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.

Geographical Distribution of Neurosurgeons and Emergency Neurosurgical Services in Pakistan.

BACKGROUND AND OBJECTIVE: According to the World Federation of Neurosurgical Societies (WFNS), a minimum neurosurgery workforce density should be 1 per 200,000 population for optimum access to neurosurgical care. Pakistan lags behind in the number of neurosurgeons, and disproportionate geographical distribution further increases disparity. Our objective was to geographically map the density of neurosurgeons and emergency neurosurgical services (ENS) in Pakistan. METHODS: This survey was circulated among 307 neurosurgeons. Data were analyzed using SPSS v21. The number of neurosurgeons and ENS were plotted on the population density map using ArcGIS Pro 3.0.0 software. RESULTS: Three hundred and seven neurosurgeons working at 74 centers responded to our survey (93.3% coverage). The current density of neurosurgeons in Pakistan is 0.14/100,000. The 2 more populous provinces, Punjab and Sindh, have 42.3% (130) and 35.8% (110) neurosurgeons, respectively. They also housed nearly 3 quarters of all the neurosurgery centers in urban districts. Karachi and Lahore accommodate 135 (44%) of all the country's neurosurgeons, having 0.29 and 0.51 neurosurgeons/100,000 respectively. Management of traumatic brain injury is offered at 65 centers (87.8%). Nearly all centers are equipped with computed tomography (CT) scan machine (74; 97%), but magnetic resonance imaging (MRI) facility is available at 55 (72%) centers and 37 (49%) centers have angiography suites. Sixty nine centers (93.2%) have C-arm fluoroscopes available. CONCLUSIONS: The geographical mapping of neurosurgeons and neurosurgical facilities is highly skewed towards urban centers, increasing disparity in access to timely neurosurgical emergency services. Four times more neurosurgeons are required in Pakistan to bridge the gap in neurosurgical workforce.

Spinal meningiomas: Management and outcomes.

Spinal meningiomas are relatively rare, benign, intradural, extramedullary tumours, that are typically slow-growing and well-defined. Surgery is always the first line for treating spinal meningiomas. Here, we have discussed the existing literature on spinal meningiomas and the role of surgery in determining the outcomes.

Quality of life in children operated for spina bifida; low- and middle-income country perspective.

INTRODUCTION: Spina bifida is a potentially disabling congenital condition and affects the quality of life (QOL). We aimed to assess clinical outcomes and QOL in children who underwent spina bifida repair at our hospital. METHODS: This was a retrospective cohort study on children who underwent spina bifida repair at our hospital over 10 years. Phone calls were made to parents of the children, and the Health Utility Index Mark 3 (HUI 3) score was used to assess QoL, and degree of disability. Demographics and clinical data were obtained from the medical chart review. Statistical analysis was done using SPSS (version 21). RESULTS: Eighty children with a median age of 1.1 months (IQR 0.03-2.0) at the time of presentation, were included in this study. The mean follow-up period was 6.04 ± 2.54 years and the median HUI-3 score was 0.64 (IQR: 0.40 - 0.96) on a scale of 0 (dead) to 1 (perfectly healthy). Based on the severity of disability, 12 (23.1%) children had mild disability, 4 (7.7%) had moderate disability, and 23 (44.2%) had severe disability. Factors including a leaking spina bifida and paraplegia at presentation; radiological findings of hydrocephalus and Chiari malformation, were associated with a significantly low QOL. Children who required CSF diversion (EVD/ VP shunt) during the repair or at a later stage also had significantly low QOL. CONCLUSION: In LMIC, children with myelomeningocele (MMC) born with lower limb weakness, hydrocephalus, Chiari malformation, and those presenting with leaking MMC, have a significantly low QoL at a mean follow-up of 6 years.

Intracranial metastasis of testicular germ cell tumours.

Brain metastasis from testicular germ cell tumour (TGCT) is rare and represents only 2% of metastatic brain tumours. Although TGCTs have a good survival rate, the prognosis of brain metastasis is poor. Due to the rarity of the diagnosis, there are limited studies on the topic and a standardized treatment protocol does not exist. Surgical management has long been considered a positive prognostic factor; however, recent studies have investigated the impact of chemotherapy and radiotherapy in these patients. Current literature suggests multiplicity of brain lesions and treatment with chemotherapy or radiotherapy alone can have a poor impact on the prognosis of the disease. However, studies with larger cohorts are required to understand and develop the optimal treatment protocol for patients with brain metastasis from TGCT.

Primary Cardiac Sarcomas: Risk of Brain Metastases and Management.

Primary cardiac neoplasms are very rarely encountered, and the most common type of malignant tumours occurring primarily in the heart are sarcomas. These carry a lethal prognosis on account of their late presentation and aggressive spread. They have a high propensity for cerebral metastases. Such cases are exceptionally uncommon, and till date only a few examples are available. Currently, there is no standard protocol for the management of primary cardiac sarcoma with brain metastases.

Effect of post-operative infections on glioblastoma outcomes.

Glioblastoma multiforme (GBM) is the most aggressive primary brain tumour with a poor prognosis. The risk of developing a post-operative infection after craniotomy is the highest in GBM patients. Historical beliefs suggest that post-operative infections render a survival advantage in GBM patients, however recent clinical neurosurgical reports involving large multicentric patient cohorts do not support this claim. Nonetheless, the relationship has not been extensively studied which poses the need for further large, scaled studies to determine the association between post-operative infections and survival benefit in GBM patients.

Quality of life in survivors of pediatric medulloblastoma: a systematic review and meta-analysis.

INTRODUCTION: Medulloblastoma (MB) is the most common malignant pediatric brain tumor. The mainstay of treatment is maximum surgical resection and craniospinal radiation, which may be followed by chemotherapy. The debilitating effect of the tumor and the intensive treatment approaches in MB lead to long-term neuropsychological, physical, and chronic medical problems. We conducted a systematic review to assess the quality of life (QoL) in the long-term survivors of MB and the factors leading to compromised QoL. METHODS: We utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for our review. A comprehensive literature search was performed using PubMed, Cochrane Library, Digital Commons Network, and Wiley Online Library databases to search for articles having quality of life, medulloblastoma, and pediatric survivors in title or abstract. We removed duplicates and screened through titles, and full texts. Twelve articles were included in our study. Articles using and reporting all domains of PaedsQL were included in the meta-analysis. The PaedsQL scores of survivors and their caregivers were compared. Subgroup analysis was conducted for craniospinal and proton radiotherapy groups. RESULTS: As compared to other posterior fossa tumors, MB survivors have the lowest QoL scores. There is a difference in the perception of QoL of survivors between caregivers and survivors themselves with survivors rating themselves higher in several domains. The overall PaedsQL scores were significantly different for both groups (p < 0.001). Subgroup analysis showed that the difference between those who were treated with craniospinal or proton radiation was not significant (p = 0.76). For the subscales, physical (p = 0.005), psychosocial (p = 0.0003), and school (p = 0.03) perceptions were significantly different for the survivors and their caregivers; however, psychosocial (p = 0.80) and emotional (p = 0.93) scales were not different for the survivors or caregivers. Patient characteristics related to a worse QoL included disease severity, metastatic disease, lesser family income, smaller current ventricle size, need for permanent hydrocephalus treatment, and lesser age at diagnosis. CONCLUSION: An analysis of various studies, using different measures of QoL, concludes that QoL is compromised in all pediatric survivors of MB; however, the perception of QoL of the survivors is better than objective or caretaker-rated QoL.

Recent management trends of subependymal giant cell astrocytoma associated with tuberous sclerosis complex.

Subependymal giant cell astrocytomas (SEGA) are benign cranial tumours typically found in patients with tuberous sclerosis complex (TSC). Surgical resection has been the standard treatment for SEGA, however, medical management through mTOR inhibitors has now predominantly replaced surgery as the primary treatment modality. Additionally, newer treatment modalities have emerged with the hopes of providing safer methods for treating the tumour such as laser interstitial thermal therapy (LITT). However, very few reports have addressed these newer methods and analysed the results.

Clinical factors affecting post-operative seizure control after supratentorial low-grade glioma resection in adults.

Up to 88% of patients with low grade glioma (LGG) experience seizures during the course of their disease. In patients who undergo surgery for supratentorial low grade glioma (SLGG), post-operative seizures can impact their quality of life and complicate the post-operative management course. Evidence suggests that epileptic activity can be related to tumour progression. In addition to the extent of resection, recent studies have investigated the possible patient and tumour factors which can influence post-operative seizure control in patients with SLGG.

Human amniotic membrane as a dural substitute in neurosurgery: A systematic review.

Background: Several studies have highlighted the use of human amniotic membrane (HAM) in neurosurgical procedures as an effective dural substitute. HAM has inherent antifibrotic and anti-inflammatory properties and exhibits immunomodulatory effect that makes it an ideal dural substitute. Other advantages including easy availability, low cost of procurement, and storage also render it a promising dural substitute especially in low- and middle-income countries. Methods: A systematic literature search was performed using PubMed, Scopus, and Google Scholar databases, using the search terms "human amniotic membrane," "dural repair," and "neurosurgery." To be eligible for inclusion in our review, papers had to report primary data, be published in English language and report dural repair on humans with human amniotic membrane. Eligibility assessment was conducted by two independent reviewers with qualitative analysis on the basis of surgical utility, postoperative complications, and histological analysis. Results: Eight articles met the predefined inclusion criteria, including three randomized control trials and five cohort studies. We evaluated the use of HAM grafts in dural repair for elective cranial surgery (four studies), trauma surgery (three studies), and elective spine surgery (one study). Cases with postoperative cerebrospinal fluid (CSF) leak were reported by two studies. Other postoperative complications including meningitis, hydrocephalus, pseudomeningocele, CSF collection in subdural space, and subacute subdural hematoma were reported by one study each. Postsurgical histological analysis was reported by three studies highlighting the antiadhesive and integrative properties of HAM. Conclusion: The current review of evidence suggests that in terms of postsurgical outcomes, HAM is comparable with commercially available dural substitutes.

Intraoperative Seizures During Awake Craniotomy for Brain Tumours.

Awake craniotomy (AC) is becoming increasingly popular for brain tumour surgery. The procedure allows better preservation of eloquent cortex and helps achieve greater tumour resection. However, a potential problem with the procedure is intraoperative seizures (IOS) that may affect the mapping and monitoring of awake patients and may even lead to abandoning of the awake procedure.

Case report: Primary ependymoma of the trigeminal nerve presenting as trigeminal neuralgia.

Background: Ependymomas are usually found in the posterior fossa originating from the fourth ventricle. Primary ependymomas arising from cranial nerves are rare with only a handful of reported cases. Trigeminal neuralgia (TN) is rarely due to space occupying lesions. Case Description: A 20-year-old female presented with TN with a rare presentation of a pure extra-axial ependymoma involving the right trigeminal nerve in the cerebellopontine angle. Conclusion: It is essential to explore the possibility of a mass arising from the trigeminal nerve when investigating the cause of TN.

Telephone validation of an Urdu translated version of the extended disability severity scale in multiple sclerosis patients.

BACKGROUND: Expanded Disability Status Scale (EDSS) is a commonly used tool to assess the extent of functional impairment in multiple sclerosis (MS) patients for clinical and research purposes. EDSS is traditionally conducted in a face-to-face setting, however, routine in-person EDSS assessments are often difficult to perform in developing countries due to the various reasons patients are unable to access healthcare and maintain clinic visits. Hence validating a locally translated telephone-based EDSS (T-EDSS) could be potentially useful to both physicians and patients by removing the need to commute to healthcare centers for disability assessment and could lead to overall improved care for MS patients. METHODS: Firstly, the EDSS scale was translated and culturally adapted into Urdu. On enrolment, EDSS was conducted during scheduled clinic visits and forty-seven subjects with MS were henceforth included in the study. Same patients were contacted via telephone following two weeks by a different neurologist to carry out the telephone-EDSS assessment. The patients' baseline EDSS scores at enrolment were blinded to prevent interviewer bias. RESULTS: Kappa value for agreement between the two assessments for EDSS scores of more than 6 was 0.73, whereas the kappa value for EDSS score of less than 4.5 was 0.35. The intraclass correlation coefficient (ICC) for T-EDSS score < 4.5 was 1.7, and for a score > 4.5 was 4.9, with the overall ICC being 0.64. Cronbach's alpha value for T-EDSS score < 4.5 was 0.59 and for the score > 4.5 was 0.79. CONCLUSIONS: This study shows that there exists a positive correlation and substantial level of agreement between in-person EDSS and T-EDSS, especially in MS patients with higher baseline EDSS scores. Hence a locally translated T-EDSS can be used in Pakistani MS patients with reasonable confidence. T-EDSS may be more useful in MS patients with moderate to severe disability.

Multiple sclerosis in Pakistan: Current status and future perspective.

Multiple sclerosis (MS) is a demyelinating disease of the central nervous system (CNS) which commonly leads to disability. We reviewed articles on MS from Pakistan using PubMed, Google Scholar and Pak Medinet to present different aspects of the disease and the status of disease modifying treatments in Pakistan and South Asia. MS is not as uncommon in Pakistan as it has been previously thought to be. Estimated prevalence of MS in Pakistan may be 10 per 100,000 population. Data suggests that most features of MS found in Pakistan are similar to those found in the West. These features include a female preponderance, mean age of onset in the third decade of life and similar risk factors including viral infections, smoking, and vitamin D deficiency, as well as genetic risk factors. Relapsing-remitting multiple sclerosis (RRMS) is the most common disease pattern seen in Pakistan which is also consistent with data from other regions. Treatment modalities in Pakistan include immunomodulatory and immunosuppressive drugs. In order to improve care for MS patients in Pakistan, it is extremely important to obtain a population-based prevalence of MS in the country and a national MS registry, along with implementing programs for patients' awareness and the training of doctors, especially internists. There are many disease modifying therapies (DMT) available in Pakistan but no data is available on the utilization and impact of these DMTs.

The Need for Transgender Healthcare Medical Education in a Developing Country.

PURPOSE: The single most significant barrier to healthcare for people who identify as transgender is poor access to healthcare providers trained in trans-health. Despite this, trans-health education is far from being a routine component of the undergraduate medical curriculum in developing countries like Pakistan. This study aimed to assess knowledge and attitudes regarding people who identify as transgender, as well as the perceived need for trans-health in the curriculum, amongst medical students in Pakistan. MATERIALS AND METHODS: A cross-sectional study using a self-designed questionnaire was carried out amongst undergraduate medical students at the Aga Khan University. Stratified random sampling was used, whereby students were stratified based on their current year of medical education. RESULTS: A total of 249 students were included in this survey. The majority (61%) had poor overall knowledge, with a significantly higher percentage of pre-clinical students (79.6%) having poor knowledge regarding differences in transgender health needs compared to clinical students (60.3%; p = 0.001). Most students acknowledged that individuals who identified as transgender faced a lack of access to healthcare (78.3%), were poorly integrated into society (92.0%) and were treated differently in a clinical setting (58.6%). Many students were unsure of how to address (49.8%) and clinically examine (38.2%) patients identifying as transgender. However, most students demonstrated good (49.4%) or fair (45.0%) attitudes towards individuals who identified as transgender, and the majority reported a high (54.6%) or moderate (42.2%) perceived need for the inclusion of trans-health in the medical curriculum. CONCLUSION: Despite deficiencies in trans-health education in the medical school curriculum, positive attitudes and a high perceived need among students lay the foundation for developing a medical curriculum that gives due priority to trans-health. In developing countries, this can help bridge disparities in healthcare provision to people who identify as transgender.

Depression among Hispanic women with type 2 diabetes.

OBJECTIVE: Investigate psychosocial barriers to self-care and the prevalence of depression among Hispanic women with type 2 diabetes. RESEARCH AND DESIGN METHODS: One hundred twenty-six (126) Hispanic women living in Miami-Dade, South Florida were recruited through outpatient diabetes clinics, physicians' offices, or community referrals to participate in a cross-sectional survey to assess psychosocial factors that can interfere with type 2 diabetes self-care. The survey collected information on sociodemographics, performance of self-care regimens, a diabetes care profile (support, knowledge, empowerment, and attitudes), depression (Beck Depression Inventory-II), health locus of control, and perceived stress, as well as other data used to evaluate diabetes status. RESULTS: Only 4 of the 126 diabetic women interviewed reported having had depression previously assessed. Mean for depression scores was 12.76 +/- 8.71. Scores on the depression inventory indicated depression in 40.6% of subjects, with 23% categorized as mildly, 11.1% moderately, and 6.3% severely depressed. Greater self-assessed depression was associated with poorer self-rated health, understanding of diabetes, and diabetes knowledge scores. Subjects classified as severely depressed had lived with diabetes for a significantly longer mean number of years than those classified as moderately, mildly, or minimally depressed. CONCLUSIONS: Depression had not been previously assessed by any healthcare providers seen by participants or addressed in most participants in this study. While the literature abounds with findings on the depression in diabetes and potential for improved compliance when depression is treated, this concept seems to not yet be adopted into mainstream diabetes care for our Hispanic population.