[Value of magnetic resonance spectroscopy in diagnosis of patients with focal brain lesion]

Objective: To describe the spectrum of Magnetic Resonance spectroscopy in focal brain lesions and determine its diagnostic accuracy in comparison to conventional MRI using histopathology as gold standard in differentiating various types of focal brain space occupying lesions. New line.

Patients and methods: 52 patients [21 males and 31 females] with single focal brain space occupying lesion diagnosed by post contrast CT or MRI are included in this study. Complete clinical evaluation, MRI, and MRS examination were performed for all these patients before surgical biopsy and/or resection. Correlation of all these findings was done with histopathology obtained in all these patients

Results: The most important markers in differentiating and grading various types of single focal brain space occupying lesion were choline level and choline/N-acetyl aspartate ratio. There is statistically significant difference between mean of Cho/NAA in high grade glioma as it was 23.13 and low grade glioma where mean of choline/NAA was 6.21 [P value = 0.02]. Lipid and lactate peaks were more frequent in high grade tumors and lipid peak together with Choline/N-acetyl aspartate ratio could differentiate between metastasis and metastasis with delayed radiation necrosis. Alanine peak appear to be pathognomonic for meningioma. Perilesional MRS metabolites could detect actual histopathological [subclinical] extension and so differentiate between high grade and low grade tumors and between high grade tumors and metastasis

Conclusion: MRI+MRS is more sensitive than MRI alone in diagnosis, differential diagnosis, and grading of focal brain space occupying lesion. MR spectroscopy could differentiate various types of focal brain space occupying lesion with sensitivity of 92.3% while sensitivity of MRI alone was 76.9%

Microscopic versus endoscopic approach to the sellar and supprasellar space, a cadaveric study

Skull base endoscopic endorasal approaches are used more and more liberally to expose the skull base transnasally. However the surgical microscope is still used by some surgeons for sellar exposure transnasally. To provide a qualitative and quantitative anatomical evaluation of the surgical exposure and maneuverability afforded by the endoscope versus that of the surgical microscope in exploring the sellar / suprasellar areas. We used seven embalmed cadaver heads whose vascular system had been injected with colored silicon material. Sublabial trans-septal exploration of the sellar/suprasellar areas was conducted using the endoscope and then microscope. The exposure and maneuverability associated with each mode were evaluated. The endoscope exposed the sellar/superasellar compartment better than the microscope in terms of maneuverability and surgical field exposure. In our model, use of the endoscope provided a better maneuverability advantage over microscope mode in the exploration of the suprasellar compartment

Briun tumor excision guided by neuron a vigation: practical application and results

Precise preoperative craniotomy planning and intra-operative lesion localization and orientation have always been paramount issue in neurosurgery. The most important issues are the capabilities of surgical navigation system in appreciation of anatomy to avoid critical structures, arteries and veins. Furthermor, surgical planning for precise craniotomy, localization of lesion, extent of tumor resection increase the confidence of surgeon. The brain lab system [vectorvision.3, Germany] was used for guidance to 30 intra cranial operations. They were 21 male and 9 female, the mean age was [47.1], the range of age group was from 21 year to 70 year. All patients with brain tumors were diagnosed and managed in the departments of neurosurgery at Maadi Armed Forces Hospital, Cairo and Assuit University Hospital Assuit during the period may 2010 to may 2012. This study has shown reduction of surgical time, decrease blood loss during operation, decrease length of 1CU stay. Histopathological diagnosis was meningioma in 12 patients [40.0%], glioblastoma multiform in 10 patients [33.3%], astrocytoma GH in 5 patients [16.7%] and pilocystic astrocvtoma 3 patients [10.0%]. The surgical navigation system is helpful in mrgical planning for precise craniotomy, localization and orientation of the lesion, extent of the surgery reduction of surgery time and decrease in the length of 1C U stay and hospital cost

Compound depressed skull fractures overlying dural venous sinuses

The purpose of this study was to characterize the patients with compound depressed skull fractures overIying dural venous sinuses clinically and radiologically and to discuss the patients' circumstances that favour conservative or surgical treatment, in addition to the outcome. Of 192 patients with depressed skull fractures admitted to our Neurosurgical Department, Assiut University Hospital between January 2004 to December 2005, 30 patients [15.6%] with compound depressed skull fractures over a dural venous sinus were prospectively studied. There were 27 [90%] males and 3 [10%] females. Eighteen patients [60%] were paediatrics [3- 18 yrs] while 12 [40%] were adults [20-60 yrs]. Twenty-four patients had a Glasgow Coma Scale [GCS] of 14- 15/15, 3 patients had a GCS of 9- 13 and 3 patients had a GCS of <8. Aetiological falls and motor vehicle accident were predominant in the paediatric group while among adults assault and motor vehide accident were predominant. The superior sagittal sinus was the most commonly involved sinus [28 out of 30 patients = 93.3%] with anterior injuries more common than posterior ones [26 out of 28 patients = 92.9%]. Thirteen patients [43.3%] were treated conservatively and 17 [56.7%] patients were treated surgically; either initially in 15 cases due to the presence of neurological deficit, underlying haematoma, egress or escape of intracranial contents and/or deep contamination, or later on in the other 2 cases due to development of intracranial hypertension. lntraoperative difficulty was experienced in 8 [47.1%] patients. Of those treated non-operatively, 3 [23.1%] patients developed wound infection while wound infection among those treated operatively was seen in 2 [11.8%] patients. There was no mortality and the neurological deficit was reversed with the aid of physiotherapy by time and the patients returned to their daily activities. Our opinion favours conservative approach to fractures involving a dural sinus, if the wound is not contaminated, as the risk of infection is low. Surgery exposes the patient to the very real risk of massive haemorrhage. In instances where there is a clear need for surgery adequate precautions should be taken. Computed tomographic venography is a reliable tool for demonstrating early sinus compression and/or occlusion that facilitates surgical decision. However, delayed intracranial hypertension is a possible complication and should always be considered in patients with the appropriate clinical findings in the follow-up period

Compound depressed skull fractures overlying dural venous sinuses

The purpose of this study was to characterize the patients with compound depressed skull fractures overlying dural venous sinuses clinically, radiologically and to discuss the patients' circumstances that favour conservative or surgical treatment in addition to the outcome. Of 192 patients with depressed skull fractures admitted to Neurosurgical Department, Assiut University hospital between January 2004 to December 2005, Thirty patients [15.6%] with compound depressed skull fractures over a dural venous sinus were prospectively studied, They were 27 [90%] males and 3 [10%] females. Regard the age, 18 [60%] were pediatrics [3-18 yrs.] while, 12 [40%] were adults [20-60yrs.]. Twenty-four patients had a Glasgow Coma Scale [GCS] of 14-15/15, while a GCS was 9-13 and <8 in 3 patients for each. Etiologically falls and motor vehicle accident were predominant in pediatric group while, among adults assault and motor vehicle accident were predominant. The superior saggital sinus was the most commonly involved sinus [28 out of 30 patients=93.3%] with anterior injuries more common than posterior one [26 out of 28 patients = 92.9%]. Thirteen patients [43.3%] were treated conservatively and 17 [56.7%] patients were treated surgically either initially in 15 cases due to the presence of neurological deficit, underlying haematoma, egress or escape of intracranial contents and/or deep contamination or later on in 2 cases due to development of intracranial hypertension. Intraoperative difficulty was experienced in 8 [47.1%] patients. Of those treated non-operatively 3 [23.1%] patients developed wound infection, while wound infection among those treated operatively was in 2 [11.8%] patients. No mortality occured, and the neurological deficit was reversed with the aid of physiotherapy by time and the patients returned to their daily activities. Our opinion favours conservative approach to fractures involving a dural sinus if the wound is not contaminated as the risk of infection is low. Surgery exposes the patient to the very real risk of massive haemorrhage. In instances where there is a clear need for surgery adequate precautions should be taken. Delayed intracranial hypertension is a possible complication when a depressed skull fracture overlies the saggital sinus and should always be considered in patients with the appropriate clinical findings in the follow-up period