ABSTRACT A 37-year-old male patient was complaining from painless forehead swelling, which started 5 years ago. Brain computed tomography scan and magnetic resonance imaging showed a large extradural mass compressing the both frontal lobes with skull bone infiltration, hyperostosis and enlargement. The patient was operated in 2 stages. In the first stage, the authors achieved separation for the tumor from the scalp and skull. In the second stage after 1 week, the authors continued with circumferential dural opening around the tumor and separation of the tumor from brain tissue. Duroplasty was performed by autologous fascia latta and skin flap was closed primarily. The specimen was received grossly as huge mass weighing 1530 g and measuring 39 × 16 × 12 cm. Histopathologic examination showed grade I meningioma extending beyond the skull to the surrounding soft tissue.

Objective: Cranioplasty is a well-established common surgery in the practice of neurosurgery and craniofacial surgery. In young patients, complete skull defect closure by bone splitting may be troublesome due to the difficulty to obtain enough bone area. In such cases, sometimes the authors need to use allografts, which may not be widely available in rural practice. In this study, the authors present the series of cranioplasty with polypropylene mesh, which is widely used in abdominal wall closure. Patients and Methods: Nine patients with depressed compound skull fracture were treated by performing this technique. Selection criteria were: compound depressed skull fractures in which bones were fragmented in a way not able to be reconstructed with and leaving a skull defect, small-sized or relatively medium-sized skull defects, and skull defects not located on the sharp curvatures of the skull which needs firm bended meshes. All patients were male and their ages ranged between 8 months and 36 years. The skull bone defect was reconstructed with polypropylene abdominal wall mesh, which was sutured circumferentially with the galeal tissue. Results: Skull defects were successfully treated in all patients. The follow-up period ranged from 4 to 13 months. One patient with a history of alcoholism and neglectance developed a wound infection after 3 weeks of surgery. This patient was treated successfully with intravenous antibiotics without the need to remove the mesh. There were no complications in the remaining 8 patients. Conclusions: Polypropylene mesh is a cheap and effective material for the reconstruction of small-sized or medium-sized skull defects. It can be a good alternative in rural practice and/or low economic communities, when other cranioplasty materials are not available.

A 7-year-old boy referred to our emergency department complaining of headache, nausea, vomiting, dizziness, generalized fatigue, ataxia and diplopia. Neurological exam showed bilateral papilledema and ataxic gait. Routine blood test, plain chest x-ray and abdominal ultrasonography were normal. Brain computed tomography (CT) scan and magnetic resonance imaging (MRI) revealed well-defined intra-axial unilocular cystic lesion in the left cerebellar hemisphere, causing mass effect on brain stem and fourth ventricle with associated tonsillar herniation and mild obstructive hydrocephalus. The authors started the treatment with Albendazole and the patient was operated with left sub-occipital craniotomy. Cyst was delivered with intact capsule. Postoperative period was uneventful and patient's symptoms improved totally after 1 week. Histopathologic examination confirmed the diagnosis of hydatid cyst.

A 14-year-old female patient presented with symptoms of chronic mid and low back pain that radiated to both lower limbs for 5 months, with rapidly progressive lower limb weakness and urine retention. Radiologic evaluation revealed an intramedullary mass at the level of first to sixth thoracic vertebrae. The patient underwent surgery and intraoperative findings showed an intramedullary mass lesion composed of well-differentiated fat tissue. A postoperative histopathologic examination revealed mature adipose tissues consistent with lipoma. Post-operatively patient showed improvement in lower limb motor power and started an extensive rehabilitation program.

A 72-year-old female patient was complaining from gradual loss of hearing in the left ear, left facial palsy with gait imbalance. Neuroimaging showed left cerebellopontine angle extra-axial mass and was diagnosed as acoustic neuroma. She was operated with left retromastoid suboccipital and gross total excision of the tumor was achieved. Early postoperative period was uneventful and brain computed tomographic (CT) scan in the postoperative day 1 showed gross total resection of the tumor without complications, and patient was discharged at the postoperative day 4. In the postoperative day 7, the patient showed decrease level of consciousness and brain CT scan showed a small hematoma in the anterior part of the left temporal lobe, which was evolved to large intraparanchymal hemorrhage with midline shift in postoperative day 9.

A 21-year-old male patient was operated for third ventricle tumor (central neurocytoma) and showed improvement in the early postoperative period. After 2 weeks of surgery, the patient neurologic status deteriorated with acute decreased level of consciousness. Neuroimaging of the brain revealed entrapped left temporo-occipital horns with adhesion bands at the level of the atrium. Patient was operated with neuronavigation-guided endoscopic approach to the left atrium through the left posterior parietal region. Band adhesiolysis was performed with no complications. The patient showed fast improvement, and follow-up brain magnetic resonance imaging after 2 years showed the release of the ventricular entrapment with significant regression of the left ventricle size.

Objective Treatment of brain arteriovenous malformations (AVMs) aims to abolish any risk for intracranial hemorrhage with the preservation of the patient’s functional status. We present the technique of pre-surgical endovascular devascularization through proximal feeder artery occlusion for the treatment of cranial AVMs rather than nidus occlusion. Also, we highlight the advantages and the possible clinical indications. Patients and Methods Two patients with brain AVM and one patient with scalp AVM were treated by pre-surgical endovascular devascularization followed by surgical resection. Endovascular devascularization was performed by occlusion of the AVM feeders only with Liquid Embolic System Agent (Onyx®) 18 without entering and filling the nidus. During surgery, feeding arteries colored with the black color of the Liquid Embolic System Agent were clearly identified and cut. Dissection of the AVM was performed, and resection of the nidus was achieved. Results Total resection of the AVM was achieved in all cases confirmed with follow-up angiographies, with no neurologic or systemic complications. Also, no major bleeding was detected. In addition, the surgical clips were avoided during surgery. Brain AVMs were safely resected in piecemeal fashion. Conclusion Pre-surgical endovascular proximal feeder artery devascularization technique shows to be a safe, simple and effective technique for the management of cranial arteriovenous malformations. This technique simplifies both the endovascular and surgical approaches to complicated cranial AVM cases.

Khaled Alawneh 1 Bashar Abuzayed Majdi Al Qawasmeh Liqaa Raffee 4 Abdelwahab Aleshawi 1Department of Radiology, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; 2Department of Neurosurgery, The Specialty Hospital, Amman, Jordan; 3Department of Neuroscience, Division of Neurology, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; 4Department of Accident and Emergency, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan; 5King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan Objective: Treatment of brain arteriovenous malformations (AVMs) aims to abolish any risk for intracranial hemorrhage with the preservation of the patient’s functional status. We present the technique of pre-surgical endovascular devascularization through proximal feeder artery occlusion for the treatment of cranial AVMs rather than nidus occlusion. Also, we highlight the advantages and the possible clinical indications. Patients and Methods: Two patients with brain AVM and one patient with scalp AVM were treated by pre-surgical endovascular devascularization followed by surgical resection. Endovascular devascularization was performed by occlusion of the AVM feeders only with Liquid Embolic System Agent (Onyx) 18 without entering and filling the nidus. During surgery, feeding arteries colored with the black color of the Liquid Embolic System Agent were clearly identified and cut. Dissection of the AVM was performed, and resection of the nidus was achieved. Results: Total resection of the AVM was achieved in all cases confirmed with follow-up angiographies, with no neurologic or systemic complications. Also, no major bleeding was detected. In addition, the surgical clips were avoided during surgery. Brain AVMs were safely resected in piecemeal fashion. Conclusion: Pre-surgical endovascular proximal feeder artery devascularization technique shows to be a safe, simple and effective technique for the management of cranial arteriovenous malformations. This technique simplifies both the endovascular and surgical approaches to complicated cranial AVM cases.

A 15-year old female patient was complaining from swelling in the left side of the neck since 3 months. Physical examination showed palpable and mobile left supraclavicular neck mass in the carotid triangle, uvula deviation to the left side and normal vocal cords position and function. Neck imagings showed well-defined, well-encapsulated left neck mass in the left carotid sheath pushing the internal jugular vein anteriorly and the common carotid artery posteriorly. The mass was extending from the level of C4 superiorly and the supraclavicular region inferiorly. Patient was operated with left anterior approach and circumferential dissection and enucleation was performed. Post-operative period was uneventful and devoid of any complications or deficits. Histopathological examination revealed Castleman disease.

Background To reduce the risk of cerebrospinal fluid leak, clinicians utilize a filling material placed in the sella followed by floor reconstruction with various materials, including glue sealing. Cyano-acrylic glue Glubran®2 glue is commercially available and is generally used as embolizing agent and for the prevention of cerebrospinal fluid leakage. Case Description A 25-year-old woman underwent endoscopic endonasal transsphenoidal surgery for pituitary adenoma. After tumor resection, sellar floor reconstruction was performed by mucosal graft and Glubran®2 glue. The early post-operative period was uneventful. However, 2 months after surgery, the patient complained of headache, facial pain and greenish foul-smelling nasal discharge with solid particles dripping from the nose. Medical treatment was unsuccessful. Brain MRI showed inflammation and thickening of the sphenoidal and para-sphenoidal mucosa. The patient underwent endoscopic endonasal surgery and a solid glass-like mass surrounded by inflamed infected mucosa was seen in the inferior and lateral aspects of the sphenoid sinus. Efforts were made to erupt and de-crust the solid mass until total resection was achieved. Early post-operative period was uneventful, and a course of antibiotics was continued until total disappearance of the discharge. Conclusion To the best of our knowledge, this is the first case reporting of acrylic glue (Glubran®2)-related sinusitis. Surgeon should be aware about similar side effects for the glue material that would complicate the surgery.

Ventriculo-femoral vein shunts have been described in few case reports as an alternative for treating complex cases of hydrocephalus in which other accesses are discarded. To our best knowledge, only 6 cases have been reported in the literature to date. We present a case of a 2-year-old female patient with hydrocephalus secondary to neonatal sepsis and meningitis. Patient was operated with various types of shunting procedures, such as ventriculo-peritoneal (V-P) shunt, ventriculo-atrial (V-A) shunt, ventriculo-pleural (V-PL) shunt, ventriculo-vesical shunt, ventriculo-superior sagittal sinus (V-SSS) shunt, and ventriculo-caval (V-C) shunt. All previous procedures were unsuccessful in treating the hydrocephalus. Finally, right ventriculo-femoro-caval shunt procedure was performed. Distal catheter was inserted into the right femoral vein and passed toward inferior vena cava under fluoroscopy guidance. The early postoperative period was uneventful. Late postoperative complications consisting of few periods of shunt dysfunction and distal obstruction were managed as an outpatient with injection for diluted heparin in the shunt valve, resulting in recovery of the shunt function. This was the management until the age of 4 when the femoral vein shunt was removed and right ventriculo-pleural shunt was placed. The patient tolerated this surgery and long-term follow-up showed good neurological status without episodes of shunt dysfunction.

BACKGROUND:Extra-axial cavernomas at the cerebellopontine angle (CPA) are rare clinical entity that can radiologically mimic several lesions encountered at this location.CASE DESCRIPTION:A 36-year-old female patient referred to our emergency service with acute decreased level of consciousness and vomiting. Neurological examination showed Glasgow Coma Scale of 12 with downbeat nystagmus of the right eye. Brain computed tomography scan and magnetic resonance imaging showed multilobulated extra-axial mass lesion located in the right CPA. The lesion was with various signal intensities in T1- and T2-weighted images suggestive of hemorrhages of different ages. T2 gradient echo sequences showed multiple sinusoid-like channels and diffuse hemosiderin deposition. These figures were compatible with cavernous malformation. The patient was operated by retrosigmoid approach. Dissection of the mass from the trigeminal, facial, vestibulocochlear, and lower cranial nerves was performed and total resection of the tumor was achieved. Histopathological examination confirmed the diagnosis of cavernoma.CONCLUSION:Although CPA cavernomas are very rare, they should be considered for differential diagnosis when evaluating CPA lesions preoperatively for better intraoperative management and postoperative outcomes.

Background: Gangliogliomas are neoplasms containing both astrocytic and neuronal components. We present a case of gangliogliomas of the optic chiasm, which are extremely rare pathologies. Case Description: A 16-year-old female patient referred to our clinic with gradual deterioration of vision for the age of 1 year mostly in the right eye. Ophthalmic examination confirmed reduced visual acuity with only perception of light in the left eye. Brain magnetic resonance imaging showed a solid mass lesion involving the hypothalamus and the optic chiasm, which was hypointense on T1-weighted images, hyperintense on T2-WI, and marked homogenous contrast enhancement. The patient was operated and bulging of the optic chiasm and the site of lamina terminalis was seen. Subtotal resection of the tumor was achieved. Histopathological examination revealed ganglioglioma (WHO Grade I). Follow-up of the patient was for 3 years and 8 months with stable neurologic and radiologic findings. Conclusion: To the best of our knowledge, 20 cases, including ours, have been reported in the literature and a presurgical diagnosis of ganglioglioma is very infrequent with confused radiologically with low-grade pilocytic astrocytomas.

The burden of stroke can be substantially studied by establishing the functional consequences of stroke and its predictors on the population, economy and to guide rehabilitation efforts. This study aims to determine the subtypes, risk factors, and epidemiology of stroke in Jordan. Methods: A retrospective cohort study design was carried out to determine the risk factors and subtypes of stroke during 2017-2018. The study sample included 176 ischemic stroke patients of the King Abdullah University Hospital. Data was collected through medical records, which was then statistically analysed through frequencies and percentages. Results: Total 176 cases were identified out of which 101 (57.38%) were males and 75 (42.61%) were females and male to female ratio was 1.9:1. Hypertension was the commonest risk factor identified (50.56%), followed by diabetes mellitus (19.88%), hyperlipidaemia (15.34%), coronary artery disease (6.25%), atrial fibrillation (4.54%), and past history of stroke (1.13%). Risk factors such as hypertension (p = 0.007), diabetes (p = 0.000), coronary artery disease (p = 0.000) were significantly associated with subtypes of ischemic strokes. Conclusion: The study concludes that mean age of men was higher as compared to women in small vessel occlusion. The risk of ischemic stroke in patients with dyslipidaemia, diabetes mellitus, and hypertension was higher in middle-aged and old patients.

Peripheral neuropathy is a common neurodegenerative disease, with vastness of inducers and causalities. The acquired form peripheral neuropathy can be caused by traumatic injuries caused by nerve lacerations or compressions. Such injuries are usually followed by Wallerian degeneration, and inflammatory reaction. We present a case of a 33-year-old female with a chronic loss of the ulnar nerve function for 8 years after traumatic laceration. After that, she regained the functions of ulnar nerve after nerve stimulation by peri-ulnar nerve injection of methylprednisolone and lidocaine. The theory behind using steroids is related to the fact that the immune system could induce a secondary injury that interferes with the recovery. Many studies have shown effectiveness in using steroids alone or when combined with other substances on nerve regeneration in animal models. We believe that this is the first report of nerve recovery using local steroidal injections after a traumatic injury.

A 63-year-old male patient was referred to our outpatient clinic with complaints of upper and lower limbs weakness, which started progressively 5 years ago.Cervical X-ray and magnetic resonance imaging showed straitening of the cervical column in a fixed flexion position and fusion of the vertebral bodies, with diffuse type posterior longitudinal ligament ossification with secondary canal stenosis.The patient was operated with C2-T2 laminectomy.In the immediate post-operative period, the patient was conscious.However, he was unable to breath by himself with insufficient respiratory tidal volume and worsening of the weakness of the extremities.Emergency cervical computed tomography scan showed proper decompression of the cervical canal, no evidence of haemorrhage, and enlarged oedematous spinal cord.The patient was diagnosed of post-decompression reperfusion injury with secondary diaphragm paralysis.Ventilation and medical treatment were applied to manage the situation and the patient improved in his lower limbs motor power and in the tidal volume.The decision was to transfer the patient to another rehabilitation centre to continue treatment.

BACKGROUND Intracranial chondroma is a rare benign tumor that more commonly arises from the skull base. Chondroma arising from the falx cerebri is very rare, with only 19 cases previously reported in the literature. The imaging characteristics of intracranial chondroma and meningioma can be similar. Surgical excision and histology are required for the diagnosis. This report is of a case of intracranial chondroma that includes the imaging findings. The methods of diagnosis, management, and prognosis are discussed. CASE REPORT A 44-year-old man presented with episodes of severe headache. Magnetic resonance imaging (MRI) showed a well-defined, extra-axial, parafalcine lesion in the right frontal region. An interhemispheric craniotomy was performed. A right frontal solid and calcified tumor attached to the falx cerebri was identified and removed. Histology confirmed the diagnosis of a benign chondroma containing areas of hemorrhage and cystic degeneration. CONCLUSIONS Chondroma arising in the falx cerebri is a rare intracranial tumor that may mimic meningiomas on imaging. Awareness of the varied imaging characteristics of these benign tumors is essential for planning the most appropriate treatment.

A 78-year-old woman with progressive worsening vertigo and new onset of diplopia. Neurological examination revealed bilateral abducens nerve paralysis and gait disturbance with truncal ataxia. Neuroimaging revealed a mass lesion within the clivus with brain stem compression. The patient was operated with provisional diagnosis of clivus chordoma by neuro-navigation-guided extended endoscopic endonasal approach. Subtotal resection of the tumor was achieved with no intra- or postoperative complications. Histopathologic examination revealed intraosseous meningioma (WHO grade I). To the authors' best knowledge this is the first case reporting clivus site of intraosseous meningioma.

Background: Traumatic spinal epidural hematomas (TSEDH) are rare, with the reported incidence being < 1% of all spinal injuries. Causes of TSEDHs include vertebral fractures, obstetrical birth trauma, lumbar punctures, postsurgical bleeding, epidural anesthesia, and missile injuries. The retrodental location has not been reported as a location for spontaneous epidural hematoma. Case Report: A 4-year-old boy was admitted to our Emergency Department after falling down and experiencing head trauma. Glasgow Coma Scale score was 15/15 with no neurologic deficit. Brain computed tomography scan showed isolated hyperdense hematoma in the retrodental area without any fractures in the skull or cervical vertebrae. Brain and cervical magnetic resonance imaging showed a retrodental acute hematoma that was isointense in T1-weighted sequences and hypointense in T2-weighted sequences. The hematoma was in the epidural space with possible odontoid process intracapsular origin. Why Should an Emergency Physician Be Aware of This?: Isolated retrodental epidural hematoma without dens fracture is an extremely rare pathology and finding, and to the best of our knowledge, this is the first case to be reported in the literature. Emergency physicians should consider this pathology for any patients presenting for head trauma with head hematoma. (C) 2019 Elsevier Inc. All rights reserved.

A 26-year-old female patient referred to our emergency service with complaint of increase headache and swelling of the left upper eye led. External examination of the head revealed left frontal scalp and left eye led swelling, which was soft and pulsatile. Brain computed tomography (CT) scan and magnetic resonance imaging showed left frontal soft tissue and left periorbital swelling with crowded left intraorbital contents. Brain CT angiography showed vascular mass lesion in the left frontal subcutaneous lesion. Six-vessel cerebral angiography showed left frontal scalp arteriovenous malformation (AVM) supplied from the right and left superficial temporal arteries from the external carotid artery and from the left supraorbital artery arising from the ophthalmic artery of the internal carotid artery. By endovascular technique, bilateral superficial temporal arteries were occluded with Onyx 18 (Micro-Therapeutics, Inc., Irvine, CA). The patient was operated after 2 days. Left eye-brow incision was performed and the supraorbital artery was exposed, ligated, and cut. Left fronto-temporal skin incision was performed and the AVM totally excised. No intraoperative nor postoperative complications seen. Follow-up cerebral angiography showed total resection of the AVM.