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Introduction and Importance: Neurofibromatosis type 1 (NF1) affects the musculoskeletal system as well as the cervical spine. It is associated with severe, progressive cervical kyphosis. Surgical intervention is the treatment of choice to avoid neurological impairment and malalignment., Case Presentation: We herein report an 11-year-old NF-1 patient with severe cervical kyphosis and intact neurological status. We applied five days of cervical traction followed by surgery utilizing the combined cervical approach (posterior release, anterior corpectomy and reconstruction, and posterior cervicothoracic instrumentation). In one-year follow-up, atlantoaxial dislocation (AAD) and basilar invagination (BI) were detected in neuroimagings. The complication was corrected by adding C1 to the previous construct via unilateral C1 lateral mass screw, contralateral C1 sublaminar hook, unilateral C3 and contralateral C4 sublaminar hook insertion, fixed with contoured rods medial to previous rods. This led to the correction of the AAD and the BI and the patients remained neurologically intact., Clinical Discussion: Severe cervical kyphosis in the setting of NF-1 is progressive and carries a considerable risk of neurologic compromise. Surgical intervention is thus necessary., Conclusion: The combined approach with complete spinal column reconstruction is the surgical approach of choice. However, complete curve correction to near-normal lordosis carries the risk of proximal junctional failure (PJF)., Competing Interests: Declaration of competing interest None of the authors have any conflict of interest to declare regarding the manuscript., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Protective loop ileostomy is performed following low anterior resection (LAR) in patients with rectal cancer to reduce the complications of primary anastomosis. The optimal timing for ileostomy closure remains controversial. The aim of the current study was to compare the effects of early (<2 weeks) versus late (≥2 months) closure of the stoma in patients with rectal cancer undergoing LAR on surgical outcome and complications rates., Methods: This prospective cohort study was conducted in two referral centers in Shiraz, Iran, during a 2-year period. We have consecutively and prospectively included adult patients with rectal adenocarcinoma who underwent LAR followed by protective loop ileostomy in our center during the study period. The baseline, tumor characteristics and complication as well as outcome was recorded in a 1-year follow-up and was compared between early and late ileostomy closure., Results: Overall, 69 patients (32 in early and 37 in late group) were included. The mean age of the patients was 59.40 ± 9.30 years and there were 46 (66.7%) men and 23 (33.3%) women. Patients undergoing early closure of the ileostomy had significantly shorter operation duration (p<0.001) and lower intraoperative bleeding (p<0.001) compared to late ileostomy closure. There was no significant difference between two study groups regarding the complications. Early closure was also not found to be a predictive factor of post-ileostomy closure complications., Conclusion: Early closure (<2 weeks) of ileostomy after LAR in patients with rectal adenocarcinoma is a safe and feasible technique which is associated with favorable outcome., (Copyright © 2023 Asian Surgical Association and Taiwan Robotic Surgery Association. Published by Elsevier B.V. All rights reserved.)

Traumatic brain injury (TBI) is considered among the leading causes of morbidity and mortality worldwide being associated with significant social and economic burden. The best sedative regimen in TBI patients is yet to be identified. This study was designed to determine the effects of dexmedotomdine hydrochloride (Percedex®, DEX) on functional outcome of patients with moderate and severe traumatic brain injury (TBI). This was a retrospective cohort study including patients with severe (3-8) and moderate (9-13) TBI referring to a level I trauma center. We studied two groups of patients, those receiving DEX or routine sedation regimen in neurointensive care unit (NICU). The main outcome measures were the Glasgow outcome scale extended (GOSE) at 3 and 6-month. We have also recorded ICU and hospital length of stay (LOS) and the tracheostomy rate. We included 138 patients in two study groups (each including 69). The baseline characteristics were comparable between groups. DEX was associated with lower LOS in hospital (p = 0.002) and NICU (p = 0.003). The GOSE was comparable between two study groups at 3 (p = 0.245) and 6-month (p = 0.497). Multivariate regression analysis revealed that after LOS of NICU and hospital stay adjustment, DEX group experienced significantly improved 6-month GOSE with the average improvement in score of 0.92 compared to the control group (p = 0.041). DEX administration in patients with moderate and severe TBI was associated with decreased NICU and hospital LOS and improved functional outcome at 6-month., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Traumatic brain injury (TBI) is strongly associated with coagulopathy that occurs in 25-35% of patients. This complication is linked to higher mortality and morbidity. Recent lines of evidance have supported administration of fibrinogen concentrate (FC) in patients with severe TBI, while its efficacy remains controversial. In this study we aim to evaluate the effectiveness of serum fibrinogen level correction from 1.5 and 2.0 g/l to more than 2.0 g/l in patients with severe TBI undergoing traumatic cranial surgery., Method: This randomized, single-blind, placebo-controlled clinical trial included trauma patients who had abbreviated injury scale (AIS) more than 3 in head and below 3 in other organs. FC was administered intravenously to patients with severe TBI undergoing TBI to correct the fibrinogen level above 2 g/l. Patients were randomly assigned to FC and control groups. The amount of intra-operative blood loss, packed cell (PC) transfusion, formation of new intracranial hemorrhage, and hemovac drainage were compared between the two study groups., Results: Forty-seven of 65 participants received the study intervention within 40-112 min of admission. Intra-operative PC transfusion was higher in FC group (80%) compared to control group (55.5%) while the differance was not statistically significant (p > 0.05). Intra-operative blood loss was significantly higher in control group than FC group (P = 0.036). Chance of re-operation and new intracranial hematoma were not significantly different between two study groups., Conclusion: Early delivery of FC, decreases intraoperative bleeding. Although based on our findings it has no other effect on other parameters, further multicenter studies are recommended to investigate the role of early FC administration in management of post traumatic coagulopathy., Competing Interests: Conflict of interest None declared., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Intervertebral disc degeneration (IDD) is the main cause of low back pain, which is a healthcare concern associated with high social and economic burden. The current medical and surgical therapies are inadequate and ineffective. Several miRNAs have been identified that modulate (via up- or down-regulation) the pathogenesis of IDD through various signaling pathways. Understanding the nature of this regulation and their signaling pathways will enable researchers to manipulate miRNA regulation to develop miRNA-based therapies. The development of miRNA-based therapies opens a future window through which to decrease the IDD process or regenerate the intervertebral disc. In the near future, the obstacles associated with miRNA-based therapies will be overcome and these therapies will move from the bench to the bedside.

Ewing sarcoma (ES) is a highly aggressive bone and soft tissue tumor that occurs mainly in young children and adolescents and is associated with primary and metastatic disease. Intramedullary ES (either primary or secondary) is rare, and the ideal management remains inconclusive. We herein report intramedullary and extramedullary metastatic ES in a single patient. A 46-year-old woman was referred to our outpatient clinic from the oncology clinic with progressive paraparesis and paresthesia for 1 week prior to presentation. She had developed left clavicular ES 2 years earlier for which surgery and chemoradiotherapy had been performed. At the present evaluation, she was diagnosed with intramedullary thoracic and lumbar extradural masses. Thoracic surgery was performed, and a biopsy of the lesion was obtained. The diagnosis of ES was confirmed histopathologically, and she underwent adjuvant chemotherapy. Her neurological status did not improve after surgery, and she underwent rehabilitation and physical therapy. The lumbar lesion resolved with chemotherapy. Metastasis of ES to the spinal cord, especially intramedullary lesions, is extremely rare, and there is no standard management guideline. However, surgical decompression and adjuvant chemotherapy are the main treatments in these cases.

During the past 30 years, rate of coronary artery disease (CAD), as the main cause of sudden death (SD), has decreased more than rate of SD. Likewise, cause of SD remains elusive in not a trivial portion of its victims. One possible reason is attention to only one organ, the heart, as the cause of SD. In fact, SD literature focuses more on the heart, less on the brain, and seldom on both. A change is required. In this paper, we first review the pathological findings seen in heart autopsies of SD victims after psychological stressors such as physical assault victims without internal injuries. Then, we summarize new studies investigating brain areas, like the insula, whose malfunctions and injuries are related to SD. Next, we review prototypes of neurological diseases and psychological stressors associated with SD and look at heart failure (HF)-related SD providing evidence for the brain-heart connection. Finally, we propose a new look at SD risk factors considering both brain and heart in their association with SD, and review strategies for prevention of SD from this perspective., (Copyright © 2022 Iranian Neurological Association, and Tehran University of Medical Sciences Published by Tehran University of Medical Sciences.)

Failed Back Surgery Syndrome (FBSS) is persistent pain and disability following lumbar laminectomy which is associated with decreased quality of life and disability and has been reported in up to 40% of the patients undergoing lumbar laminectomy. Several approaches have been introduced to reduce the rate of the FBSS. Among these, applying anti-adhesive barrier gels have been studied with interest with controversial results. The aim of the current study was to determine the effects of anti-adhesive barrier gels on functional outcome and recurrence of patients undergoing lumbar disc surgery. We searched databases including EMBASE, PUBMED, Web of Science, Scopus, Cochrane Library, and scholar databases until November 2019. To assess the heterogeneity across included studies was used Cochran's Q and I-square (I 2 ) statistics. Standardized mean difference (SMD) and 95% CI between were used to estimate pooled effect sizes. Out of 4507, 10 clinical trials found to be appropriate for current meta-analysis. The pooled results of included clinical trials indicated that adhesion barrier gel significantly decreased leg pain (LP) (SMD = -0.31; 95% CI, -0.60, -0.03; P = 0.032; I 2 : 59.2%) among patients with lumbar disc herniation surgery. Back pain (BP) (SMD = -0.03; 95% CI, -0.23, 0.16; P = 0.734; I 2 : 40.2%), and Oswestry disability index (ODI) (SMD = -0.11; 95% CI, -0.27, 0.05; P = 0.178; I 2 : 0.0%), were not significantly affected following adhesion barrier gel application. Application of adhesion barrier gel in single level lumbar disc surgery is associated with deceased leg pain. However, its application does not affect the low back pain, disability and gate. Further, larger randomized clinical trials are required., Competing Interests: The authors declare no conflict of interest., (© 2021 The Author(s).)

The prefrontal cortex is the largest lobe of the brain and is consequently involved in stroke. There is no comprehensive practical pharmacological strategy for ameliorating prefrontal cortex injury induced by cerebral ischemia. Therefore, we studied the neuroprotective properties of verapamil (Ver) on mitochondrial dysfunction and morphological features of apoptosis in transient global ischemia/reperfusion (I/R). Ninety-six Wistar rats were allocated into four groups: control, I/R, I/R+Ver (10 mg/kg twice 1 hour prior to ischemia and 1 hour after reperfusion phase), and I/R+NaCl (vehicle). Animals were sacrificed, and mitochondrial dysfunction parameters (i.e., mitochondrial swelling, mitochondrial membrane potential, ATP concentration, ROS production, and cytochrome c release), antioxidant defense (i.e., superoxide dismutase, malondialdehyde, glutathione peroxidase, catalase, and caspase-3 activation), and morphological features of apoptosis were determined. The results showed that mitochondrial damage, impairment of antioxidant defense system, and apoptosis were significantly more prevalent in the I/R group in comparison with the other groups. Ver decreased mitochondrial damage by reducing oxidative stress, augmented the activity of antioxidant enzymes in the brain, and decreased apoptosis in the I/R neurons. The current study confirmed the role of oxidative stress and mitochondrial dysfunction in I/R progression and indicated the possible antioxidative mechanism of the neuroprotective activities of Ver., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2020 Ehsan Jangholi et al.)

Convincing clinical evidence exists to support early surgical decompression in the setting of cervical spinal cord injury (SCI). However, clinical evidence on the effect of early surgery in patients with thoracic and thoracolumbar (from T1 to L1 [T1-L1]) SCI is lacking and a critical knowledge gap remains. This randomized controlled trial (RCT) sought to evaluate the safety and efficacy of early (<24 h) compared with late (24-72 h) decompressive surgery after T1-L1 SCI. From 2010 to 2018, patients (≥16 years of age) with acute T1-L1 SCI presenting to a single trauma center were randomized to receive either early (<24 h) or late (24-72 h) surgical decompression. The primary outcome was an ordinal change in American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade at 12-month follow-up. Secondary outcomes included complications and change in ASIA motor score (AMS) at 12 months. Outcome assessors were blinded to treatment assignment. Of 73 individuals whose treatment followed the study protocol, 37 received early surgery and 36 underwent late surgery. The mean age was 29.74 ± 11.4 years. In the early group 45.9% of patients and in the late group 33.3% of patients had a ≥1-grade improvement in AIS (odds ratio [OR] 1.70, 95% confidence interval [CI]: 0.66-4.39, p  = 0.271); significantly more patients in the early (24.3%) than late (5.6%) surgery group had a ≥2-grade improvement in AIS (OR 5.46, 95% CI: 1.09-27.38, p  = 0.025). There was no statistically significant difference in the secondary outcome measures. Surgical decompression within 24 h of acute traumatic T1-L1 SCI is safe and is associated with improved neurological outcome, defined as at least a 2-grade improvement in AIS at 12 months., Competing Interests: No competing financial interests exist except for Alex R Vaccaro as follows: Replication Medical, Inc., Stock/Stock Option Ownership Interest; Medtronic, Consulting/Independent Contractor, Receipt of Royalty Payments; Stryker Spine, Consulting/Independent Contractor, Receipt of Royalty Payments; Globus, Consulting/Independent Contractor, Receipt of Royalty Payments; Paradigm Spine, Stock/Stock Option Ownership Interests; Stout Medical, Consulting/Independent Contractor, Stock/Stock Option Ownership Interests; Progressive Spinal Technologies, Service on Scientific Advisory Board/Board of Directors/Service on Committees, Stock/Stock Option Ownership Interest; Advanced Spinal Intellectual Properties, Stock/Stock Option Ownership Interests; Aesculap, Receipt of Royalty Payments; Spine Medica, Stock/Stock Option Ownership Interests; Computational Biodynamics, Stock/Stock Option Ownership Interest; Spinology, Stock/Stock Option Ownership Interests; Flagship Surgical, Service on Scientific Advisory Board/Board of Directors/Service on Committees, Stock/Stock Option Ownership Interests; Cytonics, Stock/Stock Option Ownership Interests; Bonovo Orthopaedics, Stock/Stock Option Ownership Interests; Electrocore, Stock/Stock Option Ownership Interests; Insight Therapeutics, Stock/Stock Option Ownership Interests; Flow Pharma, Stock/Stock Option Ownership Interests; Rothman Institute and Related Properties, Stock/Stock Option Ownership Interests; AO Spine, Service on Scientific Advisory Board/Board of Directors/Service on Committees; Innovative Surgical Design, Consulting/Independent Contractor, Service on Scientific Advisory Board/Board of Directors/Service on Committees, Stock/Stock Option Ownership Interests; Orthobullets, Consulting/Independent Contractor; Thieme, Receipt of Royalty Payments, Deputy Editor/Editor/Editorial Board; Jaypee, Receipt of Royalty Payments; Elsevier, Receipt of Royalty Payments; Taylor Francis/Hodder and Stoughton, Receipt of Royalty Payments; Expert testimony, Consulting/Independent Contractor; Vertiflex, Stock/Stock Option Ownership Interests; Avaz Surgical, Stock/Stock Option Ownership Interests; Clinical Spine Surgery, Deputy Editor/Editor/Editorial Board; Spine Journal, Deputy Editor/Editor/Editorial Board; Prime Surgeons, Service on Scientific Advisory Board/Board of Directors/Service on Committees, Stock/Stock Option Ownership Interests; Dimension Orthotics, LLC, Stock/Stock Option Ownership Interests; Spine Therapy Network, Inc., Service on Scientific Advisory Board/Board of Directors/Service on Committees; SpineWave, Consulting/Independent Contractor, Receipt of Royalty Payments; Atlas Spine, Consulting/Independent Contractor, Receipt of Royalty Payments; Nuvasive, Consulting/Independent Contractor, Stock/Stock Option Ownership Interests; Parvizi Surgical Innovation, Service on Scientific Advisory Board/Board of Directors/Service on Committees, Stock/Stock Option Ownership Interests; Franklin Bioscience, Stock/Stock Option Ownership Interests; Sentryx, Service on Scientific Advisory Board/Board of Directors/Service on Committees., (© Ali Haghnegahdar et al., 2020; Published by Mary Ann Liebert, Inc.)

Background: Acute pain control after supratentorial craniotomy is considered among the most important indicators of postoperative recovery. The aim of this study was to determine the effects of intravenous acetaminophen on postcraniotomy pain., Methods: We searched databases including Embase, Scopus, Medline, Cochrane Library, and Web of Science until April 2019. Cochran Q test and I 2  statistic were used to assess the heterogeneity across included clinical trials. Standardized mean difference (SMD) and 95% confidence interval (CI) were used to estimate pooled effect sizes., Results: Out of 479 reports, 5 randomized controlled trials met the inclusion criteria and were appropriate for our meta-analysis, which included a total of 2635 patients. The pooled results of included clinical trials indicated that paracetamol intake significantly decreased rescue dose (SMD, -0.67; 95% CI, -1.15 to -0.19; P < 0.01; I 2  = 90.0%), total dosage of rescue (SMD, -0.78; 95% CI, -1.18 to -0.37; P < 0.01; I 2  = 86.0%), intensive care unit length of stay (SMD, -0.24; 95% CI, -0.44 to -0.04; P = 0.01; I 2  = 0.0%), and visual analog scale score (SMD, -0.16; 95% CI, -0.31 to -0.00; P = 0.04; I 2  = 71.7%) and increased patient satisfaction (SMD, 0.28; 95% CI, 0.14-0.43; P < 0.01; I 2  = 10.2%) among patients with craniotomy. Time to rescue (SMD, 0.21; 95% CI, -0.42 to 0.85; P = 0.51; I 2  = 94.3%) and hospital length of stay (SMD, -0.04; 95% CI, -0.24 to 0.16; P = 0.69; I 2  = 0.0%) did not significantly change after paracetamol intake., Conclusions: The results of this systematic review and meta-analysis indicate that preoperative intravenous administration of acetaminophen is associated with decreased postoperative pain, need for rescue analgesics, and dosages of analgesics after craniotomy surgery., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aim: To determine the expression profile of miRNA-199a-5p in intervertebral disc degeneration (IDD) and its correlation to the grade of IDD., Material and Methods: This case-controlled study was conducted during a 6-month period from 2017 to 2018 in two university hospitals in Shiraz, Iran. We included 15 patients with grade 3 and 4 of Pfirrmann and 5 patients with traumatic lumbosacral fractures with grade I. Total discectomy was performed in all the individuals and the samples were sent to the laboratory. The nucleus pulposus (NP) cells were isolated and the RNA was extracted. cDNA was synthesized by reverse transcriptase and the expression was measured using real-time polymerase chain reaction (RT-PCT)., Results: We overall included 20 patients in two study groups. Both study groups were comparable regarding the baseline and clinical characteristics except for age (p=0.026). The fold change (p=0.007), and relative expression (p=0.012) of the miRNA-199a- 5p was found to be significantly higher in patients compared to controls. The fold change (p=0.001), and relative expression (p < 0.001) were also associated with the Pfirrmann grading. We found that the area under curve (AUC) was 0.880 (95%CI: 0.721- 0.938) indicative of moderate accuracy., Conclusion: Expression of the miRNA-199a-5p is increased in the IDD. The expression of the miRNA-199a-5p was also associated with the grade of the degeneration based on the Pfirrmann grading.

Objective: Surgical repair and closure of myelomeningocele (MMC) defects are important and vital, as the mortality rate is as high as 65%-70% in untreated patients. Closure of large MMC defects is challenging for pediatric neurosurgeons and plastic surgeons. The aim of the current study is to report the operative characteristics and outcome of a series of Iranian patients with large MMC defects utilizing the V-Y flap and with latissimus dorsi or gluteal muscle advancement., Methods: This comparative study was conducted during a 4-year period from September 2013 to October 2017 in the pediatric neurosurgery department of Shiraz Namazi Hospital, Southern Iran. The authors included 24 patients with large MMC defects who underwent surgery utilizing the bilateral V-Y flap and latissimus dorsi and gluteal muscle advancement. They also retrospectively included 19 patients with similar age, sex, and defect size who underwent surgery using the primary or delayed closure techniques at their center. At least 2 years of follow-up was conducted. The frequency of leakage, necrosis, dehiscence, systemic infection (sepsis, pneumonia), need for ventriculoperitoneal shunt insertion, and mortality was compared between the 2 groups., Results: The bilateral V-Y flap with muscle advancement was associated with a significantly longer operative duration (p < 0.001) than the primary closure group. Those undergoing bilateral V-Y flaps with muscle advancement had significantly lower rates of surgical site infection (p = 0.038), wound dehiscence (p = 0.013), and postoperative CSF leakage (p = 0.030) than those undergoing primary repair. The bilateral V-Y flap with muscle advancement was also associated with a lower mortality rate (p = 0.038; OR 5.09 [95% CI 1.12-23.1]) than primary closure. In patients undergoing bilateral V-Y flap and muscle advancement, a longer operative duration was significantly associated with mortality (p = 0.008). In addition, surgical site infection (p = 0.032), wound dehiscence (p = 0.011), and postoperative leakage (p = 0.011) were predictors of mortality. Neonatal sepsis (p = 0.002) and postoperative NEC (p = 0.011) were among other predictors of mortality in this group., Conclusions: The bilateral V-Y flap with latissimus dorsi or gluteal advancement is a safe and effective surgical approach for covering large MMC defects and is associated with lower rates of surgical site infection, dehiscence, CSF leakage, and mortality. Further studies are required to elucidate the long-term outcomes.

Background: Determining the expression profile and target genes of microRNA (miRNA) would assist in determining the pathophysiologic pathways in intervertebral disk degeneration (IDD). The aim of this study was to determine the expression profile of miRNA in degenerated intervertebral disks compared with normal healthy intervertebral disks., Methods: We conducted a meta-analysis of 3 available miRNA expression datasets to identify a panel of co-deregulated miRNA genes and overlapping biological processes in IDD. Degenerated intervertebral disks were compared with normal healthy disks. We selected 35 miRNA features common to all 3 platforms. Then, we calculated differential expression P values from our unpaired data using metaMA package in R statistical software according to the moderated t test method (Limma). Based on the P values (where the threshold was <0.05), a list of differentially expressed miRNAs was identified., Results: After normalization and selection of common miRNA features across all 3 platforms, we found a total of 5 differentially expressed miRNAs, among which miR-574-3p, miR-199a-5p, and miR-483-5p were not identified in any individual studies. Our results revealed that miR-199a-5p, miR-574-3p, miR-551a, and miR-640 are commonly upregulated in IDDs compared with control disks, whereas miR-483 is commonly downregulated. Pathway analysis of identified dysregulated miRNAs indicated the involvement of extracellular matrix-receptor interaction, adherens junction, and transforming growth factor-beta signaling pathway in the pathogenesis of IDDs. Moreover, the network of predicted targets for these miRNAs identified most affected target genes as ERBB4 and CLTC., Conclusions: We found that the identified miRNAs through meta-analysis are candidate predictive markers for IDDs through different pathways., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: Reoperation after decompressive craniectomy (DC) in patients with traumatic brain injury (TBI) remains a dilemma and the risk factors are to be identified. The aim of the current study was to determine the determinants and risk factors of reoperation after DC in patients with TBI., Patients and Methods: This retrospective case-controlled study was conducted during a 4-year period from September 2013 to October 2017 in a level I trauma center affiliated with Shiraz University of Medical Sciences in southern Iran. We included all the adult (≥18 years) patients with TBI who underwent primary or secondary DC in our center during the study period. Those who underwent reoperation were compared to those who underwent DC only regarding the demographic findings, clinical features and neuroimaging findings. A univariate and multivariate logistic regression analysis was performed to determine the determining factors of reoperation., Results: Overall we included 371 patients with mean age of 36.45 ± 14.18 years. Among the patients there were 325 (87.6%) men and 46 (12.4%) women. The reoperation in patients undergoing DC due to TBI was associated with primary DC (p = 0.039) and higher Marshall grade (p = 0.027). Those who underwent reoperation after DC for TBI had significantly higher ICU (p = 0.007) and hospital LOS (p = 0.001) and lower 6-month GOSE (p = 0.010). Age (p < 0.001), GCS (p < 0.001) and pupils (p = 0.027) were predictors of outcome in reoperation group. Reoperation in primary DC group was associated with pupil reactivity (p = 0.002) and number of episodes with INR above 1.5 (p = 0.037) Conclusion: Reoperation after DC for TBI is associated with primary DC, and Marshall grade. The reoperation after DC is associated with worse outcome and longer ICU and hospital stay. The age, GCS and pupil reactivity are the main predictors of outcome in those with reoperation after DC for TBI., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Traumatic brain injury (TBI) remains a main public health problem being associated with high mortality and morbidity. The functional outcome of TBI remains unfavorable despite several surgical and medical therapies. Cerebrolysin is a neuropeptide with potential neuroregenerative entities., Objective: The aim of the current systematic review and meta-analysis was to investigate the effects of cerebrolysin on functional outcome in patients with moderate and severe TBI., Data Sources: Online databases used included Medline, Scopus, EMBASE, Google Scholar, Web of Science, and Cochrane Library., Study Eligibility Criteria: All the relevant studies with randomized clinical trial and cohort design evaluating the effects of intravenous cerebrolysin vs placebo on functional outcome of patients with TBI within the English literature up to October 2018 were included., Study Appraisal and Synthesis Methods: The articles were reviewed by two independent authors and the data were extracted to a data sheet. I 2 and Cochran's Q -statistics were used to assess heterogeneity. Based on the presence of significant heterogeneity across included studies, data were pooled using random-effects model with Dersimonian-Laird method and presented as standardized mean differences (SMDs) and corresponding 95% CI., Results: Five articles (5,685 participants) were included in the current meta-analysis. The overall pooled findings using random-effects models among patients with TBI indicated that intravenous administration of cerebrolysin significantly increased Glasgow Outcome Scale score (SMD =0.30; 95% CI: 0.18 to 0.42; P <0.001; I 2 : 87.8%) and decreased modified Rankin Scale score (SMD =-0.29; 95% CI: -0.42 to 0.16; P =0.05; I 2 : 89.6%)., Limitations: The results are mainly based on cohort studies and there is a lack of clinical trials in the literature. There is also heterogeneity among the studies regarding the dosage and duration of administration and the measurement of functional outcome., Conclusion: The results of the current study revealed that intravenous administration of cerebrolysin is associated with improved functional outcome in patients with TBI measured by the Glasgow Outcome Scale and the modified Rankin Scale scores., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Study Design: Case report OBJECTIVE.: To report surgical resection of multiple ventral cervical and thoracic lesion being diagnosed as whorling-sclerosing variant meningioma (WSM) and subsequent stabilization of cervicothoracic spine., Summary of Background Data: WSM is a rare histopathology variant of meningioma which is mostly reported in brain and only one case of cervical spine WSM has been reported. Because of the rarity of WSM, there is a paucity of information regarding the clinical, radiological, and histopathologic characteristics., Methods: A 57-year-old lady presented with progressive quadriparesis and myelopathy since 10 days. The spine magnetic resonance imaging (MRI) revealed multiple ventral cervical and thoracic lesions which were hypointense in T2-weighted images with heterogeneous and scant enhancement with gadolinium. The patient underwent anterior cervical corpectomy and gross total resection of the lesion along with 360° fixation in the first stage. The thoracic lesions were also resected totally through laminectomy and right lateral extracavitary approach followed by pedicular screw fixation., Results: The patient improved muscle powers and spasticity and is not independent (Frankel D). The histopathology examination revealed hypocellular lobulated sclerotic mass with whorling pattern of growth in the sclerotic part suggestive of WSM. Immunohistochemical evaluation demonstrated negative staining for epithelial membrane antigen, cytokeratin, Olig-2 and S-100 and immunoactivity for progesterone receptor (PR) and glial fibrillary acidic protein in the tumoral cells located at the periphery. Ki-67 indexing was low., Conclusion: The spine multiple WSM is an extremely rare condition, which has a malignant behavior and it seems that it is spread by cerebrospinal fluid seeding. Surgical removal is hard and requires experience and appropriate equipment., Level of Evidence: 4.

Objectives: The schwannoma of the trochlear nerve is rare and originates mostly from the distal parts in the interpeduncular cistern. A lesion on the proximal segment in the inferior pineal region is extremely rare. Because of the rarity of the disease, the surgical approach to this region for the resection of trochlear nerve schwannoma has not been well documented in the literature. We herein describe a novel approach to successfully resect the trochlear nerve schwannoma., Methods: A 12-year-old boy presented with occipital headache, abnormal gait, and disturbed conjoined eye movement. He was diagnosed with a lesion in the inferior pineal region compressing the superior medullary velum into the roof of the fourth ventricle. A bilateral midline suboccipital craniotomy was performed, and the fourth ventricle was exposed. The lesion was approached through the fourth ventricle superior medullary velum (transventricular transvelar approach). The lesion was totally resected, and his histopathology examination revealed trochlear schwannoma., Results: The patient's symptoms resolved, and he had no recurrence at 12-year follow-up with normal eye movement and vision., Conclusion: The transventricular transvelar approach is feasible and safe to treat a lesion of the lower part of the pineal region being pushed through the superior medullary velum., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: To report the outcome of patients with very small intracranial aneurysm (VSIA) undergoing surgical clipping using a double-clip technique., Methods: This cross-sectional study was conducted in Namazi Hospital, the main referral neurovascular center in Southern Iran during a 6-year period from September 2010 to March 2016. All patients with VSIAs (≤3 mm) undergoing surgery with double-clip technique were included. This technique reduces the clip slippage. The short- and long-term outcomes determined by Glasgow outcome score (GOS), modified Rankin Scale (MRS), and complications., Results: Operations were performed on 32 VSIAs in 26 patients with a mean ± SD age of 55.7 ± 10.1 years. Middle cerebral artery was the most common location for VSIA (50.0%). There was no neck remnant, and the complete occlusion rate was 100%. The rate of intraoperative aneurysm rupture was 30.8%, and none of the patients experienced rebleeding. The 6-month mortality rate was 0% in ruptured VSIAs and 6.25% in unruptured VSIAs. Most of the patients had favorable outcomes (88.5%), and the overall mortality rate was 11.5%. The rate of permanent neurologic deficit was 10.0% in ruptured and 12.5% in unruptured VSIAs. Multivariate logistic regression analysis revealed no association between baseline and clinical characteristics and outcome in this series., Conclusion: VSIAs are difficult to treat because of their small sizes; therefore, with a double-clip technique, one can reduce complications related to the treatment of small aneurysms., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The primitive neuroectodermal tumors (PNETs) of the spine are rare. They are usually intramedullary and reported in children. We herein report an epidural PNET of lumbosacral area presenting with the cauda equina syndrome in an adult. A 38-year-old woman presented to our emergency room with acute onset lower extremity weakness and urinary incontinence. Emergent magnetic resonance imaging revealed a mass lesion isointense on T1-weighted and heterogeneously hyperintense in T2-weighted images in the epidural lumbosacral area. The patient underwent emergent laminectomy of L1-L3 and total resection of the lesion. The patient"s neurological examination improved dramatically after the surgery and after 6-month of follow-up, she was neurologically intact. The histopathological and immunohistochemical evaluations revealed PNET. Epidural PNET of the spinal column, although rare, can present with an acute neurological deficit. Surgery remains the treatment of choice and immunohistochemistry is required for confirming the diagnosis.

Aim: To report the outcome of microsurgical revascularization in patients with Moyamoya Disease (MMD) in Southern Iran., Material and Methods: This cross-sectional study was conducted in Southern Iran during a 7-year period from 2009 to 2016. All the patients with Moyamoya Disease (confirmed with digital substraction angiography) who underwent microsurgical revascularization (extracranial-intracranial bypass or synangiosis) were included. All the patients were followed for at least 1 year and the outcome was measured using the Glasgow outcome scale (GOS) and modified Rankin scale (MRS)., Results: Overall we included 13 patients with 14 involved hemispheres undergoing direct and indirect revascularization. The mean age of the patients was 20.6±17.5 (ranging from 0.5 to 55) years and there were 5 (38.4%) males and 8 (61.6%) females. We did not have any unfavorable outcome defined as mortality and persistent vegetative state. We performed 12 (85.7%) superficial temporal artery (STA)-middle cerebral artery (MCA) bypass and 2 (14.3%) encephalo-myo-synangiosis (EMS) procedures. The symptoms improved in 7 (53.8%) patients and remained as the preoperative course in 5 (38.5%) patients. Only 1 (7.7%) patient developed immediate postoperative vasospasm and brain swelling, and was managed successfully with decompressive craniectomy and subsequent cranioplasty (GOS=5, MRS=0)., Conclusion: This is the first study to report the safety, efficacy and outcome of the direct (STA-MCA bypass) and indirect (EMS) revascularization in patients with MMD in the Iranian population. As the prevalence of MMD is low in Iranian population, the experience and technique remains in its infancy and further advancements in the field is required.

Objectives: To introduce a novel traction device for management of pediatric atlanto-axial rotatory subluxation (AARS) in source limiting areas., Background: Atlanto-axial (C1-C2) joint is accountable for up to two third of total axial craniocervical rotation. Its major role in pivotal rotation of cervical spine makes it more vulnerable to a certain type of injury known as AARS. Management of AARS is based on the Fielding classification which includes closed reduction and immobilization and cervical fusion in unstable cases. There are several cervical traction devices including the Gardner-Wells tongs and halter traction device. All the available devices require insertion of pins into the calvarial periosteum which is a painful, invasive and intolerable procedure especially for the pediatric patients., Methods: We designed a simple hand-made cervical traction device which is composed of 2 soft padded straps (40 × 4 cm) and 2 connecting strings which can be applied easily under the chin and occipital areas of the patients., Results: We successfully treated a 9-year-old girl with AARS with the device. The advantage of the device is its available, inexpensive and non-invasive and the patient might tolerate it more easily compared to the previously designed instruments., Conclusion: This hand-made simple cervical traction device in source limiting centers and hospitals is a good example of doing more with less. It was effective and the tolerance of the patient was acceptable. Further studies with larger series are required for providing appropriate evidence., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Study Design: A randomized clinical trial., Objective: To compare the functional recovery between early kyphoplasty and conservative care in paratroopers with stable thoracolumbar fractures., Summary of Background Data: Treatment of traumatic stable thoracolumbar fractures in young individuals is still a debate. Conservative management and kyphoplasty are options of therapy. But enough data are not available for supporting each., Methods: We included 70 paratroopers with stable thoracolumbar fractures (A1 and A2 classification according to AOSpine thoracolumbar spine injury classification system) presenting <60 days after trauma and hyperintensity in T2-weighted magnetic resonance imaging. Old fractures and those requiring fixation were excluded. Patients were randomly assigned to 2 study groups to undergo percutaneous balloon kyphoplasty (n=34) or conservative care (n=36) by applying orthosis for 2 months. Patients were followed for 12 months and were evaluated clinically using visual analogue scale (VAS) and Oswestry disability index (ODI)., Results: The baseline characteristics were comparable between 2 study groups. The VAS score and ODI decreased significantly in both study groups after 12 months of treatment. The VAS score was significantly lower in kyphoplasty group after the intervention (P<0.001), 1 month (P<0.001), 3 months (P<0.001), 6 months (P<0.001), and 12 months (P<0.001) after the intervention. In addition, the ODI was significantly lower after the intervention (P<0.001), 1 month (P<0.001), 3 months (P<0.001), 6 months (P<0.001), and 12 months (P<0.001) after the intervention. Kyphoplasty was associated with shorter duration of returning to parachuting (P<0.001) and shorter duration of absence from work (P<0.001)., Conclusions: Early kyphoplasty in stable thoracolumbar fractures after parachute jumping is associated with less pain, better functional recovery, less days of absence from work, and shorter duration of returning to parachuting.

The aim of the current study was to investigate the effects of atorvastatin on brain contusion volume and functional outcome of patients with moderate and severe traumatic brain injury (TBI). The study was conducted as a randomized clinical trial during a 16-month period from May 2015 and August 2016 in a level I trauma center in Shiraz, Southern Iran. We included 65 patients with moderate (GCS: 9-13) to severe (GCS: 5-8) TBI who had brain contusions of less than 30cc volume. We excluded those who required surgical intervention. Patients were randomly assigned to receive daily 20mg atorvastatin for 10days (n=21) or placebo in the same dosage (n=23). The brain contusion volumetry was performed on days 0, 3 and 7 utilizing spiral thin-cut brain CT-Scan (1-mm thickness). The outcome measured included modified Rankin scale (MRS), Glasgow Outcome Scale (GOS) and Disability rating Scale (DRS) which were all evaluated 3months post-injury. There was no significant difference between two study group regarding the baseline, 3rd day and 7th day of the contusion volume and the rate of contusion expansion. However, functional outcome scales of GOS, MRS and DRS at 3-months post-injury were significantly better in atorvastatin arm of the study compared to placebo (p values of 0.043, 0.039 and 0.030 respectively). Even though atorvastatin was not found to be more effective than placebo in reducing contusion expansion rate, it was associated with improved functional outcomes at 3-months following moderate to severe TBI., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Cerebral hydatid cyst is among the rare presentations of echinococcosis. Almost all the reported cases of intracranial hydatid cysts are in the cortical regions (parietal lobe in the territory of the middle cerebral artery), and all have been removed surgically using the water jet dissection technique. However, in locations in which there are several neuronal structures, such as the cerebellopontine angle, this method might not be applicable., Case Description: A 62-year-old lady presented to our outpatient clinic with left-sided facial deviation, inability to close the eyes, and diplopia since a month before. She was diagnosed with having a dumbbell-shape lesion in the Meckel cave extending to the left cerebellopontine angle and middle fossa just lateral to the cavernous sinus. As it was adherent to the surrounding structures, we evacuated the contents using a fine needle and then dissected the cyst totally. The patient's symptoms alleviated after the surgery, and there was no residue. After the 2-year follow-up, our patient does not have recurrence., Conclusions: The Meckel cave and cerebellopontine angle are rare locations for hydatid cysts, and the surgical technique is different due to adhesion of the cyst to several neuronal structures (lower cranial nerve, brainstem, and cerebellum). Needle aspiration along with dissection of the cyst microsurgically is recommended in similar cases., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To investigate the determinants of outcome in patients with traumatic brain injury (TBI) undergoing decompressive craniectomy (DC) in a large level I trauma center in southern Iran., Methods: This retrospective cross-sectional study was conducted during an 18-month period from 2013 to 2014 in Shahid Rajaei hospital, a Level I trauma center in Southern Iran. Patients with TBI who had undergone DC were included and the medical charts were reviewed regarding demographics, clinical, radiological and outcome characteristics. The outcome was determined by extended Glasgow outcome scale (GOS-E) after one year of surgery. The variables were compared between those with favorable and unfavorable outcome to investigate the outcome determinants., Results: Overall 142 patients with mean age of 34.8 ± 15.5 (ranging from 15 to 85) years were included. There were 127 (89.4%) men and 15 (10.6%) women among the patients. After 1-year, the mortality rate was 58 (40.8%) and 8 (5.6%) patients were persistent vegetative state. The final outcome was found to be unfavorable in 77 (54.2%) patients.  Unfavorable outcome was associated with lower GCS on admission ( p<0.001 ) as well as occurrence of postoperative hydrocephalus ( p=0.011 ). Formation of the postoperative subdural hygroma after the operation was found to be associated with favorable outcome ( p=0.019 )., Conclusion: DC in patients with TBI is associated with favorable outcome in most of them. On admission GCS, postoperative hydrocephalus and presence of postoperative subdural hygroma are among the important predictors of outcome in TBI patients undergoing DC., Competing Interests: There isn’t any conflict of interest to be declared regarding the manuscript.

Objective: Scorpion stings are a major public health problem in many countries, particularly in pediatrics. Children are more susceptible to severe clinical manifestations of envenomation. The aim of this study is to determine the epidemiological and clinical characteristics of pediatric scorpionism in Hormozgan province of Iran during 2012., Method: This was a cross-sectional study being conducted during 2010 in Hormozgan, the southern province of Iran. We included 350 patients admitted to emergency unit of the hospitals of 8 cities of Hormozgan with impression of scorpion envenomation. The clinical and epidemiological characteristics as well as the treatment and outcome were recorded., Results: The prevalence rate of pediatric scorpion stings in the province was 1.8 in 1000 children. The mean age of the patients was 5.75 ± 4.54 (range, 1-18) years. There were 208 (59.5%) boys and 142 (40.5%) girls among the patients. The most common site of sting was sole to knee in 94 (26.8%) followed by hand in 61 (17.4%) and fingers in 47 (13.4%). The most common presenting symptom was vomiting in 236 (67.4%) followed by localized pain in 131 (37.3%), erythema in 120 (34.2%), and edema in 119 (33.9%). The highest and lowest frequency occurred in July (17.7%) and January (3.2%), respectively. Nocturnal envenomations (53.7%) were more common than diurnal (46.3%). Most of scorpionism were mild (83.4%) that all evolved to cure, without any deaths., Conclusions: The results demonstrate the pediatric scorpionism is a public health problem in Hormozgan province of Iran, and special attention should be paid to prevention and treatment.

Objective: This study investigated effects of oral glibenclamide on brain contusion volume and functional outcome of patients with moderate and severe traumatic brain injuries., Methods: A randomized clinical trial including 66 patients with moderate (Glasgow Coma Scale score 9-12) to severe (Glasgow Coma Scale score 5-8) traumatic brain injury and brain contusions of <30 mL volume was conducted from May 2015 to August 2016 in a Level I trauma center in southern Iran. Patients who required surgical intervention were excluded. Patients were randomly assigned to receive 10 mg oral glibenclamide daily for 10 days (n = 29) or placebo in the same dosage (n = 23). Brain contusion volumetry was performed on days 0, 3, and 7 using spiral thin-cut brain computed tomography scan (1-mm thickness). Outcome measures including modified Rankin Scale, Glasgow Outcome Scale, and Disability Rating Scale were evaluated 3 months after injury., Results: There was no significant difference between the 2 study groups in baseline, day 3, and day 7 contusion volumes. Patients receiving glibenclamide had a significantly lower expansion ratio from first to second volumetry (P < 0.001). Similarly, the first to third expansion ratio was significantly lower in the glibenclamide group compared with placebo (P = 0.003). There was no significant difference between the 2 groups regarding functional outcome measured by Glasgow Outcome Scale, modified Rankin Scale, and Disability Rating Scale., Conclusions: Oral glibenclamide is associated with decreased contusion expansion rate in patients with moderate and severe traumatic brain injuries sustaining cerebral contusions., (Copyright © 2017 Elsevier Inc. All rights reserved.)