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Ehab El Refaee, Joerg Baldauf and Henry W. S. Schroeder

Occlusion of both foramina of Monro following third ventriculostomy is a very rare complication. The authors present the case of a 30-year-old female who underwent endoscopic third ventriculostomy (ETV) for occlusive hydrocephalus due to aqueductal stenosis. Thirty months after the ETV, she reported recurrent headaches. Magnetic resonance imaging demonstrated bilateral enlargement of the lateral ventricles with a collapsed third ventricle caused by bilateral stenosis of the foramina of Monro. Left-sided endoscopic foraminoplasty and stenting of the left foramen of Monro were performed with immediate neurological improvement.

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Ehab El Refaee, Marc Matthes and Henry W. S. Schroeder

We present the microsurgical technique in excision of intramedullary craniocervical ependymomas. A 27-year-old female came presenting with neck pain and parasthesia in her both arms and hands, where MRI was performed showing intramedullary lesion that extend in the medulla just beyond the foramen magnum to the level of C5–6 disc. Tumor was totally excised using irrigation-dissection microscopic technique with favorable outcome.

The video can be found here: http://youtu.be/Yj1yvZOaz58.

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Jan-Philip Zeden, Jan-Uwe Müller, Ehab Ahmed Mohamed El Refaee, Henry W. S. Schroeder and Dirk T. Pillich

OBJECTIVE

In traumatic spondylolistheses of the axis, there is a marked heterogeneity of the observed injury patterns, with a wide range of the severity—from stable fractures, which can be treated conservatively with very good success, to highly unstable fractures, which should be treated surgically. A number of classification systems have been devised to assess the instability of the injuries and to derive a corresponding therapy recommendation. In particular, the results and recommendations regarding medium-severity cases are still inconclusive. Minimally invasive percutaneous procedures performed using modern techniques such as 3D fluoroscopy and neuronavigation have the potential for improvements in the therapeutic outcome and procedural morbidity against open surgical procedures and conservative therapy.

METHODS

A minimally invasive method using 3D fluoroscopy and neuronavigation for percutaneous lag screw osteosynthesis of the pars interarticularis was performed in 12 patients with a Levine-Edwards Type II fracture. Ten patients had an isolated hangman’s fracture and 2 patients had an additional odontoid fracture of the axis (Type II according to the Anderson and D’Alonzo classification system). Complications, operating parameters, screw positions, and bony fusion were evaluated for the description and evaluation of the technique.

RESULTS

In 6 men and 6 women, percutaneous lag screw osteosynthesis was performed successfully. Correct placement could be verified postoperatively for all inserted screws. In the case series, nonunion was not observed. In all patients with a complete follow-up, a bony fusion, an intact vertebral alignment, and no deformity could be detected on CT scans obtained after 3 months.

CONCLUSIONS

The percutaneous pars interarticularis lag screw osteosynthesis is a minimally invasive and mobility-preserving surgical technique. Its advantages over alternative methods are its minimal invasiveness, a shortened treatment time, and high fusion rates. The benefits are offset by the risk of injury to the vertebral arteries. The lag screw osteosynthesis is only possible with Levine-Edwards Type II fractures, because the intervertebral joints to C-3 are functionally preserved. A further development and evaluation of the operative technique as well as comparison with conservative and alternative surgical treatment options are deemed necessary.

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Sascha Marx, Steffen K. Fleck, Ehab El Refaee, Jotham Manwaring, Christina Vorbau, Michael J. Fritsch, Michael R. Gaab, Henry W. S. Schroeder and Joerg Baldauf

OBJECTIVE

Since its revival in the early 1990s, neuroendoscopy has become an integral component of modern neurosurgery. Endoscopic stent placement for treatment of CSF pathway obstruction is a rarely used and underestimated procedure. The authors present the first series of neuroendoscopic intracranial stenting for CSF pathway obstruction in adults with associated results and complications spanning a long-term follow-up of 20 years.

METHODS

The authors retrospectively reviewed a prospectively maintained clinical database for endoscopic stent placement performed in adults between 1993 and 2013.

RESULTS

Of 526 endoscopic intraventricular procedures, stents were placed for treatment of CSF disorders in 25 cases (4.8%). The technique was used in the management of arachnoid cysts (ACs; n = 8), tumor-related CSF disorders (n = 13), and hydrocephalus due to stenosis of the foramen of Monro (n = 2) or aqueduct (n = 2). The mean follow-up was 87.1 months. No deaths or infections occurred that were related to endoscopic placement of intracranial stents. Late stent dislocation or migration was observed in 3 patients (12%).

CONCLUSIONS

Endoscopic intracranial stent placement in adults is rarely required but is a safe and helpful technique in select cases. It is indicated when reliable and long-lasting restoration of CSF pathway obstructions cannot be achieved with standard endoscopic techniques. In the treatment of tumor-related hydrocephalus, it is a good option to avoid reclosure of the restored CSF pathway by tumor growth. Currently, routine stent placement after endoscopic fenestration of ACs is not recommended. Stent placement for treatment of CSF disorders due to tumor is a good option for avoiding CSF shunting. To avoid stent migration and dislocation, and to allow for easy removal if needed, the device should be fixed to a bur hole reservoir.

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Ahmed Al Menabbawy, Ehab El Refaee, Mohamed A. R. Soliman, Mohamed A. Elborady, Mohamed A. Katri, Steffen Fleck, Henry W. S. Schroeder and Ahmed Zohdi

OBJECTIVE

Cerebral ventriculitis remains one of the most challenging neurosurgical conditions, with poor outcome and a long course of treatment and duration of hospital stay. Despite the current conventional management plans, i.e., using antibiotics in addition to CSF drainage, the outcome remains unsatisfactory in some cases, with no definitive therapeutic guidelines. This study aims to compare the outcome of ventricular irrigation/lavage (endoscopic irrigation or the double-drain technique) to conventional currently accepted therapy using just drainage and antibiotics.

METHODS

The authors conducted a prospective controlled study in 33 patients with cerebral ventriculitis in which most of the cases were complications of CSF shunt operations. Patients were divided into two groups. Removal of the ventricular catheter whenever present was performed in both groups. The first group was managed by ventricular lavage/irrigation, while the other group was managed using conventional therapy by inserting an external ventricular drain. Both systemic and intraventricular antibiotics were used in both groups. The outcomes were compared regarding mortality rate, modified Rankin Scale (mRS) score, and duration of hospital stay.

RESULTS

The mean age of the study population was 5.98 ± 7.02 years. The mean follow-up duration was 7.6 ± 3.2 months in the conventional group and 5.7 ± 3.4 months in the lavage group. The mortality rate was 25% (4/16) in the lavage group and 52.9% (9/17) in the nonlavage group (p = 0.1). The mRS score was less than 3 (good outcome) in 68.8% (11/16) of the lavage group cases and in 23.5% (4/17) of the conventional group (p < 0.05). The mean hospital stay duration was 20.5 ± 14.2 days in the lavage group, whereas it was 39.7 ± 16.9 days in the conventional group (p < 0.05).

CONCLUSIONS

Ventricular lavage or irrigation together with antibiotics is useful in the management of cerebral ventriculitis and associated with a better outcome and shorter hospital stay duration compared to current conventional lines of treatment.