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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: GCS12, stage 2: GCS: 8 - 12, stage 3: GCS8); 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, p0.05 was considered statistically significant. The results showed lower GCS (p0.001), higher GOS (p0.001), presence of intracranial air 7 days after surgery (p=0.002), and a high density haematoma (p0.001) were significantly associated with recurrence of CSDH. It was concluded that GOS is related with recurrence in CSDH.

Background: Postoperative infection is one of the most common complications after spine surgeries. In our study, surgical site infection (SSI) is described as; superficial (i.e., skin and subcutaneous tissues) and deep (i.e., fascia and muscles) infections occurring in the short term (i.e., 1-month) after spine surgeries (Centers for Disease Control and Prevention definition 81.00–81.08). To detect the risk factors for the occurrence of such a complication, studies require a large number of patients, a high quality of data and adequate analysis. In this study, we prospectively enrolled 987 patients undergoing spinal surgery over a 3 years period. Methods: From November 2010 to November 2013, 987 patients had a variety of spinal operations that included; disc herniation, spinal stenosis, spondylolisthesis, fracture-dislocations, spine and spinal cord tumors, and syringomyelia. Patients under the age of 10, those with a recent history of infection and antibiotherapy, and patients with immunodeficiency disorders were excluded. Results: Of the 987 spine procedures performed, 27 (2.73%) developed postoperative infections. Multi-variant data analysis indicated that multiple factors correlated with an increased risk of SSI in descending order; trauma, a past history of diabetes, smoking, being confined to bed, in the perioperative period, mean blood sugar levels above 120 mg/dl, longer lengths of incisions, and longer hospital stay. Conclusion: Considering the preventable nature of most of the factors contributing to SSI, it should be possible to reduce these complications.

Background Transsphenoidal adenomectomy has been the accepted surgical management for treatment of growth hormone (GH)–secreting pituitary adenomas. Although the goal of treatment might be to keep the GH level in the reference range, the actual definition of success in control of acromegaly is not yet clear. Methods The aim of this study was to analyze prospectively the result of transsphenoidal adenoctomy performed over 23-year period by a single neurosurgeon in one center. The analysis has been performed to determine which preoperative factor could significantly influence the long term outcome. This series consisted of 151 patients. The preoperative hormonal studies documenting the high GH and/or insulin-like growth factor were available in all the cases. At least 1 laboratory report documenting the postoperative level of hormones was also available for all of them. Transsphenoidal microsurgical adenomectomy was performed in all the cases. Results There were 90 patients with pure GH-secreting adenoma (59.6%) with the highest GH level of 235 mU/L. A second group of 12 patients had normal GH level but elevated serum level of insulin-like growth factor 1 (8%). The group with mixed secretion of GH and prolactin included 49 cases (32.4%). There was no postoperative mortality. Cerebrospinal fluid leakage occurred in 12 patients. Transient diabetes insipidus was encountered in 19 cases (12.6%) and long lasting diabetes insipidus in 2 patients (1.3%). Early and minor hypopituitarism was encountered in 14 patients, whereas a persistent condition occurred mainly after irradiation in 14 other cases. Normal postoperative serum GH level could be achieved in 98 patients (94.2%) of 104 cases with full follow-up. Conclusion In the developing countries, early diagnosis and proper surgical extirpation of the GH-secreting adenoma by an experienced and dedicated pituitary surgeon is mandatory to reduce the mortality and increase the chance of cure of this rather mortal endocrionopathy.

Several studies have demonstrated that magnesium (Mg) plays an important role in the prevention and treatment of central nervous system (CNS) insults. In this study, we tested the effect of intravenous magnesium sulfate (MgSO4) on the outcome of patients with brain tumors who underwent craniotomy. The outcome was defined clinically as the Barthel index score and paraclinically as blood levels of NSE (neuron-specific enloase) and S100Β protein. Sixty patients were randomly divided into two groups of 30 patients: the treatment and control groups. In the treatment group, 5 g of MgSO4 in normal saline was infused in 6 h 2 days before surgery, and the same dosage was repeated the day before and during surgery. The control group received placebo. Serum S100Β and NSE concentrations were measured at baseline before administration of magnesium, before surgery, and on the 2nd postoperative day. The Barthel index score was evaluated and registered before surgery, 3, and 6 months after the operation. The study results showed a significant change in S100Β protein levels before and after surgery (p

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 χ 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.

Firm tumor consistency is one of the most important factors that impede sufficient removal of pituitary macroademoas via a transsphenoidal approach. The utility of diffusion-weighted (DW) magnetic resonance imaging (MRI) in predicting the tumor consistency and successfulness of transsphenoidal resection was evaluated in this study.Thirty consecutive primary cases of nonfunctional pituitary macroadenomas were prospectively enrolled. Conventional and DW MRI were done for all the patients and the apparent diffusion coefficient (ADC) values and the signal intensity of the solid tumor were determined. Intraoperative report of tumor consistency, the degree of fibrosis and percentage of collagen content were documented. The 8 weeks postoperative MRI was used for calculation of the tumor resection rate.The tumor consistency was soft in 10 patients (33.3 %), intermediate in 14 patients (46.7 %) and hard in 6 patients (20 %). The mean collagen content percentage was 10, 23.5 and 66 % (p = 0.009) and the average resection rate was 75, 43 39 % in the three groups respectively (p = 0.001). The mean ADC value was not significantly correlated with the tumor consistency and resection rate. Tumors with isointense to hyperintense signal on DW MRI were more commonly removable by suction and had higher resection rates than those with hypointense signals (p = 0.019). For ADC values within the range of 600-740 × 10(-3) mm(2)/s, a residual volume larger than 20 % of the tumor was more likely.DW MRI was useful to predict the tumor consistency, collagen content and the chance of removal of pituitary macroadenomas through endoscopic transsphenoidal surgery, and is recommended in the preoperative patient evaluation.

Background Intraosseous Angiolipoma of the skull bone (IOAL) is a very rare bony lesion of the calvarium. This lesion occurs most commonly in the soft, subcutaneous tissue of the trunk. Only a single case of angiolipoma of the skull has been previously reported. The authors report the first case of giant IOAL of the calvarium evaluated by 3D CTS, MRI and full histopathological staining in a young lady treated surgically and with 23 months of follow up. Case description A 41-year-old female was admitted because of a prominent bulging on her right parietal region. Three dimensional CT and CT angiographic reconstruction of the cranium elucidated the geographical pattern of the lesion. MRI revealed a huge intraosseous right frontotemporoparietooccipital expansile lesion, nonhomogeneous but mostly hyperintense, in T1W images. In T2W images, the lesion was nonhomogeneously hyperintense and trabeculated with no perilesional edema. In the FLAIR-images, the lesion was trabeculated and nonhomogeneously hypointense. The lesion was excised totally followed by skull reconstruction and no recurrence after 23 months. Conclusion We hypothesize that the possible pathogenesis of IOAL may be a kind of mutation or dedifferentiation of either a primary intradiploic hemangioma or lipoma changing its growth pattern with possibly more aggressive behavior.

Summary: Hippocrates, Galen, Avicenna, and Jurjani first reported on human affliction by hydatidosis. The complete life cycle of Echinococcus includes several carnivores, but humans are infected incidentally and usually in childhood by ingestion of the ova. When an embryo of Echinococcus granulosus lodges in the brain, a solitary cyst develops. Hydatid cyst is a slow-growing lesion that does not invade the brain; it produces symptoms when the increasing size of the cyst exerts local pressure. The late appearance of focal neurologic deficits follows a long history of epileptic attacks, and symptoms compatible with increased intracranial pressure are the common clinical presentation. Serobiologic tests are not confirmatory for preoperative diagnosis, but radiologic examinations have a high degree of accuracy. In both computed tomography and magnetic resonance imaging, a spherical but occasionally ovoid cyst with clearly defined borders is visible. The cyst content is of the same density as cerebrospinal fluid on computed tomography and on T1 and T2 relaxations in magnetic resonance imaging. Usually, there is no identifiable rim in either computed tomography or magnetic resonance imaging, even after contrast injection. Surgical removal of the intact and unruptured cyst is advised in all cases. If the cyst ruptures during removal, local irrigation with 1% formalin, 0.5% silver nitrate, or hypertonic saline solutions can prevent local recurrence of the cysts. Long-term administration of oral parasiticidal agents such as mebendazole or albendazole may be effective in controlling recurrences in case of rupture of the cyst. In these two articles, the authors present their large and long-term experience in the diagnosis and management of hydatidosis of the central nervous system and orbit.

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.

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.

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.

Dear Editor: I read with interest the manuscript ‘Parasitic rachipagus twins; report of two cases’ by Navaei et al., Childs Nerv Syst (2015) 31:1001 [1]. In this paper, the researchers reported their experience with two newborns suffering from congenital dorsal midline-located masses interpreted as the remnants of a parasitic foetus attached along the spinal column named ‘rachipagus’. They presented the cases beautifully and discussed the issues clearly according to that philosophy, followed by the related references at the end. Unfortunately, it appears that they have missed our previous communication about similar cases [2]. Rachipagus is coined to name twins joined along the dorsal aspect or back of their bodies, with fusion of the vertebral arches and the soft tissue, variably from the head to the buttocks or, in the other words, twin foetuses joined at the vertebral column. In the so-called parasitic rachipagus, an ectopic or accessory limb is attached to the back of a normal baby or only a mass of viable tissue may remain. In a review of over 1200 cases of conjoined twins, one classic example of rachipagus was found: two complete infants with dorsal union of the entire head and trunk, with imaging showing clearly visible bony union of the vertebral arches from T6 to L3. After that typical case was discovered, 20 dorsal parasitic twins were re-evaluated and reclassified as rachipagus. Two had extensive vertebral fusion and 18 were united in the dorsal midline, all with meningocele, vertebral anomaly, and/or bony or neural connection [3]. A theory of the embryologic origin of these twins suggested that two embryonic discs located on diametrically opposing aspects of a single amniotic cavity might unite in the area of the closing neural folds. This again raises the controversy concerning ‘fission or fusion’ in conjoined twins [3]. In our report of three rare cases of human tails and one case of tethered cord due to a midline anomaly resembling part of a human limb (Fig. 1), we discussed different kinds of clinical and pathological conditions which may be encountered in such newborns and

Supratentorial PNETs are a group of heterogeneous neoplasms which are rarely encountered especially in adulthood. Because of the rarity of these tumors, articles describing the clinical features and their response to treatment are mostly limited to case reports and retrospective studies of relatively small series. In Addition, many of the investigators have analyzed mixed varieties of these heterogeneous tumors found in different age groups. Therefore, it is very hard to assess the clinical features, true effect of various treatment modalities, and prognosis of these tumors. Nowadays, supratentorial PNETs are distinct from medulloblastomas and peripheral PNETs.

Purpose Corneal stromal scarring partly involves the production of corneal myofibroblasts. The purpose of this study was to examine the effects of rapamycin (an inhibitor of the mammalian target of rapamycin [mTOR] pathway) on myofibroblast formation in vitro and in-vivo. Methods Human corneal fibroblasts were grown in culture and transformed into myofibroblasts using TGF-β (2 ng/mL). The phosphorylation (activation) of the mTOR pathway was examined by immunoblotting. Cell proliferation with and without rapamycin was examined by thiazolyl blue tetrazolium bromide (MTT) assay and Ki67 staining. The expression of the myofibroblast differentiation marker smooth muscle actin (SMA) was examined by immunostaining and immunoblotting. The functional effects of rapamycin were measured using a gel contraction assay. For in vivo studies, 140 μm laser ablation was performed on rabbit corneas followed by subconjunctival rapamycin or vehicle. Corneal haze development was graded at 4 weeks, while the expression of myofibroblast markers was examined by immunostaining and immunoblotting. Results The TGF-β activated the mTOR pathway with peak phosphorylation at 2 to 4 hours. Treatment of corneal fibroblasts with rapamycin reduced their proliferation by 46% compared to control. Rapamycin significantly inhibited TGF-β-induced expression of myofibroblast markers (17.2% SMA positive cells with rapamycin compared to 69.0% in control). Rapamycin also significantly inhibited TGF-β-induced collagen gel contraction. In the rabbit eyes treated with rapamycin, corneal haze development was significantly less compared to controls (0.75 ± 0.4 vs. 2.17 ± 0.7). Conclusions Rapamycin appears to inhibit proliferation and differentiation of corneal myofibroblasts and, thus, may provide an effective therapeutic measure for preventing corneal scarring.

Background: General anesthesia (GA) is the most frequently used technique for lumbar spine disc surgery. The aim of this study was to compare the intraoperative variables and postoperative outcome after GA and combined general/epidural anesthesia (CEG) in patients undergoing elective lumbar spine disk surgery. Methods: Eighty patients who underwent one or two level of laminectomy/discectomy during a 2 year period were enrolled in this randomized controlled trial (RCT). They were randomly selected to undergo GA or CEG. The data recorded during surgery were: The patients’ heart rate (HR), mean arterial blood pressure (MABP), amount of blood loss, and the medication used during anesthesia. The severity of pain score, total analgesic consumption, and complications were recorded in the postoperative period. Results: The MABP, HR, blood loss, and anesthetic medication were significantly lower in CEG group in comparison with that of GA group. In the postoperative period, the pain score and total analgesic requirement was lower in the CEG group and less complication were encountered in this group. Conclusion: The results of this study revealed that CEG have some advantages over GA in reducing the blood loss and anesthetic medication during the operation and it is also more effective in control of pain with fewer complications during the postoperative period.

Background: It is not well known whether the distributions of variations of circle of Willis (CW) are different in different populations. Previous studies have indicated: (a) The variations of the structure of the CW in different populations and ethnic and (b) some correlation between those congenital anatomical variations and possible cerebrovascular diseases. The frequency of such anatomical variations has not been evaluated sufficiently in the Iranian population. The aim of this study is to find the variations of the anatomy of the vessels in the CW in sample population of Iranian people and compare it with other available studies in the literature, providing a new grouping for variations. Methods: Samples were obtained from 200 autopsies in different ages, all retrieved in the department of Forensic Medicine, Tehran university of Medical Sciences after achieving permission from the Department of Ethics and Medico-legal Sciences. The CW was examined directly, using magnification, at the base of the brain. The cerebral vessels were observed for their configuration and their calibers were measured directly. Variations were noted and grouped into different categories. Results: Out of the 200 specimens examined, 69 (34.5%) were compatible with the typical anatomy of the CW. In the remaining 65.5% of the specimens, there were variations in the CW. Hypoplasia of the posterior communicating arteries was the most common variation in our study. One of the autopsies showed the presence of an aneurysm (0.5%). Conclusion: The anatomical variations found in our study were not significantly different from those reported in the literature. Based on the available data; (a) there is no evidence that the distribution of the variations of the anatomy of the CW is different in various societies and (b) the prevalence of the congenital aneurysmal changes in this region is not low in the Iranian population.

Brown tumor is a bone lesion secondary to hyperparathyroidism of various etiologies. Skeletal involvement in primary hyperparathyroidism secondary to parathyroid adenoma is very uncommon and brown tumor has become extremely a rare clinical entity. Hyperparathyroidism is usually associated with high levels of serum calcium. Brown tumor as the only and initial symptom of normocalcemic primary hyperparathyroidism is extremely rare. Moreover, involvement of the skull base and the orbit is exceedingly rare. The authors would report three cases of brown tumor of the anterior skull base that were associated with true normocalcemic primary hyperparathyroidism. Clinical manifestations, neuroimaging findings, pathological findings, diagnosis and treatment of the patients are discussed and the relevant literature is reviewed.

✓ 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.

Dear Editor, While practicing Neurosurgery in a society invaded by various cultures and neurosurgical philosophies, one should expect facing different traditional remedies in his/her daily practice. A 34-year-old woman with one-year history of left L5 radiculopathy was referred to our outpatient clinic. In physical examination, there were papules seen behind her lateral malleolus from which she was suffering the worst [Figure 1]. She reminded leech therapy performed a couple of weeks before, by a “traditional healer” at her rural area resulting in temporary pain relief. The patient underwent L4/L5 discectomy and the symptoms recovered completely. Similar traditional ways of treatment for sciatica have been reported by the authors from our community,[6] but the question is: “does newly emerging evidence consider any role for leech (Hirudo medicinalis) therapy in pain relief of sciatica?” Figure 1 Appearance of leech therapy behind the lateral malleolus where the most severe pain was felt by the patient The medicinal leech is one of the few examples of the use of invertebrates in the treatment of human diseases. Leech therapy, mentioned as “Jalaukavacharan” in Ayurveda (Hirudotherapy), was used for medicinal “blood-letting” and “purification”, believed to cure a variety of ailments such as gout, skin diseases, blood disorders, alopecia, filariasis, headaches, etc., The use of leech therapy became less widespread toward the end of 19th century but now has emerged again as a widely useful therapy attracting the researchers all over the world. In Ayurveda, its easy applicability without producing any adverse effects is another reason why leech therapy has been used since ancient times.[3] Although leech therapy is known as a therapeutic option in the traditional medicine, some modern indications for leech therapy have also been proposed by Food and Drug Administration (FDA).[7] The exact mechanisms through which leech therapy may exert analgesic effect(s) are not well understood. Besides of a possible placebo effect, leech therapy may exert some direct anti-inflammatory and pain-killing effects through the components of the leech saliva. Platelet-derived growth factor (PGF) is assumed to play an important role in producing the signals of neuropathic pain in spinal cord and inhibition of its release by intrathecal injection of Hirudin has been reported to suppress thermal hyperalgesia and tactile allodynia in mice.[5] We may also hypothesize that the strong sensory stimulus caused by the pain and burning sensation of the leech bite can alleviate the symptoms of the patient through the “gate theory” as well. Some recent randomized controlled trials have shown leech therapy to be effective in knee and metacarpal osteoarthritis.[4,8] Leech therapy has also been successfully applied to treat severe lumbar pain due to cancer.[2] These local effects can be due to the anti-inflammatory effects of substances in the leech saliva other than Hirudin, such as histamine-like vasodilators, kallikrein and tryptase inhibitors. Also, the role of thrombin in pain-control mechanisms is suggested by some researchers,[1] while Hirudin itself exerts some anti-inflammatory effects by inhibiting thrombin.[1] Considering far advanced methods of treatment available nowadays, this mode of therapy may look redundant. However, in medically high-risk/aged patients and those reluctant to undergo surgery, less aggressive treatments including leech therapy can be assumed as a temporary solution. Further studies to evaluate effectiveness of leech therapy in lumbago and sciatica are warranted.

Buildings must pass the test of authenticity and integrity to be considered as World Heritage sites. The combination of these attributes can be referred to as the genuineness of the site. Bam suffered from a devastating earthquake in December 2003, but even after the disaster, the area was acknowledged to have a high degree of authenticity and integrity and was successfully put forward for consideration as a World Heritage site. Apart from the uniqueness of Bam's Citadel as the world's greatest mud brick structure and of a number of buildings in the immediate vicinity of the Citadel, the rationale for its inscription was also influenced by its intangible aspects and cultural landscape. Examples of intangible heritage in Bam include the legend of Haftvad and the Kot-e Kerm and its relation to the Silk Road as well as the beliefs of people of Bam in the rituals linked to the well of the Master of Time (Imam Zaman), and the ritual of Ashura. Until recently, the integrity of a World Heritage site was mostly assessed by studying its tangible heritage. However, in 1982, UNESCO introduced a new mandate for consideration of intangible heritage to emphasise its significance and to strive for protection of traditional culture and folklore. Several regional assessments have since been made on the impacts and recommendations on the protection of traditions, culture and folklore. When protecting a tangible heritage site, the practice is mainly based on pragmatic conservation and restoration. Non-tangible heritage, on the other hand, is more subtle and requires more sophisticated approaches and methods for its preservation. This paper investigates the intangible heritage associated with the Bam Citadel as part of Bam and its cultural landscape and, where appropriate, highlights the relationship between these assets and the architectural aspects to accentuate the cultural importance of this of World Heritage site. © 2011 WIT Press.

Background: Primary spinal primitive neuroectodermal tumors (PNET) and/or spinal extraskeletal Ewing's sarcoma family tumors (ESET) are rare lesions appearing in the spinal extradural space. One hundred forty-one primary spinal PNETs, including 29 intramedullary lesions, have been reported in the literature. Encountering a case of primary epidural EES/peripheral PNET (pPNET) in sacral level, which is the fifth one occurring at this level in the literature, we have tried to conduct a meta-analysis of the reported cases. Case Description: A 44-year-old lady with epidural EES/pPNET is reported here. She was once operated for L5/S1 herniated disc, which did not ameliorate her symptoms. The clinical, imaging, surgical, and histopathologic characteristics of our case are presented and wide search of the literature is also done. All the reports were level 3 or less evidences and most of the series had missing parts. 106 cases of primary intraspinal (extradural/extramedullary-intradural) EES/pPNET and 29 cases of primary intramedullary PNET (CNS-PNET) have been reported in the literature. The most common clinical presentation in both entities was muscle weakness proportionate to the tumor location. Distant metastasis occurred in 38 of 99 (38%) cases of primary intraspinal EES/pPNET, while the rate of metastasis was 48% in patients with PNETs occurring in the intramedullary region (P > 0.05). One-year survival rate of the patients who underwent chemo-radiation after total or subtotal resection was better than those who did not receive chemotherapy or radiotherapy, or did not have total or subtotal resection. However, this difference was not repeated in 2-year survival rate in any of the tumor groups. Conclusion: It seems that total or subtotal removal of the tumor and adjuvant chemo- and radiation therapy can improve the outcome in these patients.

Hirudo Medicinalis application in medicine has long been a matter of investigation since Hippocrates. The analgesic and anti-coagulant substances in the leeches’ saliva are used in treatment of venous thrombosis and varicose veins, arthralgia, rheumatologic diseases, low back and cervical pains. Aeromonas infections, excessive bleeding, anemia, and allergic reactions are among the most common complications reported with leech therapy. The present study, reports leech therapy in two patients: one for sciatalgia and the other for deep venous thrombosis. Furthermore, a comprehensive review of the literature on different aspects of leech therapy with special focus on its neurosurgical applications and related dysfunctions is presented. Keywords: Leech therapy, Neurosurgical, Medicinal