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Structural optimization for performance-based seismic designs is aimed at finding a minimum objective function with constraints on performance requirements. In this research, a hybrid algorithm is ...

Objective: Endovascular chemical angioplasty has been in practice in patients with symptomatic cerebral vasospasm secondary to aneurysmal subarachnoid haemorrhage in many neurosurgical centres. However, the evidence base is derived from clinical case series and expert consensus. The aim of this retrospective cohort study is to evaluate the immediate and functional outcomes of endovascular intervention in aneurysmal subarachnoid haemorrhage cerebral vasospasm treated with a combination of vasodilators. Methods: A cohort of 25 patients was identified. Each patient underwent surgical clipping, and endovascular treatment for vasospasm. A combination of Verapamil and Nimodipine was intra-arterially administered. Statistical analysis was performed to determine the rate of response. The angiographic response and functional outcome on discharge (modified Rankin score - MRS) were used as markers of outcome. Results: The study cohort consisted of 25 patients with a mean age of 50.3 (SD 11.2). A total of 135 therapeutic DSA’s were performed. There was an associated between MRS outcomes and number of vasodilation’s each patient received. For each additional vasodilation episode, the odds of a poor outcome increased by 1.190. An angiographic response was demonstrated in 88% of patients, a clinical response in 27%. A good functional outcome was achieved in 17/25, 71% at discharge. Conclusion: The combination therapy of Intra-arterial nimodipine and verapamil in patients with aneurysmal subarachnoid haemorrhage vasospasm appears to have a synergistic, if not comparable, outcome to from solitary vasodilatory treatment results and potentially promote future studies with prospective designs to measure the outcomes.

Background Three-dimensional (3D) visualization of the neurovascular structures has helped preoperative surgical planning. 3D printed models and virtual reality (VR) devices are 2 options to improve 3D stereovision and stereoscopic depth perception of cerebrovascular anatomy for aneurysm surgery. Objective To investigate and compare the practicality and potential of 3D printed and VR models in a neurosurgical education context. Methods The VR angiogram was introduced through the development and testing of a VR smartphone app. Ten neurosurgical trainees from Australia and New Zealand participated in a 2-part interactive exercise using 3 3D printed and VR angiogram models followed by a questionnaire about their experience. In a separate exercise to investigate the learning curve effect on VR angiogram application, a qualified neurosurgeon was subjected to 15 exercises involving manipulating VR angiograms models. Results VR angiogram outperformed 3D printed model in terms of resolution. It had statistically significant advantage in ability to zoom, resolution, ease of manipulation, model durability, and educational potential. VR angiogram had a higher questionnaire total score than 3D models. The 3D printed models had a statistically significant advantage in depth perception and ease of manipulation. The results were independent of trainee year level, sequence of the tests, or anatomy. Conclusion In selected cases with challenging cerebrovascular anatomy where stereoscopic depth perception is helpful, VR angiogram should be considered as a viable alternative to the 3D printed models for neurosurgical training and preoperative planning. An immersive virtual environment offers excellent resolution and ability to zoom, potentiating it as an untapped educational tool.

BACKGROUND For sustainability of arteriovenous malformation (AVM) surgery, results from early career cerebrovascular neurosurgeons (ECCNs) must be acceptably safe. OBJECTIVE To determine whether ECCNs performance of Spetzler-Ponce Class A AVM (SPC A) resection can be acceptably safe. METHODS ECCNs completing a cerebrovascular fellowship (2004-2015) with the last author were included. Inclusion of the ECCN cases occurred if they: had a prospective database of all AVM cases since commencing independent practice; were the primary surgeon on SPC A; and had made the significant management decisions. All SPC A surgical cases from the beginning of the ECCN's independent surgical practice to a maximum of 8 yr were included. An adverse outcome was considered a complication of surgery leading to a new permanent neurological deficit with a last modified Rankin Scale score >1. A cumulative summation (Cusum) plot examined the performance of each surgery. The highest acceptable level of adverse outcomes for the Cusum was 3.3%, derived from the upper 95% confidence interval of the last author's reported series. RESULTS Six ECCNs contributed 110 cases for analysis. The median number of SPC A cases operated by each ECCN was 16.5 (range 4-40). Preoperative embolization was performed in 5 (4.5%). The incidence of adverse outcomes was 1.8% (95% confidence interval

Background During aneurysm surgery, neurosurgeons may need to look at the cerebral angiograms again to better orient themselves to the aneurysm and also the surrounding vascular anatomy. Simplification of the intraoperative imaging review and reduction of the time interval between the view under the microscope and the angiogram review can theoretically improve orientation. Objective To describe the use of a smartphone as a remote touchpad to simplify intraoperative visualization of three-dimensional (3D) cerebral angiograms and reduce the time interval between the view under the microscope and the angiogram review. Methods Anonymized 3D angiograms of the patients in Virtual Reality Modelling Language format are securely uploaded to sketchfab.com, accessible through smartphone Web browsers. A simple software has been developed and made available to facilitate the workflow. The smartphone is connected wirelessly to an external monitor using a Chromecast device and is used intraoperatively as a remote touchpad to view/rotate/zoom the 3D aneurysms angiograms on the external monitor. Results Implementation of the method is practical and helpful for the surgeon in certain cases. It also helps the operating staff, registrars, and students to orient themselves to the surgical anatomy. I present 10 of the uploaded angiograms published online. Conclusion The concept and method of using the smartphone as a remote touchpad to improve intraoperative visualization of 3D cerebral angiograms is described. The implementation is practical, using easily available hardware and software, in most neurosurgical centers worldwide. The method and concept have potential for further development.

Background The insertion of available cervical retractor systems is relatively complex for the limited exposure required for single-level anterior cervical diskectomy. Objective To introduce a novel cervical retractor system and report the initial experience of its application. Methods A simple retractor system was designed that is fixed to the vertebral body through Caspar pins. The design allows the retractor to move with the vertebrae during distraction via the traditional Caspar distractor system. The advantages and limitations of the device based on the initial experience are discussed. Results The author has used the current version of the retractor on 32 single-level anterior cervical diskectomies. The insertion of the retractor is easy, and its application provides safe and satisfactory anterior cervical exposure. There have not been related complications, although transient dysphagia has not been prevented. Conclusion This newly designed retractor system is simple and efficient for a single-level anterior cervical diskectomy, and its insertion is relatively easy.

Neuronavigation is an established technology in neurosurgery. In parts of the world and certain circumstances in which neuronavigation is not easily available or affordable, alternative techniques may be considered.An app to assist scalp localization of superficial supratentorial lesions has been introduced, and its accuracy has been compared with established neuronavigation systems.Sina is a simple smartphone app that overlaps the transparent patients' computed tomography/magnetic resonance images on the background camera. How to use Sina intraoperatively is described. The app was used for scalp localization of the center of the lesions in 11 patients with supratentorial pathologies3 cm in longest diameter and2 cm from the cortex. After localization of the lesion using Sina, the center of the lesion was marked on the scalp using standard neuronavigation systems and the deviations were measured.Implementation of Sina for intraoperative scalp localization is simple and practical. The center of the lesions localized by Sina was 10.2 ± 2 mm different from localization done by standard neuronavigation systems.When neuronavigation is not easily available or affordable, Sina can be helpful for scalp localization and preoperative planning of the incision for selected supratentorial pathologies.

There are studies that show that the concepts of epilepsy have been rooted in Persian medicine; Avicenna “Ibn-e-Sina”—one of the great Persian physicians in the Islamic golden age (9th–12th century AD)—has considered some types of epilepsy with the association of the stomach, the spleen, the “Maraqq,” and the whole body which has not been reviewed properly. These organs influence on the brain and can cause epilepsy. This article presents concept of Maraqq-related epilepsy; according to Avicenna’s view, “Maraqq” is a membranous structure which is located in the abdomen (equivalent of parietal peritoneum in current nomenclature). We discuss his viewpoint about the diagnosis and treatment of Maraqq-related epilepsy with focus on herbal remedies. The concept of a relationship between the “Maraqq” and the brain is well discussed in the old Persian medicine texts; however, it seems that further studies in this area are required to clarify Avicenna’s view about the pathophysiological mechanisms, clinical manifestations, and treatment strategies.

Object The goal of this paper was to investigate the long-term outcome and the possible prognostic factors that might have influenced the persistence of posttraumatic epilepsy after penetrating head injuries sustained during the Iraq–Iran war (1980–1988). Methods In this retrospective study, the authors evaluated 189 patients who sustained penetrating head injury and suffered posttraumatic epilepsy during the Iraq–Iran war (mean 18.6 ± 4.7 years after injury). The probabilities of persistent seizures (seizure occurrence in the past 2 years) in different periods after injury were estimated using the Kaplan-Meier method. The possible prognostic factors (patients and injury characteristics, clinical findings, and seizure characteristics) were studied using log-rank and Cox regression analysis. Results The probability of persistent seizures was 86.4% after 16 years and 74.7% after 21 years. In patients with < 3 pieces of shrapnel or no sphincter disturbances during seizure attacks, the probability of being seizure free after these 16 and 21 years was significantly higher. Conclusions Early seizures, prophylactic antiepileptics drugs, and surgical intervention did not significantly affect long-term outcome in regard to persistence of seizures.

Because of its geographic proximity to the major drug production centres, there is easy access to narcotic drugs in the Islamic Republic of Iran despite efforts by governmental and nongovern- mental organizations. Using a structured questionnaire as a basis for conversation, local health workers interviewed 310 residents of a rural area in Babol province about opium use. The self-reported rate of opium use, adjusted due to a bias in the sex ratio of the sample, was 8.9%. All the 42 opium users re- ported opium use at least 2-3 times per week in the previous 3 months. Opium was smoked by 95.2% and taken orally by 4.8%; there was no injecting use. There was no reported use of other substances, including alcohol. There was a statistically significant relationship between opium use and male sex, unemployment and cigarette smoking. ةيملاسلإا ناريإ ةيروهجم نم ةيفيرلا قطانلما في نويفلأا يطاعت راختفا دازبه ،سيدق دممح ديس ،يدوممح دوممح ،تقادص يبتمج ،يمثيم اشاب ليع دقف ،تاردخلما جاتنلإ ىبركلا زكارلما نم ةيملاسلإا ناريإ ةيروهملج فيارغلجا عقولما برقل :ةـصلالخا نولماعلا مدختسا دقو .ةيموكلحا يرغو ةيموكلحا تماظنلما الهذبت يتلا دوهلجا مغر اهيلع لوصلحا حبصأ ةيلاو في ةيفيرلا قطانلما في يننطاقلا نم 310 ةلباقم دنع نويفلأا يطاعت لوح مصم انايبتسا نويلحلما نويحصلا تياذلا غلابلإا ناك ،ةنيعلا في ثانلإا لىإ روكذلا ةبسن نع مجانلا ز حيحصتل نايبتسلاا ليدعت عمو .لوباب ثلاث وأ ينترم نم رثكأ هيطاعت نع اصخش 42 مهددعو نويفلأا اوطاعت نم عيجم غلبأو . %8.9 نويفلأا يطاعت نع .مهنم 4.8 ىدل مفلا قيرط نعو ،تلاالحا نم % 95.2 ىدل متي ينخدتلاب نويفلأا يطاعت ناكو .عوبسلأا في تارم دتع ي ةقلاع كانه تناكو .لوحكلا اهيف ماب ىرخأ داوم يطاعت نع غ لبي لم ماك ،نقلحاب يطاعتلا نم تلااح ركذ ت لمو .رئاجسلا ينخدتو ةلاطبلاو ركذلما سنلجا ينبو نويفلأا يطاعت ينب ايئاصحإ

CONTEXT AND OBJECTIVE: The presence of scapular fracture is believed to be associated with high rates of other injuries and accompanying morbidities. The aim was to study injury patterns and their overall outcomes in patients with scapula fractures. DESIGN AND SETTING: Cross-sectional study of trauma patients treated at six general hospitals in Tehran. METHODS: One-year trauma records were obtained from six general hospitals Among these, forty-one had sustained a scapular fracture and were included in this study. RESULTS: Scapular fracture occurred predominantly among 20 to 50-year-old patients (78%). Road traffic accidents (RTAs) were the main cause of injury (73.2%; 30/41). Pedestrians accounted for 46.7% (14/30) of the injuries due to RTAs. Falls were the next most common cause, accounting for seven cases (17.1%). Body fractures were the most common type of scapular fractures (80%). Eighteen patients (43.9%) had isolated scapular fractures. Limb fracture was the most common associated injury, detected in 18 cases (43.9%). Three patients (7.3%) had severe injuries (injury severity score, ISS > 16) which resulted in one death (2.4%). The majority of the patients were treated conservatively (87.8%). CONCLUSIONS: Patients with scapula fractures have more severe underlying chest injuries and clavicle fractures. However, this did not correlate with higher rates of injury severity score, intensive care unit admission or mortality.

Background: Many studies have investigated the variations in the anatomy of each segment of the cerebral arterial circle while a few have addressed the variations of the cerebral arterial circle as a whole. Methods: Thirty brains of recently deceased Iranian infants and fetuses were dissected. The dissection process was filmed and digitized so as to be readily available for further studies. The variations of the circle as a whole and segmental variations were evaluated. Results: Variants with uni- and bilateral hypoplasia of posterior communicating arteries (PcoAs) were the most common in our study, similar to previous works. No aplasia of the precommunicating part of the anterior cerebral artery (A1), the precommunicating part of the posterior cerebral artery (P1) and anterior communicating artery was seen. Hypoplasia of the right and left PcoA was observed in 8 and 5 cases, respectively. Aplasia of the right PcoA was found in 16.6% and of the left PcoA in 3.3%. Conclusion: In this study, we confirmed the previously described finding that the symmetrical, circular configuration of the circulus arteriosus cerebri is present in only about 42.1%. The main differences between the fetal and adult disposition are the diameter of the PcoA and the circular part of the posterior cerebral artery. According to previous studies, the fetal brain older than 4 months has anatomical characteristics very similar to the adult’s circle; our finding was mostly similar to adult samples as most samples were from infants, not fetuses.

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.

The freehand technique for insertion of an external ventricular drain (EVD) is based on fixed anatomical landmarks and does not take individual variations into consideration. A patient-tailored approach based on augmented-reality techniques using devices such as smartphones can address this shortcoming. The Sina neurosurgical assist (Sina) is an Android mobile device application (app) that was designed and developed to be used as a simple intraoperative neurosurgical planning aid. It overlaps the patient's images from previously performed CT or MRI studies on the image seen through the device camera. The device is held by an assistant who aligns the images and provides information about the relative position of the target and EVD to the surgeon who is performing EVD insertion. This app can be used to provide guidance and continuous monitoring during EVD placement. The author describes the technique of Sina-assisted EVD insertion into the frontal horn of the lateral ventricle and reports on its clinical application in 5 cases as well as the results of ex vivo studies of ease of use and precision. The technique has potential for further development and use with other augmented-reality devices.

Background: Acute brain injury (ABI) disrupts homeostasis in tissue brain. Inflammation has an important contributory role in the pathogenesis of the disease and blood cell count alteration has been shown. The clinical course is variable, and the factors or markers available for predicting survival or the functional situation of these patients are limited. Aim: The aim of this study was to measure the serum levels of interleukin (IL)-8, transforming growth factor (TGF)-β1 and nitric oxide (NO) in patients with ABI (at days 1, 2, 3 and 7) and to study their relationships to blood cell counts. Methods & results: A total of 25 patients were included in the study and 15 healthy subjects were chosen as a control group. Expression of IL-8 and TGF-β1 and production of NO were higher in ABI patients at each of the time points as compared with the control group. In the case of TGF-β1, the increase at time points 3 and 7 was greater than time points 1 and 2. White blood cells were increased significantly (12130 ± 1...

Object. The purpose of this study was to compare the efficacy of the prophylactic use of ceftriaxone for the prevention of meningitis in patients with acute traumatic pneumocephalus. Methods. In this prospective, single-institution, randomized clinical trial, 109 patients with mild head injury and traumatic pneumocephalus were randomly assigned to receive or not receive an antibiotic medication (ceftriaxone, 1 g given twice a day) until occurrence of meningitis or at least 5 days after trauma. The patients were followed up for 1 month posttrauma. The 109 patients were divided into two groups: 53 were assigned to the prophylactic antibiotics therapy group and 56 to the control group. The overall rate of meningitis was 20.1% and the rates of meningitis in the two groups were not significantly different. The results were the same when adjusted for the patient's Glasgow Coma Scale score, sex, and age, as well as for an intradural location of air, air volume, presence of cerebrospinal fluid (CSF) rhinorrhea or CSF otorrhea, radiological sign of a skull base fracture, or intracranial hemorrhage. Conclusions. The results of this study do not substantiate the efficacy of ceftriaxone used in the prevention of meningitis in patients with traumatic pneumocephalus after mild head injury or in any specific subgroup of these patients. Cerebrospinal fluid rhinorrhea and intracranial hemorrhage may be considered primary risk factors for the development of meningitis in patients with posttraumatic pneumocephalus and, in the absence of these symptoms, intradural location of air and air volume greater than 10 ml may be considered secondary risk factors. Further studies in this area are warranted.

A retrospective study was performed to analyse a prospectively collected database from a single surgeon (M.K.M.) of transverse–sigmoid sinus dural arteriovenous fistulas (DAVF) between 1991 and August 2011. During the study period, 144 patients with 160 DAVF were managed. Sixty-five of the DAVF were located in the transverse-sigmoid sinus and 42 were treated with surgery, or embolisation and surgery. All patients who underwent surgery were symptomatic with retrograde cortical venous drainage. The average follow-up period was 18 months (range, 2–82 months). Total elimination of the DAVF was achieved in all instances, including two patients (5%) who required further surgery after postoperative cerebral angiography showed that some venous drainage had persisted after the first operation. There was no new permanent neurological deficit or mortality attributable to surgery. Our institutional experience shows that in selected patients with transverse–sigmoid sinus DAVF, the involved sinus can be surgically resected with a high success rate and it is as safe as many alternative options. We suggest that this definitive treatment option should be offered to patients, and the outcome should be compared to other treatment modalities.

To determine the number of brain CT scans carried out in patients with mild head injury (MHI) during 13 months of trauma registry, and to investigate means of reducing the rate of unnecessary scans.During a trauma registry (from August 23, 1999 to September 21, 2000) in 6 general Hospitals (Imam Hussein, Moayer, Sina, Hafteteer, Imam Khomeini and Shariatti) in Tehran, Iran, 1209 cases with Glasgow Coma Scale (GCS) score13 underwent brain CT scan. To be included in the study, patients must have sustained their injury within one week prior to presentation to Emergency Rooms, and were hospitalized for more than 24 hours. The attending physicians formally reported all brain CT scan findings.For 1209 patients, there were the following characteristics: mean age was 29.4 years; the main cause of injury was traffic accidents (60.1%), followed by falls (28.5%), fights (7.2%), and other reasons (4.2%). Seventy-seven cases (6.4%) had a GCS score of 13, 212 (17.5%) had a score of 14, and 920 (76%) had a score of 15. A total of 481 abnormalities on CT scan were reported for 405 patients (33.5%) with positive report of brain CT scan, while 804 cases (66.5%) did not report abnormalities. The most common intracranial lesion was epidural hemorrhage with 146 cases (30.3%). The rate of negative reporting of brain CT scan in patients who had GCS score of 15 was 72.2%.Patients who have GCS score of 13 or 14 on admission should be considered to have a moderate rather than a mild head injury. For reduction of unnecessary brain CT scan performance in MHI patients, we must define the appropriate criteria.

✓ This 9-year-old girl with rapidly progressive cerebral demyelinating disease presented with hemiplegia and intracranial hypertension. Brain images revealed four lesions with mass effect in the subcortical white matter of both hemispheres. Demyelination was found on pathological studies of these lesions. The patient experienced some recovery with corticosteroid treatment but improved completely with decompressive aspiration of the largest lesion.

OBJECTIVE As the first step toward finding noninvasive alternatives to the traditional methods of surgical training, we have developed a small, stand-alone computer program that simulates insertion of pedicle screws in different spinal vertebrae (T10–L5). METHODS We used Delphi 5.0 and DirectX 7.0 extension for Microsoft Windows. This is a stand-alone and portable program. RESULTS The program can run on most personal computers. It provides the trainee with visual feedback during practice of the technique. At present, it uses predefined three-dimensional images of the vertebrae, but we are attempting to adapt the program to three-dimensional objects based on real computed tomographic scans of the patients. The program can be downloaded at no cost from the web site: www.tums.ac.ir/downloads CONCLUSION As a preliminary work, it requires further development, particularly toward better visual, auditory, and even proprioceptive feedback and use of the individual patient's data.

✓ Cervical actinomycosis causing spinal cord compression is a rare clinical entity. In a review of the literature, the authors found only 13 cases with actinomycosis-related spinal neurological deficit. The authors describe the case of a 26-year-old man who presented with neck pain and partial paresis of the upper limbs. Magnetic resonance imaging revealed a long cervical epidural enhancing lesion that extended from C-1 to T-2. The radiological findings resembled metastasis and other epidural infections. The patient was treated medically with penicillin and amoxicillin for 7 months and recovered neurologically. The authors conclude that although cervical epidural actinomycosis is a rare clinical entity resembling metastasis and other infections in this region, it should be considered so that this unique infection can be diagnosed in the least invasive fashion and, whenever possible, unnecessary surgery can be avoided.

This study was undertaken to determine variables that could predict, in the preoperative period, the likelihood for the need for intraoperative temporary arterial occlusion using clips (temporary clipping) when surgically repairing intracranial aneurysms. Data collected prospectively between October 1989 and March 2010 of 1129 unruptured intracranial aneurysms in 934 patients who were managed surgically was examined retrospectively. Temporary clipping was used in 400 patients (35.4%). Regression analysis of putative predictive variables revealed that aneurysms of a larger size, irregular fundus shape or midline location were more likely to be treated with temporary clipping. Basilar caput aneurysms larger than 10 mm were always managed with temporary clipping. There was no combination of factors studied that consistently predicted that temporary clipping would not be needed. Therefore, the potential need for temporary clipping must be considered for every patient with an aneurysm.

We retrospectively investigated preoperative variables contributing to adverse surgical outcome for repair of unruptured posterior circulation aneurysms on data collected prospectively between October 1989 and March 2010. Putative risk factors including age, sex, smoking status, positive family history, modified Rankin Score prior to the surgery, size of the aneurysm, specific site (basilar caput and trunk, vertebral artery and posterior inferior cerebellar artery), midline location, presence of calcium, thrombus or irregularity in the aneurysm on preoperative imaging, associated arteriovenous malformation and preoperative coiling were investigated using regression analyses. In a total of 121 operations, surgical mortality and morbidity was 16.3%. For patients with aneurysms less than 9 mm this rate was 3.2%. Among the investigated variables we found that size, calcification of the aneurysm and age were each predictors of surgical outcome of unruptured posterior circulation aneurysms.

Injuries are a major health problem in developing countries. Recently, the occurrence of injuries and those related to mortality have increased dramatically in Iran. We have conducted this study to report domestic research publications in the field of trauma from 2000 to 2006 in Iran.The contents of 128 biomedical journals were analyzed. Sina Trauma Data Bank (STDB) was selected as an indicator of trauma related articles that have been published in Iranian biomedical journals.The number of trauma related articles in Iran increased during the seven year period (2000 - 2006), but the percentage of total publications was not significantly different. The mean number of authors per article was 2.7+1.3 (1 to 12) and all first authors were Iranian. Females constituted 15.4% (n=156) of first authors. Original articles were the most frequently published articles (n=871; 86.2%). Treatment of injuries and ensuing complications were the most common topics (42%) followed by war injuries (14.1%). Traffic accidents, as the leading cause of trauma death in Iran, were investigated in 27 (2.7%) articles.According to our results, it seems that more attention from researchers and health-policy makers towards trauma is necessary in our country. In addition, publishing a journal with the main theme of injury and trauma could be an effective means for increasing the proportion of trauma related articles.

The goal of this paper was to investigate the long-term outcome and the possible prognostic factors that might have influenced the persistence of posttraumatic epilepsy after penetrating head injuries sustained during the Iraq-Iran war (1980-1988).In this retrospective study, the authors evaluated 189 patients who sustained penetrating head injury and suffered posttraumatic epilepsy during the Iraq-Iran war (mean 18.6 +/- 4.7 years after injury). The probabilities of persistent seizures (seizure occurrence in the past 2 years) in different periods after injury were estimated using the Kaplan-Meier method. The possible prognostic factors (patients and injury characteristics, clinical findings, and seizure characteristics) were studied using log-rank and Cox regression analysis.The probability of persistent seizures was 86.4% after 16 years and 74.7% after 21 years. In patients with3 pieces of shrapnel or no sphincter disturbances during seizure attacks, the probability of being seizure free after these 16 and 21 years was significantly higher.Early seizures, prophylactic antiepileptics drugs, and surgical intervention did not significantly affect long-term outcome in regard to persistence of seizures.

Many studies have investigated the variations in the anatomy of each segment of the cerebral arterial circle while a few have addressed the variations of the cerebral arterial circle as a whole.Thirty brains of recently deceased Iranian infants and fetuses were dissected. The dissection process was filmed and digitized so as to be readily available for further studies. The variations of the circle as a whole and segmental variations were evaluated.Variants with uni- and bilateral hypoplasia of posterior communicating arteries (PcoAs) were the most common in our study, similar to previous works. No aplasia of the precommunicating part of the anterior cerebral artery (A1), the precommunicating part of the posterior cerebral artery (P1) and anterior communicating artery was seen. Hypoplasia of the right and left PcoA was observed in 8 and 5 cases, respectively. Aplasia of the right PcoA was found in 16.6% and of the left PcoA in 3.3%.In this study, we confirmed the previously described finding that the symmetrical, circular configuration of the circulus arteriosus cerebri is present in only about 42.1%. The main differences between the fetal and adult disposition are the diameter of the PcoA and the circular part of the posterior cerebral artery. According to previous studies, the fetal brain older than 4 months has anatomical characteristics very similar to the adult's circle; our finding was mostly similar to adult samples as most samples were from infants, not fetuses.

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.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.Brain atrophy was the only variable with significant independent association (p0.001; 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 GCS12 was considered as the reference category.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 Imagination of the three-dimensional (3D) structure of cerebral vascular lesions using two-dimensional (2D) angiograms is one of the skills that neurosurgical residents should achieve during their training. Although ongoing progress in computer software and digital imaging systems has facilitated viewing and interpretation of cerebral angiograms enormously, these facilities are not always available. Methods We have presented the use of play dough as an adjunct to the teaching armamentarium for training in visualization of cerebral aneurysms in some cases. Results The advantages of play dough are low cost, availability and simplicity of use, being more efficient and realistic in training the less experienced resident in comparison with the simple drawings and even angiographic views from different angles without the need for computers and similar equipment. The disadvantages include the psychological resistance of residents to the use of something in surgical training that usually is considered to be a toy, and not being as clean as drawings or computerized images. Conclusion Although technology and computerized software using the patients' own imaging data seems likely to become more advanced in the future, use of play dough in some complicated cerebral aneurysm cases may be helpful in 3D reconstruction of the real situation.

Background In recent years, outcome prediction models using artificial neural network and multivariable logistic regression analysis have been developed in many areas of health care research. Both these methods have advantages and disadvantages. In this study we have compared the performance of artificial neural network and multivariable logistic regression models, in prediction of outcomes in head trauma and studied the reproducibility of the findings. Methods 1000 Logistic regression and ANN models based on initial clinical data related to the GCS, tracheal intubation status, age, systolic blood pressure, respiratory rate, pulse rate, injury severity score and the outcome of 1271 mainly head injured patients were compared in this study. For each of one thousand pairs of ANN and logistic models, the area under the receiver operating characteristic (ROC) curves, Hosmer-Lemeshow (HL) statistics and accuracy rate were calculated and compared using paired T-tests. Results ANN significantly outperformed logistic models in both fields of discrimination and calibration but under performed in accuracy. In 77.8% of cases the area under the ROC curves and in 56.4% of cases the HL statistics for the neural network model were superior to that for the logistic model. In 68% of cases the accuracy of the logistic model was superior to the neural network model. Conclusions ANN significantly outperformed the logistic models in both fields of discrimination and calibration but lagged behind in accuracy. This study clearly showed that any single comparison between these two models might not reliably represent the true end results. External validation of the designed models, using larger databases with different rates of outcomes is necessary to get an accurate measure of performance outside the development population.

Summary A simple reproducible and sensitive prognostic trauma tool is still needed. In this article we have introduced modified GCS motor response (MGMR) and evaluated the performance of logistic models based on this variable. The records of 8452 trauma patients admitted to major hospitals of Tehran from 1999 to 2000 were analysed. 7226 records with known outcome were included in our study. Logistic models based on outcome (death versus survival) as a dependent variable and Injury Severity Score (ISS), Revised Trauma Score (RTS), Glasgow Coma Scale (GCS), GCS motor component (GMR) and MGMR (following command [=2], movement but not following [=1] command and without movement [=0]) were compared based on their accuracy and area under the Receiver Operating Characteristic (ROC) curve. The accuracy of the Trauma and Injury Severity Score (TRISS), RTS, GCS, GMR and MGMR models were almost the same. Considering both the area under the ROC curve and accuracy, the age included MGMR model was also comparable with other age included models (RTS + age, GCS + age, GMR + age). We concluded that although in some situations we need more sophisticated models, should our results be reproducible in other populations, MGMR (with or without age added) model may be of considerable practical value.

Background Bilateral extradural hematomas have only rarely been reported in the literature. Even rarer are cases where the hematomas develop sequentially, one after removal of the other. Among 187 cases of operated epidural hematomas during past 4 years in our hospital, we found one case of sequentially developed bilateral epidural hematoma. Case Presentation An 18-year-old conscious male worker was admitted to our hospital after a fall. After deterioration of his consciousness, an emergency brain CT scan showed a right temporoparietal epidural hematoma. The hematoma was evacuated, but the patient did not improve afterwards. Another CT scan showed contralateral epidural hematoma and the patient was reoperated. Postoperatively, the patient recovered completely. Conclusions This case underlines the need for monitoring after an operation for an epidural hematoma and the need for repeat brain CT scans if the patient does not recover quickly after removal of the hematoma, especially if the first CT scan has been done less than 6 hours after the trauma. Intraoperative brain swelling can be considered as a clue for the development of contralateral hematoma.

Background Intraspinal bleeding especially in the form of subdural hematoma is rare in hemophiliacs. In the present case, we report a neglected hemophilic A child with such a problem and discuss its management options. Case Presentation A 9-year old hemophilic A boy presented with quadriparesis, confusion and meningismus after a fall 4 days previously. There was no sign of direct trauma to his back. His CT Scan and MRI showed spinal extramedullary hematoma extended from C5 to L2. We corrected the factor VIII level, but two days later, the patient's lower limbs weakened to 1/5 proximally as well as distally. We performed a laminectomy from T11 to L2, according to the level of the maximal neurological deficit and recent deterioration course. The subdural hematoma was evacuated. The hematoma in other spinal levels was managed conservatively. In the week following the operation, the patient's neurological status approached normal. Conclusion This case calls attention to the clinical manifestation, radiological features and management options of the rarely reported intraspinal hematoma in hemophilic children. Although this case has been managed operatively for its hematoma in the thoracolumbar region, at the same time it can be considered a successful case of conservative management of intraspinal hematoma in the cervicothoracic region. Both conservative and surgical management could be an option in managing these patients considering their neurological course.

✓ The authors describe a previously unreported malformation involving paired, bilaterally symmetrical dermal sinus tracts in the retro-auricular area, both of which passed through the asterion and posterior fossa dura mater to end intracranially. Cranial dermal sinus tracts are congenital lesions that virtually always originate from the midline scalp posteriorly at the external occipital protuberance, anteriorly at the nasion or along the nasal dorsum, or in the posterior parietal midline. A lateral origin is extremely rare, and intracranial extension of a lateral dermal sinus tract has not been reported previously. The authors propose an embryological mechanism to explain the origin of this rare malformation and discuss its management.

✓The authors report the third case of ventriculoperitoneal shunt blockage due to spontaneous knot formation in the peritoneal catheter that had been placed in a 3.5-year-old boy 8 months earlier. On surgical exploration a double knot was found 10 cm from the distal end of the peritoneal catheter. Although the underlying mechanism remains unknown, the authors used the analogy of related physical studies and true knot formation in the umbilical cord and determined the possible causes as related to the catheter, volume and configuration of the abdomen, and kinetics of the catheter movements. If further study should reveal a significantly higher incidence of this complication, the authors suggest further in vitro studies, designed to investigate the optimal characteristics and safe range of length of peritoneal catheters in different situations.

Malignant mesothelioma is an uncommon, highly invasive tumor derived from the mesothelial cells of pleura or peritoneum characterized by poor outcome. Mesothelioma was thought to metastasize locally only via direct invasion and not have distant spread. Distant metastases were discovered mostly on post-mortem examination. The authors present a case of 62-year-old man with pleural mesothelioma and brain metastasis.