Volume 14, No. 2, October 2010 Pan Arab Journal of Neurosurgery Official Journal of the Pan Arab Neurosurgical Society ALGIERS VIIIth PAN ARAB CONGRESS OF NEUROSURGICAL SOCIETY November 26-29, 2010 Indexed by EMBASE, Excerpta Medicus & WHO Eastern Mediterranean Index Medicus Official Journal of Pan Arab Neurosurgical Society Volume 14, No. 2 ISSN 1319-6995 October 2010 Patron: HRH Prince Khalid Bin Sultan Bin Abdulaziz EDITOR-IN-CHIEF ASSOCIATE EDITORS Khalaf Al Moutaery Abdeslam El Khamlichi, Morocco Antoine Nachanakian, Lebanon MANAGING EDITOR Valerie McCue EDITORIAL BOARD Benaissa Abdennebi, Algeria DESKTOP PUBLISHING Saleem Abdulrauf, Saudi Arabia (USA) Vittoriana Crisera Ahmed Ammar, Egypt Fawaz Assaad, Syria ARABIC ABSTRACTS Yousef Al-Awadi, Kuwait Translation Department Saleh Baeesa, Saudi Arabia Riyadh Military Hospital El Fatih Bashir, Sudan Mohammed Boucetta, Morocco Fady Charbel, Lebanon (USA) Please address all correspondence to: Mohamed Lotfy Ibrahim, Egypt Bermans Iskandar, Lebanon Prof. Khalaf Al Moutaery Mahmoud Z Karmi, Jordan Editor-in-Chief Mohamed Hassan Katramiz, Syria c/o Riyadh Military Hospital Moncef Khaldi, Tunisia Pan Arab Journal of Neurosurgery Abdulkarim Msaddi, UAE P O Box 7897, Riyadh 11159 Waleed Murshid, Saudi Arabia Kingdom of Saudi Arabia Ibrahim Sbeih, Jordan Fax: (966 1) 476 8273 Bassem Sheikh, Saudi Arabia Email: [email protected] Ghassan S Skaf, Lebanon www.panarabneurosurgery.org.sa Mondher Yedeas, Tunisia ADVISORY BOARD For advertising enquiries, please contact: Issam A Awad, USA Peter Mclaren Black, USA Ms. Valerie McCue Rudolf Fahlbusch, Germany Tel: (966 1) 477 7714/ 479 1000, ext. 25443 Richard G Fessler, USA Fax: (966 1) 476 8273 Michael Gaab, Germany Email: [email protected] Jens Haase, Denmark Patrick W Hitchon, Lebanon (USA) Tetsuo Kanno, Japan Yoko Kato, Japan Douglas Kondziolka, USA Donlin M Long, USA Ashok K Mahapatra, India Aim & Scope of the Journal: The Pan Arab Journal of Neuro- Ossama Al-Mefty, USA surgery aims to stimulate scientific research and associated Wai Sang Poon, Hong Kong communication among hospitals and universities throughout the Albert Rhoton, USA Arab world by publishing peer-reviewed, original articles highlighting Concezio Di Rocco, Italy current advances throughout the region in Neurosurgery and Marc Sindou, France related sciences. Manuscripts from throughout the world are also Robert F Spetzler, USA published, as well as summaries of any MD thesis successfully com- Dietmar Stolke, Germany pleted in any Arab University. In addition, an Academic Calendar is Alexander R Vaccaro, USA included in order to inform subscribers of any upcoming related sym- Andreas Weidner, Germany posia both throughout the region and abroad. M Gazi Yasargil, USA ii PAN ARAB JOURNAL OF NEUROSURGERY VOLUME 14, NO. 2, OCTOBER 2010 iii iv PAN ARAB JOURNAL OF NEUROSURGERY Editorial Message from PANS President Elect & 8th PANS Congress President Dear Colleagues, In November of this year, Algiers will have the privilege to be the host city for the 8th Pan Arab Neurosurgical Congress. I seize this opportunity to express my sincere gratitude to the members of the Executive Committee of our society who put their trust in us. It is in the nature of things that topics chosen for this meeting should be in harmony with the state of the art in neurosurgery but also taking into account our daily preoccupations. Surgical techniques such as surgery in awake patients, cortical mapping in surgery of eloquent areas, epilepsy, Parkinson’s disease, and endoscopy are more and more practised and will be covered in this meeting. Speakers will also share their knowledge on spinal, paediatric and vascular surgeries. Obviously, the Scientific Programme will include a session of “free papers“. In connection with these sessions, teachers will focus on “How I do it?” their experience in surgical approaches whereas others will tell us about “What is new?” in neurosurgery. Finally, our female colleagues will hold a round table conference to discuss their own problems. A meeting of the Executive Committee will be held where we will debate a pre established agenda. On the other hand, I would like to highlight the prominent part of the first pillar of our society, the Pan Arab Journal of Neurosurgery. Its regular issue and high scientific level of articles, not only from the Arab countries but also from all over the world, give evidence to the importance and the current place of the Arab neurosurgical society. I am sure that with the enthusiasm of all the attendees, the choice of the topics covered, the beauty of Algiers, ”the white city”, will all contribute to attendees experiencing an interesting and memorable congress. With the efforts of everybody, I wish the best for our society. As the proverb says “Where there is a will, there is a way”. Prof. Benaissa Abdennebi PANS President Elect 8th PANS Congress President Chief, Department of Neurosurgery Salim Zemirli Hospital El Harach Algiers Algeria VOLUME 14, NO. 2, OCTOBER 2010 ix Case Review Intracranial hypotension Makarand Kulkarni1, Sanjay Mongia2, K Ravishankar3, Vinay Chauhan3, Manoj Deshmukh1 Abstract: Intracranial hypotension is a clinical condition which mostly presents with orthostatic headache. It is caused by CSF leak through dura. There is varied clinical presentation and aetiology of the condition. Magnetic resonance imaging is one of the most important tools in the diagnosis of this condition. We report 5 cases of intracranial hypotension with different aetiology and clinical presentation. (p104-107) Key words: Intracranial hypotension and orthostatic headache. Introduction Intracranial hypotension (ICH) is characterised by cerebro- more so in sitting position. The initial magnetic resonance spinal fluid (CSF) leak leading to reduced CSF pressure imaging (MRI) was normal but was repeated after 15 days, within the cranium. It has a diverse aetiology varying from as the headache worsened. There was bilateral, thin subdural spontaneous(9), post lumbar puncture(13), post spinal surgery collection with diffuse pachymeningeal enhancement (Figs. (7), post traumatic CSF leak, thoracomeningeal fistula, after 1 and 2). VP shunt and leakage of the CSF through spinal meningeal cyst.1,9 There is a case report of ICH due to transdural thoracic disc herniation.14 There can be medical causes of this condition which include dehydration, diabetic coma and uraemia. Clinically it is characterised by orthostatic headache. Apart from headache, patient may present with nausea, vomiting, anorexia and neck pain. There may be diplopia, tinnitus, vertigo and galactorrhea.8 We report 5 cases of different aetiology and clinical presen- Figure 1 ↑ T2W image showing thin subdural collection over bilateral cerebral surface. Figure 2 → T1W post contrast im- tation. Four of our patients presented with postural headache age showing diffuse pachymeningeal enhancement. while one presented with only diplopia. Two patients had spontaneous onset, one patient was post traumatic, one post Magnetic resonance imaging of spine was normal. The spinal surgery and one had rupture of perineural cyst in the patient was treated conservatively with bed rest, hydration pleural space. and oral theophylline, with regression of clinical symptoms. Follow-up MRI after 5 months showed completely resolved Case Report subdural collection. This was a case of spontaneous ICH Case 1: Thirty-seven-year-old male presented with headache, and illustrates delay in the appearance of MR features. Case 2: Sixty-five-year-old female presented with sudden 1 onset of severe headache. Initial clinical picture was Consultant Radiologist 2Consultant Neurosurgeon suggestive of subarachnoid haemorrhage and hence 3Consultant Neurologist computerised tomography (CT) and MRI were done which Lilavati Hospital and Research Centre Mumbai were negative. Lumbar puncture was done with opening India CSF pressure with 11 cm of water. There were no cells in Correspondence: the CSF. With these negative findings she was diagnosed as Dr. Sanjay Mongia migraine. Her clinical symptoms worsened and the Consultant Neurosurgeon headache now related more with sitting position. Magnetic Lilavati Hospital and Research Centre Mumbai resonance imaging was repeated with screening of entire India spine showing thin bilateral subdural collection (Fig. 3). Email: [email protected] The post contrast MRI showed diffuse pachymeningeal 104 PAN ARAB JOURNAL OF NEUROSURGERY INTRACRANIAL HYPOTENSION • Mongia, et al relieved only in head low position. Magnetic resonance imaging showed thin subdural collection over bilateral cerebellar surface with diffuse dural enhancement on post contrast study (Figs. 10 and 11). The patient responded to conservative therapy with bed rest in head low position and oral theophylline. Physicians should be aware of this complication after spinal surgery.7 Figure 3 ↑ T2W image showing thin bilateral subdural collection. Figure 4 → Post contrast T1W image showing diffuse pachy- meningeal enhancement. Figure 7 ↑ Constructive interference in steady-state sequence showing CSF leak from the floor of anterior cranial fossa. Figure 8 → T2W coronal images at the level of pituitary. There is reduced distance between optic chiasm and pituitary. Figure 5 ↑ Sagittal T1W image showing prominent pituitary with reduced distance between optic chiasm and pituitary. Figure 6 → T2 coronal image of dorsal spine showing a right-sided peri- neural cyst at D10-11 level with a large right-sided pleural effusion.