Objective: For effective management of patients with unruptured intracranial aneurysms, prognostic criteria for rupture, of which aneurysm size, location, and multiplicity are key factors. The aim of this study is to determine the correlation between the aneurysm size, location, and multiplicity, and their effect on aneurysmal rupture. Materials and Methods: Eighty one patients with diagnosis of intracranial aneurysms were managed at our center from January 2008 through July 2011. The characteristics of aneurysms, such as size, location, multiplicity, and presentation were retrospectively reviewed from their charts and radiological findings. Results: Eighty one patients harboring 104 aneurysms were diagnosed, of them 45 were males (55.5%) and 36 were females (44.5%). Seventy-six patients (94%) presented with subarachnoid hemorrhage (SAH) due to ruptured aneurysm. Thirty-three patients who were presented with SAH (43%) had their ruptured aneurysm located at the anterior communicating artery with a mean size 5.8 mm. Most of the small (<7 mm) ruptured aneurysms were located at the anterior communicating artery, distal anterior cerebral arteries, posterior communicating arteries, and internal carotid artery bifurcation (51%, 13%, 11%, and 11%), respectively. There were 24 small unruptured aneurysms, 10 of them (42%) located at the middle cerebral arteries, while only 2 of them (8%) located at the anterior communicating artery. Conclusions: The aneurysm size and location play a substantial role in determining the risk of rupture. The most common location of rupture of small aneurysms was the anterior communicating artery, while the middle cerebral artery was the commonest site for small unrupured aneurysms.

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Spontaneous spinal epidural hematoma (SSEH) is an uncommon neurological emergency which can present with the features ranging from simple back pain with radiculopathy to complete paraplegia or quadriplegia depending on the site and severity of the compression. Spinal hemorrhage associated with anti-platelet drugs is rarely seen. We report a case of SSEH in a 68-year-old hypertensive male who was on a low dose clopidogrel for secondary stroke prophylaxis and presented with bilateral lower limb paralysis, preceeded by severe back bain. A spinal magnetic resonance imaging scan was performed which revealed a posterior epidural hematoma of the thoraco-lumbar spine. To the best of our knowledge, not more than four cases of clopidogrel related spinal epidural hematoma have been reported. Emergent decompressive laminectomy was done within 4 hours of the presentation with excellent clinical outcome. Clinicians should, therefore, consider the remote risk of SSEH in hypertensive patients who are on anti-platelet drugs as early decompressive laminectomy and evacuation of the hematoma minimizes the permanent neurological damage.

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Background: Medulloblastoma is a common malignancy in the pediatric population, accounting for 25% of all childhood brain tumors and relatively uncommon in adults. This review was to investigate treatment outcome and prognostic factors after treatment of medulloblastoma. Materials and Methods: A total of 53 patients with histological confirmed medulloblastoma cases treated at our institute between 2006 and 2012 were included in the study. Demographic variables, clinical variables, radiological findings and treatment details with respect to age, sex, signs and symptoms, location of tumor, extent of surgical resection, histopathology type, radiotherapy dose, follow-up period and outcomes were recorded. Survival was analyzed by using these parameters. Results: Thirty-one (58.5%) patients were pediatric (<14 years), and 22 (41.5%) patients were adults (≥14 years). Duration of symptoms were <3 months in 19 (36%) and more than 3 months in 34 (64%) patients. Tumor resection was performed in all patients with gross total resection in 8 (15%) patients, near total resection in 34 (64%) patients and subtotal resection in 11 (21%) patients. All patients underwent postoperative craniospinal irradiation (CSI) delivering a median craniospinal dose of 36 Gy with additional boosts to the posterior fossa up to 54 Gy. Median overall survival was 50 months for the total group whereas 36 months for pediatric age group and 70 months for adult group. Desmoplastic histology showed an improved outcome compared with other histologies with a median survival of 71 months compared with that of classical medulloblastoma histology being 36 months and other histologies shown a median survival of 34 only. Conclusions: Treatment of medulloblastoma with surgery and CSI yields long survival rates in both children and adults. Adult age group and desmoplastic histology were associated with a favorable outcome.

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We present a rare case of the primary intracranial melanoma in the right parafalcine frontal region in a 65-year-old male. Computed tomography and magnetic resonance imaging showed a Space occupying lesion in the right parafalcine frontal region with necrosis, vasogenic edema and mass effect. A rather well-defined, dark brown-black tumor was totally removed and histologically diagnosed as malignant melanoma. The patient improved after surgery. In our case, no systemic melanomas were found in close clinical examinations, there was a single nodular tumor attached to the leptomeninges and a favorable outcome was obtained by surgical treatment alone. Primary central nervous system melanomas have rarely been reported, and this case is reported for its rarity.

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Objective and Background: Unruptured aneurysm surgery is a challenge to all vascular neurosurgeons as the patient is asymptomatic and no even slight neurological deficits should be expected postoperatively. To this aim, multi-modality checking of the vessels during the surgery is highly recommended to assure of the patency of the parent and perforator arteries next to an aneurysm. In this paper, we present our experience in the last 1.5 years with emphasis on the role of endoscope assisted microsurgery. Methods: One hundred and seventy-five patients with unruptured intracranial aneurysms were operated in our institute in the last 1½ years. All patients underwent endoscope assisted microsurgery with pre- and post-clipping indocyanine green angiography. In selected cases, motor evoked potential monitoring was implemented. Results: No mortality was observed in this period, and only 6 patients (3.4%) suffered new permanent neurological deficits postoperatively. Our illustrative cases show how endoscopy may help the surgeon to visualize hidden vessels behind and medial to an aneurysm. Conclusions: Our results indicated that multi-modality monitoring during unruptured aneurysm surgeries is associated with excellent outcome. Endoscope is able to show blind corners during aneurysm surgery which cannot be routinely observed with microscope and its application in aneurysm surgery assists the surgeon to make certain of complete neck clipping and preservation of perforating arteries around the aneurysm.

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A 68-year-old man presented to our hospital with a 1-month history of slowly progressing altered mental status and gait disturbance. Magnetic resonance imaging and abdominal computed tomography revealed advanced pancreatic cancer (PC) with brain and para-aortic lymph node metastases. Gross total resection of the brain metastatic tumor was performed. Although symptoms improved, the patient died 3 months postoperatively. In general, the prognosis for PC patients with brain metastasis is very poor. Surgical resection of brain metastasis may play a very limited role in allowing long-term survival of patients for whom the primary PC is controlled or with particular oncocytic-type tumors.

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Introduction: Craniopharyngiomas treatment has been challenging because of their anatomical location. The endoscopic endonasal (EE) trans-sphenoidal approach is indicated in sellar, supra sellar, selected intraventricular lesions in adults and children. We are reporting our initial experience of 44 patients managed by EE approach. Materials and Methods: This is a retrospective study of 44 craniopharyngiomas. The goal of surgery was gross-total resection in all cases. All patients underwent pre- and post-operative comprehensive ophthalmological and endocrinological evaluation. Lumbar drain at the start of the operation was used in all cases with tumor larger than 3 cm maximum diameter. Binostril technique vascularized nasoseptal flap and multilayer closure of the dural defect were used. Wide sphenoidotomy, posterior ethmoidectomy, tuberculum selle, and planum removal were performed in all cases. Perioperative antibiotic prophylaxis was used for 72 h. Results: There were 44 patients of age ranging from 8 to 65 (mean: 42) years. Diameter of the tumor varied from 3.1 cm to 6.6 cm (average: 4.3 cm). Visual and pituitary dysfunctions were observed in 44 and 33, respectively, before surgery. Vision improvement, gross-total removal, cerebrospinal fluid (CSF) leak and recurrence were observed in 34, 26, four and six patients, respectively. Average follow-up was 19 months. Conclusion: Endoscopic endonasal trans-sphenoidal approach for craniopharyngioma is safe and effective alternative to transcranial approach in selected patients. Although this technique is associated with effective tumor removal and improved visual outcome, CSF leak, and endocrine dysfunctions remain a major challenge.

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Background: Significant dural sinus injury occurs in 1.5- 5% of all head injuries and injury to superior sagittal sinus accounts for 70-80% of these. Its management is also a challenging issue to every neurosurgeon. Materials and Methods: In a period of one year (Aug 2011 to july2012) out of 549 cases of head injuries operated in our department analysis of 15 cases (2.73%) shown to have superior sagittal sinus injury. Three dimensional reconstruction of skull bone during CT scan helped us to diagnose possible dural sinus injury pre-operatively. Results: SSS injury was due to direct impact of fracture segment (5 cases), extension of fracture line over sinus area (4 cases) or due to coronal suture diastases (6 cases). Injury to anterior third of sagittal sinus occurred in 12 cases (80%) and injury to middle third occurred in 3 cases (20%). Small tear over superior sagittal sinus was found in 7 cases (46.66%) and was managed with Gelfoam^; compression only and in two cases (13.33%) were large tear, which was managed with sinoraphy. In four cases (36.34%) hitch stitches over Gelfoam^; to adjacent bone given and in rest two cases (13.33%) a strip of bone was left over the sinus area and bilateral hitch stitches were applied. Conclusion: Injury to SSS in traumatic head injury patient though rarely encountered during surgery, the management is challenging to every neurosurgeon. Preoperative suspicion and combination of surgical techniques rather than one single technique may be effective in decreasing the sinus related mortality rate.

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Objective: This is a retrospective study from January 2002 to December 2012 analyzing the results of microsurgical clipping for aneurysms arising from the superior cerebellar artery (SCA). Materials and Methods: All patients with SCA were evaluated with computerized tomography angiography and/or digital subtraction angiography (DSA) prior to surgery. All patients in our series underwent microsurgical clipping and postoperative DSA to assess the extent of aneurysm occlusion. The Glasgow outcome scale (GOS) and the modified Rankin's scale (mRS) were used to grade their postoperative neurological status at discharge and 6 months, respectively. Results: Fourteen patients had SCA aneurysms (ruptured-9, unruptured-5). There were 10 females and 4 males with the mean age of 47.2 years (median - 46 years, range = 24-66 years). Subarachnoid hemorrhage (SAH) was seen in 11 patients. The mean duration of symptoms was 2.5 days (range = 1-7 days). The WFNS score at presentation was as follows: Grade 1 in 10 cases, II in 2 cases, III in 1 case and IV in 1 case. In the 9 cases with ruptured SCA aneurysm, average size of the ruptured aneurysms was 7.3 mm (range = 2.5-27 mm, median = 4.9 mm). The subtemporal approach was used in the first 7 cases. The extradural temporopolar (EDTP) approach was used in the last 5 cases. Complications include vasospasm (n = 6), third nerve palsy (n = 5) and hydrocephalus (n = 3). Two patients died following surgery. At mean follow-up 33.8 months (median - 25 months, range = 19-96 months), no patient had a rebleed. At discharge 9 (64%), had a GOS of 4 or 5 and 3 (21%) had a GOS of 3. At 6 months follow-up, 10/14 (71%) patients had mRS of 0-2, and 2 (14%) had mRS of 5. Conclusions: Aneurysms of the SCA are uncommon and tend to rupture even when the aneurysm size is small (<7 mm). They commonly present with SAH. The EDTP approach avoids complication caused by temporal lobe retraction and injury to the vein of Labbe.

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An 11-year-old boy presented with holocranial headache associated with vomiting and heaviness in right paranasal region. On examination, he had left sided upper motor neuron type facial palsy along with a subtle ipsilateral hemiparesis (grade 4/5 Medical Research Council). Magnetic resonance imaging brain revealed a contrast enhancing large well-defined extra-axial mass lesion in right middle cranial fossa with extension into the infratemporal fossa. The mass was excised in two stages. Histopathology was suggestive of clear cell meningioma (CCM). Supratentorial pediatric CCM is a rare entity. The case is discussed along with review of literature on this rare clinico-pathological entity.

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The authors present a case of 15 years male child who presented with neck pain and progressive ascending quadriparesis. Magnetic resonance imaging showed lytic mass involving C5 and C6 vertebra with soft tissue extension. Surgical excision of mass done using anterior cervical approach. Postoperatively, patient showed improvement in spasticity and power. Histopathological examination of mass was suggestive of juvenile xanthogranuloma (JXG). At 6 months follow-up, patient was improving without any evidence of recurrence. Only 12 cases of JXG of spine have been reported till date including only four cases involving the cervical spine and among these four cases only two were of pediatric age group.

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Objective: The purpose of this study was to evaluate the disability in patients with spondylolisthesis who assigned either to posterolateral fusion (PLF) or posterior lumbar interbody fusion (PLIF) and to compare it between two groups. Methods: In a prospective observational study, 102 surgical candidates with low-grade degenerative and isthmic spondylolisthesis enrolled from 2012 to 2014, and randomly assigned into two groups: PLF and PLIF. Evaluation of disability has been done by a questionnaire using Oswestry Disability Index (ODI). The questionnaire was completed by all patients before the surgery, the day after surgery, after 6 months and after 1-year. Results: There were no statistically significant differences in terms of age and sex distribution and pre-operation ODI between groups (P > 0.05). Comparison of the mean ODI scores of two groups over the whole study period showed no significant statistical difference (P = 0.074). ODIs also showed no significant differences between two groups the day after surgery, 6 ^th months and 1-year after surgery (P = 0.385, P = 0.093, P = 0.122 and P = 433) respectively. Analyzing the course of ODI over the study period, showed a significant descending pattern for either of groups (P < 0.0001). Conclusion: Both surgical fusion techniques (PLF and PLIF) were efficient to lessen the disability of patients with spondylolisthesis, and none of the fusion techniques were related to a better outcome in terms of disability.

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Full recovery from tetraplegia is uncommon in cervical spine injury. This has not being reported for cervical spine fracture in a patient with ankylosing spondylitis causing spinal epidural hematoma. We report on a case of cervical spine fracture in a patient with ankylosing spondylitis who came with tetraplegia. He underwent a two stage fixation and fusion. He had a complete recovery. Two hours after the operation he regained full strength in all the limbs while in the Intensive Care Unit. He went back to full employment. There are only two other reports in the literature where patients with ankylosing spondylitis and extradural hematoma who underwent treatment within 12 h and recovered completely from tetraparesis and paraplegia respectively. Patient with ankylosing spondylitis has a higher incidence of spinal fracture and extradural hematoma. Good outcome can be achieved by early diagnosis and treatment. This can ensure not only a stable spine, but also a rapid and complete recovery in a tetraplegic patient.

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Authors report a case of right orbital intraconal abducens nerve schwannoma in a 32-year lady, who presented with a sense of tightness and discomfort in right eye on looking extreme right side since 4 months. The tumor was totally excised with functional preservation of the nerve by superior orbitotomy. The clinical, radiological features and the management are discussed.

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Barbiturate coma therapy (BCT) is a choice treatment for refractory intracranial hypertension after all surgical or medical managements have failed to control the intracranial pressure (ICP). It helps to reduce cerebral blood flow, cerebral metabolic rate of oxygen consumption and ICP. However, this therapy can also cause many complications. One of the underreported, but life-threatening complications is refractory hypokalemia, which can lead to subsequent rebound hyperkalemia after sudden cessation. We report our experience of managing unusual complication of refractory hypokalemia during BCT with thiopentone in postdecompressive craniectomy patient.

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carotid-cavernous fistulas are spontaneous or acquired connections between the carotid artery and the cavernous sinus, being classified as direct or indirect; being usually diagnosed in postmenopausal women, but are also associated with other pathologies such as pregnancy, sinusitis and cavernous sinus thrombosis. They are clinically characterized by ophthalmological symptoms and pulsatile tinnitus. A 51-year-old woman who started her current condition about 4 years ago with pulsatile tinnitus, to which were added progressively: Pain, conjunctival erythema, right eye proptosis and the occasional headache of moderate intensity. Carotid-cavernous fistula was diagnosed, for the technical difficulty inherent in the case was made a contralateral transvenous approach and embolization with 360 ° GDG coils, with successful evolution of the patient. The endovascular management of these lesions is currently possible with excellent results.

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Isolated traumatic oculomotor nerve palsy caused by a trivial fall is extremely rare. We report a case of this condition. A 49-year-old woman had distal radius fracture and ptosis on the same side after having a trivial domestic fall. She did not show any clinical or radiological signs of head injury. Computerized tomography revealed a calcified posterior petroclinoid ligament which has direct anatomical and pathological relation with the oculomotor nerve.

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Cervical kyphosis-though a common occurrence after surgery and other conditions like trauma, infections, etc., is usually restricted to around 20-40°. It is more common in children. Angulations of more than 70-80° are exceedingly uncommon and present more treatment challenges. We discuss here the management of a 14-year-old child with a severe postoperative cervical kyphotic angulation of 92°. The child presented 10 months after surgery for a C3-C4 intramedullary cyst with neck deformity and near tetraplegic state. He underwent a combined anterior-posterior approach for correction after a trial of skull traction. Six months after the surgery, the child was ambulatory with almost total correction of the deformity. Surgical correction of postoperative cervical kyphosis usually involves a posterior approach for small angles and an anterior approach for larger angulations. The combined anterior-posterior approach is preferred for severe angulations or for those cases not correctable by a single approach. A purely posterior approach may be the only option for those cases where the anterior approach is impossible.

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Objectives: Nucleoplasty is a minimally invasive procedure that is developed to treat patients with symptomatic, but contained disc herniations or bulging discs. The purpose of this study was to evaluate a decade follow-up of coblation nucleoplasty treatment for protruded lumbar intervertebral disc. Methods: In this retrospective study there a total 50 patients who underwent intradiscal coblation therapy for symptomatic, but contained lumbar degenerative disc disease were included. Relief of low back pain, leg pain and numbness after the operation were assessed by visual analog pain scale (VAS). Function of lower limb and daily living of patients were evaluated by the Oswestry disability index (ODI) and subjective global rating of overall satisfaction were recorded and analyzed. Results: There were 27 male and 23 female with followup mean follow up of 115 months (range 105-130 months) with a mean age was 52 years (range 26-74 years). Analgesic consumption was reduced or stopped in 90% of these cases after 1 year. At 24 months follow up VAS was four points and ODI was 7.2. In three patients, we repeated the cool ablation after 36 months, at L3-4 level in two cases. Ten patients continue to be asymptomatic after 114 months of intervention. There were no complications with the procedure including nerve root injury, discitis or allergic reactions. Conclusions: Nucleoplasty may provide intermittent relief in contained disc herniation without significant complications and minimal morbidity. In accordance with the literature the evidence for intradiscal coablation therapy is moderate in managing chronic discogenic low back pain; nucleoplasty appears to be safe and effective.

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Introduction: Healthcare costs continue to rise every day as the demand outgrows the supply of surgeons. The application of telephone consultation for immediate management is needed as most neurosurgeons are technology orientated. This enables a specialist at a remote mobile site to receive the necessary information and reduce transmission time, from the second the patient is seen till the management is obtained. Materials and Methods: We conducted a survey on smartphone ownership among doctors and gathered cases that needed neurosurgical input from 1 ^st November 2012 till 30 ^th April 2013 from all 24 district hospitals in Sabah, Malaysia. Results: The percentage of smartphone ownership among doctors surveyed and usage of it for remote and daily medicine at various departments at Queen Elizabeth Hospital, Kota Kinabalu, which shows at least 90% smartphone ownership and proves 100% ownership of cross-platform instant messaging applications and its usage for remote and daily medicine. It also proves to be a more popular mode of referral compared to "teleconsultation" (TC). Discussion: In Sabah, the TC service is used for remote medical consultation and only available at four hospitals. The sender needs direct access to a computer with the TC software, and it causes delay whereas doctors using smartphones will just need to discuss the case on the spot and obtain the appropriate management within minutes. Smartphone usage is also important in daily neurosurgery especially at the department level to promote efficient communication, organization, and interaction between all the staff. As for the department's administrative sector, it is useful to notify if anyone is on leave, attending courses or even meetings as the shortage can be avoided, and redistribution easily done. It also allows us to transfer simple intra-departmental data at any time, and any place whenever required. Conclusion: With all the given fact, it is clear that a day without utilizing this service in our daily life will leave us handicapped and struggling with time and resources.

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Introduction and Aim: The management of posterior fossa arachnoid cyst (PFAC) in adults is controversial. To review our cases and literature, propose a practically useful surgical strategy, which gives excellent long-term outcome in management of PFAC. Materials and Methods: We analyzed our case records of 26 large intracranial arachnoid cysts in adults treated over 12 years. Of them, we had 7 patients with symptomatic PFAC. Reviewed the literature of 174 PFAC cases (1973-2012) and added 7 of our new cases with a follow-up ranging from 3 to 12 years. Results: In 6 cases the PFAC was located in the midline. In the 7 ^th case, it was located laterally in the cerebello-pontine (CP) angle. All patients were treated surgically. Excision of the cyst was performed in 5 of these cases. Among the two intra-fourth ventricular cysts, in both the cases cysto-peritoneal shunt was performed. Postoperative computed tomography/magnetic resonance imaging showed variable decrease in size of the cyst even though clinically all patients improved. We propose a surgical strategy for the management of these cases which would aid the surgeon in decision making. Discussion: We observed that these PFACs can occur either in the midline within the fourth ventricle or retroclival region or extra-fourth ventricular region. It can also develop laterally in the CP angle or behind the cerebellum or as intracerebellar cyst. Importance of this is except for Midline Intra-fourth ventricular cyst/retroclival cyst, the rest all can be safely excised with excellent long term outcome. The treatment strategy for Midline Intra-fourth ventricular cyst/retroclival cyst can be either cysto-peritoneal shunt or endoscopic fenestration of the cyst.

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Background: Cervical disc replacements has been shown to be as effective as fusions in the treatment of radiculopathy or myelopathy due to disc prolapse. Newer implants were designed to reduce the difficulty of end-plate preparation. Since 2010, the authors have started using Discocerv (Alphatec Spine, Carlsbad, USA) a keel-less implant and Activ-C (B. Braun, Sheffield, UK), a shallow keel implant. Aim: The aim of this study was to compare the duration of surgery between cervical disc replacement and anterior cervical discectomy and fusion, and also to evaluate the functional outcome, complications, and radiographic outcome of cervical disc replacement. Results: Fifty patients were included (20 disc replacement and 30 fusion). This was a single surgeon retrospective study, with all surgery performed by the senior author (RT). The mean operation duration for single-level disc replacement was 2.6 h, and for single-level fusion was 2.4 h (P = 0.4684). For 2-levels surgery, the result was 3.5 h for 2-level hybrid surgery (one level disc replacement and one level fusion) and 3.4 h for fusion (P = 0.4489). Disc replacement resulted in preservation of an average of 67% of the angle of motion at the sagittal plane (FFflexion-extension). The average range of motion after disc replacement was 6.1°. The median clinical follow-up duration was 2 years (average 1.8 years). There was no incidence of major complications or significant neurovascular injury in this series of patients. A significant improvement in short form-36 scores was seen as early as 3 months postoperative (from 58 preoperative to 92 at 3 months). The improvement was sustained up to the fourth year of follow-up. Conclusion: Cervical arthroplasty with keel-less and shallow keel implants are safe and relatively easy to perform. The surgical time for disc replacement is not significantly longer than standard fusion surgery. There is reasonably good preservation of motion. The short-term functional improvement is good, and we await further long-term outcome results. The authors felt that cervical disc replacement will have an important role in the treatment of cervical degenerative disc disease in the future.

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We herein describe a case of a solitary metastasis of renal cell carcinoma (RCC) in the third ventricle, which was totally removed via an interhemispheric trans-callosal trans-choroidal approach. The histological examination revealed a solitary metastasis of RCC. The postoperative course was uneventful. A stereotactic cyber knife was additionally used for the tumor cavity. As of 2 years after surgery, the patient has been doing well without recurrence. This case highlights the urgent need for an early diagnosis and surgical treatment for solitary metastasis of RCC to the third ventricle due to its critical course.

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Leptomeningeal spinal metastases from supratentorial high-grade glioma are relatively rare. Authors report an unusual case of metachronous, symptomatic, dual spinal drop metastases in a 20-year-old male patient who was operated for right insular anaplastic astrocytoma 20 months earlier. Surgical decompression of the symptomatic D11-L2 drop metastasis was carried out. Histo-pathological examination revealed features suggestive of glioblastoma multiforme. Patient was advised postoperative radiotherapy. The pertinent literature is reviewed regarding this uncommon entity.

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Central neurocytomas are intraventricular benign neoplasms located within the lateral ventricle adjacent to foramen of Monro. A rare case of a central neurocytoma extending throughout the entire ventricular system at the time of presentation is reported. The clinical course of this tumor in a 25-year-old male and its management are presented with relevant review of the literature.

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We present a case of a cervical intramedullary schwannoma (IS), which resembled a glioma on radiology. Somatic and root pain, the most common presenting complaints of IS, were lacking in our patient, and the characteristic magnetic resonance finding of an enhancing thickened nerve root in IS, was absent in our case. Preoperative diagnosis of a cervical IS is not always possible. Complete tumor resection is the ideal treatment for IS. Intraoperative frozen section can be a useful for decision making though the tumor-cord plane will ultimately decide if the tumor can be radically excised.

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Background: Lumbar Disc Herniation (LDH) and Lumbar Spinal Stenosis (LSS) are the most common diagnoses of low back and leg pain symptoms. This study aimed to cross-culturally translate, and validate the Core Outcome Measures Index (COMI) in Iran. Methods: The translation and cross-cultural adaptation of the original questionnaire were performed in accordance with published guidelines. A total of 121 patients with LDH or LSS were asked to respond to the questionnaire at two points in time: Pre and postoperative assessments (6 months follow-up). The Oswestry Disability Index (ODI) also was completed. To test the reliability, the internal consistency was assessed by Cronbach's alpha coefficient, and validity was assessed using convergent validity. Responsiveness to change also was assessed for comparing patients' pre and postoperative scores. Results: The Cronbach's alpha coefficients for the COMI at pre and postoperative assessments ranged from 0.79 to 0.82, indicating a good internal consistency. The change in the ODI after surgery was strongly correlated with change in the COMI, lending support to its good convergent validity (r = 0.79 for LDH and r = 0.77 for LSS; P < 0.001). In addition, the correlation of each item with its hypothesized subscale of the COMI showed satisfactory results suggesting, that the items had a substantial association with the subscale, representing the concept. Further analysis also indicated that the questionnaire was responsive to change (P < 0.0001). Conclusion: The Iranian version of COMI performed well, and the findings suggest that it is a reliable and valid measure of back pain treatment evaluation among LDH and lumbar canal stenosis patients.

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As open access resource, the role of Internet has been increasing in our professional life. There are several emergent new tools that can facilitate and make it more efficient to get accurate and reliable information. In this article, we discuss how we can manage to get the most from these new instruments, like blogs, Facebook, Twitter, and LinkedIn, in order to improve clinical practice. With good sense and some caution, these can turn to be of valuable help in our careers.

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Background: Treatment of cavernomas remains a challenge in surgically inaccessible regions. The purpose of this study was to evaluate outcomes after gamma-knife surgery (GKS) for these patients. Materials and Methods: A retrospective review of 100 patients treated between 2003 and 2011 was conducted in order to evaluate hemorrhage rates, complications, radiation effects after GKS. Dosage at the tumor margin was stratified into two groups: those that received ≤13 Gy; and those who received >13 Gy. The demographic and clinical characteristics of patients including age, gender, and hemorrhage rates were extracted from care records. Results: The median age was 32.5 years (ranging from 15 to 79). 44% were female. The median follow-up time was 42.2 months (ranging from 24 to 90). The median volume of the lesions was 1050.0 mm ³ (ranging from 112.0 to 4100.0) before GKS. A reduction of 27.5% in median size of cavernomas was achieved at the last follow-up. There was 12% treatment-related morbidity after GKS. The hemorrhage rate in the first 2 years after GKS was 4.1% and 1.9% thereafter. There was no mortality due to GKS, and 93 patients were alive at the last follow-up. The radiation-related complication developed with marginal dose 13 Gy. Conclusion: The GKS for cavernomas appears to be a safe and beneficial in carefully selected patients. Low-dose GKS may be effective for the management of cavernous malformations.

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Spinal epidural abscess (SEA) and spinal epidural hematoma (SEH) are neurologic emergencies with distinct etiologies and treatment. Despite similarities on magnetic resonance imaging (MRI), their differentiation is usually possible with meticulous history taking and neurologic examinations. We report an unusual case of SEA that developed from preceding SEH, posing a diagnostic challenge to physicians. A 65-year-old diabetic man suddenly experienced back pain and weakness of both legs when he lifted heavy luggage. He was afebrile, and his laboratory tests were mostly unremarkable. Spinal MRI consisting of T1-weighted, T2-weighted, and fat-suppressed T2-weighted images revealed an epidural mass over the L2-L4 spinous process. He was diagnosed with SEH based on his symptoms and MRI findings, and was treated conservatively using steroid pulse therapy. Despite initial improvement, he suddenly developed into septic shock and coma on the 10 ^th hospital day, and died shortly thereafter. An autopsy revealed massive pus accumulation in the lumbar epidural space and brain, and a postmortem diagnosis of infected SEH associated with invasive pneumococcal disease was established. Serial MRI studies, including diffusion-weighted and/or gadolinium-enhanced T1-weighted images are warranted in patients with a presumed diagnosis of SEH receiving steroid therapy to detect such infectious transformation.

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Craniocerebral eumycetomas are rare. They usually present with scalp swelling and discharging sinuses. Radiologically, they present as space-occupying lesions. We report a case of eumycetoma involving the left parietal cortex, bone, and subcutaneous tissue in a young male, farm laborer, who presented with seizures and blurring of vision. Imaging showed a dural based lesions enhancing moderately on contrast. To the best of our knowledge and belief, ours is the first published case in the English Literature where a eumycetoma has presented as a mass lesion without discharging sinuses. It is imperative to keep such atypical features of an infective etiology in mind because they may be one of differentials of "dural" based lesions where only a biopsy may suffice in the absence of significant mass effect to prove the diagnosis.

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