Intraoperative mapping and preservation of executive functions in awake craniotomy: a systematic review.

Awake craniotomy (AC) allows intraoperative brain mapping (ioBM) for maximum lesion resection while monitoring and preserving neurological function. Conventionally, language, visuospatial assessment, and motor functions are mapped, while the assessment of executive functions (EF) is uncommon. Impaired EF may lead to occupational, personal, and social limitations, thus, a compromised quality of life. A comprehensive literature search was conducted through Scopus, Medline, and Cochrane Library using a pre-defined search strategy. Articles were selected after duplicate removal, initial screening, and full-text assessment. The demographic details, ioBM techniques, intraoperative tasks, and their assessments, the extent of resection (EOR), post-op EF and neurocognitive status, and feasibility and potential adverse effects of the procedure were reviewed. The correlations of tumor locations with intraoperative EF deficits were also assessed. A total of 13 studies with intraoperative EF assessment of 351 patients were reviewed. Awake-asleep-awake protocol was most commonly used. Most studies performed ioBM using bipolar stimulation, with a frequency of 60 Hz, pulse durations ranging 1-2 ms, and intensity ranging 2-6 mA. Cognitive function was monitored with the Stroop task, spatial-2-back test, line-bisection test, trail-making-task, and digit-span tests. All studies reported similar or better EOR in patients with ioBM for EF. When comparing the neuropsychological outcomes of patients with ioBM of EF to those without it, all studies reported significantly better EF preservation in ioBM groups. Most authors reported EF mapping as a feasible tool to obtain satisfactory outcomes. Adverse effects included intraoperative seizures which were easily controlled. AC with ioBM of EF is a safe, effective, and feasible technique that allows satisfactory EOR and improved neurocognitive outcomes with minimal adverse effects.

Vocalization and physiological hyperarousal in infant-caregiver dyads where the caregiver has elevated anxiety.

Co-regulation of physiological arousal within the caregiver-child dyad precedes later self-regulation within the individual. Despite the importance of unimpaired self-regulatory development for later adjustment outcomes, little is understood about how early co-regulatory processes can become dysregulated during early life. Aspects of caregiver behavior, such as patterns of anxious speech, may be one factor influencing infant arousal dysregulation. To address this, we made day-long, naturalistic biobehavioral recordings in home settings in caregiver-infant dyads using wearable autonomic devices and miniature microphones. We examined the association between arousal, vocalization intensity, and caregiver anxiety. We found that moments of high physiological arousal in infants were more likely to be accompanied by high caregiver arousal when caregivers had high self-reported trait anxiety. Anxious caregivers were also more likely to vocalize intensely at states of high arousal and produce intense vocalizations that occurred in clusters. High-intensity vocalizations were associated with more sustained increases in autonomic arousal for both anxious caregivers and their infants. Findings indicate that caregiver vocal behavior differs in anxious parents, cooccurs with dyadic arousal dysregulation, and could contribute to physiological arousal transmission. Implications for caregiver vocalization as an intervention target are discussed.

Craniopharyngioma: A lower-middle-income-country epidemiology.

OBJECTIVE: To quantify the frequency of craniopharyngiomas presenting to tertiary care neurosurgical centres, the demographics and mortality rate, and commonly presenting to neurosurgical practice. Method: Our study was a retrospective cross-sectional analysis of patients admitted at 32 neurosurgical centres between January 1, 2019, and December 31, 2019, with brain tumour. Kruskal Wallis analysis was used to determine normality; normally distributed variables were reported as means with standard deviation, while median with interquartile range was used for non-normally distributed variables. RESULTS: Of 2750 patients with brain tumours, 114 patients presented with craniopharyngioma. The median age at diagnosis was 18 years, with 42 (42.8%) patients below the age of 15, 40 (40.9%) patients aged 15-39, and 16 (16.3%) patients aged 40 and above. There were 70 (61.4%) males and 44 (38.6%) females in our cohort. Gross total resection was performed in 42(36.8%), 45 (39.5%) underwent subtotal resection, 9 (7.9%) underwent CSF diversion only, and 2 (1.8%) had a biopsy. Most of our patients 94(82.5%) presented to public hospitals, with 20 (17.5%) patients presenting to private hospitals (p=0.002). The overall survival at two years was 86.8% in patients with known outcomes, and only 10% of patients died within 30 days of surgery. CONCLUSIONS: Craniopharyngiomas comprised a small portion of all brain tumours in our region. They are more common in males and in patients from the lower socioeconomic class. These patients mainly presented to public sector hospitals, and the three highest volume centres were all public sector institutions. The overall survival rate at two years in our region is lower than in other regions.

Gender disparities in brain tumours: A Pakistan brain tumour epidemiology study analysis.

OBJECTIVE: To explore the differences in demographic, surgical, and prognostic characteristics between the two genders in patients with brain tumours in Pakistan. Method: This study was a retrospective cross-sectional analysis of patients with a histopathological brain tumour diagnosis across 32 high-volume hospitals in Pakistan. The study period was from January 1, 2019, to December 31, 2019. There were no restrictions on inclusion apart from time.. RESULTS: From 2750 patients enrolled in the study, 1605 (58.4%) were male, and 1142 (41.6%) were female . The median age amongst males was 36 (24-49), while the median age amongst females was 37 (24-48). The ratio of married to unmarried patients was 2.7:1 for females and 1.3:1 for males. Surgical treatment was carried out for 1430 (58.1%) males and 1013 (41.9%) females. The median time to surgery was 25 (4-107) days for males and 31 (5-98) days for females. The greatest disparity in tumour malignancy was in grade IV gliomas. CONCLUSIONS: Males generally have a higher incidence of brain tumours in our experience, apart from meningiomas, which favour females. The mortality rate and glioblastoma incidence rate are both higher amongst males. However, post-treatment cure is also witnessed. Sociocultural norms play a prominent role in accessing healthcare. Women are generally at a disadvantage compared to their male counterparts, which may impact reporting of brain tumour cases and treatment outcomes.

In infancy, it's the extremes of arousal that are 'sticky': Naturalistic data challenge purely homeostatic approaches to studying self-regulation.

Most theoretical models of arousal/regulatory function emphasise the maintenance of homeostasis; consistent with this, most previous research into arousal has concentrated on examining individuals' recovery following the administration of experimentally administered stressors. Here, we take a different approach: we recorded day-long spontaneous fluctuations in autonomic arousal (indexed via electrocardiogram, heart rate variability and actigraphy) in a cohort of 82 typically developing 12-month-old infants while they were at home and awake. Based on the aforementioned models, we hypothesised that extreme high or low arousal states might be more short-lived than intermediate arousal states. Our results suggested that, contrary to this, both low- and high-arousal states were more persistent than intermediate arousal states. The same pattern was present when the data were viewed over multiple epoch sizes from 1 s to 5 min; over 10-15-minute time-scales, high-arousal states were more persistent than low- and intermediate states. One possible explanation for these findings is that extreme arousal states have intrinsically greater hysteresis; another is that, through 'metastatic' processes, small initial increases and decreases in arousal can become progressively amplified over time. Rather than exclusively using experimental paradigms to study recovery, we argue that future research should also use naturalistic data to study the mechanisms through which states can be maintained or amplified over time.

Radiofrequency Thermocoagulation in Refractory Focal Epilepsy: The Montreal Neurological Institute Experience.

BACKGROUND: Radiofrequency thermocoagulation (RF-TC) is a minimally invasive ablative option for refractory focal epilepsy. METHODS: A retrospective chart review was conducted of all patients who underwent stereoelectroencephalography (SEEG)-guided RF-TC at our institution. RESULTS: Fourteen patients underwent robot-guided electrode implantation and subsequent RF-TC. After RF-TC, one of the three patients with PVNH was seizure free, one had 18 months of seizure freedom (Engel 2b), and one required temporal neocortical/PVNH resection (Engel 1a). One of the four patients with focal cortical dysplasia (FCD) was seizure free (Engel 1a), two attained seizure freedom after resection (Engel 1a and 1b), while one continues to have significant seizures (Engel 4b). One patient with cavernoma and low central area epileptogenic zone (EZ) did not benefit from RF-TC and is planned for resection. Two of the MRI-negative patients achieved seizure freedom for 3 months and 1 year, respectively, subsequently requiring resection (Engel 1a). One remains seizure free at 4 weeks. Three had seizure recurrence immediately (Engel 4b). With RF-TC alone, two patients (14%) achieved Engel 1a, two were seizure free at 1 year, one had 3 months of seizure freedom, while the rest had recurrence immediately or within a few weeks. 7/14 patients underwent secondary interventions after RF-TC. Overall, seven patients achieved Engel 1a or 1b, one each 2b and 3a, and five Engel 4b. CONCLUSION: At our institution, RF-TC is a safe ablative procedure for refractory focal epilepsy. It can serve as a segue to secondary interventions and appears promising in PVNH cases. Its role in MRI-negative cases is less clear.

The effects of green growth, environmental-related tax, and eco-innovation towards carbon neutrality target in the US economy.

This study aims to examine the nexus between green growth and carbon neutrality targets in the context of the USA while observing the role of ecological innovation, environmental taxes, and green energy. For this purpose, data were collected from 1970 to 2015 for all the variables of interest. This research utilized the quantile autoregressive distributed lag (QARDL) method due to its various benefits, such as depicting the causality patterns based on different quantiles for different variables like green growth, ecological innovation, environmental taxes, and renewable energy. The findings through the QARDL method showed that the error correction coefficient was significant and negative with the expected negative sign for the different quantiles. The findings showed a significant and negative impact of green growth, square of green growth, ecological innovation, and environmental taxes in determining the carbon dioxide (CO2) emissions for the USA's economy under the long-run estimation. Meanwhile, the outcome for the short-term estimation confirmed that the past and lagged values of CO2 emission were significantly and negatively linked with the current and lagged values of CO2 emission. On the other hand, it was found that green growth and square of green growth, ecological innovation, environmental taxes, and renewable energy played their vital role in reducing haze pollution like PM2.5. Besides, this research also covers the limitations and policy implications.

Management of paediatric glioblastoma.

Glioblastoma is rather uncommon in children, accounting for less than 5% of all paediatric brain tumours. Recent large sample size cohorts have clearly shown that extent of resection and adjuvant chemotherapy and radiotherapy impact survival. Unfortunately, this may not be the practice in a real world setting, especially in low-middle income countries (LMIC). The aim of this review is to summarize and highlight important findings from studies on paediatric glioblastoma.

Complete versus Subtotal Resection of Paediatric Craniopharyngioma.

Optimal management of craniopharyngioma is challenging and requires multidisciplinary efforts for a successful outcome. The debate over radical versus a conservative resection followed by radiotherapy, continues. Current literature reports no difference in disease freedom and overall survival between the two surgical viewpoints, and favours conservative resection and radiotherapy, leading to lower morbidity and superior functional outcomes.

Influences of environmental stressors on autonomic function in 12-month-old infants: understanding early common pathways to atypical emotion regulation and cognitive performance.

BACKGROUND: Previous research has suggested that children exposed to more early-life stress show worse mental health outcomes and impaired cognitive performance in later life, but the mechanisms subserving these relationships remain poorly understood. METHOD: Using miniaturised microphones and physiological arousal monitors (electrocardiography, heart rate variability and actigraphy), we examined for the first time infants' autonomic reactions to environmental stressors (noise) in the home environment, in a sample of 82 12-month-old infants from mixed demographic backgrounds. The same infants also attended a laboratory testing battery where attention- and emotion-eliciting stimuli were presented. We examined how children's environmental noise exposure levels at home related to their autonomic reactivity and to their behavioural performance in the laboratory. RESULTS: Individual differences in total noise exposure were independent of other socioeconomic and parenting variables. Children exposed to higher and more rapidly fluctuating environmental noise showed more unstable autonomic arousal patterns overall in home settings. In the laboratory testing battery, this group showed more labile and short-lived autonomic changes in response to novel attention-eliciting stimuli, along with reduced visual sustained attention. They also showed increased arousal lability in response to an emotional stressor. CONCLUSIONS: Our results offer new insights into the mechanisms by which environmental noise exposure may confer increased risk of adverse mental health and impaired cognitive performance during later life.

Can patients safely be admitted to a ward after craniotomy for resection of intra-axial brain tumors?

OBJECTIVE: We reviewed the safety of our practice of admitting patients who have undergone a craniotomy for resection of an intra-axial brain tumor to a floor bed instead of an ICU. We also tried to quantify the risk that patients electively admitted to the ICU would develop a problem that could not have been effectively managed on the ward. METHODS: A retrospective chart review was performed of both adult and pediatric patients who underwent craniotomy by the senior author for resection of an intra-axial brain tumor between January 2012 and December 2015. 413 patient charts were reviewed; 16 patients were omitted due to incomplete records. RESULTS: Four hundred twenty-one craniotomies (393 supratentorial, 28 infratentorial) were performed in 397 patients, 35 of whom were <18 years of age. Three hundred fifty-five patients (83%) were admitted to floor beds; 4 (1.1%) developed complications that required transfer to an ICU. None of the 4 died or had lasting disability. Sixty-six patients, 51 adults and 15 children, were admitted to the ICU after their operation. Twenty-five of these patients had an absolute indication for ICU admission: 9 required a ventilator, 14 had an EVD and 2 were medically unstable. Of the remaining 41, none developed a complication that would have required transfer to an ICU had they been on the ward. CONCLUSION: It is safe to admit almost all patients to a floor bed after craniotomy for intra-axial brain tumor resection. The risk of a catastrophic problem occurring after a 4 hour stay in the post anesthesia care unit is extremely low. Furthermore, even patients who are electively managed in an ICU are unlikely to develop problems that would lead to a worse outcome had they been in a floor bed.

Role of palliative CSF diversion in patients with intracranial metastatic disease and symptomatic hydrocephalus.

Hydrocephalus, unless treated, is one of the terminal manifestations of intracranial metastatic disease. Single lesions causing obstructive hydrocephalus are amenable to surgical resection, but in the setting of multiple lesions and communicating hydrocephalus from leptomeningeal disease, the approach to treatment is much less defined. The use of endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunting (VPS) has been described, but data is limited. In this review, we summarize the sparse data available in literature describing the use of CSF diversion for patients with metastatic disease presenting with hydrocephalus and neurological decline.

Tumour Treating Fields (TTFs) for recurrent and newly diagnosed glioblastoma multiforme.

In the last decade, significant advances have been made in Glioblastoma Multiforme treatment with the novel use of alternating electrical fields, also termed as tumour treating fields (TTFs). This modality has shown promising results in recurrent and newly diagnosed GBM patients, and according to some, may soon be considered an addition to the previously known 'trifecta' of GBM standard of care, i.e., surgery, chemo and radiation therapy.Here we review the existing data on TTF for both recurrent and newly diagnosed GBM. This review does not discuss the limitations of TTF, especially from compliance and cost point of view.

Tumour Treating Fields (TTFs) for Paediatric Brain Tumours, Brain Metastases and other Novel Applications.

Tumour treating fields (TTFs) are now FDA approved for high grade glioma treatment. Novel application of this treatment modality is being assessed for paediatric brain tumours and intracranial metastatic disease. Clinical trials are being conducted to test the efficacy of this treatment modality as adjuvant therapy to current standard of care. Here we will discuss the existing literature on TTF its role in pathologies other than GBM. In addition, aspects of safety, compliance and cost are also discussed.

Extent of resection and timing of surgery in adult low grade glioma.

Low grade glioma is a group of WHO grade II tumours including diffuse astrocytoma, oligodendroglioma, and oligoastrocytoma. Strong evidence exists in literature now to support early surgery and higher extent of safe resection in improving outcomes. In this review, we are highlighting some of the important studies done in the last few years specifically addressing timing of surgery and extent of resection.

Multiple Dural and Pial Arteriovenous Fistulae in a Twenty-Four-Year-Old Woman in the Setting of Superior Sagittal Sinus Thrombosis: Case Report and Review of Literature.

CASE: A 24-year-old woman presented with headache, nausea, and vomiting, and was found to have chronic superior sagittal sinus (SSS) thrombosis and multiple dural arteriovenous fistulae (dAVFs). Despite anticoagulant therapy and successful recanalization of her sinus, her fistulae persisted, and she developed additional separate pial arteriovenous fistulae (pAVFs). Her fistulae were treated with staged endovascular embolization, open clipping, and gamma knife radiosurgery over the course of 10 months. Complete resolution of SSS thrombosis and all arteriovenous fistulae (AVFs) was noted on cerebral angiogram performed 18 months from initial presentation. DISCUSSION: dAVFs have frequently been associated with venous sinus thrombosis. Sinus thrombosis resulting after endovascular or surgical treatment of dural arteriovenous fistulous connections has been reported in literature and is considered a possible complication of treatment. Multiple dAVFs and pAVFs are rare and often require multimodal staged approaches for definitive treatment. CONCLUSION: We report a case of chronic sagittal sinus thrombosis resulting in multiple AVFs requiring staged multimodal treatment with successful resolution of the fistulous connections. Furthermore, upon reviewing the literature addressing multiple dAVFs and the treatment of such lesions using endovascular, microsurgical, and stereotactic radiosurgery techniques, we elucidate the success a multimodal approach to therapy can afford for the unique challenges associated with multiple lesions.

Early Intervention and Use of Autologous Grafts in Growing Skull Fractures Results in Better Outcomes: Experience From a Tertiary Pediatric Neurosurgery Center.

BACKGROUND AND OBJECTIVES: Growing skull fracture (GSF) is a rare complication of pediatric head trauma. Definitive treatment is surgical repair. We have attempted to assess whether use of autologous grafts for duraplasty and cranioplasty leads to better outcomes. We have also attempted to understand how timing of surgery might affect the degree of underlying damage to cortical tissue. METHODS: This is a single-center retrospective observational study based on review from the Great Ormond Street Hospital Neurosurgery prospective surgical database. All patients undergoing surgery for GSF repair between 1991 and 2015 were included. Surgical techniques included split calvarial grafts in 4 patients, whereas rest had full-thickness bone grafting. In all cases with full-thickness graft, the donor site was covered with morselized bone chips mixed with fibrin glue (Salami technique). RESULTS: Twenty-eight patients were identified (16 males, 12 females). The average age at the time of injury was 13 months. The mean duration of onset of symptoms from the time of injury was 4.4 months. The time interval from symptom onset to surgical repair was 5.92 months. Seven patients had Type I GSF (leptomeningeal cyst with minimal brain parenchyma), 13 had type II (hernia containing gliotic brain), and 8 had type III (porencephalic cyst extending through the skull defect into subgaleal space). Patients with delayed presentation had severe brain injury (Type III) and had more long-term complications (refractory epilepsy requiring temporo-occipito-parietal disconnection and development of hydrocephalus requiring ventriculoperitoneal shunt insertion). CONCLUSION: Autologous pericranium for duraplasty and split-thickness bone graft or the Salami technique are recommended for cranioplasty. Synthetic materials should be used if the index operation fails or there are complications. Patients with high-risk findings should be identified at the time of initial presentation and followed up in clinic early to prevent onset of neurological deficit. Early repair is associated with better neurological outcomes.

AB083. Epilepsy and low-grade glioma-seizure control after surgical resection: a retrospective cohort study.

BACKGROUND: Seizures are a common manifestation in patients with low grade glioma (60-75%), and 60-90% patients attain seizure freedom after resection. Seizure control varies with histopathology, extent of resection and type of seizures. There is inconsistency in literature regarding utility of anti-epileptic drugs (AEDs) after tumor resection. We aimed to determine factors associated with seizure control in patients after low-grade glioma (LGG) resection. METHODS: It was a retrospective cohort study. Medical record of all patients who underwent LGG resection at our center from 2019 to 2021 were reviewed; 77 patients fulfilled the selection criteria. Patients were also contacted via phone calls to collect information about their seizure control as per Engel Classification. Data was analyzed using SPSSv21. RESULTS: The mean age was 34.9±11.3 years, and there was male predominance (62; 80.5%). Generalized seizures were the most common type (54; 70%), and Levetiracetam was the most commonly prescribed AED (60; 77.9%). The median duration of pre-operative AED use was 4 [interquartile range (IQR): 1-24] months. Frontal lobe was the most common location of tumor (36; 46.8%). Most of the patients had their surgery under general anesthesia (51; 61.4%), while 29 (37.7%) underwent awake craniotomy. Nearly half of the patients had a gross total resection (31; 40.3%), and another 15 (19.5%) had near-total resection. Sixteen patients (20.8%) had their AEDs stopped within first 6 months post-operatively (at variable intervals), and all of them had Engel Class IA to ID control at time of follow-up (P=0.008). The 12 patients with grade I glioma also had optimum seizure control (P=0.03). CONCLUSIONS: Patients with grade I glioma have better seizure control after surgery. Tumor biopsy is associated with worse seizure outcome, though not statistically significant. Larger studies are needed to determine the ideal time and patient group for discontinuing AED after surgery.

AB076. Underutilization of epilepsy surgery in Pakistan: 10-year experience from the only comprehensive epilepsy center in the country.

BACKGROUND: Eighty percent of the global epilepsy burden is borne by developing countries, and 30% of these patients have drug-resistant epilepsy (DRE). Epilepsy surgery (ES) can significantly improve the cognition and quality of life in DRE. A comprehensive epilepsy center was established in Pakistan in 2010, the only facility for ES in a country of 231 million people. Hundreds of epilepsy patients are medically managed at the center each year. We aimed to study seizure control in all ES cases performed at the only comprehensive epilepsy center in the country during last 10 years. METHODS: It was a retrospective cohort study. Medical records of all cases of ES performed at our center from 2012 to 2021 were retrieved, through the Hospital's Information Management System. Patients were also contacted via phone calls where needed, to collect information about their seizure control as per Engel Classification. Data was analyzed using SPSSv21. RESULTS: Thirty-three surgeries including 10 temporal lobectomies with amygdalohippocampectomy, 11 selective amygdalohippocampectomies, 9 corpus callosotomies, 1 callosotomy with lesionectomy, 1 lesionectomy and 1 temporal lobectomy were performed. The median age of patients was 23: [18-31] years. Complex partial seizures were most common (14; 42.4%), followed by generalized seizures (10; 30.3%). The median duration of AEDs before surgery was 6 (IQR: 3.25-13.75) years. Eighteen (54.5%) patients had complete freedom from disabling seizures (Engel Class IA) at a median follow-up of 3.25 (IQR: 1.12-6) years. All patients continued to receive antiepileptic drugs after surgery, and all procedures had nearly 50% optimum seizure control outcomes. CONCLUSIONS: The clinical outcomes of ES performed at our center are consistent with evidence. However, the small volume highlights the underutilization of this extremely important service. More studies are needed to identify the factors responsible for this disparity, so that all DRE patients have access to ES.