"Brain Biopsy Revolution: Unveiling the Core Syringe Technique with Clinical Insights".

OBJECTIVES: Obtaining a definitive pathological diagnosis from brain tissue sampling was challenging due to the small, non-representative sample. This study introduced a novel syringe technique for brain biopsy aimed at enhancing diagnostic accuracy by obtaining core tissue samples that better represent the targeted tissue. METHODS: The ten patients with atypical brain lesions underwent the syringe biopsy. After meticulous preoperative planning with neuronavigation, a minimally invasive approach was used: a 3 cm skin incision and a 14 mm burr hole were created. A modified 3-cc syringe was used to create negative pressure and cannulate the brain tissue. The desired sample size (24 cm³) was obtained by controlling the syringe depth and withdrawal. Medical records were reviewed to assess sample analysis results and any complications RESULTS: The syringe technique successfully yielded adequate tissue samples in 9 out of 10 patients. In one case, the desired tissue could not be retrieved and required a microsurgical approach for removal. In all ten cases, a correct diagnosis was made without significant complications. CONCLUSION: The preliminary findings suggest that the syringe technique is both safe and effective for obtaining substantial volumes of brain tissue, facilitating accurate pathological evaluation in cases of complex neurological disorders.

Multifocal malignant peripheral nerve sheath tumor in patients with neurofibromatosis type I: Report of two cases and review of literature.

Background: Malignant peripheral nerve sheath tumors (MPNSTs) are one of the rarest soft-tissue sarcomas with a prevalence of 0.001% in the general population. It is closely associated with a unique neurocutaneous stigmata under the spectrum of the dermatological manifestations of neurofibromatosis type 1 (NF1). Almost 81% of MPNST arises from a precursor neuroma, and multifocality of these lesions is extremely rare, making up to 0.001% of cases. Moreover, spinal cases are extremely uncommon with only four cases reported internationally. Here, we present the fifth and sixth spinal MPNST cases with a brief review of literature. Case Description: We describe two unusual cases of multifocal MPNST in relation to NF1 occurring in the spinal cord. Both patients presented with local pain and myelopathic symptoms. The two patients underwent wide surgical resection, followed by neoadjuvant radiotherapy and reported immediate postoperative improvement of the presented complaint; however, one patient suffered from rapid recurrence and metastasis. Conclusion: Due to the scarcity of spinal cases related to MPNST, no clear guidelines regarding the management of these cases are set in the literature. Histopathological diagnosis remains as the most pivotal diagnostic tool as they can mimic other peripheral nerve sheath lesions, such as neuromas and schwannomas, in imaging. Cases that were managed by early surgical intervention in addition to neoadjuvant radiotherapy reported the best outcome. However, cases of MPNST in concomitance with NF1 were found to be resistant to both chemo and radiotherapy and have high recurrence rate.

Extensive cerebral venous thrombosis after resection of third ventricle colloid cyst.

Background: The third ventricle colloid cyst (CC) is a benign growth usually located in the third ventricle and can cause various neurological symptoms, including sudden death. Modern surgical interventions may still result in a wide range of complications and cerebral venous thrombosis (CVT) is among them. Case Description: A 38-year-old female with an existing diagnosis of diabetes mellitus (DM) and hypothyroidism and a 6-month history of headaches, blurred vision, and vomiting presented to our clinic 3 days after the headaches became excessively severe. Neurological examination on admission revealed bilateral papilledema without any associated focal neurological deficits. Brain computed tomography and magnetic resonance imaging confirmed the presence of a third ventricle CC and associated non-communicating hydrocephalus involving the lateral ventricles. As a result, the patient underwent emergency bilateral external ventricular drainage (EVD) insertion followed by a third ventricular CC excision under neuronavigation through a right frontal craniotomy. Twelve days postoperatively, the patient developed further headaches followed by a generalized tonic-clonic seizure that led to no postictal neurological deficits. Nonetheless, computed tomography venography of the brain revealed extensive thrombosis of the superior sagittal sinus, inferior sagittal sinus, right sigmoid sinus, and right internal jugular vein. A newly diagnosed CVT was treated with intravenous heparin. The patient was discharged with warfarin, which was discontinued after 12 months. Ten years after her illness, she remained stable and free from any neurological deficits but still suffered from chronic mild headaches. Conclusion: A preoperative venous study should be performed in all cases to gain a better understanding of the venous anatomy. We advocate meticulous microsurgical techniques to protect the venous system surrounding the foramen of Monro and reduce the amount of retraction during surgery.

Ipsilateral weakness caused by ipsilateral stroke: A case series.

INTRODUCTION: There are few reported cases of ipsilateral weakness following ischemic or hemorrhagic stroke. In these rare cases, ipsilateral weakness is typically the result of damage to uncrossed components of the corticospinal tract (CST) which were recruited in response to previous CST injury. PATIENTS AND METHODS: We report a series of six cases of acute ipsilateral weakness or numbness following a hemorrhagic or ischemic stroke from three medical institutions in Saudi Arabia. RESULTS: Three of these patients presented with right-sided weakness caused by an ipsilateral right hemispheric stroke, while two exhibited left-sided symptoms and one had only left-sided numbness. In all six cases, the ipsilateral corona radiata, internal capsule, basal ganglia, insula, and thalamus were involved. No concomitant opposite hemisphere or brainstem lesion in none of the patients was evident. Two patients had previous strokes affecting the brainstem and left corona radiata, respectively. Complete stroke workup to reveal the cause of stroke was carried out, however no functional MRI was performed. CONCLUSION: Ischemic or hemorrhagic stroke may indeed result in ipsilateral weakness or numbness, though in very rare cases. We assume that the most likely mechanism of their ipsilateral weakness subsequent to the ipsilateral stroke was a functional reorganization favoring CST pathways within the ipsilateral hemisphere.

Bibliometric analysis of the top 100 most-cited articles in neurofibromatosis.

Background: Neurofibromatosis (NF) is an umbrella term that refers to three distinct disease entities: NF Type 1, Type 2, and schwannomatosis. Here, we reviewed the scientific performance and the most influential publications on NF. Methods: A keyword-based search was performed using the Scopus database. The top 100 articles were grouped based on NF types and the studied entities. The differences between the articles, authors, and journals were quantified based on certain parameters. Other parameters were collected for the complete citational analysis. Results: The top 100 articles were published between 1961 and 2020. The most trending period of research was in the 1990s and articles studying the clinical aspect and the underlying genetic correlation made up 84% of all articles from the list. The United States of America (USA) had the highest number of contributions (69 articles, 69%). The top institute of contribution to the list was the Howard Hughes Medical Institute, USA (14 articles, 14%). Author-based analysis reveals that the neurologist D. H. Gutmann from St. Louis Children's Hospital, USA, was the most active and authored 11 articles (11%) on the list. Conclusion: The publication trends show that articles studying medical and surgical management were of little interest. The top 100 articles did not include any randomized control trials, and the highest level of evidence was obtained from reviews of pooled knowledge as well as population-based and longitudinal studies.

Bibliometric overview of the Top 100 most cited articles on hydrocephalus.

Background: Hydrocephalus is one of the most common brain disorders and numerous articles were published to address the clinical aspect and its management. This study aims to highlight the most influential work on hydrocephalus on bibliometric basis. Methods: A thorough search of Scopus database was performed using the word "hydrocephalus." The 100 most cited articles were retrieved, and variables of importance were collected including the article's title, 1st author affiliation, country of origin, year and journal of publication, article's category, and citation count according to Scopus and Google scholar databases. Results: The 100 most cited articles were thoroughly analyzed. Publication dates ranged from 1946 to 2014, with most articles (45) published between 1998 and 2007. The mean number of citations per publication was 201 with total of 20,177 citations. The United States of America contributed half of the articles. The leading institution was the Canadian hospital for Sick Children University of Toronto having published 5 articles. Hydrocephalus in general and normal pressure hydrocephalus was the two major categories addressed with most studies fall under the topic of surgical management. Neurosurgery was the specialty with the greatest contribution (47%). The articles were published in 46 different journals led by the Journal of Neurosurgery with total of 17 articles. Conclusion: This bibliometric analysis delineates the landmark publications in hydrocephalus. The listed articles depict the myriad of studied aspects historically which helps in understanding hydrocephalus overall in evidence-based module for neurosurgeons and non-neurosurgeons.

A Bibliometric Analysis of the Most-Cited Articles on Craniospinal Epidural Hematoma.

AIM: To analyze the most-cited articles on cranial and spinal epidural hematomas (EDHs). MATERIAL AND METHODS: A title-specific search was performed on the Scopus database using the term ?epidural hematoma? in June 2020, with no publication date restrictions. The top 100 most-cited articles were collected, reviewed, and analyzed. RESULTS: A total of 2165 articles were published on EDH from 1949 to 2020, and the top 100 most-cited ones were published between 1966 and 2014, receiving an average citation of 84.7 per paper. Most papers were published in Neurosurgery and Journal of Neurosurgery (JNS). 48% of the most-cited articles on EDH originated from the United States of America (USA). Notably, studies on spinal EDH represented 75% of the most-cited articles in our review. The most-cited article on EDH was published by Lawton et al. in 1995, receiving a total of 412 citations at an annual citation rate of 16.4%. CONCLUSION: This report identifies the most influential publications on EDH as well as the publications trends over the last 70 years. Recognition of the most impactful work is an important tool for clinicians and researchers as it can reflect the enormous changes in the clinical practice. This report can serve as a guide for developing evidence-based practices and identifying areas of research inadequacy.

The efficacy of wrapping the neurorrhaphy site utilizing dura substitute: A case series.

BACKGROUND: Different procedures have been developed to improve the surgical outcome of peripheral nerve injuries. The purpose of this study was to evaluate the efficacy of wrapping the neurorrhaphy site utilizing dura substitute graft as an alternative conduit in the management of peripheral nerve injury. METHODS: This retrospective clinical case series included 42 patients with a single peripheral nerve injury. The mean age was 26.8 ± 11 years, and the mean duration of symptoms was 3 ± 1.8 months. The visual analogue score (VAS) for pain and the Medical Research Council's (MRC) grading for motor power were used to evaluate the functional outcome among our patients. All patients were operated on for primary microscopic end-to-end repair, followed by wrapping the neurorrhaphy site with dura substitute graft as a conduit. Patients were followed in the outpatient clinic with regular visits for average of 6 months. RESULTS: Thirty-seven patients (83%), showed functional improvement in all aspects, the VAS for pain and the MRC for motor power, as well as the functional state. One patient (2.3%) developed a postoperative hematoma collection, which needed immediate evacuation. Superficial wound infection, reported in two patients (4.7%), was treated conservatively. No postoperative neuroma was observed among our patients during the follow-up period. CONCLUSION: Wrapping the neurorrhaphy site utilizing dura substitute as conduit appears to be safe and might prove effective in managing peripheral nerve injury.

An Unusual Case of EBV-Negative Primary CNS Lymphoma of Natural Killer/T-Cell Lineage.

Extranodal NK/T-cell lymphoma (ENKTL) is a well-defined cytotoxic lymphoma strongly associated with Epstein-Barr virus (EBV) infection, commonly affecting the nasopharynx and upper aerodigestive tract. Primary central nervous system (CNS) involvement is rare, and only 17 cases were previously reported in the literature. Here, we report the case of a 44-year-old male admitted with a 3-month history of personality changes and progressive right leg weakness. Brain magnetic resonance imaging studies (MRIs) revealed multiple rim-enhancing brain lesions bilaterally. An extensive clinical and laboratory workup was unrevealing, and 2 brain biopsies were initially considered inconclusive. Pertinently, no systemic lymphoproliferative disorder was identified. The patient initially experienced remarkable clinical improvement with dexamethasone, pulse methylprednisolone, and rituximab therapy. However, he eventually had rapid clinical deterioration, was found to have increased brain lesions, and died nearly 6 months after the initial presentation. During this time, the second brain biopsy was found to show involvement by T-cell lymphoma of NK-cell lineage, which was EBV negative. No post-mortem examination was done to identify any systemic lymphoma. This case serves to expand the spectrum of lymphomas involving the CNS.

Medial Extension of Medial Sphenoid Wing Meningioma from the Anterior Clinoid Line: Does It Truly Affect the Surgical Outcome?

Background Medial sphenoid wing meningiomas (MSWMs) account for approximately 20% of all meningiomas that are known for their critical relation to neurovasculture structures. Objective The purpose of this study is to examine the relation between the maximum diameter of the MSWM medial to the anterior clinoidal line (AC line) and surgical outcome. Methods This is a retrospective cohort study investigating all surgically resected MSWM cases at our institution over 10 years. The patients were divided into groups A and B based on the average ratio between the maximum medial extension of the MSWM from the AC line to the maximum diameter of the tumor, that is, value I = 0.42 (group A ≤ 0.42 and group B > 0.42). And into groups C and D based on the average medial extension of the tumor, that is, 14 mm (group C ≤ and D group D > 14 mm). These measurements were correlated with patients' demographics, preoperative symptoms, and postoperative assessment. Results Among 150 patients, 51patients had MSWM that fulfilled the inclusion criteria. Among them, 76.47% were females with a median age of 48 years (standard deviation [SD] = 47.75 ± 15.11). Also, 92% of the cases were World Health Organization (WHO) grade I. The follow-up period was 0.5 to 10 years. Among them, 40% of group C had gross total resection (GTR), whereas 43% in group D. In group B, 70% had GTR, whereas 48% had GTR in group A. None of the patients developed statistically significant postoperative complications. There is no statistically significant difference in the risk complication with medial extension in all groups. Conclusion The degree of medial extension of MSWM from the AC line has no statistically significant correlation with major postoperative complications, extent of resection, or clinical outcome.

A potential new brainstem reflex: The oculoglossal phenomenon.

BACKGROUND: A synchronized involuntary movement of the tongue to the same side as voluntary movements of the eyes, termed the oculoglossal phenomenon, has been observed. A description of the hypothesized pathway of this phenomenon could guide the development of a rapid clinical evaluation of the long segment of the brainstem and help facilitate further studies to establish a new reflex, if possible. The aim of this study is to describe and propose the simple concept of this pathway/phenomenon, the oculoglossal phenomenon. METHODS: This is an observational study. Of a newly observe brainstem phenomenon evaluated on a subject at the National Neuroscience Institute in king Fahad Medical City (KFMC), Riyadh, Saudi Arabia. After being observed incidentally in a single patient, 60 participants were tested between January and March 2020 to confirm the presence of the phenomenon. Each subject was instructed to protrude the tongue and then move their eyes horizontally to the side. If the tongue simultaneously and involuntarily moved to the same side as the eyes, the test was deemed confirmatory. A literature review was performed, and possible anatomical pathway was proposed. RESULTS: The oculoglossal reflex was present in most (50/60, 83.3%) of the subjects. Our proposed pathway begins at the frontal cortex, followed by a projection to the paramedian pontine reticular formation, then to the contralateral medial longitudinal fasciculus and bilaterally to the hypoglossal nuclei. CONCLUSION: An accurate description of this phenomenon could lead to additional studies and possibly establishing it as a legitimate reflex, thus conceivably adding a new tool in the neurological examination to evaluate the brainstem's integrity.

The Top-100 most cited articles on Moyamoya disease: A bibliometric analysis.

OBJECTIVE: Moyamoya disease (MMD) is a progressive steno-occlusive cerebrovascular phenomenon with unknown pathogenesis. Considering the abundance of articles addressing Moyamoya disease, a detailed analysis concerning the publication trends is of paramount importance. The aim of the study is to report the current knowledge of the top-100 most cited articles on Moyamoya disease in the literature. METHODS: A non-time restricted keyword-based search was performed in June 2020 using the Scopus database. The search keywords included the following: "Moyamoya", "Moyamoya disease", and "Moyamoya syndrome". The search result was used to rank the articles based on their citation count. The top-100 most-cited articles were obtained and classified into seven categories. RESULTS: A total of 3,543 articles on Moyamoya disease were published between 1955 and 2020. The Top-100 articles were published between 1977 and 2016 with a total of 16,119 citations, per year, and 7.23% rate of self-citation. The 1990s was the most productive decade (N=42). The most contributing country to the list was Japan (N=60). Stroke was the most active journal (N=23). Houkin, K., a Japanese neurosurgeon, was the most prolific author (N=15). CONCLUSIONS: Moyamoya disease has been extensively investigated in the literature throughout the years. The majority of articles published in the literature were addressing the surgical management and clinical outcome. Authors from neurosurgical backgrounds were the most active contributors to the field of Moyamoya disease.

Bibliometric analysis of the top 100 most-cited articles on astrocytoma.

BACKGROUND: Citation analysis reflects the scientific recognition and influential performance of a published article within its field. We aim to identify the top 100 most-cited articles on astrocytoma using this bibliometric analysis method. METHODS: In May 2020, we performed a thorough search in the Scopus database using the word "Astrocytoma." The top 100 most-cited articles were arranged based on citation count in descending order. The resultant articles were then analyzed with an assessment of pertinent factors. RESULTS: The most-cited articles on astrocytoma had been cited 23,720 times. The top-cited article received a total of 682 citations, with an average of 34.1 citations annually. The list comprised eight clinical trials, in which the highest cited article received 625 citations. Articles were published from 1975 to 2015 with the 1995-2005 era as the most prolific period. Neuropathology studies were the most studied category, followed by clinical studies. The United States of America was the most significant contributor, with 49 published articles. The University of California San Francisco was the most contributing institution by producing 11 articles. Articles were published in 32 different journals led by the Cancer Research Journal, with a total of 12 publications. Approximately 160 authors contributed to the list in which Scheithauer, B.W. contributed the most with a total of eight articles. CONCLUSION: This report clustered the most impactful articles on astrocytoma. It serves as an adequate tool to identify publication trends and helps in achieving evidence-based clinical practice.

The Top-100 most cited articles on dural arteriovenous fistula: A bibliometric analysis.

OBJECTIVE: Dural arteriovenous fistula (DAVF) is a rare pathological vascular lesion with variable clinical manifestations. Since 1968, several articles have been published to address spinal and cranial DAVFs. The aim of this study is to identify, analyse, and review the pertinent literature of the top-100 most cited articles on DAVFs published to date. METHODS: A title-specific, keyword-based search with no time restriction was performed in June 2020. The Scopus database was used to identify the top-100 most cited articles on DAVFs. The term "dural arteriovenous fistula" was used as a search keyword. The search results were arranged in descending order based on the total citation count. The top-100 articles were categorized into ten categories. RESULTS: Between 1968 and 2020, a total of 2298 articles were published on DAVFs. The top-100 most cited articles were published between 1983 and 2012. The total number of citations for the top-100 articles was 12393 (123 citations/article). Most articles (34%) were investigating the clinical aspect of DAVFs. The country contributing to the most impactful and highest volume of publications (46%) was the United States. The Mayo Clinic was the most active institute in contribution. Most articles (29%) were published by the Journal of Neurosurgery. CONCLUSIONS: In the top-100 most cited articles on DAVF, most studies were published in neurosurgery/neuroradiology-dedicated journals. This bibliometric analysis identifies the publication trends and provides a comprehensive overview of the most influential articles addressing DAVFs.

A bibliometric analysis on the most-cited publications on carotid endarterectomy throughout history

Objective@#Carotid endarterectomy (CEA) is the gold standard surgical procedure for managing carotid stenosis due to atherosclerosis and reducing the risk of ischemic stroke. This bibliometric analysis summarizes the most-cited articles on CEA and highlights the contributing articles to today’s evidence-based practice. @*Methods@#A title-specific search using the Scopus database was used to perform the search. Pertinent article-based, journal-based, and author-based parameters were obtained for review. @*Results@#A total of 6,824 articles were published between 1970 and 2020. The top 100 most-cited articles accumulated a total of 54,153 citations with an average citation count (CC) of 541, with only a 4.53% self-citation rate for all authors. The publication trends peaked between 1997 and 2010, in which two-third of the highly cited works were published. The most prolific categories with top citations are the clinical, indications, and management, in a descending order. There were 41 published Randomized Controlled Trials (RCT) in the most-cited list. @*Conclusions@#Citation analysis on carotid endarterectomy has witnessed a marked shift in the publication trends from studying the outcome and complications to comparing carotid stenting with endarterectomy. This analysis is a good introductory article to physicians interested in this topic, as it summarizes the highly impactful articles and enlists the most-cited RCT on CEA.

Bibliometric analysis of the top 100 most cited articles on craniosynostosis.

BACKGROUND: Craniosynostosis is the premature closure of cranial sutures and it continues to be a therapeutic challenge due to the diversity and complexity of the syndrome. Bibliometric analysis is a study of ranking citations and exploring the most impactful articles in a respective discipline. It also demonstrates the chronological trends of publications. METHODS: In May 2020, we performed a title-specific search of the Scopus database using "craniosynostosis" as our query term without publication date restrictions. The top 100 articles in craniosynostosis were retrieved and analyzed. RESULTS: The top 100 most-cited articles in craniosynostosis received a total 13,826 citations, and an average of 138 citations per paper. The publication dates ranged from 1920 to 2015, with a peak period of top publications between 1996 and 2005. The most common category is clinical, followed by neurogenetics. The top cited article received 540 citation counts and 19.29 citations per year. The USA was the most contributing country to the list. The Journal of Plastic and Reconstructive Surgery published the largest number of top cited articles. Neurosurgery as a specialty contributed to most articles in the list (27 articles). The institute who contributed the most was the Assistance Publique Hopitaux Paris. CONCLUSION: Bibliometric analysis in craniosynostosis revealed major trend changes of research over the years, with a focus on neurogenetics and the different types of surgical corrections. The current collection of highly cited publications may assist physicians in gaining a better understanding of the evidence-based approach in craniosynostosis.

Bibliometric Analysis of the Top 100 Most-Cited Articles on Intracranial Flow Diversion.

BACKGROUND: Flow diverters are novel, contemporary tools in treating intracranial aneurysms. There is rapid publication turnover, with newer devices introduced and expanding indications. The bibliometric analysis measures the impact of particular articles and summarizes the chronologic trends overall. METHODS: In July 2020, we performed a thorough search of the Scopus database using the terms "flow diversion," "flow diverter," and "flow diverting stent." The top 100 most impactful articles were arranged based on citation count in descending order. The collected articles were then analyzed with an assessment of relevant factors. RESULTS: Almost 1671 articles were published between 2007 and 2020. The gathered top 100 most-cited articles amassed 10,035 citations, with an average citation count of 100.35. An 8.8% self-citation rate was identified for all authors. The publication trends peaked in 2012, in which 24% of articles were published. Most prolific categories with top citations are on pipeline embolization, followed by the SILK flow diverter category. The United States published the highest number of articles. The University of Buffalo and Mayo Clinic published most of the articles among other institutions. American Journal of Neuroradiology was the most productive journal by producing 28 articles. CONCLUSIONS: This bibliometric analysis shows significant chronologic trends, with a shift from usefulness and outcome to short-term and long-term complications. Areas to improve in flow diverter research can be addressed after this analysis of the most impactful articles on this topic.

Bibliometric Analysis of the Top 100 Most Cited Articles on Cerebral Vasospasm.

OBJECTIVE: Bibliometric analysis reflects the scientific recognition and influential performance of a published article within its field. Our aim is to identify and analyze the top 100 most-cited articles on cerebral vasospasm. METHODS: A title-specific search was carried out using the Scopus database. The top 100 cited articles including the keywords "Cerebral Vasospasm" AND "Vasospasm" were retrieved and stratified in a descending order: title, authors, institution, publishing journal, country of origin, year of publication, and topic of each article were studied. RESULTS: The top 100 articles have an accumulative citation count of 20,972, with 209 average citations per article. Publication dates ranged from 1968 to 2012, with the most productive years between 1998 and 2005. Clinical studies are the most frequent category, followed by pathophysiology. The list includes 7 clinical trials, which received accumulative citations of 1525. The top cited article had received 2109 citations, with 52.7 citations per year. The top 100 articles were published across 14 countries, with most originating from the United States. The lead research institution was the University of Alberta. The most used journal was Journal of Neurosurgery. CONCLUSIONS: Bibliometric analysis has garnered major interest in recent years. It shows the publication trends, knowledge evolution, and evidence-based practice throughout the years. The collection of highly cited articles may assist physicians in gaining a better understanding of the nature of cerebral vasospasm and optimize their clinical practice.

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.

Classification of internal carotid artery injuries during endoscopic endonasal approaches to the skull base.

BACKGROUND: Internal carotid artery (ICA) injuries are a major complication of endoscopic endonasal approaches (EEAs), which can be difficult to manage. Adding to the management difficulty is the lack of literature describing the surgical anatomical classification of these types of injuries. This article proposing a novel classification of ICA injuries during EEAs. METHODS: The classification of ICA injuries during EEAs was generated from the review of the literature and analysis of the main author observation of ICA injuries in general. All published cases of ICA injuries during EEAs in the literature between January 1990 and January 2020 were carefully reviewed. We reviewed all patients' demographic features, preoperative diagnoses, modes of injury, cerebral angiography results, surgical and medical management techniques, and reported functional outcomes. RESULTS: There were 31 papers that reported ICA injuries during EEAs in the past three decades, most studies did not document the type of injury, and few described major laceration type of it. From that review of the literature, we classified ICA injuries into three main categories (Types I-III) and six sub-types. Type I is ICA branch injury, Type II is a penetrating injury to the ICA, and Type III is a laceration of the ICA wall. The functional neurological outcome was found to be worse with Type III and better with Type I. CONCLUSION: This is a novel classification system for ICA injuries during EEAs; it defines the patterns of injury. It could potentially lead to advancements in the management of ICA injuries in EEAs and facilitate communication to develop guidelines.