Surgical management of olfactory groove meningiomas

To study the bifrontal approach to olfactory groove meningiomas [OGM], the technique, outcomes, and recurrence rates in a series of 23 cases of OGM operated on during the period between 2000 and 2009. The study included twenty three patients with OGM, 15 females and 8 males. The age ranged from 26 years to 65 years with a mean of 45.2 years. Bifrontal craniotomy and excision of tumor was done for all patients. Tumor diameter varied from 3.3 to 6.1 cm [mean 4.7 cm]. Total tumor removal [Simpson grade 1 and 2] was achieved in twenty patients [86.9%] and subtotal removal [Simpson grade 3] was achieved in three patients [13.1%], in whom the anterior cerebral artery complex was encased. The pathology in all patients was Grade I meningiomas [World Health Organization grading]. There was no operative mortality. Anosmia occurrygered in all but three patients and partial left optic injury in one patient. Three patients suffered post operative cerebrospinal fluid rhinorrhea which stopped in all after repeated lumbar drainage. Three patients suffered postoperative wound infection and responded well to appropriate antibiotic treatment. There was one recurrence in the follow up period of 6 months to 8 years with a mean of 2.6 years. A variety of surgical approaches are used for OGM resection. Bifrontal approach offers excellent exposure, and when combined with modern microsurgical cranial base techniques allows maximum safety during surgery with minimal permanent morbidity, excellent neurological outcome, and very low recurrence rates

Orbitozygomatic approach to parasellar lesions

To study the orbitozygomatic approach for parasellar region. Its applicability, extent of exposure and feasibility in a series of sixteen patients with different parasellar lesions operated on during the period between 2000 and 2009. The study included sixteen patints [nine females and seven males] with different parasellar lesions operated on through the orbitozygomatic approach. The age of the patients ranged from twenty one to sixty five [mean 47.6]. The lesions included ten parasellar meningiomas, [five sphenoid ridge meningioma, three clinoidal meningioma and two cavernous sinus meningioma], five of them with intraorbital extension, three trigeminal neurinomas, one cavernous sinus cavernoma, one aneurismal bone cyst and one retrochiasmatic craniopharyngioma. The main presenting symptoms were headache, diplopia, visual disturbance, and epilepsy. Total removal was done in thirteen patients and subtotal in three [two cavernous sinus meningiomas and one cavernous sinus cavernoma]. Extraocular muscle palsy occurred in three patients, one of them had permanent deficit and two improved, one patient with third nerve palsy was subjected to operation for elevation of the upper eyelid by an ophthalmologist. CSF rhinorhea occurred in one patient and was complicated with bacterial meningitis. It was treated by repeated lumber puncture and antibiotics but it was not responding for a long period and yielded poor patient outcome. Outcome was classified into: excellent, if the patient has no neurological deficit; good if the patient has normal daily activity with minor neurological dysfunction; fair, if the patient is moderately disabled but independent with major neurologic deficit; poor if the patient has sever neurologic disability and totally dependent. In this study outcome was excellent in nine patients, good in five patients, fair in one patient and poor in one patient. The fair result was due to contralaterl hemiplegia as a result of occlusion of the sylvian vein on the left side and subsequent venous infarction. The poor result was due to post operative meningitis as a result of CSF rhinorrhea. Orbitozygomatic approach provides better exposure to the parasellar region than conventional pterional and subtemporal approaches. The exposure is wider, the working distance is shorter, and the anatomic verifications of vital structures is better. This approach, however, is technically more demanding because the familiarity with the topographic anatomy and the microsurgical techniques are essential to its execution

Surgery of craniocervical meningiomas

To study the different surgical approaches to craniocervical meningiomas in different locations in the area of the foramen magnum, whether anterior, posterior, antrolateral or posterolateral. Twenty six patients with craniocervical meningiomas were operated upon during the period from 2000 to 2009 using the standard posterior approach for posterior lesions [14 cases], extreme lateral approach without drilling of the occipital condyle in the antrolateral and posterolateral lesions[6 cases] and transcondylar approach for anterior lesions [6 cases]. This study included 16 females and 10 males, the patients' age ranged from 23 to 64 years with a mean of 51.8 years. Tumor size ranged from2 to 6.4 in its maximum diameter. Tumor location was posterior in 14 patients, lateral in 6 patients and anterior in 6 patients. Total tumor resection was done in 23 [88.4%] patients and subtotal in 3 [11.6%] patients. Postoperative complications included transient lower cranial nerves affection, transient hemiparesis. There was no mortality in this study. The follow up period ranged from 6 months to 4.8 years. Surgical approach to craniocervical meningioma has to be tailored according to the location of the tumor. Posterior tumors are safely totally removed through the slandered suboccipital approach. Posterolateral and antrolateral tumors are easily removed via the postero lateral retrocondylar approach without drilling of the occipital condyle benefiting from the working space given by lateral displacement of the brain stem. Anteriorly located tumors are better approached through the extreme lateral transcondylar approach to avoid brain stem retraction

Skull base surgery of non vestibular schwannomas of the posterior cranial fossa

To study the surgical approaches and results of surgery in twenty one patients with non vestibular schwannomas operated upon at the neurosurgery department We retrospectively analyzed a series of 21 patients with histologically verified non-vestibular schwannomas, treated at the Neurosurgery Department, Alexandria University in the period between 2003 and 2008. The age in this group of patients ranged from 20 to 65 years [Mean 38 years]. All patients underwent detailed general and neurological examination and preoperative gadolinium-enhanced magnetic resonance imaging [MRI]. Computerized tomography [CT] scan with thin slices was used in 16 cases to study the bony anatomy. The mean follow-up period was 29 months [range 10 to 61 months]. Twenty one patients with intracranial schwannomas arising from cranial nerves other than the vestibulocochlear were surgically treated in the Neurosurgery department, Alexandria University, in the period between 2003 and 2008. There were 14 males and 7 females and the mean age was 38 years. Seven of our patients underwent surgery elsewhere for partial resection before being referred to our facility; one of these cases underwent fractionated stereotactic radiotherapy for residual tumor after the first surgical intervention. Non-vestibular schwannomas are rare tumors that are best treated by total surgical resection. The location and size of the tumor dictates the surgical approach, however skull base approaches offer better tumor exposure and therefore result in better total tumor resection rate

Predictive value of lumbar infusion test in normal pressure hydrocephalus

To detect the ability of the lumbar infusion test to predict the outcome of shunt surgery in patients with suspected normal pressure hydrocephalus. Twenty patients with suspected normal pressure hydrocephalus were studied. Preoperative CT and/ or MRI of the brain was done in all cases. The absence of preceding history indicated idiopathic disease. All patients were assessed with walking and psychometric tests before lumbar infusion test and tap test assessments. Tap test was done in all cases because it is the standard test used in these cases. The lumbar infusion test was done using a constant infusion rate [0.80 ml/min] using a syringe pump and regarded as positive if the steady state CSF plateau pressure reached levels of > 22 mm Hg [16 cm H2O]. The tap test was regarded as positive if two or more of three different test items improved after CSF removal. Walking and psychometric tests were used to assess patients postoperatively. The results of the CSF tap test and the lumbar infusion test agreed in only 40% of cases. Of all cases in the study, 18 [90%] had positive test results and were operated on; 16 [80%] of patients reported subjective improvement, and postoperative assessments verified the improvements in 15 patients [75%]. Improvements were highly significant in walking and memory. Most of the patients improved by surgery [90%] were selected by a positive lumbar infusion test, and only 67% by a positive tap test. Both the lumbar infusion test and the tap test can predict a positive outcome of shunt operations in patients with suspected normal pressure hydrocephalus. Lumbar infusion test has a higher predictive value than the CSF tab test. The two tests are complementary and should be used together for a better patient selection. Key Words: - Normal pressure hydrocephalus - Lumbar infusion test - Tap test"

Functional outcome after surgical excision of cortical meningio-angiomatosis

To study the functional outcome after surgical excision of cortical meningio-angiomatosis [MA] in terms of seizure control and neurological disability. Four patients with MA were diagnosed with refractory epilepsy. All were surgically treated. Four cases of MA were reported three males and one female. Median age at presentation was 19 years [range 9-23 years]. All patients had refractory seizures for 1-18 years with a median of 8 years. Two patients had exclusively simple partial seizures, with secondary generalization; the other two patients had complex partial seizures, with secondary generalization. CT and MRI were done for all patients. The lesion was in the right frontal lobe in one patient, left frontal in one patient, left tempropolar in one patient and right temporal in one patient. After surgical resection, three patients remained seizure free without antiepileptic treatment and the fourth patient became controlled on monotherapy of antiepileptic treatment. No patients had added neurological deficit in the postoperative follow-up period of six months to eight years [mean 4.7 years] MA commonly presents as refractory epilepsy. Although MA occurs infrequently, it is important to establish the correct diagnosis. Surgical excision is usually associated with good functional outcome with the patients either stop the antiepileptic treatment or become controlled on smaller doses

Surgical management of porencephalic cyst in patients with medically-intractable epilepsy

To detect the ability of surgical management of porencephalic cyst to control intractable epilepsy. Five patients diagnosed with porencephalic cyst causing epilepsy that could not be controlled with adequate dosing of three anti-epileptic drugs were included in the study. The study included four males and one female. The age of the patients ranged from 9 to 23 with a mean of 16.4 years. All patients were submitted to complete general and neurological examination, laboratory and radiological investigations as well as Electroencephalography [EEG]. The radiological investigations included tomography [CT] and magnetic resonance imaging [MRI] of the brain. Craniotomy was done for all cases with uncapping of the cyst; removing all the gliotic tissues with or without fenestration of the cyst to the lateral ventricles. Cases were followed-up for six months postoperatively. Most cases were under 20 years old. Etiology of the porencephalic cyst included trauma, congenital, vascular insult as well as infection. The cysts were located in the frontal, parietal and the temporal lobes. All patients benefited from the surgery, four cases [80%] discontinued or reduced the dose of anti-epileptic drugs and one had epilepsy controlled with three anti-epileptic drugs. Surgical management of intractable epilepsy in porencephalic cyst patients is a valuable method for controlling epilepsy and should be resorted to in all indicated patients

Surgical choices for cervical OPLL

Ossification of the posterior longitudinal ligament [OPLL] is a common cause of cervical myelopathy, especially in Japan, and is more common in males. OPLL is classified into four types: segmental, continuous, mixed and focal. Different surgical approaches are being used to treat this disease, including laminectomy, laminoplasty and anterior, either resecting the ligament or decompressing the cord using the floating technique, leaving the ossified ligament in place. This study included sixteen patients with cervical OPLL treated at Alexandria main University Hospital during a period of two years [July 2001 to July 2003]. The age of the patients ranged from 45-67 years, with a mean age of 58.12 years. Fourteen patents were males and two were females. All patients excluding 2 presented with gradual progressive manifestations. The remaining 2 patients presented with acute onset quadriplegia after minor trauma. Upper extremity weakness and clumsiness, gait difficulty, sphincter dysfunction and neck pain were the most common complaints. Clinical evaluation and outcome of the patients was carried out using the Nurick scale. Fifteen of our patients suffered radiculomyelopathy. One patient with focal OPLL suffered radiculopathy in the distribution of right C6 root. Ten patients improved and six patients remained stationary during a follow-up period of six months. Plain x-rays, magnetic resonance imaging and computed tomography scan were done for all patients. Ossification posterior longitudinal ligament was found to be the continuous type in thirteen cases, mixed in two cases and focal in one. The maximal thickness of the OPLL was 7 mm with a range of 3-7 mm and a mean of 4.3 mm. The most commonly affected levels were C2-C4. The effective canal diameter ranged from 5-13 mm with a mean of 9.8 mm. In this study we used conventional laminectomy in eleven cases, open door laminoplasty in four cases and the anterior approach in only one patient with focal OPLL. We measured the improvement according to the Nurick scale. Ten patients improved and six patients remained stationary during a follow-up period of six months. We concluded from this study that OPLL should be kept in mind in the differential diagnosis in cases of cervical myelopathy. The effective canal diameter and the range of motion of the cervical spine are the most important factors affecting the clinical picture in cases of OPLL. Early surgery is recommended for cases of OPLL because better results are obtained in younger patients with short duration of symptoms. Laminectomy is a simple surgical option in cases of continuous type OPLL, with a stable spine as proved by dynamic study. Laminoplasty is better used in extensive involvement of the spine if the dynamic films show a high range of movement. Anterior approach has the risk of neural injury and is better avoided, especially if dural invasion could be identified in the preoperative imaging study. Anterior approach can be used in focal type OPLL and if used in extensive OPLL. The floating technique is safer than other methods to excise the OPLL