|Year : 2001 | Volume
| Issue : 1 | Page : 21-28
Selected abstracts from the first GCC forum on hearing impairment, 22 - 23 march 2000 Bahrain
|Date of Web Publication||9-Jul-2020|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Selected abstracts from the first GCC forum on hearing impairment, 22 - 23 march 2000 Bahrain. Saudi J Otorhinolaryngol Head Neck Surg 2001;3:21-8
|How to cite this URL:|
. Selected abstracts from the first GCC forum on hearing impairment, 22 - 23 march 2000 Bahrain. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2001 [cited 2021 May 5];3:21-8. Available from: https://www.sjohns.org/text.asp?2001/3/1/21/289357
| Results and future developments in cochlear implantation|| |
Prof. Dr. Med. Jan Helms
Results of speech understanding for postlingually deaf adult patients are best given in the nono-syl- labe test. A test like this is so difficult that a saturation above 85 or 90% of understanding wilt hardly be achieved. The differentiation of results of a larger group of patients is best achieved with a test like this and plotted as a distribution function, so that all tests results become evident.
More than 50% of our patients have better than 50% mono-syllable understanding which means that they can use a normal telephone. All patients benefit because also those, who can not use a telephone achieve an acoustic coupling to their surrounding and by this means a better life quality.
The measurement of results in prelingually deaf young children is much more complicated. They have to develop hearing and speech competence during years and this is why it takes years to get statistical results. However, a larger and larger group out of these children from various implanters with different systems reach the ability to enter and to stay in mainstream schools. The future development of cochlear implantation will most probably include a further improvement of speech processing strategies and in addition bilateral implantations, which were done in more than 30 cases in the Wuerzurgh ENt Department
Prof. Dr.Med. Jan Helms
Direktor DERKlinik und Poliklink Furhals-Nasen - UND/OH REKRANKE DER University by Wor Z Burg ñ Germany
| A Protocol for the Evaluation of Arabic- Speaking Cochlear Implant Children and Adults 6 Years of experience in Egypt|| |
prof. Salah M. Soliman, MD., SC.
While breathing keeps man physically alive, hearts keeps him mentally alert, socially active and emotionally stable, It follows that any significant hearing impairment will have a devastating effect on the individuals ability to re-normalize his existence. An effective procedure to achieve such a goal is cochlear implantation.
The advent of such procedure has lead to restoration of hearing close to its previous levels in most subjects, The cochlear implant program at Ain Shams University started in 1994 and to date 49 patients have been implanted, most of them successfully. The criteria for success are based on the audiological and Arabic speech tests especially developed with norms established for the Arabic Speaking patients since 1987. This protocol contains different audiological and non-audiological investigations. This includes the personal interview and detailed history-taking followed by basic audiological evaluation and aided audiogram. At this stage, patients who are potential candidates for cochlear implantation would be evaluated further using objective tests such as Audiotory Brainstem Response (ABR) and Otoacoustc Emissions (OAEs). Speech perception tests using the developed Arabic Minimal Auditory (MAC) test battery and Word Interligibility by picture Identification (WIPI) test are done for patients with aided thresholds above the long-term average speech spectrum. Electrical promomtory stimulation test is also performed for assessment of auditory nerve integrity. Other non-audiological measures include phoni- atric evaluation, radiological studies by CT scan and MRI. Some patients would require psychiatric and general medical evaluation.
Finally, complete analysis and interpretation of the results are performed by the cochlear implant team with counseling of the patients for selecting the candidates and directing the non candidates for other rehabilitative methods.
Prof. Salah Soliman
Ain Shams University 1 0 Saray Road - Al-Jazeera Al-Zamalik 11211, Egypt
| 27 years of Audiology in Egypt A professional Legacy|| |
Prof. Salah M. Soliman, MD., SC
Audiology is an art, a medical art dedicated to the welfare of both normal hearing and hearing- impaired individuals. Accordingly, audiological services of high professional quality and diversity are needed to achieve such a goal. Such services “Officially” started in Egypt in April 1973. It w as an activity whose time has come. A modern state of the art Audiology center was founded at Am Shams University, College of Medicine complete with a graduate educational program offering Master and Doctorate degrees in Audiology and Hearing Sciences to medical graduates. This constituted the backbone of the professional activity of the center, enabling it to provide other centers with trained qualified audiologists. Indeed, their qualifications match or exceed the requirements of the America Speech Language and Hearing Association (ASHA for the clinical certification in Audiology (CCC-A). Today, Egypt has 12 University Hospital centers as well as centers in Public Health hospitals in most large cities. They are staffed with over 200 Audiologists with Master and for Doctorate degrees and provide diagnostic and therapeutic professional quality designed for Arabic speaking patients of all ages in Egypt and across the Arab World
Prof. Salah Soliman
Prof, of Audiology Ain Shams University 10 Saray Road - Al-Jazeera Al-Zamalik 11211 Egypt
| Experiences with Cochlear Implant at KFSH&RC|| |
Dr. Khalid Taibah, MD., PRCS,
Dr. Haifa Al Hajjaj, Dr. Ribhi Jarrar, Ph.D.
Dr. Claire Santos Haddad
Cochlear implant shave become the treatment of choice for profoundly deaf adults and children who obtain little or no benefit from conventional amplification. Sounds are translated into small electric currents that stimulate the auditory nerves in the cochlea and generate hearing sensation. Fifly-three patients had cochlea implants surgery at King Faisal Specialist Hospital & Research Center (KFSH&RC) between year 1994 and 1999.
There were 21 congenital, pre-lingual and post-lingual children and 32, post-lingual and pre-lingual adult patients, In our services, there were 7 patients developed profound hearing loss after neurobrucellosis, with excellent outcome and considered to be the first to be reported in the literature. Ossification of the Cochlea following meningitis presents a surgical and audiological challenge. In 13 implanted cases of meningitis, there were different degrees of ossification with variable radiological interesting findings. In one patient, we inserted split electrode of MedEl device, a new surgical approach for ossified cochlea in the upper and basal turn of the cochlea. We have developed the experiences with Nucleus, Clarion and MedEl devices in our program with good outcome. The surgical experiences, complications, as well as, the audiologicai results will be discussed in details. Although, a longer period of experience is required, the pre school-aged children remain as the most challenging to our developing program
Dr. Khalid Taiba
King Faisal Specialist Hospital & Research Centre P.O. Box 3354 Riyadh 11211 K.S.A.
| The Impact of sanguinity on childhood hearing impairment in a Saudi population|| |
Dr. Tarek S. Jamal, Dr. Kamal J. Daghistani, Prof. Siraj M.Zakzouk
Objective: To determine the current status of cosanguinity in the Saudi Population and its effects on childhood hearing impairment.
Materials and Methods; A randomly selected sample of 9540 Saudi children representing all socioeconomic and demographic groups were selected. A field work was carried out to enumerate the various areas of the provinces of the Kingdom of Saudi Arabia. A survey team consisting of a social worker, otolaryngologist, audiologist and a nurse completed the questionnaire form, performed examinations and audiological assessments using free sound speech, tuning fork tests, pure tone audiometry (using clinical audiometer Ac30) and tympanometry (using GS133 and Masden Zodiac901). The data was analyzed by x2 testing using EPI-INFO computer software.
Results: A total of 9540 children below the 15 years were included. Parents of 19% of the children were first cousins or other relatives. The prevalence of hearing impairment was found to be 13% (0.83% severe, 2.4% moderate and 9.75 mild) the prevalence of hearing impairment was significantly higher in children whose parents were either first cousins (16.14%p<0.01) as compared to children whose parents were not related (10.38%).
Conclusion: Our study clearly demonstrates a high percentage of consanguinity among the Saudi population and a definite role of cosanguinity in the etiology of childhood hearing impairment. A well planned counseling program to create awareness regarding the adverse effects of cosanguineous marriages is needed to save the population from the disability of hereditary loss.
Key Words: Hearing impairment, genetic factors, cosanguinity, risk factors.
Dr. Kamal J. Daghistani
P.O. Box 11217 Jeddah 21453 K.S.A
| Hearing Screening of Infants at King Fahad Hospital of the University|| |
Prof. A.Aziz Ashoor
Aim: To check the reliability the modified Ewing Stayker Test (MEST) as Screening Hearing Test in small children
Material and Methods: 151 infants from the Well Baby Clinic and 30 from the High Risk Chmc were screened using the MEST.
Results: 7 out of 151 failed the test (4.6%) and l3 out of 30 High Risks infants failed the test (43.3 /%). Both failure were referred to proper Audiology. The validity index for both group was 71.4% and 92.3% retrospectively.
Conclusion: The Modified Ewing. Stayker Test (MEST) is a reliable practical Hearing Screening test.
Prof. Abdul Aziz Ashoor
King Faisal University King Fahad Hospital of the University P.O. Box 40181 Al-Khobar 31952 K.S.A.
| The Prevalence of Otitis Media with Effusion and its effect on Hearing Impairment in Saudi Children.|| |
Dr. AbdulMonem Al-Shaikh, Prof. Seraj Zazouk, Dr. Tarik Jamal, Dr. Kamal Daghistani & Dr. Metawakel Hajjaj
The study was designed to determine the prevalence of otitis media with effusion (OME) in Saudi children, its impact on hearing impairment and its correlation with type B tympanogram. A total of 9540 Saudi children below 15 years of age were screened during September 1994 and May 1998. Our results showed the prevalence of OME and type B tympanogram to be 5.75% and 6.28% significantly. The frequency of both OME and type B tympanogram decrease with increasing age of the children. There was a significant correlation (r = 0.89) between OME and type B tympanogram suggesting the importance of tympanometry in the diagnosis of OME. The children exposed to OME or with type B tympanogram showed significantly high rate of hearing impairment as compared to unexposed children.
Dr. Abdulmonem H. Al-Saikh P. 0. Box 10462 Jeddah 21433 K:S.A
| Experience with Cochlear Implants in Postmeningitic Cases|| |
Dr. Abdulmonem H. Al-Shaikh, MD, Dr. Afaf A. Metwalli, B.c. Ph.D. (Audiologist)
Cochlear implant surgery was performed on 15 cases with postmeningitic hearing loss. They were of both sexes with age range (11-65 years). They were representing 65.2% of the total 23 cases selected from all over the kingdom and were implanted in the King Fahad Hospital, ENT Center, Jeddah, Kingdom of Saudi Arabia, along the period extending from December 1993 through 1998 where all fulfilled the strict universal pre-selection criteria. Surgically, five cases (33.3%) represented some difficulty in inserting the implant inside the scalae tympani. This was explained being due to the fibrosis spreading inside the cochlea resulting from the pan labrynthitis occurring after bacterial meningitis that ended in suppurative labrynthitis. 10 cases (66.7%) due to viral meningitis did not show the same observation and were surgically implanted without difficulty. Radiological preoperative investigation (CT & MRI) were not so consistent in detecting postmeningitic fibrotic pan- labrynthitis and that were only detected on the theater table. It was also unique for those meningitic cases that audiologically the post viral meningitis cases showd more than the post bacterial ones who (due post suppurative fibrotic pan-labrynthitis) did not show any remnants of hearing. During the post meningitic cases showed relatively more resistance to progress, this could be explained that the meningitic problem tackled their cortexes (menin- gioencehphalitis) representing an additional problem for their learning disability.
Dr. Abdulmonem H. Al-Saikh P. 0. Box 10462 Jeddah 21433 K.S.A
| Universal Newborn Hearing Screening Program Necessity, Benefits and Justifications|| |
Mr. S. Sarguna Murthy, MSc (Sp & Hg)., Reg OSLA., CC-A, Dr. Abdulla AlNuaimi, MD., (German Board)
Aim: This presentation is intend to cover all the aspects of neonatal screening program. The authors assume that this presentation would encourage and help many of participants to lead and start a similar project on early detection of infants with “significant hearing loss”. Hearing impairment is the most common major disability of the newborn (approx 3 to 6 per 1000 new born babies) and it is unseen disability, hearing loss often goes undetected. The incidence of bilateral congenital hearing loss is alarming, and is in fact, many times greater that the combined incidence of all newborn screening tests currently performed. This congenital hearing disability will impede speech, language, and cognitive development. If a deaf child is born and we do nothing until they are almost five years old, it is too little and too late. Now this can be averted by identifying them at an early age. The prognosis for the hearing impaired is improved when the diagnosis is made as early possible. The sooner a congenital hearing loss is identified the more likely the child can lead a normal life. Considering the benefits of early identification of hearing loss, internationally much attention has been focused on newborn hearing screening as the best means of early identification of congenital permanent hearing loss.
Analysis of the case histories of 301 congenital hearing loss children seen in the department of ENT from January 1994 to December 1998. The average age of identification of congenital hearing loss in United Arab Emirates is around 32 months of age and intervention is around 46 months of age and it is later in less severe hearing impairment that is around 73 months. It is also found in 48% of the children had no risk factor for hearing loss. In most of the children, a risk factor was identified after confirmation of hearing loss.
- There should be a dramatic and immediate national policy to make real advances in early identification, prevention and rehabilitation of congenital hearing losses.
- Most of the children with congenital hearing loss are identified after much of the valuable time is lost.
- The high register is not an effective tool in identifying all the congenital hearing loss early. Inmost of the children a risk factor was identified after confirmation of hearing loss, so it is clear that high risk register is not being put to complete use in its present state.
- The authors suggest that universal screening (Screening all the neonates) at birth is the only viable method of achieving our air of early identification of congenital hearing loss and paying the way for rehabilitation and prevention of this congenital disability.
Mr. S. Murthy Department of ENT Audiology & Vestibular Unit Mafraq Hospial Abu Dhabi - U.A.E
| Analysis of Noise Induced Hearing Loss Patients Awareness What are we suppose to do about it?|| |
Dr. Abdulla AiNuaimi, MD., (German Board), Mr. S. Sarguna Murthy, MSc (Sp & Hg)., Reg OSLA., CC-A, Dr. Ahamed Haider, FRCS, Mrs. Aneeta S. B.A.S.T., Reg ISHA
This presentation is intend to conver the dangerous effects of noise, Classification of NIHL patients seen in our clinic, Hearing conservation programs, Legislations and regulation, patients and public awareness, preventive measures and recommendations.
Research has shown that excessive noise exposure is one of the leading causes of hearing loss. It has got a great negative effect on person’s social, vocational and emotional well being. Although noise induced hearing loss (NIHL) is preventable, the steady increase of noise pollution in modern industrialized environment places more and more people at risk.
Out of 3248 patients seen in audiology section between January 1998 to December 1998, 425 (or) 13 percent patients had some degree of noise induced hearing loss. The questionnaire was distributed to all the patients with the history of noise exposure and later confirmed of having hearing loss with audiological test. The results were as follows- Majority of the patients i.e. 380 patients (67.3%) did not know that noise exposure causes hearing loss. 496 or 88% did not use ear protecting devices at all. Out of this 68 patients 39 patients or 6.9% use the ear protecting device regularly. To study the public awareness. We have also asked 100 other patients about the danger of noise exposure. Only 28 person out of 100 have some idea about noise exposure and hearing loss.
Overall, results of this study reveals that many of them do not have an understanding about the danger of noise to hearing. With high percentage of patient population reporting of lack of awareness, we must pay attention to the alarming results. This survey suggests that we the professionals must act quickly and do something about correcting the effect of noise exposure to prevent further damage. Legislation and Regulations have been enacted that spell out guidelines for protection from noise exposure. The authors call on every individual at this seminar to involve himself/herself, in an on going public education program in his or her capacity.
Proposed that legislation be enacted by the government to establish a public education program, using the various media to provide information on noise and hearing loss in order to help the citizen to conserve their hearing. All the patients should get complete information on noise, it’s dangerous effect on human life and the means of protecting the hearing from further deterioration from noise exposure.
Dr. Abdulla Al-Nuaimi Department of ENT Audiology & Vestibular Unit Mafraq Hospital Abu Dhabi - U.A.E
| Auditory Brainstem Response (ABR) Findings in Post-Meningitic Children|| |
Dr. Naema M. Ismail, MD
Audiotory brainstem response (ABR) was performed on 39 children with age range (3 months - 12 years) with in one month to eight years after cure from meningitis. Twenty normal healthy children served as controls. Hearing loss was detected in the form of sensorinural hearing loss in sixteen patients (41 %) from which 10 patients had bilateral profound hearing loss. Mild conductive hearing loss was present in 4 patients (0.3%) and nineteen patients (48.7%) showed normal hearing. Brainstem abnormalities were present in the form of prolonged latencies of waves 1, V, interwave latencies of I - III an I-V Even study cases with normal hearing when compared to control revealed prolonged latency of wave V and intervvave latency 1-V which reflects subclinical neurologic affection. Age of onset of meningitis and associated neurologic complications were not associated with increase incidence of hearing loss.
Dr. Naema M. Ismail Hamad Medical Corporation Doha - Qatar Email:[email protected]
| Deafness ….The GCC Picture|| |
Dr. Mazin Al-Khabori, FRCS
Deafness is the worst solitary confinement humans can be given. Try to have conversation with fingers stuck in your ears and you will know how it feels to be deaf. You can feel the frustration, worse try to listen to a short-wave radio station with bad reception and you will know how deaf people feel (even with good hearing aids) who have poor speech discrimination.
The organs of hearing are the first to reach maturation and we can say that a baby in the womb can to some extent hear. Children have a natural born tendency to develop language. The early years not only are the most rapid of speech and language development but also critical to the acquisition of normal speech language skills. Any hearing loss (depending on the degree) can lead to an alinguis- tic child or delay and7or impaired language and language acquisition skills.
Post lingual hearing loss can lead to sudden interruption in schooling, or loss of a job both with major financial and social implications. The elderly as they go deaf are again ignored as deafness is considered part of growing old, the severe deterioration in quality of life experienced by these people is crippling psychologically.
There are unfair social and financial repercussion of deafness which depend upon which part of the worked you belong to and that may be the determining factor as to the road you wilt take i.e. the road to near normality or that of a handicapped person.
Different groups have established various protocols of alternate ways of communication and they do not complement each other much. School acceptance - parents’ acceptance of hearing aids a social stigma.
Deaf child at home, leading to disruptions, takes more time and attention of parents and thus deprive the other members of the family from their attention . Disruption of other children’s homework and normal playtime. Handicap leads to increased burden on the society.
There are nearly 200 million deaf people in the world today, according to the WHO 50% are preventable or amenable to preventable measures. The preventable measures come into primary, secondary and tertiary stages and propose to cover the widest number of people possible. For any program to succeed one has to have a good idea as to the magnitude of the problem. This is where epidemiological surveys come into the picture, these give us the numbers involved, incidence, etc. Primary preventive measures can be divided into age groups at different stages of life. We will in this talk show what has been done in AGCC countries.
Dr. Mazin Al-Khabori P. O. Box 937 Postal Code 1 1 2 Muscat - Oman Email: [email protected]
| Aetiology of Sensorineural Hearing Loss in Children in Bahrain A 10 Years Study|| |
Mr. Ahmed J. Jamal, FRCSI, FRCSED Mr. Nabeel H. Tammam, FRCSED. Dr. A.Karim Buallai, Msc
This study was carried out on children presented with deafness, speech delay or both to the hearing impaired (deaf-mute) children clinic in Salmaniya Medical Complex in Bahrain
Full detailed medical and family history including pre, peri & postnatal history relevant to hearing impairment were obtained. Otolaryngological & Audiological assessment were conducted and recorded on preset proforma. Assessment were also conducted by developmental pediatrician & children psychiatrist when indicated.
A total of 196 cases studied over 10 years period from 1986 to 1996.
Children with positive family history of deafness constituted 37/8% of the, cases (genetic group). Other aetiological groups showed the following distribution- cause unknown 33.7%, and pre-natal 3.0%, peri-natal 5.6%, post-natal 16.3% and miscellaneous group 3.6%
Our study shows that the main aetiological factors for deafness in children in Bahrain are the Genetic and the Unknown factors at 71.5% which expected to be due to recessive genes mainly as a result of high rate of consangiounus marriages at rate of 60.7%, and .this indicates that steps should be taken to facilitate pre-marriage counseling and public education as part of prevention.
Mr. Ahmed J. Jamal FRCSI, FRCSED.
Chairman & Consultant - ENT Surgeon ENT Department Salmaniya Medical Complex P. O. Box 12 Bahrain
| Parents Role in the Rehabilitation or Hearing Impaired Children|| |
Mr. Omar Y. Al-Sharif, MA
Recent reports on the parent’s role in the rehabilitation of hearing impaired children have been very encouraging.
This case study aims to emphasize and to conduct a vital message to the parents that they are in the ideal position to work on improving the communication skills of their children.
To show parents also that they are the primary teachers for their hearing impaired children. Simply because they are the only ones who can carry over learning into daily life, at breakfast, at bedtime, and on trips.To learn more about how essential the parent’s role in the team effort in the rehabilitation of their children hearing. We asked parents of 25 hearing impaired children aged 2 - 4 and their hearing - threshold levels 70 to 90 decibels, (1 5 boys & 1 0 girls(, to work with their children through a chart was giving to them to fill at home showing the amount of work and the targets they should implement with their children after finishing morning sessions. For a period of three months.
Results were compared with another results of another 20 children (15 boys & 5 girls) with the same age and hearing level. The second group was exposed to therapy at the clinic only, with no follow up at home. The results showed that the first group of children were able to acquire, maintain and generalize the targets were giving to them faster than the second group.
The first group acquired the targets in 24 sessions each session 30 minutes three days a week plus the effort at home.
The second group was able to acquire the targets in 40 sessions.
Mr. Omar Y. Al-Sharif
Speech and Language Therapist Department of ENT Saimaniya Medical Complex P.O. Box 12 Bahrain
| Pendred Syndrome .First Case Report in Bahrain|| |
Dr. Nabeel Tammam, Dr. Alawi Hassan, Dr. Shaikha S. Al-Arrayed, Dr. Sangam Kanikar
In 1896 Vaughan Pendred described two sisters with goiter and congenital deafness. In 1958 Morgan and Trotter showed that these patients might have an iodine organification defect of the thyroid gland. ,
The deafness is usually moderate to profound and the onset is typically considered to be congenital. The thyroid involvement is variable but is often associated with goiter, most commonly enlarging in adolescence.
h 1967 Jensen has described a Mondini malformation radiologically in patients with Pendred Syndrome and recently in 1996 a .linkage of Pendred Syndrome to chromosome 7q31 has been established and in 1997 the pendrin gene (PDS) was cloned.
Here in our institute we report the first case of Pendred syndrome based on the clinical findings, the audiological tests and the radiological findings.
Dr. Nabeel H. Tammam Consultant & ENT Surgeon Department of ENT Saimaniya Medical Complex P. 0. Box 12 Bahrain Email:[email protected]
| Role of MRI in Retrocochlear Sensorineural Hearing Loss|| |
Dr. Sangam Kanikar, Dr. Najeeb Jamsheer, Dr. Nabeel Tammam
Aim: To evaluate the role of MRI in the selective group of Retrochochlear Sensorineural hearing loss (SNHL).
Material & Methods: MRI was performed in 46 suspected cases of retrochochlear SNHL by ABER (Auditory Brain Stem Evoked Response). These cases were studied over the period of 18 months (July 1998 - December 1999). Patients were labeled retrochochlear SNHL when they had a delay in wave 5 in comparison between right and left ear, and prolongation of the interlatency between wave 1 and 5. All the patients were from the single institution (Saimaniya Medical Complex) and their ranged from 18-73 years.
Imaging Protocols: All the patients were subjected for high resolution MRI under superconductive MRI scanner with field strength 1 T. All the examinations were done with the head coil. Following were the sequences obtained for all the patients- 5 mm axial T2 wt (TR 3000 ms/TE 90-120 ms) and Ti wt (TR 500 ms/TE 18-20 ms) sections through the whole brain.
Axial Tl wt (TR 500 ms/TE 220 ms) and high res- olution T2 wt (TR40Qms/TEl 20 ms) 512 matrix 3 mm section through the internal auditory meatus (IAM).
Post gadolinium axial and coronal Tl wt fat saturation 3 mm section through IAM.
FLAIR sequence was obtained in the suspecte cases of demyelination and bleed.
Results: Out of 46 patients with abnormal ABER, 39 were positive on MRI while 7 patients did not show any abnormality, No lesion was found on the follow up scan after 4 weeks in 3 out of 7 patients Remaining 4 patients failed to follow up. Out of the 39 patients, 24 had an extra-axial /CP angle lesion. While 5 patients showed an intra-axial lesion.
Among the extra axial lesion acoustic shwannoma was the commonest cause of SNHL while 2 cases were due to Arnold Chiari Malformation which is a rare cause of the retrocochlear SNHL. These 2 patients showed significant improvement post operatively.
Multiple Sclerosis was the commonest cause of the intra-axial lesions while hemorrhage due to Cavernous hemangioma and diffuse axonal injury involving the brainstem were the rare causes
Dr. Sangam Kanikar Consultant Radiologist Department of Radiology Salmaniya Medical Complex P.O.Box 12