Search

Background: The literature does not offer the rate of protection provided by different types of helmets used, especially as it applies to developing countries. We hypothesize that standard versus nonstandard types of helmets might differ in the rate of complications of head and neck trauma occurring in victims of motorcycle accidents. Here we report the rate of occurrence, the type of injuries and differences thereof in standard and nonstandard helmet bearers, and its relevance to protection from serious injury., Methods: The data were gathered from a data set of motorcycle accident victims admitted to the emergency department of Sina Hospital (Teheran/Iran). A cross-sectional study was designed for a 6-month period of time, June to December 2007. Variants analyzed included: demographics, types of helmets used, level of education of the victims (as in: being trained for using helmets and status of holding a valid driving license). The latter variants were evaluated for possibly influencing the outcome of the injured motorcyclists using either kind of helmets., Results: Among a total of 576 injured motorcyclists who had head, face, or neck injuries, 432 (75%) were using some kind of helmet. A total of 144 (25%) of the injured patients were admitted to the neurosurgical emergency service. There were 100 patients whose data sheets contained all variables which could be included in the pilot analysis of this cohort., Discussion: All 100 subjects were male patients with the age range of 32 ± 11 years. Twenty-five percent were using standard helmets at the time of accident, 43% had no cranio-facio-cervical injury except very mild skin abrasions, and 23% had facial injury, including skin lacerations needing sutures, two nasal bone fractures, and no maxillofacial damage. Among the patients using standard helmets, 44% had head injuries which needed to be taken care of (mostly nonoperatively), while 61% using nonstandard helmets had head trauma (P > 0.05). The other variables did not reach a significant value affecting the use of either standard or nonstandard helmets in prevention of craniofacial damages., Conclusion: This pilot analysis (comprising the data from 100 cases of motorcycle accidents) could not demonstrate statistically significant differences in injury patterns of different types of helmets and variants influencing their respective use. However, it can lead the way for further analysis of larger and more comprehensive head trauma databases regarding factors contributing to the issue of head injury.

Osteoid osteoma affects the spine in only 10% of cases. More than 50% of the spinal cases involve the lumbar and cervical vertebrae. Involvement of C-1 and C-2 vertebrae has previously been reported only very rarely in the published literature. The authors report 4 cases of upper cervical osteoid osteoma, 1 involving C-1 and the other 3 C-2, and they discuss different aspects of management in similar cases. The patients were 14, 17, 35, and 46 years old, and all presented with neck pain and various degrees of painful limitation of head rotation not ameliorated by ordinary analgesics. Radionuclide isotope bone scans, CT scanning, and MR imaging were helpful preoperative diagnostic modalities. The first attempt at eradication of the lesions failed in 2 cases and the lesions could be excised totally at a second approach. Postoperatively, the patients all became pain free and gained full range of neck motion. There has been no tumor recurrence and no sign of instability in short- to medium-term follow-up. Among the several etiologies mentioned for neck pain and torticollis, osteoid osteoma of the first 2 cervical vertebrae should be considered as a possible but rare cause. Even though different kinds of management have been mentioned for osteoid osteoma, resection of the lesion remains the best option for achieving a cure.

The authors report the clinical features, imaging and surgical findings, and follow-up of 5 rare cases of schwannoma of the middle fossa with possible origin from the greater superficial petrosal nerve (GSPN). All patients presented to a single neurosurgical institution. The study design was a prospective follow-up of 5 cases of schwannomas of the middle fossa that most likely originated from the GSPN. The presenting features were burning pain in the eyes in 2 cases, epilepsy and behavioral changes in 2 cases, and headache in 1 case. Imaging studies showed a subtemporal mass on the anterosuperior aspect of the petrous bone in all cases. An enhancing tail on the MR images was highly suggestive of the origin of the tumor from the GSPN. All tumors were removed through a subtemporal extra- or intradural approach. Partial to complete peripheral facial nerve palsy was encountered after surgery in 3 cases, which recovered completely. Dry eye was the long-term permanent deficit in all cases. Mid- to long-term follow-up of the cases has not revealed any tumor recurrence. The 5 cases of schwannoma of the middle fossa with possible origin from GSPN were managed successfully, and their clinical presentation, differential diagnosis, and management are discussed.

Background: The ETR that should be undertaken in patients with GBM remains controversial. This study aims to reiterate some independent predicting factors and to underscore the role and the ETR in increasing the survival of patients in the situation of developing countries, that is, without preoperative MRI or tractography. The authors submit additional information to be added to the list of CTRs in the management of malignant brain tumors., Methods: The authors prospectively analyzed a cohort of 35 consecutive patients with histologically proven GBM who underwent tumor resection in surgically amenable areas for the first time at Sina Hospital, Tehran, between 2003 and 2005. Demographic data, volumetric measurements, and other characteristics identified on preoperative and immediate postoperative MR imaging as well as intraoperative and postoperative clinical data were collectively analyzed by SPSS for Windows, version 11.5 (SPSS, Chicago, Ill)., Results: Cox proportional hazards model multivariate analysis identified the following independent predictors of survival: Karnofsky performance scale ≥80 (P = .01), ETR (P = .01), tumor location in functionally silent prefrontal area (P = .002) vs tumor location in corpus callosum (P = .001), postoperative RT (P = .004), and postoperative chemotherapy (P = .001), Conclusion: Maximal resection of the tumor volume is an independent variable associated with longer survival times in patient with GBM. Gross total resection should be performed whenever possible, although not at the expense of increased morbidity., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Unlabelled: BACKGROUND/SUBJECT: A rare case of osteoblastoma of the third cervical vertebra (C3) occurring in a 16-year-old adolescent is presented. He was admitted suffering from neck pain for more than 3 years., Method: Plain X-rays, technetium bone scanning, CT scan and MRI indicated an expansile, partially sclerotic lesion of the C3 involving the superior facet and pedicle on the right side. The lesion was excised through a posterior approach., Result: Even though the 18-month follow-up is still a very short interval in our case, the subject's neck pain has resolved completely and there has been no sign of tumor recurrence in the recently taken imaging. There has been no clinical or radiologic sign of instability in the follow-up investigations. To the best of our knowledge, this is the third case of C3 osteoblastoma reported in the literature, highlighting the predilection of the reported cases to occur in 14- to 16-year-old boys., Conclusion: A full investigation is indicated in youngsters suffering from persisting neck pain and complete resection of the lesion can prevent recurrence and malignant transformation. Long-term follow-up is needed to declare a lifelong cure of the disease., (Copyright © 2011 S. Karger AG, Basel.)

Background and Objectives: Child abuse with sewing needle is a rare but well-known homicide attempt threatening the life of victims. Information about diagnosis and treatment of such cases either in the acute or chronic phases is lacking and ambiguous in the literature. This study intends to report the experience of 6 victims of homicide attempt who presented to the authors in different decades of life and were managed in different ways. This may deliver some evidences to the literature regarding management of further cases encountered by neurosurgeons., Material and Methods: The authors had the chance of managing 6 patients referred to their trauma center harboring one or more sewing needles within their cranium. There were 3 male and 3 female patients, with 2 patients in their first decade of life, and the others, each in either decade of life. The youngest was 6, and the eldest 51 year old. The elder patients were having vague headaches, for which a plain skull x-ray or CT of the brain lead to the diagnosis of persisting intracranial foreign bodies. Chronic headache was the main complaint of the patients. Four patients underwent surgical removal of the sewing needle, and 2 are being followed., Results: Among the 4 patients who underwent surgery, 1 died after a short period of 'akinetic mutism.' Headache and limb paresthesia improved 6 months after the operation in 2 cases, and the other 1 remained unchanged. The cases under observation have been doing well. Biochemical analysis of the rusted needle showed a composite of oxidant form of some of the elements of needle such as Fe, Mn, and Cr., Conclusion: In spite of standard algorithms proposed for management of penetrating head wounds, selection of the best treatment in the victims harboring sewing needles in their brain needs close cooperation between neurosurgeons, pediatricians, psychiatrists, and social workers. Furthermore, there is no absolute indication for removing sewing intracranial needles detected in the later decades of life., (Copyright 2009 Elsevier Inc. All rights reserved.)

Pilomyxoid astrocytoma (PMA) is a recently described tumor typically occurring in the hypothalamic-chiasmatic region of very young children. PMA is characterized by a more aggressive course than pilocytic astrocytoma and exhibits certain differing histological features. We report a PMA in an adolescent patient with visual field disturbance. Imaging studies revealed enlargement of the sella turcica due to a homogenously enhancing sellar and suprasellar mass identifiable both on CT scans and MRI. We believe that PMA may be included in the list of differential diagnoses of the lesions expanding the sella turcica.

Introduction: Cerebral hydatidosis is a rare larval infection of the central nervous system affecting mostly the children and young adults., Case Report: The authors report a case of a 5-year-old girl harboring a large right frontoparietal hydatid cyst. The imaging studies were not diagnostic for 'cerebral hydatidosis' and were interpreted as 'brain abscess'., Discussion: Attempting for simple cannulation of the lesion through a burr hole drained a clear fluid. The cannula was removed promptly but the cyst wall came out little by little through the hole in a single piece which turned out to be the entire wall of a hydatid cyst. She was treated by antihelmintic medications for 6 months and there has been no sign of recurrence after a year. Odd paraclinical imaging characteristics and unique accidental surgical event makes this case the first reported pediatric brain hydatidosis with spontaneous complete delivery of the cyst through a single burr hole which can certainly be considered a wrong attempt if undertaken intentionally.

Nonmissile low-velocity penetrating brain injuries are unusual among civilian population. Work-related penetrating head wounds are rarer among this group. Here, we report two rare cases of penetrating head wounds caused by industrial grinder tool. The patients (both men) were struck to the head by detached blades of the grinder tool. Depressed fractures, penetrated bone fragments, and dural lacerations were all treated by the routine fashion. Paranasal sinus damage and further cerebrospinal fluid leakage were also treated conservatively. The reported cases are unexpected variants of injuries that neurosurgeons may come across and their management is still beyond the scope of textbooks. Skill and experience of the general neurosurgeons can handle the cases properly but prevention of such incidents using safer and guarded instruments should be stressed to manufacturers.

Background: Traumatic rotary posterior dislocation of C1 on C2 without fracture (TRPDAAWF) is a very rare complication in severe accidents, and its pathophysiology is still under debate., Case Description: Although 6 similar cases have been reported previously, we report the lessons learned during handling of the patient. A young man who is a victim of severe car crash injury, with neglected displacement of the intact odontoid process to the front of the anterior arch of C1, is reported. Some problematic and life-threatening events in the management of the case are presented., Conclusions: We report a new and rare case of TRPDAAWF. It is hypothesized that a similar situation could only be possible if rotary subluxation of C1 on C2 follows a severe hyperextension injury; otherwise, traumatic fracture of the odontoid process might have been inevitable.

Background: General anesthesia and regional anesthesia have both been shown to be suitable techniques for patients undergoing lower thoracic and lumbar spine surgery; however, GA is the most frequently used method. The purpose of this study was to conduct an acceptable RCT to compare the intraoperative parameters and postoperative outcome after SA and GA in patients undergoing elective lumbar disk surgery., Methods: Patients undergoing laminectomy for herniated lumbar disk during the years 2005 and 2007 were enrolled. They were randomly selected to undergo GA and SA. The variables recorded during the operation were the patients' HR, MAP, amount of blood loss, and surgeons' satisfaction with the operating conditions. The severity of pain, nausea, vomiting, and length of stay in the hospital were recorded in the postoperative course., Results: The mean blood loss was less in the group undergoing GA; however, the difference was not statistically significant. The surgeon's satisfaction was reported to be higher in the GA group. No major intraoperative complication was reported in either series. During the recovery period, hypertension was reported to happen more frequently in the patients undergoing GA; and postoperative nausea and vomiting were more frequent among patients recovering from SA., Conclusion: Contrary to previous studies, the findings of the present study revealed that SA has no advantages over GA. Moreover, it was showed that GA can reduce the related risks and complications in several aspects.

Objective: To evaluate the correlation between admission Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS) in chronic subdural hematoma (CSDH)., Methods: 128 consecutive patients (107 men and 21 women) with CSDH were studied and the correlation between GCS on admission and postoperative GOS was determined., Results: GCS and GOS were correlated with a Spearman rank correlation coefficient of 0.557 (p<0.01)., Conclusion: GCS and GOS are well-correlated in CSDH.

The object of this study was to determine the relationship between outcome (assessed by Glasgow Outcome Scale) and recurrence in chronic subdural haematoma (CSDH). Eighty-two consecutive patients who underwent surgery for CSDH were included in this study. The relationship between the following variables and CSDH recurrence was studied: sex; age; history of trauma; Glasgow Coma Scale (GCS) at the time of admission (stage 1: GCS>12, stage 2: GCS: 8 - 12, stage 3: GCS<8); interval between head injury (when a history of trauma was present) and surgery; presence of a midline shift on CT scans; presence of intracranial air 7 days after surgery; haematoma density; haematoma width; presence of brain atrophy; and Glasgow Outcome Scale (GOS, both quantitative and non-quantitative) at the time of discharge. Throughout the analysis, p<0.05 was considered statistically significant. The results showed lower GCS (p<0.001), higher GOS (p<0.001), presence of intracranial air 7 days after surgery (p=0.002), and a high density haematoma (p<0.001) were significantly associated with recurrence of CSDH. It was concluded that GOS is related with recurrence in CSDH.

Objective: The aim of this study was to present 4 rare cases of medullary compressive lesions presenting with IH, to discuss the indications for neurosurgical decompression in such cases, and to review the possible etiologies of IH briefly., Methods: The reported cases include (1) a 19-year-old adolescent boy and a 21-year-old man with Chiari I malformation and cervical syrinx compressing or tightening the cervico-medullary junction; (2) a 35-year-old man with ependymoma extending from the lower half of the fourth ventricle to C1/C2 junction and compressing this part of the medulla; and (3) a 16-year-old adolescent boy who was referred to the emergency department in severe distress because of IH, occurring as a result of a distal PICA aneurysm located on the floor of the lower triangle of the fourth ventricle., Results: Surgical decompression in all the cases was successful in withholding the hiccups., Conclusion: The dorsal medullary area is not an unusual location for genesis of hiccup. When encountering a case of IH, appropriate CNS imaging studies should be included in the evaluation protocol.

Objectives: Chronic subdural hematoma (CSDH) is one of the most frequent types of intracranial hemorrhage. We evaluated the independent association between abnormal CT findings in CSDH and both Glasgow coma score (GCS) on admission as a measure of consciousness and Glasgow outcome score (GOS) at discharge as a measure of outcome., Patients and Methods: One hundred and sixteen consecutive patients with CSDH were studied. The variables considered were brain atrophy, hydrocephalus, hematoma location, midline shift, and hematoma density. After univariate analysis and evaluation of the role of age as a confounder in bivariate analysis, variables that had significant association with Glasgow scores were included in the final multivariate model., Results: Brain atrophy was the only variable with significant independent association (p<0.001; OR=77.214; 95% CI=8.336-715.212) with unfavorable outcome as defined by GOS. On the other hand, hydrocephalus (p=0.042; OR=6.503; 95% CI=1.072-39.449) and higher hematoma densities (p=0.027; OR=2.597; 95% CI=1.116-6.024) independently and significantly increased the risk of severe consciousness impairment when the group with GCS>12 was considered as the reference category., Conclusion: Brain atrophy independently increases the risk of unfavorable outcome after CSDH. Hydrocephalus and higher hematoma densities independently increase the risk of severe consciousness impairment after CSDH.

Background: The differential diagnosis for a dorsal midline mass presenting in a newborn encompasses a wide range of pathological conditions, including spinal dysraphisms, tumoral overgrowths including teratoma and hamartoma, disturbances in regression of fetal tail, and pseudotail formation., Objectives: To present (a) three rare cases of human tails and one case of tethered cord due to a midline anomaly resembling part of a human limb, (b) to discuss different kinds of clinical and pathological conditions which may be encountered in such newborns, (c) to hypothesize a theory about genesis of these congenital lesions, and (d) to remind drawbacks in preoperative evaluations and surgical management of these newborns., Materials and Methods: Four newborns with dorsal midline malformations initially diagnosed as heterotopias are presented. Appropriate preoperative investigations and proper surgical interventions leading to resection of the lesions were performed. All four were skin-covered lesions containing well-differentiated cellular elements of fat, vascular, muscular, bony, and cartilaginous origin. Midline spinal dysraphism was detectable both pre- and intraoperatively only in one case in which cord untethering was also performed along with the first surgical intervention. In the other three "tailed cases," midline bone defect could not be detected in the available X-ray films; consequently, simple excision of the tail-like lesions was done. The first patient had to be explored for repeat untethering of the cord after 4 years, but the others have not yet developed any sign of tethering during an average period of 12 years follow-up., Conclusion: Morphological diagnosis of these lesions is not easy, and the attending pediatrician and neurosurgeon should be familiar with the differential diagnosis of such lesions and be prepared for possible time-consuming operation mandatory to achieve total resection of the lesion in a newborn under general anesthesia. Reviewing the possible theories regarding the genesis of such anomalies, it is hypothesized and suggested that all similar cases could have been of hamartomatous origin rather than defects of embryogenesis.

Background: During military conflicts, surviving victims traditionally underwent large enough craniectomy or craniotomy to achieve extensive debridement of the in-driven bone, shell fragments, and debris. Meanwhile, the completely as well as the partially devitalized adjacent brain tissue would also be debrided. This might have led to additional neurologic deficit or lesser degree of recovery of functions., Method: We studied the efficacy and safety of much more limited or even absence of surgical intervention in a selected group of wartime head-wounded patients. Among 1,150 war victims with penetrating head wounds referred to two major centers affiliated with Tehran University of Medical Sciences during the 8-year period spanning the Iran-Iraq conflict, there were 191 head-wounded patients who underwent either no surgical intervention or a very limited debridement. We have attempted to follow up as closely as possible for more than 8 years. Ninety-nine of them fulfilled the criteria to be included in this series. Close follow-up for development of cerebral infections, functional recovery, or development of new neurologic deficits and epilepsy were performed. At least 3 contrast-enhanced CT scans were taken for each patient. All patients were victims of the battle-field areas with low- to moderate-velocity missile or shell fragment injury. The Glasgow Coma Scale (GCS) scores of the patients were between 8-14 when visited by the first attending neurosurgery staff. The factors considered to be effective in the outcome analysis were the entry point, the number of the in-driven bone fragments, the retained shell fragments, the brain compartments affected, and the paranasal sinus or skull base involvement with or without cerebrospinal fluid (CSF) fistula., Results: There were 13 unilobar, 44 bilobar, 4 trilobar, 38 transventricular, and 3 skull base lesions. The number of retained metal fragments varied between 1 to 6. The number of retained bone fragments varied between 1 to 5 in 73 victims and more than five chips in other cases. The outcome was good (back to work) in 90 patients and poor (severely disabled) in 4. Five patients died because of severity of brain damage and meningitis. The effect of the different enumerated variables upon the outcome was measured using chi(2) and Fisher exact test, which was nonsignificant for all of the variables except for the orbitofacial entry point of injury (p = 0.00006)., Conclusion: This study seems to indicate that not only is reoperation for retained bone or shell fragments unnecessary, but surgeons having modern neuroradiological instruments available to detect the proper explanation for changes in GCS of the patients may decide not to proceed with any surgical intervention in a good number of patients. As a result of the "no surgical treatment protocol," one can preserve cerebral tissue without exposing the patient to undue risk of seizures, infection, or death by leaving behind some or all the in-driven bone and shell fragments.

Background: Growing skull fractures rarely develop in the skull base region. To the best of our knowledge, only two similar cases have been reported in the English literature. This rare complication, which can occur even after a mild head injury, can produce exophthalmos and threaten the vision., Methods: The clinical and radiological findings of expanding leptomeningeal cysts extending into the orbit in nine patients referred to the department of Neurosurgery are presented. After appropriate investigations confirming the presence of the expansile retroglobal lesion, surgical exploration was performed via fronto-lateral or the preferred fronto-basal approach. The variable findings are denoted and the relevant literature is also reviewed., Results: Frontobasal head injuries play an important role in pathogenesis of these traumatic expansile leptomeningeal cysts. In this series of nine young girls, 6.65% (six out of nine) injuries happened in the first decade of life with an interval of 2 to 12 months (mean = 6.7, SD = 9.7). High-resolution coronal view computed tomography (CT) scanning with bone density window images, and high intensity cystic lesions visible on T2-weighted coronal MR images were diagnostic clues., Conclusions: Growing fractures of the anterior skull base may complicate the natural course of healing of any minor frontobasal head injury, especially during childhood. Good quality imaging is mandatory in cases of progressive unilateral exophthalmos. Proper surgical intervention will lead to a good cosmetic result.

The authors report four very rare radiation-associated tumors (or radiation-induced tumors; RITs) of the central nervous system (CNS) and review the literature on this topic. The purpose of this study was to determine the possible relationship between the harmful effects of radiation therapy, the shortest and the longest interval between the time of irradiation and the occurrence of the secondary tumor, and possible predisposing factors. The tumorigenic effects of therapeutic irradiation of the CNS have been mentioned in the literature, but the authors' literature search did not disclose either many reports of cases such as their own or a satisfactory and concise discussion on the different aspects of the late and catastrophic complications of this method of adjunct therapy to the CNS. Four rare cases of RIT in three patients are presented: a unique case of intradural meningioma of the cervical spine, which was irradiated successfully only for the patient to present with a new high-grade cerebral astrocytoma 4 years later, a paraventricular cavernoma and a fronto-temporo-orbital chondrosarcoma. These second RITs became symptomatic in the 17th, 16th and 15th years of life, respectively, in these young patients. The primary lesions were ependymomas, two in the IV ventricle and one in the left hemisphere. The time intervals between radiation and secondary tumor presentation were 14 and 18 years, 9 years and 28 months, in the order in which these patients presented. All the patients survived the second operation except the one with chondrosarcoma, who died in spite of repeated surgical interventions and adjunct therapies. It is concluded that the development of secondary RITs does not necessarily require a very long time interval; that although sarcomas are the most common RITs of the CNS in childhood and adolescence, benign and other rare and curable lesions may also occur in the field or vicinity of the field of radiation; and that in view of the possibility of occurrence of different types of RITs after varying time intervals in a single patient, whole-life followup of similar patients is mandatory.

The objective of this work was to gain more insight into the controversial characteristics of meningiomas occurring during childhood and adolescence. Management of meningiomas is an important field in pediatric neurosurgery. Every pediatric neurosurgeon has tried to resolve the problems relating to the clinical characteristics, biological behavior and outcome of this interesting and almost benign pathology, which rarely occurs in the first two decades of life. The records on central nervous system (CNS) tumors held by the two major neurosurgery centers of Tehran Medical University and Arad General Hospital were prospectively collected during last 15 years. Complete medical records are available for all 24 cases, and long-term follow-up was achieved 19 patients. All the cases were diagnosed and treated after the introduction of computed tomographic (CT) scanning. Angiography and magnetic resonance imaging (MRI) were performed as complementary studies in some cases. The sample consisted of 13 girls and 11 boys. The age range at the time of diagnosis varied between 2 and 17 years, with a mean of 9.47 and standard deviation of 3.43. Fifteen patients were below 10 years of age (62.5%), and 9 of them were between 10 and 17 years old (37.5%). The most common presenting symptoms, in declining order of frequency, were headache, epilepsy and focal neurological deficits. Similar cases associated with neurofibromatosis either at the time of presentation with meningioma or during the follow-up period were excluded (5 cases). The size of the presenting tumor was more than 5 cm in diameter in 17 cases. The locations of the lesions, taken as the site of the presumed widest dural base in each case were: spinal, orbital, ethmoidal and sphenoethmoidal in 1 case each, petroclival in 2, and tentorial or supratentorial in 18 patients. The only predisposing factor in this series of childhood meningiomas was whole-axis irradiation for previous malignancy in the case presenting with cervical intradural meningioma. There have been no surgical deaths, and gross total excision of the lesions was achieved in 21 cases. Tumor recurrence was observed during the follow-up period in 6 cases (25%). The follow-up period varied between 2 and 165 months, with a median interval of 130.2 months. This series of pediatric CNS meningiomas comprises almost 1.08% of all meningiomas operated on by the authors during the last 15 years and it also accounts for about 1.1% of all pediatric CNS tumors encountered. This series of patients has certain characteristics regarding sex distribution, unusual size, peculiar localizations, special histological features and benign clinical behavior distinguishing it from other series reported in the literature.

Background: Extracranial vessel injuries are potentially devastating complications of penetrating head and neck wounds associated with war conflicts. These vasculopathies may be occlusive or they may lead to formation of traumatic aneurysms (TA) and arteriovenous fistulae (AVF). Even though these penetrating injuries are usually clinically silent and often appear only as small superficial wounds, they may lead to catastrophic hemorrhage or vascular insult. In this study, we attempted to elucidate signs, symptoms and circumstances present in these victims who are at risk of harboring an occult vasculopathy, excluding the occlusive ones and concentrating primarily on TAs and AVFs., Materials and Methods: In a prospective study conducted during 8 years of war between Iran and Iraq, we encountered 13 cases of traumatic vasculopathies of the extracranial carotid and vertebral arteries. The type and number of injuries were: carotid-jugular fistula (CJF) 3, carotid trunk or branch aneurysm (CA) 2, superficial temporal artery aneurysm (STA) 3, vertebral artery aneurysm (VA) 2, vertebral arteriovenous fistula (VAVF) 1, ophthalmic artery aneurysm (Oph. An.) 1, and lingual artery aneurysm (Lin. An.) 1. Angiography was performed between the 5th and 30th day after the injury and surgical intervention was performed in all cases., Results: The Glasgow outcome scale (GOS) score was 13-15 in all victims at the time of discharge from the base hospital without any additional neurological deficit. The follow-up period varied from 5 to 8 years in all cases in whom no further morbidity or mortality occurred. Single photon emission computed tomography was the noninvasive tool used for measurement of cerebral blood flow in the cases in which a major vessel ligation was performed; no remarkable change in cerebral blood flow was noted., Conclusion: Early recognition of stigmas suggesting possible formation of extracranial traumatic vasculopathies such as TAs or AVFs in the difficult situation of war frontier hospitals should be highlighted for attending physicians or younger neurosurgeons. Performing angiography promptly in suspected cases can pick up such traumatic vascular lesions earlier. Using simpler surgical techniques in situations in which more sophisticated endovascular equipment is unavailable can be life-saving for these usually young victims.

Skull base venous fistulas are rare. A 15-year-old boy was stabbed in the left side of his neck, just below the mastoid process. Two years later, he presented with a protruded and pulsating left eye with red sclera. A soft murmur was audible all over his head and neck. Angiography revealed an arteriovenous fistula between the third portion of the vertebral artery (V3) and the vertebral venous plexus, as well as the ipsilateral jugular vein (VVJF). The fistula recruited several arterial feeders and rising the venous pressure along the outflow system of the skull base had led to unilateral exophthalmos.

Background: Air-gun pellet injuries (AgPI) of the central nervous system (CNS) are rare but catastrophic events. They occur mostly in children and young adults. The entrance is usually either through the orbit or through the neck and the entry wound is so small that it may be disregarded on physical examination in the emergency room. Early recognition and correct management of the possible complications of AgPIs is important and may prevent a poor outcome. METHODS We intend to present our experience with 16 cases of AgPIs of the head and neck referred to the department of neurosurgery during the last 15 years. The characteristic findings on physical examination of the cases and the imaging studies performed are described. Special management undertaken for the rare complications are mentioned and a short literature review is performed on each entity. RESULTS All our cases happened in the first and second decades of life and only in boys playing with toy guns. There were 12 head and face and four neck wounds. Damaged globe that had to be exenterated was the earliest complication, handled by ophthalmologists (four cases). Cerebrospinal fluid (CSF) leakage, meningitis, brain abscess formation, development of traumatic aneurysm (TA), carotid-cavernous sinus fistula (CCF), wandering intracerebral and intraventricular pellet, and splitting of the pellet after striking hard bone were the complications noted. In addition to plain X-ray films, computed tomography (CT) scanning and angiography were diagnostic procedures of choice. CONCLUSIONS The present series of patients is the largest collection of AgPIs to the head and neck reported in the literature in which nearly all the possible complications of such injuries have been reviewed. Early recognition and awareness of the possible cumbersome complications of such a minor penetrating wound can prevent major catastrophies in this young group of victims.

In the early days of the war between Iran and Iraq, reports of the sudden deaths of soldiers who previously had survived a penetrating head injury suggested the possibility that a late complication, traumatic aneurysm (TA), could be the cause of this catastrophe. In response, the authors planned a prospective study to perform cerebral angiography in victims with penetrating head traumas, especially in those who had artillery shells or bone fragments passing through areas of dense vasculature. Thirty-one TAs and arteriovenous fistulas were documented. Not all of the lesions, however, were deemed appropriate for surgical intervention. Six aneurysms (19.4%) healed spontaneously and shrank or disappeared on repeated serial angiograms. The authors present their cases and discuss the incidence of TAs, their natural course and behavior, and the special problems encountered in managing these interesting and potentially fatal complications of penetrating head injuries.

An hour-glass-shaped multidensity lesion found by CT in a 6-year-old boy who had been admitted to the emergency department after a mild car accident. This lesion turned out to be a congenital dermoid tumour of the right cerebellopontine angle-tentorial notch region containing 12 mature teeth and 14 pseudocarilagenous structures. This is the first case of dermoid tumour containing so many teeth, reported in an asymptomatic person and located off the midline.

Study Design: Four cases in which, during standard laminectomies, knife blades broke deep into the disc space are reported., Summary of Background Data: These broken knife blades could not be removed at the time of initial operations., Results: Follow-up studies indicated further anterior migration of retained fragments in two cases after ambulation., Conclusions: Because of the potential hazards of late intraabdominal visceral or vascular injuries, removal of sharp retained fragments at another session is recommended.

Extramedullary hematopoietic tissue occurring within the extramedullary space and causing cord compression is an unusual occurrence in childhood and adolescence, and only four cases have been reported during the first two decades of life. We had the opportunity to treat a 16-year-old girl and a 14-year-old boy with paraparesis secondary to extradural extramedullary hematopoiesis. Findings in these cases are discussed, and an attempt is made to stress once more the possibility of congenital hematopoietic rests as the origin of such hyperplastic tissue. The various modes of therapy are discussed and related literature is reviewed.

A unique case of pontine hydatid cyst is reported. Diagnosis was considered preoperatively on the basis of computed tomographic findings. Needle aspiration and removal of the endocyst were performed through the floor of the fourth ventricle. Postoperative death was due to widespread hemorrhagic infarction of the brainstem. Possible involved mechanisms are discussed.

A case of pulsating unilateral exophthalmos is presented. It was caused by a traumatic aneurysm of the intraorbital ophthalmic artery, secondary to missile injury. Evolution of the aneurysm was observed clinically, by angiography, and by computerized tomography. The differential diagnosis of pulsating exophthalmos and the pathogenesis of such aneurysms are briefly discussed.

A case of paraganglioma of the filum terminale is presented where normal sympathetic ganglion cells were seen in conjunction with tumour cells in a well-encapsulated tumour, suggesting a possible origin from heterotopic sympathetic ganglion.

The authors report the cases of three brothers with pituitary adenomas who had classical findings of acromegaly and gigantism. Two had irreducibly elevated growth hormone (GH) values and underwent transsphenoidal microsurgical extirpation of their tumors. The third acromegalic brother had a normal GH value and evidence of panhypopituitarism; he had a small intrasellar tumor and a partially empty sella. The pattern of inheritance was probably autosomal recessive. A review of literature indicated that familial incidence of isolated acromegaly with pituitary adenomas is rare.

A survey is made of neonatal skull depressions as a result of experience with ten neonates harboring noniatrogenic intrauterine skull fractures. Several mechanisms causing intrauterine skull depression are discussed. Diagnosis was made after delivery in all cases and was confirmed by skull radiography. Various modes of therapy are mentioned and a stepwise guideline is suggested for correction of the depression by applying CT as an adjuvant diagnostic tool.

A rare case of bilateral intracavernous internal carotid artery aneurysms is presented. The clinical and laboratory data strongly suggested the mycotic nature of the aneurysms. Internal carotid artery ligation was performed because of clinical evidence of progressive enlargement of the right-sided aneurysm. The left-sided aneurysm was managed medically. It remained asymptomatic and, 14 months later, a control angiogram showed no significant change in its size and configuration.