[Low-pressure] variant of idiopathic intracranial hypertension: a unique subtype of chronic daily headache

Headache, papilledema and elevated CSF pressure above 200 mm H2O [250 mm H2O in obese patients] in a patient with normal neurological examination and neuro-imaging meet the international headache society [IHS] diagnostic criteria for idiopathic intracranial hypertension [IIH]. However variants of the classic syndrome have been reported i.e apapilledimic [without papilledema] and pure ophthalmic [without headache]. The aim of this study was to investigate a series of patients with refractory chronic daily headache [CDH] without papilledema, and with borderline CSF pressure [160-200 mm H2O in non-obese patients; 160-250 mm H2O in obese patients] to highlight their clinical, and neuroimaging findings. Twenty five cases with refractory chronic daily headache [CDH] who presented at the neurosurgery and neurology outpatient clinics were included in the study. All patients were evaluated clinically and radiologically and CSF manometry was recorded. All patients had unclassified chronic daily headache, visual field defects, a partial empty sella on imaging studies and borderline CSF pressure [160-200 mm H20 in non-obese patients; 160-250 mm H2O in obese patients]-. The majority of patients showed headache improvement after treatment with medications that lower intracranial pressure in combination with their conventional headache therapy regimens. The constellation of chronic daily headache, field defects, a partial empty sella and borderline CSF pressure in a patient with normal neurologic examination may constitute a [low-pressure] variant of idiopathic intracranial hypertension

Surgery for cervical spondylotic myelopathy: anterior versus posterior approaches

Surgical treatment of cervical spondylotic myelopathy [CSM] remains controversial. Several approaches have been advocated to treat cervical spondylotic myelopathy including anterior, posterior and combined approaches. The aim of this study was to review the clinical and imaging varieties of cervical spondylotic myelopathy and their influence on choosing the appropriate surgical approach. Fifty five cases with cervical spondylotic myelopathy operated upon at the neurosurgery department, Alexandria University were reviewed. The different clinical and imaging features were analyzed, and parameters for choice of surgical approach were addressed. Among all patients with CSM, neck pain was present in 49%, brachialgia in 67%, mild myelopathy in 44% and moderate myelopathy in 56%. Following cervical laminectomy, neck pain improved in 50% and remained stationary in 50%; brachialgia recovered in 33%, improved in 50% and remained stationary in 17%; mild myelopathy showed good outcome in 80% and fair outcome in 20%; whereas moderate myelopathy showed good outcome in 20%, fair outcome in 60% and poor outcome in 20%. Following anterior discectomy with fusion, neck pain recovered in 28.5%, improved in 38% and remained stationary in 28.5%; brachialgia recovered in 58.5%, improved in 31% and remained stationary in 10.5%; mild myelopathy showed excellent outcome in 17%, good outcome in 58% and fair outcome in 25%; whereas moderate myelopathy showed good outcome in 35%, fair outcome in 30% and poor outcome in 35%. Following cervical laminoplasty, neck pain improved in 100%; brachialgia remained stationary in 100%; mild myelopathy showed good outcome in 100%; whereas moderate myelopathy showed fair outcome in 50% and poor outcome in 50%. Early surgical intervention for CSM is associated with higher recovery rate. Selection of surgical approach depends on age, cord morphology, and spine geometry mostly spinal curve and canal diameter. The presense of cervical spine instability necessitates complementation of spine decompression with spine fixation

Endoscopic removal of third ventricular colloid cysts in non dilated ventricles

Colloid cysts are benign conditions forming not more than 1% of all intracranial neoplasm. The natural history of colloid cysts is not fully understood and the presenting manifestations are usually non specific. Many treatment options have been established for treating colloid cysts, the most recent of them is the endoscopic removal Although small or non dilated ventricles add difficulty to the procedure, yet it is not an obstacle against safe and complete resection. Between 2004 and 2007 we have operated on 10 cases of colloid cysts with non dilated ventricles [average or small sized]. Eight cases were females and two were males. The age ranged between 18 and 43 years. Headache was the outstanding symptom and occurred in all patients. Two patients suffered short term memory deficit. We used the Gaab endoscopic system with an outer sheath diameter of 6.5mm. We used neither neuronavigation nor stereotactic guidance. Follow up period ranged from 35 to 2 monthes. we were able to achieve total cyst removal in all cases. Mild transient short term memory deficit occurred in I patient. There was no mortality. Taping and working inside dilated ventricles are easier than that in smaller ones, however average or even small ventricles are not a contraindication against endoscopic colloid cyst removal even in the absence of neuronavigation and stereotaxy. Still the endoscope in small ventricles can be used safely, effectively with shorter operative period and shorter hospital stay when compared to the traditional operative techniques

Conservative versus surgical management of hypertensive putaminal hemorrhage

Hypertensive putaminal hemorrhage is the most common type of intraparenchymal cerebral hemorrhage, yet the therapeutic policy is still controversial. The aim of this work was to analyze clinical and imaging data of patients with hypertensive putaminal hemorrhage and identify selection criteria for appropriate treatment. Thirty cases with hypertensive putaminal hemorrhage admitted to the neurosurgical emergency unit, Alexandria University were included in the study. All patients were evaluated clinically and using imaging studies. Analysis of data was conducted and parameters suggestive of therapeutic modality were identified. Patients with hypertensive putaminal hemorrhage had acute onset in 86.7% and subacute onset in 13.3%. The clinical course was progressive in 33.3%, regressive in 20%, and stationary in 46.7%. Putaminal hematomas were focal in 6.7%, insular in 13.3%, ruptured in 26.7%, dissecting in 26.7%, and massive in 26.7%. The ipsilateral lateral ventricle was patent in 6.7%, effaced in 40%, obliterated in 26.7%, obstructed in 6.7%, and occluded in 20%. Midline structures were central in 33.3%, mild shift in 33.3%, moderate shift in 13.3%, and severe shift in 20%. Associated brain stem hemorrhage was present in 13.3%. Hypertensive putaminal hematomas have different clinical and imaging presentations. Indications for surgical evacuation include; progressive clinical course, moderate [5-10 mm] and severe [>10 mm] midline shift, as well as dissecting and massive hematomas. Predictors for bad outcome include; old age, major brain attack, massive hematoma, occluded ipsilateral lateral venticle, severe midline shift [>10 mm] and associated brain stem hemorrhage