Psychometric properties of the Alcohol Use Disorders Identification Test (AUDIT) across cross-cultural subgroups, genders, and sexual orientations: Findings from the International Sex Survey (ISS).

INTRODUCTION: Despite being a widely used screening questionnaire, there is no consensus on the most appropriate measurement model for the Alcohol Use Disorders Identification Test (AUDIT). Furthermore, there have been limited studies on its measurement invariance across cross-cultural subgroups, genders, and sexual orientations. AIMS: The present study aimed to examine the fit of different measurement models for the AUDIT and its measurement invariance across a wide range of subgroups by country, language, gender, and sexual orientation. METHODS: Responses concerning past-year alcohol use from the participants of the cross-sectional International Sex Survey were considered (N = 62,943; Mage: 32.73; SD = 12.59). Confirmatory factor analysis, as well as measurement invariance tests were performed for 21 countries, 14 languages, three genders, and four sexual-orientation subgroups that met the minimum sample size requirement for inclusion in these analyses. RESULTS: A two-factor model with factors describing 'alcohol use' (items 1-3) and 'alcohol problems' (items 4-10) showed the best model fit across countries, languages, genders, and sexual orientations. For the former two, scalar and latent mean levels of invariance were reached considering different criteria. For gender and sexual orientation, a latent mean level of invariance was reached. CONCLUSIONS: In line with the two-factor model, the calculation of separate alcohol-use and alcohol-problem scores is recommended when using the AUDIT. The high levels of measurement invariance achieved for the AUDIT support its use in cross-cultural research, capable also of meaningful comparisons among genders and sexual orientations.

The Cultural Evolution and Social Pressures of Liposuction Among Iraqi Women: Navigating Modern Beauty Standards Amidst Conservative Traditions.

This editorial explores the impact of societal transformation on Iraqi women's lives, particularly concerning beauty standards and cosmetic procedures like liposuction. It examines the influences of modernization, social media, and social pressures juxtaposed with traditional conservative values. The transition from repressive regimes to more open, albeit unstable, political landscapes has led to significant shifts in women's roles, with increased conservatism contrasting with emerging modernist influences. The role of social media in amplifying modern beauty ideals creates internal conflicts for women striving to balance these with traditional expectations. The growing acceptance of cosmetic procedures indicates a shift toward integrating modern beauty standards within Iraqi society.

Epiploic Appendagitis Unveiled: A Case of Misleading Abdominal Pain With Omental Fat Necrosis.

Epiploic appendagitis is a benign inflammatory condition of the epiploic appendages, small fat-filled structures attached to the colon. Misdiagnosed frequently as more serious conditions like appendicitis or diverticulitis, it usually resolves with minimal treatment. This case report aims to emphasize the importance of recognizing epiploic appendagitis in differential diagnoses, highlighting the role of accurate imaging and surgical intervention in managing unusual presentations. We report a case involving a 27-year-old male who presented with acute, severe pain in the left iliac fossa. Initial assessments showed stable vital signs and negative virology screenings. Ultrasound imaging did not reveal any abnormalities in the abdominal organs but noted multiple gas-filled bowel loops and a 48 x 22 mm collection in the left iliac region. A CT scan with IV contrast further identified a 35 x 26 mm area of fat stranding in the left iliac fossa, indicative of epiploic appendagitis, and a 1 cm area of omental fat necrosis near the hepatic flexure. Persistent symptoms led to a diagnostic laparoscopy, which confirmed and treated gangrenous appendices epiploica. The patient's postoperative recovery was uneventful, highlighting the effectiveness of surgical management. This case underscores the necessity for heightened awareness and diagnostic precision when encountering patients with acute abdominal pain that does not match common ailments. Early and accurate imaging, followed by timely surgical intervention if needed, can significantly improve outcomes by preventing complications from misdiagnosis or delayed treatment.

Innovative surgical precision: The electronic pen needle holder based on neurophysiological principles.

Background: The electronic pen needle holder (EPNH) was developed to enhance surgical precision, reduce operative time, and improve patient outcomes. By integrating microergonomics, penization, and electronics with surgical instruments, the EPNH aims to provide surgeons with a tool that minimizes hand strain and maximizes control during delicate procedures. Methods: The EPNH was ergonomically designed to fit the surgeon's hand, using titanium for its strength and biocompatibility. It was manufactured through industrial-grade 3D printing, and its mechanical properties were verified using finite element analysis. A force-sensitive resistor and vibratory mechanism were integrated to provide real-time feedback and assistance during surgeries. Results: Testing by 10 neurosurgeons demonstrated significant precision, control, and efficiency improvements. The EPNH reduced hand strain and fatigue, allowing longer, more comfortable operation times. The time required for suturing tasks has decreased by 40% compared to traditional needle holders. Surgeons reported high satisfaction with the EPNH's performance and usability. Conclusion: The EPNH represents a major advancement in surgical instrument design, offering enhanced precision, reduced hand strain, and increased efficiency. Its innovative features and ergonomic design make it a valuable tool for improving surgical outcomes and transforming microsurgical practices.

Orbital varices: Epidemiology, clinical presentation, and treatment outcomes - A scoping review.

Background: Orbital varices are vein dilations in the orbit presenting various symptoms. This scoping review synthesizes existing evidence on their epidemiology, clinical features, and treatment efficacy. Methods: Literature was reviewed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed and Scopus were searched until April 31, 2024, for articles on clinically diagnosed ocular varices detailing diagnostic methods, treatments, and outcomes. Exclusions were reviews, animal studies, and incomplete case reports. Data on study characteristics, diagnosis, management, and outcomes were extracted and assessed for quality and bias. Results: Eight studies met the inclusion criteria, with sample sizes ranging from 4 to 30 and ages from 1 to 87 years. Diagnostic tools included magnetic resonance imaging and computed tomography, while treatments ranged from conservative methods to invasive procedures and radiosurgery. Notably, higher symptom resolution rates were associated with observational strategies and minimally invasive surgeries. However, Gamma Knife radiosurgery, although promising, posed risks of vision impairment in some cases. Conclusion: The management of orbital varices has evolved significantly with newer, less invasive techniques improving outcomes and reducing recovery times. Despite advancements, challenges such as disease recurrence and the need for personalized treatment regimens persist, underscoring the ongoing need for research to refine and standardize treatment approaches.

Neuroanatomical perspectives on transorbital approaches: A meta-analysis.

Background: Transorbital approaches represent a paradigm shift in skull base surgery, focusing on minimally invasive techniques that prioritize patient outcomes and surgical precision. The scientific community, recognizing the significance of these advances, necessitates a possible review and meta-analysis to encapsulate the collective efficacy, safety, and developmental trajectory of these approaches. Methods: This was a literature review targeting literature in the past 10 years to present evidence for studies on surgical approaches transorbital. The included articles were analyzed. In addition, the references list of the included papers was searched for further articles. Results: Studies based on the endoscopic endonasal and transorbital approach have emphasized that it is minimally invasive; on the other hand, it offers an advantage to maximal resection success in the case of skull base tumors with advanced endoscopic skills. Transorbital neuroendoscopic surgery was criticized for being highly technical and narrow in its scope, with reduced morbidity. Superior Eyelid Approach involves a direct access with hidden incisions, potential for eyelid complications. Lateral orbitotomy entailed some inherent risks, such as muscle and nerve injury, but it gave excellent exposure to lesions that are lateral in the orbit. The transorbital endoscopic intraconal approach and the transconjunctival approach give direct advantages but are, however, limited to the type of lesion and location. Conclusion: The main technique focused on in this overview is the approaches through orbits, which greatly contribute to further innovation brought into the surgical panorama of skull base interventions. All such techniques do have their characteristics and applications, keeping them moving toward less invasiveness.

A case that encapsulates the challenges of being a neurosurgeon in war-torn countries: Perspectives from Iraq.

Background: The provision of healthcare services in Iraq has been negatively affected by a lack of resources, strained healthcare infrastructure, and low patient socioeconomic status. This paper describes a case of multiple intracranial aneurysms (MIAs) that highlight the challenges of practicing vascular neurosurgery in Iraq. Case Description: A 57-year-old female presented with sudden-onset severe headache, photophobia, and drowsiness and was diagnosed with subarachnoid hemorrhage in the basal cistern. Despite international guidelines recommending urgent treatment for suspected ruptured intracranial aneurysms, the patient's healthcare team in Babylon advised against a CT angiogram (CTA). The patient's family took responsibility for transferring her to a private facility for a CTA, which showed four aneurysms. Due to financial constraints, the family opted for open surgery, during which a ruptured aneurysm was found and successfully managed. The remaining two aneurysms were monitored with serial follow-up imaging. Conclusion: The case highlights the challenges of practicing vascular neurosurgery in Iraq and the impact of financial constraints on the management of MIA. It emphasizes the need for increased resources and expertise in the country's healthcare system to provide optimal care for patients with life-threatening conditions.

Machine Learning and Vision: Advancing the Frontiers of Diabetic Cataract Management.

This comprehensive review explores the integration of machine learning (ML) in managing diabetic cataracts. It discusses the potential application of ML to identify novel methodologies for early detection, diagnosis, and therapeutic interventions. The review also addresses clinical translation challenges, including pharmacokinetics properties and ethical considerations. The approach toward cataractogenesis, therefore, has to be from a holistic viewpoint, bringing oxidative stress and metabolic disturbances to the top of importance. It outlines the important requirements, including continued research, diversified datasets, and uses interdisciplinary collaborations in making improvements in ML models and thereafter bridging the gap between computational promise and clinical implication, with the aim to help in the maximization of patient care in the management of diabetic cataract. A literature search through databases like PubMed and Scopus focusing on understanding of current innovations, challenges, and future directions in employing ML in diabetic cataract management was undertaken. This review has explored both recent and foundational studies in order to explain the development and gaps of current research with an aim to enhance outcomes of patient care by promoting future investigation. Key findings revealed a wide application of ML in ophthalmology including treatment identification, cataract detection and grading, and improving the surgical outcomes. However, this is accompanied by some obstacles, including risk of bias, concerns regarding artificial intelligence application as a diagnostic tool, and legal regulations. ML promises extraordinary developments in the treatment of diabetic cataracts through betterment in diagnosis, treatment, and patient care. With this, it is full of clinical translation and ethical challenges, yet there is recognition in general that continuous model refinement and interdisciplinary collaboration, along with the expansion of the two identified key elements in enhancing patient outcomes, are essential for this to continue.

Enhancing neuro-ophthalmic surgical education: The role of neuroanatomy and 3D digital technologies - An overview.

Background: Neuro-ophthalmology, bridging neurology and ophthalmology, highlights the nervous system's crucial role in vision, encompassing afferent and efferent pathways. The evolution of this field has emphasized the importance of neuroanatomy for precise surgical interventions, presenting educational challenges in blending complex anatomical knowledge with surgical skills. This review examines the interplay between neuroanatomy and surgical practices in neuro-ophthalmology, aiming to identify educational gaps and suggest improvements. Methods: A literature search across databases such as PubMed, Scopus, and Web of Science was conducted, focusing on the implications of neuroanatomy in neuro-ophthalmic surgery education and practice. The review synthesizes insights from both recent and foundational studies to highlight current understandings and future research directions, particularly in educational approaches. Results: Findings indicate that 3D digital modeling and virtual reality have significantly enhanced neuroophthalmic surgical education by providing immersive and engaging learning experiences. For instance, detailed 3D brain atlases offer comprehensive resources for understanding the central nervous system's normal and pathological states. Although studies show that 3D and traditional 2D methods achieve similar post-test results, 3D methods notably improve engagement and motivation, suggesting a shift toward more interactive learning environments. Conclusion: Integrating both traditional and innovative educational tools is crucial for the progression of neuro-ophthalmic surgical training. This balance helps overcome educational hurdles and better prepare future surgeons. Continuous research and collaboration are essential to refine educational strategies, ultimately aiming to enhance patient care in neuro-ophthalmology.

Emergency Resection of a Large Third Ventricle Colloid Cyst: Ipsilateral vs. Contralateral Interhemispheric Approach Based on the Hydrocephalus Status.

Colloid cysts of the third ventricle are rare, benign intracranial tumors that can cause significant neurological symptoms and complications, particularly when they lead to obstructive hydrocephalus. The aim of this study is to present a case of a large third ventricle colloid cyst causing acute hydrocephalus and fainting attacks, necessitating emergency surgery. This is a case of a 46-year-old female presenting with headaches and recurrent fainting attacks. Cardiac evaluations were normal. Brain MRI revealed a 3x3 cm cystic lesion in the anterior superior portion of the third ventricle, causing moderate hydrocephalus with a transependymal edema. Due to acute hydrocephalus and fainting attacks attributed to arrhythmias from hypothalamic compression, emergency surgical resection was performed. A contralateral interhemispheric transcallosal approach with a right frontal craniotomy was used to achieve gross total resection. Postoperative recovery was uneventful, and a follow-up MRI showed an empty tumor bed and resolved hydrocephalus. In conclusion, prompt diagnosis and emergency surgical intervention are crucial in cases of acute hydrocephalus caused by third ventricle colloid cysts. The successful outcome of this emergency resection demonstrates the effectiveness of timely surgical management in preventing severe complications.

Transnasal Transsphenoidal Approach for a Nine-Year-Old Child With Pituitary Apoplexy: A Case Report.

Pituitary apoplexy is a rare but potentially life-threatening condition of sudden hemorrhage or infarction within the pituitary gland that results in symptoms of acute onset such as severe headache, visual impairment, and hormonal deficiencies. Though more common in adults, the same criteria for diagnostic and management dilemmas apply to pediatric cases. We present the case of a nine-year-old boy presenting with acute-onset severe headache and significant visual deterioration suggestive of pituitary apoplexy. An emergency MRI was performed, which showed a hemorrhagic sellar and suprasellar mass compressing the optic chiasm. Given the severe visual symptoms in this case, emergency surgical intervention was indicated. Decompression and gross total resection of the tumor were successfully attained using the endoscopic transnasal transsphenoidal approach by a multidisciplinary team. After the surgery, there was a significant improvement in the visual field, especially regarding the right eye's nasal hemifield, and the motor strength and consciousness remained stable. This case underscores the importance of early diagnosis and expedited surgical management in pediatric pituitary apoplexy. The transnasal transsphenoidal approach is practical for maximal decompression of the optic apparatus and reduces the risk of long-term visual deficits. In addition, it points out the need for coordinated, multidisciplinary treatment with the participation of neurosurgeons, endocrinologists, and pediatricians both for immediate and long-term consequences, including potential hormonal deficiencies. The report emphasizes the need for vigilance and prompt intervention in pediatric presentations, unlike the index case, for better outcomes and to avoid permanent morbidity.

Innovations in Breast Cancer Surgery and Their Adoption and Adaptation in Iraq.

Through this editorial, we have attempted to provide an update on the changing scenario for breast cancer surgery in Iraq by describing giant steps toward the adoption of new treatments. One factor to consider is the general trend towards neoadjuvant chemotherapy (NACT) and breast-conserving surgery (BCS) in regions such as Kurdistan, which indicates a preference for these minimally invasive approaches. Additionally, new perspectives on multifocal breast cancer in Baghdad demonstrate that BCS can be effective, with local recurrence rates comparable to mastectomy. Radiotherapy, particularly hypofractionated three-dimensional conformal radiotherapy (3DCRT), has shown substantial benefits in local control and progression-free survival. The importance of timely surgical interventions is also emphasized; most Iraqi women who receive a mastectomy stress to go through surgical interventions within three months of diagnosis. All these are significant reasons for optimism with regard to attaining more exemplary outcomes in patients as well as good strides toward international best practices. Such steps show that Iraq is keen on incorporating advanced surgical techniques that ameliorate breast cancer management.

Evaluating Postoperative Prognosis: A Single Surgeon's Experience With Total Mesorectal Excision in Middle and Lower Rectal Cancer Cases in Iraq.

INTRODUCTION: Surgical intervention for rectal cancer is widely recognized for its potential to significantly impact quality of life, chiefly due to the high probability of permanent colostomy and the associated postoperative complications. OBJECTIVE: This study aimed to evaluate the short-term outcomes and morbidity associated with total mesorectal excision for middle and lower rectal cancer within an Iraqi cohort, in a prospective setting. METHODS: This study prospectively collected and analyzed data from 89 patients who underwent a standardized radical rectal resection, with a follow-up period extending to one month post-surgery. RESULTS: The mean age of patients was 54.4 ± 12.9 years, with a gender distribution of 46 males and 43 females. A total of 33 patients presented with preoperative comorbidities, which heightened the risk of adverse short-term outcomes by a factor of 7.51. The most prevalent comorbidities were hypertension and diabetes mellitus, affecting 22 and 20 patients, respectively. Patients aged 60 years and above were at a 3.97 times greater risk of developing complications. The overall complication rate was 21.35%, with wound infections (9.0%) and cardiovascular events (3.4%) being the most common. Mortality during the follow-up was 1.1%. CONCLUSION: The findings indicate that increased age and the presence of comorbidities are significant risk factors for morbidity and mortality post-surgery. Neoadjuvant chemoradiotherapy or radiotherapy was shown to reduce morbidity and mortality rates while improving survival. The morbidity and mortality rates observed in this study concur with existing literature.

Optimal Timing of Microsurgical Treatment for Ruptured Arteriovenous Malformations: A Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVES: The timing of microsurgical treatment (MST) for ruptured brain arteriovenous malformations (bAVM) is a contentious issue in the literature. This study aimed to investigate the impact of MST timing on outcomes in patients with ruptured bAVMs, considering MST with and without preoperative endovascular treatment (EVT). METHOD: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, a comprehensive search was conducted across multiple databases, yielding 15 studies meeting the inclusion criteria. The timing was defined as the duration from the rupture of bAVM to the MST. The patients were divided into 4 different groups based on MST timing: <48 hours, <1 week, <2 weeks, and <1 month. The primary outcome was favorable outcome defined as a modified Rankin Scale score of 0 to 2 or a Glasgow Outcome Scale score of 4 to 5 in the last clinical follow-up. Secondary outcomes included periprocedural mortality and complete excision. RESULTS: MST time >48 hours were associated with a significantly higher favorable outcome rate (odds ratio: 9.71, 95% Cl: 3.09-30.57, P < .01) and a lower mortality rate (OR: 0.15, 95% Cl: 0.02-0.88, P = .04) compared with MST timing ≤48 hours. After exclusion of patients who underwent MST with preoperative EVT, MST time >48 hours had a significantly higher rate of favorable outcome (OR: 9.39, 95% CI: 2.53-34.89, P < .01). CONCLUSION: This meta-analysis suggests that delayed surgical intervention beyond 48 hours may be associated with improved favorable outcomes in patients who underwent MST with and without preoperative EVT for ruptured bAVMs.

Perioperative blood transfusion management in surgical resection of intracranial meningiomas: A meta-analysis.

Background: Gross total resection (GTR) of intracranial meningiomas is curative in most cases. However, perioperative blood transfusions may be necessary for complex skull bases and/or high-grade meningiomas. Guidelines for blood transfusions during intracranial meningioma surgery remain unclear. This scoping review aims to delineate the main characteristics of patients who underwent intracranial meningioma surgery, the prevalence of the selected patients who required blood transfusions, and common causes for transfusion. Methods: A scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Reviews guidelines to include studies reporting eligibility, protocols, and potential complications related to blood transfusion within the perioperative management of intracranial meningiomas. Results: A total of 33 articles encompassing 3009 meningioma patients were included in the study. The most common symptom was headache (18%), and the most frequent type of meningioma was World Health Organization grade-1 meningothelial (50.4%). The lateral supraorbital approach was the most common surgical corridor (59.1%) in skull base meningiomas, and most patients underwent GTR (69%). Blood transfusion was required for 20% of patients, with a mean estimated intraoperative blood loss of 703 mL (ranging from 200 mL to 2000 mL). The main indications for blood transfusion in meningioma surgery were intraoperative blood loss (86%) and preoperative anemia (7.3%). Conclusion: This scoping found that 20% of the included patients required blood transfusion. It also points out that several factors could influence the necessity for a transfusion, encompassing surgical blood loss, pre-existing anemia, and the surgery's length. This scoping review may provide surgeons with a potential guide to inform their decision-making process regarding blood transfusions during meningioma surgeries.

Anatomical Study of the Supratentorial Extension for the Retrolabyrinthine Presigmoid Approaches.

BACKGROUND: Supratentorial craniotomy represents the upper part of the combined trans-tentorial or the supra-infratentorial presigmoid approach. In this study, we provide qualitative and quantitative analyses for the supratentorial extension of the presigmoid retrolabyrinthine suprameatal approach (PRSA). METHODS: The infratentorial PRSA followed by the supratentorial extension craniotomy with dividing and removal of the tentorial strip were performed on both sides of 5 injected human cadaver heads (n = 10 sides). Quantitative analysis was performed for the surface area gained (surgical accessibility) by adding the supratentorial craniotomy. Qualitative analysis was performed for the parts of the brainstem, cranial nerves, and vascular structures that became accessible by adding the supratentorial craniotomy. The anatomical obstacles encountered in the added operative corridor were analyzed. RESULTS: The supratentorial extension of PRSA provides an increase in surgical accessibility of 102.65% as compared to the PRSA standalone. The mean surface area of the exposed brainstem is 197.98 (standard deviation: 76.222) and 401.209 (standard deviation: 123.96) for the infratentorial and the combined supra-infratentorial presigmoid approach, respectively. Exposure for parts of III, IV, and V cranial nerves is added after the extension, and the surface area of the outer craniotomy defect has increased by 60.32%. Parts of the basilar, anterior inferior cerebellar, and superior cerebellar arteries are accessible after the supratentorial extension. CONCLUSIONS: The supratentorial extension of PRSA allows access to the supra-trigeminal area of the pons and the lower part of the midbrain. Considering this surgical accessibility and exposure significantly assists in planning such complex approaches while targeting central skull base lesions.

Planning a sustainable neurosurgery mentorship program in a war-torn country: experience from Iraq.

The importance of mentorships in medical education and neurosurgery is highly attributed to the support and encouragement of the advances and learning opportunities for medical students and junior neurosurgeons. Planning a mentorship program according to the target audience offers to satisfy different interests and enhance education. One of the main issues with most of the already implemented programs is the sustainability and inability to maintain continuous cycles of mentorship, which have a negative impact and have led to an interrupted pattern of learning which eventually leads to a decline in the engagement of participants and loss of interest. This problem is most pronounced in war-torn countries, with Iraq as an example, where external circumstances lead to an arrest in the educational process and a depletion of the resources useful for such programs and training courses. This paper aims to address the main pathways essential in planning a sustainable mentorship program in a war-torn country by highlighting our experience in maintaining an ongoing mentorship with nine consecutive courses over the last 6 years in Iraq.

Intracranial aneurysms and abducent nerve palsy.

Background: Cranial nerve (CN) palsy may manifest as an initial presentation of intracranial aneurysms or due to the treatment. The literature reveals a paucity of studies addressing the involvement of the 6th CN in the presentation of cerebral aneurysms. Methods: Clinical patient data, aneurysmal characteristics, and CN 6th palsy outcome were retrospectively reviewed and analyzed. Results: Out of 1311 cases analyzed, a total of 12 cases were identified as having CN 6th palsy at the presentation. Eight out of the 12 were found in the unruptured aneurysm in the cavernous segment of the internal carotid artery (ICA). The other four cases of CN 6th palsy were found in association with ruptured aneurysms located exclusively at the posterior inferior cerebellar artery (PICA). For the full functional recovery of the CN 6th palsy, there was 50% documented full recovery in the eight cases of the unruptured cavernous ICA aneurysm. On the other hand, all four patients with ruptured PICA aneurysms have a full recovery of CN 6th palsy. The duration for recovery for CN palsy ranges from 1 to 5 months. Conclusion: The association between intracranial aneurysms and CN 6th palsy at presentation may suggest distinct patterns related to aneurysmal location and size. The abducent nerve palsy can be linked to unruptured cavernous ICA and ruptured PICA aneurysms. The recovery of CN 6th palsy may be influenced by aneurysm size, rupture status, location, and treatment modality.

Neuro-Ophthalmic Manifestations of Carotid Cavernous Fistulas: A Systematic Review and Meta-Analysis.

Carotid-cavernous fistulas (CCFs) are pathologic, arteriovenous communications between the carotid artery and cavernous sinus. They cause various complex neuro-ophthalmic symptoms by shunting the flow of arterial blood into the venous system. In this study, a systematic review is conducted on the neuro-ophthalmic presentations associated with CCFs. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines were followed during the systematic review. We searched PubMed, Scopus, and Web of Science from inception to December 31, 2023. Articles written in English on patients with confirmed CCFs reporting clinical features, diagnostic modalities, treatment approaches, and outcomes were included. Abstracted data included demography, clinical presentations, venous flow dynamics, trauma history, investigative methodology, approaches to treatment, and outcomes. Overall, 33 studies with a total number of 403 patients were included. The mean age at presentation was 42.99 years for patients with direct CCFs and 55.88 years for those with indirect CCFs. Preponderance was observed in male patients with direct CCFs, constituting 51.56%, while females predominated in those with indirect CCFs, at 56.44%. The clinical symptoms in all patients with CCFs were proptosis in 58 cases (14.39%), conjunctival congestion in 29 patients (7.20%), diplopia in nine patients (2.23%), vision blurring in four patients (0.99%), eyelid swelling in five patients (1.24%), pain in the eye in three patients (0.74%), and an upper lid mass in one patient (0.25%). Endovascular treatments, including coil and Onyx embolization, have been effective in relieving clinical symptoms and arresting the progression of these symptoms. In conclusion, the common clinical features in CCFs usually underline proptosis, congestion, and diplopia, necessitating a comprehensive neuro-ophthalmological review. Prompt identification of the symptoms of blurred vision is crucial to avoid permanent damage. Lid swelling, ocular pain, and an upper lid mass are less common but equally essential presentations for comprehensive evaluation. The recognition of these variable presentations is essential not only for timely intervention but also for the improvement in patient outcomes, thus emphasizing the role of clinician awareness in managing CCF cases.

Teleproctoring in therapeutic neurointervention: Experience from Iraq-Saudi Arabia collaboration.

Background: Proctoring in neuroendovascular surgery is one of the potential solutions for the shortage of personnel and experience, particularly in unstable and limited-resource areas such as Iraq. Methods: The study was conducted at the Baghdad Neurovascular Center (BNC), the first Hybrid neurovascular institution in Iraq, where sequential online zoom-based meetings between the BNC team and the expert from the Kingdom of Saudi Arabia were used for teleproctoring for neurointerventional procedures. Results: A total of 28 sessions were conducted, four sessions for each case. Seven cases with various intracranial vascular lesions were operated for neuroendovascular procedures from July/2021 to March/2022. The teleproctoring for each case included four sequential sessions: (1) preoperative planning, (2) device selection and preparation, (3) intraoperative live-stream proctoring, and (4) postoperative reflection and follow-up planning. The procedures include coiling for dural arteriovenous fistula; preoperative tumor embolization; preoperative, partial, and staged embolization for arteriovenous malformation; coiling for intracranial aneurysm; and attempted Giant aneurysm flow-diversion. Major complications were avoided through teleproctoring, and all patients had good outcomes. In addition, the teleproctoring provided an effective training experience to the local neuroendovascular team that is otherwise not feasible. Conclusion: Teleproctoring is an effective and feasible tool to improve patient outcomes and provide a training experience to the local neuroendovascular teams in resource-limited regions.