Objective: To determine the influence of the tumor size and the preoperative duration of symptoms on the postoperative visual outcome in patients with suprasellar meningiomas.

Methods: This is a retrospective clinical analysis. Between 2003 and 2005, at the Department of Neurosurgery, Cairo University Hospitals, 13 consecutive patients with histopathologically proved suprasellar meningiomas received surgical treatment. We analyzed the patients retrospectively based on their clinical and radiological data. We compared the preoperative visual condition using visual acuity, field, and fundus examination, with the postoperative visual condition at 1 week, one month, and 6 months intervals postoperatively. We emphasized on the relation between the visual prognosis postoperatively and both the tumor size and duration of symptoms preoperatively. Follow up period ranged from 7 months to 16 months (mean 10.7 months).

Results: The age of the patients ranged from 39 to 58 years (average 48.8 years).The female to male ratio was (3.3 to 1). Tumor volume ranged from 1.9 to 5.6 cm with a mean of (3.3 cm) in diameter. Seven patients (53.8%) had a tumor size of 3 cm or less and six patients (46.2%) had tumor size larger than 3 cm. The duration of symptoms at the time of diagnosis ranged from 9 months to 5 years with a mean of (2.5 years). Five patients had a preoperative duration of symptoms lasting for one year or less, while eight patients had pre operative symptoms for more than one year. Visual affection was the commonest presenting symptom (84% of the patients). Results showed that visual prognosis was definitely better in patients with tumors 3cm or less in size and in those with duration of symptoms of one year or less.

Conclusion: Better visual outcome postoperatively was favorably affected by a tumor size of 3 cm or less, and duration of symptoms of one year or less.

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Objective: to emphasize that this approach is simple, rapid & anatomical & not related to morbidity of these cases.

Patients and Methods: this is a prospective study done on thirty cases with spontaneous intracerebral hematoma due to different pathologies, and all were operated upon by the same standardized pterional trans-sylvian trans-insular approach.

Results: in this study, median age was 52yrs old, male : female was 17:13, primary hypertension was present in 20 cases, secondary hypertension in 4 cases, generalized hemorrhagic blood diseases in 6 cases, diabetes mellitus was present in 20 cases, Glasgow Coma Scale was mildly affected in 13 cases, moderately affected in 9 cases, severely affected in 8 cases, the volume of the hematoma was small in 15 cases, moderate in 10 cases, large in 5 cases, outcome was 18 survival, survival was related to the conscious level of the admission, and the volume of the hematoma, epilepsy was present in 4 cases of the survivals.

Conclusion: this approach is very effective, simple, rapid, with no inherited morbidity and can be effectively performed on the dominant cerebral hemisphere.

Objective: One of the many applications of interactive image guidance is to provide a precise planning of the craniotomy to target small superficial brain lesions. However, because of the expenses associated with the purchase and use of these navigation systems, it would be necessary to demonstrate the true benefits delivered to patients for the costs associated with this technology especially when applied in developing countries with limited financial resources like Egypt.

Methods: Neuronavigation was applied for surgical localization of craniotomy in 60 patients having extra-axial (38 patients) or superficial intra-axial lesions (22 patients), lying in the cerebral convexity or parasagittal regions. The radiological diagnoses of these 60 patients were meningiomas in 38, gliomas in 14, metastases in 5, and cavernous malformation in 3 patients. The maximal diameter of the lesions was less than 3 cm in 15 patients (25%), between 3 and 6 cm in 28 patients (46.7%), and more than 6 cm in 17 patients (28.3%). Before actual planning of craniotomy with the neuronavigation assistance, the position of craniotomy was clinically estimated using the usual practice by mental correlation of the image studies with the patient anatomy. Then, the neuronavigation was set up to plan the exact tumor margin and the overlying craniotomy. The two designed bone flaps, marked on the scalp of the same patient, were then compared to each other regarding their size and location to determine the accuracy of the clinically (free-hand) designed craniotomy in comparison to that planned with the neuronavigation assistance.

Results: It was found that the accuracy of the free-hand localization of craniotomy flaps was comparable to those of image guided localization with regard there size and location. Excellent or good free-hand localization of the craniotomy flap (i.e. >75% accuracy) was achieved in 83.3% of patients. On the other hand, image guidance seemed mandatory in two patients (3.3%) and necessary in eight patients (13.3%). Analysis of the results showed that image guidance was mandatory in localization of small subcortical lesions (<3cm). It was necessary for small extra-axial lesions (<3cm) and for optimisation of craniotomy for larger subcortical lesions lying in the cerebral convexity in the posterior parietal or occipital region. The navigation was also found very helpful in preoperative planning of craniotomy for extra-axial lesions related to the transverse or superior sagittal sinus or lesions lying near the central sulcus.

Conclusion: Although neuronavigation was very effective in eliminating guess work and allowed optimization of craniotomy, yet the benefit of the neuronavigation is still complementary for most of patients and can not act as a substitute for the sound surgical planning gained by the surgeon. Moreover, the cost-benefit ratio of the neuronavigation system is still too high to be widely adopted in daily routine neurosurgical practice especially in a developing country with limited resources like Egypt.

Introduction: The sympathectomy technique has evolved over the last decade. In the 1920s, chemical sympathectomies with alcohol or phenol had become popular, and then by the 1930s, "modern" techniques of open surgical thoracic, lumbar, and splanchnic sympathectomies were being used. Percutaneous radiofrequency sympathectomies were introduced in the 1980s for thoracic sympathectomy and later for lumbar sympathectomy, and they have undergone subsequent technical improvements. Objectives: To determine the efficacy and long-term outcome of percutaneous radiofrequency thermocoagulation for upper thoracic ganglionectomy and sympathectomy in patients with palmer and craniofacial hyperhydrosis with the use of X- ray fluoroscopy image guidance. Patients and Method: This prospective clinical study was performed from April 2004 to May 2006, upon 20 patients presented to Ain shams University hospitals, suffering from primary palmer and/ or craniofacial hyperhydrosis. Those patients were treated by unilateral or bilateral dorsal sympathectomy using X- ray fluoroscopy image guided percutaneous radiofrequency thermocoagulation technique. Cases with recurrence after any surgical modalities or those who had this procedure to treat other diseases as painful causalgia were excluded from the study to unify the group of patients. The procedure's complications, and the surgical results; as indicated by the post operative degree of decrease of hyperhydrosis and the patient's satisfaction, were assessed. Long term follows up and complications (as compensatory hyperhydrosis) were evaluated after one year at least after the procedures. The degree of hyperhydrosis was graded according to the following criteria: mild (skin is frequently moist but patient can do most of the daily work without difficulties and only has social embracement), moderate (skin sweat was profuse enough to handicap some of the daily work of the patients), or severe (hyperhydrosis was associated with skin changes).

Results: There were twelve male and eight female patients. Age of patients ranged from 13 to 46 years with mean age 27.2 years. Eighteen patients were suffering only from palmer hyperhydrosis, while one patient had additionally facial hyperhydrosis and another patient had also palmo-.axillary hyperhydrosis. Thirty six procedures were done to the twenty patients (four patients had only unilateral procedure). Both the second and the third sympathetic ganglia (T2 and T3) were lesioned in all but one patient. Because this patient had severe axillo-palmer hyperhydrosis the lesions were bilaterally made in T4 as well as in T2 and T3. Intra-operative accidental puncture of the pleura was done in one case (2.8%) that was diagnosed post-operative by developing pneumothorax. Also in another patient there was postoperative dorsal radicular pain that improved within three weeks. There was improvement in the degree of hyperhydrosis in 97.2% (35 out of 36 procedures). Recurrence of hyperhydrosis was happened 6 and 9 months after two procedures (5.6%). There were no cases with compensatory sweating. Moreover decreased plantar sweating was noted during follow-up in 2 of patients.

Conclusion: Percutaneous Radiofrequency Sympathectomy is an effective and simple modality for treatment of palmer and craniofacial hyperhydrosis.

Objective: Spasticity represents the most handicapping sequel of cerebral palsy children. Although selective posterior rhizotomy is the most commonly performed neurosurgical procedure for reduction of diffuse spasticity in these patients, neurotomies have been used for the treatment of spasticity in certain patients with more localized form of spasticity. This prospective study was performed to evaluate the results of microsurgical selective peripheral neurotomies in the treatment of lower limb spasticity in children with cerebral palsy. Methods: Between January 2004 and January 2006, 18 children with cerebral palsy suffering from handicapping spasticity affecting the lower limbs were operated-upon by microsurgical selective peripheral neurotomies at Neurosurgery Department, Ain-Shams University. All patients were objectively evaluated both clinically (as regard motor power, muscle tone, joint range of motion and degree of disability) and electro-physiologically (nerve conduction and electromyografic studies). Assessment was performed a week prior to surgery and at 1, 6, 12 and 18 months post-intervention. Neurotomies done for these children were: 27 tibial, 6 sciatic and 14 obturator neurotomies. Complementary orthopedic procedures including tendons lengthening, tenotomies and derotation osteotomy of the femur were performed in 16 children. Results: Statistical analysis of the results showed significant improvement in all the assessment parameters including physical (motor power, muscle tone, joint range of motion), functional (degree of disability) and electro-physiological measurements with no recurrence of spasticity throughout the follow-up period which ranged from 6 to 18 months (mean: 11 months). There was transient post-operative weakness in all patients but the motor power has returned to the baseline within 6 months post-operatively. Two children had experienced transient parathesia following tibial neurotomy and one had wound infection necessitated debridement and secondary sutures. Conclusion: Microsurgical selective peripheral neurotomy showed good results in children with spastic diplegic cerebral palsy in both physical and functional outcomes and this was supported by the electrophysiological measurements. It carries the advantage of being simple and safe surgical technique for focal and multifocal spasticity.

Introduction: Medulloblastoma, as a critical 4th ventricular tumor, represents a challenge to neurosurgeons because of severe deficits that occur following injury to delicate structures in the ventricular wall and floor. The two most common surgical approaches to medulloblastoma are the transvermian and telovelar approaches. Aim of study: This study was done to compare between the two previous approaches regarding the morbidity and mortality and also to study the different variables that may affect the final outcome of each approach and to define the different indications for each of them, as regards the site, the size and extension of the tumor.

Patients & Methods: This is a prospective study done on 20 patients with posterior fossa midline primitive neuroectodermal tumors (medulloblastoma) who were operated upon in Ain Shams University Hospitals, Egypt, from February 2003 till August 2006. Two approaches had been used; transvermian and telovelar, which were selected on alternating basis so first patient had transvermian approach and the second had telovelar approach and so on. Intra-operative difficulties, complications and the final outcome were reported. Statistical analysis: All patients' data had been tabulated in two groups (each formed of ten patients); group I those who had transvermian approach and group II those with telovelar approach. Different variables that might have affected the final outcome were studied in each group and also the final outcome was compared between the two groups. Qualitative and quantitative statistical tests were used for statistical analysis of the patients' data.

Results: Headache of increased intracranial tension was the most frequent symptom followed by ataxia (70 % and 65 %, respectively). Pre-operative radiological investigations showed presence of obstructive hydrocephalus in twelve patients (60 %). Regarding the tumors sizes, there were four patients with small tumors, eleven patients with medium tumors and five patients with large ones. There was increase in cerebellar signs in 100 % of patients in group I and in group II it was increased in only 40% of patients. But all patients had improved regarding the ataxia in long term follow-up. Lower cranial nerve affection occurred in one patient in group I. There were two patients with cerebellar mutism in group I and only one patient in group II. Disturbed level of consciousness had occurred in the patient with injured PICA in group II. There was one patient in group I with post-operative CSF leakage that was complicated by infection. This patient died one month after surgery from ventriculitis. Another patient with mortality had occurred in group II due to brain stem infarction from PICA injury. Total excision of the tumors was achieved in eleven patients; seven patients (70 %) in group I and four patients (40 %) in group II.

Conclusion: Both transvermian and telovelar approaches were useful for excision of medulloblastomas. The unilateral telovalar approach seemed more suitable for small tumors. However, in practice, most of these tumors were large and reaching the aqueduct, so the extensive (bilateral) telovelar approach will be needed to achieve tumor resection with increased incidences of post-operative mutism and ataxia that might be similar to those associated with the transvermian approach.

Objective: The aim of this study is to evaluate the role of cervical medial branch block in diagnosis and treatment of patients with axial facetogenic neck pain.

Methods: This study included 30 patients with cervical axial neck pain diagnosed as cervical facet syndromes who are complaining of persistent neck pain not responding to medical treatment (19 males and 11 females). All the patients had cervical medial branch blocks as an outpatient procedure. Blocks were performed at a minimum of 2 levels to block a single joint with fluoroscopic projection using 1 ml bupivacaine 0.5 % & 0.5 ml of methylprednisolone. Patients were examined for pain and neurologically immediately after the procedure and after one week, two weeks then monthly for neck pain (using VAS) free interval and any recurrence of symptoms.

Results: Out of 30 patients, 8 patients (26.7%) showed negatives test block and 22 patients (73.3%) showed positive response. The mean preoperative pain VAS was 7 with the mean postoperative score is 2.13. There is 70% reduction in pain intensity in patients with improved neck pains after one week of the procedure. Neck pain free intervals after one month seen in 8 patients (26.7%) and at 2 months in 4 patients (13.3%).

Conclusion: Medial branch blocks are a simple way to diagnose facetogenic neck pain. The procedure is technically easily performed, safe done as outpatient procedure. Cervical medial branch blocks procedures may be considered as a therapeutic tool and not only a diagnostic tool based on the long pain free period in some patient.

Preservation of the pituitary stalk in surgery of sellar & suprasellar tumors is a surgical challenge of utmost importance. Destruction of the pituitary stalk happens when surgeon is not minded with the stalk and its expected site during pituitary surgery. Stalk injury may result in varying degrees of hypopituitarism mainly diabetes insipidus and when it does occur, is usually looked upon as nothing more than nuisance for the patient rather than as a life threatening disorder. Moreover if damage to the pituitary stalk is extended to the hypothalamus, diabetes insipidus will be accompanied with adypsia and this is the most serious condition since serum osmolality may change rapidly. Object: The aim of this work is to identify and preserve if possible the pituitary stalk during surgical resection of sellar & suprasellar tumors.

Methods: 40 patients with documented sellar and suprasellar tumors had been operated upon during the period from 2002 to 2006 at the neurosurgery department in Ain Shams university hospitals.

Results: The pituitary stalk was identified and preserved in 45% of cases and it was not visualized or identified but not injured in 45% of the cases, i.e. overall preservation was 90% while it was injured in 10% of the cases and led to pituitary isolation syndrome and permanent D.I. In 50 % of the cases, preservation of the functional anatomy of the pituitary stalk was on the expense of total tumor removal.

Conclusion: for preserving the maximum post operative endocrinological functions of the patients, it is better to pay as much attention to the pituitary stalk & to preserve it intact as much as possible.

Pseudotumor cerebri or idiopathic intracranial hypertension is a known complication of morbid obesity that often requires neurosurgical intervention for worsening symptoms. Placement of a lumboperitoneal shunt (LPS) is one of the treatment options, but in a morbidly obese patient the placement of LP shunt is very difficult & necessitate a very big abdominal surgical incision and even the evaluation of the shunt tube patency can be technically challenging. This procedure can now be done using a laparoscopic-assisted technique.

Objective: This study was designed to evaluate the usefulness, efficacy and safety of laparoscopic-assisted LPS in treating patients with IIH, as well as for the evaluation of the function and patency of the shunt tube in reccurence of symptoms, where no other diagnostic modality can be used.

Methods: 31patients were included in this study. Laparoscopy was used for primary placement of the peritoneal portion of shunt catheter in the right subphrenic recess. It was used secondary in 3 patients (who had recurrence of symptoms after surgical LP shunt placement), for the evaluation of shunt patency and position inside the peritoneal cavity, cleaning of the distal end from debris, repositioning of the displaced shunt, or reinsertion of another shunt as needed.

Results: In this series, one month postoperatively, headache resolved in 100% of the patients , papilledema resolved in 87.17% and improved in 7.69%, visual acuity improved in 85% of the patients,while 94.2% showed expansion in their V.F., with a minimal complication rate; Shunt malfunction occurred in 6.45%, mechanical shunt obstruction occurred in 3.22% of patients, shunt infection was noted in only 3.22%, while Secondary transient intracranial hypotension with the development of low-pressure symptoms was the most common complication, it occurred in 29% of the patients and resolved completley.

Conclusion: Microlaparoscopic assisted lumboperitoneal shunt placement in the lateral position is an efficient and safe method for the treatment of pseudotumor cerebri. It is a minimally invasive, simple, effective tool for placing the peritoneal catheter for LPS.

Objective: To study the neurological and radiological outcomes in patients who underwent surgery for tuberculosis of thoracic and lumbar spine.

Patients ad Methods: We retrospectively reviewed 18 patients with tuberculous spondylitis of thoracic and lumbar spine treated surgically. These patients were treated between January 2004 and April 2006. Patients were assessed clinically, regarding severity of pain and neurological status, and radiologically, regarding the presence of epidural abscess and spinal instability. Nine patients were treated by anterior approach and nine patients were treated by posterolateral approach. All patients were followed up from 6 months to 3 years.

Results: Eight patients were men and ten patients were women, with ages ranging from 30 to 85 years (mean 49). Persistent back pain was present in all 18 patients and 17 patients had neurological deficit in the form of weakness attributable to the location of their lesion. The neurological status was assessed according to the scoring system of Frankel et al. The thoracic spine was involved in ten patients and lumbar spine in eight patients. Plain X-ray, MRI and occasionally CT and 3D-CT scan confirmed spondylodiscitis. Back pain was fully relieved in seven patients and eleven patients reported improvement compared with their preoperative condition. Neurological deficits were improved at the final follow up examination in 17 patients as defined by the scoring system of Frankel et al.

Conclusion: Spinal tuberculosis was best treated with appropriate anti-tuberculous chemotherapy and radical debridement surgery when indicated. Surgery is reserved for patients with progressive neurological deficit, spinal instability, drainage of abscess or severe pain despite of anti-tuberculous therapy. Surgical treatment has provided much earlier healing, quicker pain relief, earlier abscess drainage and sinus tract resolution, and a better chance of neurologic recovery, as well as a lesser degree of spinal deformity.