AB095. Methylation class infant-type hemispheric glioma with CDKN2A/B deletion: a rare case report.

BACKGROUND: Gliomas are the most common central nervous system (CNS) tumors in infant but with incidence rate only 1.38 per 100,000. Due to distinctive clinical, histologic, and molecular features, the current World Health Organization (WHO) CNS5 separate gliomas in children from adult as pediatric-type diffuse high-grade and low-grade gliomas. Infant hemispheric gliomas constitute a biologically and clinically distinct subgroup of pediatric-type diffuse high-grade. In this case we present clinical, radiographic, intraoperative, and methylation profiling of the first infant-type hemispheric glioma diagnosed in Indonesia. CASE DESCRIPTION: This is a case report of infant operated at Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia in February 2024. A 6-month-old male infant brought to regional hospital due to head enlargement compared to infant of the same age, head circumference was 50 cm [>2 standard deviation (SD)] with frontal bossing. Brain MRI showed large multi-loculated cystic lesion at left parietooccipital region, which appeared hypointense on T1-weithgted (T1W), hyperintense on T2-weighted (T2W) and fluid-attenuated inversion recovery (FLAIR), with irregular contrast enhancing border. There was isointense lesion on T1W with inhomogeneous contrast enhancement. The largest volume of cystic lesion was 216 cm. Intraoperatively, parietal bone was thinner than usual. The brain was tense, purplish, and non-pulsating, giving the impression of a tumor with indistinct borders with the normal cortex. Dark clear yellowish fluid was spurt after the cortex was incised. Histopathological findings revealed moderate to high cellularity tumor tissue with mitosis, microvascular proliferation, palisading necrosis. In collaboration with German Cancer Research Center (DKFZ), DNA methylation array analysis showed the tumor to match the Infant-type Hemispheric Glioma methylation class (calibrated score 0.94) with deletion of cyclin dependent kinase inhibitor 2A/B (CDKN2A/B). CONCLUSIONS: Methylation class (MC) infant-type hemispheric glioma may present with macrocephaly. On magnetic resonance imaging (MRI) it may appear as large multi-loculated cystic lesion and irregular contrast enhancing border. The key diagnostic criteria for infant-type hemispheric glioma involve combination of clinical, pathological, and molecular feature.

Free Vascularized Osseous Fibula Flap for Vertebral Body Defect in a Patient with Tuberculosis Spondylitis.

In the context of tuberculous spondylitis, a rare form of extrapulmonary tuberculosis causing significant discomfort and neurological deficits, surgery becomes imperative to alleviate symptoms alongside antituberculosis treatment. However, the utilization of free vascularized fibula flaps for repairing vertebral deformities remains uncommon. This report presents the case of a 21-year-old man with limb weakness and sensory disturbances who was referred to our hospital, where contrast magnetic resonance imaging revealed a paravertebral abscess spanning several thoracic vertebrae. Collaborating with neurosurgeons, we performed decompression laminectomy, pedicle screw fixation, thoracic vertebrectomy, and restoration of the corporal defect using a free fibula flap. Utilizing a 2.5-cm fibula segment from the patient's left leg without a skin paddle, the surgery demonstrated a pedicle length of 12 cm and a total ischemic time of 183 minutes. The fibula was press-fitted, with recipient vessels identified as 1-mm artery and vein from the intercostal artery perforator. Postsurgery, flap vitality was assessed using Doppler ultrasound, showing positive signals immediately and at 1-month follow-up, with the patient experiencing reduced pain and improved leg strength. Despite its rarity, free fibula flap reconstruction for spinal defects proves effective, safe, and beneficial, necessitating thorough preoperative planning and interdisciplinary collaboration for successful outcomes, marking this case as the first reported instance in Indonesia.

Breaking boundaries in neurosurgery through art and technology: A historical perspective.

Introduction: Since the past, art has been used as a tool to elaborate anatomical knowledge and guide surgeons to perform surgeries. Through the eras, art has taken role by conveying the knowledge to people in forms of illustrations and models, including neuroanatomy knowledge for neurosurgical purposes. With the advancement of technology, neurosurgical trainings and care evolve more than before. Research question: How do art and technology play role in tbe education and development of neurosurgery? Materials and methods: A literature search was conducted to find the role of art and technology in forms of illustrations, models, or others in neurosurgery. Results: Illustration was known as one of the tools to understand it in the past. Now, in the modern era, neurosurgical learning, training, and teaching process have integrated both art and technology throughout the process. Not only as two-dimenional drawings, art and technology have gone as far as being developed into three-dimensional models and create specific models for surgical plannings and simulations. Artificial intelligence, virtual reality, and augmented reality have also been used to achieve accurate and efficient learning process and neurosurgical care. Discussion and conclusion: Art does take significant role in the progression of neurosurgery. When combined with technology, art give greater utility and impact through the learning, teaching process, and delivery of care in neurosurgical world.

Endovascular embolization of Spetzler-Martin Grade I brain arteriovenous malformations: A case report on patient-centered neurointervention.

Brain arteriovenous malformations (AVM) present complex treatment decisions, particularly for low-grade AVM where surgical resection is often considered the standard. This case report emphasizes the importance of patient preferences and cultural considerations in selecting endovascular embolization over traditional surgical approaches for Spetzler-Martin Grade I AVM management, highlighting the evolving practice of patient-centered care in neurointervention. A 30-year-old male presented with recurrent seizures, characterized by a sudden onset of headache followed by speech arrest, without any preceding medical history of neurological deficits. Initial physical examination revealed no focal neurological deficits. Non-contrast computed tomography, magnetic resonance imaging, and magnetic resonance angiography suggested an AVM involving the cortical-subcortical regions of the left frontal lobe, measuring approximately 1.7 × 2.6 × 1.5 cm, fed by the left middle cerebral artery M3 segment, and draining into the superior sagittal sinus. Spetzler-Martin Grade I classification was confirmed via digital subtraction angiography. Given the patient's strong preference against invasive procedures, driven by personal and cultural beliefs, endovascular embolization was selected as the treatment strategy. Post-embolization, the patient showed marked symptomatic improvement with no evidence of residual AVM on follow-up imaging, and no postprocedure complications were reported. This case highlights the importance of considering patient preferences in AVM treatment planning, illustrating that endovascular embolization can be an effective and less invasive alternative to surgery in selected patients, reinforcing the need for personalized, patient-centered approaches in neurointerventional care.

Open surgery vs. stereotactic radiosurgery for tumour-related trigeminal neuralgia: A systematic review.

BACKGROUND: Secondary trigeminal neuralgia is a facial pain in trigeminal nerve dermatome caused by an underlying disease, such as cerebellopontine angle tumours. Treatment options to relieve the pains were surgical tumour resection and stereotactic radiosurgery of the tumour or trigeminal nerve. This study aims to review the efficacy of open surgery and stereotactic radiosurgery and recommend the treatment of choice for secondary trigeminal neuralgia due to cerebellopontine angle tumours. METHOD: The inclusion criteria were studies covering patients with trigeminal neuralgia associated with cerebellopontine angle tumours that were treated with either open surgery or stereotactic radiosurgery and reported pain outcomes after treatment. Non-English articles or studies with a population of less than five were excluded. We systematically searched studies from PubMed, Ebscohost, and Cochrane Library from inception until December 20, 2021. Several works of literature from manual search were also added. Selected articles were appraised using a critical appraisal tool for prognostic studies. RESULT: Included articles were 26 retrospective studies and one prospective study comprising 517 patients. Of 127 schwannomas, 226 epidermoids, 154 meningiomas, and ten other tumours, 320 cases received surgical tumour excision with or without MVD, 196 had tumour-targeted radiosurgery, and 22 underwent nerve-targeted radiosurgery. In surgical series, 92.2 % gained pain improvement, 2.8 % were unchanged, and 4.5 % had recurrence; none of the patients had worsened outcomes. In cases treated with tumour-targeted radiosurgery, the improvement rate was 79.1 %, unchanged at 14.3 %, recurrence at 26.5 %, and worse symptoms rate after the intervention was 6.6 %. Six patients with recurrent pain after tumour-targeted radiosurgery received secondary nerve-targeted radiosurgery with improved outcomes. Only one patient in our review underwent primary nerve-targeted radiosurgery, and the result was satisfactory. One study treated 15 patients with a single session of tumour-targeted and nerve-targeted radiosurgery, with an improvement rate of 93.3 % and a recurrence rate of 21.4 %. CONCLUSION: Open surgery releasing the nerve root from compressive lesions is advocated to be the first-line treatment to gain satisfactory outcomes. Total removal surgery is recommended if possible. Nerve-targeted radiosurgery should be reserved as a secondary treatment for recurrent cases.

The role of intraoperative neuromonitoring in pygopagus separation: two-institution experience in Indonesia.

INTRODUCTION: Pygopagus comprises 17% of all conjoined twin cases. Survival rate is higher compared to other variations of conjoined twins, but separation is a great challenge due to multiorgan involvement. Intraoperative neuromonitoring (IONM) used aims to aid operator in preserving as much function as possible. CASE PRESENTATIONS: The authors reported 2 pairs of pygopagus separation. Intraoperatively, motor-evoked potential (MEP) and sensory-evoked potential (SEP) were used in all patients. Three patients survived in which all had transient motor deficits. Urinary retention was reported in one patient. One patient died 2 weeks after separation as twins only had one kidney which was spared for the healthier twin. DISCUSSION: IONM was used to guide operator in dissecting, identify the ownership of the neural structures, and determine the safest point to separate in pygopagus separation. Despite the normal MEP and SEP recordings, transient motor weakness may still occur transiently. The motor tract development of children is achieved in adolescence, making MEP less accurate. However, the reliability of MEP increases when it is combined with SEP. Autonomic function monitoring such as bulbocavernosus reflex (BCR) could not be assessed due to the unavailability of the probe. CONCLUSION: IONM can aid operator in pygopagus separation during determining the origins of the structure, dissecting, and cutting the neural structures. Normal MEP interpretations are still possible to correlate with transient deficits, but reliability can be improved with the use of SEP. In surgeries involving the lower spine level, BCR monitoring is recommended to avoid autonomic deficits.

Bone fusion in transcele reconstruction of frontoethmoidal meningoencephalocele.

OBJECTIVE: In surgical correction of frontoethmoidal encephalocele with transcranial approach, advanced facilities are required. While with extracranial approach, though deemed as a safe option in area with limited facilities, procedure was associated with cerebrospinal fluid (CSF) leakage. In this case series, we evaluate the results of transcele reconstruction of frontoethmoidal encephalocele, our approach to reduce the incidence of CSF leaks by focusing on the closure of layers by its embryological derivatives, by its bone fusion. METHODS: A case series of 14 patients with various types of frontoethmoidal encephalocele who underwent surgery for defect closure using transcele approach between June 2015 and December 2018 was carried out. Surgery was done by a single surgeon in the Department of Neurosurgery of Cipto Mangunkusumo Hospital in Jakarta, Indonesia. We collected the data of intraoperative blood loss and any signs of infection and CSF leak during the patients' one-year follow up. Bone fusion in the defect was evaluated from 3D rendering of head CT scan that was performed before and in 1 year after surgery. RESULTS: The median percentage of intraoperative blood loss was 5.9% (0.5-18.7%). All 3D rendering of head CT post-surgery during 1 year follow up showed bone fusion and no patient experienced CSF leaks or CNS infections. CONCLUSIONS: This study showed that using transcele approach in frontoethmoidal reconstruction could give good bone fusion with minimal blood loss and no CSF leaks. We assumed that closure of the layers by its embryological derivative played an important part in bone fusion and in reducing the incidence of CSF leaks, although this finding has to be validated with large-scale studies.

Spontaneous subarachnoid hemorrhage due to arteriovenous malformation mimicking migraine: A case report.

Subarachnoid hemorrhage (SAH) due to Arteriovenous Malformation (AVM) is a rare emergency case, which is often misdiagnosed as migraine. Here we present a case of SAH due to AVM that mimics migraine. A 41-year-old man came with headaches that radiated to the neck, worsened in the last week, accompanied by nausea, vomiting, photophobia, and a history of intermittent headaches for the previous 2 years. Physical examination was within normal limits, initial laboratory tests showed leukocytosis, and CT scan was not typical. The patient was diagnosed with migraine. Apparently, the lumbar puncture showed very high red blood cells, suspected as SAH. CT angiography revealed an extra-axial AVM. The patient was later diagnosed as SAH due to AVM. We recommend applying 4 key points, namely headache progressivity, neck pain, neck stiffness, and leukocytosis, to differentiate SAH due to AVM from migraine, especially in areas with limited facilities.

Risk Factors Associated with Post-therapeutic Outcome for Medulloblastoma: An Experience from Indonesia.

CONTEXT: The prognosis of medulloblastoma is better in patients who underwent complete treatment consisting of surgery, radiotherapy, and chemotherapy. However, the realization of such multidiscipline management is quite challenging in developing countries, including Indonesia. Until now, no study on the management of medulloblastoma has ever been conducted in Indonesia. AIMS: The authors aimed to study the characteristics, management, and mortality outcome of medulloblastoma patients in Dr. Cipto Mangunkusumo National Referral Hospital, Jakarta, Indonesia. SUBJECTS AND METHODS: This study was based on medical record and registry of 44 medulloblastoma patients who underwent tumor removal in Dr. Cipto Mangunkusumo National Referral Hospital, Jakarta, Indonesia, between 2011 and 2018. STATISTICAL ANALYSIS USED: Cox regression analysis was utilized to determine the relationship between patients' demography, tumor characteristics, and treatment, with mortality. RESULTS: The incidence of mortality was 84.1% and median months' survival time (95% confidence interval [CI]) was 13 (8.67-17.32). Gross total removal (GTR) was performed in 43.2% of all tumor removal surgery. Only 50% of all patients completed radiotherapy, and 6.8% concluded multimodalities treatment (surgery, radiotherapy, and chemotherapy). Significant statistical association between age, gender, and extent of resection with mortality was identified (HR [95% CI] for age: 0.44 [0.22-0.88], gender: 0.001 [0.000-0.27; REF: female], and biopsy: 31.52 [1.09-910.56; REF: GTR]). CONCLUSIONS: The survival rate of medulloblastoma in Indonesia is inferior to that previously reported in other studies. There is no unusual characteristic contributing to neoteric risk factor. The authors surmise that insufficient multidisciplinary management for the disease, consisting of suboptimal tumor resection, the absence of risk stratification, and incomplete postsurgical treatment (radiotherapy and chemotherapy) resulted in such outcome.

New adaptation of neurosurgical practice and residency programs during the Covid-19 pandemic and their effects on neurosurgery resident satisfaction and welfare at the National General Hospital, Jakarta, Indonesia.

INTRODUCTION: Many institutions in numerous countries have made changes in their health care services during the COVID-19 pandemic. One change has been to reduce elective neurosurgery cases, which has impacted neurosurgery education. Published literature is lacking about the healthcare services, education, and residents' well-being during adaptation to the pandemic, especially in national referral hospitals in developing countries. METHODS: We conducted a cross-sectional study on current neurosurgical services during 2020. We evaluated 34 neurosurgery residents in Cipto Mangunkusumo National General Hospital using a self-made questionnaire to determine the effects of the COVID-19 pandemic on their surroundings, education process, and satisfaction with the currently adapted education program. We used the modified Maslach Burnout Inventory to assess burnout in the residents before and during the pandemic. RESULTS: Neurosurgical residents spent more time studying neurosurgical theory (Mode 1-1.5h/day, p < 0.05) but spent less time learning neurosurgical skills (Mode 30 min-1 h/day, p < 0.05) compared to before the pandemic. The resident satisfaction mean score (scale 0-10) was 7.58 for live surgery and 8.53 for the microsurgical skills lab training program. On a scale of 1-10, the residents' stress level increased after the pandemic but the change was not statistically significant (6.61 ± 1.87, p > 0.05). The Modified Maslach Burnout inventory score was 3.02 ± 3.74 during the pandemic, and increased from before the pandemic (2.41 ± 3.18), but the difference was not statistically significant. CONCLUSION: The COVID-19 pandemics have reduced the working hours and the clinical exposure of neurosurgical residents. Fortunately, this pandemic has led to a new opportunity to find many suitable learning methods which may decrease the risk of burnout. The psychological burden of residents is still worrisome, and planned management is necessary to sustain resident performance.

Predicting outcome of hemifacial spasm after microvascular decompression with intraoperative monitoring: A systematic review.

BACKGROUND: Microvascular decompression has been established as a primary treatment for hemifacial spasm. Intraoperative monitoring is used during the surgery to guide neurosurgeons to determine whether the decompression of facial nerve from the vessel is sufficient. We performed a systematic review to assess the role of lateral spread response (LSR) monitoring in predicting hemifacial spasm outcomes after microvascular decompression. METHOD: A systematic search of PubMed, ScienceDirect, Cochrane, and Google Scholar was conducted. We included studies that performed microvascular decompression surgery with intraoperative monitoring analyzing the correlation between lateral spread response and spasm relief. A critical appraisal was conducted for selected studies. RESULT: Twenty-two studies comprising 6404 cases of hemifacial spasm, which underwent microvascular decompression surgery with intraoperative monitoring, were included. Of 15 articles that assessed symptoms shortly after surgery, 12 studies showed a significant correlation between lateral spread response resolution and disappearance of spasm. Four of six studies that evaluated the outcome at 3-month follow-up showed significant relationship between LSR and outcome, so did five of six articles that assessed spasm relief at 6-month follow-up. As much as 62.5% of studies (10 of 16) showed the result at long-term follow-up (≥1-year) was not significant. CONCLUSION: Intraoperative monitoring during microvascular decompression surgery can be a useful tool to predict hemifacial spasm resolution. Though long-term outcomes of patients with LSR relief and persistence are similar, resolution of symptoms shortly after surgery will provide comfort to patients thereby improving their quality of life.

Algorithm of traumatic brain injury management at Indonesia in the COVID 19 pandemic ERA. Retrospective cohort study.

OBJECTIVES: COVID-19, a global pandemic, affects neurosurgical care in Indonesia. This study has objective to propose guideline and algorithm recommendation for the management of TBI patients during this pandemic, which can be used flexibly at neurosurgery centers, both in Indonesia and throughout the world. METHODS: We performed retrospective Cohort analysis from TBI database at tertiary public general hospitals. All neurotrauma cases from mid-February until mid-August 2020 was included in this study. The chronology of COVID-19 pandemics impact in Indonesia was defined by early period from mid-February until end of May 2020, and late period are latter. All subjects undergone the screening and perioperative measures that based on our proposes scoring system and algorithm as follows. RESULTS: There are many guidelines that explain screening methods in neurosurgery patients in general, as well as neurotrauma in particular. But here, we proposed our own scoring and screening algorithm that has been developed based on conditions in Indonesia. In total of 757 neurotrauma cases data were collected from the pandemic starts in Indonesia. DISCUSSION: Screening is a crucial initial step in this pandemic period, not only for COVID patients, but also all patients who enter the emergency room. The use of PPE is a necessity in several neurosurgery centers, especially with high COVID-19 case rates. CONCLUSION: The management of neurotrauma patients with suspected and confirmed COVID-19 requires special attention, starting from admission of the patient in ER. Rapid scoring and screening are important and the highest level of PPE is mandatory during patient care.

Telestroke strategies to enhance acute stroke management in rural settings: A systematic review and meta-analysis.

BACKGROUND: The potential of telestroke implementation in resource-limited areas has yet to be systematically evaluated. This study aims to investigate the implementation of telestroke on acute stroke care in rural areas. METHODS: Eligible studies published up to November 2019 were included in this study. Randomized trials were further evaluated for risk of bias with Cochrane RoB 2, while nonrandomized studies with ROBINS-I tool. Random effects model was utilized to estimate effect sizes, and the certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool. RESULTS: The search yielded 19 studies involving a total of 28,496 subjects, comprising of prehospital and in-hospital telestroke interventions in the form of mobile stroke units and hub-and-spoke hospitals network, respectively. Telestroke successfully increased the proportion of patients treated ≤3 hr (OR 2.15; 95% CI 1.37-3.40; I2  = 0%) and better three-month functional outcome (OR 1.29; 95% CI 1.01-1.63; I2  = 44%) without increasing symptomatic intracranial hemorrhage rate (OR 1.27; 0.65-2.49; I2  = 0%). Furthermore, telestroke was also associated with shorter onset-to-treatment time (mean difference -27.97 min; 95% CI -35.51, -20.42; I2  = 63%) and lower in-hospital mortality rate (OR 0.67; 95% CI 0.52-0.87; I2  = 0%). GRADE assessments yielded low-to-moderate certainty of body evidences. CONCLUSION: Telestroke implementation in rural areas was associated with better clinical outcomes as compared to usual care. Its integration in both prehospital and in-hospital settings could help optimize emergency stroke approach. Further studies with higher-level evidence are needed to confirm these findings.