Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Comparison of Intrathecal Morphine and Fentanyl in Postoperative Pain Management of Spine Surgeries: A Randomized Double-blind Clinical Trial 1 9 EN Ehsan Parsa Department of Neurosurgery, Kerman University of Medical Sciences, Kerman, Iran. Mehran Ilaghi Kerman Neuroscience Research Center, Institute of Neuropharmacology, Kerman, Iran. Hamed Reihani-Kermani Department of Neurosurgery, Kerman University of Medical Sciences, Kerman, Iran. Background and Aim: This study aims to compare the effectiveness of intrathecal morphine and fentanyl in reducing postoperative pain in patients undergoing spinal surgery. Methods and Materials/Patients: This was a randomized, double-blind clinical trial involving 80 patients who were candidates for spinal surgery. The participants were randomly assigned to two groups (n=40 each) and received either intrathecal morphine (0.2 mg) or fentanyl (25 µg). Postoperative pain was evaluated utilizing the visual analogue scale (VAS) at 4, 6, 12, and 18 h postsurgery. The time interval before a supplementary analgesic dose was required for pain control was recorded. Side effects, including pruritus, nausea/vomiting, and respiratory depression were monitored. Results: No significant differences were observed in age, sex, or operation type between the two groups. Patients in the morphine group exhibited remarkably lower VAS scores at all the assessed postoperative time points (P=0.001). Moreover, patients in the morphine group showed significantly lower overall mean VAS scores than those in the fentanyl group (3.75; 95% confidence interval [CI], 3.53%, 3.97% vs 5.06; 95% CI, 4.85%, 5.27%; P<0.001). The time to analgesic administration was significantly longer in the morphine group compared to the fentanyl group (P=0.001). The occurrence of postoperative nausea and vomiting was significantly higher in the morphine group (37.5%) than in the fentanyl group (15.0%, P=0.022). The incidence of pruritus did not differ significantly between the two groups. No cases of respiratory depression have been reported. Conclusion: Intrathecal morphine was more effective in reducing postoperative pain and prolonging the time to rescue analgesic administration compared to intrathecal fentanyl in patients undergoing spine surgeries. However, a higher incidence of postoperative nausea/vomiting should be considered.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 A Comparative Study on Therapeutic Modalities of Spontaneous Supratentorial Intracerebral Hemorrhage at a Teaching Institute 10 26 EN Nitin Barde Department of Neurosurgery, Vilasrao Deshmukh Government Medical College, Latur Superspeciality Hospital, Latur, India. Ramesh Chandra VV Department of Neurosurgery, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, India. Dattatray Kulkarni Department of Neurosurgery, Vilasrao Deshmukh Government Medical College, Latur Superspeciality Hospital, Latur, India. Meghraj Chawada Department of Neurosurgery, Vilasrao Deshmukh Government Medical College, Latur Superspeciality Hospital, Latur, India. Background and Aim: To evaluate immediate outcomes and prognostic factors in surgical and medical treatment for spontaneous supratentorial intracerebral hemorrhage (SICH). Methods and Materials/Patients: We prospectively investigated the two treatment groups, medical (88 patients) and surgical (40 patients), based on standard guidelines between May 2018 and November 2019. Immediate outcomes in the two groups were measured using the Glasgow outcome scale (GOS) at three months. Prognostic factors in the two groups were compared using the chi-square test. Results: Of 128 patients with spontaneous SICH, 88 were in the medical group, and 40 were in the surgical group. The mean age of the medical group was 57±13 years, and that of the surgical group was 53.7±12 years. In both groups, the predominant bleeding site was the left capsuloganglionic region. Hypertension was the most common risk factor in both groups (90%). In the medical group (n=88), 57 patients (65%) had good outcomes, and 31 patients (35%) had poor outcomes. In the surgical group (n=40), 19 patients (48%) had good outcomes, and 21 patients (35%) had poor outcomes. Mortality rates were 25% (n=22) in the medical group and 30% (n=12) in the surgical group till 3 months. Patients in our surgical group with intracerebral hemorrhage (ICH) score of 3 had a poorer outcome (68%) and lower mortality (46%) than those in the medical group (66% poor outcome and 55% mortality). The medical group with intraventricular hemorrhage (IVH) (n=28) had poor and good outcomes in 71% and 29% of cases, respectively. The surgical group with IVH (n=20) had poor outcomes in 85% of cases and good outcomes in 15% of cases. The medical and surgical groups without IVH had similar good outcomes in 80% of the cases. Conclusion: The surgical group had improved outcomes compared to the medical group containing patients with midline shift >6 mm, >30 cc of bleed, and Glasgow coma scale (GCS) 8-12. With higher ICH scores and IVH, the surgical group showed poorer outcomes and fewer deaths.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 A Retrospective Analysis of Head Injury Patients Admitted in an Indian Tertiary Hospital During the COVID 19 Pandemic 27 33 EN Obaid Ahmad Siddiqui Department of Anaesthesiology, Jawaharlal Nehru Medical College, Aligarh Muslim University (AMU), Aligarh, India. farah nasreen Department of Anaesthesiology, Jawaharlal Nehru Medical College, Aligarh Muslim University (AMU), Aligarh, India. Sobia Manaal Siddiqui Department of Anaesthesiology, Jawaharlal Nehru Medical College, Aligarh Muslim University (AMU), Aligarh, India. Atif Khalid Department of Anaesthesiology, Jawaharlal Nehru Medical College, Aligarh Muslim University (AMU), Aligarh, India. Background and Aim: The general effect of the COVID-19 pandemic has so far been enormous. The impact of traumatic brain injury (TBI) and related conditions during the pandemic has been largely misunderstood. Head injury with subsequent TBI is a major source of morbidity and mortality and presents a challenge in the intensive care unit (ICU). This study aims to describe TBI cases during the COVID-19 outbreak in patients admitted to an emergency trauma ICU. Methods and Materials/Patients: A retrospective study was conducted on patients admitted to the nine-bed multidisciplinary ICU between January 2021 and December 2021. Sociodemographic parameters, causes of TBI, and outcomes in terms of Glasgow coma scale (GCS) score, mortality, tracheostomy, and extubation were evaluated. Results: Mean age of patients was 37.09±14.64 years. Most patients were men (72.4%). A total of 73.6% of patients had TBI due to road traffic accidents (RTA). Mortality was high among patients with higher Rotterdam computed tomography (CT) scores. Mechanical ventilation following TBI was required in 84.2% of patients. Mortality following TBI was high, with 46.05% of all patients dying. Conclusion: The management of TBI patients has had a substantial impact due to the COVID-19 pandemic. Patients with TBI sustained high mortality rates during the pandemic despite a decrease in the number of ICU admissions  

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Osteochondroma as a Rare Cause of Lower Limb Radiculopathy: A Case Report 34 39 EN Seyed Habibollah Hassani Department of Neurosurgery, School of Medicine, Babol University of Medical Sciences, Babol, Iran. Ali Kazeminezhad Department of Neurosurgery, Peymanieh Hospital, Jahrom University of Medical Sciences, Jahrom, Iran. Hesam Ghadirian Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran. Simin Mouodi Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran. Background and Importance: Spinal osteochondroma is a rare benign primary spinal column tumor. Its most common site is the cervical spine, and lumbar involvement is rare. Case Presentation: A 53-year-old male patient of Iranian ethnicity presented to our clinic with severe pain and acute radiculopathy in his right lower limb for 10 days. The patient did not respond to oral analgesics for pain management. When the patient was examined with magnetic resonance imaging (MRI) and computed tomography (CT) scan, a bone tumor in the inferior facet of L4 was found. The patient underwent surgery, and the tumor was completely removed. Histopathological examination revealed osteochondroma. The patient was followed up for five years after surgery; fortunately, no symptoms or signs of recurrence occurred. Conclusion: Although osteochondroma usually occurs in the cervical region, in this case, the lesion was observed in the lumbar region, with clinical features of acute radiculopathy. Therefore, osteochondroma should be considered a differential diagnosis for lower limb radiculopathies.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Artificial Intelligence for Improved Diagnosis of Spinal Stenosis: Implications for Neurosurgical Practice 40 50 EN Misagh Shafizad Department of Neurosurgery, Orthopedic Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran. Saeid Ehteshami Department of Neurosurgery, Orthopedic Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran. Pooria Sobhanian Student Research Committee, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran. Mahla Hosseinzade Student Research Committee, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran. Background and Aim: Spinal stenosis is a common condition in the elderly and is characterized by the narrowing of the spinal canal, leading to significant neurological symptoms. Traditional imaging methods, such as magnetic resonance imaging (MRI) and computed tomography (CT), have limitations, including interpretation and time consumption variability. Integrating artificial intelligence (AI), particularly deep-learning algorithms, into MRI analysis shows promise for enhancing diagnostic accuracy and efficiency. This narrative review aims to explore AI’s application in diagnosing spinal stenosis and its implications for treatment planning and patient outcomes in neurosurgery practice. Methods and Materials/Patients: A literature search was conducted using Google Scholar, MEDLINE, and PubMed to identify original studies on AI in diagnosing lumbar and cervical spinal stenosis. Relevant studies were included after screening. Data extraction was performed using a structured spreadsheet, and findings were analyzed thematically to identify trends in AI applications for diagnostic accuracy. Results: Integrating AI into the diagnostic process for lumbar and cervical spinal stenosis has significantly improved accuracy and efficiency. By employing advanced deep learning (DL) algorithms, particularly convolutional neural networks (CNNs), AI systems can analyze imaging data more effectively and identify subtle patterns indicative of stenosis that human clinicians may overlook. This capability enhances diagnostic precision and facilitates earlier interventions, ultimately improving patient outcomes. As research continues to advance in this field, the role of AI is expected to expand, further transforming the landscape of spinal stenosis diagnoses. Conclusion: AI has shown significant promise in enhancing the diagnosis of cervical and lumbar spinal stenosis. By utilizing deep-learning algorithms, AI can analyze imaging data more accurately and efficiently, identifying subtle patterns indicative of stenosis that human observers may miss. This can ultimately facilitate earlier interventions and improve patient outcomes.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Recurrent Tolosa Hunt Syndrome, After Cervical Spine Surgery: Case Report 51 54 EN Abdolhadi Daneshi Department of Neurosurgery, School of Medicine, Iran University of Medical Sciences, Tehran, Iran. Omid Masoudi Department of Neurosurgery, School of Medicine, Iran University of Medical Sciences, Tehran, Iran. Saina Darvishnia Department of Anesthesiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran. Seyed Mohammad Reza Mohajeri Department of Neurosurgery, School of Medicine, Iran University of Medical Sciences, Tehran, Iran. Hossein Ghazvini Department of Neurosurgery, School of Medicine, Iran University of Medical Sciences, Tehran, Iran. Background and Importance: Tolosa hunt syndrome (THS) is a rare ophthalmoplegia that occurs in one person per million people. Clinical presentation, magnetic resonance imaging (MRI) findings, and a good response to steroids are used to diagnose THS. Case Presentation:We present a 59-year-old man with right ophthalmodynia and ophthalmoplegia after cervical laminectomy and surgical site infection (SSI). After the first course of low-dose dexamethasone, the patient’s symptoms relapsed within a short time. During the second course of treatment, high-dose dexamethasone was administered. The symptoms were treated without relapse within one year. Conclusion: Infection, such as SSI, can trigger THS. Also, high-dose dexamethasone and longer treatment periods can prevent short-term recurrence of THS.  

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Plasmacytoma-induced Pathological Axis Fracture: A Case Report and Literature Review 55 60 EN Mohammad Ali Abouie Mehrizi Department of Neurosurgery, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. Amir Hossein Haghir Department of Neurosurgery, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. Mostafa Ghanavizian Department of Neurosurgery, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. Milad Mojazi-Amiri Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. Bahador Maleki-poor Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Saman Mohazzab-Torabi Department of Neurosurgery, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. Background and Importance: For the cervical spine, managing the pathological body of the axis tumor is controversial. In older patients, major procedures may be hazardous, and non-operative treatment is associated with cervical instability. Case Presentation: A 70-year-old woman presented with chronic neck pain, mild quadriparesis, and a “sensation” of skull instability. Computed tomography (CT) showed a lytic lesion involving almost the entire body of the C2 vertebra. Magnetic resonance imaging (MRI) revealed a hypotensive infiltrative lesion involving the axis. Posterior cervical fusion was suggested to improve clinical symptoms and prevent future vertebral collapse with catastrophic neurological consequences. Under general anesthesia and neurophysiological monitoring, one-stage surgery was performed with C1 laminar hook and C3-C4 lateral mass screw insertion. A cytological sample from the lytic lesion was transpedicular through C2. Her neurological function recovered well, and he could walk independently 15 days postoperatively. Histopathology with further immunohistochemistry (IHC) of the C2 vertebral body also showed plasmacytoma. Conclusion: No specific approach is observed to treat the axis’s rare, solitary pathological lesions. Posterior cervical fixation has proven safe and effective in palliative treatment, improving neurological function and cervical stability at the beginning of early chemotherapy.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 A Rare Case of Multiple Wasp Stings Causing Bilateral Ischemic Stroke 61 69 EN Binoy Damodar Thavara Department of Neurosurgery, Government Medical College, Kozhikode, India. Rajeev Mandaka Parambil Department of Neurosurgery, Government Medical College, Kozhikode, India. Byjo Valiyaveetil Jose Department of Neurosurgery, Government Medical College, Kozhikode, India. Prem kumar Sasi Department of Neurosurgery, Government Medical College, Kozhikode, India. Shanavas Cholakkal Department of Neurosurgery, Government Medical College, Kozhikode, India. Ebby Sebastian Department of Neurosurgery, Government Medical College, Kozhikode, India. Atul Kale Keshavrao Department of Neurosurgery, Government Medical College, Kozhikode, India. Background and Importance: Only 19 cases of wasp stings causing proven ischemic stroke have been reported. Authors reported a rare case of multiple wasp stings causing bilateral ischemic stroke. Case Presentation: The authors report a 49-year-old man presenting with multiple (more than 50) wasp stings all over his body. The patient developed loss of consciousness (LOC) and right hemiparesis of Medical Research Council (MRC) grade 1 power. Magnetic resonance imaging (MRI) of the brain revealed a large area of infarction in the left front-temporal-parietal region involving basal ganglia, corona radiata, centrum semiovale, and the right parietal cortex. Computed tomography (CT) scan the next day showed a significant increase in brain edema with a midline shift to the right side. The patient underwent a left front-temporalparietal decompressive craniectomy and duraplasty. His condition gradually improved and underwent cranioplasty five months later. Conclusion: Multiple wasp stings can cause life-threatening cerebral infarcts. Wasp stings causing large ischemic infarcts require decompressive craniectomy to save the patient. Early radiological evaluation of suspicious cases and prompt medical and surgical intervention are the key to successful treatment of cerebral infarction due to wasp sting  

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Improving Diagnosis and Management of Nonhypertensive Intracerebral Hemorrhage With Cone Beam CT Angiography 70 75 EN Mohammad Ghorbani Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran. Mohammad Hasanpoor Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran. Hojjat Mirsardoo Department of Neurosurgery, Kerman University of Medical Sciences, Kerman, Iran. Seifollah Jafari Department of Neurosurgery, Poursina Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran. Fakhrialsadat Ghasemigeskeminjan Department of Neurosurgery, Poursina Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran. Rouzbeh Shams Amiri Department of Neurological Surgery, Neuroscience Research Center, Golestan University of Medical Sciences. Gorgan, Iran. Background and Importance: Cerebral micro-arteriovenous malformations (micro-AVMs), defined as occult nidus smaller than 1 cm, pose diagnostic challenges on conventional imaging and complicate treatment due to their small size and risk of hemorrhage. Advanced imaging modalities, such as intra-arterial cone-beam computed tomography angiography (CBCT-A), have shown promise in enhancing diagnostic accuracy and treatment planning. Case Presentation: We report the case of a 58-year-old woman who presented with intracerebral hemorrhage (ICH) without a history of hypertension. Initial computed tomography (CT) and magnetic resonance imaging (MRI) failed to identify the underlying vascular anomaly, necessitating catheter-based intra-arterial digital subtraction angiography (DSA), which revealed a small, low-flow nidus indicative of an AVM. Selective CBCT-A provided a detailed angioarchitectural evaluation, enabling precise catheterization and effective nidus occlusion with Onyx 18. Conclusion: This case highlights the critical role of combining digital subtraction angiography (DSA) and CBCT-A in the management of AVMs, particularly when traditional imaging is inconclusive. These modalities are crucial for managing AVMs, especially in patients with atypical presentations or those without common cerebrovascular risk factors.  

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Neurourogenital Aspects of Lumbosacral Spinal Stenosis 76 81 EN Hossein Hakimellahi Jahrom University of Medical Sciences, Jahrom, Iran. Navid Kalani Department of Anesthesiology, Critical Care and Pain Management Research Center, Jahrom University of Medical Sciences, Jahrom, Iran. Ali Kazeminezhad Department of Neurosurgery, Peymanieh Hospital, Jahrom University of Medical Sciences, Jahrom, Iran. Background and Aim: Lumbosacral spinal stenosis (LSS) is a disease in elderly cases and in its advanced forms gives rise to intractable leg pain and in many cases various degrees of bladder dysfunction. In LSS bladder dysfunction can occur following compression of lumbar nerve roots or cauda equine. Urological manifestations like lower urinary tract complaints (LUTC) and sexual dysfunction of LSS are rare and reviewed in this study. From neuro-urological aspect urodynamic study (UDS) is vital in LSS and asseses the function of lower urinary tract, provides informations about diagnosis and prognosis, and permits planing a rational therapeutic paln to prevent renal dysfunction. Methods and Materials/Patients: Using the keywords lumbar stenosis, neurogenic bladder, surgical decompression, and UDS, all the corresponding surveys were held on Google Scholar, and PubMed Medline. Results: Urological presentations of LSS are rare; however, many patients present with various degrees of bladder malfunction. UDS is crucial in detecting neurogenic bladder malfunction, preventing renal function aggravation, and evaluating the neuro-urological effects of LSS surgery. Conclusion: LSS may present with genitourinary symptoms. In contrast to conservative therapy, surgical decompression yields an adequate improvement in the neurourological aspects of LSS, with no significant relationship between the operation for LSS and the resolution of the upper urinary tract lesions (UUTL). More conclusive studies with a long follow-up period and a large case population are required to explore the final treatment results.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Endovascular Coiling Versus Neurosurgical Clipping for Aneurysmal Subarachnoid Hemorrhage: Single-center Experience 82 89 EN Ali Batiar Laboratory Science Research Center, Golestan University of Medical Sciences, Gorgan, Iran Mohammad Hossein Mirbolouk Department of Neurosurgery, School of Medicine, Firoozgar Hospital, Iran University of Medical Science, Tehran, Iran. Mohsen Nabiuni Department of Neurosurgery, School of Medicine, Iran University of Medical Sciences, Tehran, Iran Seyed Aidin Sajedi Clinical Research Development Unit, Sayyad Shirazi Hospital, Golestan University of Medical Sciences, Gorgan, Iran. Fateme Shahrokhi Laboratory Sciences Research Center, Golestan University of Medical Sciences. Gorgan, Iran. Rahim Kohansal Department of Neurology, Shafa Hospital, Gorgan, Iran. Rouzbeh Shams Amiri Neurological Surgery Department, Neuroscience Research Center, School of Medicine, Golestan University of Medical Sciences, Gorgan, Iran. Background and Aim: Subarachnoid hemorrhage (SAH) resulting from ruptured intracranial aneurysms is associated with high mortality rates and presents a significant clinical challenge. The primary interventions to mitigate the risk of rebleeding and improve patient outcomes are neurosurgical clipping and endovascular coiling. While neurosurgical clipping has historically been the gold standard, endovascular coiling offers a less invasive alternative. Accordingly, this study compares the efficacy and outcomes of these two interventions in patients with aneurysmal SAH. Methods and Materials/Patients: A total of 65 consecutive patients with aneurysmal SAH, treated either with neurosurgical clipping or endovascular coiling, were included in the retrospective cohort study. Functional outcomes were assessed using the modified Rankin score, and the complications were evaluated. Results: No significant differences were found in functional outcomes between neurosurgical clipping and endovascular coiling groups (P=0.92); however, patients undergoing endovascular coiling had shorter lengths of in-hospital and in-intensive care unit stays compared to those treated with neurosurgical clipping (P=0.02). Conversely, endovascular coiling was associated with higher intervention costs (P<0.01). Subgroup analyses based on disease severity revealed small differences in functional outcomes between the two groups. Conclusion: While both neurosurgical clipping and endovascular coiling demonstrate comparable efficacy in preventing rebleeding and improving functional outcomes, they present distinct advantages and considerations. Future studies should be performed to improve treatment algorithms and patient outcomes in this complex clinical situation. Additionally, larger prospective studies are needed to validate these findings and provide stronger evidence for guiding clinical decision-making.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Investigating the Correlation of Magnetic Resonance Imaging Findings and Clinical Outcome in Patients With Spondylodiscitis 90 100 EN Golnaz Izadi Department of Radiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Kowsar Pourkarim arabi Department of Radiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Seyed Ahmad Moayedmortazavi Department of Radiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Navid Askariardehjani Department of Neurosurgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. Background and Aim: Spondylodiscitis is a rare but serious infection of the intervertebral disc and the endplate of the vertebrae. Various causes have been described for this disease, one of which is iatrogenic and following previous spinal surgery. This study investigates the relationship between the parameters described in the initial magnetic resonance images and the clinical outcome of the patients. Methods and Materials/Patients: A total of 32 patients with clinical and laboratory evidence and imaging findings consistent with spondylodiscitis who had a history of spine surgery and fusion device implantation during the last 3 months were studied. Initial magnetic resonance imaging findings were compared and interpreted in conjunction with the outcomes of these patients, based on C-reactive protein (CRP) levels, pain scores, and the need for re-surgery during a 3-month follow-up. Results: The average follow-up CRP level in patients experiencing stable pain was 17.71±8.03 and was significantly higher than other patients (P<0.05). Among the total cohort (n=32), the ring-like enhancement pattern was observed in 13 patients (40.6%). Of these, 7 patients were in the poor outcome group (n=7 [100%]), and 6 were in the good outcome group (n=25 [24%]). Additionally, among patients with persistent pain (n=14), 9 (64.3%) exhibited the ring-like pattern, compared to only 4 of 18(22.2%) patients with minimal or no pain. Conclusion: Vertebral height reduction and disc destruction, and ring-like enhancement pattern in soft tissue and dura, as well as CRP level above 10 values in follow-up, are associated with persistent pain in patients.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 CT Scan-based Morphometric Study of Cervical Screw Placement in the Iranian Population 101 110 EN Yasaman Ghiasi Student Research Committee, Qazvin University of Medical Sciences, Qazvin, Iran. Yong Yie Liew Department of Neurosurgery, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom. Sina Abdollahzade Department of Neurosurgery, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom. arup ray Department of Neurosurgery, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom. Background and Aim: The stability of the cervical spine is essential for treating spinal pathologies, including trauma, malformations, and tumors. Surgical stabilization, especially in the subaxial cervical vertebrae, often needs the use of lateral mass screws, laminar screws, and transpedicular screw fixation (TPSF). Due to the complex anatomy of the cervical spine and its variations among different ethnicities, as well as the high risks of surgical complications, it is crucial to understand its morphometric characteristics for more effective and safer surgical interventions. This study evaluates the feasibility of placing transpedicular, translaminar, and lateral mass screws (LMS) in the subaxial cervical vertebrae in the Iranian population by analyzing morphometric data obtained from cervical computed tomography (CT) scans. Methods and Materials/Patients: A cross-sectional study was conducted using cervical CT scan imaging of 100 patients from Rajayee Hospital in Qazvin City, Iran. Specific measurements of the pedicle, lamina, and lateral mass were recorded. Statistical analysis was performed using SPSS software, version 19, with a focus on descriptive statistics and tests for differences between genders. Results: The study presents detailed morphometric measurements of the subaxial cervical vertebrae in the Iranian population, including data from various cervical levels. Particularly, parameters, such as pedicle transverse angle, translaminar thickness, height, sagittal diagonal, and various lateral mass measurements, were analyzed, showing notable differences at each cervical level. Conclusion: Comparing the data from the present study to similar studies of different ethnicities provides valuable insights into the morphometry of the subaxial cervical vertebrae in the Iranian population. The findings emphasize the importance of considering ethnic-specific anatomical variations in surgical planning, eventually leading to safer and less complicated surgical outcomes in spine surgeries.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Prognostic Value of Cerebrospinal Fluid Neutrophil-toLymphocyte Ratio in Adult Patients With Hydrocephalus Treated With an External Ventricular Drain: A Retrospective Study 111 122 EN Morteza Modaenama Neuroscience Research Center, Trauma Institute, Guilan University of Medical Sciences, Rasht, Iran Babak alijani Guilan Road Trauma Research Center, Trauma Institute, Guilan University of Medical Sciences, Rasht, Iran. Zoheir Reihanian Neuroscience Research Center, Trauma Institute, Guilan University of Medical Sciences, Rasht, Iran. Seifolla Jafari Department of Neurosurgery, School of Medicine, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran. Background and Aim: The neutrophil-to-lymphocyte ratio (NLR) in whole blood is an indicator of prognosis in several disorders; however, its predictive value in the cerebrospinal fluid (CSF) of hydrocephalus patients has not been studied. Accordingly, this study determines the prognostic relevance of NLR at admission and its implications for clinical outcomes in patients with hydrocephalus treated with an external ventricular drain (EVD). Methods and Materials/Patients: This retrospective study examined consecutive individuals with hydrocephalus who were admitted to an adult intensive care unit in a single center between 2020 and 2022. Patient demographics, clinical characteristics, laboratory data, and computed tomography (CT) scans were gathered. Receiver operating characteristic (ROC) curve analysis was used to identify the optimal NLR and clinical variable cutoff values for mortality. Univariate and multivariate logistic regression analyses were carried out to assess the independent impact of variables on mortality. Results: This study included 40 patients with hydrocephaly in the present study. There were 24 males (60%) and 16 females (40%) patients, with an average age of 51.68±16.34 years. NLR was considerably higher in the dead group compared to the alive group (8.49±6.53 vs 5.05±3.78; P=0.027). In a model of ROC analysis, NLR (area under curve [AUC]=0.702, 95% confidence interval [CI], 0.537%, 0.836%; P=0.0171), age (AUC=0.674; 95% CI, 0.507%, 0.813%; P=0.0496), underlying disease (AUC=0.650; 95% CI, 0.483%, 0.794%; P=0.0126), and level of consciousness level (AUC=0.946; 95% CI, 0.825%, 0.993%; P<0001) were significantly associated with mortality. The best predictive threshold of the NLR was 8.88 (sensitivity=40% and specificity=100%). Univariate analysis revealed that NLR in the three groups by Glasgow coma scale (GCS) in coma and semicoma is more substantially connected to mortality than in the stupor group (P<0.05). According to an adjusted multivariate logistic regression analysis, the level of consciousness upon admission was an independent predictor of mortality and was positively linked with mortality (odds ratio (OR)=0.23; 95% CI, 0.08%, 0.65%; P=0.005). Furthermore, the multivariable analysis demonstrated that NLR > 8.88 in combination with GCS<8 (coma and semicoma) on admission had a higher prognostic value for mortality (P<0.0001). Conclusion: In the current research, a high NLR (>8.88) in CSF was associated with an increased risk of mortality in individuals with hydrocephalus. When paired with a GCS score of <8, admission NLR>8.88 considerably improves the accuracy of predicting outcomes following EVD.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Endoscopic Endonasal Management of Cavernous Sinus Hemangioma: A Case Report 0 0 EN Matin Akhbari Department of Neurosurgery, Faculty of Medicine, Ege University Izmir, Turkey. Bilal Bahadır Akbulut Department of Neurosurgery, Faculty of Medicine, Ege University Izmir, Turkey. Mustafa Serdar Bölük Department of Neurosurgery, Faculty of Medicine, Ege University Izmir, Turkey. Taşkın Yurtseven Department of Neurosurgery, Faculty of Medicine, Ege University Izmir, Turkey. Hüseyin Biçeroğlu Department of Neurosurgery, Faculty of Medicine, Ege University Izmir, Turkey. Background and Aim: Cavernous sinus hemangiomas (CSH) are rare benign vascular tumors that can result in headaches, visual disturbances, and cranial nerve palsies due to their location within the cavernous sinus. Case Presentation: A 56-year-old woman presented with a headache and blurred vision persisting for the last 3 months. There were no previous surgeries, allergies, or known diseases. Upon admission, a neurological examination revealed no cranial nerve involvement, motor or sensory deficits, or other vision disturbances. Cranial magnetic resonance imaging (MRI) was obtained, which showed a 16.1×17.9 mm T2 hyperintense lesion in the cavernous sinus. Endoscopic endonasal transsphenoidal was used for the removal of the tumor. Post-operative MRI revealed total removal of the tumor. Histopathological analysis confirmed the lesion to cavernous sinus hemangioma. There were no complications or recurrences during the 6-month follow-up. Conclusion: This case demonstrates the successful application of endoscopic endonasal transsphenoidal surgery (EETS) for the complete resection of cavernous sinus hemangioma.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Traumatic Lumbar Fracture in Ankylosing Spondylitis: A Narrative Review with Case Illustration 128 137 EN Sadegh Bagherzadeh Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran Mohammad Jafari Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran Saeed Ehteshami Orthopedic research center,Mazandaran University of medical sciences,Sari,Iran Faramarz Roohollahi Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran Mark Greenberg Department of Neurosurgery, Brain and Spine, Morsani College of Medicine, University of South Florida, Tampa, United States. Puya Alikhani Department of Neurosurgery, Brain and Spine, Morsani College of Medicine, University of South Florida, Tampa, United States. Mohsen Rostami Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran Background and Aim: Ankylosing spondylitis (AS) increases the risk of spinal fractures, often after minor trauma, due to fragile and rigid spinal anatomy. Lumbar fractures in AS patients are rare, and optimal management strategies are not well established. This study presents a case of traumatic lumbar spine fracture in an AS patient and reviews the current literature on diagnosis and management. Methods and Materials/Patients: A 48-year-old male with longstanding AS presented with a traumatic L2-L3 AO type C fracture and neurological deficits following a motorcycle accident. He underwent staged surgical management: First, multilevel posterior fixation, followed by anterior column reconstruction with cage placement. A literature review was conducted to collect evidence-based recommendations for managing such fractures. Results: The patient’s neurological function improved substantially following surgery, with progressive recovery of motor function and bladder control by three months. Literature review suggests that surgical intervention is generally preferred for unstable fractures in AS, with special attention required for anatomical challenges and perioperative risks. Conclusion: Lumbar spine fractures in AS often result from low-energy trauma and can present with subtle symptoms. Prompt diagnosis and individualized surgical management can lead to favorable outcomes, emphasizing the importance of careful perioperative planning in this unique patient population.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Radiological and Biochemical Characteristics of Chronic Subdural Hematoma 138 144 EN Sangeetha Adhikesavan Sri Ramachandra Medical College and Research Institute, Chennai, India. Visvanathan Krishnaswamy Sri Ramachandra Medical College and Research Institute, Chennai, India. Sai Sriram Swamiyappan Sri Ramachandra Medical College and Research Institute, Chennai, India. Vivek Visvesvaran Sri Ramachandra Medical College and Research Institute, Chennai, India. Balasubramanian Kannan Sri Ramachandra Medical College and Research Institute, Chennai, India. Background and Aim: Chronic subdural hematomas (CSDH) are a common neurosurgical issue characterized by the accumulation of blood between the brain and its outermost protective membrane. The pathogenesis of CSDH involves a cycle of recurrent hemorrhage, fibrinolysis, inflammation, and angiogenesis. D-dimer, a marker of fibrinolysis, has been investigated in CSDH. This study explores the correlation between D-dimer levels, computed tomography (CT) findings, and recurrence of CSDH. Methods and Materials/Patients: This prospective study included 80 patients with CSDH who underwent surgical evacuation between 2018 and 2020. The CSDHs were classified based on CT scan appearance, and D-dimer levels were measured in the hematoma fluid and peripheral blood samples. The statistical analysis was performed to identify correlations between D-dimer levels, CT subtypes, and recurrence rates. Results: The mean D-dimer value in the Hypodense group was 454.2 mg/L while the value in the isodense group was 777.74 mg/L. The highest mean value was observed in the mixed subgroup, at 2370 mg/L. The layered group had a mean value of 1146.85 mg/L. The mean D-dimer value in the homogenous group was 622.48 mg/L while the mean in the heterogenous group was 2014.57 mg/L. There was a statistically significant correlation between the imaging subtypes and the D-dimer values (P=0.01). Conclusion: The mean D-dimer values were highest in the mixed subtype of CSDH, followed by the layered subtype, while the hypo- and isodense subtypes had lower D-dimer levels. There was a significant correlation between the imaging subtypes and D-dimer values. Additionally, a higher rate of recurrence was observed in the mixed subtype group, which also had higher D-dimer values. Steroid administration after surgery showed a statistically significant negative correlation with recurrence rates.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Pediatric Head Injury: Analysis, Prognostic Markers, and Its Outcomes 145 154 EN Manish Singh Department of Neurosurgery, GSVM Medical College, Kanpur, India. Alok Raghav Department of Anatomy and Cell Biology, College of Medicine, Gachon University, Incheon, South Korea. Sachin Kumar Department of Pharmacy, GSVM Medical College, Kanpur, India Kirti Amresh Gautam Department of Biosciences, GD Goenka University, Gurugram, India. Pankaj Kumar Department of Neurosurgery, GSVM Medical College, Kanpur, India. Background and Aim: Pediatric head injury is a significant and preventable public health concern, contributing substantially to morbidity and mortality in children. Understanding its epidemiological and clinical profile is essential for optimizing management and outcomes. Accordingly, this study evaluates the incidence, demographic distribution, mechanisms of injury, clinical presentation, radiological findings, and outcomes of head injuries in pediatric patients aged 0–14 years, with a focus on prognostic markers such as level of consciousness and pupillary response. Methods and Materials/Patients: A retrospective analysis was conducted on 165 children with traumatic brain injury (TBI) admitted to the Department of Neurosurgery, GSVM Medical College, Kanpur, India, over two years. Clinical parameters, including Glasgow coma scale (GCS), pupillary reactivity, and computed tomography (CT) findings, were recorded. Outcomes were classified using the Glasgow outcome scale (GOS). Results: Of the 165 patients, 69.09% were male and 30.90% female. The most common cause of injury was falling from height (55.15%), followed by road traffic accidents (38.78%). GCS scores revealed mild TBI in 18.78%, moderate in 56.33%, and severe in 24.84% of cases. Pupillary abnormalities were present in 14.5% of patients, strongly correlating with poor outcomes. Overall mortality was highest (36.53%) in patients with GCS equal of 3–7. In contrast, patients with GCS 13–15 had a 90.32% good recovery rate. Pupillary reaction was a significant prognostic factor; accordingly, 75% of those with abnormal pupillary responses either died or were in a vegetative state. CT findings, such as combined intra- and extra-axial lesions and midline shift >5 mm, were also associated with higher mortality. Conclusion: Low GCS at presentation and abnormal pupillary reactions are strong predictors of poor outcomes in pediatric TBI. Timely assessment and neuroimaging are crucial. Preventive strategies, especially targeting falls and road accidents, are vital to reducing the burden of head injury in children.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Ossification of the Posterior Longitudinal Ligament: A Closer Look at The Disease 155 158 EN Shahrokh Yousefzade-Chabok Guilan Road Trauma Research Center, Trauma Institute, Guilan University of Medical Sciences, Rasht, Iran. Ali Davoudi-Kiakalayeh Guilan Road Trauma Research Center, Trauma Institute, Guilan University of Medical Sciences, Rasht, Iran. Ossification of the posterior longitudinal ligament (OPLL) is due to abnormal calcification of the posterior longitudinal ligament. It primarily affects the cervical spine—various classification systems group OPLL based on its morphological properties and clinical implications.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Retrospective Analysis of two different Cranioplasty Methods : A Single Institution Experience 159 165 EN P.R Rajkumar Department of Neurosurgery, PSG Institute of Medical Sciences and Research, Coimbatore, India. Thirumurthy Subramanian Department of Neurosurgery, PSG Institute of Medical Sciences and Research, Coimbatore, India. Jayaprakash Duraisamy Department of Neurosurgery, PSG Institute of Medical Sciences and Research, Coimbatore, India. Aniketh Shankar Komarraju Department of Neurosurgery, PSG Institute of Medical Sciences and Research, Coimbatore, India. Background and Importance: Decompressive craniectomy is an emergency neurosurgical procedure to reduce intracranial hypertension. Cranioplasty is an elective neurosurgical procedure to reconstruct the skull defect due to decompressive craniectomy. This study aims to review two different types of cranioplasty and comparecomputer-designed patientspecific titanium implant cranioplasty against titanium mesh with polymethyl methacrylate (PMMA) cranioplasty, regardingtheir complications and outcomes after the procedure. Case Presentation: This is a retrospective analysis of 150 patients who had undergone cranioplasty in PSG Institute of Medical Sciences and Research, Coimbatore, India from January 2014 to January 2023. A total of 46 patients underwent cranioplasty with a computerdesigned, patient-specific titanium implant, and 104 patients underwent cranioplasty with a titanium mesh and PMMA implant. The parameters compared between the two procedures included the timing of surgery, cosmetic satisfaction, duration of hospital stay, wound infection, wound gaping, implant exposure, and necessity of implant removal. Conclusion: Even though both procedures protect brain parenchyma from injuries due to direct trauma, patient-specific implant cranioplasty yielded shorter operating time, less wound infection, smaller wound gaping, reduced implant exposure, and better cosmetic appearance when compared with titanium mesh with PMMA implant cranioplasty.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 A Rare Case of Adult Thoracic SCIWORA: Complete Cord Transection Without Vertebral Injury 0 0 EN Vaner Köksal Department of Neurosurgery, Faculty of Medicine, Samsun Training and Research Hospital, Samsun University, Samsun, Türkey. Cem Demirel Department of Neurosurgery, Faculty of Medicine, Samsun Training and Research Hospital, Samsun University, Samsun, Türkey. Melih Van Department of Neurosurgery, Faculty of Medicine, Samsun Training and Research Hospital, Samsun University, Samsun, Türkey. Fatih Tomakin Department of Neurosurgery, Faculty of Medicine, Samsun Training and Research Hospital, Samsun University, Samsun, Türkey. Recai Engin Department of Neurosurgery, Faculty of Medicine, Samsun Training and Research Hospital, Samsun University, Samsun, Türkey. Background and Importance: Spinal cord injury without radiographic abnormality (SCIWORA) is predominantly reported in pediatric populations, especially involving the cervical spine. In adults, particularly in the thoracic region, such injuries are exceedingly rare due to the biomechanical rigidity of the thoracic vertebrae. This case report presents an adult patient with a complete spinal cord transection at the T7–T8 level in the absence of any vertebral fracture or dislocation. Case Presentation: A 25-year-old male was admitted to the intensive care unit following a highenergy motor vehicle accident. Although the initial computed tomography (CT) of the thoracic spine showed no signs of vertebral injury, the patient developed complete paraplegia upon regaining consciousness. Magnetic resonance imaging (MRI) revealed a full-thickness transection of the spinal cord at the T7–T8 level. No surgical intervention was indicated due to the absence of compressive or unstable elements. Conclusion: Adult thoracic SCIWORA is an exceptionally rare clinical entity. In cases of severe neurological deficit with negative radiographs and CT scans, a prompt MRI is crucial for diagnosis. This case highlights the need for refined classification systems that incorporate MRI findings and biomechanical assessments to characterize such presentations better and inform clinical management.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Bioinformatics-based Study of Cancer Stem Cell Function as Diagnostic Biomarkers in Glioblastoma Multiforme 0 0 EN Haniye Abbasi School of Medicine, Guilan University of Medical Sciences, Rasht, Iran Saman Morovat Department of Medical Genetics and Molecular Biology, School of Medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran Shahrokh Yousefzadeh-Chabok Guilan Road Trauma Research Center, Trauma Institute, Guilan University of Medical Sciences, Rasht, Iran. Seyedeh Elham Norollahi Reproductive Health Research Center, Al-Zahra Hospital, Guilan University of Medical Sciences, Rasht, Iran. Fatemeh Nejatifar Department of Hematology and Oncology, Razi Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran. Kourosh Delpasand Department of Medical Ethics, Guilan University of Medical Sciences, Rasht, Iran. Kosar Babaei Noncommunicable Diseases Research Center, Neyshabur University of Medical Sciences, Neyshabur, Iran. Afshin Dalili Guilan Road Trauma Research Center, Trauma Institute, Guilan University of Medical Sciences, Rasht, Iran. Ali Akbar Samadani Guilan Road Trauma Research Center, Trauma Institute, Guilan University of Medical Sciences, Rasht, Iran. Background and Aim: Glioblastoma multiforme (GBM) is a highly aggressive primary brain tumor with poor prognosis, largely driven by glioma stem-like cells (GSCs). Novel biomarkers that both characterize GSCs and predict patient survival are urgently needed. This study aims to identify GSCrelated genes with prognostic value in GBM through integrated bioinformatics analyses. Methods and Materials/Patients: Microarray data (GSE23806) comparing glioma cell lines and GSCs were downloaded via GEOquery in R and normalized. Differentially expressed genes (DEGs) were identified using the limma package (log₂ fold change ≥1, adjusted P<0.01). DEGs were crossreferenced with TCGA GBM tumor data via GEPIA2 to find common dysregulated genes. Kaplan– Meier survival analyses were performed using GEPIA2 to identify genes associated with survival. Protein–protein interaction (PPI) networks were built using GeneMANIA in cytoscape. Functional enrichment analyses (GO and KEGG) were conducted using clusterProfiler, with q<0.01. Results: A total of 1212 DEGs were i SMAD13 dentified in GSCs vs glioma cell lines and 5224 DEGs in GBM tumors vs normal tissues; 355 genes were commonly differentially expressed. Survival analysis revealed six genes (APLP1, CA14, PTPRN2, POR, ARMC10, and SMAD13) significantly associated with overall survival. Among these, CA14 and SMAD13 appeared protective (Hazzard ratio [R]~0.53–0.56), while APLP1, PTPRN2, POR, and ARMC10 were associated with risk (HR 1.6– 1.7). A PPI network with 26 nodes and 256 edges underscored extensive functional interactions. Enrichment analyses highlighted dysregulation in pathways including hypoxia response, metabolic processes, TGFβ signaling, and stem-like phenotypes. Conclusion: Our integrated bioinformatics framework identified six novel GSC-related genes with prognostic significance in GBM, representing diverse biological roles that range from tumor suppression to oncogenic signaling. These genes hold promise as diagnostic or therapeutic targets, but require experimental validation, including gene expression assays and functional studies to substantiate their roles in GBM pathogenesis and therapy resistance.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Comparative Outcomes of Combined Spinal-general Anesthesia versus General Anesthesia in Lumbar Spine Fusion Surgery 0 0 EN Afshin Mardvar Department of Neurosurgery, School of Medicine, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran. Zoheir Reihanian Department of Neurosurgery, School of Medicine, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran. Seifollah Jafari Department of Neurosurgery, School of Medicine, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran. Morteza Modaenama Department of Neurosurgery, School of Medicine, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran. Mohammadali Yazdanipour Neuroscience Research Center, Trauma Institute, Guilan University of Medical Sciences, Rasht, Iran. Mahdieh Torkashvand Poursina Clinical Research Development Unit, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran. Ali Ashraf Poursina Clinical Research Development Unit, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran. Background and Aim: In lumbar spine fusion surgeries, spinal anesthesia (SA) can enhance comfort and reduce postoperative pain compared to general anesthesia (GA). This study aimed to compare the preoperative and postoperative outcomes of the two approaches, given their unique advantages and disadvantages. Methods and Materials/Patients: This randomized, single-blind clinical trial involved 48 patients aged 18-65, classified as American society of anesthesiologists (ASA) I or II, who were candidates for spinal fusion surgery. Participants were divided into two groups: General and spinal anesthesia (GSA, n=24) and GA (n=24). The primary outcome was hemodynamic changes, while the secondary outcomes focused on pain intensity and side effects, such as postoperative nausea, vomiting, and shivering. The key variables included vital signs, intraoperative blood loss, propofol and midazolam doses, and surgical duration from operating room entry to discharge from recovery. Results: No significant differences in demographics or medical history were observed between the groups. The operative time was shorter in the GSA group (P=0.048). No notable differences were observed in terms of bleeding, nausea/vomiting, or shivering between the two methods. However, the median postoperative heart rate was significantly lower in the GSA group (P=0.007), and pain levels were also significantly reduced in both groups, with lower scores observed in the GSA group compared to GA (P=0.005). Hemoglobin levels decreased in both groups post-surgery (P<0.001). Repeated-measures analysis of variance (ANOVA) indicated significant effects on blood pressure, with GSA consistently showing lower readings than GA throughout the observation period. Conclusion: Evidence from clinical trials indicates that combining GSA leads to shorter operative times, improved postoperative cardiac regulation, more stable intraoperative blood pressure, and better immediate pain control. These benefits promote the use of spinal anesthetic adjuvants in suitable surgical groups, ensuring hemodynamic stability without affecting recovery time or increasing bleeding risk. These findings are crucial for enhancing anesthetic practices and optimizing patient outcomes.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Middle Meningeal Artery Embolization in Septated Chronic Subdural Hematoma: A Narrative Review 0 0 EN Farzan Fahim Functional Neurosurgery Research Center, Research Institute of Functional Neurosurgery, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Mahdi Mehmandoost Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Hesan Abbasi Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Shahrzad Sharifzadeh Functional Neurosurgery Research Center, Research Institute of Functional Neurosurgery, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Amir Mohammad Bahri Functional Neurosurgery Research Center, Research Institute of Functional Neurosurgery, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Sayeh Oveisi Functional Neurosurgery Research Center, Research Institute of Functional Neurosurgery, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Background and Aim: Chronic subdural hematoma (cSDH), particularly its septated subtype (sCSDH), poses significant therapeutic challenges due to its propensity for recurrence and resistance to conventional surgical interventions. Septated cSDH is characterized by fibrin membranes that compartmentalize the hematoma, impeding complete drainage and perpetuating inflammationdriven neovascularization. Current management strategies including burr-hole craniostomy (BHC), craniotomy, and pharmacotherapy exhibit recurrence rates of 20–30% in septated cases, underscoring the need for alternative approaches. Methods and Materials/Patients: A targeted narrative review was conducted by searching PubMed, Scopus, and Web of Science (January 2000–July 2025) and peer-reviewed human studies meeting predefined inclusion criteria were reviewed. This review synthesizes existing literature to evaluate MMAE’s efficacy in septated cSDH. Results: Key findings highlight MMAE’s ability to reduce recurrence rates (3.1% vs 23.4% in nonembolized septated cases) when used adjunctively with surgery or as monotherapy, particularly in high-risk or recurrent patients. Technical considerations, such as transradial access (TRA) and embolic agent selection (e.g. polyvinyl alcohol, gelatin sponge), further enhance procedural safety and outcomes. Emerging evidence supports MMAE’s role in disrupting the angiogenicinflammatory cycle unique to septated cSDH, offering a paradigm shift in management. Conclusion: Despite promising results, challenges persist, including the need for specialized expertise and limited long-term data. However, prospective randomized trials are warranted to optimize protocols and solidify its position in clinical guidelines. This review underscores MMAE as a transformative adjunctive strategy for septated cSDH, bridging gaps in traditional therapies while advocating for further research to refine its application.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Recurrent Epidural and Subgaleal Effusion After PatientSpecific PEEK Cranioplasty as an Allergic Reaction: A TwoCase Report 0 0 EN Morteza Modaenama Guilan Road Trauma Research Center,Trauma Institute, Guilan University of Medical Sciences, Rasht, Iran. Khatere Mokhtari Department of Cell and Molecular Biology and Microbiology, Faculty of Biological Science and Technology, University of Isfahan, Isfahan, Iran. Background and Importance: Patient-specific polyetheretherketone (PEEK) implants are increasingly used in cranioplasty due to their biocompatibility, radiolucency, and favorable cosmetic outcomes. However, postoperative complications such as fluid collections remain a clinical concern. Case Presentation: We describe two male patients with severe traumatic brain injury who underwent bilateral decompressive craniectomy followed by delayed cranioplasty using custom-made PEEK implants. Both patients developed recurrent epidural and subgaleal effusions during follow-up. The first case was successfully managed conservatively with aspiration, corticosteroid therapy, and compressive bandaging. The second case developed progressive effusion resistant to conservative management, ultimately requiring implant removal and reconstruction with a titanium mesh, which resolved the complication. Although PEEK implants offer significant advantages in cranial reconstruction, they may be associated with recurrent effusion. Conservative management may be sufficient in some cases; however, persistent or refractory effusions may necessitate implant removal. Careful follow-up is essential for early detection and management of such complications. Conclusion: Although PEEK implants offer significant advantages in cranial reconstruction, they may be associated with recurrent effusion. Conservative management may be sufficient in some cases; however, persistent or refractory effusions may necessitate implant removal. Careful followup is essential for early detection and management of such complications.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Glymphatic System Reconstruction in the Management of Alzheimer’s Disease 0 0 EN Ashkan Asgari Gashtrodkhani School of Medicine, Guilan University of Medical Sciences, Rasht, Iran. Roxana Kaveh Guilan Road Trauma Research Center, Trauma Institute, Guilan University of Medical Sciences, Rasht, Iran. Zoheir Reihanian Department of Neurosurgery, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran. Shahrokh Yousefzadeh-Chabok Guilan Road Trauma Research Center, Trauma Institute, Guilan University of Medical Sciences, Rasht, Iran. Sasan Andalib Guilan Road Trauma Research Center, Trauma Institute, Guilan University of Medical Sciences, Rasht, Iran. Alzheimer’s disease (AD) is a major public health challenge. The exact cause of AD is unknown, but it is characterized by progressive impairment in cognitive and memory functions and pathological changes in the brain, such as aggregation of two main proteins, amyloid-beta (Aβ) and neurofibrillary tangles (NFTs) of tau. Nonetheless, the pathogenesis of AD appears to be complicated by vascular changes, neuroinflammation, synaptic loss, and impaired clearance of cellular waste products. Currently, the limited efficacy of available treatments underscores the need for alternative therapeutic strategies. The glymphatic system is a paravascular network in the central nervous system, responsible for the removal of cellular waste. The present review discusses the glymphatic system and its reconstructive surgery as a potential treatment approach for AD. Both experimental and human studies have demonstrated the role of the impaired glymphatic system in the pathogenesis of AD by increasing the accumulation of Aβ and tau proteins, thus holding potential as a new target for AD treatment. Moreover, glymphatic system dysfunction can lead to neurodegeneration, cognitive decline, and disease progression. Studies have also shown the potential role of microsurgical lymphatic reconstruction as a possible therapeutic target for AD treatment. Glymphatic system dysfunction may be a possible contributing factor to the pathogenesis and progression of AD. Moreover, glymphatic and meningeal reconstruction microsurgery may have the potential for the treatment of AD.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Comparing Neuroendoscopic and Nonendoscopic Surgical Techniques in Treating Septated Chronic Subdural Hematoma: A Randomized Controlled Trial 0 0 EN Hamidreza Doostabadi Departments of Neurosurgery, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran. Fahimeh Esmaeili Departments of Neurosurgery, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran. Background and Aim: Chronic subdural hematoma (CSDH) usually occurs in the sixth and seventh decades of people’s lives and causes severe permanent complications and even death. Today, the most appropriate treatment for this condition has not been determined. Although spontaneous hematoma absorption has been reported, the best treatment remains surgery. There are different surgical methods for this disease; each has its unique advantages and disadvantages. The present study compared open and endoscopic methods with respect to postoperative neurological symptoms, residual hematoma, recurrence, and operative time. Methods and Materials/Patients: In this clinical trial, 32 patients were randomly assigned to two groups using the simple random block method: endoscopic and open techniques. This randomized controlled trial compared neuroendoscopic surgery (n=16) with conventional burrhole craniostomy (n=16) in patients with septated CSDH. The patients’ clinical examinations and computed tomography (CT) scans were reviewed, and the necessary information was extracted from their files. For follow-up, patients were contacted by phone 6 months after discharge from the hospital. Results: After spending a day in the intensive care unit (ICU), all patients were transferred to the ward. The average hospitalization duration and bleeding were significantly lower in the endoscopic group than in the nonendoscopic group (P=0.014). The duration of surgery did not differ significantly between the two groups. The frequency distribution of history of trauma, mortality, and neurological complications in the two groups of nonendoscopic and endoscopic patients was not significantly different from each other (P>0.999, P=0.654, P>0.999, respectively). The recurrence frequency distribution in the endoscopic group was significantly lower than in the nonendoscopic group (P=0.023). Conclusion: Neuroendoscopic surgery significantly reduced recurrence and hospitalization duration compared to burr-hole craniostomy, with comparable operative times and neurological outcomes.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 The Role of Defensive Mechanisms on Emotional Expressiveness and Symptoms of Social Anxiety Disorder in Spinal Cord-injured Patients 0 0 EN Sima Garshasbi Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran. Seyed Hassan Emami-Razavi Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran. Majid Saffarinia Department of Psychology, Payame Noor University, Tehran, Iran Nila Elmi Manesh Department of Psychology, Payam Noor University, Tehran, Iran. Background and Aim: Defense mechanisms influence emotional expression and symptoms of social anxiety disorder, but this effect is unclear in people with spinal cord injury (SCI). This study investigated the role of coping mechanisms on emotional expressiveness and symptoms of social anxiety disorder in people with SCI. Methods and Materials/Patients: This study, entitled “Investigating the relationship between defense mechanisms, emotional expressiveness, and social anxiety disorder symptoms in individuals with SCI,” began in April 2023 and continued over 1 year. A total of 100 people with SCI were randomly selected from those referred to Tehran Welfare Center, Tehran City, Iran. Social anxiety, emotional expressiveness, and defensive styles questionnaires were used for data collection. The t-test was used for data analysis using SPSS software, version 22. Results: This study showed a relationship between defense mechanisms and emotional expressiveness in people with SCI (P<0.05). However, there is no relationship between defense mechanisms and social anxiety disorder in these people. There is no significant relationship between the demographic characteristics and either social phobia disorder or emotional expressiveness. However, a significant relationship was obtained between mature defense styles and being single (P<0.05). Conclusion: Individuals with SCI may use self-coping mechanisms to express their emotions. In people with SCI, efforts should be made to use appropriate coping mechanisms to express their excitement in proper ways.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Nasal-aperture Buccal Fat Harvest for CSF-leak Prevention in Endoscopic Transsphenoidal Pituitary Surgery: A Single-center Clinical Trial 0 0 EN Ahmad Rezaeian Department of Otorhinolaryngology, School of Medicine, Al‐Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran. Mohammadreza Moznebiisfahani Department of Neurosurgery, School of Medicine, Al‐Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran. Zahra Akbari Department of Otorhinolaryngology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. Background and Aim: Pituitary adenomas commonly require endoscopic transsphenoidal surgery (ETSS). Although ETSS is minimally invasive, intraoperative cerebrospinal fluid (CSF) leaks occur in up to 50% of cases and can lead to meningitis or pneumocephalus if not well repaired. Autologous fat grafting from the periumbilical region is effective for dural reconstruction but carries donor-site morbidity and surgical-site infection (SSI). Buccal fat harvested intraorally reduces abdominal morbidity but risks contamination from oral flora. We evaluated a novel endonasal nasal-aperture approach to buccal fat harvest, hypothesizing comparable efficacy with fewer donor-site complications. Methods and Materials/Patients: In a single-center, single-blinded, nonrandomized trial at Alzahra Hospital (affiliated with Isfahan University of Medical Sciences, Isfahan City, Iran, 2024–2025), 30 patients with macroadenomas undergoing ETSS were allocated 1:1 to nasal-aperture buccal fat harvest (n=15) or standard periumbilical abdominal fat harvest (n=15). The same surgeon used consistent anesthesia and postoperative protocols. The primary outcome was postoperative CSF leak. Secondary outcomes included operative time, length of stay, postoperative bleeding, SSI, donor-site pain, facial numbness, and cosmetic sequelae. Follow-up visits occurred at 2 weeks, 1, 2, 4 months, and 1 year. Statistical comparisons used the t-test, Mann-Whitney U test, and chi-square test (α=0.05). Results: Groups were demographically similar (mean age 48.2±3 years; 56.7% male; mean BMI 25.4±1.2 kg/m²). Operative time (116.7±3.2 vs 115.9±3.8 min, P=0.54) and hospital stay (4.6±0.5 vs 4.5±0.5 days, P=0.67) did not differ between study groups. Both groups achieved 100% CSFleak closure without graft failure. The nasal-aperture group had significantly lower postoperative bleeding (20% vs 66.7%, P=0.01) and SSI (6.7% vs 33.3%, P=0.04). Transient facial numbness occurred in 6.7% of the nasal-aperture group; one immediate asymmetry resolved within 24 hours. No persistent donor-site complications or neurologic deficits were observed. Conclusion: Endonasal nasal-aperture buccal fat harvest during ETSS provides equivalent CSFleak prevention to abdominal fat grafting while reducing bleeding, infection risk, and donor-site morbidity, and improving cosmetic outcomes. Larger randomized, multicenter trials with longer follow-up and patient-reported outcomes are warranted.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 11 Continuous Publishing 2025 1 1 Trend of Brachial Plexus Birth Paralysis Incidence in North Iran: An 11-year Analytic Study 0 0 EN Fatemeh Hosseinzadeh Department of Obstetrics and Gynecology, Reproductive Health Research Center, School of Medicine, Al-Zahra Hospital, Guilan University of Medical Sciences, Rasht, Iran. Sahel Rezaee Student Research Committee, Guilan University of Medical Sciences, Rasht, Iran. Maryam Ghalandari Vice-Chancellorship of Research and Technology, Guilan University of Medical Sciences, Rasht, Iran. Roya faraji Darkhane Department of Obstetrics and Gynecology, Reproductive Health Research Center, School of Medicine, Al-Zahra Hospital, Guilan University of Medical Sciences, Rasht, Iran. Mohammadreza Emamhadi Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran. Shahrokh Yousefzadeh-Chabok Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Iran. Background and Aim: Newborns with brachial plexus birth paralysis (BPBP) impose a heavy burden on their families. Given the importance of awareness of its incidence, our main goal was to assess changes in its trend. Also, this study aimed to evaluate the correlation between BPBP trends and the policy aiming at increasing rates of vaginal delivery (VD) (2018). Methods and Materials/Patients: This analytic cross-sectional study was conducted among patients with BPBP born at Al-Zahra Hospital, the Main Center of Obstetrics in Rasht City, Iran, between 2013 and 2023. Descriptive statistics were used to examine the patients’ demographic and clinical characteristics. The results were analyzed using SPSS software, version 26. Results: Over 11 years, 41617 live births occurred. Our study revealed a BPBP incidence of 1.54 cases per 1000 live births during this period. Of these, 33 newborns (51.6%) were male. In our study, the Joinpoint regression analysis showed that the incidence of BPBP increased throughout the study period (P<0.05). Also, there was no significant change in the rising trend of BPBP at the time the established policy aimed at increasing VD rates. In fact, the policy had no significant impact on the trend of BPBP. Moreover, there were no instrumental deliveries among the patients, despite the increasing trend of this injury. Only 10.9% of the patients with BPBP had a clavicle fracture after birth. There was no humerus fracture among all the patients. Also, only 11.5% of the cases had shoulder dystocia in our study. Conclusion: The findings indicate that the incidence of BPBP increased over the 11 years. Our study highlighted that the policy aimed at increasing VD rates did not significantly affect BPBP rate. Therefore, enhanced training for early-career obstetricians and improved preventive strategies are recommended.