Background: Ventriculoperitoneal or ventriculoatrial shunt malfunction is a common problem and sometimes difficult to diagnose and manage. Clinical presentation in patients with shunt malfunction is typically nonspecific, and brain imaging often fails to show a change in ventricular size. The radiographic shuntogram is a simple method to evaluate the function and patency of a ventriculoperitoneal or ventriculoatrial shunt.

Patients and technique: The procedure involves placing nonionic contrast material into the valve of a shunt system and following the flow for appropriate clearing of contrast agent from the shunt tubing by serial filming over a 15-minute period. The method can be used to establish valve malfunction, ventricular or distal catheter obstruction, and peritoneal encystment. Thirty four studies were obtained in 31 patients in whom shunt malfunction was suspected.

Results: patients were verified into 18 (58.1%) males and 13 (41.9%) females, the average age was14 years. Radiographic shuntogram results were 25 (73.5%) true positive studies, 6 (17.6%) true negative studies, 3 (8.8%) false negative studies and no false positive results. The sites of true positive cases verified into 15 (60%) distal block, 9(36%) proximal block, 2 (8%) proximal and distal blocks (tube disconnection) and 2 (8%) valve malfunction.

Conclusion: our opinion favour the use of radiographic shuntogram in the diagnosis of obstructed CSF ventricular shunts as it is simple procedure, minimally invasive and is rapid as well as easy to perform. Its advantage over other methods lies in not only diagnose shunt malfunction but also localize and qualify the malfunction thus it can be used to establish valve malfunction, ventricular or distal catheter obstruction, and peritoneal encystment aiding the neurosurgeon in targeting the part of the shunt requiring revision.

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Background: After lumbar spinal fusion, adjacent segment degeneration (ASD) is a concern to both patients and surgeons and is a potential cause of further spinal surgery. Although ASD may be considered as a part of the normal aging process and degenerative change, it could be influenced by changes in the stress acting on the adjacent segment after spinal fusion. There are confusing reports in literature on whether ASD development affects the patients' outcome, in terms of changing his clinical status to the worse or not. No enough studies has correlated the development of ASD especially the symptomatic cases and postoperative sagittal alignment and the presence of preoperative facet tropism. The authors hypothesized that mal-alignment of the sagittal balance after posterior spinal fusion at least increases (If not causes) the phenomenon of ASD development and progress. Also the authors hypothesized that facet tropism may play a role in the development and/or advancement of ASD.

Patients and Methods: This prospective study was run in Ain Shams University hospitals and hospitals of ministry of health in Cairo from April, 2004 till January, 2008. We had 53 patients (39 females and 14 males with ratio of 2.8: 1). All were operated upon for degenerative indication and were selected according to strict inclusion criteria and all were fully fused by April of 2005. Range of follow up was 30-40 months with mean of 33 months but we considered the 30 months follow up visit as the final follow up. Patients were categorized into group A with no facet tropism and B with facet tropism of the levels intended for fusion and their adjacent segments. Every group was subcategorized according to sagittal alignment at full fusion (measured using cobb method) into group 1 with normal lordosis angle of 20-65 degrees and group 2 with hypolordotic alignment and group 3 with hyperlordotic alignment. Patients were assessed clinically according to modified functional scale of Ghiselli et al and radiographically by AP and lateral plain films and dynamic laterals in the post fusion visits to assess ASD signs in the adjacent segments above and below fusion. The changes were graded according to University of California at Los Angeles Grading Scale for Intervertebral Space Degeneration. MRI was added for patients with symptomatic ASD and was done for all patients at the final follow up.

Results: The results of this work prove that the incidence of asymptomatic ASD at 30 months follow up was only 5.2% and the symptomatic ASD was only 2.4% for the directly adjacent segment above fusion at 30 months follow up for group A1 patients ( 0.96 % per year) and this is far less than the recorded symptomatic ASD in most series that amounts to 3 % per year of follow up so it is 7.5% for that length of follow up. In group A2 with hypolordotic alignment there was 50% incidence of asymptomatic ASD in the directly adjacent segment above fusion and 50% incidence of symptomatic ASD in the directly adjacent segment above so actually all the segments directly above fusion got ASD in this group. In group A3 all the levels directly below fusion showed ASD (66.7% Asymptomatic and 33.3 symptomatic) and all are in the directly adjacent segment below and that proves that hyperlordosis puts extra-demand on the adjacent segment below fusion. In group B1 of facet tropism even with the preservation of physiological lordosis we had all levels directly above fusion levels showing ASD at the 30 months follow up (80% asymptomatic and 20% symptomatic) which is significantly different than the same alignment group with no facet tropism in our series(5.2% and 2.4% respectively). B2 and B3 group's patient population were insufficient for proper result analysis.

Conclusion: The results of this work prove that keeping lordotic alignment performing lumbar fusion for degenerative diseases within physiological ranges decreased the incidence of both symptomatic and non symptomatic ASD and that the disturbance of this alignment increased the incidence of symptomatic and non symptomatic ASD in the segments directly above fusion in hypolordotic alignment and in the segment directly below in hyperlordotic alignment and thus keeping physiologic lordosis plays detrimental role in decreasing the incidence of ASD and that this should be taken care of during surgery. Also the authors concluded that patients with facet tropism are more likely to develop ASD than those with no tropism so those patients should be informed of this possibility and that they are more likely to need treatment that could be surgical for that condition in a while after fusion surgery. More patient population and longer follow up are needed to further solidify the concluded facts.

Objectives: many modalities for treatment of syringomyelia associated with Chiari type 1- malformation have evolved. The aim of our study is to evaluate the results of cranio-cervical decompression together with arachnoid lysis, and duraplasty for symptomatic syringomyelia associated with Chiari type- I malformation in 16 adult patients.

Methods: Sixteen adult patients with symptomatic syringomyelia associated with Chiari type 1- malformation underwent surgery. Surgery was performed via cranio-cervical decompression (posterior fossa craniectomy, with C-1, and C-2 laminectomies) with duraplasty. Arachnoid adhesions around the herniated tonsils are looked for and then divided. Neither tonsillar resection, nor obex plugging was performed. Duraplasty was made with periosteum patch, harvested from the supra-occipital region, to enlarge the posterior fossa and restore a capacious cisterna magna in ten cases. In the remaining six cases, the duraplasty was done using artificial dural patch. A retrospective study was conducted by analyzing pre operative clinical data, neuro-imaging studies, operative reports, and post operative clinical and radiological outcome.

Results: The most common presenting symptom was neck pain. On MRI, the tip of the cerebellar tonsils was extending between the foramen magnum and C-1 in 12 patients (75 %), and between C-1 and C-2 in four patients (25 %). A syrinx was found in the cervical cord in ten patients (62.5%), and with cervico- thoracic extension in six patients (37. 5 %). Periodic post operative clinical and radiological follow up period ranged from six to 80 months (mean 40 months). On post operative MR images, the position of the tonsils was normalized and the syrinx diameter had decreased in 14 of the 16 patients (87. 5 %). Eleven of these 14 patients (78. 6 %) improved clinically (average 18 months from surgery); while the remaining three patients were clinically stable (no further deterioration- average 18 months from surgery). The two patients, in whom the syrinx was radiologically unchanged, expressed more clinical deterioration in the form of myelopathy.

Conclusions: As there are many debates about the pathogenesis of syringomyelia associated with Chiari type-I malformation, there are many modalities for the treatment. Cranio-cervical decompression together with arachnoidal lysis and duraplasty without tonsillar resection or obex plugging seems to be a valid modality for such cases. Radiological improvement dose not mean equivalent clinical improvement. However, a larger number of patients and longer follow-up will be necessary to determine the efficacy of such modality.

Objective The superiority of a fascial loop technique to the classic Stiles-Bunnell split flexor digitorum superficialis transfer to the lateral bands was investigated as to correcting intrinsic minus deformity after low ulnar nerve palsy.

Materials and Methods: 6 patients presenting low ulnar nerve palst, 2 with a flexible intrinsic minus deformity, 4 with a fixed deformity were operated upon. Fascial grafts were looped around the lateral bands of the ring and little fingers and around the tendon of the adductor pollicis. The loops were passed posterior to the carpal tunnel and sutured to the palmaris longus tendon.

Conclusion: The closed fascial loop method is a valuable alternative to the Sterling-Bunnell transfer for correction of intrinsic minus defor,ity after low ulnar nerve palsy.

Objectives: Sphenoid wing meningiomas are a formidable surgical challenge when they extend into the cavernous sinus. The goal of the present study is to evaluate the results of surgical management of sphenoid wing meningioma stressing on the factors determining the degree of tumor respectability and recurrence on the basis of experience with 34 cases.

Methods: Thirty four patients with sphenoid meningiomas underwent surgery. Surgery was performed via fronto-temporal approach, and fronto-temporal with orbito-zygomatic (O-Z) osteotomy (23 cases and 11 cases respectively). A retrospective study was conducted by analyzing clinical data, neuro-imaging studies, operative findings, and histopathological reports. The degree of tumor removal, clinical outcome, post operative complications, and recurrence are described. The patients were classified into four subtypes, lateral, middle, medial (Clinoidal without CS invasion), and spheno-cavernous (with CS invasion) subtypes. The extent of tumor resection was graded according to the Simpson classification.

Results: Encasement of the ICA and its branches was observed in ten (29.4 %) cases, while hyperostosis was present in four (11.8%) cases. Postoperative infarction from injury of middle cerebral artery territory occurred in four patients (11. 8%), two with medial (clinoidal) meningioma with encasement of MCA, and another two with middle sphenoid meningioma. Four patients died (11.8%). Three died from cerebral infarction after MCA injury during dissection (two clinoidal meningioma- one middle sphenoidal meningioma). Another patient died after evacuation of post operative ICH (spheno-cavernous). Total resection (Simpson Grade 2) was achieved in 14 patients (41.2%), subtotal resection (Simpson Grade 3) was achieved in nine patients (26. 5%), while Subtotal removal (Simpson Grade 4) was obtained in 11 patients (32.6%).

Conclusions: The surgical treatment of medial sphenoid wing meningiomas still represents a difficult task for neurosurgeons. Location of the meningioma is an important factor determining the degree of tumor resectability. Encasement of ICA and/or MCA and their branches together with CS invasion and extension into superior orbital fissure are limiting factors for radical removal. Presence of hyperostosis, incomplete tumor removal, and atypical histopathological variant are factors responsible for recurrence. Conservative surgical strategy for clinoidal and spheno-cavernous meningiomas for better functional outcome should be taken in mind particularly with the advent of radiosurgery.

Objectives: to evaluate posterior endoscopic cervical foraminotomy and discectomy (PECF,D) as a new minimally invasive technique for isolated radiculopathy.

Methods: From January 2004 to December 2007 a prospective study was carried out according to inclusion and exclusion criteria for evaluation of posterior endoscopic cervical foraminotomy and discectomy (PECF, D) in isolated radiculopathy due to either unilateral foraminal stenosis , osteophyte or disc. The study included 16 patients (9 males,and 7 females ). Age ranged between 27-52 years (mean 42.8 years). Preoperatively, all patients underwent static and dynamic plain X-rays and MRI on cervical spine. Postoperatively, all patients underwent static and dynamic plain X-rays and MRI or 3 D-CT on cervical spine. Patients were routinely evaluated at 1 week, 2 weeks, 4 weeks, 3 months, 6 months, and 1 year. Follow up period ranged between 6-48 months.

Results: All patients (n=16) reported neck and radicular pain .Nine patients observed radicular weakness and only one patient had quadriparesis due to large lateral disc. Twenty surgical levels in 16 patients (4 patients had 2 levels) were operated upon. The most affected levels were recorded in C5-6, and C6-7 in 8 patients (40%) for each. Posterior endoscopic cervical discectomy (PECD) was carried out in 12 patients and lasted 90-120 minutes, while only foraminotomy (PECF) in 4 patients and lasted 60-90 minutes. Vertical skin incision was used in 11 patients, while transverse skin incision in 5 patients. A minimal amount of blood loss was observed in all patients (20-50 cc). Complete resolution of radicular pain was observed in 12 patients (75%), while 3 patients (18.8%) experienced infrequent parasthesia. Only one patient (6.2%) reported unchanged radicular pain, resulted from residual disc fragment, however, patient was lost in follow up . Off 10 patients presented with motor deficit, 8 patients (80%) experienced immediate post operative complete motor recovery, while one patient (10%) reported delayed (after 1 week) complete motor recovery. One patient (10%) presented with quadriparesis due to large lateral disc, reported deterioration of motor deficit. One patient underwent further anterior cervical plate. Tow patients recorded intraoperative durotomy but without CSF leak. All patients were discharged from hospital after 1-1.5 days without neck collar. They returned to moderate activity after 7-10 days, while to normal activity after 30-45 days (n= 14). Follow up period ranged between 6-48 months. The study revealed that 11 patients (68.8%) reported excellent results, while 3 patients (18.8%) showed infrequent parasthesia, with Complete resolution of motor deficit and returned to normal work.

Conclusion: PECF, D is a safe efficacious technique in relieving root compression due to isolated disc, osteophyte, or foraminal stenosis with less tissue destruction. It obviates the need of implant fixation, and preserves the motion segment resulting in rapid recovery and early return to normal activities and work.

Objective: To evaluate minimally invasive surgery, using spinal endoscopy in patients with lumbar radiculopathy due to prolapsed lumbar disc.

Methods: From January 2000 to December 2006, 102 selected patients with lumbar radiculopathy due to herniated lumbar disc underwent posterior endoscopic interlaminar lumbar discectomy (PEILD) (2 patients went out the study as they have been turned into open surgery due to dural tear). Patients included 55 males and 45 females with age ranged between 27-74 years (mean = 44.6). All patients underwent preoperative plain films (A-P,lateral views) and MRI on lumbosacral spine. Immediate postoperative antero-posterior, and lateral view x-ray films, and CT or MRI on lumbo-sacral spine after one month (3 D- CT on lumbo-sacral spine has been done for last 10 patients) have been carried out for all patients. Follow up period ranged between 6-72 months.

Conclusion: Minimally invasive surgery in the form of PEILD could be a good alternative to standard open surgery in disc prolapse. It offers less tissue destruction, early recovery, less hospital stay, and early return to work. Complications are comparable for those occurred in standard surgery. Cases with tight canal stenosis require skilful procedure to avoid the high incidence of neurogenic deficit. The recommended entry point is 1-5mm off midline to avoid the extraforaminal direction. However, it is early to shift totally to minimal invasive procedures, but a learning curve is very essential to master these procedures.

Objectives: Preservation of facial nerve functions represents a major challenge in skull base surgery. The goal of the present retrospective study is to analyze the result of hypoglossal-facial anastomosis in 12 consecutive patients. Also the extent of the functional outcome and the factors affecting recovery are evaluated.

Methods: A retrospective study involved twelve patients suffered from permanent damage of the facial nerve after surgery for acoustic neuroma in seven patients, cerebellopontine angle meningiomas in two patients and following skull base fracture in three cases. All the patients were treated surgically by doing classic (end to end) hypoglossal-facial anastomosis.

Results: The study included 6 men and 6 women with their age ranged from 15 to 60 years. The time elapsed between injury and anastomosis ranged from one month to 24 months. The follow up period after hypoglossal-facial anastomosis ranged from 2 to 72 months. Functional assessment of the facial nerve was evaluated by using House-Brackmann and Pitty-Tator scales. The mean time between operation and sign of improvement was 7.25 months, ranging from 2- 17 months. Good outcome was recorded in seven (58.3%) patients, fair in three (25%) patients and poor in two (16.7%) patients. All the twelve patients had disorders of speech and swallowing due to hemiglossal atrophy which was controlled within 2 to 3 months by appropriate speech therapy and rehabilitation.

Conclusions: Hypoglossal-facial nerve anastomosis is an effective and reliable technique that gives consistent and satisfying results to reanimate the paralyzed facial nerve.

Objective: The cranio-orbital minicraniotomy is a modification of the subfrontal approach with orbital osteotomy. The purpose of this study is to describe the technique of this approach and evaluate the outcome in 28 consecutive patients suffering from various orbital lesions.

Methods: This is a retrospective study carried out on 28 patients having different orbital lesions. All the patients were operated upon by cranio-orbital minicraniotomy through eyebrow skin incision and a small craniotomy measured 2.5cm height and 3.5cm width with added orbital osteotomy. All the patients were evaluated for the degree of surgical excision and outcome.

Conclusion: Despite the small size of craniotomy and skin incision, the cranio-orbital minicraniotomy allowed enough room for intra-orbital manipulation and excision of different orbital lesions. Microsurgery with cranio-orbital minicraniotomy is a safe and effective method for treatment of patients having orbital lesions.

Objectives: To evaluate different endovascular techniques for cerebral vasospasm following subarachnoid hemorrhage.

Methods: Between March 2004 & September 2006, 30 patients with 58 spastic vessels following aneurismal subarachnoid hemorrhage were treated by using different endovascular techniques (Intra-arterial Papaverine infusion, Intra-arterial Nimodipine Infusion, transluminal balloon angioplasty [TBA]) and Transdermal Nitroglycerin Ointment at Ain Shams University Hospitals. The age of the patients ranged from 9 years to 77 years with a mean 44.97. There were 17 (56.7%) male patients and 13 (43.3%) female patients. Patients were evaluated and followed up according to Glasgow Coma Scale (GCS) at day1, day 4 and day 7 after the procedure. On discharge patients were assessed by Glasgow Outcome Scale (GOS). Patients were followed up clinically and radiologically for a period of one month after the treatment on different timings during this month.

Conclusion: Endovascular management should be considered when symptomatic cerebral vasospasm occurs besides the traditional medical management. Nimodipine infusion appears to be superior to papaverine in treating both proximal and distal vessels with fewer incidences of recurrence and very low risk profile, while TBA should be reserved only for refractory cases.

Myxopapillary ependymomas arise almost exclusively in the region of the conus and filum terminale. Rarely, they may arise in an extradural postsacral location, presumably from the coccygeal medullary vestige.Myxopapillary ependymoma of the conus medullaris and filum terminale is a relatively common spinal intradural neoplasm in adulthood. However, only a reported 8-12% of such tumors affect this site in children.With the advances in microsurgical techniques, Myxopapillary ependymomas are gross totally resected more frequently. The use of adjuvant radiotherapy has become questionable with gross total resection and its role for residual neoplasm need to be redefined.

Patients and Methods: Between January 2000 and May 2007, nineteen patients [M:F=12:7; age range: 13 to 65 years] with a myxopapillary ependymoma were treated. Tumour location was distributed as 4 cases in the conus, and 15 cases in the filum terminale. Pre-operative MRI, with and without contrast, diagnosed the intraspinal tumor, and pathology reports demonstrated that each patient had a histologically confirmed myxopapillary ependymoma. At the time of diagnosis, the most common symptoms presented were pain (in 16 patients=84.2%). The pattern of progression of clinical symptoms was directly related to the location of the tumor.

Results: All 19 patients underwent surgical exploration with an attempted gross total resection (achieved in 16 patients=79%) through a posterior approach. Marked adhesions halted further resection in 3 patients with questionable tumor margins. Each patient had an MRI immediately after surgery, approximately 6 months post-operatively, and then annually. Radiation therapy was employed as a surgical adjunct in 3 patients (15.8%) because of possible residual tumor. All patients were followed up postoperatively for an average of 50.6 months (range 6 months to 6 years). All patients are surviving to date. Surgical resection of these tumors led to significant alleviation of pre-operative symptoms.

Conclusion: Based on this study, the authors propose that: (1) the gross feature of myxopapillary ependymoma allowing for complete resectability appears to be the key prognostic factor; (2) radiotherapy appeared to have no proven value in completely resected tumors especially in children; (3) postoperative baseline MRI and regular sequential imaging studies are essential for long-term follow-up.

Objective: Anterior cervical discectomy (ACD) is an effective and safe treatment for nerve root or spinal cord compression caused by disc herniation or spondylosis. Cervical interbody fusion allows preservation of the physiological lordosis and stability of the cervical spine. Based on data reported in the literature, fusion rates decrease significantly when more than one level undergoes surgery, and some authors recommend the addition of a plate system to improve results. We describe our experience in the treatment of 20 patients with two-level disease treated with cervical carbon fiber cages (CFCs) and titanium cages alone.

Methods: Nine patients with cervical radiculopathy and eleven with radiculomyelopathy underwent ACD. Surgery was performed at C5-6 and C6-7 in twelve, at C4-5 and C5-6 in six, at C3-4 and C4-5 in one patient, and at C3-4 and C6-7 in one patient. All the patients underwent magnetic resonance imaging to assess the results of surgery. Titanium cages were used in five patients while carbon cages were used in fifteen patients.

Results: Radiculopathy improved after surgery in all the cases, whereas myelopathy resolved in only five patients. At 1 year fusion was achieved in 80% of the surgically treated discs with use of titanium cages and in 86.7% of those operated with carbon fiber cages while the overall rate of fusion in our 20 patients was 85%; this was verified on cervical spine x-ray films in all patients. Cervical lordosis was restored in five of the six patients in whom it was lost preoperatively. No complications related to cage extrusion and no cases of symptomatic pseudarthrosis were observed.

Conclusions: Interbody fusion cages have a load-sharing function and stabilize the spine to increase segmental stiffness, thus achieving fusion rates similar to those associated with bone grafts, even in multilevel disease.

Objective: Chronic subdural hematoma (CSDH) is a common neurosurgical disorder that often requires surgical evacuation. To minimize the complications associated with catheter insertion in subdural space (SD), modified the direction of burr hole was admitted. In this study the surgical results of using acute angle burr hole are evaluated in avoidance the pitfalls of standard burr hole.

Methods: 100 patients who underwent surgical evacuation of 125 chronic SDHs by catheter insertion in subdural (SD) space through acute angle burr hole were included in this study. They were operated upon at King Fahd Hospital, in Al-Madina Al-Munawarah, SA between 2003 and 2008. Data including clinical features, imaging finding, and technique of the acute angle burr hole were used to analyze the advantages of this simple technique.

Results: The acute angle burr hole was mainly admitted to avoid the frequent complications associated with standard burr hole as parenchymal brain injury and kinked tube at the edge from standard burr hole. Among the patients who treated with the acute angle burr hole, no complications were reported related to catheter-burr hole interface.

Conclusions: Acute angle burr hole is an effective, simple, and safe technique but may be not easier than the standard one in management of chronic SDHs. By using this technique the risk of catheter-related parenchymal injury and drainage obstruction are avoided.

Objective: The purpose of this study is to evaluate the overall results of management of patients presented with subarachnoid hemorrhage (SAH) due to rupture cerebral aneurysms who were admitted at general hospital lacking to the standard known neurovascular surgical facilities.

Methods: The author had reviewed retrospectively the clinical characteristics of 70 patients presenting with SAH due to rupture cerebral aneurysm admitted from January 2003 to January 2008 at neurosurgical department, King Fahd Hospital, Al-Madina Al-Munawarah, SA. Surgical group included 30 patients were operated upon for clipping of the rupture aneurysm. Nonsurgical group included 25 patients were managed conservatively at our hospital, while 10 patients transferred to higher center, and 5 patients refused surgery anywhere. Data including clinical presentations, imaging studies, and results of management for both groups were used to analyze the overall results.

Results: In surgical patients the results was excellent in 25 patients, good in 2, poor in one, and two patients died. Anterior communicating artery aneurysm was predominance in surgical group. In non surgical group 20 patients died and 5 patients in persistent vegetative state. Multiple system failure, cerebral infarction, and rebleeding were the causes for deterioration and death in non surgical patients. The incidence of rebleeding was 5% in our patients which considered not high to be as a main cause of deterioration in both groups of patients.

Conclusion: Management of patients with SAH due to ruptured cerebral aneurysms at general hospital with limited neurovascular resources and facilities must be adopted to fit the actual local circumstances and coup with culture and believing thoughts of the population. The excellent surgical results can be achieved in selected patients with ruptured cerebral aneurysm regardless the presence of standard high level neurovascular facilities.

Objective: Evaluation of the role of continuous lumbar CSF drain in management of early CSF leakage post spinal surgeries.

Methods: This is a cohort study of 43 patients who were operated upon for different pathological conditions who suffered form CSF leakage within the first week after surgery. In all patients an epidural catheter ( G 17) was inserted intraduraly for a maximum of 5 days.

Results: Out of 43 cases included in this study, the CSF leak stopped in 36 cases and never recurred after the drain removal. In 4 cases (83.7 %) the leak did not stop and in 3 cases (9.3 %) it recurred after removal of the drain. Complications included headache in 40 cases (93 %), reoperation for repair in 5 cases (11.6 %), infection in 2 cases (4.6 %) and bifrontal subdural collection in one case (2.3 %).
Conclusion: This method offered a reliable and safe method in management of early CSF leakage after spinal surgeries.

Lesions inside or surrounding the third ventricle and associated with hydrocephalus represent an ideal indication for endoscopic management since many goals can be achieved in one stage surgery through a minimally invasive procedure. The hydrocephalus can be treated by endoscopic third ventriculostomy or septostomy and shunt placement. Furthermore, CSF sampling for tumor marker analysis and/or tumor biopsy or excision can be achieved. In this retrospective study of 26 cases; Hydrocephalus was present in 25 cases and was successfully managed in 21 cases (84%); by ETV or removal of the obstructive cause in 19, Septostomy and shunt placement in 2 and shunt was implanted in 4 due to complications and ETV failure. Positive histological diagnosis was achieved in all 6 colloid cysts, 5/7 pineal tumors, 2 quadrigeminal cistern epidermoid cysts and 3/5 thalamic tumors. The procedure was definitive in managing 21 cases (81%) and further surgery was needed only in 5 cases (19%). Transient manageable complications were encountered in 3 cases (11.5%) and no mortalities occurred related to the procedure. Nevertheless, operative time and hospital stay were much less than with patients with similar conditions and managed with open microsurgical procedures.

Conclusion: The neuroendoscope can safely be used in management for patients with pathologies inside or surrounding the third ventricle as it offers not only palliative but in many instances definitive surgical treatment, especially when associated with hydrocephalus that in many cases is relieved without the need of shunting.

Objectives: While medulloblastoma is the most common primary childhood CNS tumor, it is much rare in adults, accounting for approximately 1% of all adult primary brain tumors. The goal of the present study is to describe the management of adult patients with medulloblastoma to identify prognostic factors important for survival and disease control on the basis of experience with 15 cases.

Methods: Fifteen patients who were 16 years old or more and had medulloblastoma were treated between 2002 and 2007 in the department of Neurosurgery, Ain Shams University Hospitals. There were eight women and seven men with a median age of 24 years (range 16-35 years). Surgery was performed via midline trans-vermian in two patients, telovelar approach in three patients, and retro-sigmoid trans-cerebellar approach in 12 patients (ten de novo, and two after recurrence). A retrospective study was conducted by analyzing clinical data, neuro-imaging studies, operative findings, and histopathological reports. The degree of tumor resection, clinical outcome, adjuvant therapy, and recurrence are described. The staging of the patient was done by using Chang staging system.

Results: The duration of symptoms prior to diagnosis ranged between one to six months; with a mean value of 3 months. Medulloblastoma was present in the lateral cerebellar hemisphere in ten cases (66.7%), while it was midline vermian in five cases (33.3%). Nine patients (60%) had classic variant, while six patients (40%) had desmoplastic variant. Eleven cases (73.3%) underwent gross total resection, eight patients with lateral subtype, and three cases with vermian subtype. The remaining four cases (26. 7%) underwent subtotal resection (two vermian with brainstem infiltration, and two lateral with middle cerebellar peduncle infiltration). All the patients received cranio- spinal irradiation, while four patients (26.7%) received adjuvant chemotherapy. Recurrence was reported in four patients (26.7%). Three out of four with recurrence died during chemotherapy course. No operative related mortality, and over all mortality rate was three of 15 patients (20%).

Conclusion: with the advent of microsurgical techniques, and chemo-radiotherapy, the long term survival is possible in adults treated for medulloblastoma. Lateral medulloblastomas are more amenable to complete resection. Tumor location, brainstem infiltration, and degree of tumor resection are important prognostic factors. Complete tumor resection according to the selected approach, and prompt radiotherapy is recommended. Tumor recurrences should be treated with aggressive therapies and close follow up should be taken in mind. Prognostic factors vary from one study to another but prospective trials with large number of patients should continue to analyze classic factors such as sex, and histopathological variants.

Background: The development of new technology in neurosurgery, interventional neurovascular techniques, and gamma knife surgery (GKS) has dramatically changed the therapeutic alternatives for brain arteriovenous malformations (AVMs).The purpose of this study is to report the safety and efficacy of transarterial embolization of intracranial arteriovenous malformations treated with N-Butyl Cyanoacrylate (Histoacryl).

Patients & Methods: We present a prospective analysis of 42 consecutive patients with brain AVMs treated in Ain Shams University from June 2005 to January 2007, (30 men, 12 women). The patients' average age was 30.5 years. Seizures was the presenting symptom in 24 patients. The average Spetzelar - Martin grade at presentation was grade 3 .The AVMs Nidus volume ranged from 2 cm3 to 90 cm3. Embolization of the AVMs by N-Butyl Cyanoacrylate was done in 42 patients. All patients were treated with the ultimate goal of complete AVMs obliteration. AVMs that are not totally obliterated were embolized to reduce the size and referred to gamma knife treatment. The course of treatment for each patient was reviewed. The effectiveness at the end of treatment was analyzed if not totally occluded, and the ability to reduce the AVMs to radiation size is assessed. Additionally, the safety of each embolization technique was evaluated in terms of the safety of the procedure itself, and the outcome at the end of the treatment.

Results: One hundred and four procedures were done in 42 patients. The number of sessions varied from 1 to 6 sessions. The percentage of volume reduction ranged from 100% to 78.2%. Total occlusion (cured by embolization only) was achieved in ten patients (23.8%), reduction to a volume less than 4 cm3 (suitable for radiosurgery) was achieved in 30 patients (71.4%), while in two patients (4.8%) reduction to a volume between 4-10 cm3 was achieved. Complications occurred in three patients (7.1%); seizures occurred in two patients; while intracerebral with intraventricular hemorrhage occurred in one patient (2.4%). There was minimal transient morbidity in one patient (2.4%) in the form of temporary decrease in visual acuity. Permanent morbidity related to the procedures observed in one patient (2.4%) in the form hemi-paresis grade 3.There was no mortality in this study.

Conclusion: Intracranial arteriovenous malformation embolization with N-Butyl Cyanoacrylate (Histoacryl) is a safe and effective technique that permits complete cure of brain AVMs. However, larger AVMs are reduced in volume to be fit for radiosurgery.

Objectives: The present prospective study aimed to evaluate the outcome of anterior microdiscectomy with cervical spinal fixation using polyetheretherketone (PEEK) cage in patients with multi-level cervical spondylotic myelopathy (CSM).

Patients & Methods: The study included 50 patients; 27 males and 23 females with a mean age of 50.4±7.2 years and had CSM caused by osteophytic ridge or soft disc herniation in single or multiple levels. Clinically; 23 patients (46%) had radiculopathy, 5 patients (10%) had mylopathy and 22 patients (44%) had combination of rediculomylopathy. X-ray and MR imaging detected spondylotic lesions at 83 discs; 27 patients had spondylotic lesions at one level, 13 patients at 2 levels and 10 patients at 3 levels with C5-6 was the commonest level affected. All patients underwent surgeries using the anterior approach and PEEK cage was used for spinal fixation. Postoperative follow-up was conducted using radiological examinations and the patients' function and working ability were assessed preoperatively, postoperatively and at the end of follow-up, using the Coopers' scale.

Results: All patients passed smooth intraoperative course and a total discectomies were performed at 83 levels. Postoperatively, 3 patients developed complications with a postoperative complication rate of 6%. At 6-months after surgery, 44 patients had good fusion and by 9 months 47 patients had good fusion with a mean duration of 4.1±2.4 months till having good fusion. Mean postoperative mean interbody height was 11.3±1.8 mm and was significantly increased compared to preoperative height and a mean increase in the height of the foramina of 29.4%. All patients showed functional and ability improvement of varied degrees with a mean postoperative Cooper scale of 1.18±0.72; range: 0-3 that was significantly lower compared to the preoperative (3.2±0.95; range: 2-5) score and a mean improvement of Cooper scale by 62.5% in comparison to preoperative score. Subjectively, 40 patients reported excellent-to-good improvement. There were no patients with cage failure, dislodgement, or pseudoarthrosis was noted at the 1-year follow-up examination.

Conclusion: cervical microdiscectomy with PEEK cage fusion could be considered as a safe, effective modality for managing patients with multi-level cervical disc disease providing good fusion by 6-months with excellent-to-good functional results in 80% of patients with minor or no intraoperative and postoperative complications.

Objectives: The present study was designed to determine the surgical yield of C1-C2 fixation by implantation of Halifax clamp for the treatment of patients with C1-C2 instability.

Patients & Methods: The present study included 14 patients; 9 males and 5 females with mean age of 36.5±10.9 years, assigned for C1-C2 fusion for non-neoplastic disease; diagnosis and inclusion was confirmed by MR imaging. The applied technique for C1-C2 hook fixation was conducted according to Holness et al., using either iliac crest or autogenic bone graft. Postoperative bracing (firm collar) was applied for 1 week. Outcome Measures included radiological evaluation of successful bone fusion, neurological evaluation using the American Spinal Injury Association (ASIA) motor score, neck and arm pain scoring, neck disability index (NDI) and the functional independence measure (FIM) presented as total motor score. Evaluations were conducted preoperatively and at end of follow-up.

Results: The study included 8 patients with odontoid fracture, 2 transverse atlantal ligament injuries, 2 os odontoideum and 2 had rheumatoid C1-C2 instability. The mean duration of symptoms was 15±10.1; range: 3-30 months. Preoperative neurological evaluation detected 7 patients were ASIA grade B, 4 were ASIA grade C and 3 patients were ASIA grade D. All surgeries were conducted smoothly without intraoperative complications and an autogenous iliac crest graft was applied in 8 patients, while artificial bone grafts were used in 6 patients. Radiological examinations conducted at end of follow-up period for 23.4±8; range: 6-36 months showed evidence of fusion, defined as the absence of C1-C2 movement on lateral flexion-extension radiographs and continuity of trabecular bone formation between C1 and C2 across the graft and disappearance of spine instability. Postoperative clinical evaluation revealed significant improvement of neurological ASIA grading and 12 patients (85.7%) showed complete recovery without motor or sensory deficit and only 2 patients had persistent upper limb weakness and exaggerated reflexes. Both pain and neck disability scores showed significant decrease postoperatively compared to preoperative scores. Postoperative total FMI motor power scoring was significantly higher compared to preoperative measures.

Conclusion: Posterior C1-C2 fixation using Halifax clamp system is technically simple to apply and can be done safely without concomitant intra- or postoperative complications. High success rates in obtaining fusion and significant improvement at the end of follow-up with high quality-of-life scores make this method of posterior fixation and fusion an ideal surgical modality for higher cervical spine instability.

Objective: In this retrospective review of prospectively collected data, we report the clinical outcomes of thirty patients with anterior communicating artery (ACoA) aneurysms who presented and operated upon late (from day 4 to day 14) from the onset of subarachnoid hemorrhage (SAH).

Methods: (A)Patient selection: patients presented to the Neuroemergency unit in Kasr El-Einy Hospital from January 2006 to December 2007with ACoA aneurysmal SAH of clinical grade I,II &III presented late (after 4th day) who underwent clipping of ACoA aneurysms at day 4 to day 14 form the onset of SAH. (b) Procedure: conventional operative clipping of the neck by the appropriate clip. (c) Evaluation of postoperative clinical outcome by the modified Rankin Scale at the time of hospital discharge and at 6-months thereafter, then comparing the clinical outcomes with those of the early clipping procedures as well as those with late clipping in other researches.

Results: The overall outcomes at the time of hospital discharge using the modified Rankin Scale were good in 21 patient (70%), fair in 6 patients (20%), and poor in 3 patients (10%). At 6-months follow up, outcomes were good in 24 patients 80% as 3 patients were back to normal life among 21 patients who had previously worked , fair in 3 patients (10%), poor in 3 patients (10%).mortality was 2 cases, vegetative state was 1 case . overall ,80%of patients returned to work after 5 months , 10% were mildly disabled.

Conclusions: With suitable perioperative resuscitation the timing of surgery for ruptured anterior communicating aneurysms apparently no longer affects surgical outcome. In this series late surgery was done due to certain delay in diagnosis, referral , logistic factors and not due to clinical decision found that there is no difference in surgical outcome between results of our series and the results of other series underwent operation in early period , however we did not recommend any delay in clipping as early clipping will reduce the high risks of rebleeding and also results in a more rapid discharge from hospital resulting in decreasing the cost.