7^th Global Neurologists Annual Meeting on Neurology and Neuro Surgery August 22-24, 2016 Vienna, Austria

Biography:

Haris Huseinagić is the head of Department of radiology and nuclear medicine in University Clinical Center Tuzla Tuzla, Bosnia and Herzegovina

Abstract:

Endovascular treatment of giant basilar artery aneurysm is a complex procedure that requires the work of an experienced team and a range of materials and techniques available. Treatment of a giant aneurysm of the basilar artery in the body which includes the initial parts of both arteriae cerebelaris posterior was a special kind of technical challenges and use techniques Waffle cone. Technically it was not possible to implement the classic waffle cone technique, and made modifications to the horizontal stenting in the right artery cerebelaris posterior, and above it are set Koil, and the aneurysm successfully closed with rear patent cerebellar artery. Technical correctly written procedure with good outcome for the patient left the question of objective verification of results. Using Voronoi diagrams and indirect visualization of the 3D models of aneurysms with the analysis of the dynamics of flow (flow dynamics), an objective verification of results. Results of verification coincide with the real results to the patient. The new method of analysis of endovascular treatment has proven to be an effective model verification results

Biography:

Mirza Moranjkic is a renowned neurosurgeon of Clinical Center Tuzla Tuzla, Bosnia and Herzegovina

Abstract:

Introduction: Fusiform and some wide-neck aneurysms remained unaddressed by both reconstructive surgical and endovascular techniques until the introduction of dedicated intracranial self-expandable stent.

Aim: The aim of the current study was to review a single center experience with stent-assited aneurysm coilling.

Results: Approximately 200 endovascular procedures were performed in our department for various cerebrovascular conditions over the course of some 30 months. Of those, there were over 100 aneurysm patients, and over 50 patients were treated with stent-assisted coilling. We encountered 2 technical complications (one stent migration, and one stent dislodgment). No thromboembolic complications were noted, and none of those technical complications proved to be clinically relevant.

Conclusion: Stent-assisted aneurysm coiling is a safe and highly effective endovascular technique that provides us with means to treat aneurysms previously deemed untreatable by endovascular means.

Biography:

Biljana Milatović has completed her postgraduate Specialist academic studies in Radiology with the paper entitled “The Comparison of Digital Subtraction Angiography and Multi slice CT Angiography in the Evaluation of Intracranial Aneurysms“ and completed her PhD in neuroradiology with paper entitled as “ Predictive factors for haemorrhage in arteriovenous malformations by digital subtraction angiography and MDCT angiography of the brain”. In 2006 and 2007 she worked as a general practitioner at the Institute for the Medical Protection of Mother and Child, at the Radiology department. She started working as a general practitioner at Radiology – Neurosurgery department (Interventional Neuroradiology, MSCT neuroradiology imaging and MRI imaging) in October 2007. She has worked at the Emergency and Trauma Center since September 1st, 2009 (Diagnostic emergency neuroradiology, Ultrasound diagnostics and x-ray diagnostics). Dr. Biljana Milatović is currently working at the Clinical center of Serbia as a neuroradiologist in Center for Radiology and Magnetic resonance Imaging since February 1st, 2008. She is a member of the European Association of Radiologists since 2008.

Abstract:

Patients with brain arteriovenous malformation (AVM) have a certain risk to bleed, and the goal of this study is to examine the effect of radiological and clinical predictive characteristics of AVM hemorrhage using multidetector CT angiography (MDCT).

Material: this is a series of 57 patients with a mean age of 35.46 years, who were diagnosed at the Institute for Radiology and MRI, while the same were hospitalized at the Clinic of Neurosurgery, Clinical Center of Serbia in the period from January 2008 to March 2016. For all patients, the diagnosis was made using MDCT angiography. Two groups of patients were observed. The first group includes patients who were not initially presented by hemorrhage, while the second group was initially presented by hemorrhage. Both groups were treated with medical therapy, or a combination of medical therapy with embolization / surgery / radiotherapy.

Results: Deep venous drainage (p <0.05), the combined arterial supply from different basins (p <0.05) with a length> 60mm, venous dilation present in the drainage vein (p <0.01) and the angle of casting supply arteries in the nidus (p <0.01), carry a risk of repeated bleeding. In the group of patients who had initial hemorrhage a mean value of the sized corner casting was 130o, while the group that did not had initially bleeding mean value of the size of the measured angle was 103.81 with a standard deviation of 17.21 (p <0.01).

Conclusion: arterio-venous malformations with the deep venous drainage from the carotid and VB basin, the length of the feeding arteries> 60mm, angle of casting feeding arteries in the nidus ≥ 130 ° and dilatation and / or venous aneurysm drainage vessel are predictive model for clinical presenting by hemorrhage.

Key Words: AVM of the brain, bleeding, morphological parameters

Biography:

Abstract:

Acute ischemic stroke is a medical emergency and accounts for a worldwide mortality of 6.2 million lives each year. There has been a revolution of sorts in the endovascular management of acute ischemic stroke in the past two years. Our hospital experience in acute ischemic strokes presenting in the window period has evolved with a view to better the management outcomes of such cases. Based on intra-hospital logistics imaging in these cases has evolved from MRI & MRA to NCCT & CTA and more recently to CT based collateral scoring. The endovascular management similary has seen the use of various stentreivers and more recently the use of thromboaspiration using the ADAPT technique utilising the Penumbra system. The paper shall also cover the current evidence in the endovascular management of Acute ischmic stroke.

Biography:

Abstract:

Functional Magnetic Resonance Imaging (fMRI) is a technique that takes advantage of the diferences in magnetic susceptibility between oxyhemoglobin and deoxyhemoglobin. Once the goal of neurosurgery is to maximize patient safety and to minimize residual tumor, fMRI may be an alternative, non-invasive and reproducible tool for assessing potential risk of dysfunction resulting from brain ressection near eloquente cortex. Tumoral mass effects can distort normal cortical anatomy losing anatomical landmarks. So fMRI studies with specific –tasks combines structural with physiological information and provides data helping in localizing cortex controlling language, motor, sensory, hearing and visual pathways , according to tumor region. In addition, many studies confirm the large individual variability in cortical localization of language and fmri data may aid in the determination of language laterality and localization of Wernicke’s and Broca’s areas in cases of temporo-parietal lesions. Althout fmri can show cortical signals, imaging the White matter bundle may be just as crucial. Therefore Diffusion Tensor imaging complements fMRI examinations and provides the surgeon with fiber-tracking information. In summary, fMRI data can alter a neurosurgical approach to a tumor, indicates eloquent cortex in distorted areas, guide surgical resections or even emphasize too high risk in total tumor resection in other cases. Clinical cases showing such fMRI applications and a literature review about clinical outcomes is presented.

Biography:

Abstract:

The comprehension of the inner mechanism of low back pain is hard and often the conventional diagnostic approach can’t reveal the exact cause of the disease. The functional radiologic study of the spine is not so precise, and only bone structures are directly seen. More complex conventional radiologic functional studies like myelography and stereo-radiology are invasive or obsolete and difficult to obtain; in any case the informations obtained are quite always “indirect”, since anatomical structures as discs, roots and ligaments are not visible. In last 20 years, a possible “in vivo” bio-mechanic approach in the study of the spine has been proposed with the use of devices like the Axial Loader and the Dynawell able to produce a variable axial load on the spine during CT or MR examinations on conventional diagnostic units. This allows to directly image all the anatomical structures in a precise way during a work. This lecture reviews the personal experience in the study mainly on the lumbar spine with the Axial Loader (AL) both in CT and in MR. The Axial Loader device is described together with the CT and MR acquisitions. The disc, intersomatic and articular facet changes obtained during the examinations are described with a breakdown of the classification of findings as Elementary Dynamic Modifications (EDMs) or Complex Dynamic Modifications (CDMs). From this data derived a possible functional model of the lumbar spine. A particular look will be given to the post-surgical functional evaluation of the lumbar spine. Early data from AL studies of pediatric isthmian lysis with MR will be presented. Finally a comparison with data from studies with MR units that allows real orthostatic spine studies will be attempted.

Biography:

Abstract:

Purpose: It has been shown that using variable window width and center level settings facilitates the detection of ischemic brain parenchyma in unenhanced cerebral CT (CCT) by accentuating the contrast between normal and edematous tissue. The aim of this study was to apply color-coded volume rendering to CCT datasets and assess the clinical value of the resulting volume-rendered CCT images in the detection of early infarction signs.

Method and Materials: Ethics committee at our institute approved this study. The calculated sample size was 80 patients. Unenhanced CCT datasets of 80 consecutive patients with clinical suspicion of acute stroke were retrospectively evaluated. Utilizing commercially available software, CCT images were reconstructed and a specific color was assigned to each voxel corresponding to its HU value. Two resident doctors, after completion of their neuroradiological training, evaluated source and volume-rendered CCT images. The reference standard was MRI with DWI that proved or ruled out an acute infarction. The diagnostic confidence in the presence of acute brain ischemia was scored by using a 5-point ordinal scale (1, definitely present and 5, definitely absent) and assessed with ROC analysis.

Results: All volume-rendered CCT images were of good and diagnostic image quality. On DWI, 57 hyperacute cerebral infarction foci in 43 patients were identified. Volume-rendered CCT images allowed better performance than gray-scale CT images (Az, 0.84 and 0.61, respectively) in detecting early signs of infarction. Mean sensitivity, specificity and accuracy were 79%, 86% and 81%, respectively for volume-rendered images and 53%, 86% and 59%, respectively for source images. Interobserver agreement was substantial for volume-rendered and moderate for gray-scale CT images.

Conclusion: Particularly for radiologists in training, color-coded volume-rendered CCT images may facilitate the visualization of ischemic brain parenchyma and augment its diagnostic confidence in the detection of acute stroke

Biography:

Abstract:

NCCT states a first-line diagnostic procedure for the emergency assessment of acute stroke. Although the NCCT is highly specific in differentiation of intracerebral hemorrhage from ischemia, it has a poor sensitivity in evaluation of acute ischemic stroke. Hence, computer-aided diagnosis is able to improve the performance. In 2013 we introduced a computational method for detection and localization of visible infarcts in NCCT. Herein, we aimed to evaluate and extend our method to localize a non-visible hyperacute ischemia by means of Stroke Imaging Marker (SIM). Based on the SIM and its components: ratio of percentile differences in subranges of HU distribution (P-ratio), ratio of voxels count in ranges of brain CT intensity (N-ratio), median HU attenuation value (MAV); the infarct localization was performed in 140 early and follow-up scans of 70 patients. The infarct was not visible to a radiologist or to an experienced stroke neuroradiologist in any of the early scans. The infarcted hemisphere detection rate and sensitivity of infarct localization were measured by comparing the detected region in the initial scan, with the gold standard set in respective follow-up examination. The best performance of the algorithm was found for the P-ratio including 7 percentile subranges within the range of 35th- 75th percentile. The modified SIM provided 76% ischemic hemisphere detection rate and 54% sensitivity in spatial localization of hyperacute ischemia (68% among properly detected sides). The improved SIM is a dedicated and potentially useful tool for hyperacute non-visible brain infarcts detection in NCCT and may contribute to decision to triage.

Biography:

Abstract:

Both psychoanalysis and medical models, the two theoretical empires of psychological empires of mental disorders, suffer from serious theoretical and empirical difficulties (see Rofé, 2000, 2010; Rofé & Rofé, 2013, 2015). In an attempt to resolve the theoretical confusion in this field, a new theory was proposed termed, Psycho-Bizarreness: An intuitive Rational-Choice Theory of Madness. Basically, this theory claims that when individuals are confronted with intolerable levels of current stress, they are likely to choose a mad behavior when other options, such as suicide, drug abuse, and antisocial behaviors, are unavailable or too costly. The major benefit of madness is repression, which the new theory defines in line with Freud’s (1915, p. 147) original suggestion, as distraction. The distractive effect of the mad behaviors is so strong that it blocks the accessibility of stress-related thoughts. Hence, while Freud claimed that repression causes madness, according to Psycho-Bizarreness Theory (PBT), madness results in repression. Accordingly, the choice of a specific mad behavior is determined by the same principles used in consumer decision-making when purchasing a specific economic product. Lack of awareness of the Knowledge of Self-Involvement (KSI) is induced through sophisticated information processing that causes the forgetting of KSI and enables the development of a self-deceptive belief. As already demonstrated, PBT can integrate all studies pertaining to the development and treatment of neuroses and psychos into one theoretical framework (see Rofé, 2000, 2010; Rofé & Rofé, 2013, 2015).

Biography:

Abstract:

Endoscopy and cross-sectional imaging are considered indispensible for evaluation of larynx and oral cavity.USG is undoubtedly a powerful investigative tool in head and neck pathologies. Larynx and tongue are no exception. But, when compared to cross-sectional imaging where USG does stand is the question raised and answered in this paper. It is important to follow a systematic USG technique to evaluate the larynx and the tongue. USG has accuracy of 71.4% while CT had 92.8% accuracy in assessing cancer of hypopharynx. USG has accuracy of 61%, while MRI has accuracy of 91% in assessing tongue cancer. Post cricoid extension and small PFS growth are not appreciable on USG in cases of larynx cancers, where as small intrinsic tongue muscle growths and alveolar involvement were not seen on USG in cases of tongue malignancy.USG can easily visualize vocal cord movements, pre-epiglottic space lesions and sub-mandibular duct involvement, which are relatively difficult to appreciate on cross-sectional imaging. Even though small tumors are difficult to visualize, USG can play a significant role in assessment of the tumor extension inside and outside the organ. Especially when cross-sectional imaging is unavailable, unaffordable, contraindicated and in post treatment follow up cases.

Biography:

Abstract:

Introduction: Febrile seizures (FS) are always a relevant topic; thermoregulation and febrile responses, complex processes, are important aspects of the unsolved puzzle.

Methods: Here, FS are explored from comparative “evolutionary pressure” data-sets for insights/contributing factors to age dependent vulnerability and for potential MRI data acquisition for evidence-based medicine.

Results/Discussion: Thermoregulatory responses’ evolutionary quest is for maximal performance at optimal temperature, experimentally shown for insects’/viruses’ population growth, not performance. Relying on external heat sources, ectotherms’ narrow range of performance thermal sensitivities is explained by natural selection, not thermodynamics; endotherms’, birds’/mammals’, thermally constrained set-points evolved promoting heat loss, not enhancing performance. Mammalian brains’ selective brain cooling (SBC) is a special evolutionary case within the thermal core because hyperthermia, causing febrile seizures, limits performance; SBC separates brain temperature (T) regulation independently from the body to keep Tbrain < Ttrunk, p<0.01.

Species-specific SBC mechanisms during hyperthermia promote reversing normal blood flow, from brain->skin to skin->brain, to cool/maintain constant cerebral metabolism. A 4-part venous pathway connects extracranial diploic/emissary veins with intracranial meningeal veins/sinuses; the richly vascularized/complex human diploe has an age dependent developmental pattern, fully established, age 5, large variations at each age. Primate emissary veins respond immediately to hyperthermia; their parietal/mastoid/condyloid/ post-glenoid foramina prominence shifts in an evolutionary pattern: Tarsius 0%,0%,0%,100%; Lemurs 0%,74.4%,0%,99%; orangutan 3%,81.6%, 1%,2%; chimpanzee 8.7%,14%,16.5%,0%; human 60.5%,68%,77%,0.6%. Furthermore, intrinsic brain geometry plays an important evolutionary role in thermoregulatory patterns/heat distribution. Notably, perinatal discontinuity of ontological size/ shape changes in chimps/humans at 4-6 months, p<0.0044, produces topographical changes in vascular system; an expanded human frontoparietal volume, now globular, with highest concentration of diploic/emissary veins, richly anastomosed/reticulated, affects heat dissipation. Brain surface:volume ratio values for chimps’/humans’ heat loading, 1.59 vs 0.91, respectively, confirms globular shape decreases thermic values in heat transfer.

Conclusion: In light of evolution, human ontological variations from MRI measurements may offer an option to FS’ unsolved puzzle for evidence-based medicine.

Biography:

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Biography:

Abstract:

Introduction: Burkholderia pseudomallei is a gram negative environmental bacterium found in soil and surface water which causes melioidosis, commonly reported to occur in south-east Asia and northern Australia. It is being increasingly reported in India and transmission is through inhalation, inoculation and ingestion. Two clinical forms are recognised – acute septicemic form and the chronic granulomatous form. Both these forms are recognised to affect the neuraxis and the adjacent soft tissues and bone. Involvement of these structures is rare but of importance due to the significant mortality and morbidity associated with cranio-spinal infection

Methods: 14 culture proven cases with involvement of the cranio-spinal structures were retrospectively identified between Jan 2008 and May 2016 via search of the hospital’s electronic database Involvement of the cranio-spinal structures included multiple parenchymal abscesses(5) which usually occurred in contiguity with skull osteomyelitis. Parenchymal and leptomeningeal disease was secondary to septicaemia. Pachymeningeal disease was found to be secondary to sino-nasal involvement and otomastoid infections(5). Acute myelitis (1) and spondylodiscitis (3) were the other forms seen Parenchymal involvement ranged from cerebritis, early and mature parenchymal abscess formation. Patients with fewer abscesses which were amenable to surgical evacuation had a favourable outcome compared to those who had multiple small, widespread abscesses Chronic pachymeningeal disease was invariably associated with sino-nasal, otomastoid infections or a skull osteomyelitis. Multiple cranial neuropathies were recorded in those with pachymeningitis. Local inoculation or inhalation is presumed to be the route of infection One patient who presented with longitudinally extensive transverse myelitis had received immunosuppression prior to admission and this exacerbated the progression of disease 2 patients with parenchymal abscesses and the one with myelitis succumbed to their illness

Conclusion: CNS manifestations of Burkholderia in the form of pachymeningeal disease and myelitis must be suspected in the appropriate clinical scenario as alternative imaging and clinical differentials entail therapy with immunosuppression which are detrimental

Biography:

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Biography:

Abstract:

The dyskinetic subtype of cerebral palsy is difficult to manage, and there is no established gold standard for treating the condition. External rotation of the shoulder(s) is often managed non-surgicallynonsurgically using injections of botulinum toxin A into the external rotator muscles. I present a novel surgical technique designed to for manage external rotation when botulinum toxin A treatment is not sufficient or possible. Six patients with dyskinetic cerebral palsy underwent denervation of the infraspinatus muscle and release of the posterior part of the deltoid muscle. Postoperative questionnaires were given to the patients/caregivers, and video recordings were made both pre- and postoperatively. Preoperative and postoperative Assisting Hand Assessment was possible in only 1 case. Five patients were very satisfied with their outcome. Four patients’ video recordings showed improvement in of their condition. One patient developed postoperative complications.The results indicate that denervation of the infraspinatus muscle and posterior deltoid release can be an option for patients with dyskinetic cerebral palsy to manage external rotation of the shoulder when other treatment alternatives are insufficient.

Biography:

Abstract:

Purpose: Because unusual entrance of vertebral artery into the cervical transverse foramen (UE-V2S) is relatively common anomaly in clinical field, therefore spine surgeon always have one’s eye to understand its anatomical characteristics and clinical implications. The aim of this study is to assess the above task with a very large number of UE-V2S anomaly cases.

Methods: Retrospectively, the authors analyzed 2207 three-dimensional head and neck computed tomographic angiograms (CTA) without a specific vascular abnormalities. After confirming the unusual entrance of the vertebral artery (VA) into the transverse foramen (TF), we measured its vertebral artery diameter (VAD), transverse foramen area (TFA) and pedicle width (PW) from C3 to C7, bilaterally. The shortest horizontal distance from the vertical line in the medial margin of the TF to VA (D-TFVA) were measured in extra-osseous region to estimate the exact location of extra-osseous VA, excepting C7 level.

Results: The unusual V2 entrance was observed in 11.4 % (252 patients) of all 2207 consecutive patients and 6.5 % (268 courses) of all 4414 courses. The prevalence of unilateral UE-V2S level was followed as below: E5 > E4 > E7> E3 and prevalence of bilateral UE-V2S were ordered as below: E5 (bilateral) was most prominent and E4 (right) / E5 (left) and E4 (bilateral) was followed. Generally, the VAD of the anomaly side was statistically smaller than the normal contra-lateral side, which can induce small value of TFA in all sub-axial level. Although UE-V2S can assure larger PW dimension in below adjacent level of UE-V2S, the difference value of PW between anomaly and normal side was not much in it, or insignificant in some types of UE-V2S (E4-Right and E7-both). The least value of D-TFVA was -3.8 mm in this study, which means that we should take a care not to pass exceeding 3.8mm medial to the vertical line of medial wall of TF during dissection in anterior cervical approach.

Conclusions: For avoiding unexpected VA injury or improving efficiency of cervical operation, spine surgeon should know the possible presence of UE-V2S in a routine cervical operation and understand its clinical characteristics in advance.

Keywords: Cervical spine, Vertebral artery, V2 segment, Anomalous course, CT angiography

Biography:

Abstract:

Object: Frame-based image-guided system is the most widely used for stereotactic brain biopsy. Recently frameless stereotactic biopsy techniques have become utilized. We evaluated the application usefulness of skull-mounted frameless image-guided stereotactic brain biopsy system.

Methods: We reviewed consecutive 10 patients using skull-mounted frameless image-guided stereotactic brain biopsy system compared to patients using conventional frame-based system. We evaluated the usability and the advantage of both systems.

Results: To set up frameless system needed less invasive procedure and shortened surgical time in comparison to frame-based system. In many cases frame-based system required the drilling of the external table and the diploe of calvaria to insert the biopsy needle away from the skull. Consequently large skin incision were made. On the other hand there is a limit of insertion angle in the frameless system. In one case flame-less system could not be used due to this limitation.

Conclusion: With regard to less invasiveness and shortening of the surgical time, skull-mounted frameless image-guided stereotactic brain biopsy system may represent more efficient means of biopsy though there is a limitation of biopsy needle insertion angle.

Biography:

Abstract:

Background: Dehydration is associated with poor outcome after acute ischemic stroke. However, the relationship between hydration therapy during acute ischemic stroke and clinical outcome remains unclear. Our study aimed to determine whether providing hydration therapy to patients with a blood urea nitrogen/creatinine (BUN/Cr) ratio ≥15 improves their clinical outcome.

Methods: A non-blinded, phase II single arm prospective study of patients with acute ischemic stroke and BUN/Cr ratio ≥15 was conducted from January 2011 to December 2013, with historical controls from November 2007 to June 2010. The hydration group received intravenous bolus (300–500 mL) saline followed by maintenance saline infusion (40–80 mL/h for the first 72 h), while the control group received maintenance saline infusion (40–60 mL/h for the first 24 h and 0–60 mL/h for 24–72 h). The study endpoint was the proportion of patients with favorable outcome, defined as modified Rankin scale (mRS) ≤ 2 at 3 months post stroke.

Results: Overall, 237 patients were enrolled (hydration group, n = 134; control group, n = 103). The median volume of infused saline from day 1 to day 3 was significantly larger (P < 0.001) and the rate of favorable outcome at 3 months post stroke was significantly higher (P =0.016) in the hydration group. Dividing acute ischemic stroke into lacunar and non-lacunar subtypes, the difference was significant only in the lacunar stroke subtype (P=0.020). Conclusion: Thus, providing saline hydration therapy to patients with acute ischemic stroke based on BUN/Cr ratio can significantly increase the rate of favorable clinical outcome with functional independence at 3 months post stroke.

Biography:

Abstract:

Background: Brain tumors can present to the emergency department for many causes. It is unusual for those patients to need emergency tumor resection surgery. One of the exceptions is patients with markedly increased ICP secondary to the tumor mass.

Objective: To define an international guideline for the indications of urgent surgical resection of brain tumors according to inclusion criteria.

Methods: A prospective analysis for twenty patients who undergone urgent brain tumor resection surgery at Neurosurgery Teaching Hospital –Baghdad-Iraq was conducted from October 2014 to February 2016. The variables assessed for each case is gender, age, GCS score (pre and post-op.), functional deficit (pre and post-op.), Brain CT-scan criteria for each tumor, medical therapy trial in hours and the histopathological data.

Results: Analysis for the 20 urgently operated cases is done. According to this analysis the female gender is 55%, the mean age is 43 year (SD 16.056), the mean pre-op GCS score is 9, 19 brain tumors is supratentorial and 1 brain tumor is infratentorial, For supratentorial tumors 11 tumors is in the right hemisphere, the tumors are 55% intra-axial, 45% extra-axial, the lobes affected are temporal (11 patient) then parietal (5 patient), others (3 patients), hemorrhagic tumor is found in 20%, the minimum midline shift in brain CT scan is 1 cm (mean 1.79 cm), the mean tumor size is 5.5 cm in maximum diameter, medical therapy is tried for a minimum of 2 hours (mean 3.50 hours), the histopathological data as follows meningioma (9 patients), glioma (6 patients 4 of those are glioblastoma multiforme), metastasis (5 patients), post-op GCS score is 15 (except 1 case GCS score 14), the paired test for pre and post-op GCS score shows strongly significant improvement (P value > 0.01), ), the paired test for pre and post-op functional deterioration shows strongly significant improvement (P value > 0.01).

Conclusion: From the study result we suggest the following inclusion criteria as indication guideline for urgent brain tumor resection surgery. The selected patient for surgery must fulfill all the following criteria: (1) Acute neurological deterioration [life-threatening decrease in GCS or functional deterioration (motor or visual function)]. (2) Significant midline shift in Brain CT-scan ( < 1cm). (3) The response to medical therapy trial to decrease ICP is either unexpected or failed. (4) The tumor mass is the main cause of deterioration: (A) Strong indication: tumor size maximum diameter > 4 cm or tumors that involve or compress the temporal lobe. (B) Relative Indication: hemorrhagic tumors.

Abbreviations: GCS= Glascow Coma scale, CT=Computerized Tomography.