Endovascular neurointervention in Iraq: Realistic obstacles, a hopeful start with "Al-Hayat center".

Endovascular neurointervention nowadays plays an important role in the effective treatment of different head and neck vascular pathologies using minimally invasive means. In Iraq, until recently, endovascular neurointervention field is nearly absent. A new hope was started when an advanced neurointerventional center was created to improve and develop this field in Iraq.

Factors associated with the severity of traumatic brain injury.

Introduction: Traumatic brain injury (TBI) is a defect in the brain function resulting from the action of external factors. The condition ranges from transient shifts in cellular ionic concentrations to total structural damage; the clinical symptoms can vary from brief confusion to death. The current classification system, based on the Glasgow Coma Scale (GCS), divides TBI into mild (GCS 14 to 15), moderate (GCS 9 to 13), and severe TBI (GCS 3 to 8). The leading causes of head injury in the population can be falls, motor vehicle collisions, blasts, and bullet injuries. The ultimate survival and neurologic outcome of the head trauma patient depend on the extent of TBI occurring at the time of injury. The aim of the study is to assess the factors associated with brain injury and their effect on its severity. Method: A cross sectional, retrospective study including 469 adult patients with head injury was carried out in the emergency department of Baghdad teaching hospital between 1 October 2016 - 30 October 2017. Data of all the patients were entered and analyzed using the statistical package for social sciences (SPSS) software for Windows, version 24. The significance of correlation was assessed using a Chi-square test. Level of significance was set at ≤ 0.05. Final findings were presented in tables with an explanatory paragraph for each table using the MS. Office (Word 2013) for Windows. Results: A total number of 469 patients were enrolled in this study with a mean age of 42.6 ± 13.7 years. The vast majority of the patients were males (383/469), which represented 81.7%. The male to female ratio was 4.45 to 1. The distribution of the patients according to their traumatic brain injury was 241 patients (51.4%) with mild, 99 (21.1%) with moderate and 129 (27.5%) with severe TBI. Associated injuries among the studied group were facial injuries in 133 (28.4%), skull fracture in 150 (32%), and thoracolumbar fracture in 51 (10.9%). The associated injuries were more frequent in the extremities - 112/469 (23.9%), combined injuries in 112 (23.9%), chest and abdomen injuries were reported in only 6% and 6.8%, respectively. The causes of injuries in the studied group were road traffic accidents (RTA), the most frequent mechanism - 37.1% of the cases, followed by fall from height (FFH) (23.9%), blast injury (16.8%), bullet injury (13%), while other mechanisms represented only (9.2%). There is a significant association reported with gender, where severe injuries were more frequent among males than females (P=0.014). All associated injuries were significantly associated with severe traumatic brain injury (P<0.05), also bullet injury was significantly associated with severe traumatic brain injury, followed by blast injury (P<0.001). Severe traumatic brain injury was significantly associated with the presence of clinical and radiographic findings (P<0.001). Conclusion: The severity of TBI is significantly related to the type of the associated injury, mechanism of injury, clinical and radiological findings, and to the male gender, while it is not dependent on the age of the patient.

Bilateral Internal Carotid Artery Dissection as a Possible Complication in a patient with Covid-19 infections and coughing.

Background: Cervical carotid dissection is one of the causes of ischemic stroke in young people. Most of the patients with carotid dissection do not have connective tissue diseases (Marfan syndrome, Ehlers-Danlos syndrome). It seems that dissection may occur without an obvious cause or may follow environmental injuries like vigorous neck movements, chiropractic manipulation, emesis, severe coughs, and some infections. We present a case of bilateral carotid dissection in a patient following coronavirus infection and severe coughs. Case Presentation: A 38-year-old right-handed man presented with recurrent episodes of transient right hemiparesis and aphasia. He had a history of coronavirus infection and severe persistent, nonproductive cough 7 days before the onset of his symptoms. Carotid angiography showed tapered flame-like appearance in proximal segment of left ICA starting about 2 cm distal to the carotid bulb caused complete occlusion of left ICA and in right CCA angiography there is pseudo aneurysm in right cervical ICA just before the Petrous segment. In 3 months in follow up DSA there is evidence of complete occlusion of right pseudo aneurysm and recanalization of left ICA without stenosis. Conclusion: COVID-19 may have role in the processes that eventually led to CAD.

The role of computed tomography and Glasgow Coma Scale in detecting spinal injury associated with traumatic brain injuries.

Objectives: The aim of this study is to identify the role of computed tomography scan (CT scan) of the cervical spine and Glasgow Coma Scale (GCS) in detecting spinal injuries associated with head injury. Methods: This cross sectional study was conducted in the emergency department of Baghdad teaching hospital prospectively from October 2016 to October 2017. A total of 469 patients were included in this study, 59 of them with spine injury. All patients were examined promptly and were treated accordingly; all were subjected to X-rays and CT-scan of the skull and cervical spine for evaluation of head and cervical spinal injury, respectively. Results: A total of 469 patients were enrolled in this study, mean age of 42.6 ± 13.7 years. The majority of patients were male (383/469) representing 81.7%. There was a significant correlation between Severity of TBI and cervical injury (P<0.001). There was a significant association between cervical injury and the presence of clinical and radiographic findings and associated injuries (P<0.001). It was found that cervical injury was more frequent in patients who were exposed to fall from a height. Conclusion: CT scan and Glasgow coma scale are highly specific, sensitive, and accurate, with positive and negative predictive values.

COVID-19 outbreak as a probable cause of increased risk of intracranial rebleeding in partially treated cerebral arteriovenous malformations.

Patients who are infected with COVID-19 and have cerebral arteriovenous malformations which are partially treated or untreated may be more liable to rupture or bleed than not infected patients.

Treatment of post-traumatic direct carotid-cavernous fistulas using flow diverting stents: Is it alone satisfactory?

BACKGROUND: Direct carotid cavernous fistula (CCF) occurs between the internal carotid artery (ICA) and the cavernous sinus. Carotid cavernous fistulas (CCFs) frequently present with chemosis, pulsatile proptosis, ocular bruit, vision loss, and occasionally intracerebral hemorrhage or seizure. In this article, we share our experience in endovascular treatment of six patients having this pathology with intracranial flow diverting stents with review of literatures. CASE DESCRIPTION: All six patients had posttraumatic direct CCF, most of their signs and symptoms were visual disturbance, chemosis, orbital bruit, headache, paralysis of extraocular muscles. They were treated with flow diversion stents with or without coils or liquid embolizing material; transvenous and transarterial routes were used. Most of them underwent multiple sessions, and their conditions were improved dramatically. CONCLUSION: The best and most effective method is to start the procedure by coiling to convert the high-flow fistula to an aneurysmal pouch with the smallest possible size in the cavernous sinus, and then close the defect site with one or two flow diversion devices (FDDs).

Primary intraosseous osteolytic meningioma without an evidence of soft tissue invasion.

Primary intraosseous osteolytic meningiomas are not common, and total surgical removal is the best treatment option if the location allows that; however, long-term follow-up is recommended since it may recur.

Supratentorial intracerebral hemorrhage as a complication of infratentorial tumor removal: A case report.

INTRODUCTION: In this article we report a case of supratentorial intracerebral hemorrhage developed following days of posterior fossa surgical tumor removal. PRESENTATION OF CASE: Nine years old female was diagnosed as a patient with posterior fossa tumor and hydrocephalus, endoscopic third ventriculostomy was done and the tumor was resected using craniectomy and trans-vermian approach. The patient was discharged home on post-operative day 10 but re-admitted on day 35 with a new insult of right temporo-parieto-occipital intracerebral hematoma which was evacuated successfully urgently and the patient had got better on day 4, but then she developed right hemispheric ischemia and died. DISCUSSION: Although this complication is rare, it carries significant morbidity and mortality, literatures discussing this condition are scanty and no obvious cause was mentioned. CONCLUSION: We recommend putting in mind such a complication in case of any post-operative neurological deterioration occurs to a patient with surgically excised posterior fossa lesion.

The effect of adenosine in inducing cardiac arrest for endovascular treatment of paediatric high-flow brain and spinal vascular malformation.

INTRODUCTION: Endovascular treatment of high-flow vascular lesions with onyx may be very dangerous due to premature occlusion of the vein resulting from high flow-induced migration of this embolic substance without occlusion of the feeding vessels and the nidus. It is also dangerous because of the risk of occlusion of the normal vessels around the lesion. Inducing temporary cardiac arrest using adenosine may be helpful in limiting and minimizing these risks. However anaesthetic management of this procedure in children suffering from high-flow vascular lesions is difficult and challenging. METHODS: We report three paediatric patients with high-flow cerebrospinal vascular lesions that underwent endovascular treatment under general anaesthesia and temporary cardiac arrest with adenosine. Adenosine was administered in escalating doses to induce a few seconds of cardiac standstill and the onyx injection was synchronized with the onset of adenosine-induced cardiac standstill, the fistula being occluded by onyx. RESULTS: There were no complications in peri-procedural treatment in all three cases. Post-embolization angiography revealed complete obliteration of the lesion, and the patients' neurological status progressively improved at follow-up. CONCLUSION: Adenosine-induced temporary cardiac standstill was successfully used to facilitate safe and controlled endovascular onyx embolization of high-flow central nervous system vascular lesions.