Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 5 3 2019 11 1 Ventrolateral Preoptic Nucleus of Hypothalamus: A Possible Target for Deep Brain Stimulation for Treating Sexual Dysfunction 99 102 EN Fariborz Ghaffarpasand Neuromodulation and Pain Research Center, Shiraz University of Medical Sciences, Shiraz, Iran Mousa Taghipour Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran Sexual function and orientation is a complex platform of human personality which is being modulated by several brain circuities which is less understood currently. Recently, several studies have demonstrated interesting results regarding the role of several brain locations in sexual behaviors and orientation. Sexual arousal in homosexual men is associated with activation of the left angular gyrus, left caudate nucleus, Ventrolateral Preoptic (VLPO) Nucleus of Hypothalamus and right pallidum; while it is associated with bilateral lingual gyrus, right hippocampus, and right parahippocampal gyrus in heterosexual men. We postulate that sexual-orientation behaviors are being mediated by several circuits in the brain in the center of which the VLPO is playing an indistinguishable role. We hypothesize that the different aspects of the sexual dysfunction could be associated with innate or acquired lesions of VLPO. Accordingly, the electrical stimulation of the nucleus in those with sexual dysfunction would be a treatment option. Thus the VLPO could be considered a target for Deep Brain Stimulation (DBS) in individuals with impaired sexual function.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 5 3 2019 11 1 Predicting Unilateral Post-laminectomy C5 Palsy by Measuring C5 Exit Foramen Area on Preoperative Computed Tomography 103 108 EN Masoud Khadivi Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran Mohammad Reza Golbakhsh Department of Orthopedic Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Mersad Mossavi Department of Orthopedic Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Seyed Sina Ahmadi Abhari Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran Background and aim: Postoperative C5 motor palsy is known as a common complication, not only after cervical laminectomy but also after anterior discectomy. There is no consensus on any of the proposed mechanisms of C5 palsy following posterior cervical decompression. It was found that C5 palsy is more common in patients with smaller C5 root foramen area. The purpose of this study was to define a cut-off value for C4-C5 foraminal area on preoperative computed tomography images to predict post-laminectomy C5 palsy. Methods and Materials/Patients: In this prospective clinical study, C4-C5 foraminal area of 119 patients with cervical spondylotic myelopathy calculated on reformatted pure sagittal computed tomography images value was defined by measuring maximal height and transverse diameter of foramina and a cut-off in which with lesser amounts, post-laminectomy C5 palsy was more common. Results: Of 119 patients with spondylotic myelopathy undergoing cervical laminectomy,23 ones experienced postoperative C5 palsy with mean C4-C5 foraminal area of 44.54±0.72 mm2.Mean C5 root exit foraminal area in patients with intact post-operative root function was calculated 56.78±5.48 mm2 and the difference between these two groups was statistically significant (P<0.05). No patient with C5 exit foraminal area more than 46 mm2had C5 palsy after laminectomy. Conclusion: The incidence of post-laminectomy C5 palsy is significantly higher in patients with C5 exit foraminal area less than 46 mm2. Prophylactic C4-C5 foraminotomy in this group may significantly reduce the risk of postoperative C5 nerve motor palsy, although the effect of this procedure is still debatable.  

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 5 3 2019 11 1 The Role of Dietitian in Improving Energy and Protein Intake in Traumatic Brain Injury Patients Admitted to the Neurosurgical Intensive Care Unit 109 116 EN Fatemeh Ramezani Kapourchali Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, US And Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran Ali Malekshahi Moghadam Faculty of Veterinary Medicine, University of Tehran, Tehran, Iran Anoush Dehnadi Moghadam Department of Anesthesiology, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran Shahrokh Yousefzadeh-Chabok Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran And Department of Neurosurgery, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran Fatemeh Toorang Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, Iran Mohammad Hassan Javanbakht Department of Cellular and Molecular Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran Sara Ramezani Neuroscience Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran. Introduction:Early and sufficient nutritional support is vital to improve outcomes in patients with traumatic brain injury. This study aims to determine the effects of dietitian involvementin the nutritional and clinical outcomes inpatients with traumatic brain injuries admitted tothe neurosurgical ICU. Materials &Methods: Forty-eight male patients with traumatic brain injuries admitted to Poursina Hospital neurosurgical ICU were studied, retrospectively. Patients were divided to either receive dietitian intervention or without any nutritional recommendation(control). Demographic information, Glasgow Coma Scale and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, the timing of initial enteral feeding, the amount of energy and protein intakeon day 4, the duration of mechanical ventilation and ICU length of stay were recorded. Results:Patients under the dietitian recommendation had significantly lower timing of initial enteral nutrition compared to the other cases (P=0.02). The average energy or protein intake and the percentage of target energy or protein intake on day4 appeared to be significantly lower in the subjects in the control group than in those with nutritional intervention(P≤0.001). There was no statistically significant difference in the duration of mechanical ventilation and ICU length of staybetween different groups of patients. Conclusions:Instead of occasional consultations for exclusive cases, the daily attendance of dietitians during multidisciplinary rounds of ICU is required to assess the nutritional needs of patients.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 5 3 2019 11 1 Risk Factors of Neural Tube Defects in a Sample of Iranian Population From Southern Iran: A Hospital-based InvestigationIranian Population From Southern Iran: A Hospital-based Investigation 117 124 EN Mohammad Sadegh Masoudi Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran Negin Hadi Department of Community Medicine, Shiraz University of Medical Sciences, Shiraz, Iran Fariborz Ghaffarpasand Neuromodulation and Pain Research Center, Shiraz University of Medical Sciences, Shiraz, Iran Mohammadreza Askarpour Department of Community Medicine, Shiraz University of Medical Sciences, Shiraz, Iran Faeze Ershadi Student Research Committee, Department of Community Medicine, Shiraz University of Medical Sciences, Shiraz, Iran Tayebeh Sadeghpour Department of Pediatric Neurosurgery, Namazi Hospital, Shiraz, Iran Background and Aim: The risk factors of the Neural Tube Defects (NTD) have been previously described but there are ethnic and geographical variations. Data from the Iranian population is still scarce. The objective of the current study was to investigate the NTDs risk factors in a large sample of Iranian patients admitted to a single center.  Methods and Materials/Patients: This case-control study was performed within five years from 2012 to 2017 in Namazi Hospital of Shiraz, a tertiary referral center for neonatal anomalies in the south of Iran. One hundred newborns with NTDs were included in the study as the case group and 200 healthy newborns as the control group. We recorded the baseline characteristics including the maternal variables (age, weight, height, previous pregnancy and gravidity, gestational age), newborn information (birth weight, clinical diagnosis, clinical findings in the examination, and clinical findings in radiologic test) and medical history of the perinatal period. Results: The baseline characteristics of the mothers were matched in both groups. NTDs were associated with lower folic acid intake during pregnancy (66% vs. 78%; P=0.030; OR 95% CI=1.82) and before pregnancy (P=0.002; OR95% CI=2.36). The prevalence of NTD was significantly higher in patients who lived in hot climates (P=0.001). Conclusion: Taking adequate folic acid supplements before and during pregnancy can reduce the risk of NTDs in the Iranian population. Hot climate zones were associated with an increased risk of NTDs in Iran.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 5 3 2019 11 1 Tandem Spinal Stenosis at the Brazzaville Academic Hospital 125 132 EN Boukassa Leon Marien Ngouabi University and Brazzaville Academic Hospital, Brazzaville, Republic of the Congo Ngackosso Olivier Brice Brazzaville Academic Hospital, Brazzaville, Republic of the Congo Kinata Bambino Sinclair Brice Brazzaville Academic Hospital, Brazzaville, Republic of the Congo Ekouele Mbaki Hugues Brieux Marien Ngouabi University and Brazzaville Academic Hospital, Brazzaville, Republic of the Congo Background and Aim: Tandem Spinal Stenosis (TSS) can be defined as simultaneous stenosis of two distinct spinal (cervical, thoracic and lumbar) areas. Characterized by an association of the spinal, radicular and medullary signs of the limbs, the planning of his surgery remains controversial. We reported the one that was set up on the cases observed at the Brazzaville Academic Hospital.  Methods and Materials/Patients: A retrospective study of 16 patients operated for TSS, from June 2009 to May 2019, was conducted. We analyzed the demographic, clinical, paraclinical, therapeutic and evolutionary data of these patients. Results: For ten years, a total of 16 patients (9 men and 7 women) with SST have been received. The average age was 57 years (ranged 41-72 years). The signs evolved for 17.6 months (13 and 30 months). These were lombo-sciatalgias in 15 cases, signs of medullary compression: cervical in 14 cases and thoracic in 2 cases. Medical imaging had objective 13 cervico-lumbar associations, two thoraco-lumbar associations and one cervico-thoracic. The surgery was performed in one stage in two cases and two stages in 14 cases. These were laminectomies for lumbar and thoracic disorders, discectomy or somatotomy in the cervical segment. The order of surgical management was cervico-thoraco-lumbar (cranio- caudal order). Signs improved in 13 patients and stabilized in 3 patients. Conclusion: TSS is not uncommon. It should be researched in a patient with bifocal spinal and radiculo-medullary signs. Their early surgical treatment, in one or two stages, yields satisfactory results.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 5 3 2019 11 1 A Prospective Study on the Role of Neurophysiological Studies in Predicting Functional Outcome After Lumbar DiscectomyStudies in Predicting Functional Outcome After Lumbar Discectomy 133 140 EN Shanti Lal Sankhla Department of Orthopaedics, Mahatama Gandhi Medical College, Jaipur, India Anshul Dahuja Department of Orthopedics, Guru Gobind Singh Medical College and Hospital, India Rashmeet Kaur Department of Radiodiagnosis, Gobind Singh Medical College and Hospital, India Jagdeep Singh Department of Orthopedics, Guru Gobind Singh Medical College and Hospital, India Ankit Rai Departement of Orthopedics, All India Institute of Medical Sciences (AIIMS), Jodhpur, India Background and Aim: Lumbar intervertebral discs are complex anatomical structures essential for the mobility of intervertebral joints. There is general consensus for some indications for surgery, including acute or progressive neurological deficit(s), cauda equine syndrome, or refractory pain unresponsive to conservative treatments. However, controversy exists regarding the optimal management of cases with the disparity between radiological and clinical findings, which includes a great proportion of patients. This study examines whether neurophysiological studies can be used to identify subgroups with improved post-operative outcomes. Methods and Materials/Patients: This prospective cohort study was conducted on 60 patients with clinical and imaging evidence in favor of Lumbar Disc Herniation (LDH). The pre-operative radiological assessment was the lateral X-rays in flexion and extension positions, and lumbar spine Magnetic Resonance Imaging (MRI). Pre-operative clinical assessment was done by the Oswestry Low Back Pain Disability Questionnaire and Visual Analog Scale (VAS). Neurophysiological studies were done at least one month after the onset of radiculopathy. Surgery was performed at the level suggested by neuroimaging. In all patients, we found an abnormal disc, which was removed along with any loose disc material. The patients were followed up for 1 year with intervals of 3  months for post-operative assessments. Results: In the two study arms with abnormal or normal pre-operative electrodiagnostic studies, a significant decrease was observed in the percentages of visual analog scale reduction (73.69% and 95.59%, respectively) and Oswestry disability score (65.3% and 76.2%, respectively) at the month 12 post-operative (P=0.993 to 0.002 and P=0.200 to 0.037, respectively). Conclusion: Neurophysiological studies could be regarded as helpful adjuncts to distinguish a subgroup of patients with LDH, who may experience a favorable outcome after surgical intervention.  

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 5 3 2019 11 1 Short Segment Rigid Fixation for a Patient of Basilar Invagination and Assimilated C1 With QuadriparesisInvagination and Assimilated C1 With Quadriparesis 141 146 EN Moshiur Rahman Moshiur Neurosurgery Department, Holy Family Red Crescent Medical College, Dhaka, Bangladesh S.I.M. Khairun Nabi Khan Khairun Neurosurgery Department, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh Robert Ahmed Khan Neurosurgery Department, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh Rokibul Islam Rokibul Neurosurgery Department, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh Mainul Haque Sarker Neurosurgery Department, Dhaka Medical College, Dhaka, Bangladesh Background & Importance: Atlas assimilation is the congenital Atlas fusion with the base of the occipital bone. Case Presentation: A patient was presented with neck pain, dysaesthesia and tingling of hands and feet and difficulty in walking for 4 years. On examinations, the patient had a short neck with rigidity in neck muscles and there were exaggerated jerks with bilateral Babinski sign. Cervical spinal x-ray indicated basilar invagination with the absence of a C1 arch and CT scan of the cervical spine showed assimilation of C1 with basilar invagination. Occipitocervical stabilization has been commonly proposed for the operational fusion. The iliac crest interposing bone graft was performed for fusion and stabilization of the occipitocervical region. The patient was treated surgically and soon after operation became painless and was able to move easily. Conclusion: In C1 assimilation with basilar invagination, bicortical occipital screws and C2 pedicle screws with interposition bone graft can be the way to optimize the shortest segmental stabilization and fusion procedure for occipitocervical fusion.  

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 5 3 2019 11 1 Liponeurocytoma of the Cerebellopontine Angle: An Interesting Case Report and Literature ReviewInteresting Case Report and Literature Review 147 153 EN Seyed Ali Mousavinejad Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran Ahmad Jabbari Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran Mahmoud Dehghan Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Ira Kaveh Ebrahimzadeh Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Ira Kasra Amin Kazemi Department of Neurosurgery, Ayat Allah Mousavi Hospital, Zanjan University of Medical Sciences, Zanjan, Iran Jouan Taheri Talesh Department of Neurosurgery, Ayat Allah Mousavi Hospital, Zanjan University of Medical Sciences, Zanjan, Iran Omidvar Rezaei Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran Background and Importance: Liponeurocytoma is a rare tumor of the CNS. Some of its prominent features include low neuronal proliferation with foci of lipomatous differentiation. So far, 70 reports on cases of brain liponeurocytoma have been published. Most of them were located in the cerebellar hemisphere, but only 7 cases of primary Cerebellopontine Angle (CPA) liponeurocytoma have been reported. Case Presentation: We presented a 27-year-old woman with a 6-month progressive headache and dizziness. More recently, she developed progressive hearing loss and ataxia. Pre-operative MRI of the brain demonstrated a heterogeneous solid extra-axial lesion in the right CPA with hydrocephalus. The operation was performed via the retro sigmoid approach. Histopathological diagnosis was confirmed as liponeurocytoma. No radiotherapy was performed. The patient was followed up for two years. There were no signs of recurrence. Conclusion: Liponeurocytoma is a rare tumor. In most of the cases, it is presented in the cerebellum, and the CPA as the primary location of this tumor is extremely uncommon. Typically, surgery is the treatment of choice for these lesions. If the tumor is subtotal, radiotherapy after operation and resection can also be advantageous.  

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 5 3 2019 11 1 Aspergillus Spondylodiscitis After Spinal Stenosis Surgery: A Case ReportA Case Report 155 160 EN Mohsen Aghapoor Department of Neurosurgery, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran Babak Alijani Alijani Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran Mahsa Pakseresht-Mogharab * Department of Neurosurgery, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran Background and Importance: Spondylodiscitis is an inflammatory disease of the body of one or more vertebrae and intervertebral disc. The fungal etiology of this disease is rare, particularly in patients without immunodeficiency. Delay in diagnosis and treatment of this disease can lead to complications and even death. Case Presentation: A 63-year-old diabetic female patient, who had a history of spinal surgery and complaining radicular lumbar pain in both lower limbs with a probable diagnosis of spondylodiscitis, underwent partial L2 and complete L3 and L4 corpectomy and fusion. As a result of pathology from tissue biopsy specimen, Aspergillus fungi were observed. There was no evidence of immunodeficiency in the patient. The patient was treated with Itraconazole 100 mg twice a day for two months. Pain, neurological symptom, and laboratory tests improved. Conclusion: The debridement surgery coupled with antifungal drugs can lead to the best therapeutic results.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 5 3 2019 11 1 Ochronosis, the Rare Cause of Herniation of a Disc: A Case ReportReport 161 166 EN Ali Baradaran Bagheri Department of Neurosurgery, Alborz University of Medical Sciences, Karaj, Iran Farsad Biglari Department of Orthopedics, Alborz University of Medical Sciences, Karaj, Iran Somayeh Soroureddin Department of Internal Medicine, Alborz University of Medical Sciences, Karaj, Iran Salman Azarsina Department of Orthopedics, Alborz University of Medical Sciences, Karaj, Iran Mohammad Kamangar Department of Neurosurgery, Alborz University of Medical Sciences, Karaj, Iran Background and Importance: Alkaptonuria is a rare genetic disorder due to homogentisic acid oxidase deficiency which eventuates in the reposition of homogentisic acid in different parts of the body and multi-organ involvements. The characteristic bluish-black discoloration of the skin and cartilage tissue is known as ochronosis. Case Presentation: Herein, we reported a 45-year-old woman with chronic pain in the lumbar area and radicular pain in her left leg, aggravating gradually during the previous six months before the operation. She also suffered from progressive muscle weakness in her left lower extremity. The patient was operated for prolapsed disc herniation. Macroscopically, no abnormality of the skin, muscles, or ligaments was observed during surgery. After incision of the annulus in level L3-L4, surprisingly the excised nucleus pulposus was black. The alkaptonuria was diagnosed after histopathological examination of the black disc material and confirmed by urinalysis. Conclusion: The postoperative course was uneventful and the patient was free from low back pain and leg pain after surgery. In patients without any manifestations of alkaptonuria or ochronosis such as our case, timely diagnosis of this pathologic condition is momentous for investigation, treatment, and prevention of other organs’ involvement.