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PROFESSIONAL EVENT SPEAKERS


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Malignant Pathology of Brain Meningioma Tumor as the Best Predictor for Mortality and Recurrency rate of Meningioma

Key Note Speech By Dr. Mojataba Mafi Medical Doctor/ Physician from Tehran university

We studied on meningioma among 614 patients with Brain tumor (consists of meningioma, glioma and pituitary tumor). 145 patients had meningioma. Our results are in various topics: 1. Clinical features of meningioma 2. Anatomical distribution 3. Radiation induced meningioma 4. Meningioma and foster Kennedy syndrome 5. Meningioma and pseudo foster Kennedy syndrome 6. Multiple meningioma 7. Post traumatic and skull fracture meningioma 8. Cutaneous meningioma 9. Meningioma and DVT 10. Trigeminal neuralgia and meningioma 11. Recurrent meningioma 12. Meningioma mortality rate And some others. We are going on to continue this study. This research project has been held in neurosurgery ward Shariati Hospital and had been scientifically registered. We studied during 6 years on meningioma patients to find the risk factors for meningioma recurrence as well as answer to these questions: 1. What is the recurrence rate of meningioma? 2. Which anatomical locations are more prevalent for overall recurrency? 3. What is tumor specific recurrence rate according to anatomical location? 4. How long does it take after meningioma surgery till tumor recurrence? 5. Are age and gender determining factors for meningioma recurrency? 6. The correlation between meningioma cellular pathology and recurrency? 7. Is mortality rate of recurrent meningioma more than primary tumor? We found that 20.7% of all patients with meningioma recur after 4.6 years after surgery. Female to male ratio was 1.72 among recurrent tumors with no significant difference with this ratio among all meningioma study sample was 1.96 but it seems recurrence rate is more among men. The more prevalent anatomical location for overall recurrency were: 1. Convexity: 43.3% 2. Parasagittal: 26.7% 3. Sphenoid wing: 16.7% Tumor specific recurrence rate: 1. Parasagittal: 42% 2. Pentorial: 33.3 % 3. Convexity: 27.6% Tumor specific mortality rate: 1. C-P Angle: 33.3% 2. Petroclival: 25% 3. Sphenoid wing = Convexity: 16.7% Mortality rate among recurrent meningioma patients is 13.3% in compare with primary meningioma patients’ mortality rate that was 6.9%, is approximately 2 times more. 75% of recurrent tumors with mortality were malignance meningioma pathologically or anaplastic meningioma, it shows that cellular malignance pathology has an important role for meningioma mortality and recurrency. We dedicate with honor the surgical procedures in details, follow up outcomes, history of radiotherapy and cellular pathology at oral presentation time. Thanks and regards. Mojtaba Mafi, MD, Study director. Fateme Rezvani, Bioinformatics, Study manager.

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Adopting laughter therapy to get dosage of happy hormones to remove stress caused by being in slight pain, being depressed, being unhappy anxious or sad. Saying positive affirmations aloud changes body cell energy.

Key Note Speech By MS. SUCHI B.Sc. ,B. Ed., Specialist Diploma In Early Childhood Education

Statement of the Problem: There is a lack of awareness about what happy hormones are, how to use positive words to feel energetic and what can be done to get happy hormones. People tend to feel unhappy for multiple reasons and neuropathic pain adds on Stress levels of not only the patient but the caregivers as well. Being in pain leads to feeling depressed and anxious in some cases.

Methodology & Theoretical Orientation: 

Review of Books and Research shows that getting a dosage of happy  hormones will not only ease slight  pain of the patient but  feeling happy will also have a positive impact on the recovery of the patient. Adopting Laughter therapy and getting hormones which makes one feel good will help many to recover from Neuropathic pain /Long term sadness caused by having grief, Anger or Resentment, Depression & Anxiety.

Findings: One needs to work on his/her energies using Laughter Therapy which is a positive approach for not having Depression & Anxiety caused by Neuropathic pain. The therapy can be used as a Holistic way to recovery. 

Conclusion & Significance: The Laughter therapy which includes ways to get the dosage of happy hormones promotes overcoming Depression & Anxiety caused by Neuropathic pain, is a fun way to manage pain.  Repeated sessions to be conducted to remind patients that  life while having pain or during the recovery should go beyond just seeking medical and counselling help and also include rebuilding Spiritual, Physical, Emotional, Relational and Mental health. The model has been put together from for testing in many settings including hospitals, elderly homes and senior citizen centres.  This is not a research book or paper. It is just an effort to demystify the help available for Depression & Anxiety caused by pain. It is an attempt to motivate and encourage people to seek help and take a simple approach to remember and work on all aspects of their recovery. 

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Indole-3-carbinol (I3C) mitigates the neurobehavioural alterations in a focal cerebral ischemic stroke model

Oral Speech By Siddhartha Das Pramanik

A stroke is a sudden interruption in the blood supply of the brain. Most strokes are caused by an abrupt blockage of arteries leading to the brain (ischemic stroke).  Other strokes are caused by bleeding into brain tissue when a blood vessel bursts (haemorrhagic stroke). Ischemic stroke has been found to affect 80% of stroke patients. Recombinant tissue plasminogen activator (rtPA) is the widely used drug for the ischemic stroke with narrow therapeutic window. Middle cerebral artery occlusion (MCAO) was done to create a focal cerebral ischemic model in rats and was used followed by reperfusion after 2h of ischemia for the evaluation of the I3C against ischemic stroke. Indole-3-carbinol (I3C) is a natural compound obtained from brassica species having antithrombotic activity. After reperfusion, I3C (12.5, 25, and 50mg/kg) was given by oral route once daily and continued up to the 14th day. Mean cerebral blood flow (CBF) was improved by treatment with I3C (12.5 mg/kg) by 60% of baseline at 6 h. I3C inhibited ADP-induced platelet aggregation and reduced ischemic volume significantly. Behavioural studies including postural reflex, forelimb placing, and cylinder tests showed I3C attenuated the MCAO induced increase in average score and asymmetry score efficiently. Furthermore, I3C showed prophylactic anti-thrombotic activity against carrageenan induced tail thrombosis. Consequently, the present examination demonstrates preclinical proof that I3C can be used as a potential candidate in cerebral ischemic stroke.

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Long term caffeine intake modulate GR-mediated response exaggerates post-traumatic stress disorder-like symptoms in rats

Oral Speech By Arghya Chowdhury

The most consumed central nervous system stimulant in form of coffee and other beverages is Caffeine. However, its repeated administration induces anxiety, disturbance in hypothalamic-pituitary-adrenal (HPA) axis and psychiatric symptoms in humans. As much evidence links PTSD to HPA axis dysfunction having anxiety as a hallmark symptom, repeated administration of caffeine may exacerbate symptoms of PTSD. In this study, we evaluated the effect of repetitive administration of caffeine on stress re-stress (SRS) model of PTSD. SRS-induced depressive and anxiety-like behaviour was aggravated by caffeine at dose 20 and 30 mg/kg. Caffeine (30mg/kg) treated control animals showed depressive, anxiety-like behaviour, and cognitive deficits. SRS-induced decrease in plasma corticosterone and increase in serotonin (5HT) levels in the PFC, HIP and AMY which were not altered by caffeine. Also, caffeine did not modulate the SRS-induced decrease in glucocorticoid receptor (GR) and mineralocorticoid receptors (MR). In contrast, caffeine decreased GR and MR expression and their ratio in unstressed animal. The investigation suggests that repeated intake of caffeine aggravates PTSD-like symptoms in traumatized rats and induces PTSD-like effect in unstressed rats by altering the expression of glucocorticoid receptors. 

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Cognitive Biomarkers for differentiating Individuals with Normal aging and Mild Cognitive Impairment

Oral Speech By Ranjitha Kashyap(Research Officer, All India Institute of Speech and Hearing, Mysuru, India)

Introduction: Mild cognitive impairment (MCI) is the stage between the expected cognitive decline of normal aging and the more serious decline of dementia. It can involve problems with memory, executive functions and language that coincide with that of normal aging; hence differential diagnosis becomes a major concern and biggest challenge to professionals. Executive function comprises of a variety of domains such as attention, response inhibition, cognitive flexibility and set shifting which has fascinated researchers globally. These domains are found to be very sensitive in assessing early cognitive changes in aged individuals, mild cognitive impairment (MCI) and dementia. However the findings disseminating the status of executive functions in this population are not uniform.

Aim: The aim of the present study was to explore the performance of individuals with MCI on executive function tasks and compare it with that of individuals with normal aging.

Method: 50 individuals (20 MCI and 30 normal aging) were recruited for the study. From a careful review of literature, Navons letter Identification, Phoneme monitoring task, Flanker’s task; Selective naming, Stroop task, phoneme fluency and alternate fluency (Conventional tasks) were shortlisted to assess the domain of executive functions.Stimuli were presented through DMDX version 5.3.1.4 software. Reaction time and accuracy of responses were noted.

Results: The results revealed that individuals with MCI had difficulty performing all the tasks of the domains of executive functioning: Attention, Response Inhibition, Cognitive flexibility and set shifting. However, more difficulty was in performing the tasks of cognitive flexibility and set shifting. Within the tasks, they had more difficulty performing stroop task, phoneme fluency and alternative tasks compared to all other tasks. The difference in performance between the groups was significant on Man Whitney U test.

Conclusion: Poor performance of persons with MCI in executive function tasks signify evident cognitive breakdown in this population. Cognitive control is tapped using stroop task, phoneme and alternate fluency tasks and the findings show that the cognitive control may be the first of the executive functions to get compromised in MCI. Thus it can be inferred that the cognitive control is the major biomarker for identifying the early cognitive changes in individuals with MCI.

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Simple method of animal stroke model of luminal occlusion of middle cerebral artery in Indonesia

Oral Speech By Feda Anisah Makkiyah

Background: Although there are many experimental studies describing the suture method of middle cerebral

Artery occlusion (MCAO) in rats, this is still a new procedure in Indonesia and the techniques for applying this stroke model in animal research are not well known. There has been a perception in Indonesian scientific community that the technique would be difficult and require advanced equipment. The aim of this study is to demonstrate that it is possible to perform the technique with minimal resources using simple method and basic surgical loupe equipment.

Methods: A total of 30 male Wistar rats, aged 6 months, weighing 250 g–400 g Wistar rats, were obtained from the Bandung Biofarma Pasteur. Preliminary trials were performed to gain an understanding of the detailed anatomy of the animals and to master the techniques. A ×8 loupe magnification was used for all surgical steps in this study except taking of surgical operation photos. The procedures applied simple methods, using two loop temporary knots instead of any animal vascular clips.

Results: After an extensive training period, two of the 30 rats died within 4 weeks after the procedure. The effects of MCAO were confirmed clinically and by hematoxylin-eosin staining pathology slides.

Conclusion: With simple methods, this MCAO procedure could be implemented in developing countries such as Indonesia without the requirement for advanced equipment.

 

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Artificial Intelligence based facial recognition for Mood Charting among men on life style modification and it’s correlation with cortisol

Oral Speech By Ravish Huchegowda

Background:Today, clinicians and researchers believe that mood disorders in children and adolescents remain one of the most under diagnosed mental health problems. Mood disorders in adolescents also put them at risk for other conditions that may persist long after the initial episodes of depression are resolved. In our study we have assessed the mood state spectrum of a person over the time and validated the same by correlating with salivary cortisol, psychologist assessment results

Methods and materials:Images from the training dataset are classified according to one among the nine emotions. The Images that are classified accordingly are taken as training set and a suitable convolutional neural network is trained/retrained for this data. The mean values predicted moods are considered as input for another model that predicts higher the stress level.

Results:With the inception v3 trained for 1,00,000 times with the data set that’s close to 12,000 images classified accordingly to the nine emotion classes as specified by psychologist the model was able to obtain 78.4% of testing accuracy while with the near perfect training accuracy.

Conclusion:The mood analysis was conclusively helpful in the estimation of the negative emotion parameter as close to the values that are obtained by with Depression , Anxiety and stress scale (DASS21) the mood analysis. The  salivary cortisol  as unbiased variable correlating with DASS 21 score could have a potential uses in early detection of mood disorder and correction. This platform will be helping the subject as a early mood screening tool.  

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Neurovascular Coupling in patients with ischemic stroke

Oral speech By Xiuyun Liu

Background

Neurovascular coupling enables adaptation of cerebral blood flow (CBF) to support neuronal activity. Modern techniques enable the simultaneous recording of neuronal activities and hemodynamic parameters. However, the neurovascular coupling mechanism remains understudied. In this study, we applied a phase-amplitude cross-frequency coupling (PAC) algorithm to investigate multimodal neuro signals including surface electroencephalogram (EEG) and CBF from transcranial Doppler ultrasonography (TCD). We also investigated the causal relationship between EEG and CBF with using Granger causality (GC) analysis.

Methods

Twenty simultaneous recordings of EEG and TCD cerebral blood flow velocity (CBFV) from 17 acute ischemic stroke patients admitted to the Neurointensive Care Unit, Tiantan Hospital, Capital Medical University (Beijing, China) were studied. Each patient had simultaneous, continuous monitoring of EEG and bilateral CBFV in either the middle cerebral arteries (MCA) or posterior cerebral arteries (PCA). PAC was calculated between the phase of CBFV in frequency bands (0–0.05 and 0.05–0.15 Hz) and the EEG amplitude in five bands (δ, θ, α, β, γ). The global PAC was calculated as the sum of all PACs across the six EEG channels and five EEG bands for each patient. The hemispherical asymmetry of cross-frequency coupling (CFC) was calculated as the difference between left and right PAC.GC analysis was carried out to investigate causal interactions between slow waves of FV (frequency band: 0.006 - 0.4 Hz) and the amplitude of EEG in five frequency bands. Mean GC index across EEG frequency bands was calculated to estimate the causal relationship between EEG and CBFFV and then correlated with NIH Stroke Scale (NIHSS) at admission/discharge and the modified Rankin Scale (mRS, favorable outcome when mRS ≤ 2) at discharge.

Results

The PAC between CBFV and EEG was significantly higher in β and γ bands than in the other three bands. Occipital region (P3-O1 and P4-O2 channels) showed stronger PAC than\ the other regions. The deceased group tended to have smaller global PAC than the survival group (the area under the receiver operating characteristic curve [AUROC] was
0.81, p = 0.57). The unfavorable outcome group showed smaller global PAC than the favorable group (AUROC = 0.65, p = 0.23). The PAC asymmetry between the two brain hemispheres correlates with the degree of stenosis in stroke patients (p = 0.01).

Granger analysis identified a causal relationship from EEG –> FV, indicating past EEG contained information that predicted CBFV. The NIHSS negatively correlates with mean GC index value, which means a stronger causality between EEG and FV exists in patients who are less severely affected. No significant difference in GC index exists between patients with favorable and unfavorable outcomes (p>0.05).

 

Conclusion

We showed that CBFV interacts with EEG in β and γ bands through a phase-amplitude CFC relationship, with the strongest PAC found in the occipital region and that the degree of hemispherical asymmetry of CFC correlates with the degree of stenosis. A G-causality causal relationship from EEG → CBFV may exist in patients with ischemic stroke. The strength of G-causality may be related to stroke severity at discharge. 

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Potential role of Serpina3n in neuroprotection after Ischemic stroke

Oral Speech By Mehwish Saba Aslam

Ischemic stroke is a ruinous CNS insult with finite effective therapeutical approaches. Primary limitation to develop novel restorative drugs is partially understood multidimensional underlying mechanisms and complicated crosstalk between them aiding to this pathophysiology. Recently, extracellular liberation of Granzyme B has been reported as an aider to neurodegeneration followed by CNS Ischemia. Inhibition of Granzyme B can be considered as one of the potential approach to reduce the neuronal damage. Murine serine protease inhibitor Serpina3n has a unique affinity for granzyme B while its human homolog serpina3 is incapable to inhibit granzyme B. By considering such reports, serpina3n can be considered as a potent therapeutical strategy to induce neuroprotection subsequent to ischemia by inhibiting granzyme B and serpina3 can be taken in parallel to investigate the underlying mechanism and unveil the contributing factors.Recombinant serpina3n and serpina3 proteins were overexpressed using mammalian cells and purified. Recombinant proteins were tested for their invitro granzyme B inhibition. Neuroprotective effects of both proteins at different concentrations 20mM, 50mM and 100mM were investigated with N2A cell line by using invitro enzymatic ischemia/reperfusion model. Furthermore invivo experiments were undertaken by generating photothrombic ischemic mouse model and treated with 50mg/kg of recombinant proteins. Harvested brains were used to evaluate the infarct volume, immunohistochemical tests and western blot analysis for treated and untreated groups.Treatment with recombinant serpina3n and serpina3 increased cell viability in dosage dependent manner invitro followed by enzymatic ischemia. Post-ischemia administration induced neuroprotection confirmed by infarction volume. Exogenous proteins were successfully delivered to the ischemic lesion site across the blood brain-barrier.Post- ischemia Serpina3n and Serpina3 induce neuroprotection and can be delivered successfully to the lesion focal area.

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Developing composite molecular system network of aggression

E-poster presentation By Anila Khalique

Objective: It is now widely established that aggressive behavior is underpinned by several genetic and molecular factors. Here we use the approaches of systems biology in order to illustrate the composite molecular network which delineates the molecular events that forms the underlying molecular basis of anger development and its progression.

Methodology: Briefly, molecular network of each aggression associated gene (n=25) will be explored by text mining, co-expression, co-localization, physical and/or transcriptional interactions using STRING v9.0. Attempts were made in order to link one molecular network with other at variety of confidence levels. Gradient sieving of the confidence filters start with 0.9, followed by 0.7 and 0.4. Finally, the lacunae left in the interactions will be filled using basic physiology of the genes and/or encoded proteins.

Results: NGF and BDNF proteins showed maximum number of intermediate binding  partners, which through their intermediate partner, GIPC1, link with DRD2 receptor. DRD2 in turn associated with DRD3, DRD4 and SLC6A3. These interactions congregate them with the physiology of dopamine and other proteins involved in cAMP regulation like HTR1B, AKAP5, OXT, AVP and MAOA. Of these SLC6A3, HTR1B and MAOA form a molecular bridge between dopamine and serotonin physiology. The later involve additional proteins like SLC6A4, TPH1 and TPH2. An auxiliary association was also noted between SLC6A3 with AR which in turn result in the transcriptional regulation via CREB, reflecting the role of testosterone with the anger physiology.  Finally the CREB is known to regulate the expression of BDNF making the entire molecular network link together.

Conclusion: The study provide a molecular resolution to the aggression physiology which could be exploited to screen the targeted population and design therapeutic interventions.

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The effect of neurofeedback treatment on reducing attention deficit hyperactivity disorder symptoms and tendency to substance abuse in adult clients

Oral Speech By Najmeh Hamid


The purpose of this research was to determine the efficacy of neurofeedback treatment on reducing attention deficit hyperactivity disorder symptoms and tendency to substance abuse in adult clients in Tehran’s psychology clinics.

The research method was experimental with pre-post, follow-up and control group. The sample consisted of 12 men of between 18 to 40 years old referred to clinics and were matched from educational status, sex, not suffering from acute physical and mental disorders and other criteria considered in this research, then randomly divided into two experimental and control groups. The research instruments were Barkleys ADHD questionnaire and Zargars substance tendency questionnaire. The experimental group received 40-sessions neurofeedback treatment but the control group did not receive any intervention.

The results showed that there was a significant difference between experimental and control group in ADHD symptoms (p<0.004). The rate of ADHD symptoms significantly decreased in comparison with pretest and control group, but there was no significant difference between two groups in substance tendency. These results significantly persisted after follow-up period

The neurofeedback significantly reduced the symptoms of hyperactivity in the experimental group compared to the pre-test and control group. These results continued significantly during the follow-up period, while there was no difference between the two groups in the trend toward drug use in the post-test and follow-up periods. 

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Neural processing of speech and music stimuli in aided and unaided condition

Oral Speech By Sneha

Speech and music are considered to be the most difficult stimuli to be processed in the auditory system. The difficulty is due to the complexity of the spectral and temporal components of complex stimuli. Speech understanding is very crucial in day to day living conditions. As speech, music is also an important and enjoyable part in many people’s life. Music listening has recreational and rehabilitative function and can improve quality of life. According to the studies music can enhance IQ in developing children. For example, music involvement can enhance IQ in developing children (Hille, Gust, Bitz, & Kammer, 2011) and can mitigate symptoms of Alzheimer’s disease in older adults (Simmons-stern, Budson, &amp; Ally,2010). The neural representations of speech have been studied for over two decades (Sachs & Young, 1979; Palmer et al.1986) and the music has been studied past a decade (Tervaniemi et al; 2009; Kraus and Chandrashekaran, 2010; Bidelman, Gandour &; Krishnan, 2011; Besson, Chobert, & Marie, 2011)

Complex task requiring multiple stages of neural processing is needed to decode the speech and music segments into a comprehensible manner.

The perception and processing furthermore gets worsen if the auditory system is impaired. The individuals with hearing impairment have difficulty perceiving and processing the complex spectral and temporal cues in the speech and music stimuli, as a result they have impaired communication. Hearing aid is the most important rehabilitative device for individuals with decreased hearing sensitivity. An individual with impaired auditory system cannot perceive and appreciate music. Even though numerous researches is being done on hearing aid technology, it is still unclear why there is variable results in terms of hearing aid benefit in subjects with similar degree and type of hearing loss with similar hearing devices (Tremblay, Billings, Friesen, &amp; Souza, 2006). There is a lack of literature related to the hearing aid processes encoding of speech and music at the auditory brainstem. Though there are behavioural evidences of music perception through hearing aids, there are lot of variation among responses that were observed. Hence, an objective electrophysiological tool will provide an insight into processing of speech and music for those with hearing aid.

The present study is aimed to estimate and compare the neural processing of music and speech evoked frequency following response in unaided (without hearing aid) and aided (with hearing aid) condition through hearing aids in individuals with mild and moderate sensori-neural hearing loss.

Total of forty participants with mild and moderate sensorineural hearing (SNHL) loss participated in the research. To study the neural processing, frequency following response (FFR), was recorded for speech and music stimuli in both the groups. FFR was recorded for speech stimulus /da/ and /ga/ and for music stimuli violin excerpt /sa-ga/ and /ga-sa/ from mayamalavagavla ra:ga from Carnatic music

The auditory brainstem FFRs revealed that individuals had significantly higher amplitudes of harmonics and significantly better pitch tracking abilities in aided condition in both the groups. Individuals with mild hearing loss had significantly better amplitudes and pitch tracking abilities compared to participants with moderate sensorineural hearing loss. Overall, results of the present investigation showed that individuals had superior representation for both speech and music stimuli at brainstem as well as at cortical levels in aided condition than in unaided condition.

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Recognizing oro-mandibular dystonia and its management: a case study

Oral Speech By Anagha

Oro Mandibular Dystonia (OMD)is a focal dystonia affecting the muscles of lips, tongue and/or jaw which can impact speech production. The estimated annual incidence is 3.3 to 6.9 cases per 1 million people (Merz et al,2010) and the etiology is largely unknown. The different clinical forms encountered are jaw-opening oromandibular dystonia (JOOD), jawclosing oromandibular dystonia (JCOD), and mixed OMD (patients with two or more combinations of either JCOD, JOOD, or jaw deviation (JD), and with no clinical predominance of any subtype (Tan,1999). OMD is a chronic condition affecting speech and swallowing, leading to an impaired quality of life. Symptoms of OMD are generally task specific and occur only during activities such as speaking or chewing. Since OMD is a rare condition that mostly happens because of unknown cause, it is important to profile the features exhibited by the client using a detailed assessment procedure and also to plan appropriate treatment strategies that maximally benefits the client. Through this study we aim to profile clinical characteristics of OMD and to plan appropriate treatment strategies for a 33year-old male who complained of unintelligible speech and difficulty in tongue movements during speech production. The radiological evaluation of the client revealed no areas of altered density in bilateral cerebral and cerebellar hemispheres. After a detailed speech, language and swallowing evaluation, the client was diagnosed as having hyperkinetic dysarthria secondary to oro - mandibular dystonia (with oral-phase dysphagia). Based on the reports, speech and swallowing therapy goals were formulated and treatment strategies such as relaxation techniques & sensory tricks were used. Major changes in speech and swallowing abilities were observed during the treatment period. Hence this study permits us to discuss the clinical assessment and treatment procedures for an individual with OMD.

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Endoscopic removal of growth hormone secreting pituitary tumor- My experiences of twelve cases

Oral Speech By Atikur Rahman

The use of endoscope for the management of pituitary adenoma is not new.

The better magnification and illumination provided by the endoscope gives better outcome

than microscopic pituitary surgery. The purpose of the study to find outcome of growth hormone secreting pituitary adenoma. I did twelve cases of pituitary adenoma last three years. All patients presented to me features of acromegaly with headache and visual disturbances and hormone profile shows growth hormone above normal level. I prepared all patients for surgery by purely endoscopic removal. After surgery growth hormone became normal of 10 cases and one became half of initial level and patient need re surgery by transcranial approaches and one is lost of follow up. I used fat graft, fascia lata, vascularized pedicle flap, biological glow for repair of seller floor. No mortality and no CSF leak in reported cases.

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