Atypical Presentation of Idiopathic Intracranial Hypertension: A Case Series and Literature Review.

Idiopathic intracranial hypertension (IIH) is a condition in which intracranial pressure (ICP) increases without an apparent cause. Typically, patients present with headaches, dizziness, pulsatile tinnitus, visual disturbances, blurred vision, diplopia, photophobia, visual field defects, and papilledema on fundoscopy. The association between IIH, spontaneous cerebrospinal fluid (CSF) rhinorrhea, and arachnoid cysts has been discussed in the literature; however, there is no clear explanation for this association. We aimed to present a series of four patients with a confirmed diagnosis of IIH with atypical presentations, discuss the management of each case, and provide an explanation for this association to alert clinicians to the atypical presentation of IIH and facilitate early diagnosis and proper treatment of this condition by CSF diversion. This was a retrospective case series of all patients who were diagnosed with IIH and showed improvement after ventriculoperitoneal shunt insertion after failure of at least one operative intervention resulting from primary radiological and clinical findings in 2001 to 2022. Data on demographics, clinical presentation, radiological findings, surgical management, and diagnostic criteria for IIH were recorded. We identified four patients with a confirmed diagnosis of IIH who presented with atypical presentations as follows: intracranial arachnoid cyst, cervical spine arachnoid cyst, giant Virchow perivascular space, and spontaneous CSF (CSF) rhinorrhea. All patients responded to CSF diversion after failure of surgical treatment targeting the primary pathology. IIH should be suspected after the failure of primary surgical treatment in cases of spontaneous CSF rhinorrhea, spinal and cranial arachnoid cysts, and symptomatic ventriculoperitoneal shunt. Treatment in such situations should be directed toward IIH with CSF diversion.

How frequently MRI modifies thoracolumbar fractures' classification or decision-making? A systematic review and meta-analysis.

PURPOSE: To provide the first meta-analysis of the impact of magnetic resonance imaging (MRI) on thoracolumbar fractures (TLFs) classification and decision-making. METHODS: A systematic review was conducted following PRISMA guidelines. We searched PubMed, Scopus, Cochrane, and Web of Science from inception to June 30, 2023 for studies evaluating the change in TLFs classification and treatment decisions after MRI. The studies extracted key findings, objectives, and patient population. A meta-analysis was performed for the pooled frequency of change in AO fracture classification or treatment decisions from surgical to conservative or vice versa after MRI. RESULTS: This meta-analysis included four studies comprising 554 patients. The pooled frequency of change in TLFs classification was 17% (95% CI 9-31%), and treatment decision was 22% (95% CI 11-40%). An upgrade from type A to type B was reported in 15.7% (95% CI 7.2-30.6%), and downgrading type B to type A in 1.2% (95% CI 0.17-8.3%). A change from conservative to surgery recommendation of 17% (95% CI 5.0-43%) was higher than a change from surgery to conservative 2% (95% CI 1-34%). CONCLUSIONS: MRI can significantly change the thoracolumbar classification and decision-making, primarily due to upgrading type A to type B fractures and changing from conservative to surgery, respectively. These findings suggest that MRI could change decision-making sufficiently to justify its use for TLFs. Type A subtypes, indeterminate PLC status, and spine regions might help to predict a change in TLFs' classification. However, more studies are needed to confirm the association of these variables with changes in treatment decisions to set the indications of MRI in neurologically intact patients with TLFs. An interactive version of our analysis can be accessed from here: https://databoard.shinyapps.io/mri_spine/ .

A Prospective Comparison Between Soft Tissue Dissection Techniques in Pterional Craniotomy: Functional, Radiological, and Aesthetic Outcomes.

BACKGROUND AND OBJECTIVES: Given the complex anatomy of the operative region and individual surgeon preferences, some techniques for soft tissue dissection before pterional craniotomy have gained more popularity than others. This prospective study used subjective and objective measurements to compare the functional, radiological, and aesthetic outcomes of 3 such dissection techniques. METHODS: This multicenter prospective cohort study included all patients who underwent elective pterional craniotomy between 2018 and 2020 at 3 centers in Riyadh, Saudi Arabia. All patients underwent 1 of 3 soft tissue dissection techniques: myocutaneous flap, interfascial, and subfascial dissection techniques. Clinical and radiological assessments were performed upon discharge and at the 3- and 6-month follow-ups. RESULTS: We included 78 patients, with a mean age of 44.9 ± 16.3 years. Myocutaneous flap, interfascial, and subfascial dissections were performed in 34 (43%), 24 (30%), and 20 patients (25%), respectively. The myocutaneous flap method had the shortest opening ( P = .001) and closure ( P = .005) times; tenderness was more evident in this group than in the others ( P = .05). The frontalis muscle was most affected in the interfascial dissection group ( P = .05). The frontalis nerve function was similar in all groups after 6 months ( P = .54). The incidence of temporomandibular joint dysfunction was highest in the myocutaneous flap group (29%). Decreased temporalis muscle thickness at the 6-month postoperative follow-up was most severe in the subfascial dissection group (12.6%), followed by the myocutaneous flap (11.9%) and interfascial dissection (9.9%) groups, with no significant difference ( P = .85). Temporal hollowing was more prominent in the myocutaneous flap group ( P = .03). Cosmetic satisfaction was highest in the interfascial dissection group, with no significant difference ( P = .4). CONCLUSION: This study provides important information for neurosurgeons in weighing the benefits and risks of each technique for their patients.

Lhermitte-Duclos disease: A systematic review.

Background: Lhermitte-Duclos disease (LDD) is a rare tumor, with only about 300 reported cases. It often shows comorbidity with Cowden syndrome (CS); however, it can occur by itself. Radiologically, the "tiger-stripe" appearance is considered pathognomonic. Surgical resection remains the mainstay of treatment. This report aims to describe the clinical and radiological characteristics of LDD and its relationship with CS according to age group. Methods: PubMed electronic databases were searched in August 2022. The search terms included "Lhermitte- Duclos disease" and "dysplastic gangliocytoma," which yielded 297 and 103 research articles, respectively. The articles were collected and reviewed by three researchers. Results: Out of 400 identified articles, we analyzed 302 reported cases. The mean age at presentation was 33.6 ± 16 years; 171 patients (56.6%) were female, and 123 (40.7%) were male. The most commonly reported symptom was headache (174 patients, 57.6%), followed by ataxia (109, 36.1%). In addition, 99 cases (32.8%) were associated with CS, and 60 (19.9%) had a confirmed phosphatase and tensin homolog (PTEN) mutation. A tiger-stripe appearance was observed in 208 cases (58.7%); surgical resection was performed in 64.2% of the cases. Mortality and recurrence rates were 4.3% and 8.6%, respectively. No statistically significant difference was found between adult- and pediatric-onset LDD for the association with CS (P = 0.128). Conclusion: Our findings suggest that adult and pediatric LDD have major commonalities; however, further prospective studies are warranted.

Intraosseous meningioma, a rare presentation of a common brain tumor: illustrative case.

BACKGROUND: The subset of extradural meningiomas arising from bone is called primary intraosseous meningioma. The present article outlines the clinical presentation, investigation, surgical management, and clinical outcomes of a challenging case of intraosseous meningioma. OBSERVATIONS: A 27-year-old male presented with new-onset seizure of 3 years' duration and growing painless hard swelling involving the left frontoparietal bone, the medial aspect of the left orbit, the nasal bone, and the temporal bone. Brain computed tomography showed a diffuse intradiploic space osseous lesion with a ground-glass appearance. The patient underwent bifrontal craniotomy and tumor excision. The histopathological sections showed the presence of classic whorls of meningothelial cells around reactive bony tissue suggestive of intraosseous meningioma. Postoperatively, the patient was neurologically intact, and he was discharged in a stable condition. The outcome of this case was satisfactory. LESSONS: The treatment of primary intraosseous meningioma is wide surgical excision together with the involved dura and any intradural tumor. The location of the tumor determines the approach and the amount of resection, keeping in mind preservation of function. The use of adjuvant therapy is reserved for cases of tumor recurrence or an atypical type.

Ten-year survival in glioblastoma patient with neurofibromatosis type 1: illustrative case.

BACKGROUND: Gliomas are commonly detected in patients with neurofibromatosis type 1 (NF1) at an early age. Few patients with NF1 are diagnosed with glioblastoma. The course of management, response to therapy, and prognosis of such patients are unknown. Few reports have shown longer-than-average survival rates for patients with NF1 with glioblastoma. OBSERVATIONS: A 27-year-old man with NF1 presented with symptoms of high intracranial pressure. Imaging and pathology showed left frontotemporal glioblastoma. Gross total resection was achieved, and concurrent chemoradiotherapy was administered. Recurrence of tumor was detected 48 months later, and the patient underwent tumor debulking and concurrent chemoradiotherapy. The patient received first-, second-, and third-line chemotherapy (temozolomide, bevacizumab, bevacizumab/irinotecan) with good tolerance and has survived >10 years since then with good functional status. LESSONS: This case demonstrates >10 years overall survival of glioblastoma in a patient with NF1. Reports of patients with NF1 with longer survival may be attributed to the young age at diagnosis and relatively better tolerance for therapy. It might also support the growing evidence of a unique subset of glioblastoma associated with NF1 and opens the door for a more molecular targeted therapy in the future.

Postoperative intensive care management and residual endocrinopathy of pediatric supratentorial brain tumors: a retrospective cohort study.

OBJECTIVES: Endocrinopathy can occur as a postoperative sequel in children treated for supratentorial tumors (STTs). We assessed prediction of a residual hypothalamic/pituitary insufficiency (HPI) in these patients and factors associated with prolonged length of hospital stay (LOS). METHODS: This is a retrospective cohort study of children who had surgery for STTs in two tertiary centers in Saudi Arabia (2009-2019). We assessed PICU postoperative management and risk of HPI. Data were analyzed using SPSS V24.0 and a logistic regression model for a prediction of a prolonged LOS. RESULTS: Data included 55 children (1-18 years, mean 9.5 ± 4.9 years) who required STT surgeries, 32 (54%) females. Craniopharyngioma (27.3%) was the commonest STTs and 20% of patients had initial symptoms of HPI. PICU management included the use of different types of intravenous fluids (IVFs) and medications such as steroids and desmopressin (DDAVP). An early postoperative DI was reported in 21.8% (n=12/55). Residual HPI included 24 (43.6%) presumed cortisol deficient and 18 (32.7%) central DI patients. Risk factors for postoperative HPI were female gender, age <6 years, headache and preoperative pituitary symptoms. LOS (Median=25.5 ± 12.2 days) was significantly prolonged in patients who required two or more doses of DDAVP [B=13; 95% CI= (1.7-24.3) days] and reduced in patients who had suspected preoperative HPI [B=-19.6; 95% CI= (-31.1, -8.2) days]. CONCLUSIONS: Prediction of postoperative HPI in pediatric STTs enhances an early initiation of treatment in PICU and reduces LOS. A meticulous use of IVF and medications supervised by a multidisciplinary team is essential for a favorable outcome.

Outcome of Childhood Cerebellar Pilocytic Astrocytoma: A Series With 20 Years of Follow Up.

BACKGROUND: Cerebellar pilocytic astrocytoma (PCA) is one of the few CNS tumors that can be cured with gross-total removal (GTR). In this series, we had 39 patients diagnosed with cerebellar PCA, 27 patients (70%) had GTR, and mean follow-up period was 62 months with no tumor recurrence. OBJECTIVE: To assess the long-term outcome of childhood cerebellar PCA treated at our institute during the period 2000-2020 and to highlight our surgical protocol. METHODOLOGY: Retrospective review of all patients under 18 years of age who were diagnosed with cerebellar PCA and had surgical excision between 2000 and 2020 at the Medical City of King Saud University. RESULTS: The study included 39 patients: 17 males and 22 females, the mean age was 8.4 years. Radiologically, the tumor was solid in eight patients, cystic in 15 patients, and mixed components were found in 16 patients. The lesion was located in the right cerebellar hemisphere in 12 patients, left cerebellar hemisphere in five patients, and midline 22 patients. The tumor size ranged from 2 to 7 cm in its greatest diameter, it was <5 cm in 13 patients and >5 cm in 26 patients. Thirty-one patients had preoperative hydrocephalus. GTR of the tumor was achieved in 27 patients and subtotal resection (STR) was done in 12 patients, 18 patients required permanent ventriculoperitoneal (V-P) shunt, and five patients had postoperative radiotherapy. Postoperative complications included infection in two patients, cerebellar mutism in two patients, and significant neurologic disability in four patients. The duration of follow-up ranged from 0 to 240 months (mean follow-up period: 62.0 months). The outcome at 10 years was good in 30 patients, fair in four patients, poor in four patients, and one patient died. Recurrence was documented in nine patients, seven of them had GTR and two had STR. CONCLUSION: GTR, if achievable, is curative for childhood cerebellar PCA. Many posterior fossa surgical complications could be avoided with watertight dural closure. Although new dural substitutes are available we prefer using autologous grafts (pericranium). It is easy to harvest pericranial graft from the external ventricular drain (EVD) site. The insertion of EVD synchronously with GTR of the tumor and gradual weaning of EVD could avoid the insertion of V-P shunt.

Otogenic Pneumocephalus After Tegmen Bone Reconstruction: A Case Report.

Pneumocephalus is usually induced by trauma, infections, tumors of the skull base, and surgical interventions. Spontaneous pneumocephalus occurs due to a defect in the temporal bone with no obvious cause. Few cases have been reported with spontaneous otogenic pneumocephalus. However, delayed postoperative pneumocephalus is rarely reported in the literature. Here, we present a case of otogenic pneumocephalus through Eustachian tube (ET) preceded by nose blowing 10 days after surgical treatment of meningoencephalocele of the right middle ear (ME) cleft and reconstruction of tegmen and dural defects. Pneumocephalus was provoked by decreased intracranial pressure (ICP) secondary to placement of lumbar drain, which caused direct communication between unsutured dural defect and the defective posterior wall of external auditory canal skin. A revision surgery of combined transmastoid/middle cranial fossa approach was performed for intracranial decompression followed by appropriate closure by suturing the dura, obliterating the ET and ME.

Effects of compressive lesions on intraoperative human spinal cord elasticity.

OBJECTIVE: Although evaluating tissue elasticity has various clinical applications, spinal cord elasticity (SCE) in humans has never been well documented. In this study, the authors aimed to evaluate the impact of compression on human SCE in vivo. METHODS: The authors prospectively assessed SCE using intraoperative shear wave elastography (SWE). All consecutive patients undergoing spinal cord (SC) decompression (laminectomy or corpectomy) between June 2018 and June 2019 were included. After intraoperative exposure of the patient's dura mater, at least three SWE measurements of the SC and its coverings were performed. Intraoperative neurological monitoring in the form of motor and somatosensory evoked potentials was utilized. Cases were divided into two groups based on the state of SC compression following bone removal (laminectomy or corpectomy): patients with adequate decompression (the decompressed SC group [DCG]) following bone removal and patients with remining compression, e.g., compressing tumor or instability (the compressed SC group [COG]). RESULTS: A total of 25 patients were included (8 females and 17 males) with a mean age of 48.28 ± 21.47 years. Most cases were degenerative diseases (10 cases) followed by tumors (6 cases), and the compression was observed at cervical (n = 14), thoracic (n = 9), and conus medullaris (n = 2) levels. The COG (6 cases) expressed significantly higher elasticity values, i.e., greater stiffness (median 93.84, IQR 75.27-121.75 kPa) than the decompressed SC in DCG (median 9.35, IQR 6.95-11.22 kPa, p < 0.001). Similarly, the compressed dura mater in the COG was significantly stiffer (mean ± SD 121.83 ± 70.63 kPa) than that in the DCG (29.78 ± 18.31 kPa, p = 0.042). Following SC decompression in COG, SCE values were significantly reduced (p = 0.006; adjusted for multiple comparisons). Intraoperative monitoring demonstrated no worsening from the baseline. CONCLUSIONS: The current study is to the authors' knowledge the first to quantitatively demonstrate increased stiffness (i.e., elasticity value) of the human SC and dura mater in response to external compression in vivo. It appears that SCE is a dynamic phenomenon and is reduced following decompression. Moreover, the evaluation of human SCE using the SWE technique is feasible and safe. Information from future studies aiming to further define SCE could be valuable in the early and accurate diagnosis of the compressed SC.

The longitudinal impact of COVID-19 pandemic on neurosurgical practice.

OBJECTIVE: This observational cross-sectional multicenter study aimed to evaluate the longitudinal impact of the coronavirus disease 2019 (COVID-19) pandemic on neurosurgical practice. METHODS: We included 29 participating neurosurgeons in centers from all geographical regions in the Kingdom of Saudi Arabia. The study period, which was between March 5, 2020 and May 20, 2020, was divided into three equal periods to determine the longitudinal effect of COVID-19 measures on neurosurgical practice over time. RESULTS: During the 11-week study period, 474 neurosurgical interventions were performed. The median number of neurosurgical procedures per day was 5.5 (interquartile range [IQR]: 3.5-8). The number of cases declined from 72 in the first week and plateaued at the 30's range in subsequent weeks. The most and least number of performed procedures were oncology (129 [27.2 %]) and functional procedures (6 [1.3 %]), respectively. Emergency (Priority 1) cases were more frequent than non-urgent (Priority 4) cases (178 [37.6 %] vs. 74 [15.6 %], respectively). In our series, there were three positive COVID-19 cases. There was a significant among-period difference in the length of hospital stay, which dropped from a median stay of 7 days (IQR: 4-18) to 6 (IQR: 3-13) to 5 days (IQR: 2-8). There was no significant among-period difference with respect to institution type, complications, or mortality. CONCLUSION: Our study demonstrated that the COVID-19 pandemic decreased the number of procedures performed in neurosurgery practice. The load of emergency neurosurgery procedures did not change throughout the three periods, which reflects the need to designate ample resources to cover emergencies. Notably, with strict screening for COVID -19 infections, neurosurgical procedures could be safely performed during the early pandemic phase. We recommend to restart performing neurosurgical procedures once the pandemic gets stabilized to avoid possible post pandemic health-care system intolerable overload.

Neurosurgical Procedures and Safety During the COVID-19 Pandemic: A Case-Control Multicenter Study.

OBJECTIVE: Quantitative documentation of the effects of outbreaks, including the coronavirus disease 2019 (COVID-19) pandemic, is limited in neurosurgery. Our study aimed to evaluate the effects of the COVID-19 pandemic on neurosurgical practice and to determine whether surgical procedures are associated with increased morbidity and mortality. METHODS: A multicenter case-control study was conducted, involving patients who underwent neurosurgical intervention in the Kingdom of Saudi Arabia during 2 periods: pre-COVID-19 and during the COVID-19 pandemic. The surgical intervention data evaluated included diagnostic category, case priority, complications, length of hospital stay, and 30-day mortality. RESULTS: A total of 850 procedures were included, 36% during COVID-19. The median number of procedures per day was significantly lower during the COVID-19 period (5.5 cases) than during the pre-COVID-19 period (12 cases; P < 0.0001). Complications, length of hospital stay, and 30-day mortality did not differ during the pandemic. In a multivariate analysis comparing both periods, case priority levels 1 (immediate) (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.24-2.67), 1 (1-24 h) (OR, 1.63; 95% CI, 1.10-2.41), and 4 (OR, 0.28; 95% CI, 0.19-0.42) showed significant differences. CONCLUSIONS: During the early phase of the COVID-19 pandemic, the overall number of neurosurgical procedures declined, but the load of emergency procedures remained the same, thus highlighting the need to allocate sufficient resources for emergencies. More importantly, performing neurosurgical procedures during the pandemic in regions with limited effects of the outbreak on the health care system was safe. Our findings may aid in developing guidelines for acute and long-term care during pandemics in surgical subspecialties.

Aggressive surgical management of recurrent intracranial juvenile xanthogranuloma: case report and review of the literature.

INTRODUCTION: Juvenile xanthogranuloma (JXG) with the central nervous system (CNS) involvement is a rare disease entity that remains poorly understood, especially when the condition develops following treatment for Langerhans cell histiocytosis (LCH). CASE REPORT: A 21-year-old man who was diagnosed with LCH at age 2, several years following which he developed signs and symptoms of CNS involvement. Magnetic resonance imaging (MRI) of the brain revealed JXG with bilateral choroid plexus involvement. As radiation therapy for the intraventricular masses proved unsuccessful, he underwent two surgical resections. In the following years, he developed another large JXG in the meninges, which was managed conservatively until he required surgery due to symptom progression. Twelve years after the first surgery, the patient is in stable condition with no evidence of recurrence. CONCLUSION: Due to the rarity of JXG in the CNS, optimal treatment strategies and the precise duration of therapy remain to be determined. Future studies should aim to develop an appropriate treatment algorithm for such rare cases.

Effect of quadriceps and calf muscles fatigue on standing balance in healthy young adult males.

OBJECTIVE: The present study aimed to compare the effects of quadriceps or calf muscles fatigue on static and dynamic standing balance in young healthy adult males. METHODS: Forty-five healthy, physically active male adults aged 18-30 years were randomly divided into three groups; Quadriceps muscle fatigue group (n=15), Calf muscles fatigue group (n=15), and a control group (n=15). The Modified Clinical Test of Sensory Interaction on Balance, Unilateral Stance, and Limits of Stability (reaction time and movement velocity) were selected as outcome measures for this study. RESULTS: The results showed a non-significant difference between pretest and posttest balance scores (p>0.05) for quadriceps and calf muscles fatigue on balance. Similarly, there were non-significant differences in posttest balance scores when comparing fatigue effects between the groups (p>0.05). CONCLUSIONS: These results suggested that the fatigue of the quadriceps or calf muscles did not influence standing balance in healthy young adult males. Future longitudinal studies are recommended to further understanding the mechanisms behind localized muscle fatigue effects on standing balance in subjects of different age groups of both genders.

Giant Tumefactive Perivascular Spaces: A Case Report and Literature Review.

BACKGROUND: Perivascular spaces (PVS), also known as Virchow-Robin spaces, are pial-lined, interstitial fluid-filled structures in the brain that accompany cerebral vessels as they penetrate the cerebral substance. In healthy individuals, a PVS diameter of <2 mm is considered normal and can typically be seen within the white matter on magnetic resonance imaging (MRI). When PVS dilate, they are considered benign lesions and are associated with aging and other risk factors. These dilated PVS can cause neurologic symptoms, depending on their size and location. Symptomatic, massive enlargement of PVS are referred to as "giant" or "tumefactive" PVS; these are extremely rare and require neurosurgical intervention. CASE DESCRIPTION: We present a rare case of giant tumefactive PVS (GTPVS) associated with hydrocephalus in a female patient who presented with progressive headache for 6 months. The patient was found to have giant tumefactive dilatation of PVS involving the right midbrain, with extension to the pons and thalamus, and with supratentorial moderate hydrocephalus. She was treated with cerebrospinal fluid diversion alone. CONCLUSIONS: PVS are found on MRI in healthy people; rarely, they may dilate and cause neurologic symptoms. GTPVS are rare and can be misdiagnosed as central nervous system tumors; however, their imaging characteristics facilitate diagnosis. It has been postulated that these expanding PVS are due to defects in the drainage of interstitial fluid, where it enters into the ventricular system, and they are not the result of increased intraventricular pressure. We hypothesize that this may have been the case for the patient in our study, as the GTPVS collapsed following the insertion of a ventriculoperitoneal shunt. However, more recent literature provides evidence to support the idea that hydrocephalus is the consequence, and not the cause, of aqueduct compression by the lesion.

Tumors of the lateral and third ventricle: surgical management and outcome analysis in 42 cases.

OBJECTIVE: To discuss the clinical presentation, pathological diagnosis, and surgical outcome for a series of 42 consecutive patients treated for lateral and third ventricular tumors. METHODS: This is a retrospective series study conducted between 2001 and 2015 and included 42 patients (mean age: 25 years; range: 2 months-65 years) with lateral and third ventricle tumors surgically treated at King Khaled University Hospital, Riyadh, Kingdom of Saudi Arabia. Demographic, clinical, radiological, surgical, histopathological, and follow up data were analyzed. RESULTS: The most common symptoms at presentation included headache (69%), nausea/vomiting (38%), visual deficits (24%), and seizures (17%). Lesions were located in the lateral ventricle in 15 patients, third ventricle in 20 patients, and involved both the lateral and third ventricles in 7 patients. The most common tumor types in the overall cohort were colloid cysts (n=6) and pineal tumors (n=6). The postoperative complication rate was 36%. The most common postoperative complications were seizure and hydrocephalus (n=5 each, 12%). Surgical mortality was 5%. CONCLUSION: The selection of the surgical approach for intraventricular tumor resection is fundamentally dependent on the surgeon`s experience and preference. We recommend that this decision be based on the anatomic considerations that provide the best and safest access to the mass, rather than on the risk of seizure following transcortical approach.

Structural and mechanical characterization of custom design cranial implant created using additive manufacturing

Background: Reconstruction of customized cranial implants with a mesh structure using computer-assisted design and additive manufacturing improves the implant design, surgical planning, defect evaluation, implant-tissue interaction and surgeon's accuracy. The objective of this study is to design, develop and fabricate cranial implant with mechanical properties closer to that of bone and drastically decreases the implant failure and to improve the esthetic outcome in cranial surgery with precision fitting for a better quality of life. A customized cranial mesh implant is designed digitally, based on the Digital Imaging and Communication in Medicine files and fabricated using state of the Art-Electron Beam Melting an Additive Manufacturing technology. The EBM produced titanium implant was evaluated based on their mechanical strength and structural characterization. Results: The result shows, the produced mesh implants have a high permeability of bone ingrowth with its reduced weight and modulus of elasticity closer to that the natural bone thus reducing the stress shielding effect. Scanning electron microscope and micro-computed tomography (CT) scanning confirms, that the produced cranial implant has a highly regular pattern of the porous structure with interconnected channels without any internal defect and voids. Conclusions: The study reveals that the use of mesh implants in cranial reconstruction satisfies the need of lighter implants with an adequate mechanical strength, thus restoring better functionality and esthetic outcomes for the patients.

Split cord malformation associated with spinal open neural tube defect.

OBJECTIVE: To illustrate the clinical and radiological findings of split cord malformation (SCM) in patients with spinal open neural tube defect (SONTD), and report the outcome of their treatment. METHODS: A retrospective study of the clinical and radiological findings of 11 patients diagnosed with SCM, identified among 83 patients with SONTD at King Khalid University Hospital, in Riyadh, Saudi Arabia between 1995 and 2010. RESULTS: There were 6 girls and 5 boys; their age ranged from less than a year to 9 years (mean 4.2 years). Six patients had type I SCM, and 5 patients type II SCM. The CT and MRI imaging showed characteristic bony, cartilaginous, or fibrous septum, and other SONTD-associated anomalies. Seven patients were graded A & B according to the Frankel grading score, and none of them required surgery, while worsening neurology led to surgical intervention in 3 patients, with clinical improvement after surgery, and one patient that underwent cord untethering remained stable. CONCLUSION: Split cord malformation is not uncommon among patients with SONTD. It tends to involve mainly the lumbar spine, and female predominance is more remarkable in type I. Neurological manifestations of SCM may be superimposed with SONTD. Surgery is effective for symptomatic patients, and not indicated in the severely disabled.

Agenesis of the corpus callosum associated with spinal open neural tube defect.

OBJECTIVE: To ascertain the incidence and clinical implications of agenesis of the corpus callosum (ACC) in spinal open neural tube defects (SONTD). METHODS: All cases of SONTD registered at the Spina Bifida Clinic in King Khalid University Hospital, Riyadh, Saudi Arabia between 1995 and 2010 were retrospectively reviewed, and mid-sagittal MRI of the corpus callosum (CC) area was analyzed in each case. Neurodevelopmental outcome was classified as poor in children with seizures, severe neurodevelopmental impairment, or death. RESULTS: Thirty-eight patients (45.8%) with ACC were identified among 83 cases with SONTD. Patients' age ranged between one and 16 years. Total ACC was found in 10 patients, partial ACC in 25, and in 3 patients, the CC was hypoplastic. Active hydrocephalus was an associated finding in 9 out of 10 patients with total ACC, 22 out of 25 with partial ACC, and in all patients with hypoplasia of the CC. Thirteen patients (34.2%) had normal intellectual function, whereas 24 patients presented with learning disability, epilepsy, or poor intellectual function; and one patient died of respiratory failure. CONCLUSION: Agenesis of the corpus callosum is found in a significant portion of patients with SONTD. When associated with hydrocephalus, its presence affects neuro-developmental outcome.

Management strategies for acute brain lesions presenting during pregnancy: a case series.

BACKGROUND: The management of brain lesions diagnosed during pregnancy is challenging to both obstetricians and neurosurgeons. In this study, a series of nine pregnant women were admitted to neurosurgery presenting with different acute brain lesions. OBJECTIVE: To establish guidelines for the management of acute brain lesions that present during pregnancy. PATIENTS AND METHODS: Retrospective review of the medical records of all pregnant women admitted for urgent care to King Khalid University Hospital (KKUH) from 1995 to 2009. RESULTS: Eight patients were multiparous, and one was primigravida, two were in the first trimester, and seven were in the second or third trimester. The mean age was 30.5 years. Six patients had brain tumours, while one patient had tuberculoma, and two had aneurismal subarachnoid haemorrhages (SAH). Three patients completed a full term pregnancy following surgery. Two patients had emergency caesarean section (CS) immediately followed by neurosurgery in the same session. Two patients completed their pregnancies to full term and had craniotomies after delivery. Two patients had therapeutic abortions followed by neurosurgery. No maternal or foetal complications were recorded in this series. CONCLUSION: The management of pregnant patients with acute brain lesions should be individualised and multidisciplinary. As it is difficult to allocate a single, general treatment protocol to pregnant patients with brain lesions, we suggest the following guidelines: for patients in the second and early third trimesters, it is safe to perform a craniotomy first and allow the patient to complete a full term pregnancy. For patients at 34 weeks or more of gestation, emergency CS followed by a craniotomy is recommended. For patients in the 1st trimester, it is advisable to terminate the pregnancy to allow safe management, although the laws governing this will vary from country to country. For patients with benign tumours who respond to corticosteriods, it is possible to complete the pregnancy and postpone surgery until after delivery.