Unusual vascular anatomical variant leads to spontaneous hemorrhage in a cavum septum pellucidum in an adolescent: A case report and literature review.

Background: Hemorrhagic lesions of the septum pellucidum are rare and usually occur in neonates. They can be due to a number of etiologies. Here, we report a rare case of adolescent nontraumatic septum pellucidum hemorrhage with a review of literature. Case Description: A 16-year-old girl presented with a 1-month history of gradual visual deterioration in the left eye, intermittent headache, and vomiting. Brain imaging showed hematoma located between the leaflets of the septum pellucidum with obstructive hydrocephalus. Transcallosal resection of interventricular mass was done. The patient was discharged with improved neurological symptoms; however, the left eye vision did not recover. Imaging demonstrated a unique anatomical variant in deep vascular structures. Conclusion: Cavum septum pellucidum hemorrhage is rare in adults. Many theories were constructed to explain its etiology. Bleeding due a vascular anatomical variant was not previously encountered. Understanding the embryological origin and anatomical details are important for proper clinical assessment and management of these patients.

Effect of cranioplasty timing on the functional neurological outcome and postoperative complications.

BACKGROUND: The optimal timing for performing cranioplasty and its effect on functional outcome remains debatable. Multiple confounding factors may come into role; including the material used, surgical technique, cognitive assessment tools, and the overall complications. The aim of this study is to assess the neurological outcome and postoperative complications in patients who underwent early versus late cranioplasty. METHODS: A retrospective cohort study was conducted to investigate the neurological outcome and postoperative complications in patients who underwent cranioplasty between 2005 and 2018 at a Level l trauma center. Early and late cranioplasties were defined as surgeries performed within and more than 90 days of decompressive craniectomy, respectively. The Glasgow Outcome Score (GOS) and modified Rankin scale (mRS), recorded within 1 week of cranioplasty, were used to assess the neurological outcome. RESULTS: A total of 101 cases of cranioplasty were included in the study. The mean age of the patients was 31.4 ± 13.9 years. Most patients (n = 86; 85.1%) were male. The mean GOS for all patients was 4.0 ± 1.0. The mean mRS was 2.2 ± 1.78. Hydrocephalus was noted in 18 patients (early, n = 6; late, n = 12; P = 0.48). Seizures developed in 28 patients (early, n = 12; late, n = 16; P = 0.77). CONCLUSION: The neurological outcome in patients who underwent early versus late cranioplasty is almost identical. The differences in the rates of overall postoperative complications between early versus late cranioplasty were statistically insignificant. The optimal timing for performing cranioplasty is mainly dependent on the resolution of cerebral swelling.

Efficacy of routine post-operative head computed tomography on cranial surgery patients outcome.

OBJECTIVE: To identify the role of routine postoperative head CT in changing postoperative management after elective craniotomies. METHODS: We conducted a retrospective study on adult patients who underwent cranial surgery. Exclusion criteria includes cranial CTs done postoperatively for urgent clinical indications, pediatric patients, CSF diversion procedures and sedated patients. Patients were placed into "positive" group if the physical assessment changed from the baseline in the form of clinical deterioration, and the "negative" group if the exam did not change. The data then were analyzed to identify which patients needed further medical or surgical management based on CT findings only with "negative" physical examination. RESULTS: Total of 222 were included in the study. 151 patients had negative physical examination. Only 8 out of 151 patients had positive CT findings. Two patients out of 222 (0.9%) had a negative physical exam and positive CT findings that required additional action that wouldn`t be done urgently without routine postoperative brain CT. Only one patient out of 222 (0.4%) who was re-operated urgently based CT findings only and negative physical examination. CONCLUSION: Routine postoperative routine brain CT did not alter the course of medical management, even in the presence of significant radiological findings.

The incidence of odontoid fractures following trauma in a major trauma center, a retrospective study.

BACKGROUND: Cervical spine injury is the most common vertebral injury after major trauma, 20% of all cervical fractures happen to be odontoid fractures. In young adults, odontoid fracture usually happens as a result of high-energy trauma after a motor vehicle accident (MVA). MVA in Riyadh represents 38.4% of all trauma cases, in which the head-and-neck are the most injured body parts. This research aims to provide information about the incidence of odontoid process fracture post-MVA in Riyadh, Saudi Arabia. METHODS: The design of this study was retrospective. A single level one trauma center database (trauma registry) was used to identify odontoid fractures post-MVA. All trauma cases from 2008 to the most recent were included, a total of 17,047 patients, to identify cervical spine fractures and further identify odontoid fracture incidence. The patients' radiographs were reviewed retrospectively, and odontoid fractures were classified by a board-certified spine surgeon. A descriptive analysis was carried out to report basic data distribution. Pearson's correlation was carried out to assess associations. RESULTS: A total number of cervical spine fracture was 1195 patients (6.6% of the total sample). The incidence of odontoid fractures during the entire study period from 2008 to 2018 was 42 of 480 patients with C2 cervical trauma, constituting 8.75% C2 fractures, and 3.5% of cervical spine fractures. The mean age was 41.75 ± 18 years. There were three patients (onemale, two females) with type I odontoid fracture, 26 (all males) with type II, and 13 (11 males, 2 females) with type III. Most patients were managed conservatively (83.33%), whereas 16.67% underwent surgical management. CONCLUSION: The incidence of posttraumatic odontoid fractures is low, given the younger population of this study. This does not predict future incidence rates with the continued improvement of road traffic laws and awareness in the population.

One-year postoperative mortality rate among the elderly with hip fractures at a single tertiary care center.

BACKGROUND: Hip fractures are one of the leading causes of disability and dependency among the elderly. The rate of hip fractures has been progressively increasing due to the continuing increase in average life expectancy. Surgical intervention is the mainstay of treatment, but with an increasing prevalence of comorbid conditions and decreased functional capacity in elderly patients, more patients are prone to postoperative complications. OBJECTIVES: Assess the value of surgical intervention for hip fractures among the elderly by quantifying the 1-year mortality rate and assessing factors associated with mortality. DESIGN: Medical record review. SETTING: Tertiary care center. PATIENTS AND METHODS: All patients 60 years o age or older who sustained a hip fracture between the period of 2008 to 2018 in a single tertiary healthcare center. Data was obtained from case files, using both electronic and paper files. MAIN OUTCOME MEASURES: The 1-year mortality rate for hip fracture, postoperative complications and factors associated with mortality. SAMPLE SIZE: 802 patients. RESULTS: The majority of patients underwent surgical intervention (93%). Intra- and postoperative complications were 3% and 16%, respectively. Four percent of the sample died within 30 days, and 11% died within one year. In a multivariate analysis, an increased risk of 1-year mortality was associated with neck of femur fractures and postoperative complications (P=.034, <.001, respectively) CONCLUSION: The 1-year mortality risk in our study reinforces the importance of aggressive surgical intervention for hip fractures. LIMITATION: Single-centered study. CONFLICT OF INTEREST: None.

Tension Pneumoventricle Secondary to Cutaneous-Ventricular Fistula: Case Report and Literature Review.

BACKGROUND: Tension pneumoventricle (TPV) is a subtype of tension pneumocephalus in which the air is trapped inside the ventricles through a one-way osteodural defect, causing an increase in intracranial pressure. TPV secondary to cutaneous-ventricular fistula has been reported only twice in the literature. CASE DESCRIPTION: Herein, we report the third case in a 53-year-old woman who developed TPV with decreased level of consciousness after removal of a posterior fossa meningioma while she was on external ventricular drainage. There was no identifiable bony defect on neuroimaging. The drain was changed urgently, and the fistula located at the drain tunneling site was sealed. CONCLUSIONS: This case report highlights the importance of suspecting and treating cutaneous-ventricular fistulas in TPV urgently in patients without skull base defects or those who showed no improvements with external ventricular drainage.

Cranioplasty: A Comprehensive Review of the History, Materials, Surgical Aspects, and Complications.

Cranioplasty is a common neurosurgical procedure performed to reconstruct cranial defects. The materials used to replace bone defects have evolved throughout history. Cranioplasty materials can be broadly divided into biological and synthetic materials. Biological materials can be further subdivided into autologous grafts, allografts, and xenografts. Allografts (bony materials and cartilage from cadavers) and xenografts (bony materials from animals) are out of favor for use in cranioplasty because of their high rates of infection, resorption, and rejection. In autologous cranioplasty, either the cranial bone itself or bones from other parts of the body of the patient are used. Synthetic bone grafts have reduced the operation time and led to better cosmetic results because of the advancement of computer-based customization and three-dimensional printing. Aluminum was the first synthetic bone graft material used, but it was found to irritate neural tissue, induce seizures, and dissolve over time. Acrylic, in the form of methyl methacrylate, is the most widely used material in cranioplasty. Hydroxyapatite is a natural component of bone and is believed to enhance bone repair, resulting in decreased tissue reactions and promoting good osteointegration. Polyetheretherketones are light and nonconductive and do not interfere with imaging modalities. The complication rates of cranioplasty are high, and surgical site infection is the most common complication. The effect of cranioplasty timing on cognitive function remains debatable. However, the timing of cranioplasty is independent of neurologic outcomes. In this article, the history, materials, complications, and evolution of current practices used in cranioplasty are comprehensively reviewed.

Sinus Pericranii Complicated by Hydrocephalus: Case Report and Literature Review.

BACKGROUND: Sinus pericranii (SP) is a rare vascular condition that results when abnormal communication between the intracranial and extracranial venous systems is present. Here we report a rare case of hydrocephalus revealed through a SP scalp mass with a review of literature. CASE DESCRIPTION: A 13-year-old girl presented with a history of bulging left eye, bilateral gradual deterioration of vision, nausea, and progressive headaches. The family reported the sudden appearance of a scalp mass prior to these symptoms. Brain imaging showed supra- and infratentorial communicating hydrocephalus and subcutaneous vascular collaterals from the midportion of the superior sagittal sinus. After ventriculoperitoneal shunt insertion, interval reduction of the ventricular size and disappearance of extracranial veins without associated intra- or extracranial vascular anomalies was observed. CONCLUSIONS: SP is divided into two main types: (1) Spontaneous type, in which lesions are formed due to acquired causes without a syndromic association or other vascular anomalies or stenosis. The most commonly reported cause is trauma in which SP may develop at the trauma site rather than the midline. (2) Congenital type, in which case the most commonly reported association is craniosynostosis. It can also be seen with vein of Galen hypoplasia, vein of Galen malformations, dural sinus malformations, solitary developmental venous anomalies, and intraosseous arteriovenous malformations. We are reporting the first case of idiopathic SP with hydrocephalus without a congenital association or acquired cause, including trauma. The sudden change in SP size can indicate a change in intracranial pressure and the development of hydrocephalus.

Infantile atypical subependymal giant cell astrocytoma.

Subependymal giant cell astrocytoma is a benign WHO grade I intraventricular tumor arise in patients with tuberous sclerosis complex. Previous reported described histopathological predictors of more aggressive forms, terms atypical SEGA in infantile age group. Other reports showed possible transformation of SEGA into glioblastoma, or misdiagnosis as glioblastoma due to the presence of atypical histopathological features. Here, we report a case of an infant who presented with right frontal extraventricular SEGA and underwent craniotomy with complete resection. Eight months later, he presented with fast recurrence in same location with midline shift and subfalcine herniation. Histopathological description showed high grade features including Ki labeling index of 60%, atypical mitotic figures, cellular plemorphism and necrosis. We also discussed the possible presence of different entity (termed atypical SEGA) which may have more aggressive clinical course, with literature review of predictors of SEGA aggressiveness and possible transformation/misdiagnosis as glioblastoma.

Angiocentric glioma of brainstem.

Angiocentric glioma is a rare brain tumor commonly found in frontal or temporal lobes. It has a benign course, and surgical resection can be curative. Brainstem location is extremely rare, with only six cases reported so far in the literature. In the present study, the seventh case of brainstem angiocentric glioma has been reported, and its course in comparison with supratentorial location and the role of molecular diagnosis has been discussed.

Spinal Pilomyxoid Astrocytoma.

Pilomyxoid astrocytoma (PMA) is a rare brain tumour generally located in the chiasmatic-hypothalamic region. In comparison to pilocytic astrocytoma, PMA has distinct histopathological features, aggressive clinical behaviour, a high recurrence rate, and early cerebrospinal fluid dissemination. Only 14 cases of PMA have been reported in the spinal cord since its pathological description in 1999. Here, we report the 15th case in a 3-year-old girl who was treated with chemoradiotherapy and followed up for 5 years. In this report, we also present a review of spinal PMA including treatment options and prognosis.

Burnout during ophthalmology residency training: A national survey in Saudi Arabia.

PURPOSE: The aim of this study is to identify burnout prevalence among ophthalmology residents and the predisposing factors associated with higher levels of burnout. METHODS: A cross-sectional study was conducted on all ophthalmology residents in Saudi Arabia using Maslach Burnout Inventory in January 2018. Associations between Emotional Exhaustion scores and other continuous variables were evaluated using Spearman's correlation coefficients. Logistic regression model was constructed, and results were reported as odds ratios with 95% confidence intervals. The significance level was set at p < 0.05. RESULTS: A total of 117 residents responded to the survey with a 70% response rate. The response rate was above 65% for each training programs by region. 41% of ophthalmology residents scored a positive burnout result on the common subscales (Emotional Exhaustion and/or Depersonalization). Further sub-analysis of data showed positive Spearman's correlation with number of call days per month and EE subscale (r 0.195). Multivariate logistic regression of the sample yielded significant results with satisfaction with work/life balance and choosing medicine again as a graduate level major p ≤ 0.05. The regression model also showed the Southern program had significantly higher burnout on the common subscales p ≤ 0.05. CONCLUSIONS: Prevalence of burnout among ophthalmology residents was lower when compared to plastic surgery and otolaryngology residents in Saudi Arabia. Work hours and on call days were associated with higher burnout. Actions must be taken to ensure that all training programs implement work hour limitations. Special attention should be given to the Southern region program due to its significantly higher levels of burnout.

Pretruncal Nonaneurysmal Subarachnoid Hemorrhage with Underlying Hemophilia C.

BACKGROUND: Pretruncal nonaneurysmal subarachnoid hemorrhage (PNSAH) accounts for 15%-12% of all case of subarachnoid hemorrhage. Its precise etiology is not yet established. Multiple theories and risk factors have been investigated to address the possible cause of this type of hemorrhage including basilar tip dissecting aneurysms, high spinal arteriovenous fistula, venous stenosis/hypertension or venous bleeding. Hereditary coagulopathies and hemophilias have rarely been reported in the literature as a potential cause of PNSAH. CASE DESCRIPTION: Here, we reported a rare case of PNSAH with negative angiogram and magnetic resonance imaging who was also found to have hemophilia C (factor XI deficiency) confirmed by laboratory investigation. We also included a literature review of hereditary coagulopathies and their role as a possible cause of PNSAH. CONCLUSIONS: Detailed medical history and physical examination of patients with PNSAH may lead to further hematologic evaluation for this group of patients, as in this case, and may reveal more cases of mild coagulopathy that require treatment.

Supratentorial Craniotomies with or without Dural Closure-A Comparison.

BACKGROUND: Dural closure is a routine surgical step in neurosurgery. The benefit of suturing the dura to achieve watertight closure-with or without the use of dural substitutes-has been questioned in supratentorial craniotomy. We performed a retrospective study to examine the possible benefits and harms of suturing the dura compared with no dural closure and the occurrence of postoperative infection, cerebrospinal fluid (CSF) leak, and postcraniotomy headaches. METHODS: We performed a retrospective study to compare the incidence of CSF leak, infection, surgical site swelling, and postcraniotomy headaches between patients with watertight dural closure (closed group) and patients without watertight dural closure (open group). Any method used to close the dura and to achieve watertight closure was included, whether primary or secondary closure (with or without using suturable dural substitute). RESULTS: Overall, 216 patients were included in the present study, with 112 patients in the open group and 114 in the closed group. The open group experienced a greater incidence of infection and CSF leak (6 in the open group vs. 2 in the closed group), but without statistical significance (P = 0.15). We found no difference in surgical site swelling (P = 0.29). However, the closed group showed a greater association with the development of postcraniotomy headaches (P = 0.001). CONCLUSION: We found no difference in the occurrence of CSF leak, infection, or surgical site swelling between the closed and open groups. The incidence of postcraniotomy headaches was greater in the closed group, and the difference was statistically significant.

Canalis basalis medianus with cerebrospinal fluid leak: rare presentation and literature review.

Canalis Basalis Medianus is a rare congenital normal anatomically variant of the clivus .We report a very rare case of cerebrospinal fluid leak from a canalis basilaris medianus in a 22-year-old male, who presented to our hospital with frontal headache and running nose two weeks after an elective septoplasty.

Lhermitte-Duclos Disease with Cervical Arteriovenous Fistula.

Lhermitte-Duclos disease is a rare condition with less than 250 cases reported in the literature. It was considered a neoplastic or hamartomatous growth in the cerebellum. It commonly presents with symptoms of high intracranial pressure or obstructive hydrocephalus. Surgical resection is often curative. The lesion is associated with PTEN gene mutation, and it is considered to be one of the diagnostic criteria of Cowden's syndrome. Vascular tumors are reported in this syndrome, including glioblastomas and meningiomas. Furthermore, central nervous system vascular lesions were also reported in Lhermitte-Duclos disease, such as deep venous anomalies and brain arteriovenous fistulas. A report of an asymptomatic spinal cervical AVF in a patient with Lhermitte-Duclos disease was published in 2006. We present the second case of Lhermitte-Duclos disease associated with an asymptomatic spinal cervical AVF in a 17-year-old young woman with literature review of central nervous system vascular lesions in Lhermitte-Duclos disease.

Prevention of recurrence post leptomeningeal cyst repair.

Leptomeningeal cysts, which are cystic collections filled with cerebrospinal fluid, are rare complications following pediatric head trauma and surgical correction of craniosynostosis. These cysts develop due to cerebrospinal fluid pulsations and brain growth that cause expansion of the dural tears. Although primary repair of the dural defect is the definitive treatment, the risk of cyst recurrence remains. Factors that increase this risk include syndromic craniosynostosis, hydrocephalus, increased intracranial pressure, and inadequate duraplasty/cranioplasty. Here, we report the successful treatment of a child with a complex leptomeningeal cyst on one hemisphere, Crouzon syndrome, and hydrocephalus who showed no cyst recurrence over 2 years of follow-up. We have also reviewed the literature for predictors of post-repair cyst recurrence and preventive surgical techniques in patients with high risk of recurrence.

Minimally Invasive Brain Port Approach for Accessing Deep-Seated Lesions Using Simple Syringe.

BACKGROUND: Retraction-related injury is a recognized complication in neurosurgery. Use of tubular retractors that distribute the pressure on brain tissue was introduced to minimize brain injury. We developed a modified technique using a simple plastic syringe with a Foley catheter to achieve atraumatic cannulation in accessing deep lesions. METHODS: A retrospective pilot study was conducted to assess safety of the syringe transtubular technique for accessing deep lesions as a cost-effective substitute for commercial brain port methods and to identify retraction-related injury using diffusion-weighted magnetic resonance imaging postoperatively. Nine patients were operated on using the syringe technique. Lesions selected were intraparenchymal, deeply located in the supratentorial compartment. Lesions were located in the insula (n = 2), thalamus or basal ganglia (n = 5), subcortical frontoparietal (n = 1) lobe, and right temporal lobe (n = 1). Patients with hematomas, intraventricular lesions, superficially located lesions; pediatric patients less than 12 years old; and patients undergoing redo surgeries were excluded. RESULTS: Surgical goals were achieved in 8 patients. Three patients had transient deficits; one patient had significant morbidity, which was diagnosed postoperatively as toxoplasmosis. Diffusion restriction was noted in all patients at the surgical cavity but not in the cannulation path. CONCLUSIONS: Transtubular approaches have a good safety profile and can help achieve surgical goals. Larger studies are needed to compare this approach with other methods, including its effect on hospital stay and survival. The syringe technique is an alternative safe method that can be used in certain neurosurgical centers where commercial tube systems are unavailable.

Medical students' logbook case loads do not predict final exam scores in surgery clerkship.

Purpose: To investigate the reliability of medical student logbook data in assessing student performance and predicting outcomes in an objective standardized clinical exam and a multiplechoice exam during surgery rotation. In addition, we examined the relationship between exam performance and the number of clinical tutors per student. Materials and methods: A retrospective review of the logbooks of first and third clinical year medical students at the Faculty of Medicine, Kuwait University, was undertaken during their surgery rotation during the academic year 2012-2013. Results: Logbooks of 184 students were reviewed and analyzed. There were 92 and 93 students in the first and third clinical years, respectively. We did not identify any correlation between the number of clinical encounters and clinical exam or multiple-choice exam scores; however, there was an inverse relationship between the number of clinical tutors encountered during a rotation and clinical exam scores. Conclusion: Overall, there was no correlation between the volume of self-reported clinical encounters and exam scores. Furthermore, an inverse correlation between the number of clinical tutors encountered and clinical exam scores was detected. These findings indicate a need for reevaluation of the way logbook data are entered and used as an assessment tool.