Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 5 2 2019 4 1 Steroids Use in Glioblastoma: Why Do We Persist? 51 53 EN Mostafa Fatehi Hassanabad Division of Neurosurgery, Vancouver General Hospital, Vancouver, Canada   Glioblastoma (GBM) is the most common malignant brain tumor and arises from glial cells. The condition was initially described ninety years ago; but, despite intense research efforts, the prognosis for most patients remains woefully poor. Over the past few decades, our understanding of the pathologic processes implicated in GBM have improved and we have a greater appreciation for the tumor-microenvironment interactions. We also have a much clearer perspective of the molecular genetics of the disease which will allow us to rationally develop new therapeutic strategies. However, an issue that remains somewhat overlooked is the significance of immune compromise in patients with GBM. Unfortunately, as surgeons and oncologists we continue to prescribe corticosteroids; a patently flawed therapeutic strategy.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 5 2 2019 4 1 Post-Market Surveillance Study of a Skull Flap Fixation Device: Cranfixer 54 62 EN Seyed Roholah Ghodsi DanaWell Company, Tehran University of Medical Sciences, Tehran, Iran Hosein Esmaili Dezaki DanaWell Company, Tehran University of Medical Sciences, Tehran, Iran Morteza Alizadeh . Department of Tissue Engineering, School of Advanced Technologies, Shahrekord University of Medical Sciences, Shahrekord, Iran Zahra Namazi Department of Dental Biomaterials, School of Dentistry, Shahid Beheshti Univeristy of Medical Sciences, Tehran, Iran Background and Aim: Cranfixer was approved in 2017 by the Food and Drug Administration of Iran as a skull flap fixation and also a burr hole cover. The effectiveness and safety of this commercial medical device were investigated in detail by the regulatory auditors. Methods and Materials/Patients: Cranfixer was used for ninety-five patients. Sixty patients were selected from a list if they had at least two follow-ups after surgery. The following variables were investigated: age, gender, number of Cranfixers, device loosening, infection, and prominence. In addition, a retrospective review was performed about the reason of surgery. Results: Flap loosening and infection were the major variables surveyed. On average, two Cranfixers were used for each patient. Patients’ median age was 44 years. There was no sex preference (50% male). The craniotomy occurred in the frontal (50%), occipital (3%), parietal (20%), and temporal (27%) lobes. Based on examination and CT imaging, no cases of loosening were observed. Just in one patient, one of two Cranfixers was infected (P<0.001). Conclusion: The reliability and functionality of Cranfixer were proved in pre-market test and the results of this study confirm them. Cranfixer provides safe, reliable and long-term functionality.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 5 2 2019 4 1 Cranial and Spinal Locations of Histoplasma Capsulatum var. duboisii in Brazzaville, Congo 63 69 EN Leon Boukassa Department of Surgery, Division of Neurosurgery, Brazzaville Academic Hospital, Republic ‎of Congo, Africa Olivier Braice Ngackosso Department of Surgery, Division of Neurosurgery, Brazzaville Academic Hospital, Republic ‎of Congo Sinclair Brice Kinata Bambino Department of Surgery, Division of Neurosurgery, Brazzaville Academic Hospital, Republic ‎of Congo Hugues Brieux Ekouele Mbaki Department of Surgery, Division of Neurosurgery, Brazzaville Academic Hospital, Republic ‎of Congo Sylvain Andre Ngounda Monianga Department of Surgery, Division of Thoracic surgery, Brazzaville Academic Hospital, ‎Republic of Congo Khedel Mavoungou Biatsi Department of Anatomopathology, Brazzaville Academic Hospital, Republic of Congo‎ Jean Felix Pecko Department of Anatomopathology, Brazzaville Academic Hospital, Republic of Congo‎ Background & Aim: Histoplasma capsulatum var. duboisii is a rare fungus that is endemic in the Sahara and Madagascar in southern Africa. The present study was conducted to explain the confirmed cases of histoplasmosis. Methods and Materials/Patients: This retrospective study was conducted at the Division of Neurosurgery of Brazzaville teaching hospital in the Republic of Congo. The clinical records of all of the confirmed cases admitted between January 2014 and December 2017 were reviewed. Results: All of the five cases of confirmed histoplasmosis, including two women and three men, with a mean age of 42 years old, admitted to the Division of Neurosurgery over four years were immunocompetent to HIV. Radiological imaging identified a localized form of cold abscess in two of the patients and disseminated forms in three male cases. Lung lesions were also observed in two patients with multilevel spondylodiscitis and lung diseases, and clavicular osteitis in the other patient. Clavicular osteitis was also found to be associated with cutaneous fistulization in one of the patients, with cutaneous nodules in the second patient and with cutaneous nodules and pulmonary lesions in the third. Appropriate outcomes were observed for the localized forms but undesirable ones for the disseminated forms. Four patients had received medical and surgical treatments. This treatment caused an appropriate evolution in patients with localized forms and an undesirable evolution in the two scattered forms. These patients died upon admission due to the complications associated with their severe neurological condition. The final case died before beginning the antifungal treatment following a septic shock with the fistulization of osteitis clavicularis as its potential cause.  Conclusion: Although infections with Histoplasma capsulatum var. duboisii are rare, the lack of comprehensive knowledge on this fungus in the majority of medical staff can explain the delays in treating these infections. Microbiological analyses are therefore required to be performed on pathological materials in the event of suppuration to assist with early diagnosis and effective management.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 5 2 2019 4 1 The Effect of Intravenous Tranexamic Acid Before and During Spinal Surgery in Bleeding Volume During and After Surgical Operation 71 78 EN Majid Rezvani Medical School of Isfahan University of Medical Sciences, Isfahan, Iran Homayoun Tabesh Medical School of Isfahan University of Medical Sciences, Isfahan, Iran Meisam Adimi Medical School of Isfahan University of Medical Sciences, Isfahan, Iran Mohammad Alavi Medical School of Isfahan University of Medical Sciences, Isfahan, Iran Abolfazl Zareian Medical School of Isfahan University of Medical Sciences, Isfahan, Iran Mitra Rahiminejad Medical School of Isfahan University of Medical Sciences, Isfahan, Iran Mehrdad Lari Medical School of Isfahan University of Medical Sciences, Isfahan, Iran Background and Aim: Bleeding during surgery is one of the most common surgical complications. In this study, we decided to determine the effect of Tranexamic Acid (TA) in reducing blood loss in patients undergoing spinal surgeries. Methods and Materials/Patients: In this clinical trial, 100 patients undergoing spinal surgeries were randomly divided into two groups. One group received TA and the other was selected as the control group. Patients in the treatment group received 1 gram of intravenous TA and another 250 milligram intravenously, one hour after the beginning of the surgery. Bleeding during the surgery, in the first 24 hours and the first 48 hours were recorded separately. The need for transfusion and its volume, as well as the hospital stay length were compared in the two groups.  Results: Bleeding during surgery in TA group was significantly lower than that in the control group (433 ml vs. 522 ml respectively, P=0.009). Also, during the first 24 hours after surgery, bleeding in TA group was significantly less than that in the control group (P=0.011). During the second 24 hours after surgery, bleeding was similar between the two groups (P=0.112). The values of hemoglobin in both groups slowly decreased and the trend of decrease was not significantly different between them (P=0.154). Conclusion: In spinal surgeries, TA administration in the beginning of the process reduces surgical bleeding during surgery and in the first 24 hours after surgery. Considering the possible complications, TA administration is suggested for patients with hemoglobin less than 12 g/dl. Future studies are needed to conclude the advantages and disadvantages of TA administration in spinal surgeries.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 5 2 2019 4 1 Validity and Reliability of the Short Form Health Survey Questionnaire (SF-36) for Use in Iranian Patients With Traumatic Brain Injury (TBI) 79 91 EN Sajjad Rezaei Department of Psychology, University of Guilan, Rasht, Iran Zahra Khaksari Department of Psychology, Payame Noor University,Tehran, Iran Background and Aim: The assessment of Quality of Life (QoL) as a measurement of Traumatic Brain Injury (TBI) outcome can play a key role in identifying the adverse effects of TBI. There is no study on the evaluation of psychometric properties of the Persian version of Short Form Health Survey Questionnaire (SF-36) in the TBI patient population. Therefore, the present study aimed to validate and test the reliability of the Persian version of the SF-36 in patients with TBI. Methods and Materials/Patients: In the present cross-sectional study, 185 patients with TBI were selected by non-probability and consecutive sampling. First, the construct validity of the Persian version of the SF-36 questionnaire was evaluated using the Confirmatory Factor Analysis (CFA) in AMOS-22, and then the internal consistency reliability and item-total score correlation of each subscale were assessed by SPSS V. 22. Results: Results of CFA indicated that the dimensionality of SF-29 questionnaire with eight-factor structure among the Iranian TBI patients had construct validity (GFI=0.825, CFI=0.963, NFI=0.919, TLI=0.957, RMSEA=0.06) by eliminating 6 items and freeing some of the covariance errors between items, but the two-factor dimensionality (physical and psychological components of QoL) of this questionnaire was not approved. Internal consistency of the eight-factor form of SF-29 subscales was acceptable to excellent (=α0.70 to 0.99). Correlation analysis of item-total score for determining the construct validity of SF-29 indicated that except for 2 items, all items of the questionnaire had a positive and strong correlation with their subscales (r=0.40 to 0.99, P<0.0001). Conclusion: Persian version of SF-29 with an eight-factor construct had good validity and reliability and could be used to measure health-related QoL in Iranian patients with TBI.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 5 2 2019 4 1 Endoscopic Transsphenoidal Fenestration of a Medial Temporal Arachnoid Cyst With Extension to Sphenoid Sinus in a Patient With Temporal Lobe Epilepsy 93 98 EN Arash Saffarian Neurosurgery Department, Shiraz University of Medical Sciences, Shiraz, Iran Nima Derakhshan Neurosurgery Department, Shiraz University of Medical Sciences, Shiraz, Iran Mousa Taghipour Neurosurgery Department, Shiraz University of Medical Sciences, Shiraz, Iran Mohammad Faramarzi Department of Otolaryngology, Shiraz University of Medical Sciences, Shiraz, Iran Ali Akbar Asadipooya 1. Department of Neurology, Shiraz University of Medical Sciences, Shiraz, Iran 2. Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA Amirreza Dehghanian Pathology Department, Shiraz University of Medical Sciences, Shiraz, Iran Keyvan Eghbal Neurosurgery Department, Shiraz University of Medical Sciences, Shiraz, Iran Background and Importance: Arachnoid cysts are developmental cystic lesions which may be found as an incidental finding on neuroimaging or present with symptoms of headache, seizure and neurologic deficit. Presentation with seizure is more common with larger sizes and temporal location. Presentation with Temporal Lobe Epilepsy (TLE) is rare, and fenestration of cysts has variable results for seizure control. We reported controlling TLE symptoms following endoscopic transsphenoidal fenestration of an arachnoid cyst. The anteromedial location in middle fossa, extension toward sphenoid sinus and normal appearance of mesial temporal structures on MRI encouraged us to consider this surgical approach. Case Presentation: A 26-year-old patient with a 13-year history of TLE with uncontrolled symptoms despite taking a combination of AEDs (LTG, CBZ, LEV, CLB) was referred to our clinic. Neuroimaging revealed an arachnoid cyst in anteromedial part of temporal fossa which extended to sphenoid sinus, but showed no abnormality in mesial temporal structures. Endoscopic endonasal transsphenoidal fenestration of the arachnoid cyst was performed, and followed by reconstruction of the skull base. The procedure improved the seizure control during the 9-month follow-up and no sign of radiologic recurrence was observed. Conclusion: Transsphenoidal endoscopic fenestration is a safe and feasible surgical approach for treatment of symptomatic arachnoid cysts in anteromedial part of middle fossa especially when they extend toward lateral wall of sphenoid sinus. This surgical corridor has the privilege of avoiding cortical injury accompanied by transcranial approaches, which is deleterious in epileptic patients.