the thoracolumbar or spinopelvic region, and less interest has been paid to the relationship between cervical sagittal balance and functional outcome of the patients. This study aims to compare the cervical sagittal parameters between patients with non-specific neck pain and asymptomatic controls. METHOD: Twenty-five patients (21 females/4 males) with non-specific neck pain and 25 age-, sex- and BMI-matched controls (18 females/7 males) participated in the study. Using a standard lateral cervical radiography, the Cobb angle between occiput-C2, C1-C2, C1-C7 and C2-C7 as well as the thoracic inlet angle (TIA) and C7 and T1 slope angles was measured. Also the spine cranial angle (SCA) and the C2-SVA (sacral vertical axis) and C1-SVA were measured. The primary outcome measure of the study was comparison of the sagittal balance variables between the patients and the healthy controls. Secondary outcome measures were correlation between pain intensity of the patients in neck pain group and their demographic and radiographic findings. Data analysis was performed using independent sample T test and Pearson's correlation for primary and secondary outcome measurements, respectively. RESULTS: There was no difference in cervical lordosis curvature (measured by C2-C7 and C1-C7 lordosis angle) between patients with non-specific NP and healthy controls (P value = 0.45 and 0.37, respectively). We found that T1 slope angle was significantly (P value = 0.02) lower in patients with neck pain. CONCLUSION: Our findings showed that the slope of the upper endplate of T1 vertebrae body (T1 slope) is significantly lower among patients with non-specific neck pain compared to controls. A compensatory mechanism to bring the center of head gravity back to the spinal axis might be the possible explanation for this difference. These slides can be retrieved under Electronic Supplementary Material.

A rare presentation of Rosai-Dorfman disease as a single dural-based lumbar intradural lesion: A case report.

Central nervous system Rosai Dorfman disease (RDD) is a rare condition and it is just reported in 5% of 600 registered RDD cases. In previously reported patients, the intradural extramedullary spinal lesion is extremely rare. In this article, we aim to report a case of intradural extramedullary Rosai-Dorfman lesion of the lumbar spine which was managed with gross total resection. Lumbar meningioma was the pre-operative diagnosis for this patient, the final correct diagnosis of Rosai-Dorfman disease was made after histological examination. RDD should be considered in the differential diagnosis of single intradural extramedullary lesions of the lumbar spine.

Translation, cross-cultural adaptation and validation of the Persian version of selected PROMIS measures for use in lumbar canal stenosis patients.

BACKGROUND: The National Institutes of Health (NIH) developed a new measurement system called the Patient-Reported Outcomes Measurement Information System (PROMIS) which can be used for multiple health conditions. The 29-item short form (PROMIS-29) with seven domains was more often used by clinical researchers to measure the physical function, mood and sleeping status of patients with low back pain (LBP). Translation of the PROMIS into multiple languages and adaptation of its application in different cultural diversities can help to further standardize clinical research studies and make them comparable to each other. This study aimed to cross-culturally adapt the PROMIS-29 into Persian (P-PROMIS-29) and evaluate the construct validity and reliability of the translated questionnaire among patients with lumbar canal stenosis. MATERIALS AND METHODS: The translation was conducted by using the multilingual translation methodology guideline. Construct validity, internal consistency, and test-retest reliability at a two-week interval for the P-PROMIS-29 were calculated. Construct validity was assessed by calculating correlations between the P-PROMIS-29 with Oswestry Disability Index (ODI) and Roland-Morris results. RESULTS: The study sample included 70 participants with lumbar canal stenosis. Internal consistencies were moderate to good with Cronbach's alpha ranging from 0.2 to 0.94. The test-retest reliability evaluation was excellent with intraclass correlation coefficients (ICCs) ranging from 0.885 to 0.986. Construct validity of different domains of P-PROMIS-29 were moderate to good, with Pearson's correlation coefficient results ranging from 0.223 to 0.749. CONCLUSION: Our results showed that P-PROMIS-29 is a valid and reliable measurement tool for evaluation of patients with lumbar canal stenosis.

The Impact of Rigid Cervical Collars on Outcome of Patients Who Underwent Posterior Cervical Laminectomy and Fusion: A Retrospective Comparative Study.

STUDY DESIGN: Retrospective cohort study. PURPOSE: This study aimed to investigate the cervical collar impact on the functional outcomes of patients after posterior cervical laminectomy and lateral mass screw fixation (PCLF) surgery. OVERVIEW OF LITERATURE: The safety and possible benefits of implementing rigid cervical collars subsequent to PCLF are insufficiently investigated. METHODS: Patients who underwent PCLF and received postoperative cervical collars from 2018 to 2020 were included in this retrospective cohort study. Their data were compared with an age- and sex-matched group of subjects who did not receive collars after PCLF during the same period. Pain intensity (using the Visual Analog Scale), Neck Disability Index, and quality of life (using 36-item Short Form Health Survey) of the patients were compared at baseline, 1, 3, 6, and 12 months postoperatively. RESULTS: A total of 36 patients who received cervical collars after surgery and 40 controls were included. At baseline and 1-month follow-up, there were no differences in pain intensity, functional status, and quality of life between the groups. However, at 3 months postoperatively, the quality of life of the subjects with no orthosis was higher than those who received cervical collars (p =0.01). At 6- and 12-month follow-up, there were no differences between the groups in pain intensity, functional status, and quality of life. CONCLUSIONS: No difference in the pain intensity and functional status of patients who used cervical collars and controls was shown in our study. Patients who did not wear cervical collars had a higher quality of life during the 3-month postoperative evaluation. Future prospective, well-controlled studies with longer follow-ups are needed to further investigate the effects of cervical orthosis on the clinical outcome of patients after PCLF.

Clinicoradiological Outcomes and Complication Profiles of Bilateral Dual Sacral-Alar-Iliac Screws versus Bilateral Single Sacral-Alar-Iliac Screws in Patients with Spinal Deformity Who Underwent Grade 3 or 4 Spinal Osteotomies: A Retrospective Comparative Study.

OBJECTIVE: To compare short-term clinical and radiological outcomes and complication profiles between bilateral dual sacral-2-alar-iliac (S2AI) screw and bilateral single S2AI screw fixation techniques in patients who underwent grade 3 or 4 spinal osteotomies. METHODS: A retrospective review of 83 patients treated with bilateral dual S2AI screws and 32 patients treated with bilateral single S2AI screws was conducted between 2018 and 2020 with a minimum 1-year follow-up. Clinical and radiological outcomes of patients and incidence of perioperative complications, including rod breakage, screw dislodgment, proximal junctional kyphosis, proximal junctional failure, need for reoperation, and systemic adverse effects, were collected and statistically compared between the groups. RESULTS: With a mean follow-up of 18.2 months, rod fracture (6.0% vs. 18.7%, P = 0.03), screw dislodgment (0 vs. 12.5%, P < 0.01), and S2AI screw loosening (1.2% vs. 18.7%, P < 0.01) were significantly lower in the dual S2AI screws group than in the single S2AI screws group. However, the reoperation rate was similar between the 2 groups (24.1% vs. 34.3%, P = 0.26). No significant differences in clinical and radiological outcomes as well as proximal junctional kyphosis (10.8% vs. 18.7%, P = 0.25) and proximal junctional failure (9.6% vs. 18.7%, P = 0.18) were identified between the 2 groups. CONCLUSIONS: The dual S2AI screw fixation technique showed more advantages over the single S2AI screw fixation technique with reduced incidence of screw dislodgment, rod fractures, and sacral-alar-iliac screw loosening.

Effect of Topical Administration of Tranexamic Acid on Intraoperative and Postoperative Blood Loss during Posterior Cervical Laminectomy and Fusion Surgery: A Retrospective Study.

AIM: To assess the role of topical administration of tranexamic acid (TXA) on intraoperative and postoperative blood loss of patients undergoing posterior cervical laminectomy and lateral mass screw ?xation (PCLF) compared to a control group. MATERIAL AND METHODS: The data of 88 patients that underwent PCLF surgery, including 41 females and 47 males, were included in this retrospective study. Data elements including intraoperative blood loss (IBL), postoperative blood loss (PBL), amount of blood transfusion, surgical time, use of hemostatic agents, length of hospital stay, and time to return to work were extracted from medical records and compared between those who received topical TXA during surgery (irrigation of the surgical field with a solution of 3 g TXA in 100 ml normal saline) and an age- and sex-matched control group. RESULTS: There were 48 patients in the TXA group and 40 patients in the control group. There were no significant differences in the baseline measurements and the level of operation between the two groups. The results showed that IBL and PBL were significantly lower in the TXA group compared to the control group (p=0.03 and p < 0.01, respectively). There were no significant differences in the need for blood transfusion, surgical time, and hospital stay between the two groups (p > 0.05). Moreover, the use of hemostatic materials during surgery and the time to return to work were significantly lower in the topical TXA group (p=0.04 and p < 0.01, respectively). CONCLUSION: Topical TXA efficiently reduces intraoperative and postoperative bleeding in patients undergoing posterior cervical laminectomy and PCLF surgery. These results need further investigation in future studies to draw a definite conclusion.

The role of cross-link augmentation on fusion rate and patient satisfaction among patients with traumatic thoracolumbar spinal fracture: A randomized clinical trial.

INTRODUCTION AND OBJECTIVES: Most of the studies evaluating the effect of cross links on spinal stability are performed in vitro on porcine or human spine segments and there is limited data regarding clinical benefits of cross link augmentation in traumatic injuries. In this study we aimed to evaluate the effects of cross-links insertion between rods on the fusion rates and post-surgical patients' satisfaction among patients with traumatic thoracolumbar fractures who underwent posterior spinal fixation with pedicle screws. MATERIALS AND METHODS: This study was conducted as a randomized clinical trial on 60 patients suffering from traumatic thoracolumbar vertebrae fractures. Patients were randomized into three groups: A (without any cross-link), B (One cross-link insertion) and C (two cross-links insertion). Six months after surgery outcomes were evaluated: fusion rates (plain X-ray and CT scan), Back pain (Visual Analog Scale) and patient satisfaction (fair, good, excellent). RESULTS: In group A 13 (65%) patients had structured bone fusion, but in 7 (35%) patients bone fusion was not observed. In both groups B and C, 19 patients (95%) had bone fusion, but only in 1 patient (5%) fusion failed (p=0.009). In group A, fair satisfaction has the highest rate (8 patients (40%)) compared to the other groups. The highest reported severity of back pain was observed in group A while the lowest reported intensity of back pain was related to group B (p=0.001). CONCLUSIONS: Adding cross link to posterior spinal fixations of patients with traumatic thoracolumbar fractures can be associated with better final fusion results and patients' satisfaction. However it is necessary to design studies with greater sample sizes to confirm this theory. TRIAL REGISTRATION NUMBER: IRCT20120527009878N3.

The Effect of Topical Tranexamic Acid on Intraoperative Blood Loss in Patients Undergoing Posterior Lumbar Laminectomy and Discectomy: A Randomized, Double-Blind, Controlled Trial Study.

STUDY DESIGN: Randomized, double-blind, controlled trial study. PURPOSE: This study aimed to evaluate the safety and efficacy of topical tranexamic acid (TXA) on intraoperative blood loss (IBL) in patients that have degenerative lumbar canal stenosis and undergo posterior lumbar laminectomy and discectomy. OVERVIEW OF LITERATURE: The volume of IBL is directly proportional to potential surgical complications. Recent reports have shown that the topical use of antifibrinolytic drugs, such as TXA, during surgery might decrease IBL and improve patient outcomes. METHODS: A total of 104 patients with lumbar canal stenosis were enrolled in this randomized, double blinded clinical trial. Participants were randomized and divided into two groups: TXA (54 cases) and control (50 cases). In the TXA group, a TXA solution was used for washing and soaking, whereas, in the control group, irrigation of wound was with normal saline. IBL, pre- and postoperative coagulative studies, operation time, conventional hemostatic agent usage, systemic complications, and length of hospitalization were consecutively recorded. All participants were followed for an additional two months to gather data on their recovery status and time to return to work (RTW). RESULTS: At baseline, there was no difference in clinical or lab findings, between the groups. IBL and use of hemostatic agents were significantly decreased in TXA group, as compared to the control group (p=0.001 and p=0.011, respectively). Systemic complications, length of hospitalization, and RTW were not significantly different between groups (p=0.47, p=0.38, and p=0.08, respectively). CONCLUSIONS: This study showed that topical use of TXA during surgery may decrease IBL and minimize the use of hemostatic materials during posterior midline-approach laminectomy and discectomy, without increasing the potential for complications seen with intravenous TXA usage.

Role of Percutaneous Laser Disc Decompression in Patients with Lumbar Disc Herniation on Pain Relief: A Quasi-Experimental Pilot Study:.

Background: Disc herniation is broadly defined as a localized or focal displacement of disc material beyond the limits of the intervertebral disc space. The disc material may be the nucleus, cartilage, fragmented apophyseal bone, annular tissue, or any combination thereof. Laser surgery is one of the treatment modalities for treating patients with lumbar disc herniation. This study aims to examine the effect of Percutaneous Laser Disc Decompression (PLDD) in patients with lumbar disc herniation. Materials and Methods: This study was conducted on 58 patients who underwent PLDD (optical fiber inserted through an 18G needle, 8 joules, and 8 watts). Individuals were monitored before and after treatment using the comparing visual analog scale (VAS) pain score (from 0 [no pain] to 10 [severe pain]). Results: The mean age of participants was 63.19±13.48 years. Regarding gender, 24 patients (41.4%) were female. The mean VAS score before surgery was 8.73±1.29, and VAS score after surgery was 55.2±2.71, which means pain was significantly reduced (P0.001). Conclusion: The patients' post-PLDD pain may decrease; hence, PLDD can use as an appropriate method for treating lumbar disc herniation.

The role of cross-link augmentation on fusion rate and patient satisfaction among patients with traumatic thoracolumbar spinal fracture: A randomized clinical trial.

INTRODUCTION AND OBJECTIVES: Most of the studies evaluating the effect of cross links on spinal stability are performed in vitro on porcine or human spine segments and there is limited data regarding clinical benefits of cross link augmentation in traumatic injuries. In this study we aimed to evaluate the effects of cross-links insertion between rods on the fusion rates and post-surgical patients' satisfaction among patients with traumatic thoracolumbar fractures who underwent posterior spinal fixation with pedicle screws. MATERIALS AND METHODS: This study was conducted as a randomized clinical trial on 60 patients suffering from traumatic thoracolumbar vertebrae fractures. Patients were randomized into three groups: A (without any cross-link), B (One cross-link insertion) and C (two cross-links insertion). Six months after surgery outcomes were evaluated: fusion rates (plain X-ray and CT scan), Back pain (Visual Analog Scale) and patient satisfaction (fair, good, excellent). RESULTS: In group A 13 (65%) patients had structured bone fusion, but in 7 (35%) patients bone fusion was not observed. In both groups B and C, 19 patients (95%) had bone fusion, but only in 1 patient (5%) fusion failed (p=0.009). In group A, fair satisfaction has the highest rate (8 patients (40%)) compared to the other groups. The highest reported severity of back pain was observed in group A while the lowest reported intensity of back pain was related to group B (p=0.001). CONCLUSIONS: Adding cross link to posterior spinal fixations of patients with traumatic thoracolumbar fractures can be associated with better final fusion results and patients' satisfaction. However it is necessary to design studies with greater sample sizes to confirm this theory. TRIAL REGISTRATION NUMBER: IRCT20120527009878N3.

The Impact of Single-Level Anterior Cervical Discectomy and Fusion on Cervical Sagittal Parameters and Its Correlation With Pain and Functional Outcome of Patients With Neck Pain.

BACKGROUND: This study examines the changes in segmental and global cervical sagittal parameters after single-level anterior cervical discectomy and fusion (ACDF) in patients with cervical radiculopathy or myelopathy. We also investigate whether these changes have any relation with postoperative pain and functional outcome of the patients. METHODS: Sixty patients (37 females and 23 males) with a mean age of 45.9 ± 9.5 years who were candidates of single-level ACDF due to cervical myelopathy or radiculopathy participated in the study. At baseline, 1 month, and 6 months after ACDF, outcomes of the study including sagittal balance parameters, pain intensity, and Neck Disability Index (NDI) were measured among the patients. Intensity of pain and neck disability were measured using the visual analog scale (VAS) and validated version of NDI, respectively. Using a standard lateral cervical radiography, the Cobb angle for occiput-C2, C1-C2, and C2-C7 as well as operation-level angle (OA; Cobb's angle at the level of discopathy), the thoracic inlet angle, and C7 and T1 slope angles were measured. RESULTS: The intensity of pain and neck disability of patients improved significantly during the follow up of the study comparing with baseline measurements (P < .001). There was a significant correlation between the increase of C2-C7 angle, C1-C2 angle, and OA and improvement in neck pain and NDI at 1- and 6-month follow ups. CONCLUSIONS: We found that changes at C2-C7 angle, C1-C2 angle, and OA have positive significant correlation with clinical outcome including pain improvement and decrease of disability in patients who undergo ACDF. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: The results of this study might be beneficial in selection of cervical cages with appropriate size during ACDF surgery, as our findinds showed that larger cages could lead to better functional outcome in patients.

National Guidelines for Cognitive Assessment and Rehabilitation of Iranian Traumatic Brain Injury Patients.

BACKGROUND: Individuals with moderate to severe traumatic brain injury (TBI) often have prolonged cognitive impairments, resulting in long-term problems with their real-life activities. Given the urgent need for evidence-based recommendations for neuropsychological management of Iranian TBI patients, the current work aimed to adapt eligible international guidelines for cognitive assessment and rehabilitation of the TBI patients in Iran. METHODS: The project was led by an executive committee, under the supervision of the Iranian Ministry of Health and Medical Education (MOHME). Following a systematic literature search and selection process, four guidelines were included for adaptation. Clinical recommendations of the source guidelines were tabulated as possible clinical scenarios for 90 PICO clinical questions covering all relevant phases of care. After summing up the scenarios, our initial list of recommendations was drafted according to the Iranian patients' conditions. The final decision-making, with the contribution of a national interdisciplinary panel of 37 experts from across the country, was conducted in two rounds using online and offline survey forms (Round 1), and face-to-face and telephone meetings (Round 2). RESULTS: A total of 63 recommendations in six sections were included in the final list of recommendations, among which 24 were considered as key recommendations. In addition, some of the recommendations were identified as fundamental, meaning that proper implementation of the other recommendations is largely dependent on their implementation. CONCLUSION: Iranian health policy makers and rehabilitation program managers are recommended to address some fundamental issues to provide the necessary infrastructure to set up an efficient cognitive rehabilitation service system.

Adaptation of Traumatic Brain Injury Guidelines in Iran.

CONTEXT: The National institute for health and care excellence (NICE) and scottish intercollegiate guidelines network (SIGN) are two well-known sources of clinical guideline development. In the past years, they have developed clinical guidelines for the management of head injury. In this report, we will highlight our modifications to these guidelines according to the domestic situation in a developing country. EVIDENCE ACQUISITION: The guidelines were appraised using the appraisal of guidelines for research and evaluation (AGREE) instrument. All key recommendations were reviewed by 14 prominent Iranian neurosurgeons; levels of evidence were evaluated and items with limited evidence were determined. Available evidence for selected items were reviewed and discussed. RESULTS: The following items were the most challenging when accounting for the domestic situation in Iran: age as a risk factor for referral, computed tomography scan, the impact of medical comorbidities, pregnancy, consultation, referral to a neurosurgical unit, and teleconsulting and observation before discharge. CONCLUSIONS: The evidence in the discussed topics was limited and controversial. This report is important because it exposes the current knowledge gap in head trauma studies in Iran.

Frequency of Vertebral Endplate Modic Changes in Patients with Unstable Lumbar Spine and Its Effect on Surgical Outcome.

STUDY DESIGN: Prospective cohort study. PURPOSE: In this study, we investigated the frequency of vertebral endplate Modic changes (MCs) and their effects on surgical outcomes in patients with unstable lumbar spines. OVERVIEW OF LITERATURE: Signal changes in endplates have been classified into three types by Modic. The prognostic role of MCs has been investigated in various spinal disorders. METHODS: A series of 70 patients with clinical and radiographic unstable lumbar spine were included in the study. Endplate signal intensity was determined according to Modic classification. All patients underwent instrumented posterolateral fusion. Functional evaluation was made using the visual analog scale (VAS) and Oswestry disability index (ODI). RESULTS: Eighteen patients (26%) had normal endplate intensity, 31 patients (44%) had MC type I, 20 patients (28%) had MC type II, and one patient (1.4%) had MC type III. Pain level VAS and ODI decreased significantly from the preoperative evaluation to the six-month and one-year postoperative evaluations. The surgical outcome (VAS and ODI) was not significantly different between the various types of MC. CONCLUSIONS: Posterolateral fusion is an effective treatment in patients with unstable lumbar spines. MC do not have a significant effect on the surgical outcome of these patients.

Accuracy of magnetic resonance spectroscopy in distinction between radiation necrosis and recurrence of brain tumors.

BACKGROUND: Distinction between radiation necrosis and recurrence of intraparenchymal tumors is necessary to select the appropriate treatment, but it is often difficult based on imaging features alone. We developed an algorithm for analyzing magnetic resonance spectroscopy (MRS) findings and studied its accuracy in differentiation between radiation necrosis and tumor recurrence. METHODS: Thirty-three patients with a history of intraparenchymal brain tumor resection and radiotherapy, which had developed new enhancing lesion were evaluated by MRS and subsequently underwent reoperation. Lesions with Choline (Cho)/N-acetyl aspartate (NAA) > 1.8 or Cho/Lipid > 1 were considered as tumor recurrence and the remaining as radiation necrosis. Finally, pre-perative MRS diagnoses were compared with histopathological report. RESULTS: The histological diagnosis was recurrence in 25 patients and necrosis in 8 patients. Mean Cho/NAA in recurrent tumors was 2.72, but it was 1.46 in radiation necrosis (P < 0.01). Furthermore, Cho/Lipid was significantly higher in recurrent tumors (P < 0.01) with the mean of 2.78 in recurrent tumors and 0.6 in radiation necrosis. Sensitivity, specificity, and diagnostic accuracy of the algorithm for detecting tumor recurrence were 84%, 75% and 81%, respectively. CONCLUSION: MRS is a safe and informative tool for differentiating between tumor recurrence and radiation necrosis.

Pial arteriovenous fistula with giant varices: report of two cases with good surgical outcome.

Pial arteriovenous fistulas (pAVF) are rare vascular lesions consisting of one or more arterial connections to a single venous channel without any intervening nidus of vessels or capillaries. Case 1: A 65-year-old woman with a complaint of headache and left hand paresthesia was referred to us. Magnetic resonance imaging showed a large saccular lesion with signal void in the posterior part of the right sylvian fissure and catheter angiography showed a giant venous aneurysm fed by one branch of the middle cerebral artery (MCA) and draining into the vein of Trolard. Case 2: A 12-year-old boy was transferred to our hospital with a history of sudden loss of consciousness and hemiplegia. Brain computed tomography revealed a massive hemorrhagic mass in the right hemisphere and cerebral angiography showed a pAVF with a large aneurysmal varix, which was fed by multiple branches of the right MCA and draining into the superior sagittal sinus. Both patients underwent craniotomy and after ligation of vascular connections, aneurysmal varices were removed completely. Surgical resection can be a safe method for treatment of pAVFs, particularly in those with large varices.

Intramedullary spinal cord metastasis from endometrioid adenocarcinoma.

Intramedullary spinal cord metastases are rare .The majority of these metastases reportedly spread from lung cancer in the cervical region; however, they have been seen to arise from a variety of other primary sources. Here, we report what is, to the best of our knowledge, the first known case of an intramedullary spinal cord metastatic lesion in the conus region arising from primary endometrioid adenocarcinoma.