Temporal Delays in the Management of Traumatic Brain Injury: A Comparative Meta-Analysis of Global Literature.

OBJECTIVE: A meta-analysis was conducted to compare: (1) time from traumatic brain injury (TBI) to the hospital, and (2) time within the hospital to intervention or surgery, by country-level income, WHO region and healthcare payment system. METHODS: A comprehensive literature search was conducted and followed by a meta-analysis comparing duration of delays (prehospital and intrahospital) in TBI management. Means and standard deviations were pooled using a random effects model and subgroup analysis was performed using R Software. RESULTS: Our analysis comprised 95,554 TBI patients from 45 countries. BY COUNTRY-LEVEL INCOME: From 23 LMICs, a longer mean time from injury to surgery (862.53 minutes, CI: 107.42-1617.63), pre-hospital (217.46 minutes, CI: -27.34 - 462.25), and intra-hospital (166.36 minutes, 95% CI: 96.12 - 236.60) durations were found compared to 22 HICs. BY WHO REGION: African Region (AFR) had the greatest total (1062.3 minutes, CI: -1072.23-3196.62), pre-hospital (256.57 minutes (CI: -202.36 - 715.51)), and intrahospital durations (593.22 minutes, CI: -3546.45 - 4732.89). BY HEALTHCARE PAYMENT SYSTEM: Multiple-Payer Health Systems (MPHS) had a greater pre-hospital duration (132.62 minutes, CI: 54.55 - 210.68) but greater intrahospital delays were found in Single-Payer Health Systems (SPHS) (309.37 minutes, CI: -21.95 - 640.69). CONCLUSION: Our study concludes that TBI patients in LMIC within AFR countries face prolonged delays in both prehospital and intra hospital management compared to HIC. Additionally, patients within SPHS experienced prolonged intra-hospital delays. An urgent need to address global disparities in neurotrauma care has been highlighted.

Barriers to Neurosurgical Care of Brain Tumors in Low- and Middle-Income Countries: A Systematic Review of the Service Delivery Challenges.

INTRODUCTION: Brain tumors pose a major challenge in low- and middle-income countries (LMICs) due to limited resources and high costs, resulting in an hampered service delivery of neurosurgical care and significant disparities in patient outcomes compared to high-income nations. Therefore, our systematic review aims to identify barriers to service delivery in providing adequate surgical care for the management of brain tumors in LMICs. METHODS: We searched Scopus, PubMed, Google Scholar, and CINAHL, from inception to October 20, 2022. The data from the eligible studies was extracted and analyzed qualitatively. RESULTS: The final analysis included 35 articles, which highlighted significant challenges in providing adequate surgical care for brain tumors in LMICs. Among the cited studies, 10% reported lack of multidisciplinary team structures, 61% noted delayed patient presentation, 16% highlighted delays in neuroimaging, 10% reported delays in scheduling surgery, lack of training for specialized surgery (3%), lack of intra-operative facilities (19%), power supply interruption (6%), and lack of advanced diagnostic and specialized surgery facilities (19%). Strategies for addressing these challenges include cross-border collaboration (7%), public education, and awareness (13%), establishing multidisciplinary teams (20%), utilizing alternative surgical techniques (13% awake craniotomy, 7% intraoperative ultrasound, 13% intraoperative cytology smear), and establishing satellite hospitals for low-risk care (7%), standard operating procedure and infection control (13%). CONCLUSION: Targeted interventions considering economic constraints are essential to improve the availability, affordability, and quality of neuro-oncological services in developing countries. International collaborations and building capacity are vital for improving patient outcomes and service delivery, as well as forming multidisciplinary teams and utilizing resource-saving, innovative methods.

Impact of medical school experiences on the career choice of neurosurgery: a cross- sectional study from Pakistan.

BACKGROUND: Pakistan grapples with the issue of an inadequate neurosurgery workforce but the reasons for such a disparity remain uncertain. Previous studies have highlighted how various factors including medical school experiences have an impact on career choice, but no study has delved into the impact of medical school exposure among Pakistani medical students, especially for the field of neurosurgery. This study aims to evaluate the impact of neurosurgery exposure, mentorship, and interest groups on medical students' decision to pursue neurosurgery. METHODS: A national cross-sectional survey was conducted in Pakistan, collecting data from medical students, interns, and medical officers over a one-month period. Ethical approval was obtained from the Ethical Review Committee at Aga Khan University, Pakistan. The data was analyzed using SPSS version 26. RESULTS: Out of 2618 participants, 38.0% were male and 62.0% were female, with an average age of 21.82 years (± 2.65). Among them, only 358 (13.6%) were interested in pursuing neurosurgery as a career, while the remaining 2,260 (86.3%) were not. More females (58.9%) than males (41.1%) expressed interest in pursuing neurosurgery as their intended career. Most medical students interested in pursuing neurosurgery were in the early years of their medical school (1st Year: 19.6%, 2nd Year: 26.0%, 3rd Year: 20.9%). In our study, students from public sector institutions (52.2%) showed more interest in neurosurgery as a career choice compared to those from private sector institutions (44.1%). The main deterrents for choosing neurosurgery were intense training (42.2%), work-life balance (39.9%), limited residency slots (56.7%), medical knowledge (34.1%), and surgical skills (36.6%). CONCLUSION: This study highlights the need for increased student engagement to inculcate the decision to pursue neurosurgery among medical students in Pakistan. A significant gap is highlighted, with the majority of interested students in early years. Public sector students show higher interest than their private sector counterparts. However, barriers like intense training, limited residency slots, and work-life balance concerns influence career choice. Targeted interventions like mentorship programs are crucial for fostering future neurosurgeons and advancing patient care and research. By addressing the identified disparities in experiences and promoting a supportive educational environment, it is possible to cultivate a future generation of skilled and dedicated neurosurgeons who can contribute to advancements in patient care and research in the field.

Proposed novel classification of circumscribed Lower-Grade Gliomas (cLGG) vs. infiltrating Lower-Grade Gliomas (iLGG): Correlations of radiological features and clinical outcomes.

Purpose: We hypothesize that lower grade gliomas (LGG) can be identified and classified into two distinct subtypes: radiologically circumscribed Lower-Grade Gliomas (cLGG) and infiltrating Lower-Grade Gliomas (iLGG) based on radiological parameters and that these two different subtypes behave differently in terms of clinical outcomes. Methods: We conducted a retrospective cohort study on surgical patients diagnosed with lower grade glioma over five years. Patient records and MRIs were reviewed, and neurosurgeons classified tumors into cLGG and iLGG groups. Results: From the 165 patients in our cohort, 30 (18.2%) patients were classified as cLGG and 135 (81.8%) patients were classified as iLGG Mean age in cLGG was 31.4 years while mean age in iLGG was 37.9 years (p = 0.004). There was significant difference in mean blood loss between cLGG and iLGG groups (270 and 411 ml respectively, p = 0.020). cLGG had a significantly higher proportion of grade II tumors (p < 0.001). The overall mean survival time for the iLGG group was 14.96 ± 1.23 months, and 18.77 ± 2.72 months for the cLGG group. In univariate cox regression, the survival difference between LGG groups was not significant (HR = 0.888, p = 0.581), however on multivariate regression cLGG showed a significant (aHZ = 0.443, p = 0.015) positive correlation with survival. Intense contrast enhancement (HZ = 41.468, p = 0.018), blood loss (HZ = 1.002, p = 0.049), and moderately high Ki-67 (HZ = 4.589, p = 0.032) were also significant on univariate analyses.Conclusion: cLGG and iLGG are radiologically distinct groups with separate prognoses, surgical experience, and associations.

Exploring the neurosurgery training landscape in Pakistan: A trainee's perspective in resource-limited settings.

Background: Shortage of neurosurgeons in Pakistan, one per 720,000 people, stems from a lack of trainees. Therefore, it is vital to assess the training experience, career opportunities, and satisfaction levels of neurosurgical trainees in Pakistan. Methods: A nationwide survey was conducted, covering 22 CPSP-accredited neurosurgery training programs in Pakistan. Convenience sampling was utilized with a pilot tested questionnaire and responses were analyzed using STATA 15. Results: The response rate was 98% (120/122) with 70.8% male and mean age of 30.4 ± 4.1 years. Training programs included teaching courses (79%) and journal club (66%); however, there was a lack of cadaver workshops (14%) and cranial model-based stimulation (22%). 67% of trainees lacked publications in indexed journals. 69% worked 50-100 h weekly, with 62% experiencing burnout due to workload and hours and a third reporting poor work-life balance. Trainees dedicated more to operating rooms (37%, 10-24 h/week) and clinics (34%, 24-48 h/week) compared to study (42%, <5 h/week) and research (64%, <5 h/week). Gender equality was rated poorly by 50%. Disparities emerged in subspecialty exposure, with over half of trainees lacking exposure to deep brain stimulation (67%), and epilepsy (75%). 52.5% of the training institutes did not offer fellowships and 64.1% of trainees planned to pursue fellowships abroad. Conclusions: Steps need to be taken to improve working hours, gender equity, and increase simulation courses, diversify subspecialty exposure, and promote research initiatives.

Intraoperative mapping and preservation of executive functions in awake craniotomy: a systematic review.

Awake craniotomy (AC) allows intraoperative brain mapping (ioBM) for maximum lesion resection while monitoring and preserving neurological function. Conventionally, language, visuospatial assessment, and motor functions are mapped, while the assessment of executive functions (EF) is uncommon. Impaired EF may lead to occupational, personal, and social limitations, thus, a compromised quality of life. A comprehensive literature search was conducted through Scopus, Medline, and Cochrane Library using a pre-defined search strategy. Articles were selected after duplicate removal, initial screening, and full-text assessment. The demographic details, ioBM techniques, intraoperative tasks, and their assessments, the extent of resection (EOR), post-op EF and neurocognitive status, and feasibility and potential adverse effects of the procedure were reviewed. The correlations of tumor locations with intraoperative EF deficits were also assessed. A total of 13 studies with intraoperative EF assessment of 351 patients were reviewed. Awake-asleep-awake protocol was most commonly used. Most studies performed ioBM using bipolar stimulation, with a frequency of 60 Hz, pulse durations ranging 1-2 ms, and intensity ranging 2-6 mA. Cognitive function was monitored with the Stroop task, spatial-2-back test, line-bisection test, trail-making-task, and digit-span tests. All studies reported similar or better EOR in patients with ioBM for EF. When comparing the neuropsychological outcomes of patients with ioBM of EF to those without it, all studies reported significantly better EF preservation in ioBM groups. Most authors reported EF mapping as a feasible tool to obtain satisfactory outcomes. Adverse effects included intraoperative seizures which were easily controlled. AC with ioBM of EF is a safe, effective, and feasible technique that allows satisfactory EOR and improved neurocognitive outcomes with minimal adverse effects.

Capacity building for pediatric neuro-oncology in Pakistan- a project by my child matters program of Foundation S.

Introduction: Initiated in June 2019, this collaborative effort involved 15 public and private sector hospitals in Pakistan. The primary objective was to enhance the capacity for pediatric neuro-oncology (PNO) care, supported by a My Child Matters/Foundation S grant. Methods: We aimed to establish and operate Multidisciplinary Tumor Boards (MTBs) on a national scale, covering 76% of the population (185.7 million people). In response to the COVID-19 pandemic, MTBs transitioned to videoconferencing. Fifteen hospitals with essential infrastructure participated, holding monthly sessions addressing diagnostic and treatment challenges. Patient cases were anonymized for confidentiality. Educational initiatives, originally planned as in-person events, shifted to a virtual format, enabling continued implementation and collaboration despite pandemic constraints. Results: A total of 124 meetings were conducted, addressing 545 cases. To augment knowledge, awareness, and expertise, over 40 longitudinal lectures were organized for healthcare professionals engaged in PNO care. Additionally, two symposia with international collaborators and keynote speakers were also held to raise national awareness. The project achieved significant milestones, including the development of standardized national treatment protocols for low-grade glioma, medulloblastoma, and high-grade glioma. Further protocols are currently under development. Notably, Pakistan's first pediatric neuro-oncology fellowship program was launched, producing two graduates and increasing the number of trained pediatric neuro-oncologists in the country to three. Discussion: The initiative exemplifies the potential for capacity building in PNO within low-middle income countries. Success is attributed to intra-national twinning programs, emphasizing collaborative efforts. Efforts are underway to establish a national case registry for PNO, ensuring a comprehensive and organized approach to monitoring and managing cases. This collaborative initiative, supported by the My Child Matters/Foundation S grant, showcases the success of capacity building in pediatric neuro-oncology in low-middle income countries. The establishment of treatment protocols, fellowship programs, and regional tumor boards highlights the potential for sustainable improvements in PNO care.

Diagnostic Accuracy of Intraoperative Brain Smear: A Meta-Analysis of Studies from Resource-Limited Settings.

BACKGROUND: Intraoperative brain smear is an easy, rapid, and cost-effective technique for immediate diagnosis of brain tumors. Earlier studies have gauged its application on limited number of samples, but its diagnostic accuracy especially in low-resource settings, where its practice would be extremely helpful, is still undetermined. To investigate the diagnostic accuracy of intraoperative brain smear in resource-limited settings for diagnosis of brain tumors. METHODS: A systematic search was conducted on PubMed, Google Scholar, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Embase for all articles utilizing intraoperative brain smears that were extracted. Studies from low- and middle-income countries (LMICs) with test performance characteristics were selected and subsequent values were summarized using a hierarchical summary receiver operating characteristic (ROC) curve via STATA and pooled using a random-effects model on MetaDiSc 2.0. RESULTS: Twelve studies consisting of 1124 patients were identified. Six studies included both adult and pediatric population groups, while 4 investigated adults and 2 included pediatric patients. The pooled diagnostic odds ratio (OR) was calculated to be 212.52 (CI: [104.27-433.13]) of Bivariable pooled specificity and sensitivity were 92% (CI: [86%-96%]) and 96% (CI: [93%-98%]), respectively. CONCLUSIONS: Our study shows that intraoperative brain smear is not only an accurate and sensitive diagnostic modality in resource-rich settings, but it is also equally useful in resource-limited settings, making it an ideal method for rapid diagnosis.

Does gender disparity exist in neurosurgery training? Evidence from a nationwide survey from Pakistan.

Gender disparities are prevalent in the neurosurgical field, particularly for female trainees, despite the growing demand for neurosurgeons. The situation is bleaker in low-and middle-income countries, where gender disparities among neurosurgical trainees have not been evaluated. We aimed to gauge the gender differences in opportunities and perceptions of neurosurgery training in Pakistan by comparing responses between males and females. A nationwide web-based survey was conducted in Pakistan, covering 22 College of Physicians and Surgeons of Pakistan (CPSP) accredited neurosurgery training programs. Convenience sampling was used with a pilot-tested questionnaire. Data analysis was performed using SPSS version 26. A total of 120 trainees participated in our survey. The mean age of the participants was 30.4 ± 4.1 years, with 29.2% females and 70.8% males. Concerns about gender equity were more among females (34.3%) than males (27.1%). Poor work-life balance was reported by more females (34.3%) than males (30.6%). Burnout due to working hours was strongly agreed by more females (54.3%) than males (35.3%). More females (40%) acknowledged sufficient mentorship opportunities versus males (25%). Female respondents (65.7%) worked 50-100 hours per week, less than males (69.4%). Satisfaction with surgical exposure was lower among females (2.9%) compared to males (18.8%). More females reported access to teaching courses (82.9% vs. 77.6% males) and neurosurgical conferences (85.7% vs. 80.0% males), cadaver workshops (17.1% vs. 12.9% males), morbidity and mortality meetings (88.6% vs. 82.4% males), case-based sessions (82.9% vs. 75.3% males), and radiology discussions (82.9% vs. 74.1% males). Our study highlights substantial gender gaps in neurosurgical training, concerns over working hours, burnout, mentorship, work-life balance, and gender equity. These findings underscore the necessity for interventions to rectify these disparities and foster gender equity in neurosurgical training.

Gender Differences in Medical Students' Perception of Neurosurgery: A Cross-Sectional Study from Pakistan.

BACKGROUND: Despite 15,000 annual medical graduates, few choose neurosurgery, especially women. The scarcity of female neurosurgeons is a global concern, particularly in resource-limited settings such as Pakistan. This study focuses on gender-based differences in medical student perceptions of neurosurgery in Pakistan. METHODS: A nationwide cross-sectional study was conducted from March 6 to April 20, 2023, using a Web-based survey. Data collectors were recruited through an ambassadorship program, distributed evenly across all provinces. A questionnaire was used after a pilot study. Data analysis was performed using SPSS version 26 and STATA 15. RESULTS: A total of 2353 medical students participated in the study, of which 63.4% were female and 36.5% were male. Around 40.3% of women strongly agreed to the existence of potential gender bias in neurosurgery, in contrast to their corresponding male students, at 17.3%. Some of the highlighted deterring factors in pursuing neurosurgery as a career according to women include longer training duration (44.6%), poor work-life balance (41%), limited residency slots (50.6%), and limited exposure to neurosurgery (45.1%). Other factors included the high-intensity nature of training (33.6%), perceived gender bias (31.4%), competitive work environment (29.1%), complex surgical skills (38.6%), required level of medical knowledge (29.6%), and financial burden (33.9%). CONCLUSIONS: Our study shows that female students are more likely to believe in the existence of potential gender bias in the field compared with their counterpart male participants, which highlights the graveness of the situation in view of the evident paucity of female neurosurgeons in the country.

Paediatric choroid plexus carcinoma: a retrospective case series from Karachi.

The objective of this study is to report clinical, radiological, and histopathological characteristics of three paediatric patients diagnosed as Choroid plexus carcinoma seen at our hospital, between 2015 and 2020. Three patients were diagnosed with choroid plexus carcinomas between 2015 and 2018. The mean age at diagnosis was 1.3 years (range 8 months to 1.5 years). All the three patients had subtotal resection and received adjuvant chemotherapy. One patient also received adjuvant radiotherapy. Despite these treatment measures, residual disease was noted in all three patients and two patients were subsequently treated on palliative care grounds. The average duration of follow-up after the first surgery for all three patients was approximately 33 months. Attaining satisfactory outcome in patients with CPC is challenging. Our case series reflects the difficulty in achieving gross total resection and ensuring that the disease does not recur.

Awake Surgery for Lesional Epilepsy in Resource-Limited Settings: Case Report and Review of Literature.

Epilepsy surgery is a well-established treatment for drug-resistant epilepsy, with awake craniotomy being used in certain cases to remove epileptogenic foci while preserving crucial brain functions. We are presenting the first reported case from Pakistan of a 19-year-old woman who underwent awake epilepsy surgery to treat cortical dysplasia. She had a history of generalized tonic-clonic seizures since her childhood and was referred to our clinic due to an increase in seizure frequency. EEG and MRI identified the epileptogenic focus in the right parieto-temporal region. The patient underwent a neuro-navigation guided awake craniotomy and an excision of the epileptogenic focus in the right parieto-temporal region. The procedure was carried out using a scalp block and dexmedetomidine for conscious sedation, enabling the patient to remain awake throughout the surgery. Intraoperative mapping and electrocorticography were used for complex multidisciplinary care. Post-resection corticography showed no spikes along the resected margins. The patient was discharged without any complications and remained free of symptoms a year after the surgery. Awake epilepsy surgery is a viable option for removing epileptogenic foci while preserving vital cognitive functions. However, it is seldom used in low- and middle-income countries such as Pakistan. The successful outcome of this case underscores the need for greater awareness and availability of epilepsy surgery in resource-limited settings. Cost-effective measures, such as using small subdural strips for intraoperative localization, can be implemented.

Intraoperative Seizures During Awake Craniotomy for Brain Tumor Resection.

Background Intra-operative seizures (IOS) can occur during awake craniotomies (AC) for brain tumors. They can potentially result in an increased risk of morbidity; however, literature is scarce on IOS, its risk factors, and predictors. This study aims to ascertain the frequency of IOS in patients undergoing AC and determine possible IOS predictors. Methods In this retrospective study, we reviewed the records of all patients who underwent AC for tumor resection at a single university hospital between January 2016 and December 2020. IOS was defined as any seizure, including partial or generalized, experienced by any patient at any time from the beginning of the procedure till the end of surgery. Results Two hundred patients underwent AC during the study period. Seven (3.5%) patients experienced IOS. Compared to the non-seizure group, no significant correlation existed with any demographic variable. No significant difference was seen between the initial complaints presented by the two groups. In addition, the post-operative course of the seizure group did not significantly differ from the non-seizure group. Due to the low frequency of IOS in our cohort, an extensive analysis to determine predictors could not be performed. Conclusion In this study, we observed a low frequency of IOS (3.5%) during AC. The possible predictors and risk factors must be further investigated in large cohorts; to help limit the consequences of this possible intraoperative complication.

Socio-demographic and antenatal risk factors of brain tumor in children and young people: A matched case-control study from Karachi, Pakistan.

Background: Brain tumors are a common cause of morbidity, disability, cognitive deterioration and mortality in children, even after treatment. Little is know about the specific causes. The study aimed to assess potential socio-demographic and antenatal factors in primary brain tumor (PBTs) in children and young people (CYP) in Karachi, Pakistan. Designs and methods: A single center hospital based matched case control study in Karachi, Pakistan. Cases were defined as CYP aged between 5 and 21 years with any histological type and grade of primary brain tumor of any histology, stage or grade. Data were collected from parents of 244 patients at the selected center between 2017 and 2021 via telephonic interview. Controls were 5-21 years old CYP admitted with non-oncological diagnoses matched on age and sex. Matched Odds Ratios for predictors of brain tumor in children were derived. Those of statistical significance were included in a multivariable logistic regression model. Results: In the adjusted model, lower paternal education (matched adjusted odds ratio (maOR) 2.46; 95% CI 1.09-5.55), higher household monthly income (maOR 3.4; 95% CI 1.1-10.2), antenatal paternal use of addictive substances (maOR 19.5; 95% CI 2.1-179.8), and antenatal maternal use of analgesics during pregnancy (maOR 3.0; 95% CI 1.2-7.9) were all independently predictive of brain tumors. Conclusion: This matched case-control study found novel associations between maternal use of analgesics, paternal use of addictive substances, higher household income, and lower paternal education and Primary Brain Tumors in Children and Young People. Longitudinal multicenter studies will be required to test these associations prospectively.

Factors Delaying the Continuum of Care for the Management of Traumatic Brain Injury in Low- and Middle-Income Countries: A Systematic Review.

BACKGROUND: Considering the disproportionate burden of delayed traumatic brain injury (TBI) management in low- and middle-income countries (LMICs), there is pressing demand for investigations. Therefore, our study aims to evaluate factors delaying the continuum of care for the management of TBIs in LMICs. METHODS: A systematic review was conducted with PubMed, Scopus, Google Scholar and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Observational studies with TBI patients in LMIC were included. The factors affecting management of TBI were extracted and analyzed descriptively. RESULTS: A total of 55 articles were included consisting of 60,603 TBI cases from 18 LMICs. Road traffic accidents (58.7%) were the most common cause of injury. Among included studies, factors contributing to prehospital delays included a poor referral system and lack of an organized system of referral (14%), long travel distances (11%), inadequacy of emergency medical services (16.6%), and self-treatment practices (2.38%). For in-hospital delays, factors such as lack of trained physicians (10%), improper triage systems (20%), and absence of imaging protocols (10%), lack of in-house computed tomography scanners (35%), malfunctioning computed tomography scanners (10%), and a lack of invasive monitoring of intracranial pressure (5%), limited theater space (28%), lack of in-house neurosurgical facilities (28%), absence of in-house neurosurgeons (28%), and financial constraints (14%) were identified. CONCLUSIONS: Several factors, both before and during hospitalization contribute to delays in the management of TBIs in LMICs. Strategically addressing these factors can help overcome delays and improve TBI management in LMICs.

Utilization of an ultra-low-field, portable magnetic resonance imaging for brain tumor assessment in lower middle-income countries.

Background: Access to neuroimaging is limited in low-middle-income countries (LMICs) due to financial and resource constraints. A new, ultra-low-field, low-cost, and portable magnetic resonance imaging (pMRI) device could potentially increase access to imaging in LMICs. Case Description: We have presented the first brain tumor case scanned using an Ultra-low-field pMRI at Aga Khan University Hospital in Karachi, Pakistan. Conclusion: The imaging results suggest that the pMRI device can aid in neuroradiological diagnosis in resource-constrained settings. Further, research is needed to assess its compatibility for imaging other neurological disorders and compare its results with conventional MRI results.

Intraoperative use of ultra-low-field, portable magnetic resonance imaging - first report.

Background: Intraoperative use of portable magnetic resonance imaging (pMRI) has become a valuable tool in a surgeon's arsenal since its inception. It allows intraoperative localization of tumor extent and identification of residual disease, hence maximizing tumor resection. Its utility has been widespread in high-income countries for the past 20 years, but in lower-middle-income countries (LMIC), it is still not widely available due to several reasons, including cost constraints. The use of intraoperative pMRI may be a cost-effective and efficient substitute for conventional MRI machines. The authors present a case where a pMRI device was used intraoperatively in an LMIC setting. Case Description: The authors performed a microscopic transsphenoidal resection of a sellar lesion with intraoperative imaging using the pMRI system on a 45-year-old man with a nonfunctioning pituitary macroadenoma. Without the need for an MRI suite or other MRI-compatible equipment, the scan was conducted within the confinements of a standard operating room. Low-field MRI showed some residual disease and postsurgical changes, comparable to postoperative high-field MRI. Conclusion: To the best of our knowledge, our report provides the first documented successful intraoperative transsphenoidal resection of a pituitary adenoma using an ultra-low-field pMRI device. The device can potentially enhance neurosurgical capacity in resource-constrained settings and improve patient outcomes in developing country.

Risk factors and predictors of intraoperative seizures during awake craniotomy: A systematic review and meta-analysis.

Background: Awake craniotomy (AC) aims to minimize postoperative neurological complications while allowing maximum safe resection. Intraoperative seizures (IOSs) have been a reported complication during AC; however, literature delving into the predictors of IOS remains limited. Therefore, we planned a systematic review and meta-analysis of existing literature to explore predictors of IOS during AC. Methods: From the inception until June 1, 2022, systematic searches of PubMed, Scopus, the Cochrane Library, CINAHL, and Cochrane's Central Register of Controlled Trials were conducted to look for published studies reporting IOS predictors during AC. Results: We found 83 different studies in total; included were six studies with a total of 1815 patients, and 8.4% of them experienced IOSs. The mean age of included patients was 45.3 years, and 38% of the sample was female. Glioma was the most common diagnosis among the patients. A pooled random effect odds ratio (OR) of frontal lobe lesions was 2.42 (95% confidence intervals [CI]: 1.10-5.33, P = 0.03). Those with a pre-existing history of seizures had an OR of 1.80 (95% CI: 1.13-2.87, P = 0.01), and patients on antiepileptic drugs (AEDs) had a pooled OR of 2.47 (95% CI: 1.59-3.85, P < 0.001). Conclusion: Patients with lesions of the frontal lobe, a prior history of seizures, and patients on AEDs are at higher risk of IOSs. These factors should be taken into consideration during the patient's preparation for an AC to avoid an intractable seizure and consequently a failed AC.

Psychosocial factors influencing quality of life in patients with primary brain tumors in Pakistan: an analytical cross-sectional study.

OBJECTIVE: Despite quality of life (QoL) being recognized as an important outcome in neuro-oncology, there is a lack of research from Pakistan where sociocultural differences may influence QoL. This study aimed to measure the QoL in patients with primary brain tumors (PBTs) and assess its association with mental health outcomes and social support. RESULTS: Our study included a total of 250 patients, with a median age of 42 years (range 33-54 years). The commonest brain tumors were glioma (46.8%) and meningioma (21.2). The mean global QoL of the sample was 75.73 ± 14.9. The majority of patients had high social support (97.6%) and were not depressed (90%) or anxious (91.6%). On multivariable linear regression, global QoL was inversely associated with no or low income (beta coefficients: -8.75 to -11.84), having hypertension (-5.53), currently using a urine catheter (-13.55), having low social support (-28.16) suffering from mild (-15.31) or symptomatic (-23.84) depression, or mild anxiety (-13.22).

Factors affecting well-being in brain tumor patients: An LMIC perspective.

Introduction: Brain tumor is a devastating and often fatal diagnosis; quality of life and patient well-being are important goals of treatment. This study addresses the gap in culture-specific literature exploring the needs and coping strategies of brain tumor patients within an LMIC setting. Methodology: A qualitative approach was undertaken using an exploratory descriptive study design. In-depth interviews were conducted to capture the perspective of 250 brain tumor patients at a private tertiary center followed by extensive content analysis to identify major themes and sub-themes across responses. Results: The analysis identified three major themes: (i) Factors affecting the lives of brain tumor survivors (BTSs) and their impact (ii) What works to improve QoL according to the survivors' perspectives, and (iii) Coping tactics & fostering healthy relationships. The need for financial navigation strategies improved patient-physician relationships, and reinforcing positive coping strategies were emphasized. Conclusion: In our population, family support and spiritual connection played an important role in helping patients mitigate the psychosocial burden of illness. However, financial concerns were pervasive and need to be addressed for better overall well-being.