Delayed definitive treatment of life-threatening neurosurgery patient with suspected coronavirus disease 2019 infection in the midst of pandemic: Report of two cases.

BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic has affected global health system; in the context of the COVID-19 pandemic, both surgeon and anesthesiologist often dealt with emergency situation, optimal timing of surgery and safety protocol in hospital setting must be implemented with many facets for both patients and health-care providers. CASE DESCRIPTION: We reported two cases. Case#1 - A 16-year-old male was referred to our hospital, due to a decreased of consciousness following a motor vehicle accident. Head CT scan revealed an epidural hemorrhage on the left temporoparietal. The patient was suspected for having COVID-19 from the reactivity of his serum against SARS-CoV-2 antigen. Procedures for the confirmation of COVID-19 and surgical preparation caused 12 h delayed from the admission. Nevertheless, the patient was deteriorated clinically before he was transported to the operating room and died after 6 cycles of cardiopulmonary resuscitation. Case#2 - A 25-year-old male was referred to RSHS, due to a decreased of consciousness, diagnosed as bilateral proximal shunt exposed with suspected COVID-19; delay occurred due to unavailability of negative pressure intensive unit for postoperative care. This caused 5760 h (4 days) delayed for bilateral shunt removal and temporary extraventricular drainage. CONCLUSION: Optimal timing of surgery, a good safety, and health protocol during pandemic in emergency setting are an obligation to protect health providers and patients. A decision-making plan must be organized precisely to maintain alertness, achieve the highest possible standard of care, and outcome in emergency surgical cases. Lack of monitoring must be abated to avoid fatality for patient, especially in emergency surgery setting.

Analysis of Mutant Isocitrate Dehydrogenase 1 Immunoexpression, Ki-67 and Programmed Death Ligand 1 in Diffuse Astrocytic Tumours : Study of Single Center in Bandung, Indonesia.

OBJECTIVE: Diffuse astrocytic tumour (DAT) is a diffuse infiltrative astrocytoma tumour accompanied by molecular parameters such as the presence or absence of isocitrate dehydrogenase (IDH) gene mutations. Ki-67 is a marker for DAT proliferation, while programmed death ligand 1 (PD-L1) indicates an immune evasion mechanism. This study aimed to analyze the correlation among mutant IDH1 R132H, Ki-67, and PD-L1 immunoexpression in the DAT. METHODS: A cross-sectional study was carried out on 30 paraffin blocks of DAT cases. Paraffin block samples consist of grade II (n=14), grade III (n=8), and grade IV (n=8). In this study, the immunohistochemistry-staining of mutant IDH1 R132H, Ki-67, and PD-L1 were carried out to determine the frequency of DAT with IDH1 mutations. RESULTS: Our study shown the frequency of IDH1 mutations in grade II 50.0% (7/14), grade III 37.5% (3/8), and grade IV 12.5% (1/8). Our study also showed a difference in Ki-67 and PD-L1 expression between each the degree of DAT histopathology (p=0.0001 and p=0.002, respectively). There was an association between both mutant IDH1 R132H, and Ki-67 with PD-L1 expression in DAT (p=0.0087 and p=0.0049, respectively). CONCLUSION: DAT with the mutant IDH1 is frequently observed in grade II and small number of grade III. The expression of wild type IDH1, Ki-67, and PD-L1 were found to be higher in high grade DAT (grade III and grade IV). There is a correlation between each of mutant IDH1 status and Ki-67 with PD-L1 expression in DAT.

The neurological significance of COVID-19: Lesson learn from the pandemic.

Coronavirus Infectious Disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; previously known as 2019 novel coronavirus) is an emerging and rapidly evolving health issue that has been widespread globally and become a pandemic. The typical symptoms of COVID-19 are: a cough, shortness of breath and a fever; from the initial estimates, about 15% of COVID-19 patients present with severe respiratory symptoms and requires hospitalization and intensive care. Recent accumulated evidences showed that the neurological insults also occurred in patients with COVID-19, ranging from mild headache to severe neurological symptoms. In this review, we summarize the COVID-19 and neurological significance of COVID-19.

An Infratemporal Dermoid Cyst That Expanded the Foramen Ovale: A Case Report.

BACKGROUND: Dermoid cysts are rare tumors usually seen in the midline structure of the brain but rarely arise in the petrous apex and cavernous sinus. There have been very few reports of dermoid cysts arising in the infratemporal fossa, with scarce anatomic descriptions. Here we report the case of a patient with a dermoid cyst in the left infratemporal fossa. CASE DESCRIPTION: The patient was a 43-year-old female with complaints of nonspecific headaches. A computed tomography (CT) scan revealed a cystic lesion measuring 25 × 18 × 15 mm in the left infratemporal fossa that had expanded the foramen ovale. The same lesion was observed as a high-intensity area on T1-weighted magnetic resonance imaging (MRI) with fat saturation. Diffusion-weighted MRI showed no restriction, unlike in cases of epidermoid cysts. A left fronto-temporo-sphenoidal craniotomy with a detachment of the zygoma was performed to approach the lesion. The tumor wall was continuously attached to the dura, although the tumor itself was entirely extradural in location. The V3 branch of the trigeminal nerve was firmly attached around the tumor. The tumor was cystic, and it shrunk after the fatty yellowish contents were suctioned. Complete resection was achieved without complications. A pathological analysis enabled the diagnosis of a dermoid cyst. No tumor recurrences or associated complications were observed at the 1-year follow-up. CONCLUSIONS: Dermoid cysts in the infratemporal fossa are extremely rare. However, tumor resections can be performed safely and efficaciously using anatomically detailed preoperative planning.

The Bandung neurosurgery patient outcomes project, Indonesia (Part I): Methods, participant characteristics, and pre-discharge outcomes.

INTRODUCTION: Little is known about neurosurgery patient outcomes in Indonesia. Our study sought to describe patient characteristics, health care pathways, health-related quality of life, and health/rehabilitation care needs of patients admitted to, and discharged from, a major neurosurgery department. METHODS: Eligible patients were aged ≥18 years admitted to the Neurosurgery Department in a regional referral hospital in Bandung, Indonesia. Baseline data was collected on admission. An in-person interview (in the Indonesian language) was held 1 to 2 days pre-discharge. Sociodemographic along with clinical characteristics, Glasgow Coma Scale (GCS), and EQ-5D-5L data were collected. RESULTS: A total of 217 patients were admitted, 37 died before discharge, and a pre-discharge interview was undertaken by 178 (82%). Almost half (48%) were admitted because of injury, 38% brain tumour, 10% acute illness, and 4% other conditions. The mean age was 41 years. On admission, 63% had a mild Glasgow Coma Scale, 31% moderate, and 3% severe. The average hospital stay was 8 days for injury and 24 days for illness patients. Prior to discharge, one-third, or less, of the 178 patients interviewed reported "no problems" in the EQ-5D dimensions of mobility (32%), self-care (27%), usual activities (16%), and pain/discomfort (32%), whereas 70% reported "no problems" with anxiety/depression. CONCLUSION: A large proportion of patients are being discharged with considerable levels of difficulty in four of the five EQ-5D dimensions. This stresses the importance of providing good follow-up and support of patients and their families.

The Bandung neurosurgery patient outcomes project, Indonesia (Part II): Patient pathways and feasibility and acceptability of telephone follow-up.

INTRODUCTION: Support of neurosurgery patients following discharge from hospital is important. Currently, little is known about patients' in low- and middle-income countries before and after their hospital treatment. This companion paper reports patients' pathways before and after hospital admission and the feasibility of following up this ill-patient population by telephone. METHODS: Eligible patients were aged ≥18 years admitted to the Neurosurgery Department in Dr. Hasan Sadikin Hospital-a regional referral hospital in Bandung City, Indonesia. Clinical data were collected on admission by clinicians. In-person interviews were undertaken with a clinical research nurse 1 to 2 days pre-discharge, and telephone follow-up interviews at 1, 2, and 3 months post-discharge. Information was also collected on pathways prior to admission and following discharge. The number of contact attempts for each patient interview was documented, as was the overall acceptability of undertaking a telephone interview. RESULTS: Of 178 patients discharged from hospital, 12 later died. Of the remaining 166 patients, 95% were able to be followed up to 3 months. Two-thirds of patients had been referred from another hospital. Patients came from, and were discharged to, locations throughout the West Java region. At the 1-month interview, 84% participants reported that they had had a follow-up consultation with a health professional-mostly with a neurosurgeon. CONCLUSION: This study has shown that, with a neurosurgery nurse delegated to the role, it is feasible to conduct follow-up telephone interviews with patients after discharge from a neurosurgery ward and that in fact such follow-up was appreciated by patients.

Surgical management of giant skull osteomas.

OBJECTIVE: Surgical management of giant skull osteomas Osteomas are benign, generally slow growing, bone forming tumors limited to the craniofacial and jaw bones. MATERIALS AND METHODS: A retrospective review of all cases of osteoma diagnosed from 2009 to 2013 treated in our hospital. The data collected included age at diagnosis, gender, lesion location, size, presenting and duration of symptoms, treatment, complication and outcome. RESULTS: During our study period there were 15 cases that were treated surgically. Their mean age was 42 years (range: 15-65 years) and all of our patients were female. The average duration of symptoms was 3 years and size varying from 4 cm to 12 cm. Eight patients complained of headache, whereas 6 patients complained about esthetics, and 1 patient presented with proptosis. The tumor was excised by cutting the base of the tumor and then residual tumor was grinded using a round head cutting bar. Osteoma was removed with esthetically acceptable appearance. CONCLUSION: There were no major complications during operative and postoperative period. Although osteomas are usually slow growing but surgery is usually performed due to esthetic reasons. It is important to plan an appropriate surgical approach that minimizes any damage to the adjacent structures.

Multiple meningiomas consisting of fibrous meningioma, transitional meningioma, and meningotheliomatous meningioma in one adult patient.

Multiple histopathology of meningioma is a condition in which the patient has more than one histopathology feature of meningioma in different intracranial locations, with or without sign of neurofibromatosis. Meningiomas are the most common, non-glial, primitive intracranial tumors; their prevalence among operated tumors is around 13-19%. They may occur at any age, but have a peak incidence around 45 years of age. The incidence of multiple intracranial meningiomas varies from 1% to 10% in different series, and the frequency of multiple meningiomas without neurofibromatosis was reported to be <3%.

Hollow-organ perforation following thoracolumbar spinal injuries of fall from height.

INTRODUCTION: Spinal trauma is the cause of high mortality and morbidity, the fall from height as mechanism that can cause a wide variety of lesions, associated both with the direct impact on the ground and with the deceleration. In such fall cases greater heights and higher mortality are involved. PRESENTATION OF CASE: We report the successful management of life-threatening hollow-organ perforation following thoracolumbar spinal injury. DISCUSSION: Perforation of the hollow-organ in the setting of thoracolumbar trauma may delay the diagnosis and can have devastating consequences. CONCLUSIONS: This case supports the recommendation for neurosurgeon in the setting of thoracolumbar injury that perforation of the hollow-organ can have devastating consequences. It is vital to achieve an early diagnosis to improve survival rate.

Trumpet laminectomy microdecompression for lumbal canal stenosis.

Microsurgery techniques are useful innovations towards minimizing the insult of canal stenosis. Here, we describe the trumpet laminectomy microdecompression (TLM) technique, advantages and disadvantages. Sixty-two TLM patients with lumbar disc herniation, facet hypertrophy or yellow ligament or intracanal granulation tissue. The symptoms are low back pain, dysesthesia and severe pain on both legs. Spine levels operated Th11-S1; the patients who had trumpet-type fenestration, 62.9% had hypertrophy of the facet joint, 11.3% had intracanal granulation tissue, 79.1% had hypertrophy of the yellow ligament and 64.5% had disc herniation. The average of procedure duration was 68.9 min and intraoperative blood loss was 47.4 mL. Intraoperative complications were found in 3.2% of patients, with dural damage but without cerebrospinal fluid leakage. The TLM can be performed for all ages and all levels of spinal canal stenosis, without the complication of spondilolistesis. The TLM has a shorter duration, with minimal intraoperative blood loss.

Enhanced expression of proapoptotic and autophagic proteins involved in the cell death of glioblastoma induced by synthetic glycans.

OBJECT: Glioblastoma is the most aggressive malignant brain tumor, and overall patient survival has not been prolonged even by conventional therapies. Previously, the authors found that chemically synthesized glycans could be anticancer agents against growth of a series of cancer cells. In this study, the authors examined the effects of glycans on the growth of glioblastoma cells both in vitro and in vivo. METHODS: The authors investigated not only the occurrence of changes in the cell signaling molecules and expression levels of various proteins related to cell death, but also a mouse model involving the injection of glioblastoma cells following the administration of synthetic glycans. RESULTS: Synthetic glycans inhibited the growth of glioblastoma cells, induced the apoptosis of the cells with cleaved poly (adenosine diphosphate-ribose) polymerase (PARP) expression and DNA fragmentation, and also caused autophagy, as shown by the detection of autophagosome proteins and monodansylcadaverine staining. Furthermore, tumor growth in the in vivo mouse model was significantly inhibited. A dramatic induction of programmed cell death was found in glioblastoma cells after treatment with synthetic glycans. CONCLUSIONS: These results suggest that synthetic glycans could be a promising novel anticancer agent for performing chemotherapy against glioblastoma.

Comprehensive management of frontal and cerebellar tumor patients with personality changes and suicidal tendencies.

BACKGROUND: Brain tumor patients have a tendency to suffer from psychiatric disturbances. One of the most frequent disturbance experienced by frontal area tumor patients are personality changes. CASE DESCRIPTION: In this paper, the authors report a 28-year-old male patient who presented with headache and personality changes, with no other neurological disturbance. The patient became increasingly pensive and apathetic with frontal and cerebellopontine angle tumor. The diagnosis is based on computed tomography scanning images, and histopathological examination of the excised tumor results in meningioma. CONCLUSION: Before the operation was performed, the patient suffered from personality changes and suicidal tendencies. After the operation, the patient's suicidal tendency was gone, but the personality changes still persist. For this reason, a comprehensive management of the patient is required, including postoperative pharmacological and psychological treatment.

Pterional approach versus unilateral frontal approach on tuberculum sellae meningioma: Single centre experiences.

INTRODUCTION: Tuberculum Sellae Meningioma is one of the most challenging surgeries among neurosurgeons. Many approaches have been established in the effort of removing the tumor and some of them are supported by an advanced neurosurgical technology. In this study, we aim to compare the efficacy of the two most common approaches, the pterional and the unilateral frontal. MATERIALS AND METHODS: This was a restrospective study that aimed to observe the efficacy of the two most common approaches used in our center, the pterional and the unilateral frontal, in resecting the tuberculum sellae meningioma, which was held in Dr. Hasan Sadikin General Hospital, Bandung, from July 2007-July 2010. Twenty patients were enrolled with half of them operated by the pterional approach and the rest by unilateral frontal approach. We evaluated six parameters: tumor size, degree of tumor removal, surgery duration, post-operative cerebral edema, patients' outcome, and length of stay, which were evaluated to take measure of the efficacy of each procedure. RESULTS: We found that the pterional approach gave more advantages than the unilateral frontal. Total tumor removal, especially in tumor size ≥ 3 cm was achieved in a greater number of subjects in the pterional (P<0.023). Other advantages of the pterional compared to the unilateral frontal were a shorter surgical duration (P=0.024), shorter length of stay (P=0.009) and less frequency of post-operative cerebral edema incidence (P=0.023). CONCLUSION: According to our facilities and conditions, it seems that the pterional approach have more advantages than the unilateral frontal approach in tuberculum sellae meningioma surgery.

Penetrating skull fracture by a wooden object: Management dilemmas and literature review.

Most penetrating skull injuries are caused by gun shot wounds or missiles. The compound depressed skull fracture represents an acute neurosurgical emergency. Management and diagnosis of such cases have been described, but its occurence following a fall onto a piece of wood is quite unusual. A 75-year-old female fell onto a piece of wood that penetrated her skull on the left frontal region and was treated in our department. The patient had no neurological deficits during presentation. She was managed surgically and removal of the wooden object was performed to prevent early or late infection complications. Wooden foreign bodies often pose a different set of challenges as far as penetrating injuries to the brain are concerned. Radiological difficulties and increased rates of infection due to its porous nature make these types of injuries particularly interesting. Their early diagnosis and appropriate treatment can minimize the risk of complications.

Inhibition of activated NR2B gene- and caspase-3 protein-expression by glutathione following traumatic brain injury in a rat model.

BACKGROUND.: Traumatic brain injury (TBI) remains a major cause of death and disability. Oxidative stress is an important element of the injury cascade following TBI. Progressive compromise of antioxidant defenses and free radical-mediated lipid peroxidation are one of the major mechanisms of secondary TBI. NR2B is a glutamate receptor and its activation is caused by TBI increasing a brain cell death, along with caspase-3 as a hall mark of apoptosis. Glutathione is a potent free radical scavenger that might prevent secondary TBI damage and inhibited apoptosis. MATERIALS AND METHODS.: In the present study, it aims to demonstrate the effect of glutathione on inhibition of brain oxidative damage in a TBI rat model. RESULTS.: In this study, the expressions of mRNA NR2B in placebo group and groups with glutathione administration at 0, 3, and 6 hours after TBI were 328.14, 229.90, 178.50, and 136.14, respectively (P<0.001). The highest caspase-3 expression was shown in placebo group with 66.7% showing strong positive results (>80%); as expected, glutathione administered in 0, 3, and 6 hours groups had lower strong positive results of 50%, 16.7%, and 16.7%, respectively, (P=0.025). CONCLUSION.: In conclusion, this study showed that glutathione administration in a TBI rat model decreased NR2B gene- and caspase-3 protein-expression that lead to the inhibition of brain cell death. Our results suggest that glutathione, as a potent free radical scavenger, has a brain cell protective effect against oxidative damage and cell death induced by TBI in rat model.