Safety and feasibility of autologous olfactory ensheathing cell and bone marrow mesenchymal stem cell co-transplantation in chronic human spinal cord injury: a clinical trial.

STUDY DESIGN: This is a phase I clinical trial. OBJECTIVES: Our objective was to assess the safety and feasibility of autologous mucosal olfactory ensheathing cell (OEC) and bone marrow mesenchymal stem cell (MSC) co-transplantation in people with chronic, complete (American Spinal Injury Association (ASIA) Impairment Scale (AIS) classification A) spinal cord injury (SCI). SETTING: This study was performed at Shohada Tajrish Hospital, Tehran, Iran. METHODS: Three individuals with the traumatic SCI of the thoracic level were enrolled. They received the autologous OEC and MSC combination through the lumbar puncture. All adverse events and possible functional outcomes were documented performing pre- and post-operative general clinical examination, magnetic resonance imaging (MRI), neurological assessment based on the International Standard of Neurological Classification for SCI, and functional evaluation using Spinal Cord Independence Measure version III (SCIM III). RESULTS: No serious safety issue was recorded during the 2 years of follow-up. MRI findings remained unchanged with no neoplastic tissue formation. AIS improved from A to B in one of the participants. SCIM III evaluation also showed some degrees of progress in this participant's functional ability. The two other research participants had negligible or no improvement in their sensory scores without any changes in the AIS and SCIM III scores. No motor recovery was observed in any of the participants. CONCLUSIONS: Overall, this 2-year trial was not associated with any adverse findings, which may suggest the safety of autologous OEC and bone marrow MSC combination for the treatment of human SCI.

Deep brain nucleus targeting in Parkinson's disease and essential tremor by image guided surgery using neuronavigation system with tractography and volume of tissue of activated assessment.

OBJECTIVE: Deep Brain Stimulation (DBS) is an effective surgical approach for treatment of Parkinson's disease (PD), dystonia and essential tremor (ET). Traditionally, DBS is performed using frame-based stereotactic technique. Recently, image guided surgery (IGS) using neuronavigation has gained popularity in neurosurgical procedures. We aim to investigate whether DBS using neuronavigation is capable of improving patient's outcome and minimize its complications. SUBJECT AND METHODS: From February 2011 to October 2016, 20 patients with PD and 6 patients with ET were enrolled in the study. Patients aged between 18 to 70 years, were included and they underwent Magnetic Resonance Imaging (MRI) for deep brain nucleus volumetry. Among PD patients, 14 cases underwent subthalamic nucleus (STN) implantation, while other 6 cases underwent globus pallidus internus (GPi) implantation. Furthermore, ventral intermediate nucleus (VIN) implantation was performed for ET patients, all with IGS using neuronavigation system. Patients were assessed by unified Parkinson's disease rating scale (UPDRS) for PD and tremor scores for ET in their follow ups. Authors utilized Butson model for volume of tissue activated (VTA) assessment. In addition, detailed tractography was performed to evaluate white matter circuits radiating from deep nucleuses. RESULTS: PD patients with GPi volume of more than 600mm3 and less than 400mm3 were excluded from the study. Mean right and left GPi volume was 519±94.2mm3 and 480±80.3mm3, respectively. Calculated VTA based on Butson model revealed that 70% of cases who exhibited improved UPDRS of more than 50% in the 7th month of follow-up, had their VTA outside their defined GPi and STN boundaries with outer layer overlap. In contrast, 60% of cases who showed UPDRS improvement of less than 50% in same follow-up month, have their VTA inside defined GPi and STN boundaries. Moreover, ET patients experienced mean 55% and 79% improvement in tremor scores at mean 6.7 and 9.9 follow up month respectively. No surgery related complications were observed. Furthermore, tractography analysis revealed increased superior frontal gyrus and thalamus connection in patients with improved UPDRS. CONCLUSION: IGS using neuronavigation allowed more accurate deep nucleus targeting, minimized intra- and post-operative complications and improved clinical outcome in DBS candidate patients. Our study revealed that increased white matter connections with remote parts of the brain would suggest that isolated deep nucleus stimulation could not explain symptom recovery and that patients' specific white matter stimulation by tractography coupled with IGS should be in priority.

Psychological consideration in patients with cerebral gliomas candidates for intra-operative radiation therapy based on tumor location.

OBJECTIVE: Intra-operative Radiation Therapy (IORT) is gaining popularity as an adjuvant option to surgical resection, in treatment of glioblastoma multiforme (GBM) for increasing survival rate, which a highly aggressive cerebral tumor with poor prognosis. Τhe authors plan to investigate the effects of IORT combined with surgical resection on the psychological status of these patients based on tumor location. SUBJECT AND METHODS: From December 2013 to February 2017, we have enrolled 109 patients with high grade cerebral gliomas, documented by Magnetic Resonance Spectroscopy (MRS). Patients with previous history of brain surgery or radiation, altered mental status and psychological content and patients diagnosed with metastases were excluded. Demographic data, tumor volume based on pre-operative Magnetic Resonance Imaging (MRI) and psychological status were recorded based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. The remaining 56 patients, were equally randomized into conventional (surgical resection-group A), and trial (surgical resection with IORT-group B) who underwent IORT using the 50kV INTRABEAM® system (Carl Zeiss Meditec AG, Germany). Psychological profiles of both groups were re-evaluated in the 3rd post-operative month. RESULTS: Group A consisted of 18 males and 10 females with mean age of 54.4 years, while group B consisted of 16 males and 12 females with mean age of 57.8 years. Tumor volumetry revealed mean 81.52cc and 82.8cc for group A and B respectively. (P value 0.14) Patients were classified based on glioma location on pre-operative MRI: a) left parietal lobe (6 in group A, 5 in group B); b) left temporal lobe (7 in group A, 5 in group B); c) right parietal lobe (5 in group A, 6 in group B); d) left fronto-temporal lobe (4 in group A, 6 in group B); e) left parieto-temporal lobe (4 in group A, 5 in group B); and, f) right frontal lobe (2 in group A, 1 in group B). Group B received mean 8.05 Gy radiation for mean 11.2 minutes. Post-operative psychological in the 3rd month evaluation revealed the following in each class: a) Group A: 1 mild depression, Group B: 1 mild depression and 2 major depression; b) Group A: no disorder, Group B: 1 mild depression; c) no disorders in both groups; d) Group A: no disorder, Group B: 1 mild depression, 1 major depression and 1 Obsessive-Compulsive Disorder (OCD); Conclusion: Utilization of IORT is shown to improve survival rate of patients suffering from GBM. However, the psychological status is a major determinating factor for the quality of life of these patients. Our study showed that IORT increased psychological disorders in patients with gliomas located in left parietal, left fronto-temporal and left parieto-temporal lobes and should be considered in pre-operative strategy selection.

Psychological aspects in brain tumor patients: A prospective study.

OBJECTIVE: Very few studies have utilized specific criteria to assess mental disorders in brain tumor patients, and from them, they are mainly descriptive. The purpose of this study is to examine mental disorders in relation to tumor characteristics and patients' psychosocial factors using DSM-IV (depression, sleep and mood) criteria, among brain tumor patients. MATERIALS AND METHODS: From March 2009 to July 2011, 98 patients who surgically treated with intracranial neoplasm were included in this prospective study. The mean age of the patient group was 42.2 years with a range of 18-60 years with a male to female ratio of 1.2. The most common tumor type was glioblastoma multiform (30.3%), followed by meningioma (16.8%) and anaplastic glioma (12.3%). RESULTS: In our study, the prevalence of mild depression was about 30% for males and 38% for females before surgery; however at 3 months after surgery, this amount decreased to the amount of 25.6% and 26% for male and female patients respectively. Before tumor operation, the prevalence of major depression was 10.4% for males and 19.7% for females. At 3 months after operation the prevalence of major depression was 12.8% for males, and 6.7% for females. Aggression or suicide attempts were not seen related to depression. Before operative intervention, severe anxiousness as well as severe Obsessive Compulsive Disorder (OCD) symptoms was present in 14.7% of males while at 3 months after operation, prevalence of severe anxiousness and severe OCD symptoms decreased to 4% and 9.3% respectively. In females, 28.7% of the subjects had reported to have severe anxiousness and 25.6% severe OCD symptoms. Three months after surgery, these amounts were 17.6% and 38.7% respectively. CONCLUSION: Depressive symptoms as well as anxious and OCD psychopathology were shown to be prevalent signs among patients with brain tumor. Diagnosis of the previous mentioned symptoms were totally based on DSM-IV criteria and these disorders and the percentiles don't seem to be related to each other. Due to high variability of tumor stages, statistical analysis of whether the mentioned psychiatric symptoms get worsen at the later stages of the tumor genesis was not feasible. Although not measured directly, mentioned psychiatric symptoms seem to get worsen at the later stages of the brain tumor. The associated factors are tumor location, patient's premorbid psychiatric status, cognitive symptoms and adaptive or maladaptive response to stress.

Radioguided surgery using gamma detection probe technology for resection of cerebral glioma.

OBJECTIVE: Using microsurgical procedures without intraoperative imaging, Gross Total Resection (GTR) has so far only been achieved in less than 30% of all cases. Radio-guided surgery was introduced in the clinical setting in 1985 in an attempt to facilitate intraoperative tumor detection. Because of few studies in literature about this subject, we decided to use gamma probe with the hypothesis that we could increase extent of tumor resection. MATERIALS AND METHODS: From January 2013 till February 2014, 22 patients with cerebral glioma were randomized equally into two groups and evaluated. In the first group, 370MBq of Technetiumc-99m was injected. The microsurgical resection of the tumor was performed as much as possible, and then the tumoral bed was examined, if the signal was more than 2 times of the background signal, more tissue resection performed if feasible until the signal was diminished. In the control group, conventional resection of the tumor was performed. The extent of tumor resection was assessed by contrast magnetic resonance imaging (MRI) study. RESULTS: Before surgery the patients in the first group had average tumor volume of 81.68±9.78. In the second group the average tumor volume before surgery was 82.63±10.06cc. There is no significant difference between preoperative tumor volumes in two groups. In the first group, in the post-operative MRI, the tumor volume was 5.04±2.69cc and in the second group it was 9.5±4.8cc. Eight patients (72.7%) in the radioguided group experienced radical resection (more than 95%), but in the control group radical resection was achieved in just 3 patients (27.2%), radical resection was significantly higher in radioguided group (P<0.001). Due to the usage of the gamma detection probe, time of finding the tumor in the radioguided group was significantly less than control group (P=0.02). However total operation time in the radioguided group, was not significantly more than the control group (P=0.88). CONCLUSIONS: Neuronavigation system increases the percentage of gross total resection, but it is expensive, increases duration of surgery is not considered a real-time assessment, and is not accurate in determining the borders of glioma due to brain shift. In contrast, radio-guided surgery is easy to use, real time, not expensive, and increases the extent of tumor resection.

Features and functions of decision support systems for appropriate diagnostic imaging: a scoping review.

BACKGROUND: Diagnostic imaging decision support (DI-DS) systems could be effective tools for reducing inappropriate diagnostic imaging examinations. Since effective design and evaluation of these systems requires in-depth understanding of their features and functions, the present study aims to map the existing literature on DI-DS systems to identify features and functions of these systems. METHODS: The search was performed using Scopus, Embase, PubMed, Web of Science, and Cochrane Central Registry of Controlled Trials (CENTRAL) and was limited to 2000 to 2021. Analytical studies, descriptive studies, reviews and book chapters that explicitly addressed the functions or features of DI-DS systems were included. RESULTS: A total of 6,046 studies were identified. Out of these, 55 studies met the inclusion criteria. From these, 22 functions and 22 features were identified. Some of the identified features were: visibility, content chunking/grouping, deployed as a multidisciplinary program, clinically valid and relevant feedback, embedding current evidence, and targeted recommendations. And, some of the identified functions were: displaying an appropriateness score, recommending alternative or more appropriate imaging examination(s), providing recommendations for next diagnostic steps, and providing safety alerts. CONCLUSIONS: The set of features and functions obtained in the present study can provide a basis for developing well-designed DI-DS systems, which could help to improve adherence to diagnostic imaging guidelines, minimize unnecessary costs, and improve the outcome of care through appropriate diagnosis and on-time care delivery.

Factors predicting early deterioration in mild brain trauma: a prospective study.

PRIMARY OBJECTIVE: To evaluate risk factors for clinical deterioration in mild traumatic brain injury. RESEARCH DESIGN: Prospective cross-sectional. METHODS AND PROCEDURES: This study evaluated 203 patients with mild traumatic brain injury. A brain computed tomography scan was performed in all patients and they were observed for 6-48 hours. MAIN OUTCOMES AND RESULTS: Among these patients, 2.5% had cerebral contusions and the most common sites for contusions were frontal lobes; 94% of patients had no hematoma in the initial scan, while 3% had subgaleal haematoma, 1.5% had subdural haematoma, 1% showed subarachnoid haemorrhage, 0.5% intracerebral haemorrhage and 0.5% epidural haemorrhage. GCS was 15 in 96.6% and 13-14 in 3.4%. GCS deteriorated in three (1.5%). Presence of coagulopathy, anticoagulant drug use, GCS of 13-14 and increased age predicted further deterioration. Among CT findings, those with midline shift, cerebral contusion and diffuse cerebral oedema deteriorated more. Among different haematoma types, only SDH predicted a worse outcome. CONCLUSIONS: Although deterioration rarely occurs in patients with mild brain injury, those with coagulopathy, anticoagulant drug use, GCS of 13-14, increased age, midline shift, cerebral contusions, diffuse cerebral oedema and SDH were more prone to deterioration.

Asymptomatic presentation of huge extradural hematoma in a patient with arachnoid cyst.

Haemorrhagic complications of arachnoid cysts have been reported as subdural or intracystic hematoma following trauma. In this paper, we report a patient with arachnoid cyst who developed extradural hematoma after a subtle head injury and presented with very mild symptoms in spite of the huge size of the hematoma.

Descriptive Epidemiology of Brain and Central Nervous System Tumours: Results from Iran National Cancer Registry, 2010-2014.

BACKGROUND: Central nervous system (CNS) tumours account for only 1-2% of cancer incidence but are a major reason for mortality and morbidity due to malignancies. Recent studies show an increase in the rate of CNS tumours worldwide, especially in developing countries. Moreover, there is significant heterogeneity in epidemiological patterns worldwide. This study is aimed at representing nationwide epidemiology of CNS tumours in Iran. METHODS: Iran National Cancer Registry 2010-2014 data were reviewed for CNS tumours. The epidemiological rates were calculated for both genders and all age groups using the 2011 census information. RESULTS: Out of 17345 cases, 58.5% were men and 41.5% were women. The mean age was 45.55 years ranging from less than 1 month to 100 years old. Average total age-standardized incidence rate (ASR) was 5.19 for primary tumours. The annual percent change (APC) was 14.23% during the study period. The most frequent site and histology recorded were brain, NOS and diffuse astrocytic, respectively. Geographical distribution showed about five-fold difference in ASRs between different provinces. CONCLUSION: The overall ASR calculated was higher than the global rate in 2012 but lower than that of most developed countries, showing an increasing trend which may be due to either advances in diagnosing or risk factor augmentation. The mean age and incident rates were higher than those of previous reports in Iran.

Evaluating the effect of hydrocephalus cause on the manner of changes in the effective parameters and clinical symptoms of the disease.

In the present study, the heads of 11 normal subjects and 21 patients affected by hydrocephalus due to three different causes were simulated using fluid-structure interaction (FSI). To validate the results, the calculated diagram of CSF velocity in aqueduct of Sylvius (AS) was compared with the similar velocity diagram measured using Cine PC-MRI for the same subject. After ensuring the agreement of results, other outputs such as CSF pressure were calculated non-invasively using FSI. The intracranial pressure and CSF pressure in AS and behind the optic nerve sheath were in patients 5-5.3 times the value in normal subjects and the ventricular system volume in patients was 10.2-11.1 times the value in normal subjects. However, the difference between the coefficient of variation and the maximum value of pressure and volume in different types of hydrocephalus was small. Furthermore, the difference between CSF stroke volumes in various types of hydrocephalus patients was less than 4.4%. Results showed that the intensity of clinical symptoms was similar in patients with similar CSF pressure and the cause of the hydrocephalus disease didn't have any significant effect on the intensity of patients' clinical symptoms and the manner of changes in effective parameters on disease. It was also found that the relation of CSF pressure and volume was 16.7% greater in patients with non-communicating hydrocephalus than in patients with communicating hydrocephalus. These results enhance the insight into hydrocephalus bio-mechanism and can help to choose the proper treatment method for hydrocephalus patients.

The role of tranexamic acid in prevention of hemorrhage in major spinal surgeries.

BACKGROUND: Blood loss that necessitates blood transfusion is one of the most frequent complications of major spinal surgeries. This study has been designed to evaluate the efficacy and safety of prophylactic tranexamic acid (TA) in decreasing perioperative blood loss. MATERIALS AND METHODS: From January to August 2011, all the patients who needed major spinal surgeries and aged between 18 and 60-year-old were divided into two groups randomly, the experimental group received 10 mg/kg of TA 20 min after inducing the anesthesia as loading dose followed by 0.5 mg/kg/h until skin closure and the control group received equal amounts of normal saline as placebo. Intraoperative blood loss was recorded by estimating blood with the suction tube plus the number of bloody gasses. The amounts compared between the 2 groups and analyzed. RESULTS: Forty patients were enrolled in this study in the first group intraoperative, the 1st and 2nd postoperative days, the mean blood loss were 574 ml, 80.5 ml, and 669.5 ml while in the second group were 797 ml, 124 ml, and 921.5 ml. CONCLUSION: TA seems to be safe and can be considered in spinal surgeries with significant excepted blood loss especially in female patients and instrumental procedures. We suggest further studies on TAs efficacy and safety in larger scales.

Neural differentiation of choroid plexus epithelial cells: role of human traumatic cerebrospinal fluid.

As the key producer of cerebrospinal fluid (CSF), the choroid plexus (CP) provides a unique protective system in the central nervous system. CSF components are not invariable and they can change based on the pathological conditions of the central nervous system. The purpose of the present study was to assess the effects of non-traumatic and traumatic CSF on the differentiation of multipotent stem-like cells of CP into the neural and/or glial cells. CP epithelial cells were isolated from adult male rats and treated with human non-traumatic and traumatic CSF. Alterations in mRNA expression of Nestin and microtubule-associated protein (MAP2), as the specific markers of neurogenesis, and astrocyte marker glial fibrillary acidic protein (GFAP) in cultured CP epithelial cells were evaluated using quantitative real-time PCR. The data revealed that treatment with CSF (non-traumatic and traumatic) led to increase in mRNA expression levels of MAP2 and GFAP. Moreover, the expression of Nestin decreased in CP epithelial cells treated with non-traumatic CSF, while treatment with traumatic CSF significantly increased its mRNA level compared to the cells cultured only in DMEM/F12 as control. It seems that CP epithelial cells contain multipotent stem-like cells which are inducible under pathological conditions including exposure to traumatic CSF because of its compositions.

First Experience of Intraoperative Radiation Therapy in Cerebral High Grade Glioma in Iran: A Report of Three Cases and Literature Review.

INTRODUCTION: Among the high grade cerebral gliomas, Glioblastoma multiform for instance, would be the main pattern of local recurrence causes clinical deterioration and deaths. This has observed 2 - 3 cm upon the initial lesion. During the period of 2 - 4 weeks post-surgery, remaining tumor cells have re-grown until radiochemotherapy has initiated. So it has seemed clear that improved local control could hopefully translate into improved survival. As a matter of fact, mass reduction has insufficiently achieved in almost every case of GBM as that the tumor cell number has not fallen below a "threshold" that tumor control might achieve by the host immune system. Intraoperative Radiation therapy has been one of those add-on therapies, which has performed during or directly after resection and cleared the tumor cavity from microscopically remaining cells. Although IORT has presented a novel and feasible principle, the method faced a number of technical and geometrical errors and limitations, which has decreased its potential in the reports of previous studies. Examples could be mentioned as incomplete target volume coverage that seemed as the greatest influence on survival, due to irradiation with an inadequate electron cone size, due to angle errors, or inadequately low energies. In contrast to the previously used forward-beaming electron cones, spherical irradiation sources were specifically attractive in brain tumor IORT, even in post resection cavities with normal complex shapes. CASE PRESENTATION: We have been reporting 3 cases of high grade gliomas, one recurrent GBM, one primary glioma grade III, and the last one recurrent Rhabdoid GBM, which have been fulfilling our entrance criteria of IORT procedure, by using spherical applicators, which has been increasingly discussed in recent studies. CONCLUSIONS: It was the first experience of intraoperative radiation therapy for cerebral malignant tumours in Iran. Finally, we had a brief overview on the past and present IORT strategies in the treatment of GBM.

Effect of Ondansetron on Postoperative Shivering After Craniotomy.

INTRODUCTION: Postoperative shivering (POS) is an early complication after craniotomy. Preventive pharmacologic drugs are the mainstay of treatment. Meperidine is the drug of choice but with increased risk of apnea, nausea, and increased intracranial pressure. Some reports have suggested that ondansetron and meperidine have similar anti-shivering effects. OBJECTIVES: To assess the preventive effect of ondansetron on POS after craniotomy. METHODS: In a randomized, double-blind, placebo-controlled trial, 80 patients with American Society of Anesthesiologists status I to II between 20 and 60 years of age scheduled for elective craniotomy were enrolled in the study. Patients received either intravenous ondansetron 4 mg (n = 40) or saline (n = 40) 10 minutes before the end of surgery. RESULTS: POS was observed in 3 patients (7.5%) in the ondansetron group, significantly lower than in the control group (6 patients [15%]; P =0.048). Ondansetron decreased the relative risk of occurrence of POS after craniotomy from 4.42 (95% confidence interval [CI], 2.3-8.5; P = 0.0021) in the control group to 1.05 (95% CI, 0.76-2.20; P = 0.074). In the ondansetron group, the mean (± standard deviation) core temperature in the preoperative phase (36.6°C ± 0.66°C) was significantly higher than in the postoperative phase (34.2°C ± 0.56°C) (P = 0.001). In addition, the mean (± standard deviation) peripheral temperature in the preoperative phase (36.5°C ± 0.72°C) was significantly higher than in the postoperative phase (34.4°C ± 0.51°C) (P = 0.001). CONCLUSIONS: Ondansetron can effectively decrease POS after craniotomy. This effect is not mediated through maintenance of the core or peripheral temperature. Ondansetron probably acts by a central inhibitory mechanism on POS through 5-hydroxytryptaminergic pathways, not by changing thermoregulatory set points.

Diffusion tensor tractography in the presurgical assessment of cerebral gliomas.

Glioma is the most common intra-axial brain tumor characterized by invasion into the surrounding white matter (WM) tracts. These tumors are usually diagnosed by conventional MRI, but this method is unable to describe the relationship between tumor and neighboring WM tracts. Diffusion tensor tractography (DTT) is a new imaging modality which can solve this problem. The current study evaluated the application of DTT imaging in the presurgical assessment of gliomas, and introduces this new modality and its importance to physicians and imaging centers in Iran. Ten patients with intra-axial brain tumor and suspicion of glioma underwent conventional brain MRI pulse sequences and DTT imaging between December 2011 and February 2013 with a 1.5 Tesla system using 64 independent diffusion encoding directions. Acquired images were assessed by the neuroradiologist and neurosurgeon. The treatment strategies were recognized and compared using data before and after the tractography. On the basis of DTT data, the treatment strategy changed from radiotherapy to the craniotomy in seven patients, and in one patient, the neurosurgeon preferred to avoid surgery. In one patient, the treatment technique did not change, and in the last one radiosurgery was replaced by craniotomy. As we can infer from this study, based on the tractography results, the treatment strategy may be changed, and the treatment technique could be devised more accurately and may lead to fewer postoperative neurological deficits and better outcomes.

Biaxial mechanical properties of human ureter under tension.

PURPOSE: The Mechanical properties of the ureteral wall may be altered by certain diseases such as megaureter. Ureter compliance and wall tension alterations can occur, leading to some abnormalities such as reflex mechanisms. Familiarizing with the mechanical properties of the ureter can help us advance in the understanding of urinary tract diseases. MATERIALS AND METHODS: A constitutive model that can predict the mechanical response of ureteral tissue under complex mechanical loading is required. Parameters characterizing the mechanical behaviour of the material were estimated from planar biaxial test data, where human ureter specimens were simultaneously loaded along the longitudinal and circumferential directions. RESULTS: The biaxial stress-stretch curve was plotted and fitted to a hyperelastic four-parameter Fung type model and five-parameter Mooney-Rivlin model. The average strength in the longitudinal direction was 3.48 ± 0.47 MPa and 2.31 ± 0.46 MPa (P <.05) for the circumferential direction.In the Fung model the value of parameter a2 (0.699 ± 0.17) was higher than a1 (0.279 ± 0.07), which may be due to the collagen fiber orientation's preference along the longitudinal axis. CONCLUSION: According to this study, it seems that ureter tissue is stiffer in the longitudinal than in the circumferential direction and maybe the collagen fiber are along the axial axes. Also the specimens showed some degree of anisotropy.

Accuracy of combined EEG parameters in prediction the depth of anesthesia.

BACKGROUND: The importance of proper qualitative evaluation of EEG parameters during surgery has been recognized since many years. Although none of the characteristics based on the frequency, entropy, and Bi spectral characteristics have been regarded as a good predictor for detection of the depth of anesthesia alone. So it seems necessary to study multiple characteristics together. OBJECTIVES: In this study we tried to introduce the best combination of the mentioned characteristics. MATERIALS AND METHODS: EEG data of 64 patients undergoing general anesthesia with the same anesthesia protocol (total intravenous anesthesia) were recorded in all anesthetic stages in Shohada Tajrish Hospital. Quantitative EEG characteristics are classified into 4 categories: time, frequency, bi spectral and entropy based characteristics. Their sensitivity, specificity and accuracy in determination of the depth of anesthesia are yielded by comparison with recorded reference signal in awake, light anesthesia, deep anesthesia and brain death patients. Then, with combining 2, 3, 4 and 5 of characteristics and using coded algorithm we determined the error degree and introduced the combination yielding the least error. RESULTS: Fifteen vectors (of dimension two to five) which yielded the best results were introduced. Vectors combined of entropy based characteristics obtained 100% specificity and sensitivity during all 4 stages. CONCLUSIONS: The combination entropy based characteristics had high accuracy in predicting the depth of anesthesia. Reevaluation of classic indices cortical status index and BIS seems necessary. The next step is to find a system to simplify the evaluation of this information for technicians.

Comparison of the acute physiology and chronic health evaluation score (APACHE) II with GCS in predicting hospital mortality of neurosurgical intensive care unit patients.

BACKGROUND: The Glasgow Coma Scale (GCS) is popular, simple, and reliable, and provides information about the level of consciousness in trauma patients. However, a systemic evaluation scale specially in patients with multiple trauma is so important. The revised Acute Physiology and Chronic Health Evaluation system type 2 (APACHE II) is a physiologically based system including physiological variables. This study compares the efficacy of the predicting power for mortality and functional outcome of GCS and APACHEII in patients with multiple trauma in intensive care unit. METHODS: This study included the patients with head injury associated with systemic trauma admitted in the ICU of Shahid Rajaee Hospital in 2007 and 2008. Sensitivity, specificity and correct prediction of outcome by GCS and APACHE II were assessed and compared. RESULTS: This study included 93 patients (79 males, 14 females; mean age 60.5; range 14 to 87 years) with head injury associated with systemic trauma in 2007 and 2008. Mortality increased in the elderly group. The mean survival score using APACHE II was 36.5 and death score was 67.4 . These values using GCS were 10.3 and 6.8, respectively. CONCLUSION: For the assessment of mortality, the GCS score still provides simple, less-time consuming and effective information concerning head injury patients, especially in emergencies; however, for the prediction of mortality in patients with multiple trauma. APACHE II is superior to GCS since it includes the main physiologic parameters of patients.

Presentation of a minimally symptomatic large extradural hematoma in a patient with an arachnoid cyst: a case report and review of the literature.

INTRODUCTION: Hemorrhagic complications of arachnoid cysts have been reported, extensively presenting with subdural or intracystic hematoma after trauma, but presentation with extradural hemorrhage is very rare. In this paper, we report the case of a patient with an arachnoid cyst who developed an extradural hematoma after a subtle head injury. Our patient presented with very mild symptoms in spite of the very large size of the hematoma. CASE PRESENTATION: Our patient was a 23-year-old Iranian man who complained of diffuse progressive headache and vomiting after mild head trauma. A brain computerized scan showed a very large extradural hematoma in the left frontotemporoparietal convexity over a large arachnoid cyst. CONCLUSION: Brain parenchyma containing an arachnoid cyst is vulnerable to trauma and increases the risk of serious hemorrhagic complications. We also suggest that the abnormal shape of the head should be considered as an indication for a computerized tomography scan in cases of mild head injury.

Extramedullary hematopoiesis presenting as a compressive cord and cerebral lesion in a patient without a significant hematologic disorder: a case report.

INTRODUCTION: Intracranial or spinal compressive lesions due to extramedullary hematopoiesis have been reported in the medical literature. Most of the reported cases are extradural lesions or, on rare occasions, foci within another neoplasm such as hemangioblastoma, meningioma or pilocytic astrocytoma. Often these cases occur in patients with an underlying hematological disorder such as acute myelogenic leukemia, myelofibrosis, or other myelodysplastic syndromes. Such lesions have also been reported in thalassemia major. CASE PRESENTATION: We report the case of a 43-year-old Iranian woman in whom extramedullary hematopoiesis presented as a compressive cord lesion and then later as an intracranial lesion. CONCLUSIONS: To the best of our knowledge, we document the first reported case of sacral, lumbar, thoracic and cranial involvement in the same patient with extramedullary hematopoiesis, which seems both rare and remarkable.