Background: Incidental dural tears or durotomy (ID) during lumbar decompressive surgery is a relatively rare complication causing severe consequences. Their incidence varies widely among different authors (1-17%) and in general depends on the type and complexity of the spinal procedures performed. With the present investigation the authors aim to evaluate the incidence of incidental durotomies during the different types of decompressive and reconstructive surgical procedures in the lumbar region, also indicating the most common reasons for incidental durotomies, treatment options and the early and remote outcome. Material and Methods: The records of 553 consecutive patients with different types of posterior and posterolateral decompressive and reconstructive procedures in the lumbar region are investigated retrospectively for the period January 2005 - march 2009. Results: The overall incidence of the incidental durotomies in the investigated group is 12.66%. In the subgroups it varies depending on the specificity of the surgical procedures performed. The biggest is the number of IDs in the reoperative spinal surgery subgroup, followed by the subgroup of the patients who sustained spinal trauma, followed by those with degenerative spinal stenosis, tumors and lumbar disc herniations. Conclusion: IDs should be considered as a serious complication with a multitude of unwanted consequences for the patients. Prevention is the best way to treat the complications and disability that attend the unwanted dural tears. Knowing about the mechanisms and predisposing factors for that objectionable complication is a matter of utmost importance when planning and performing spinal surgical procedures.

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Objective: This is a cadaveric anatomical study on the localization of the optic radiation within the temporal lobe and to find whether surgical intervention to the temporal lobe, especially amygdalohippocampectomy, can damage the optic radiation or not. Method: 11 cadaveric cerebral hemispheres were used for the study. A 2 cm long antero-posterior incision was done with a sharp knife, on middle temporal gyrus, starting 3 cm posterior to temporal pole. The incision was deepened perpendicular to surface of the gyrus to reach the temporal horn. The optic radiation was dissected under operating microscope using Klinger's fiber dissection technique and measurements were taken to define the anterior and lateral extension of optic radiation. The optic radiation in each hemispehere was inspected for any incision related damage. Results: No damage to the optic radiation was found, caused by the 2 cm long anterior-posterior incision on middle temporal gyrus 3 cm posterior to temporal pole. Most anterior 9mm (8-10mm) of the Meyer loop was completely on the roof and there was no extension over lateral wall of the temporal horn. In next posterior 17.5mm (16-20 mm) it extended over lateral wall of temporal horn with gradual progression. The most anterior extension of optic radiation was 26mm (23-31mm) posterior to temporal pole. Amygdalohippocampectomy through a 2 cm long horizontal incision on the middle temporal gyrus , starting 3 cm posterior to the temporal pole, to enter into the temporal horn through the lower aspect of the lateral wall is unlikely to cause damage to the Meyer's loop. Any entry from the superior aspect of the temporal horn and any temporal lobectomy inclusive of the superior temporal gyrus to enter the temporal horn is likely to cause Meyer's loop injury. Conclusion: The findings support the fact that the more inferior the surgical trajectory to the temporal horn of the lateral ventricle, the lover is the risk of visual field damage.

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The aim of this article is to introduce the principal part of the JSNT-guidelines for the management of severe head injury in adults. The JSNT-guidelines were developed in 2000 by the Guidelines Committee of the Japan Society of Neurotraumatology (JSNT) based on the results of literature review and the Committee consensus. The guidelines updated in 2006 consist of 7 topics pertaining not only to prehospital care, initial, ICU and surgical management, but also the management of pediatric and geriatric patients. The JSNT-guidelines are of practical nature accounting for the difference in the medical system and conditions in Japan, but in their essence they are similar to those of Western countries. Reports on the application of these guidelines indicate their positive affect on the results of management of severe head injury.

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Background: The sellar and parasellar region is a confluence of several critical anatomical structures from various physiological systems located in close proximity to one another. Patients with pathology in this critical region of the central nervous system therefore make up a unique subset of neurosurgical patients that require careful preoperative and postoperative attention to numerous management details involving neurological, visual, and neuroendocrine function. A thorough understanding of the underlying anatomical and physiological principles of each of these systems, as well as the medical and surgical nuances involved in each case, is required to provide optimized management for patients with pituitary pathology. In this review, we discuss the major preoperative and postoperative considerations in patients undergoing resection for pituitary lesions in the modern era of transsphenoidal surgery.

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The treatment of hydrocephalus is a challenging one. The development of shunt devices have greatly improved the survival and quality of life of paediatric patients with hydrocephalus; however, shunt dysfunction is a common problem which represents a significant scope of work for paediatric neurosurgeons with shunt failures occuring in up to 40 to 50% of patients during the first two years after shunt surgery. Numerous pathologies ranging from congenital to acquired conditions can result in the development of hydrocephalus in the paediatric population. Obstruction of proximal or distal catheter ends, misplacement, infections and over drainage are some of the common problems accounting for shunt failures. We discussed some of the pertinent problems and nuances involved in treatment of paediatric hydrocephalus with VPS as well as to review the role of endoscopic procedures as an alternative to VPS.

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In Japan, there are two simulation based training systems for neurosurgical diseases, that are ISLS (Immediate Stroke Life Support) and PNLS (Primary Neurosurgical Life Support). Workshop on "First ISLS International Version Trial Task Force" came to a successful conclusion on November 12, 2009, in Nagoya, Japan. More than 30 international participants attended this workshop, organized by the Department of Neurosurgery, Fujita Health University. This report summarizes the modules for ISLS/PSLS combined course as international version from the workshop.

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The health scenario of western Nepal is bleak and especially the Neurosurgical facilities are poor. We started the Department of Neurosurgery in April 2008 and has been improvising to do various cases with good success rate. Although not very well equipped, we have tried to do our best and the results have been encouraging.

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Object: The aim is to evalute the outcome of posterior lumbar interbody fusion with autologous bone graft versus titanium Cages, BAK system (Bagby - Kuslich, Spine Tech, Inc. Minneapolis, MN) for low grade spondyloisthesis (Grade1,11). Interbody cages have been developed to replace tricortical Interbody grafts in posterior lumbar interbody fusion (PLIF) procedures. The cages provide immediate post operative stability and facilitate bony union with cancellous bone packed in the cage itself. Method: We Evaluated 50 consecutive patients in whom surgery was performed between June 2000 to June 2003 in the Main Alexandria University Hospital at EGYPT. Twenty five patients were operated using autologous bone graft and 25 patients using the BAK cages. The neuro-radiologic al work up consisted of; plain X - ray lumbosacral spine including dynamic films preoperative and postoperative follow up; C.T lumbosacral spine and MRI lumbosacral spine. The surgery was performed at L4-5 level in 34 cases and at L5-S1 level in 16 cases. The median follow up was 15 months. Results: Satisfactory fusion was obtained at all levels at a minimum one year follow - up. The fusion rate was 96% (24 patients) for the cage group and 80% (20 patients) for bone graft group however clinical improvement was 64% (16 patients) for those with bone graft group. Conclusion: A higher fusion rates and a better clinical outcome have been obtained by Instrumented PLIF with titanium cages that with bone graft. Inderbody fusion cages help to stabilize spainal segment primarily by distracting them as well as by allowing bone ingrowth and fusion. The procedure is safe and effective with 96% fusion rate and 76% overall Satisfactory rate. The use of cages help to distract the space between the vertebral bodies making the correction of the degree of spondylolisthesis easier. Long term follow up revealed better fusion rate and better realignment and less resorption with cages than with bone grafts.

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Traumatic Brain Injury (TBI) may lead to specific handicap, often hidden, mainly due to cognitive and behavioural sequelae. Social re-entry is a long-term, fluctuant and precarious process. The French experience will be illustrated by 6 initiatives answering to 6 challenges to do with TBI specificities:

1. bridging the gap, between initial rehabilitation and community re-entry, via transitional units dealing with assessment, retraining, social/vocational orientation and follow-up. Today, there are 30 such units based on multidisciplinary teams.
2. assessing recovery by TBI-specific and validated evaluation tools: EBIS holistic document, BNI Screening of higher cerebral functions, Glasgow outcome extended, and QOLIBRI, a TBI-specific quality of life tool.
3. promoting specific re-entry programmes founded on limited medication, ecological neuro-psychological rehabilitation, exchange groups and workshops, violence prevention, continuity of care, environmental structuration, and "resocialisation".
4. taking into account the "head injured family"
5. facilitating recovery after sports-related concussion
6. facing medico-legal consequences and compensation: In that perspective, we developed guidelines for TBI-specific expert appraisal, including mandatory neuro-psychological assessment, family interview and an annual forum gathering lawyers and health professionals.

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Objective and background: We evaluated the feasibility and effectiveness of transsphenoidal surgery for large and giant pituitary adenomas with suprasellar extensions as these tumors have been therapeutic challenge. Subjects and Methods: We retrospectively analyzed 50 cases with 56 surgeries in patients with pituitary adenomas that were surgically treated between January 2005 and January 2010 at Fujita Health University. Among those cases, 39 cases were large or giant pituitary adenomas including 11 cases of giant adenomas. Results: 37 cases 41 approaches were transsphenoidal, 2 approaches were transcranial, and in 1 case transcranial approach following transsphenoidal surgery was performed. The most frequent preoperative symptoms were visual impairment and visual field defect (28 cases, 75.6%), and improvement of visual function after surgery was observed in 18 cases, 64%. As endocrinological results, among the 11 cases of functioning adenomas, improvement of endocrinological examination was observed in 10 cases, and normalization of the hormonal examination and complete remission was seen in 7 cases which was 64%. Conclusions: Transsphenoidal approach is safe and effective procedure even in large or giant pituitary adenomas, because it allows rapid and appropriate decompression of the optic nerves and chiasm with low morbidity rates. Transcranial approaches were indicated only in irregular shaped adenomas or eccentric extensions that could not be reached through the transsphenoidal route.

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Epidermoids are generally recognized as benign tumors; however, total resection is often difficult. The recurrence from the residual capsule, dissemination of the tumor, and aseptic meningitis are common problems. The aim of the present study was to analyze and report on the clinical characteristics of intracranial epidermoids, particularly complications and cases with a poor clinical outcome. 24 patients with intracranial epidermoids who were treated surgically at Tokyo Women's Medical University Hospital between 1997 and 2007 were examined. The location and size of the tumor, pre-and postoperative symptoms, adherence of the tumor to cranial nerves, and proliferative capacity were determined. The most frequent site of the tumor was the cerebello-pontine (C-P) angle (16/24); eight of these patients presented with hearing loss and six presented with trigeminal neuralgia. In many cases, hearing loss and diplopia persisted after surgery. All epidermoids located in the C-P angle were attached to and/or compressed the trigeminal nerves, therefore, the origin is suggested to be the dura mafer of petrous bone around the trigeminal nerve. Of all 24 patients, the tumor recurred in four (after 3, 5, 10 and 20 years). One patient had a poor prognosis, with dissemination and brain stem infarction. Epidermoids can recur from residual capsule adhering to the brain stem or cranial nerves up to 10-20 years after the initial surgery. Long­term follow-up imaging studies are required when complete resection of the tumor capsule is not possible. In rare cases, spontaneous cyst rupture, dissemination, and brain stem infarction result in a poor prognosis.

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Myospherulosis is a rare and recently discovered disease apparently caused by the placement of mineral oil, petrolatum-based products or haemostatic agent into different tissues. It can mimic various pathological conditions in different tissues of the body. A sixty year old man presented with left sciatica and a gluteal mass. Imaging showed a retroperitoneal mass extending in gluteal region through the left ileum. Preoperative Fine Needle Aspiration Cytology (FNAC) reported as schwannoma. Patient was managed surgically. Histopathology confirmed myospherulosis. To the author's knowledge, this is the first report of myospherulosis that involved retroperitoneal space and gluteal region through the ileum. In this case presentation clinical features, investigations and surgical management will be discussed.

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The exact role of inflammatory response in hemorrhagic contusions is not fully characterized. The present study quantified IL-6 plasmatic levels in patients with closed head trauma and hemorrhagic contusions during the first 6 to 12 hours postrauma. The association between the plasmatic IL-6 levels, severity of trauma according to the Glasgow Coma Scale, volume of intracerebral hemorrhage and patient's clinical evolution were investigated. Although inflammation is a multifactorial process, a strong correlation between IL-6 levels, volume of traumatic hemorrhage and in-hospital evolution could be observed. A correlation between the IL-6 levels quantified 6 hours postrauma and progression of lesion volume between admission and 12 hours postrauma is suggested. The present study reinforces the importance of IL-6 in influencing the clinical conditions of a patient with cerebral injuries, particularly hemorrhagic contusions.

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A prospective study was performed to evaluate the efficacy of neurophysiological monitoring (NPM) techniques in the detection of ischemic changes that may be seen during endovascular treatment of cerebral aneurysms. Sixty three patients underwent NPM during first­stage endovascular treatment of cerebral aneurysms. The endovascular procedures included coil embolization (26 patients), balloon-remodeling coiling (16 patients), stent-assisted coiling (10 patients), balloon-stent-assisted coiling (9 patients), and balloon test occlusion (2 patients). NPM included electroencephalography, somatosensory evoked potentials, and brain stem auditory evoked potentials, depending on the location of the aneurysm and its associated vascular territory. NPM changes were seen in 3 (4.8%) patients and the procedures were altered immediately. No neurological changes were found postendovascularly. Ten patients demonstrated abnormal angiographic findings without concurrent NPM changes, of which 5 patients developed visual disturbance or hemiparesis. It is concluded that NPM is a valuable monitoring tool for endovascular treatment of cerebral aneurysms.

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Spinal sarcoidosis represents a rare subgroup of neurosarcoidosis. Most spinal sarcoid lesions are intramedullary, and only a few cases of Intradural Extramedullary (IDEM) sarcoidosis have been reported till date. A thirty years-old female patient with intradural extramedullary sarcoid lesion in the cervico-dorsal spinal canal (C7-D1) without any systemic involvement of sarcoidosis is described. The patient presented with rapidly progressive compressive myelopathy with bladder involvement. She was treated with surgical removal of the lesion coupled with the administration of steroid and showed marked improvement.

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Schwannomas represent about 8 % of all intracranial tumours, however, ventricular location of schwannomas is extremely rare. If they occur, they are located mostly in the lateral ventricle. To our knowledge there was only one case of third ventricular schwannoma described in the literature. Our case is the second one.

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