Cost of Healthcare Services in Geriatric Neuro-oncology: A descriptive Analysis.

BACKGROUND: The percentage of brain tumor incidence exceeds 50% in the geriatric population admitted at Khoula Hospital (a tertiary care hospital in Oman) as compared to the younger population, furthermore, geriatric patients impose a higher cost of healthcare in general. Therefore, geriatric tumor care is causing a significant burden on the healthcare service in Oman. For this reason, we have developed this study to identify the cost of care for this group. METHODS: Medical data with their costs were collected retrospectively for 108 patients diagnosed with a brain tumor above the age of 65 years and admitted at Khoula Hospital between 2016 and 2019. RESULTS: The two most common diagnoses in terms of incidence were Meningiomas (31.73%) and Glioblastomas (16.34%). Lymphoma peaked with regards to the cost, with an average cost of 8993.83 USD per diagnosis, followed by glioblastoma and then metastatic lesions (with 5039.18 and 4915.76 USD respectively). Of these surgeries, 82.61% were elective, most of which had a cost above or equal to the average. Emergency surgeries showed equal numbers above and below the average cost of surgeries (P< 0.05). The total costs of imaging were 73759.4 USD, with CT (35.8%) + MRI (32.9%) forming 68.7% of the total imaging costs. While laboratory investigation costs totaled 64110.93 USD. CONCLUSION: The cost of tumor care in Oman is variable based on multiple factors. The reported results represent useful information forming the basis for further analysis such as cost-benefit analysis, cost-effectiveness analysis, and cost-utility analysis.

Trends in Stereotactic Radiosurgery for Meningioma: the Top 100 Most Cited Articles.

BACKGROUND: Stereotactic radiosurgery is a well-known and influential management option for meningioma. This article aims to highlight the most cited publications on this topic. METHODS: All Scopus articles published in English under Stereotactic radiosurgery and meningioma were sorted according to the number of citations. The keywords used were: "Stereotactic radiosurgery, SRS, Meningioma, Intracranial meningioma". The top 100 cited articles meeting the criteria were included. Certain features of these articles were collected and analyzed using Microsoft Excel and SPSS. RESULTS: The included articles were published between 1991 and 2020 with a total of 9149 citations. The most cited article is "Meningiomas: Knowledge base, treatment outcomes, and uncertainties. A RANO review" by Rogers L. et al. 2015 with 349 citations. No significant association was found between the number of citations and the impact factor of the publishing journal. CONCLUSION: This study gives a concise and updated summary of impactful research on stereotactic radiosurgery and meningioma, highlighting the main contributors and scientific connections.

Cost Associated with Geriatric Traumatic Brain Injury in Developing Countries: An Observational Study.

BACKGROUND: Traumatic brain injury (TBI) in the geriatric population is a serious public health problem and has a huge impact on mortality and morbidity. METHODS: A retrospective cohort study including patients aged above 65 admitted to a tertiary specialized trauma center, in the period from January 2016 to 31 December 2019. The data collected include patients' demographics, diagnosis, Glasgow Coma Scale (GCS) on arrival, length of stay, investigations, and type of surgery done. RESULTS: Total number of TBI cases in our study is 145. The most frequent single diagnosis was subdural hematoma (85). Subsequently, it was the costliest diagnosis with an average cost of 3569 USD per patient. Length of stay on average was 17.11 ± 41 hours, with the majority (109 patients) having nonprolonged hospital stay (<14 days). Most of those managed by observation have below-average costs compared to other patients (P < 0.001). Complete blood count was the highly requested test with a total cost 5070 $ in the study period. And head computed tomography had the highest total cost 58,864 $. 21 craniotomies and 30 burr holes were made with a total cost of 30,000 and 25,325 respectively. Patients with lower GCS (64.6%) have below-average hospitalization costs compared to those who got high GCS scores (P < 0.001). CONCLUSIONS: This study provides the first estimates of the financial burden of Geriatric TBI in the region, which signifies the importance of developing strategies to prevent TBIs and help in resource allocation and healthcare policy formation.

Metformin use is associated with longer survival in glioblastoma patients with MGMT gene silencing.

PURPOSE: New treatments are needed to improve the overall survival of patients with glioblastoma Metformin is known for anti-tumorigenic effects in cancers, including breast and pancreas cancers. In this study, we assessed the association between metformin use and overall survival in glioblastoma patients. METHODS: We retrospectively studied 241 patients who underwent surgery at diagnosis of glioblastoma between 2014 and 2018. Metformin was used for pre-existing type 2 diabetes mellitus or in the prevention or management of glucocorticoid induced hyperglycemia. Kaplan-Meier curves and log-rank p test were used for univariate analysis. Cox-proportional hazards model was used to generate adjusted hazard ratios for multivariate analysis. RESULTS: Metformin use was associated with longer survival in patients with tumors that had a methylated O6-methylguanine DNA methyltransferase gene (MGMT) promoter (484 days 95% CI: 56-911 vs. 394 days 95% CI: 249-538, Log-Rank test: 6.5, p = 0.01). Cox regression analysis shows that metformin associates with lower risk of death at 2 years in patients with glioblastoma containing a methylated MGMT promoter (aHR = 0.497, 95% CI 0.26-0.93, p = 0.028). CONCLUSION: Our findings suggest a survival benefit with metformin use in patients with glioblastomas having methylation of the MGMT promoter.

Awake Craniotomy Surgery in Pediatrics: A Systematic Review.

BACKGROUND: Awake craniotomy is a unique method to prevent motor deficits during the resection of lesions located in or close to functional areas. We sought to study the outcomes of pediatric craniotomy on published studies. METHODS: The search for articles was performed through multiple search engines: PubMed, Google Scholar, Web of Science, and Wiley. The following search terms were used for screening the titles and abstracts: "awake brain surgery" and "children" or "pediatrics," "awake craniotomy," and "children" or "pediatrics," "pediatrics awake craniotomy," "awake brain surgery pediatrics," and "tumors." On initial screening of the titles and abstracts, 54 articles were found. After a thorough review of the full texts of obtained articles and removing duplicates, 16 articles remained. RESULTS: The mean age group was 12.23 years. There was a slight difference between genders who underwent awake craniotomy in the pediatric age group, 52.7% male and 47.3% for female. Tumor resection was the most common indication of the surgery. Almost half (47.9%) experienced complete recovery following the surgery. However, of those who had complicated recovery, 7.5% experienced a speech deficit. CONCLUSIONS: This systematic review summarized that awake brain surgery can prevent significant motor and language deficits postoperatively in children after tumor resection as it is considered a feasible and safe procedure.

Characterization of perioperative glycemic status and dexamethasone use with associated postoperative complications in glioblastoma patients.

PURPOSE: Postoperative morbidity in glioblastoma (GBM) patients can be due to the disease course but can also come from postoperative complications. Our objective was to study the association of dexamethasone use and perioperative hyperglycemia with postoperative complications in GBM patients. METHODS: A single-center, retrospective cohort study was conducted in patients who underwent surgery for primary GBM from 2014-2018. Patients with perioperative fasting blood glucose (FBG) measurements and adequate follow-up to assess for complications were included. RESULTS: A total of 199 patients were included. More than half (53%) had poor perioperative glycemic control (FBG ≥ 7 mM for ≥ 20% perioperative days). Higher dexamethasone dose (≥ 8 mg) was associated with higher FBG on postoperative days 2-4 and 5 (p = 0.02,0.05,0.004,0.02, respectively). Poor glycemic control was associated with increased odds of 30-day any complication and 30-day infection on univariate analysis (UVA), and 30-day any complication and increased length of stay (LOS) on multivariate analysis (MVA). Higher average perioperative daily dexamethasone dose was associated with increased odds of 30-day any complication and 30-day infection on MVA. Elevated hemoglobin A1c (HgbA1c, ≥ 6.5%) was associated with increased odds of 30-day any complication, 30-day infection, and LOS on UVA. In a multivariate linear regression model, only the diagnosis of diabetes mellitus predicted perioperative hyperglycemia. CONCLUSIONS: Perioperative hyperglycemia, higher average dexamethasone use and elevated preoperative HgbA1c are associated with increased risk of postoperative complications in GBM patients. Avoiding hyperglycemia and limiting dexamethasone use in postoperative period may decrease the risk of complications. Select HgbA1c screening may allow the identification of a group of patients at higher risk of complications.

Selection of Neurosurgical Applicants in the High-Income Developing Country Lacking Local Residency Program: A Cross-Sectional Study.

Background Neurosurgery residency became one of the most competitive specialties in the medical field worldwide, which is increasing with time in contrast to the limited positions. Therefore, the requirements for the program have increased. There are different criteria for each program, which are determined by specific factors. It has become increasingly important for medical students to be aware of the factors that affect their acceptance into the program. There was a lack of data regarding the factors that contribute to the selection of neurosurgery residents in Oman Methods A questionnaire composed of 14 questions was conducted, using the SurveyMonkey Web site, among neurosurgeons in Oman which was distributed to the five hospitals that have neurosurgery departments in Oman. SPSS software was used in the analysis of the collected data. Results Forty-four participants responded to the survey. Ninety-five percent of them answered all the questions. Out of all participants, only two were female participants. Standardized international exam scores, such as the United State Medical Licensing Examination and Medical Council of Canada Qualifying Examination, ranked as the most important factor with a percentage of 44, followed by interview performance with a percentage of 33. While the least important factor was the age of applicants, which 46% of the participants ranked 8. Conclusion Most of the participants agreed that standardized exams are the most important factor in the selection of neurosurgery residents followed by interview performance, although there was no significant statistical difference between the two.

Subtle magnetic resonance imaging differences in tegmental pilocytic astrocytomas as a caution against attempting gross-total resection: illustrative cases.

BACKGROUND: Although surgery within the tegmentum of the midbrain is challenging, resection of tegmental pilocytic astrocytomas (PAs) is a standard treatment because this has been shown to outperform chemotherapy and radiotherapy in terms of long-term tumor control. Gross total resection (GTR) assisted by intraoperative neuroelectrophysiological monitoring can be achieved with a reasonable risk-to-benefit ratio, especially for well-circumscribed tumors, but careful scrutiny of magnetic resonance imaging (MRI) is critical to surgical decision making. The authors present two cases of tegmental PAs, which appeared grossly similar on MRI and were operated on via the same surgical approach using the same intraoperative adjuncts. OBSERVATIONS: The tumors had identical histopathological and molecular diagnoses but drastically different functional outcomes for the patients, with significant long-term complications for one of the children, which the authors believe was due to a slightly more invasive nature of this tumor. The authors demonstrate subtle preoperative MRI findings that might be potential clues to a more infiltrative nature of one PA versus another and present pathological findings supporting this argument. LESSONS: This report serves as a reminder that not all tegmental PAs can be managed by the same surgical approach. Subtle signs of infiltration may indicate that GTR should not be attempted.

The Top 100 Most Cited Neurosurgical Articles on COVID-19: A Bibliometric Analysis.

BACKGROUND: The first case of coronavirus disease 2019 (COVID-19) was reported in December 2019 in Wuhan, China. This study uses a bibliometric analysis of the top 100 most cited neurosurgical COVID-19-related articles to date to identify and determine their characteristics. METHODS: The Scopus library was searched for all published articles on neurosurgery and COVID-19. The main keywords were used for the search "neurosurgery, neurosurgical, and COVID-19". English language articles reporting on neurosurgical aspects during COVID-19 were included in the study. The retrieved top 100 articles were analyzed, and the following characteristics were noted for each article: 1) article title, 2) year of publication, 3) citations, 4) first author, 5) corresponding author, 6) names of other authors, 7) journal name 8) article type, 9) study focus and 10) involvement of the patient. RESULTS: Our search obtained articles published from December 2019 until 29 March 2022. It was observed that 93% of the documents were published in 2020. The top 100 articles have been cited 2649 times in total. The most cited article was "Factors Associated with Surgical Mortality and Complications among Patients with and without Coronavirus Disease 2019 (COVID-19) in Italy" by Doglietto F. et al., published in JAMA Neurology in June 2020, with 124 citations. CONCLUSIONS: This analysis facilitated in making evidence-based clinical decisions and drawing the attention of researchers to identify and contribute to the increasing scientific work by identifying the top 100 most cited neurosurgical COVID-19-related articles published.

Anti-Epileptic Drugs in Geriatric Neurosurgery: A Review of 669 Neurosurgical Cases.

Background and Purpose: Patients over the age of 75 are more likely to develop epilepsy than children under the age of 10. Patients of all ages are prescribed anti-epileptic drugs; however, those over the age of 65 are the most typically prescribed group. Methods: This is a retrospective study of geriatric cases admitted to the Neurosurgery Department in Khoula Hospital from January 1, 2016 to December 31, 2019. A medical records of 669 patients were identified. Patients' demographics, risk factors, usage of anti-epileptic drug (AED), type of tumor, tumor location, neuro-vital signs diagnosis, Glasgow coma scale on arrival, treatment types, and length of stay (LOS) were recorded. Results: The prevalence of AEDs use was 19%. Patients with traumatic brain injury (TBI) were found to have a higher rate of using AEDs (32.1%) followed by patients with oncological and vascular pathologies, respectively (30.1% and 21.6%). There was a significant relationship between the utilization of AEDs among different neurological diseases investigated (p<0.05). Patients who received surgical interventions were using AEDs much more than patients with conservative management (p=0.001). There was a significant difference in the LOS and the usage of AEDs. Added to that, the results signify a relationship between the intensive care unit (ICU) admission and the utilization of AEDs in which the majority of the patients who were not on AEDs were not admitted to the ICU (p<0.05). Phenytoin was the most commonly used AED among different neurosurgical pathologies in the present study (n=110). Conclusions: AEDs are used as prophylaxis to prevent seizures before most neurosurgical procedures and were commonly prescribed in TBI patients. Phenytoin was found to be the commonest AEDs utilized among the different neurosurgical categories followed by levetiracetam.

Intracranial Hemorrhage following Spinal Surgery: A Systematic Review of a Rare Complication.

Introduction Intracranial hemorrhage (ICH) is a potentially severe complication of spinal surgeries. The occurrence of such complications causes deterioration of the patient's clinical status and delayed discharge from the hospital. Although no specific etiological factors were identified for this complication, but multiple risk factors might play role in its development, they include the use of anticoagulants, presence of uncontrolled hypertension, and perioperative patient positioning. Aim A systematic review of the literature to investigate the prevalence of different types of intracranial hemorrhages in patients who underwent spinal surgeries. Methods A literature review was conducted using multiple research databases. Data were extracted using multiple variables that were formulated incongruent with the study aim and then further analyzed. Results A total of 79 studies were included in our analysis after applying the exclusion criteria and removing of repeated studies, 109 patients were identified where they were diagnosed with intracranial hemorrhage after spine surgery with a mean age of 54 years. The most common type of hemorrhage was cerebellar hemorrhage (56.0%) followed by SDH and intraparenchymal hemorrhage; 23.9 and 17.4%, respectively. The most common spine surgery was laminectomy (70.6%), followed by fixation and fusion (50.5%), excision of spinal lesions was done in 20.2% of the patient, and discectomy (14.7%). Conclusion The data in this study showed that out of 112 patients with ICH, cerebellar hemorrhage was the most common type. ICH post-spine surgery is a rare complication and the real etiologies behind this complication are still unknown, cerebrospinal fluid drain and durotomy were suggested.

Cerebral Venous Sinus Thrombosis in Closed Head Injury: Systematic Review and Meta-analysis.

BACKGROUND: Cerebral venous sinus thrombosis (CSVT) is a rare condition, causing 0.5% of all strokes only, several mechanisms might be involved in forming the thrombosis, including closed head injury. METHODS: Systematic review was done by using the following databases: PubMed, Google Scholar, Microsoft Academic, Clinical Trials, Cochrane Library, and Web of Science. RESULTS: 25 articles met our criteria out of 152 articles, average and standard deviation of the age was 38.2 ± 16.8 years with an age range of 18-82. The majority of cases presented with loss of consciousness or decreased GCS (41%), followed by headache (26%), scalp abrasions/lacerations (21%), paralysis (18%), visual disturbance (18%), nystagmus (15%), and agitation (15%). The most commonly used diagnostic method was angiography. Thrombosis was the most frequently reported radiological finding among all the cases (26/34, 76%). Comparisons of outcomes between patients who underwent surgical intervention and those who did not undergo surgery revealed a significant difference in outcome favoring non-surgical treatment (p < 0.005, odds ratio (OR) 0.04, (95% CI) 0.003 - 0.30). CONCLUSION: Non-surgical outcomes were better than the surgical outcomes. However, no significant difference was seen comparing anti-coagulation versus conservative management (supportive without anticoagulation), single versus multi-sinuses (≥2 sinuses) involvement, and between any of the sinuses involved.

Systemic Review and Meta-analysis of the Intellectual Integrity of Children with Neurofibromatosis Type 1.

BACKGROUND: Cognitive impairment is a common neurologic complication of neurofibromatosis type 1 (NF-1) in childhood. A great number of learning disabilities appear in 30%-65% of children with NF-1. The aim of the study is to compare intelligence quotient (IQ) scores between children with NF-1 and comparable control groups. METHODS: A literature review was conducted using the following databases: Cochrane, PubMed, Wiley, Microsoft Academic, and Google Scholar. We identified 180 papers. The pertinence of any study to the inclusion criteria was determined by assessing the title, key words, and abstracts. Data were extracted using multiple variables that were formulated incongruent with the study aim and then further analyzed. RESULTS: Eleven articles met our criteria, with the highest level of evidence of 3c. A total of 483 NF1 and 443 control participants were included in this meta-analysis. The average and standard deviation of the age was 9.15 ± 3.15 years with an age range of 3.3-18 including 488 male and 438 female. The pooled estimate of the mean difference in all 3 parameters used full-scale IQ, verbal IQ, and performance IQ. Statistically, there was a significantly lower IQ in the NF-1 group compared with the control group with a 95% CI and (P < 0.00001). CONCLUSION: The current meta-analysis illustrated a significant intellectual deficit in children with NF-1 compared with their typically developed peers who were matched by age. Performance IQ was significantly impaired compared with verbal IQ in NF-1 children. The current findings may guide experts to tailor individualized educational programs for children with NF-1.

Geriatric Neuro-Oncology in the Middle East: A Sultanate of Oman Experience.

Brain tumors are primary or metastatic malignancies of the central nervous system (CNS) with significant morbidity and mortality. The overall prevalence of cancer including brain cancer has increased by more than 10% according to the National Institute of cancer statistics. The average percent increase in primary brain tumor incidence for ages 75-79, 80-84, and 85 and older were 7%, 20.4%, and 23.4%, respectively. This manuscript describes a retrospective study of geriatric cases admitted to the Neurosurgical Department in Khoula Hospital (KH) and diagnosed with brain cancer from 1 January 2016 to 31 December 2019. Of the study cohort, 58.5% were more than 75 years of age. The male-to-female ratio was (1:1.1). Meningiomas are found to be the commonest tumor (52.8%) followed by glioblastoma (GBM) (18.9%). Most of the patients had a Glasgow coma scale (GCS) score of 14-15 on admission (69.9%). Patients diagnosed with a non-meningioma tumor had lower GCS score on admission compared to meningioma patients with statistical significance (p = 0.04). Also, there was a significant difference between the length of stay (LOS) and the type of intervention (surgical vs. conservative), in which patients received a conservative type of management found to have a shorter length of stay (LOS) compared with the patients who underwent surgical intervention (p < 0.005). In Oman, the number of geriatric oncology cases remained stable over the 4 years. The incidence of geriatric neuro-oncology cases was higher in patients aged more than 75 years of age. Finally, the GCS score was affected by the type of tumor. The length of stay varies according to the treatment administered. Special care must be taken when dealing with geriatric neuro-oncological cases due to the high potential rate of mortality and morbidity among those group, and a more holistic approach is recommended as an essential need to evaluate the overall situation of those patients and manage them accordingly.

Invasive growth associated with cold-inducible RNA-binding protein expression drives recurrence of surgically resected brain metastases.

BACKGROUND: Sixty percent of surgically resected brain metastases (BrM) recur within 1 year. These recurrences have long been thought to result from the dispersion of cancer cells during surgery. We tested the alternative hypothesis that invasion of cancer cells into the adjacent brain plays a significant role in local recurrence and shortened overall survival. METHODS: We determined the invasion pattern of 164 surgically resected BrM and correlated with local recurrence and overall survival. We performed single-cell RNA sequencing (scRNAseq) of >15,000 cells from BrM and adjacent brain tissue. Validation of targets was performed with a novel cohort of BrM patient-derived xenografts (PDX) and patient tissues. RESULTS: We demonstrate that invasion of metastatic cancer cells into the adjacent brain is associated with local recurrence and shortened overall survival. scRNAseq of paired tumor and adjacent brain samples confirmed the existence of invasive cancer cells in the tumor-adjacent brain. Analysis of these cells identified cold-inducible RNA-binding protein (CIRBP) overexpression in invasive cancer cells compared to cancer cells located within the metastases. Applying PDX models that recapitulate the invasion pattern observed in patients, we show that CIRBP is overexpressed in highly invasive BrM and is required for efficient invasive growth in the brain. CONCLUSIONS: These data demonstrate peritumoral invasion as a driver of treatment failure in BrM that is functionally mediated by CIRBP. These findings improve our understanding of the biology underlying postoperative treatment failure and lay the groundwork for rational clinical trial development based upon invasion pattern in surgically resected BrM.

Surgical Management of Isolated Fourth Ventricular Hydrocephalus Associated with Injury to the Guillain-Mollaret Triangle.

BACKGROUND: The occurrence of isolated fourth ventricle and injury to the Guillain-Mollaret triangle in the setting of posterior fossa ependymoma represents a new association. In this case report, we discuss the clinical, theoretical, and therapeutic aspects of this problem. We describe a lateral transcerebellar trajectory and shunt valve configuration for safe fourth ventricle shunting in a patient with prior posterior fossa surgery. CASE DESCRIPTION: A 45-year-old woman underwent subtotal resection of a fourth ventricle ependymoma (World Health Organization grade III) followed by radiation therapy to control the residual tumor. Her course was complicated by a cerebral abscess and subsequent communicating hydrocephalus, for which she received a lateral ventriculoperitoneal shunt. After placement of the lateral ventricle shunt, there was a progressive increase in the volume of the fourth ventricle over the next 2 years, from 2.5 to 12.0 mL. She developed palatal myoclonus, hand incoordination, bilateral foot numbness, and progressive ataxia. Neuroimaging also revealed hypertrophic degeneration of the inferior olivary nuclei bilaterally. The isolated fourth ventricle was treated by a separate fourth ventriculoperitoneal shunt inserted through a lateral transcerebellar trajectory. A programmable variable pressure valve was implemented. CONCLUSIONS: Development of an isolated fourth ventricle and injury to the Guillain-Mollaret triangle in the setting of fourth ventricular ependymoma is a newly encountered complication. Choice of treatment modality and timing of intervention should be carefully considered on a case-by-case basis. The data presented in this report may assist in the selection of surgical treatment for isolated fourth ventricle.