Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 2 2 2016 9 1 Frequency of Instrumentation in Lumbar Spinal Stenosis and Lumbar Disc Herniation 6 9 EN Seyyed Ebrahim Hejazian MD, Assistant Professor of Neurosurgery, Shahid Beheshti Hospital, Babol University of Medical Sciences, Babol, Iran Mersedeh Dadpour MD, General Physician, Shahid Beheshti Hospital, Babol University of Medical Sciences, Babol, Iran Background & Aim: Lumbosacral pain is extremely common as age increases. Spinal instrumentation is sometimes recommended for lumbar canal stenosis and disk herniation surgery. This study aimed at studying the frequency of instrumentation in patients referring to our center. Methods & Materials/Patients: This retrospective cross-sectional study included 1200 patients with low back and/or radicular pain who had referred to the Shahid Beheshti and Ayatallah Roohani hospitals from 2013 to 2014 in Babol city. Data were analyzed by t-test and chisquare using SPSS (Version 20). Results: In this study, 150 of 1200 patients needed surgery for lumbar canal stenosis and/or disk herniation (mean age of 42.21 ± 11.41 years old, ranging from 26-69). Of all patients, 76 were men (50.7%) and 74 women (49.3%). L4-L5 was the most involved level. There was a significant relationship between pathology and gender (p<001). At some levels, either men or women were involved. Moreover, 55 patients (36.7%) underwent surgery with instrumentation and 95 patients (63.3%) without instrumentation. Complete improvement was reported in 102 patients (68%). No significant relationship was observed between the degree of improvement and surgery technique and gender (p=0.78, p=0.72). Conclusion: Most patients (63.3%) underwent surgery without instrumentation and about one third needed fixation during surgery.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 2 2 2016 9 1 Initial Experience with Brain Mapping under Awake Craniotomy for Resection of Insular Gliomas of the Dominant Hemisphere 10 14 EN Mohammad Shirani MD, Assistant Professor of Neurosurgery, Sina Hospital, Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran Maysam Alimohamadi MD, PhD, Assistant Professor of Neurosurgery, Sina Hospital, Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran Reza Shariat Moharari MD, Professor of Anesthesiology, Department of Anesthesiology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran Koorosh Karimi Yarandi MD, Assistant Professor of Neurosurgery, Sina Hospital, Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran Seyed Ebrahim Ketabchi MD, Professor of Neurosurgery, Sina Hospital, Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran Abbas Amirjamshidi MD, Professor of Neurosurgery, Sina Hospital, Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran Background & Importance: Insular lobe is located at the depth of sylvian fissure and is hidden by frontal, temporal and parietal lobes in close vicinity of internal capsule and basal ganglia and adjacent to the speech centers in the dominant hemisphere. Thus, radical resection of insular gliomas can be even more difficult. Brain mapping techniques can be used to maximize the extent of tumor removal and minimize postoperative morbidities. Case Presentation: Patients with newly diagnosed gliomas of dominant insula were enrolled. The exclusion criteria were severe cognitive and/or psychological disturbances, those with difficulty in communication, older than 65 years, severely obese patients, those with difficult airways for intubation and severe cardiovascular or respiratory diseases. All patients were evaluated by contrast enhanced brain MRI, functional brain MRI and diffusion tensor tractography of language and motor systems preoperatively. All were operated under awake craniotomy with the same anesthesiology protocol. Intraoperative monitoring included continuous motor evoked potential, electromyography, electrocorticography, direct electrical stimulation of cortex and subcortical tracts. They were followed with serial neurological examination and imaging. Conclusion: Seven patients were enrolled including 3 man and 4 women with mean age of 44.4 years. 5 patients suffered from low grade and 2 from high grade glioma. The most common clinical presentation was seizure followed by speech disturbance, hemiparesis and memory loss. Extent of tumor resection ranged from 73 to 100%. No mortality or major postoperative neurological deficit was encountered. Seizure control improved in 3/4 of patients with medical refractory epilepsy. One patient suffered from permanent deterioration of speech after surgery. Brain mapping under awake craniotomy may be considered a safe method to maximize the extent of tumor resection, while preserving neurological function in patients with gliomas of the dominant insular lobe.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 2 2 2016 9 1 Open Drainage in Chronic Subdural Hematomas: A Prospective Study of 189 Cases 15 19 EN Souad Bakhti MD, Professor, Pediatric Neurosurgery Division, Mustapha Pacha University Hospital, Algiers Algeria Nabila Tighilt MD, Assistant Professor, Pediatric Neurosurgery Division, Mustapha Pacha University Hospital, Algiers, Algeria Mohamed Djennas MD, Professor, Chief Department of Neurosurgery, Mustapha Pacha University Hospital, Algiers, Algeria Background & Importance: Chronic subdural hematoma (CSH) is one of the most frequent intracranial hemorrhages in adults. However, gold standard treatment of CSH is not yet defined. Since the 80’s, closed drainage is a standard among techniques using drains because the open type has been incriminated in high rates of postoperative infections. However, closed drainage requires materiel which is sometimes not available or expensive in some countries. Open drainage was reintroduced in our department in the middle of the 90’s because of economic crisis at this time. We have then conducted a prospective study to assess safety and efficacy of open drainage in treatment of CSH. Case Presentation: A prospective study of adult patients with CSH was conducted from January 2008 to December 2011. All patients have the same surgical procedure which included one burr-hole craniostomy, spontaneous evacuation and open drainage. The study focused on infectious complications, postoperative seizures, and recurrences. Results are compared with those of literature. In our study, 189 patients were operated with mean age of 69.2 years old. Of all, 163 patients were cured. Overall rate of complications was 15.34% with an infection rate of 1.58%, a postoperative seizure rate of 1.05% and a recurrence rate of 14.2%. Mortality rate was 5.8%. Results were in concordance with those of large series of literature. Conclusion: Data of the current study suggested that open drainage is a safe and efficient method in treatment of CSH. It is also a costefficient treatment that could be very interesting for middle- a nd low-income countries.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 2 2 2016 9 1 Foreign Body Reaction Mimicking Intracranial Abscess following the Use of Oxidized Regenerated Cellulose (SurgicelTM): Case Report and Literature Review 20 23 EN Matteo Capozza MD, Department of Neurosurgery, University of Florence, Italy Gastone Pansini MD, Neurosurgical Unit, Careggi General Hospital, Florence, Italy Anna Maria Buccoliero MD, Unit of Pathology, Meyer Hospital, Florence, Italy Giovanni Barbagli MD, Department of Neurosurgery, University of Florence, Italy Bahman Ashraf-Noubari MD, Department of Neurosurgery, University of Florence, Italy Furio Mariotti MD, Neurosurgical Unit, Careggi General Hospital, Florence, Italy Franco Ammannati MD, Neurosurgical Unit, Careggi General Hospital, Florence, Italy Background & Importance: The use of local hemostatic agents in neurosurgery is mandatory in order to control the sequelae of intracerebal hemorrhage. It is widely used in oxidized regenerated cellulose (Surgicel™). Case Presentation: A 54-year-old man previously operated for grade II meningioma came back to our attention due to the onset of left side arm weakness one month after surgery. The CT scan and MRI showed an extensive lesion on the surgical site with the suspect of intracranial abscess. Intraoperative detections suggested the features of a granulomatous foreign body reaction. Conclusion: The occurrence of granulomatous reaction to oxidized regenerated cellulose, when used as hemostatic agent, is a very rare finding following intracranial surgery.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 2 2 2016 9 1 The Cervical Sequestrated Disc Fragment Presenting as Mass Lesion: Case Report and Review of the Literature 24 29 EN Ali Babashahi MD, Assistant Professor of Neurosurgery, Iran University of Medical Sciences, Rasool-e Akram Hospital, Tehran, Iran Morteza Taheri MD, Resident of Neurosurgery, Iran University of Medical Sciences, Rasool-e Akram Hospital, Tehran, Iran Background & Importance: Disc herniation is defined as the prolapsed of material disc into the spinal canal. If the disc fragment is free in spinal canal, it is called sequestration disc fragment. Occasionally, alteration in sequestration disc fragment makes the diagnosis of the disc herniation, challenging. Case Presentation: We reviewed a rare case of the cervical sequestrated disc herniation mimicking a spinal canal extradural abscess. The 55-year-old man presented cervical axial and radicular pain. Cervical spine MRI showed an extra-axial longitudinal mass behind C5 and C6 vertebral body association with anterior compression on cord. In T2 images of lesion, the signal intensity varied from isointense to hyperintense and marked peripheral enhancement with GD injection. After unilateral right C6 hemilaminectomy, a sequestrated disc fragment was resected from epidural space. Conclusion: The histopathologic findings were in favor of sequestrated disc herniation. Although MRI is the main preoperative diagnostic tool for accurate diagnosis of the sequestrated disc herniation, the sequestrated disc fragment can show the variable features on MRI and can be misdiagnosed with the other space-occupying lesions.

Neurolosurgical Society of Iran Iranian Journal of Neurosurgery 2423-6497 2 2 2016 9 1 A Rare Huge Sacral Tarlov Cyst with Progressive Neurologic Deficit: A Case Report 30 33 EN Kaveh Haddadi MD, Assistant Professor, Department of Neurosurgery, Emam Hospital, Orthopedic Research Center, Mazandaran University of Medical Sciences, Sari, Iran Hamid Reza Ganjeh Qazvini MD, Resident of Neurosurgery, Department of Neurosurgery, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran Hassan Shayan Majd MD, Resident of Neurosurgery, Department of Neurosurgery, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran Mojtaba Saleh Ahangar MD, Resident of Neurosurgery, Department of Neurosurgery, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran Background and Importance: Perineural cysts, also known as Tarlov cysts, are benign cysts of the spinal cord containing a collection of cerebrospinal fluid. They most frequently originate in the sacral spine and can be asymptomatic. Case Presentation: We presented a 30-year-old woman who was referred to our clinic with an 8-month history of perianal paresthesia, slowly progressive lower back pain, pain in back of the left and right thigh, and a one-week history of bladder incontinence. Magnetic resonance imaging (MRI) done six months ago showed a large cyst with size of 74x40x22 mm in S1 from S4 of the spinal canal. The cyst was uncovered after laminectomy of S1 to S4. The cyst was aspirated, its neck ligated, and the dismissed portion was excised. The nerve roots were reserved intact. Postoperatively, the patient reported noticeable pain relief. At month 3, the patient's bowel and bladder control recovered. Sensation and deep reflexes were also normal. Conclusion: A giant sacral Tarlov cyst and the development of associated radicular symptoms are powerfully associated with an outstanding outcome following surgery.