The economic burden of ventriculoperitoneal shunt insertion and its complications: findings from a cohort in the Philippines.

PURPOSE: Ventriculoperitoneal shunt (VPS) insertion is the gold standard treatment for congenital hydrocephalus, but there is little data about the cost of this procedure in developing countries. We aimed to determine the in-hospitalization cost of initial VPS insertion and its complications (malfunction and infection) and identify predictors of increased cost. METHODS: We performed a retrospective cohort study by reviewing the medical and financial records of pediatric patients with congenital hydrocephalus and underwent shunt surgery at our institution between 2015 and 2019. We also performed multivariable linear regression analysis to determine clinical characteristics that were predictive of cost. RESULTS: A total of 230 cerebrospinal fluid diversion procedures were performed on 125 patients. The mean age during index VPS insertion was 9.8 months (range: 7 days-8 years). Over a median follow-up of 222 days, 15 patients (12%) developed shunt malfunction while 25 (20%) had a shunt infection. The mean in-hospitalization cost for all patients was PHP 94,573.50 (USD 1815). The predictors of higher cost included shunt infection (p < 0.001), shunt malfunction (p < 0.001), pneumonia (p = 0.006), sepsis (p = 0.004), and length of hospital stay (p = 0.005). Patients complicated by shunt infection had a higher mean cost (PHP 282,631.60; USD 5425) than uncomplicated patients (PHP 40,587.20 or USD 779; p < 0.001) and patients who had shunt malfunction (PHP 87,065.70 or USD 1671; p < 0.001). CONCLUSION: The study provided current data on the in-hospitalization cost of VPS insertion in a public tertiary hospital in a developing country. Shunt infection, malfunction, pneumonia, sepsis, and length of hospital stay were significant predictors of cost.

Nonaneurysmal perimesencephalic subarachnoid hemorrhage on noncontrast head CT: An accuracy, inter-rater, and intra-rater reliability study.

BACKGROUND AND PURPOSE: To evaluate the reliability and accuracy of nonaneurysmal perimesencephalic subarachnoid hemorrhage (NAPSAH) on Noncontrast Head CT (NCCT) between numerous raters. MATERIALS AND METHODS: 45 NCCT of adult patients with SAH who also had a catheter angiography (CA) were independently evaluated by 48 diverse raters; 45 raters performed a second assessment one month later. For each case, raters were asked: 1) whether they judged the bleeding pattern to be perimesencephalic; 2) whether there was blood anterior to brainstem; 3) complete filling of the anterior interhemispheric fissure (AIF); 4) extension to the lateral part of the sylvian fissure (LSF); 5) frank intraventricular hemorrhage; 6) whether in the hypothetical presence of a negative CT angiogram they would still recommend CA. An automatic NAPSAH diagnosis was also generated by combining responses to questions 2-5. Reliability was estimated using Gwet's AC1 (κG), and the relationship between the NCCT diagnosis of NAPSAH and the recommendation to perform CA using Cramer's V test. Multi-rater accuracy of NCCT in predicting negative CA was explored. RESULTS: Inter-rater reliability for the presence of NAPSAH was moderate (κG = 0.58; 95%CI: 0.47, 0.69), but improved to substantial when automatically generated (κG = 0.70; 95%CI: 0.59, 0.81). The most reliable criteria were the absence of AIF filling (κG = 0.79) and extension to LSF (κG = 0.79). Mean intra-rater reliability was substantial (κG = 0.65). NAPSAH weakly correlated with CA decision (V = 0.50). Mean sensitivity and specificity were 58% (95%CI: 44%, 71%) and 83 % (95%CI: 72 %, 94%), respectively. CONCLUSION: NAPSAH remains a diagnosis of exclusion. The NCCT diagnosis was moderately reliable and its impact on clinical decisions modest.

A shift from open to endovascular repair in the treatment of ruptured middle cerebral artery aneurysms: a single institution experience.

PURPOSE: Middle cerebral aneurysms were underrepresented in the two largest trials (BRAT and ISAT) for the treatment of ruptured intracranial aneurysms. Recent institutional series addressing the choice between endovascular or open repair for this subset of aneurysms are few and have not yielded a definitive conclusion. We compare clinical outcomes of patients presenting with acute subarachnoid hemorrhage from ruptured middle cerebral artery aneurysms undergoing either open or endovascular repair. METHODS: We conducted a retrospective review of 138 consecutive patients with ruptured middle cerebral artery aneurysms admitted into our institution from January 2008 to March 2019 to compare endovascular and open surgical outcomes. RESULTS: Of the ruptured middle cerebral artery aneurysms, 57 underwent endovascular repair while 81 were treated with open surgery. Over the study period, there was a notable shift in practice toward more frequent endovascular treatment of ruptured MCA aneurysms (31% in 2008 vs. 91% in 2018). At discharge (49.1% vs 29.6%; p = .002) and at 6 months (84.3% vs 58.6%; p = 0.003), patients who underwent endovascular repair had a higher proportion of patients with good clinical outcomes (mRS 0-2) compared to those undergoing open surgery. Long-term follow-up data (endovascular 54.9 ± 37.9 months vs clipping 18.6 ± 13.4 months) showed no difference in rebleeding (1.8% vs 3.7%, p = 0.642) and retreatment (5.3% vs 3.7%, p = 0.691) in both groups. CONCLUSION: Our series suggests equipoise in the treatment of ruptured middle cerebral artery aneurysms and demonstrates endovascular repair as a potentially feasible treatment strategy. Future randomized trials could clarify the roles of these treatment modalities.

Survival times of patients with glioblastoma in low- and middle-income countries: a systematic review and meta-analysis.

Little is known about the survivorship of glioblastoma (GBM) patients in low- and middle-income countries (LMICs). We hypothesize that this would be lower than published figures for high-income countries due to cancer health disparities. We performed a systematic review and meta-analysis to estimate the median overall survival (OS) of GBM in LMICs and determine factors affecting OS. A systematic review of 12 electronic databases was conducted according to PRISMA guidelines to identify studies of newly diagnosed adult GBM patients done in countries classified as LMIC by the World Bank (WB) from inception to December 2020. Random effects meta-analysis of collected median overall survival data was done. Subgroup analysis and meta-regression were done to determine if WB income classification (WBIC), start year of recruitment (pre- or post-popularization of the standard Stupp protocol), and treatment modality affected OS. The 24 articles (n = 2,552) that met the inclusion criteria were from 8 low-middle income and upper-middle income countries, with 0 articles from low-income countries. Random effects analysis of 24 studies showed a pooled median OS of 14.17 months (95% CI 12.90-15.43, I2 = 79). Subgroup analysis showed a significant difference (p < 0.05) in the pooled median OS of studies predating Stupp protocol (12.54 mo, 95% CI 11.13-13.96, I2 = 80%; n = 1027) and studies postdating Stupp protocol (15.64 mo, 95% CI 13.58-17.69, I2 = 77; n = 1412). Subgroup analysis of WBIC and treatment modalities did not show significant differences. Published data on the survivorship of GBM patients in LMICs is sparse, highlighting the need for good quality pragmatic studies from LMICs. The limited evidence suggests improving survivorship after introduction of the Stupp protocol.

Efficacy of aspirin for sporadic vestibular schwannoma: a meta-analysis.

BACKGROUND: Pharmacologic treatment of vestibular schwannomas (VSs) may increase the success of conservative management for small lesions, and offer an alternative to surgery and stereotactic radiotherapy in symptomatic cases in the high-risk population. Agents that have been studied include aspirin (ASA), but the results of the preliminary studies have been conflicting. In this study, we aimed to systematically review the evidence on the effect of ASA intake on tumor growth in patients with VSs. METHODS: Pubmed, Cochrane, Scopus, Embase, ClinicalTrials.gov , and Web of Science were searched for studies comparing VS tumor growth in patients with aspirin intake and those without. Random-effect meta-analysis was used to evaluate the outcomes in terms of linear and/or volumetric tumor growth. RESULTS: Four retrospective cohort studies were included in the meta-analysis. No significant difference was found in tumor growth between VS patients with aspirin intake and those without. This result held true for the analysis of linear tumor growth (OR 1.23; 95% CI 0.49, 3.10), volumetric tumor growth (OR 1.41; 95% CI 0.36, 5.59), and both combined (OR 1.02; 95% CI 0.56, 1.86). CONCLUSIONS: Our meta-analysis suggests that there is insufficient evidence to recommend ASA therapy in patients with VSs. High-quality randomized controlled trials are warranted to determine the efficacy of this drug in reducing VS tumor growth.

Success and complication rates of endoscopic third ventriculostomy for tuberculous meningitis: a systematic review and meta-analysis.

Because ventriculoperitoneal shunt (VPS) insertion for patients with hydrocephalus from tuberculous meningitis (TBM) can be complicated by shunt infection and malfunction, endoscopic third ventriculostomy (ETV) has been proposed as an alternative. The aim of this review was to determine the success, technical failure, and complication rates of ETV in TBM in a meta-analysis and determine which factors are predictive of outcome. The PubMed, Scopus, and CENTRAL databases were searched from inception to April 2020 for case series, cohort studies, or randomized controlled trials reporting success, technical failure, or complication rates. For studies with individual patient data available, logistic regression analysis was done to determine whether age, sex, clinical grade, and type of hydrocephalus on imaging was predictive of outcome. Eight studies with a total of 174 patients were included in the review. Using random-effects modeling, the pooled estimate of success rate was 59% (95% CI 50-68%), with low heterogeneity (I2 = 30%). The technical failure and complication rates were 5% and 15%, respectively, but these variables had moderate heterogeneity. In 36 patients with individual patient data, a non-communicating type of hydrocephalus on imaging was associated with an odds ratio of 5.90 (95% CI 1.1-32.9, p = 0.043) for success. In summary, ETV for TBM had a pooled success rate of 59%, technical failure rate of 5%, and complication rate of 15%. An imaging finding of non-communicating hydrocephalus was associated with increased success. High-quality randomized, prospective studies using VPS insertion as control are needed to further define the role of ETV in TBM.

Giant Cerebellar Cavernomas in Pediatric Patients: Systematic Review with Illustrative Case.

INTRODUCTION: Giant cavernomas (GCMs) are angiographically occult vascular malformations of the central nervous system measuring at least 4 cm in diameter. These are rare lesions, especially in the cerebellum. As such, the clinical and radiologic features, surgical management, and outcomes of treatment for this condition are unknown. METHODS: We performed a systematic review of SCOPUS and PubMed databases for case reports and case series of histopathologically proven GCMs arising from the cerebellum in the pediatric population, and included a case managed at our center. Data on clinical presentation, imaging features, surgical treatment and outcomes of management were collected. RESULTS: A total of 10 cases were identified from the systematic review, including our case report. The patients' median age was 6 months, with a slight male sex predilection (1.5:1). The most common neurologic manifestations were bulging fontanelle in infants, and headache and focal cerebellar deficits in older children. Surgical excision was done in all cases, while 50% of the cases had CSF diversion surgery done prior to excision. In cases with reported outcome, complete neurologic recovery was achieved in seven while partial recovery was reported in one case. No deaths were reported at median follow-up of 12 months. CONCLUSION: Our case report and systematic review show that giant cerebellar cavernoma is a rare differential diagnosis for symptomatic hemorrhagic cerebellar masses in the pediatric age group. Mainstay of treatment is surgical excision, which can be associated with favorable outcome in most cases.

Safety and Clinical Outcome of Good-Grade Aneurysmal Subarachnoid Hemorrhage in Non-Intensive Care Units.

BACKGROUND: While patients with good grade aneurysmal subarachnoid hemorrhage are routinely admitted in intensive care units, critical care capacity in low-middle income countries (LMICs) is limited. In this study, we report the outcomes of good-grade SAH (Hunt and Hess grades I & II) patients admitted in ICU and non-ICU settings at a center in the Philippines and determine if site of care is predictive of outcome. METHODS: We performed a retrospective study of all adults diagnosed with good-grade SAH in a five-year period. Patients were analyzed according to three groups based on site of care: Group A (>50% of length of stay in ICU), Group B (>50% of LOS in non-ICU), and Group C (100% of LOS in non-ICU). The primary outcome measures were in-hospital mortality and mRS score at discharge. The secondary outcome measures were complication rate and LOS. RESULTS: A total of 242 patients was included in the cohort, which had a mean age of 51.16 years and a female predilection (64%). The rates of in-hospital mortality and favorable functional outcome at discharge were 0.82% and 93.8%, respectively, with no difference across groups. Delayed cerebral ischemia and infection were more frequently diagnosed in ICUs (p < 0.001), while rebleeding occurred more commonly in non-ICUs (p = 0.02). The median LOS was significantly longer in patients who developed complications. CONCLUSIONS: Admission of good-grade aneurysmal SAH patients in non-ICU settings did not adversely affect both in-hospital mortality and functional outcome at discharge. Prospective, randomized studies may lead to changes in pattern of ICU utilization which are critical for LMICs.

Non-Traumatic Intracerebral Hematoma in the Young: Findings from a Tertiary Hospital in the Philippines.

BACKGROUND: There is geographic variability in the clinical profile and outcomes of non-traumatic intracerebral hematoma (ICH) in the young, and data for the Philippines is lacking. We aimed to describe this in a cohort from the Philippines, and identify predictors of mortality. METHODS: We performed a retrospective study of all patients aged 19-49 years with radiographic evidence of non-traumatic ICH admitted in our institution over five years. Data on demographics, risk factors, imaging, etiologies, surgical management, in-hospital mortality, and discharge functional outcomes were collected. Multivariate logistic regression analysis was done to determine factors predictive of mortality. RESULTS: A total of 185 patients were included, which had a mean age of 40.98 years and a male predilection (71.9%). The most common hematoma location was subcortical, but it was lobar for the subgroup of patients aged 19-29 years. Overall, the most common etiology was hypertension (73.0%), especially in patients aged 40-49. Conversely, the incidence of vascular lesions and thrombocytopenia was higher in patients aged 19-29. Surgery was done in 7.0% of patients. The rates of mortality and favorable functional outcome at discharge were 8.7% and 35.1%, respectively. Younger age (p = 0.004), higher NIHSS score on admission (p=0.01), higher capillary blood glucose on admission (p=0.02), and intraventricular extension of hematoma (p = 0.01) predicted mortality. CONCLUSIONS: In the Philippines, the most common etiology of ICH in young patients was hypertension, while aneurysms and AVM's were the most common etiology in the subgroup aged 19 - 29 years. Independent predictors of mortality were identified.

Hydranencephaly complicated by central diabetes insipidus: report of two cases and systematic review of literature.

PURPOSE: Hydranencephaly is a congenital condition characterized by the complete or near-complete absence of the cerebral cortex and basal ganglia, while central diabetes insipidus (CDI) is a condition characterized by the inability to concentrate urine due to a deficiency in antidiuretic hormone (ADH). CDI is known to occur in midline congenital malformations such as holoprosencephaly and septo-optic dysplasia, but its association with hydranencephaly is less well-established. METHODS: We reported two cases of hydranencephaly complicated by CDI. We also performed a systematic review of the SCOPUS and PubMed databases for case reports and case series of patients with hydranencephaly and CDI, and compiled data on the clinical features and treatment options. RESULTS: Seven cases of hydranencephaly complicated by CDI were identified from the systematic review in addition to the two cases reported here, resulting in a total of nine cases. The patients' age ranged from 4 days to 4 years, and there was a female sex predilection (3.5:1). Patients most commonly presented with macrocephaly, developmental delay, and seizures, with dysmorphic features noted in 33%. In addition to CDI, other endocrinologic derangements included hypothyroidism (22%), hypocortisolemia (22%), and panhypopituitarism (22%). CDI was treated using sublingual or oral desmopressin while hypopituitarism was treated with the appropriate hormone replacement therapy. Insertion of a ventriculoperitoneal (VP) shunt was reported in 44% of cases. CONCLUSION: The case reports and systematic review suggest a previously unknown association between hydranencephaly and CDI. Clinicians managing cases of hydranencephaly are advised to have a high index of suspicion for CDI in patients presenting with the characteristic signs and symptoms.

Clinical Uncertainty in Large Vessel Occlusion ischemic stroke (CULVO): Does automated perfusion scanning make a difference? Protocol of an intrarater and interrater agreement study.

BACKGROUND: Guidelines recommend the use of perfusion computed tomography (CT) to identify emergent large vessel ischemic stroke (ELVIS) patients who are likely to benefit from endovascular thrombectomy (EVT) if they present within 6-24 hour (late window) of stroke onset. We aim to determine if the interrater and intrarater reliability among physicians when recommending EVT is significantly different when perfusion CT or non-perfusion CT is reviewed. METHODS: A total of 30 non-consecutive patients will be selected from our institutional database comprising 3144 cranial CT scans performed for acute stroke symptoms January 2018 to August 2022. The clinical and radiologic data of the 30 patients will be presented in random order to a group of 29 physicians in two separate sessions at least three weeks apart. In each session, the physicians will evaluate each patient once with automated perfusion images and once without. We will use non-overlapping 95% confidence intervals and difference in agreement classification as criteria to suggest a difference between the Gwet AC1 statistics (κG). DISCUSSION: The results obtained from this study, combined with the clinical outcomes data of patients categorized through the two imaging techniques and a cost-effectiveness analysis, will offer a comprehensive evaluation of the clinical utility of perfusion CT neuroimaging. Should there be no significant disparity in the reliability of decisions made by clinicians using the two neuroimaging protocols, it may be necessary to revise existing recommendations regarding neuroimaging in the later time window to align with these findings.

Perfusion vs non-perfusion computed tomography imaging in the late window of emergent large vessel ischemic stroke: A systematic review and meta-analysis.

BACKGROUND: Guidelines recommend the treatment of emergent large vessel ischemic stroke (ELVIS) patients presenting beyond 6 hours of last known well time with endovascular thrombectomy (EVT) based on perfusion computed tomography (CT) neuroimaging. We compared the outcomes (long-term good clinical outcomes, symptomatic intracranial hemorrhage (sICH), and mortality) of ELVIS patients according to the type of CT neuroimaging they underwent. METHODS: We searched the following databases: Medline, Embase, CENTRAL, and Scopus from January 1, 2015, to June 14, 2023. We included studies of late-presenting ELVIS patients undergoing EVT that had with data for non-perfusion and perfusion CT neuroimaging. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data were pooled using a random effects model. RESULTS: We found 7 observational cohorts. Non-perfusion versus perfusion CT was not statistically significantly different for both long-term clinical (n = 3,224; RR: 0.96; 95% CI 0.86 to 1.06; I2 = 18%) and sICH (n = 3,724; RR: 1.08 95% CI 0.60 to 1.94; I2 = 76%). Perfusion CT had less mortality (n = 3874; RR: 1.22; 95% CI 1.07 to 1.40; I2 = 0%). The certainty of these findings is very low because of limitations in the risk of bias, indirectness, and imprecision domains of the Grading of Recommendations, Assessment, Development and Evaluations. CONCLUSION: The use of either non-perfusion or perfusion CT neuroimaging may have little to no effect on long-term clinical outcomes and sICH for late-presenting EVT patients. Perfusion CT neuroimaging may be associated with a reduced the risk of mortality. Evidence uncertainty warrants randomized trial data.

Endoscopic third ventriculostomy with or without choroid plexus coagulation for myelomeningocele-associated hydrocephalus: systematic review and meta-analysis.

OBJECTIVE: While ventriculoperitoneal shunt (VPS) insertion is the standard treatment for myelomeningocele-associated hydrocephalus (MAH), it can be complicated by infection and shunt malfunction. As such, endoscopic third ventriculostomy (ETV), with or without choroid plexus coagulation (CPC), has been proposed as an alternative. The aim of this review was to determine the success, technical failure, and complication rates of ETV with or without CPC in patients with MAH. METHODS: PubMed, Scopus, and Cochrane Central Register of Controlled Trials databases were searched from inception to June 2020 for case series, cohort studies, or randomized controlled trials reporting success, technical failure, or complication rates. Random-effects analysis was performed to determine the estimates for these outcome measures. Studies were evaluated using the Newcastle-Ottawa Scale for quality and risk of bias. RESULTS: Thirteen studies with a total of 325 patients who underwent either ETV or ETV+CPC were included in the review. Using random-effects modeling, the pooled estimate of the success rate was 56% (95% CI 44%-68%, I2 = 78%), while the technical failure rate was 2% (95% CI 0%-6%, I2 = 32%). The estimate for the success rate had high heterogeneity, due to the type of surgical intervention (ETV vs ETV+CPC, p < 0.001). Random-effects analysis of 9 studies with 117 patients who underwent ETV alone yielded an estimated success rate of 48% (95% CI 0.39-0.57, I2 = 0%), while analysis of 4 studies with 166 patients who underwent ETV+CPC revealed a success rate of 75% (95% CI 67%-82%, I2 = 21%). The estimates for the mild/moderate, severe, and fatal complication rates were 0 (95% CI 0%-4%, I2 = 0%), 2% (95% CI 0%-10%, I2 = 52%), and 0 (95% CI 0%-1%, I2 = 0%), respectively. CONCLUSIONS: ETV+CPC was associated with a higher success rate than ETV alone for MAH in a meta-analysis of published studies. ETV, with or without CPC, was technically feasible and safe for this patient population.

Meningiomas Associated with Subdural Hematomas: A Systematic Review of Clinical Features and Outcomes.

BACKGROUND: Meningiomas associated with subdural hematomas (SDHs) are exceedingly rare. As such, the clinical features, optimal medical and surgical management, and outcomes of treatment for these lesions remain unknown. METHODS: We performed a systematic review of the PubMed and Scopus databases for case reports and case series of patients with presumptive clinical or definitive diagnoses of meningiomas presenting with SDH on computed tomography scan or magnetic resonance imaging. Data on demographics, clinical manifestations, surgical management, adjuvant treatment, and outcome on last follow-up were collected. RESULTS: Inclusion criteria were met by 59 cases, including a case described in the current study. Mean age of patients was 62 years (range: 5-85 years), with a slight female predilection (1.3:1). The most common clinical symptom and sign were headache and focal weakness, respectively. All except 2 patients underwent surgery, either a single or staged procedure, for evacuation of hematoma and/or excision of tumor. Treatment for meningioma in patients who presented with SDH was associated with a mortality rate of 12% (6/51) at a median follow-up of 3 months. Complete neurologic recovery was reported in 71% of patients. CONCLUSIONS: SDHs are rare manifestations of intracranial meningiomas. Current management is largely surgical for immediate relief of mass effect and oncologic control. Most reported patients survived with complete neurologic recovery.

Socioeconomic factors affecting survivorship of glioblastoma patients in the Philippines.

Glioblastoma (GBM) is the most common malignant primary brain tumor in adults worldwide. However, data on the survivorship of GBM patients in low- and middle-income countries is sparse. We determined whether socioeconomic factors such as marital status, place of residence, educational attainment, employment status, and income affected survival. A retrospective cohort study of surgically managed GBM patients (n = 48) in a single center over a five-year period was conducted using chart review and telephone interview. The mean age was 41 years, with a male predilection (62%). Most patients were married (73%), employed full time (79%), resided in a rural location (56%), completed secondary education (44%), and had a low income (83%). Most of the tumors were > 5 cm at the time of diagnosis (90%) and involved more than one lobe (40%). Majority underwent subtotal resection (56%). Only 15% (n = 7) had adjuvant chemoradiation while 23% (n = 11) had radiotherapy alone. Median overall survival was 7.6 months. Multivariate analysis showed that extent of resection (gross total resection, p = 0.0033; subtotal resection, p = 0.0069) and adjuvant treatment (p = 0.0254) were associated with improved survival, while low income (p = 0.0178) and educational (p = 0.0206) levels and part-time employment (p = 0.0063) were associated with decreased survival. Many GBM patients at our center presented at an advanced stage in their natural history, and majority (62%) did not receive adjuvant treatment after surgery. As such, the median overall survival was less than that reported in developed countries. Of the socioeconomic factors analyzed, low income and educational levels and part-time employment were negatively associated with survivorship.

Predictive Value of Hematologic Inflammatory Markers in Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND AND OBJECTIVE: Our study aimed to determine the ability of hematologic markers (neutrophil/lymphocyte ratio [NLR], platelet/lymphocyte ratio, and red cell distribution width [RDW]) in predicting delayed cerebral ischemia (DCI), modified Rankin Scale scores, and mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS: A retrospective observational 6-year review of medical records was conducted to identify all consecutive patients with aSAH admitted to the largest training hospital in the Philippines. Univariable and multivariable regression analyses were performed to determine the association of the biomarkers with the respective outcomes. Receiver operating characteristic curves were used to detect overall predictive accuracy. RESULTS: A total of 222 patients with aSAH were included, of whom 11.71% developed DCI. Most patients with NLR ≥5.9 subsequently died (77 vs. 52%; P = 0.03). DCI was also associated with poor functional outcomes with higher modified Rankin Scale scores (3-6) on discharge (92% vs. 49%; P < 0.01), and longer duration of hospitalization (median, 20 vs. 13 days; P = 0.01). In receiver operating characteristic analyses, the value of RDW was predictive for DCI (area under the curve, 0.70; 95% confidence interval, 0.62-0.79; P < 0.01). The values of NLR (area under the curve, 0.67; 95% CI, 0.59-0.74) potentially predict functional outcome. RDW, NLR, and their combinations were poor discriminators of mortality. CONCLUSIONS: Our study showed that some hematologic parameters analyzed could be of potential value as prognostic biomarkers in patients with aSAH. Hematologic biomarkers are widely available and practical parameters that may be of considerable clinical value in aSAH management, especially in lower-middle-income countries such as the Philippines.

Neurosurgical research in Southeast Asia: A bibliometric analysis.

OBJECTIVES: Bibliometric analysis can provide insight into the growth, development and dissemination of research in neurosurgery. Little work has been done to examine the role of country-specific characteristics affecting research productivity. We aimed to characterize andcompare the research productivity among SEA countries in terms of bibliometric indicesand determine associations with country-specific factors. METHODS: We performed a systematic search of all articles by authors affiliated with a neurosurgical department in any of the Southeast Asian countries, indexed in 3 databases from inception to June 10, 2020. Bibliometric indices - number of publications, number of citations, average citations per publication, h-index, and the i-10-index - were computed for each country. Correlations between the indices and country-specific characteristics (population size, GDP per capita, percentage of GDP allocation to research and development (R&D), number of neurosurgeons, number of neurosurgeons per capita, and number of collaborations with non-SEA authors) were determined. RESULTS: The number of publications showed an increasing trend up to 2019. Most studies were cohort studies (37%) or case reports or series (37%). Of the country-specific factors analyzed, only percentage of the GDP allocated to R&D was positively correlated with number of publications (p = 0.0004), total citations (p < 0.0001), H-index (p < 0.0001), and i(10)-index (p < 0.0001). Number of collaborations also positively correlated with the same indices. CONCLUSION: Our bibliometric analysis showed increasing contribution by neurosurgeons in the SEA region. Correlational analysis support the view that increased R&D budget allocation and international collaboration can improve neurosurgical research capacity and productivity.

Intracranial Mass Lesions in Human Immunodeficiency Virus Patients in the Philippines: A Retrospective Cohort Study.

BACKGROUND: Central nervous system involvement is commonly seen in patients with human immunodeficiency virus (HIV) infection, with up to 2%-10% of patients presenting with intracranial mass lesions. The management of these lesions depends largely on their etiology and their relative frequency in the local population. METHODS: We performed a retrospective chart review of patients with HIV and evidence of intracranial mass lesions on cranial magnetic resonance imaging or computed tomography from 2007 to 2018. Demographic data, clinical features, etiology, surgical management, and outcomes were collected. RESULTS: The prevalence of intracranial mass lesions in our cohort was 2.2% (45/2032). Patients were predominantly male (98%), with a mean age at diagnosis of 28 years. The most common clinical manifestations were headache (75%), focal weakness (49%), and seizures (32%). The most common diagnoses were toxoplasmic encephalitis (51%) and tuberculosis (24%). Biopsy or excision was performed in 10% of cases, leading to a definitive diagnosis in 60% of these cases. A favorable outcome was observed in 58% of all patients at 46 months median follow-up, with adequate disease-specific treatment. CONCLUSIONS: The prevalence of intracranial mass lesions in Filipino patients with HIV is 2.2%. The most common etiology was toxoplasmic encephalitis followed by tuberculosis. These findings are substantially different from other findings reported in the literature and should be considered in formulating guidelines for the Filipino population.

Awake Craniotomy in Low-Resource Settings: Findings from a Retrospective Cohort in the Philippines.

BACKGROUND: Awake craniotomy is a technique used to maximize resection of lesions in eloquent areas of the brain and preserve function. Although its use in high-income centers is well documented for tumors and vascular lesions, reports of its use in low-middle-income countries are limited. There are no published series from the Philippines. METHODS: We performed a retrospective review of all patients who underwent awake craniotomy at a tertiary referral center in Manila, Philippines from 2010 to 2019. Data on demographics, clinical features, diagnoses, intraoperative and postoperative complications, and outcomes were collected. Regression analyses were performed to correlate use of intraoperative adjuncts with outcome measures (extent of resection, complication rate, neurologic status after surgery and on last follow-up, and in-hospital mortality). RESULTS: A total of 65 patients were included in the cohort, who had a male predilection (60%) and a mean age at diagnosis of 40.4 years. The most common indication was tumor excision (90%), followed by excision of arteriovenous malformations (5%) and cavernomas (3%). Of the tumors, the most common histopathologic diagnosis was low-grade glioma (48%). The intraoperative complication rate was 13.8%, with the most common complication being patient intolerance. Gross total excision rate for tumors was 78.3%. Univariate analysis showed that use of a cortical stimulator was associated with improved neurologic status on last follow-up (P = 0.0471). CONCLUSIONS: Our experience shows that awake craniotomy is feasible in low-middle-income country settings and is safe and effective for excision of tumors, arteriovenous malformations, and cavernomas.

Successful management of intraventricular rupture of pyogenic brain abscess (IVROBA): Systematic review and illustrative case.

OBJECTIVES: Intraventricular rupture of brain abscess (IVROBA) is one of the most dreaded complications of pyogenic brain abscess due to its high mortality rate. Because of its relative infrequency and poor outcome, the optimal management of this condition remains to be determined. PATIENTS AND METHODS: We report the case of a 5-year old female with a presumptive diagnosis of IVROBA who was discharged with good neurologic outcome after completing intravenous antibiotic treatment and undergoing insertion of an external ventricular drain (EVD) and later, a ventriculoperitoneal (VP) shunt. We also performed a systematic review of the SCOPUS and PubMed databases for case reports and series documenting patients who survived after undergoing treatment for IVROBA. RESULTS: A total of 24 cases of IVROBA survivors were reported in the literature, including the present case. The median age was 48.5 years (range: 5-71), with a male predilection (3:1). The most common location of the brain abscesses was temporal while the most common route of spread was hematogenous. Surgery was performed in 92% of cases, with EVD being the most common surgical procedure. Twenty nine percent of cases required a VP shunt. The duration of systemic antibiotic treatment ranged from 31 to 180 days (median: 56 days) while intraventricular antibiotics were given for 8-42 days (median: 14 days). CONCLUSION: The management of IVROBA in this series varied widely, with surgery playing an important role. Although IVROBA is still a devastating complication of intracranial abscess, a good neurologic outcome may still be possible with treatment.