Role of Machine Learning in Liquid Biopsy of Brain Tumours.

Liquid biopsy has multiple benefits and is used extensively in other fields of oncology, but its role in neuro-oncology has been limited so far. Multiple tumour-derived materials like circulating tumour cells (CTCs), tumour-educated platelets (TEPs), cell-free DNA (cfDNA), circulating tumour DNA (ctDNA), and miRNA are studied in CSF, blood (plasma, serum) or urine. Large and complex amounts of data from liquid biopsy can be simplified by machine learning using various algorithms. By using this technique, we can diagnose brain tumours and differentiate low versus highgrade glioma and true progression from pseudo-progression. The potential of liquid biopsy in brain tumours has not been extensively studied, but it has a bright future in the coming years. Here, we present a literature review on the role of machine learning in liquid biopsy of brain tumours.

Conducting the Pakistan brain tumour epidemiology study - report on the methodology.

Objectives: To combat the lack of brain tumour registries, the Pakistan Brain Tumour Epidemiology Study (PBTES) was conducted without any funding from an external source. METHODS: A retrospective analysis of patient data, including patients of all age groups diagnosed with all histopathological types of brain tumours from all over Pakistan, was performed. For this, Pakistan Brain Tumour Consortium (PBTC) was established, including 32 neurosurgical centres from around the country. Data was collected online through a proforma that included variables such as patient demographics, clinical characteristics, operative details, postoperative complications, survival indices, and current functional status. The data collection and analysis team included principal investigators, core leads, regional leads, regional associates, and student facilitators. Despite logistical concerns and lack of resources, the PBTES was conducted successfully, and a formal brain tumour surveillance database was formed without any external funding, which remains unheard of. CONCLUSIONS: The methods applied in this study are reproducible and can be employed not just to develop more robust brain tumour and other cancer registries but also to study the epidemiology of communicable and non-communicable diseases in resource-limited settings, both locally and globally.

Modifications in lumbar facet joint are associated with spondylolisthesis in the degenerative spine diseases: a comparative analysis.

BACKGROUND: Magnetic resonance imaging (MRI) is important in the assessment of degenerative spine disease. However, its role is limited in the identification of spinal instability; therefore, weight-bearing and dynamic studies like X-rays are required. The supine position eliminates the gravitational pull, corrects the vertebral slippage, and opens the facet joints leading to the collection of the synovial fluid into the joint space, which is detected on the MRI and can serve as a marker for instability. We aim to compare the facet fluid, facet hypertrophy, facet angle, and disc degenerative changes among the patients presenting with degenerative spondylolisthesis (DS) and those without. METHODS: We performed a retrospective review for all the patients treated at our institution from January 2015 to December 2016. Facet Fluid Index (FFI) (ratio of facet fluid width and facet joint width) was calculated to assess the joint fluid. The percentage of spondylolisthesis was measured on X-rays. Each radiological parameter was compared between the two groups, i.e., patients with DS and patients without DS. A p value < 0.05 was considered significant. RESULTS: In total, 61 patients, 28 with DS and 33 without DS, were enrolled. Baseline characteristics were similar in the two groups (p > 0.05). The average values of FFI, facet fluid width, and the difference between the superior and inferior facet were significantly higher in the group with instability (p < 0.05). Multivariate analysis demonstrated a 4.44 (95% confidence interval [CI] 2.03-5.365) times increase in the odds of instability with a unit increase in FFI, p < 0.0001. CONCLUSIONS: We report a positive linear correlation between the facet joint effusion and facet hypertrophy on MRI and the percentage of vertebral translation on X-ray. Prospective studies will determine if these markers can play a role in predicting spinal instability.

Work-life balance amongst residents in surgical and non-surgical specialties in a tertiary care hospital in Karachi.

OBJECTIVE: To assess work-life balance among medical residents at a tertiary hospital. METHODS: The cross-sectional study was conducted from September to December 2016 at a private-sector tertiary care hospital in Karachi, and comprised medical residents working at the facility. A standardised, self-administered questionnaire was developed on the basis of Canadian Mental Health quiz and a study in literature. The questions aimed at assessing satisfaction with work as well as emotional and personal life of residents in various medical and surgical specialties. SPSS 20 was used for data analysis. RESULTS: Of the 275 residents, 129(46.9%) were males and 146(53.1%) were females. The overall mean age was 28.19±2.194 years. Of the total, 13(4.7%) participants thought they had work-life balance; 165(60%) felt their job had negatively affected their private lives; 118(42.9%) felt worn out; 109(39.6%) expressed moderate dissatisfaction with work-related factors; 119(43.3%) were dissatisfied with life outside work; and 93(33.8%) were dissatisfied their health. CONCLUSIONS: There was minimal work-life balance among the residents.

Role of extent of resection on quality of life in patients with newly diagnosed GBM.

Glioblastomas known for their adverse outcomes are most reportedly managed by surgical resection. Studies on the impact of (Extent of Resection) EOR against Quality of Life (QOL) are very limited. We have collected data from recent studies in this review to extract a general consensus among the neurosurgeons regarding the EOR. Key parameters like functional independence, neurocognitive improvements and global health status have been explored in the context of QOL. The currently available data suggests that an increased EOR may help improve QOL in GBM patients. With the help of recent advancements it may be possible to attain a better extent of resection while operating on GBMs.

Survival benefit of surgery in recurrent glioblastoma multiforme.

There is an ongoing debate regarding role of surgery for recurrent glioblastoma multiforme (GBM). Older literature hinted at only modest survival benefits with surgery and a high rate of morbidity. However, more recent literature suggests better survival that may be attributed to better surgical techniques and better options in adjuvant treatment. Herein the authors review recent literature with regards to the possible role of surgery in recurrent GBM and also look into the key factors impacting second surgery. .

Awake craniotomy for brain tumours in Pakistan: An initial case series from a developing country.

Awake craniotomy offers safe resection of brain tumours in eloquent area. Aga Khan University Hospital, Karachi, recently started the programme in Pakistan, and the current study was planned to assess our experience of the first 16 procedures. The retrospective study comprised all such procedures done from November 2015 to May 2016. Pre-operative and post-operative variables were analysed. Of the 16 patients, 11(68.75%) were males and 5(31.25%) were females. The overall median age was 37 years (interquartile range[IQR]: 23-62 years). The most common presenting complaint was seizures 8(50%), followed by headache6(38%). The common pathologies operated include oligodendroglioma and glioblastoma. Pre-operative mean Karnofsky Performance Status score was 76±10, which increased to 96±7 post-operatively at discharge. Besides, 2(12.5%) intra-operative complications were observed, i.e. seizure and brain oedema, in the series. The study had median operative time of 176 minutes (IQR: 115-352) and median length of stay of 4 days (IQR: 3-7).Awake craniotomy was highly effective in maintaining post-operative functionality of the patient following glioma resection. It was also associated with shorter hospital course and so lower cost of management.

Predictors of poor outcome of decompressive craniectomy in pediatric patients with severe traumatic brain injury: a retrospective single center study from Pakistan.

OBJECTIVE: This study aimed to determine the risk factors associated with poor outcome of decompressive craniectomy (DC) for severe traumatic brain injury (TBI) in pediatric patients. METHODS: This retrospective study is conducted on pediatric population (age 1-15 years) presenting with TBI who underwent DC at our institute between January 2000 and 2010. Based on Glasgow outcome score (GOS) at a minimum follow-up of 5 months, patients were divided into two groups, namely poor outcome (GOS 1, 2, and 3) and good outcome (GOS 4 and 5). Records were reviewed and analyzed for preoperative and intraoperative predictors. RESULTS: We found 25 patients who were eligible as per selection criteria. Mean age at presentation was 6 ± 4 years and there was male preponderance (84%). Fall (60%) was the most common mechanism of injury followed by gunshots and road traffic accident. On univariate analysis, presenting GCS ≤5 (p value = 0.009), delay in presentation of more than 150 min (p value = 0.010), DC performed after more than 4 h of arrival in hospital (p value = 0.042), and intraoperative blood loss exceeding 300 ml (p value = 0.001) were significant predictors of poor outcome. CONCLUSION: Our study suggests that DC in children is not only a life-saving procedure, but also leads to a good functional outcome after severe injury. However, patient selection still remains an important aspect, and the above-mentioned factors should be considered while deciding for DC to improve survival. Further prospective studies on larger sample size are warranted to validate our results.

Feasibility of awake craniotomy for brain arteriovenous malformations: A scoping review.

Background: Brain Arteriovenous Malformations (AVMs) located in proximity to eloquent brain regions are associated with poor surgical outcomes, which may be due to higher rates of postoperative neurological deterioration. Current treatment protocols include stereotactic radiosurgery, transarterial embolization, and surgical resection under general anesthesia. Awake Craniotomy (AC) allows intraoperative mapping of eloquent areas to improve post-operative neurologic outcomes. Objectives: We reviewed the current literature reporting surgical outcomes and assessed the feasibility of AC for AVM resection. Methods: The PRISMA guidelines were utilized as a template for the review. Three databases including PubMed, Scopus, and Cochrane Library were searched using a predefined search strategy. After removing duplicates and screening, full texts were analyzed. Outcomes including the extent of resection, intra-operative and post-operative complications, and long-term neurologic outcomes were assessed. Results: 12 studies were included with a total of 122 AVM cases. Spetzler-Martin grading was used for the classification of the AVMs. The asleep-awake-asleep protocol was most commonly used for AC. Complete resection was achieved in all cases except 5. Intraoperative complications included seizures (n = 2) and bleeding (n = 4). Short-term post-operative complications included hemorrhage (n = 3), neurologic dysfunctions including paresis (n = 3), hemiplegia (n = 10), dysphasia/aphasia (n = 6), cranial nerve dysfunction (n = 3), and pulmonary embolism (n = 1). Almost all neurological deficits after surgery gradually improved on subsequent follow-ups. Conclusion: AVMs may shift the anatomical location of eloquent brain areas which may be mapped during AC. All studies recommended AC for the resection of AVMs in close proximity to eloquent areas as mapping during AC identifies the eloquent cortex thus promoting careful tissue handling which may preserve neurologic function and/or predict the postoperative functional status of the patients We, therefore, conclude that AC is a viable modality for AVMs resection near eloquent language and motor areas.

Redundant nerve roots indicate higher degree of stenosis in lumbar spine stenotic patients.

OBJECTIVES: Redundant Nerve Root (RNR) is a tortuous and elongated radiological appearance of cauda equina on Magnetic Resonance Imaging (MRI) in Lumbar Spinal Canal Stenosis (LSCS) patients. This study evaluated preoperative spinal morphometry associated with the development of RNR. METHODS: The retrospective cohort was conducted at The Aga Khan University Hospital, and included patients undergoing decompressive spinal surgery secondary to degenerative LSCS in 2015. The patients were divided into two groups with respect to the presence of preoperative RNR. Spinal morphometry was defined by several radiological parameters, including areas of dural sac (DSA), spinal canal, spinal foramen, facets, and spinal joints, and bilateral angles based on vertebral anatomy. RESULTS: A total of 55 patients were enrolled with a mean age of 57.1 years, in which 22 (40%) expressed RNR in their MRI. The RNR group had significantly lower mean DSA (59.64 vs 84.01 mm2; p = 0.028), bilateral posterior facet angle (Right: 33.84 vs 46.21, p = 0.004; Left: 36.43 vs 43.80, p = 0.039) and higher bilateral anterior facet angles (Right: 54.85 vs 44.57, p = 0.026; Left: 55.27 vs 46.36, p = 0.050) compared to the non-RNR group. The other bidimensional and angular parameters did not observe any statistical difference between the two groups. CONCLUSION: RNR was associated with a higher degree of stenosis in patients with LSCS. Bilateral anterior and posterior facets angles contribute to its development, indicating particular spinal morphology to be vulnerable to the stenotic disease.

Intramedullary schwannoma - A case report.

Background: Schwannomas are benign but clinically progressive tumors. Mostly, they present as intradural extramedullary lesions. They are quite rare in the intramedullary (IM) region. We report a case of IM schwannoma. Case Description: A 52-year-old gentleman presented with a history of gait instability and numbness in bilateral lower limbs. He had clinical signs of myelopathy. His magnetic resonance imaging (MRI) dorsal spine was done that showed an intradural IM lesion at the level of D11, with one differential of ependymoma. Near total resection of lesion was done and histopathology reported it schwannoma. Conclusion: Preoperative radiologic assessment for IM spinal lesions is difficult and high degree of suspicion should be present when approaching a patient with somatic pain and IM lesion on MRI, keeping in mind one differential of IM schwannoma.

Craniotomy or Craniectomy for Acute Subdural Hematoma? Difference in Patient Characteristics and Outcomes at a Tertiary Care Hospital.

Objective This article compares the outcomes of patients with traumatic acute subdural hemorrhage (SDH) managed either with craniotomy (CO) or with decompressive craniectomy (DC). Methods In this single-center, retrospective analysis we included all adult patients with acute traumatic SDH who were treated either using CO or DC. Sixteen-year hospital data was reviewed for patient demographics, injury details, and hospital course. Outcomes were noted in terms of intraoperative blood loss, intensive care unit stay, need for tracheostomy, post-surgery Glasgow Coma Score (GCS; calculated immediately after surgery), delayed GCS (DGCS; calculated 1 week after surgery), and delayed Glasgow Outcome Score (DGOS) after 6 months of surgery. Postoperative complications were noted during hospital stay, while mortality was noted within 6 months of surgery for each patient. Results Patients who underwent DC were younger (mean age 34.4 ± 16.8 years vs. 42.4 ± 19.9 years in the CO group) ( p = 0.006). Patients who underwent DC also had worst degree of traumatic brain injury as per Marshall grade (62.4% patients with Marshall grade 4 in the DC group vs. only 41.2% patients in the CO group) ( p = 0.037). Mean size of hematoma was 23.8 ± 24.6 mm in the DC group versus 11.3 ± 8.2 mm in the CO group ( p = 0.001). Mean postop GCS was lower in the DC group; 8.0 ± 4 versus 10.8 ± 4 in the CO group ( p < 0.001). However, there was no significant difference in DGCS and DGOS between the DC and CO groups ( p = 0.76 and 0.90, respectively). Mortality rate was 24 (30.8%) in the DC group versus 18 (20.7%) in the CO group ( p = 0.14). Conclusion The patients who underwent DC were younger, had larger size hematoma, and poor Marshall grade. We did not find any significant difference in the outcomes of CO and DC for management of subdural hematoma.

Current Management Trends for Surgical Site Infection After Posterior Lumbar Spinal Instrumentation: A Systematic Review.

OBJECTIVE: The objective of this systematic review is to determine the fate of spinal implants when patients develop postoperative wound infection after posterior instrumental fusion in a degenerative spine. METHODS: A systematic review of the English-language literature (published between January 2001 and July 2020) was undertaken to identify articles documenting the management strategy for surgical site infections (SSIs) after posterior lumbar spinal fusion. Studies on pedicle screw fixation after trauma, immunocompromised, metastatic spine disease, and combined anterior/posterior approach were excluded. Two independent reviewers assessed the level of evidence quality using the criteria set by the North American Spine Society, and disagreements were resolved by consensus. RESULTS: Of the 3071 citations identified, 49 met the criteria to undergo full-text review. Outcomes after SSIs were studied from a combined pool of 1150 patients who had undergone instrumental spinal fusion. The collected data showed that 456 patients (39.97%) had undergone spinal implant removal after SSI while 694 patients (60.03%) had their implants retained until the resolution of SSI. There was an absolute risk reduction (ARR) of 29% (-0.292) and a relative risk reduction (RRR) of 50.3% (-0.503) of implant removal if the patient underwent wound debridement following SSI. The number needed to treat (NNT) for wound debridement was calculated at 3.31 from our pooled cohort. The ARR in implant removal following vacuum-assisted closure (VAC) therapy was 16.6% and RRR was noted at 40.4%. This led to a high value of NNT at 6.0 patients. There was an ARR of 33.5% and a RRR of 70.7% was estimated in patients undergoing continuous irrigation. CONCLUSIONS: Our review of the literature suggests that surgeons prefer early wound debridement with or without negative pressure wound therapy under antimicrobial coverage for eradication of SSI after posterior lumbar spinal fusion. Implant removal is generally reserved for cases refractory to the other treatment modalities.

Spinal Radiology associated with Redundant Nerve Roots of cauda equina in lumbar spine stenosis.

OBJECTIVES: Redundant Nerve Roots (RNR) is a common radiological observation of elongated tortuous appearance of cauda equina nerve roots in sagittal MRI. It is considered a poor prognostic factor, but the associated spinal morphometry remains unfamiliar. METHODS: A retrospective cohort study was conducted at the Aga Khan University Hospital, Pakistan. Patients, aged 18 or above, undergoing decompressive spinal surgery due to degenerative Lumbar Spinal Canal Stenosis (LSCS) in 2015 were included. Patients were divided in groups as per presence of RNR and assessed for spinal morphometric parameters. RESULTS: Fifty-two patients, aged 57.52 ± 12.08 years, were enrolled in the study. The patients in RNR group were older than those in non-RNR group (p = 0.023). RNR was significantly associated with sedimentation sign (15 vs 11; p = 0.011), as well as L2/L3 (12 vs 9; p = 0.043) and L3/L4 (18 vs 18; p = 0.034) stenosis. Ligamentum flavum hypertrophy at the most stenotic level was more common in the RNR group (20 vs 19; p = 0.006). The only quantitative parameter statistically associated with RNR was lower ligamentous interfacet distance (5.07 ± 1.95 vs 8.07 ± 4.26 mm; p = 0.010). All other parameters did not contribute to the development of RNR in LSCS patients. The multivariate model revealed significant contribution of age, male sex, ligamentous interfacet distance and disc bulge to develop RNR. CONCLUSION: Certain spinal morphometric parameters contribute towards RNR formation, which represents higher degree of spinal stenosis. These parameters, along with RNR, should be regularly reported for preoperative consideration of LSCS management.

Role of redundant nerve roots in clinical manifestations of lumbar spine stenosis.

BACKGROUND: Redundant nerve roots (RNRs) are defined as elongated, thickened, and tortious appearing roots of the cauda equina secondary to lumbar spinal canal stenosis (LSCS). The study compared the clinical and radiological features of patients with LSCS with versus without RNR. METHODS: This retrospective study was performed on 55 patients who underwent decompressive surgery for degenerative LSCS. Patients were divided into two groups based on the presence of RNR in their preoperative magnetic resonance imaging, as evaluated by a radiologist blinded to the study design. Medical records were reviewed for basic demographic, clinical MR presentation, and outcomes utilizing Japanese Orthopaedic Association (JOA) scores. RESULTS: The mean age of enrolled patients was 57.1, with mean follow-up of 4.0 months. RNR was found in 22 (40%) of patients with LSCS. These patients were older than those patients without RNR (62.2 vs. 53.7). Interestingly, there were no statistically significant differences in clinical presentations, duration of symptoms, and outcomes using JOA scores between the two groups. CONCLUSION: RNR is a relatively common radiological finding (i.e., 40%) in patients with LSCS. It is more likely to be observed in older patients. However, no significant differences were noted in clinical presentation and functional outcomes with respect to the presence or absence of RNR.

Gallbladder perforation: a rare complication of acute cholecystitis.

Gallbladder perforation is a rare but potentially fatal disease and therefore is a dilemma for early diagnosis. It is usually a complication of acute cholecystitis with or without gallstones. We present a case of 70-year-old female with abdominal pain and fever. Initial ultrasound revealed cholelithiasis with possible acute cholecystitis. Clinical condition of the patient worsened and suspicion of gallbladder perforation was entertained. Hence, a repeat ultrasound and CT scan was done. Following this a gallbladder perforation was confirmed intra operatively.

Superior gluteal artery aneurysm.

To report the successful coil embolization of a rare gluteal artery aneurysm and review therapeutic options for this rare condition. We report a case of pseudo-aneurysm of superior gluteal artery initially diagnosed as gluteal abscess. They can be diagnosed by Doppler ultrasound, computed tomography or magnetic resonance imaging. Mainstay of the diagnosis is by angiography and the preferred management with good clinical results is with angiographic embolization. This report reviews the literature and addresses the incidence, aetiology, and treatment of gluteal artery aneurysms.

Awareness of bird flu amongst young college students.

OBJECTIVE: To assess the awareness among students about the disease, their attitude during the outbreak, along with their perceptions about treatment, and severity of disease. METHODS: A cross sectional study was conducted among 220 intermediate students. The data was collected through a self filled questionnaire after taking verbal consent. The variables included in this study were age, gender and department (medical/non-medical). RESULTS: A total of 220 students participated with mean age of 17 +/- 1 year. There were 132 (61%) males and 84 (39%) females. The students were divided into pre-medical 110 (50%) and non-premedical 110 (50%). About 211 (96%) students said that they had heard about bird flu but only 86 (39%) correctly identified it as a disease of birds and humans both. One hundred and fifty-four (70%) participants said that virus causes it and the most common source of knowledge was media (T.V) by 153 (70%) followed by newspaper 113 (51%) respondents. Flu like symptoms were identified by 77 (35%) and 160 (73%) considered birds to human as the most likely route of transmission. Regarding vaccine, 133 (70%) replied that it is not available and 80 (41%) said that there is a treatment for the disease. About 143 (73%) thought that it is life-threatening. According to 105 (48%) the suitable preventive measure taken by the government would be to kill susceptible chickens. CONCLUSION: The awareness regarding bird flu was quite low among students. As bird flu is a world wide public health problem therefore increasing awareness would be a solution to avoid its spread and complications.

Value of Routine Preoperative Tests for Coagulation Before Elective Cranial Surgery. Results of an Institutional Audit and a Nationwide Survey of Neurosurgical Centers in Pakistan.

BACKGROUND: Routine preoperative blood testing has become a dogma. The general practice is to order preoperative workup as a knee-jerk response rather than individualize it for each patient. The fact that the bleeding brain tends to swell, which coupled with limited options for proximal control, packing, and overall hemostasis, leads to an overemphasis on the preoperative coagulation profile. MATERIAL AND METHODS: This is a retrospective review of the medical records of patients admitted at Aga Khan University Hospital from January 2010 to December 2015 for an elective craniotomy. The hospital registry was used to identify files for review. Data were collected on a predefined proforma. A nationwide survey was performed, and 30 neurosurgery centers were contacted across Pakistan to confirm the practice of preoperative workup. RESULTS: The survey revealed that all centers had a similar practice of preoperative workup. This included complete blood count, serum electrolytes, and coagulation profile, including prothrombin time, activated partial thromboplastin time (aPTT), and international normalized ratio (INR). A total of 1800 files were reviewed. Nine (0.5%) patients were found to have deranged clotting profile without any predictive history of clotting derangement; 56% were male and 44% were female. Median age was 32 years with an interquartile range of 27 years. Median aPTT was (40.8 with 20.8 IQR). Median INR was (1.59 with 0.48 IQR). Median blood loss was (400 with 50 IQR). No significant association between coagulation profile (aPTT, INR) and blood loss was found (P = 0.85, r = -0.07). CONCLUSIONS: We conclude that patients without a history of coagulopathy and normal physical examination do not require routine coagulation screening before elective craniotomy.

Intrathecal and intraventricular antibiotics for postoperative Gram-negative meningitis and ventriculitis.

BACKGROUND: Postoperative meningitis is a growing cause of concern, especially with the evolution of multidrug-resistant organism. The authors evaluate the use of intraventricular/intrathecal (IVT/IT) antibiotics for postoperative gram-negative meningitis in patients whom intravenous antibiotics were ineffective. METHODS: Medical records were retrospectively reviewed and neurosurgery patients with gram-negative postoperative infection meningitis/ventriculitis were enrolled in the study. Their demographics, hospital course, and outcomes were recorded in a pro forma and analyzed using Statistical Package for the Social Sciences, version 19. RESULTS: The review identified 21 patients with postneurosurgical gram-negative meningitis/ventriculitis who were treated with IVT or IT antibiotics. The most common organism was Acinetobacter species (n = 14; 66%). Amikacin was used in 7 patients, polymyxin B in 9 patients, and colistin in 5 patients. A combination of antibiotics was used in one patient. Cerebrospinal fluid sterility was achieved in all patients with no incidence of relapse. There was a single death, though that was not related to the infectious process as the patient had a massive pulmonary embolism. CONCLUSION: The findings of this study suggest that IVT and IT antibiotic therapy is a useful option in patients who are nonresponsive to standard intravenous therapy with little or no side effects.