Fluorescence-Guided versus Conventional Surgical Resection of High Grade Glioma: A Single-Centre, 7-Year, Comparative Effectiveness Study.

BACKGROUND: High grade gliomas (HGGs) are locally invasive brain tumours that carry a dismal prognosis. Although complete resection increases median survival, the difficulty in reliably demonstrating the tumour border intraoperatively is a norm. The Department of Neurosurgery, Hospital Sungai Buloh is the first public hospital in Malaysia to overcome this problem by adopting fluorescence-guided (FG) surgery using 5-aminolevulinic acid (5-ALA). METHODS: A total of 74 patients with histologically proven HGGs treated between January 2008 and December 2014, who fulfilled the inclusion criteria, were enrolled. Kaplan-Meier survival estimates and Cox proportional hazard regression were used. RESULTS: Significant longer survival time (months) was observed in the FG group compared with the conventional group (12 months versus 8 months, P < 0.020). Even without adjuvant therapy, HGG patients from FG group survived longer than those from the conventional group (8 months versus 3 months, P = 0.006). No significant differences were seen in postoperative Karnofsky performance scale (KPS) between the groups at 6 weeks and 6 months after surgery compared to pre-operative KPS. Cox proportional hazard regression identified four independent predictors of survival: KPS > 80 (P = 0.010), histology (P < 0.001), surgical method (P < 0.001) and adjuvant therapy (P < 0.001). CONCLUSION: This study showed a significant clinical benefit for HGG patients in terms of overall survival using FG surgery as it did not result in worsening of post-operative function outcome when compared with the conventional surgical method. We advocate a further multicentered, randomised controlled trial to support these findings before FG surgery can be implemented as a standard surgical adjunct in local practice for the benefit of HGG patients.

Depiction of Cerebral Aneurysm Wall by Computational Fluid Dynamics (CFD) and Preoperative Illustration.

Introduction Preoperative illustration is a part of an important exercise to study the configuration, direction, and presence of any perforations, and is the weakest point in the wall of the cerebral aneurysm. The same illustration is used to study the surrounding brain structures to decide the best and safe surgical approach prior to any surgical procedure. With the evolution of the aneurysm wall study and study of flow dynamic within the involved artery and its aneurysm wall using computational fluid dynamics (CFD), a better surgical plan can be formulated to improve the flow dynamics. As one of the clinical applications of CFD, we propose a study using a composite image that combines preoperative illustration and CFD, which is traditionally widely used in neurosurgery. Methods and Materials We study the use of illustrations of the unruptured cerebral aneurysm of internal carotid-posterior communicating (ICPC) artery and anterior communicating artery (AcomA) treated at our hospital. The combinations of both preoperative illustrations and CFD images by using "ipad Pro" were used. Result and Conclusion Medical illustration in the preoperative study of unruptured cerebral aneurysm with combinations of CFD and surrounding brain structures is helpful to decide the surgical approaches and successful surgical treatments.

Preoperative 3D Image Evaluation of EC-IC Bypass by 3D Visualization Analysis Software Amira®.

Background: Careful evaluation of the preoperative imaging for extracranial-intracranial bypass performed for conditions like intracranial stenosis and Moya disease is important. The traditional use of 2D imaging has a significant limitation for neurosurgeons, primarily to determine the optimal location of the recipient artery for performing the surgical bypass. Therefore, many neurosurgeons use 3D angiograms more frequently to overcome these shortcomings. Materials And Methods: We performed the preoperative evaluation of the possibility of performing an anastomosis between the superficial temporal artery and the middle cerebral artery (STA-MCA) bypass by synthesizing images of computerized tomography (CT), magnetic resonance imaging (MRI), and digital subtraction angiography (DSA) using Amira® of 3D visualization analysis software (Thermo Scientific Co.). Results: The 3D images prepared before surgery using this software showed good agreement with the intraoperative findings. Conclusion: Preoperative image processing using tools like Amira provide optimal information for good planning and communication for performing STA-MCA bypass and may become a helpful tool.

Acute Spontaneous Cervical Spinal Epidural Haematoma a Very Rare Presentation Mimicking of Carotid Dissection during Sleep.

Acute spontaneous spinal epidural hematoma without any identified etiology is a rare phenomenon and an uncommon cause of acute spinal cord compression. We report a case of acute spontaneous cervical spinal epidural hematoma, with sudden onset of acute neck pain and left-side body weakness during sleep which resembling of cervicle carotid dissection. The pain commenced suddenly, early in the morning while the patient was asleep. He had no previous history of any relevant medical disorder. Cervical Spine MRI revealed a cervical epidural haematoma at C3/C4, mainly on the left side, with spinal cord compression. Therefore, an emergent C3/C6 hemilaminectomy and evacuation of hematoma were carried out within 24 h of presentation. The patient's neck pain resolved after surgery and he was able to walk, though he required bladder catheterization on discharge after 1 week. He has nearly intact motor neurological examination in the second month of the operation.

Women in Neurosurgery (WIN): Barriers to Progress, World WIN Directory and the Way Forward.

Women in Neurosurgery (WIN) have come a long way and are making inroads in every neurosurgical subspecialty. There has been a worldwide increase in the number of female neurosurgeons both in the training and practice. Although this is a welcome trend, gender equality at work in terms of opportunities, promotions, and pay scales are yet to be attained. This is more apparent in the developing and underdeveloped nations. Barriers for a female neurosurgeon exist in every phase before entering residency, during training, and at workplace. In the neurosurgical specialty, only a few women are in chief academic and leadership positions, and this situation needs to improve. WIN should be motivated to pursue fellowships, sub-specialty training, research, and academic activities. Furthermore, men should come forward to mentor women, only then the gender debates will disappear and true excellence in neurosurgery can be attained. This article reviews the issues that are relevant in the present era focusing on the barriers faced by female neurosurgeons in the developing and underdeveloped countries and the possible solutions to achieve gender equality in neurosurgery. The authors also present the data from the World WIN Directory collected as a part of Asian Congress of Neurological Surgeons-WINS project 2019. These numbers are expected to grow as the WIN progress and add value to the neurosurgical community at large.

High-Flow Bypass with Radial Artery Graft for Cavernous Carotid Aneurysms: A Case Series.

BACKGROUND: The incidence of cavernous carotid aneurysms (CCAs) of intracranial aneurysms is low. Majority of cases presented as incidental findings with benign natural progression. The most common presenting symptoms are multiple cranial neuropathies among symptomatic patients. The treatment modalities for symptomatic patients include direct surgical clipping, endovascular coil embolization, or placement of flow diverter, or indirect procedures such as occlusion of parent artery with and without revascularization techniques. The advancement in the microsurgical treatments and endovascular devices have enable a high success rate in the treatment of patients with CCAs with low morbidity and mortality rates. OBJECTIVE: To study the surgical outcomes of patients with cavernous aneurysm who underwent high-flow bypass between 2015 and 2020 in our institution. MATERIALS AND METHODS: A total of six patients in a single institution presented with CCAs who were treated with high-flow bypass surgery were included in this case-series. A single-case illustration was presented focusing on the details of surgical case management of CCA. The intraoperative middle cerebral artery (MCA) pressure monitoring during bypass surgery was also described. RESULTS: All five female patients and one male patient who were diagnosed with cavernous carotid aneurysms were studied. The mean age was 68.8 years old (range: 24-84 years old) and the mean size of the aneurysm was 19.6mm (range: 9.7 - 30mm). There were successfully treated with high flow bypasses using radial artery graft without any neurological sequelae. CONCLUSION: The surgical treatments of cavernous carotid aneurysms should be limited to experienced neurosurgeons in view of significant risk of morbidity and mortality. Endovascular procedures may be the main stay of treatments. The success shown in this case series with parent artery occlusion and bypass surgery may provide an safe alternative to the endovascular treatment.

Current Updates on Idiopathic Normal Pressure Hydrocephalus.

Idiopathic normal pressure hydrocephalus (iNPH) is one of the neurodegenerative diseases which can be treated surgically with favorable outcome. The gait disturbance, cognitive, and urinary symptoms are known as the clinical triad of iNPH. In this review, we have addressed the comorbidities, differential diagnoses, clinical presentations, and pathology of iNPH. We have also summarized the imaging studies and clinical procedures used for the diagnosis of iNPH. The treatment modality, outcomes, and prognosis were also discussed.

Expert Consensus on the Management of Brain Arteriovenous Malformations.

Brain arteriovenous malformations (bAVMs) are complex, heterogeneous, and uncommon intracranial lesions. They can be treated by one or a combination of the following treatment modalities, namely embolization, radiosurgery, or microsurgical resection. In Spetzler-Martin Grade 4 and 5 arteriovenous malformations (AVMs), conservative management may be the best option. A group of experts in the management of AVMs of different disciplines gathered in January 2019 in Hanoi to compile the "Expert Consensus on the Management of Brain Arteriovenous Malformations".

A randomized, multicenter, open-label trial to establish therapeutic equivalence between the Carex and ultra disconnect systems in patients on continuous ambulatory peritoneal dialysis.

OBJECTIVE: In the present study, we undertook to establish therapeutic equivalence with respect to peritonitis and technique failure between the Carex disconnect system (B. Braun Carex, Mirandola, Italy) and the standard Ultra system (Baxter Healthcare, Tokyo, Japan) in patients on continuous ambulatory peritoneal dialysis (CAPD). DESIGN: This multicenter, parallel group, randomized controlled trial involved 363 prevalent CAPD patients from 8 centers. The primary endpoint was peritonitis rate; secondary endpoints were technique failure and technical problems encountered. The duration of the evaluation was 1 year. RESULTS: The risk of peritonitis on Carex varied between the centers. We found a significant treatment-center interaction effect (likelihood ratio test: p = 0.03). The incidence rate ratio (IRR) of peritonitis on Carex as compared with Ultra ranged from 0.4 to 7.2. In two centers, Carex was inferior to Ultra with regard to peritonitis; but, in five centers, the results were inconclusive. Equivalence was not demonstrated in any center. The overall rate of peritonitis in the Carex group was twice that in the Ultra group [IRR: 2.18; 95% confidence interval (CI): 1.51 to 3.14]. Technique failure and technical problems were more common with the Carex system. Technique failure rate at 1 year was 44% in the Carex group and 22% in the Ultra group. CONCLUSIONS: Equivalence between the Carex disconnect system and the Ultra disconnect system could not be demonstrated. The risk of peritonitis on Carex varied significantly between centers.