Low-Profile Visualized Intraluminal Support Device for Y-Stent-Assisted Coiling of Wide-Neck Intracranial Aneurysms: A Single Center Experience

BACKGROUND

The Low-Profile Visualized Intraluminal Support (LVIS) device has been frequently used as intracranial stent for treating intracranial aneurysms. However, the feasibility and efficacy of LVIS devices in Y-stent-assisted coiling (Y-SAC) have remained contentious. This study aimed to evaluate long-term angiographic and clinical outcomes of Y-SAC using LVIS devices.

METHODS

We retrospectively reviewed the clinical presentation and angiography data of patients treated with Y-SAC using LVIS stents. The vascular angle geometry between the parent and the two branch vessels, before and after stent deployment and after coiling were analyzed. Based on Raymond-Roy Occlusion Classification (RROC), aneurysm occlusion status was classified. Clinical outcomes were assessed using the modified Rankin Scale (MRS).

RESULTS

Forty patients with 40 aneurysms were included in this study. Immediate postprocedural angiograms revealed complete/near-complete occlusion (RROC 1 and 2) in 31 aneurysms (77.5%). The long-term follow-up angiographic studies were available in 32 patients revealing RROC class 1 and 2 in 93.8% of patients. Y-SAC with LVIS devices significantly decreased the angle between the bifurcation branches from 171.90 ° ± 48.0° (SD) to 130.21° ± 46.3° (SD) (p<0.0001). Periprocedural complications occurred in five patients (12.5%) including four in-stent thrombosis (10.5%). Thirty-six patients (90.0%) had favorable clinical outcomes at the final follow-up. Univariate analysis depicted that WFNS of 3-5, thick of subarachnoid hemorrhage on head CT scan, intraprocedural complications, and in-stent thrombosis were predictors of poor outcome.

CONCLUSION

Y-SAC using LVIS device for intracranial bifurcation aneurysms is a feasible and relatively safe procedure with favorable long-term angiographic and clinical outcomes.

Long-term outcome of endovascular treatment for indirect carotid-cavernous fistulas

OBJECTIVE

Endovascular treatment (EVT) is the primary approach used to treat indirect carotid-cavernous fistulas (CCFs). In this study, the authors evaluated the immediate and long-term efficacy and safety of different endovascular techniques for indirect CCFs.

METHODS

The databases of two endovascular centers were retrospectively reviewed to collect the patients with indirect CCFs treated using endovascular techniques between 2013 and 2023. Demographics, clinical presentation, CCF features, EVT characteristics, and clinical and radiological outcomes were evaluated and analyzed. The analysis was performed to compare the clinical and radiological data between different endovascular approaches and different embolic materials.

RESULTS

Ninety-eight patients were included in the study. EVT was successful in 95 patients (96.9%). Immediate complete obliteration of the CCF was achieved in 93.9% of patients, with 98% undergoing embolization with liquid embolic agents (LEAs) and 95.6% undergoing coiling alone. Complete CCF obliteration was higher in the transvenous than in the transarterial approach (94.3% vs 75%, p = 0.010). At ≥ 6 months follow-up, complete CCF obliteration was achieved in all patients (100%). The rate of procedure-related complications was higher following LEAs than with coiling alone (32.0% vs 15.6%). New cranial nerve (CN) palsy was diagnosed in 26.0% and 2.2% after embolization with LEAs and coiling alone, respectively (p = 0.001), with complete CN palsy recovery in 78.6%. Procedure-related intracranial hemorrhage occurred in 3 patients (3.1%). Two patients experienced an ischemic stroke following Onyx migration into the internal carotid artery. Ocular symptoms improved in 93% (83/89) of the patients who were followed.

CONCLUSIONS

In this study, complete obliteration of an indirect CCF was achieved in more than 90% of patients. Despite the occurrence of some new postprocedural ocular CN palsy, ocular symptoms improved in most patients in long-term follow-up. The transvenous approach was the most effective method for treating the indirect CCF. Coiling was safer than LEAs for the embolization of the indirect CCF.

Alterations in hypothalamic-pituitary axis (HPA) hormones 6 months after cranial radiotherapy in adult patients with primary brain tumors outside the HPA region

BACKGROUND

Cranial radiotherapy is a common treatment for brain tumors, but it can affect the hypothalamic-pituitary (H-P) axis and lead to hormonal disorders. This study aimed to compare serum levels of HPA hormones before and after cranial radiation.

MATERIALS AND METHODS

This study involved 27 adult patients who underwent brain tumor resection before the initiation of radiotherapy, and none had metastatic brain tumors. All participants had the HPA within the radiation field, and their tumors were located in brain areas outside from the HPA. Serum levels of HPA hormones were recorded both before and 6 months after cranial radiotherapy.

RESULTS

A total of 27 adult patients, comprising 16 (59.3%) males and 11 (40.7%) females, with a mean age of 56.37 ± 11.38 years, were subjected to evaluation. Six months post-radiotherapy, serum levels of GH and TSH exhibited a significant decrease. Prior to radiotherapy, a substantial and direct correlation was observed between TSH and FSH (p = 0.005) as well as LH (p = 0.014). Additionally, a significant and direct relationship was noted between serum FSH and LH (p < 0.001) before radiotherapy. After radiotherapy, a significant and direct correlation persisted between TSH and FSH (p = 0.003) as well as LH (p = 0.005), along with a significant and direct relationship between serum FSH and LH (p < 0.001). Furthermore, a significant and direct association was identified between changes in serum GH levels and FSH (p = 0.04), as well as between serum LH and FSH (p < 0.001).

CONCLUSION

Reduced serum levels of HPA hormones are a significant complication of cranial radiotherapy and should be evaluated in follow-up assessments.

Diagnostic Value of Computed Tomography Angiography in Confirmation of Brain Death

BACKGROUND

Accurate and on-time confirmation of brain death (BD) is necessary to prevent unnecessary treatment and allow for well-timed organ harvest for transplantation. Although the clinical criteria for BD are legally reliable in some countries, others might prefer complementary ancillary tests to assess the brain's electrical activity and/or blood circulation. The present study aims to define the sensitivity and specificity of computed tomography angiography using 4-, 7-, and 10-point tests compared with the clinical criteria and electroencephalographic findings in patients with BD.

METHODS

A total of 32 patients with a confirmed diagnosis of BD according to their clinical criteria (cases) and 18 patients with a Glasgow coma scale score of 3 and absent brain stem and papillary reflexes who had spontaneous respiration (controls) were included in the present study. All the patients had blood pressure >90 mm Hg, diuresis >100 mL/hour, and central venous pressure >6-8 mm Hg, and undergone computed tomography angiography (CTA). The 4-, 6-, and 10-point criteria were used to determine the opacity and lack of opacity of the brain vessels in the CTA evaluation scales for the diagnosis of BD.

RESULTS

The 2 groups were homogeneous in terms of age, gender distribution, and coma etiology. All 18 patients in the control group received a score of 0 in the 4-, 7-, and 10-point scores. In contrast, the average values for the 4-, 7-, and 10-point scores for the patients with confirmed BD were 3.75 ± 0.67, 6.4 ± 1.36, and 9.06 ± 2.2, respectively. Of the patients with BD, 28 (87.5%), 26 (81.25%), and 25 (78.12%) received the full score for the 4-point, 7-point, and 10-point tests. The sensitivity, specificity, and negative and positive predictive values for all 3 scores were 100%. Also, the sensitivity for the various cerebral vessels were as follows: internal cerebral vein, 100%; great cerebral vein, 96.9%; posterior 2, 90.6%, middle 4, 87.5%; basilar artery, 84.4%; and anterior 3, 84.4%. Finally, the specificity for the lack of opacification in all these vessels for the diagnosis of BD was 100%.

CONCLUSIONS

According to our findings, the CTA-based 4-point scoring system with 100% specificity can be used with the clinical examination findings to confirm BD.

Safety of dual antiplatelet therapy in the acute phase of aneurysmal subarachnoid hemorrhage: a propensity score-matched study

OBJECTIVE

With the evolution of neuroendovascular treatments, there is a great trend to treat acutely ruptured wide-necked aneurysms with stent-assisted coiling (SAC) and flow diverters (FDs), which inevitably requires dual antiplatelet therapy (DAPT). This therapy can increase the rate of hemorrhagic complications following other neurosurgical maneuvers, such as external ventricular drain (EVD) placement or removal. In this study, the authors aimed to evaluate the safety of DAPT in patients with aneurysmal subarachnoid hemorrhage (SAH) treated with SAC or FDs and the therapy's potential benefit in reducing cerebral ischemia and cerebral vasospasm.

METHODS

In this retrospective study, the authors reviewed the records of patients who had been admitted to their hospital with acute aneurysmal SAH and treated with SAC, FDs, and/or coiling between 2012 and 2022. Patients were classified into two groups: a DAPT group, including patients who had received DAPT for SAC or FDs, and a non-DAPT group, including patients who had not received any antiplatelet regimen and had been treated with coiling. Perioperative hemorrhagic and ischemic complications and clinical outcomes were compared between the two groups.

RESULTS

From among 938 cases of acute ruptured aneurysms treated during 10 years of study, 192 patients were included in this analysis, with 96 patients in each treatment group, after propensity score matching. All basic clinical and imaging characteristics were equivalent between the two groups except for the neck size of aneurysms (p < 0.001). EVD-related hemorrhage was significantly higher in the DAPT group than in the non-DAPT group (p = 0.035). In most patients, however, the EVD-related hemorrhage was insignificant. Parent artery or stent-induced thrombosis was higher in the DAPT group than in the non-DAPT group (p = 0.003). The rate of cerebral ischemia was slightly lower in the DAPT group than in the non-DAPT group (11.5% vs 15.6%, p = 0.399). In the multivariate analysis, cerebral ischemia, rebleeding before securing the aneurysm, extracranial hemorrhage, and cerebral vasospasm were the predictive factors of a poor clinical outcome (p < 0.001, p < 0.001, p = 0.038, and p = 0.038, respectively).

CONCLUSIONS

The DAPT regimen may be safe in the setting of acute aneurysmal SAH. Although EVD-related hemorrhage is more common in the DAPT group than the non-DAPT group, it is usually insignificant without any neurological deficit.

Transradial access for neurointerventional procedures: A practical approach

INTRODUCTION

Transradial approach (TRA) is a new technique proposed for performing cerebral angiography and neuro-interventional procedures. In this article, we sought to provide a step-by-step guide for carrying out a diagnostic cerebral angiography using this approach and summarize our center's experience.

MATERIAL AND METHODS

Records of patients since January 2020 were investigated, and data on demographic indices, reports of the procedures, outcomes, and complications were extracted. Then, these data were used to develop a step-by-step instruction for TRA cerebral angiography.

RESULTS

Two hundred eighty-nine patients matched our eligibility criteria with a mean age of 50 years and a female-to-male ratio of 1.18. Overall, TRA was carried out successfully for 97.2% (281 patients). In case TRA failed, transfemoral approach was considered for the procedure. Three minor complications (two vasospasm and one small hematoma) and two major complications (one pseudoaneurysm of the radial artery and one radial artery avulsion) were observed.

CONCLUSION

This article covers challenges a neurointerventionalist may face during a diagnostic cerebral angiography using TRA. Furthermore, our findings indicated that cerebral angiography with TRA might be performed safely and with a great success rate.

Xanthogranulomatous hypophysitis: A rare presentation in a young female patient

Hypophysitis is a rare inflammatory condition that may present both clinically and radiologically as a neoplastic lesion. Xanthogranulomas are rare intracranial lesions with controversial etiology. Here, we report a clinical case of histologically confirmed xanthogranulomatosis hypophysitis in a young female with type I diabetes mellitus and hypothyroidism.

Hypopituitarism is an important cause of persistent hypoglycemia in a patient with previously well‐controlled diabetes. The combination of autoimmunity, hypopituitarism, and a sellar mass may represent autoimmune hypophysitis, which can mimic a pituitary adenoma. Several histological subtypes of hypophysitis have been found, and XH is a rare subtype.

Endovascular treatment as the first-line approach for cure of low-grade brain arteriovenous malformation

OBJECTIVE

While microsurgery has been proposed as the first-line treatment for patients with low-grade (Spetzler-Martin grade I or II) brain arteriovenous malformations (bAVMs), recent studies have shown promising results for endovascular treatment (EVT) as a single proper choice for the management of this group of bAVMs. In this study, the authors evaluated the safety and efficacy of EVT as a first-line strategy for curing low-grade bAVMs at their center.

METHODS

All patients with low-grade bAVMs managed primarily by EVT between 2015 and 2021 were enrolled in this study. Patients were evaluated and treated by the same team and followed with the same protocol. The primary endpoint was the efficacy of EVT on the cure of low-grade bAVMs. The second endpoint was the safety of EVT for the treatment of low-grade bAVMs, including procedural complications and long-term clinical outcomes.

RESULTS

A total of 109 patients were enrolled and represented in the study population. The mean patient age was 31.6 ± 14.8 years. Forty-eight AVMs (44%) were Spetzler-Martin grade I and 61 (56%) were grade II. Of 99 patients who completed their EVT sessions, complete exclusion was achieved in 89 patients (89.9%). Overall, complete exclusion was achieved in 59.6% of patients after a single EVT session. At the 6-month follow-up, 106 patients (97.2%) had a favorable outcome. Four patients (4.6%) experienced transient neurological deficits, and 1 patient (0.9%) had a permanent neurological deficit.

CONCLUSIONS

EVT can be offered as the first choice of treatment for select patients with low-grade bAVMs, with a high cure rate and low morbidity.

Aneurysmal subarachnoid haemorrhage-cerebral vasospasm and prophylactic ibuprofen: a randomised controlled pilot trial protocol

INTRODUCTION

Cerebral vasospasm (CVS) is the leading cause of mortality and morbidity following aneurysmal subarachnoid haemorrhage (aSAH). One of the recently implicated underlying mechanisms of CVS is inflammatory cascades. Specific feasibility objectives include determining the ability to recruit 30 participants over 24 months while at least 75% of them comply with at least 75% of the study protocol and being able to follow 85% of them for 3 months after discharge.

METHODS AND ANALYSIS

This is a feasibility study for a randomised controlled trial. Eligible participants are adult patients who are 18 years of age and older with an aSAH confirmed by a brain CT scan, and CT angiography, or magnetic resonance angiography, or digital subtraction angiography who admitted to the emergency department within 12 hours of the ictus. Eligible subjects will be randomised 1:1 for the administration of either ibuprofen or a placebo, while both groups will concomitantly be treated by the standard of care for 2 weeks. Care givers, patients, outcome assessors and data analysts will be blinded. This will be the first study to investigate the preventive effects of a short-acting non-steroidal anti-inflammatory drug on CVS and the key expected outcome of this pilot study is the feasibility and safety assessment of the administration of ibuprofen in patients with aSAH. The objectives of the definitive trial would be to assess the effect of ibuprofen relative to placebo on mortality, CVS, delayed cerebral ischaemia, and level of disability at 3-month follow-up.

ETHICS AND DISSEMINATION

This study is approved by Mashhad University of Medical Sciences ethical committee (IR.MUMS.MEDICAL.REC.1398.225). Results from the study will be submitted for publication regardless of whether or not there are significant findings.

TRIAL REGISTRATION NUMBER

ISRCTN14611625.

Prophylactic Therapies for Morbidity and Mortality After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Network Meta-Analysis of Randomized Trials

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortality and morbidity. We aimed to determine the relative benefits of pharmacological prophylactic treatments in patients with aneurysmal subarachnoid hemorrhage by performing a network meta-analysis of randomized trials.

METHODS

We searched Medline, Web of Science, Embase, Scopus, ProQuest, and Cochrane Central to February 2020. Pairs of reviewers independently identified eligible trials, extracted data, and assessed the risk of bias. Eligible trials compared the prophylactic effects of any oral or intravenous medications or intracranial drug-eluting implants to one another or placebo or standard of care in adult hospitalized patients with confirmed aneurysmal subarachnoid hemorrhage. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the certainty of the evidence.

RESULTS

We included 53 trials enrolling 10 415 patients. Nimodipine likely reduces all-cause mortality compared to placebo (odds ratio [OR],0.73 [95% CI, 0.53-1.00]; moderate certainty; absolute risk reduction (ARR), -3.35%). Nimodipine (OR, 1.46 [95% CI, 1.07-1.99]; high certainty; absolute risk increase, 8.25%) and cilostazol (OR, 3.73 [95% CI, 1.14-12.18]; moderate certainty; absolute risk increase, 23.15%) were the most effective treatments in improving disability at the longest follow-up. Compared to placebo, clazosentan (10 mg/kg; OR, 0.39 [95% CI, 0.22-0.68]; high certainty; ARR, -16.65%), nicardipine (OR, 0.48 [95% CI, 0.24-0.94]; moderate certainty; ARR, -13.70%), fasudil (OR, 0.55 [95% CI, 0.31-0.98]; moderate certainty; ARR, -11.54%), and magnesium (OR, 0.66 [95% CI, 0.46-0.94]; high certainty; ARR, -8.37%) proved most effective in reducing the likelihood of delayed cerebral ischemia.

CONCLUSIONS

Nimodipine and cilostazol are likely the most effective treatments in preventing morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage. Clazosentan, nicardipine, fasudil, and magnesium showed beneficial effects on delayed cerebral ischemia and vasospasm but they were not found to reduce mortality or disability. Future trials are warranted to elaborately investigate the prophylactic effects of medications that may improve mortality and long-term functional outcomes, such as cilostazol and clazosentan.

REGISTRATION

URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42019122183.

Progress in neurosurgery: Contributions of women neurosurgeons in the Middle East

The Middle East is known for its complex history and rich environment and culture. The region is home to a wide variety of traditions, cultures and religions, which have made the area vulnerable to political conflicts. Despite these difficulties, science and medicine have always thrived in the region, with many medical practices and principles established by physicians and scholars living in the Middle East. The first academic neurosurgical activity in the region started in the 1950s. The first women neurosurgeons in the Middle East started training in the 1970s, and were from Iran, Palestine, followed by Saudi Arabia in the 1970s. These pioneers have encountered serious challenges, yet have become role models for the next generation. These women have paved the way and facilitated neurosurgical training and practice for more women surgeons. The gradual increase in the number of women neurosurgical residents in the region leads to the expectation that women will play a more prominent role in the future as leaders in neurosurgery in the Middle East. This collaborative study, which identifies the known women neurosurgeons in the Middle East for the first time, may serve to provide background and context for further contributions of women neurosurgeons for our profession and our patients.

Rhinitis as the Presenting Symptom of Pineal Region Epidermoid Tumor: A Case Report

Brain tumors are the rarest cause of cerebrospinal fluid rhinorrhea. Non-traumatic cerebrospinal fluid rhinorrhea is also a relatively rare condition. It may be misdiagnosed as allergic rhinitis or chronic sinusitis and lead to unsuitable treatment. We described a 34-year-old man who came to our allergy clinic with a chief complaint of clear rhinorrhea from his left nostril with more than four years of duration. Onlyhypertrophy of left inferior concha was found in the clinical examination. His rhinorrhea aggravated when bending forward. So we were suspicious of CSF rhinorrhea. MRI was done for him and demonstrated a large tumor in the pineal region. The patient underwent surgery with resection of the mass via an infratentorial-supracerebellar approach. This case showed the role of maintaining differential diagnosis for a common complaint; rhinitis which is seen as usual.

Rate and Risk Factors of Early Ventriculoperitoneal Shunt Revision: A Five-Year Retrospective Analysis of a Referral Center

BACKGROUND

Cerebral shunts are the mainstay treatment of hydrocephalus. Because most previous studies have focused on factors related to long-term outcomes of shunt surgery, we aimed to assess the rates and causes of 30-day ventriculoperitoneal shunt (VPS) failure in a single referral center over 5 years in both adult and pediatric patients.

METHODS

Patients who underwent VPS surgery from February 2012 to February 2017 in Ghaem Teaching Hospital, Mashhad, Iran were evaluated retrospectively through clinical history, operative reports, imaging studies, and follow-up notes. Data of 12 possible factors related to shunt failure were collected comprising age, gender, household income, level of education, cause of hydrocephalus, causes of revision, type of failure, anatomic site, duration of operation, time of surgery, surgeons' level of expertise, and Glasgow Coma Scale (GCS) score.

RESULTS

Among 403 VPS placements, 121 VPS revisions were performed, and 82 eligible patients were included in the study (57.3% male and 42.7% female). The 30-day shunt failure rate was 24.4% among all revisions. Obstruction and malposition were the most common causes of early revisions. Six factors were statistically significant in the univariate analysis. After adjustment in a logistic regression model, 2 factors, namely surgeons' level of expertise (odds ratio, 10.33; 95% confidence interval, 1.08-98.80) and anatomic site of the shunt (odds ratio, 10.28; 95% confidence interval, 1.21-87.35) were associated with early shunt revision.

CONCLUSIONS

Shunt surgeries performed by junior residents and shunts placed in the frontal site were associated with early shunt failure.

A Self-Made, Reusable, and Adjustable Device for Making Burr Hole Bone Plugs: Doing More with Less

BACKGROUND

Burr hole craniotomy is a daily procedure in neurosurgery. Defects after burr hole craniotomies will not spontaneously heal and can result in skin dents and cosmetic dissatisfaction. We have introduced a self-made, reusable, and adjustable bone plug packer to use in the repair of burr holes via packing of autologous bone dust. Our bone plug packer is free of charge and can be readily available in neurosurgical operating rooms.

METHODS

We have produced a stainless steel bone packer device that can be assembled without the use of a special wrench. The instrument consists of a container plate and a main cylinder for packing, in which an adjustable airtight piston is placed to compress the bone dust and create a bone plug of the desired dimensions.

RESULTS

Some recent studies have shown that burr holes filled by autologous bone dust will result in good cosmetic and osteogenic outcomes. Although we did not perform a long-term follow-up assessment of the burr holes filled with bone plugs, in the short term, we have not seen any local reactions or infections in our patients. The autologous bone plug is a more affordable and available option with no technical or clinical complications in the short term.

CONCLUSION

We have introduced a practical, convenient, and cost-effective bone packer device. Bone plugs formed using our device can be a potential substitute for expensive covering materials in countries with limited access to other repair options. Providing proper evidence will require the performance of large studies to assess our suggested method in the long term and, possibly, compare it with the usual options in controlled studies.

Association of Opium Addiction with Rupture of Intracranial Aneurysms: A Case-Control Study

BACKGROUND

Disorders related to opioid use account for the most substantial burden of disease attributable to drug use disorders. We aimed to justify if there is an association between either opium consumption or addiction and rupture of intracranial aneurysms.

METHODS

In this case-control study, we enrolled 50 cases with ruptured intracranial aneurysms and 43 control subjects with an incidental finding of an intracranial aneurysm without history of subarachnoid hemorrhage (SAH). Four major risk factors of rupture including age, sex, size, and site of aneurysm were matched among both groups. All participants were asked about cigarette smoking state, opium addiction, opium consumption, and duration and route of opium consumption. Eight other trigger factors were assessed in the period soon before SAH (hazard period). The odds ratio (OR) of all factors was calculated separately, and then a logistic regression for the factors with significant odds was calculated.

RESULTS

Sixty-two percent of cases and 32.6% of control subjects were addicted to opium. The OR for opium consumption in the hazard period was 8.1 (95% confidence interval [CI], 2.2-30.1) and for opium addiction was 3.3 (95% CI, 1.4-7.9). Of those trigger factors, cola consumption was included in the logistic regression model. After adjustment, results demonstrated an OR of 9.2 (95% CI, 2.4-34.7) for opium consumption in the hazard period.

CONCLUSIONS

There is an association between opium addiction and opium consumption in the hazard period with the occurrence of aneurysmal SAH. Replication of the study with a larger sample size and conduction of prospective studies is suggested.

Enoxaparin in the treatment of severe traumatic brain injury: A randomized clinical trial

Background:

Enoxaparin was shown to have a neuroprotective effect in animal models as well as a human study following traumatic brain injury. This study was conducted to assess the effect of enoxaparin on the clinical outcome of severe traumatic brain injury (TBI) and its safety.

Methods:

This study is a randomized double-blinded placebo-controlled trial. The inclusion criteria were age 16–70, a closed head injury, a postresuscitation Glasgow Coma Scale (GCS) between 5 and 8, and a latency time between the injury and entering the study of less than 5 h. The patients were randomized into enoxaparin and placebo groups. In the enoxaparin group, 0.5 mg/kg enoxaparin was injected subcutaneously every 6 h in six total doses. The two groups were compared for the occurrence of intracranial hematoma (ICH) and for clinical neurological outcome, assessed by the Glasgow Outcome Scale.

Results:

Twenty-seven patients were assigned to the placebo group and 26 to the enoxaparin group. The two groups were similar regarding baseline characteristics, including age, sex, postresuscitation GCS, and best motor response. The occurrence of new ICH or an ICH size increase was insignificantly more frequent in the enoxaparin group than the placebo group (26.9% vs. 7.4%, P = 0.076). The favorable outcome rate in the enoxaparin group was significantly higher than in the placebo group (57.7% vs. 25.9%, P = 0.019).

Conclusions:

This study showed that the early administration of enoxaparin could lead to favorable outcomes in severe TBI patients without significantly increasing cerebral hemorrhagic complications.

Giant Tarlov Cyst of Infancy

We report an 8-month-old female infant with complaints of irritability and recent inability to sit in a stable position. On physical examination, a palpable mass in the left upper quadrant of her abdomen was evident. Sonography and magnetic resonance imaging showed a giant cyst, consisting of 2 communicating compartments: dorsal and ventrolateral. The dorsal part compressed the conus medullaris, and the ventrolateral part compressed the left kidney. Partial cyst wall resection and imbrication for the dorsal pouch were done, and diagnosis of Tarlov cyst was confirmed via the visualization of the endocystic nerve root during surgery. Familiarizing physicians with this unusual presentation of Tarlov cyst may help them in early recognition of this lesion, and subsequent surgery might be considered to prevent clinical sequela. To our knowledge, a lumbar Tarlov cyst presenting as a giant abdominal cyst in an infant has not been reported in the English-language literature.

17-Year-Delayed Fistula Formation After Elective Spinal Instrumentation: A Case Report

Introduction

A late-developing infection after an uneventful initial spinal instrumentation procedure is rare. Delayed infection and new fistula formation have been reported from a few months to 13 years. Here we report an unusual 17-year-delayed fistula formation after primary spinal instrumentation. The patient underwent hardware removal surgery with antibiotic therapy as a definitive treatment.

Case Presentation

Here we report an unusual 17-year delayed fistula formation after primary spinal instrumentation due to spinal trauma. He was admitted to Ghaem General Hospital, a chief referral center, Mashhad, North-East of Iran in August 2014. The patient underwent hardware removal surgery with antibiotic therapy as a definitive treatment.

Conclusions

Late inflammation may occur around spinal instruments and results in cutaneous fistula formation. After oral or intravenous antibiotic treatment, total device extraction is the cornerstone of treatment.

Remote transplantation of a third ventricle colloid cyst: case report

The authors report the case of a 15-year-old girl with a third ventricle colloid cyst. She presented with prolonged headache, nausea, vomiting, and loss of visual acuity with bilateral papilledema. Computed tomography and MRI revealed severe biventricular hydrocephalus with transependymal periventricular fluid and a minimally enhancing cystic mass of the third ventricle. The patient was diagnosed with a colloid cyst and obstructive hydrocephalus, and endoscopic resection with ablation of the cyst remnant was performed. While attempting to extricate the cyst from the patient's head, control of the cyst was lost and the cyst fell into the lateral ventricle beyond the surgeon's view. Postoperative imaging showed that the cyst had settled in the right occipital horn. After 3 years of follow-up, imaging suggests growth of the cyst in its new position without necrosis or displacement on prone imaging.

Transvenous embolization of a carotid cavernous fistula complicated by a hematoma at the tentorial edge

Indirect (dural) carotid cavernous fistulae are generally treated by endovascular surgery primary transvenous embolization that is safe and effective. We describe here a case of a left indirect carotid cavernous fistula that presented with proptosis and eye redness. The patient underwent transvenous embolization of carotid cavernous sinus. The procedure was complicated by a haemorrhage from the cavernous sinus. The post procedural CT scan showed a haematoma at the tentorial edge. Precise diagnosis and prompt treatment could prevent severe complications.

Acute interdural hematoma mimicking epidural hematoma: a case report

Intracranial hematoma rarely presents between two dural layers of pachimeninges. Here, we present a case of an interdural hematoma with similar appearance to an epidural hematoma. A 51-year-old man presented with a left temporal contusion following a motor vehicle accident. After craniotomy and contusion removal, the post-operative CT scan showed a parietal intracranial hematoma located posterior and superior to the bone flap. The CT scan appearance of the new hematoma was similar to the CT scan appearance of an epidural hematoma. Upon operation, we determined that the hematoma was located between two layers of dura mater, i.e., an interdural hematoma. We removed the hematoma and sutured the two layers of dura to each other at multiple sites. Interdural hematoma is a rare entity. Its appearance in a CT scan can be mistaken for an extradural hematoma.