Utility of cell index in the diagnosis of healthcare-associated ventriculitis and meningitis: an analytical cross-sectional study.

BACKGROUND: The diagnosis of healthcare-associated ventriculitis and meningitis (HCAVM) can be complex because multiple factors confound the interpretation of cerebrospinal fluid (CSF) tests. The cell index (CI) may help in the diagnosis of HCAVM. It does not incur additional medical cost and it avoids delays from the turnaround time of CSF cultures. It is derived by calculating the ratio of CSF white blood cell (WBC) and red blood cell (RBC) divided by the ratio of peripheral WBC and RBC. This study aimed to evaluate the diagnostic utility of this parameter. METHODS: An analytic, observational, cross-sectional study was conducted at the University of the Philippines - Philippine General Hospital. All admitted pediatric and adult patients from 2015 to 2022 who underwent external ventricular drain (EVD) insertion for hydrocephalus secondary to intracranial hemorrhage (ICH), acute ischemic stroke, intracranial neoplasms, traumatic brain injury, or congenital hydrocephalus were screened. Records of patients fulfilling the inclusion criteria were then reviewed. RESULTS: A total of 363 patients underwent EVD insertion from 2015 to 2022. Of these, 161 were included in the study. Two-thirds (66.5%) were adults ≥ 19 years old whereas the remaining were pediatric patients 1 to < 19 years old. There were no patients < 12 months old as they fulfilled at least one exclusion criteria. Forty-nine of them were later confirmed to have HCAVM based on the CDC/NHSN criteria. A CI cut-off of ≥ 1.21 gave a maximum sensitivity of 30.6% and specificity of 86.4%. Receiver operating characteristic area under the curve (AUC-ROC) analysis was 0.585. Subgroup analysis by age showed sensitivity of 52.9% in the pediatric age group and 3.13% in adults. Subgroup analysis by neurologic indication showed sensitivity of 27.6% for ICH and 35.0% for neoplasms. Subsequent AUC-ROC analyses, however, showed that CI failed to adequately diagnose HCAVM in these subgroups. CONCLUSIONS: In our population of neurologic patients who underwent EVD insertion, the cell index is not a reliable parameter in the diagnosis of HCAVM.

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

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

Pediatric fibromyxoid brachial plexus tumor with YWHAZ::PLAG1 gene fusion: a case report.

Pediatric fibromyxoid soft tissue tumors may be associated with gene fusions such as YHWAZ::PLAG1, with only three reported cases in the literature. We present the fourth case, a 13-year-old male with a pediatric fibromyxoid brachial plexus tumor with YWHAZ::PLAG1 gene fusion. This is also the first case to be reported in an adolescent, in the brachial plexus, and in the Philippines. The patient presented with a 10-year history of a slowly growing left supraclavicular mass and a 1-year history of intermittent dysesthesia in the left upper extremity. Neurologic examination was unremarkable. Imaging revealed a large left supraclavicular lesion with intrathoracic extension. Surgical excision was performed, and histopathology revealed a fibromyxoid tumor with YWHAZ::PLAG1 gene fusion. Although previous examples of this gene fusion pointed toward lipoblastoma as their primary pathology, our tumor does not completely fulfill the current diagnostic criteria for a lipoblastoma and may represent an intermediate form of the disease. Our case is unique not only because it is the first reported adolescent patient harboring such a lesion but also because of the relatively lengthy natural history exhibited by the tumor prior to its resection. This provided us with valuable information about its behavior, which suggests a more indolent growth pattern. This case also highlights the clinical importance of molecular testing of tumors, where recognition of disease entities can assist clinicians in deciding and advocating for the proper management.

Establishing and developing a magnetic resonance-guided focused ultrasound program in a resource-limited setting: the Philippine experience.

Magnetic resonance-guided focused ultrasound (MRgFUS) is a non-invasive lesioning technique used to treat movement disorders such as essential tremor (ET), Parkinson's disease (PD), and X-linked dystonia-parkinsonism (XDP). We would like to report our experience in establishing and developing our MRgFUS program and preliminary results. Adult patients with tremor-dominant PD (TDPD), ET, and XDP were considered for initial screening (neurologic evaluation, skull density ratio [SDR] determination). Eligible patients underwent secondary screening (neurosurgical and neuropsychological evaluation, psychiatric and medical clearance). During the procedure, a neuro-anesthesiologist and neurologist were also present to monitor the patient and perform neurologic evaluation, respectively. Clinical follow-up was scheduled at 2 weeks post-treatment, then at every 3 months. A total of 30 patients underwent MRgFUS treatment: 22 TDPD, 6 XDP, and 2 ET. The mean age was 55.7 years, and majority were male (86.7%). Mean disease duration was 8.6 years. Mean SDR was 0.46. The targets for TDPD and ET were the contralateral ventral intermediate nucleus of the thalamus; for XDP, it was the pallidothalamic tract. The mean maximum temperature was 59.8oC; number of sonocations, 7.3; and treatment time, 64.6 min. Majority of patients improved after the procedure. Transient intraprocedural adverse events (headache, dizziness) were reported in 20% of patients while post-procedural events (mild weakness, numbness) were seen in 16.7%. Only 26.7% of patients had follow-up data. Despite the unique challenges encountered, MRgFUS treatment is feasible in resource-limited settings. Additional steps would have to be made to develop and improve the program.

Transcranial magnetic resonance-guided focused ultrasound pallidothalamic tractotomy for patients with X-linked dystonia-parkinsonism: a study protocol.

Transcranial magnetic resonance-guided focused ultrasound (MRgFUS) is a noninvasive method for controlling tremor and has recently been used in patients with X-linked dystonia-parkinsonism (XDP). This study aims to determine the improvement in dystonia and parkinsonism in patients with XDP after MRgFUS pallidothalamic tractotomy. This prospective study will be conducted at the Philippine General Hospital, University of the Philippines Manila. The primary outcome measure is the change in the pre- and post-treatment XDP-Movement Disorder Society of the Philippines Scale scores. In addition, demographic and clinical data will be collected, including the Burke-Fahn-Marsden Dystonia Rating Scale, Part III of the Movement Disorder Society-Unified Parkinson's disease Rating Scale score, XDP clinical and functional stage, the five-level EuroQol five-dimensional questionnaire, Montreal Cognitive Assessment scores, MRgFUS treatment parameters, and adverse events. Patients will be assessed within 24 hours of treatment, then at 2 weeks, 3 months, 6 months, 9 months, and 12 months post-treatment. This protocol was approved by the University of the Philippines Manila Research Ethics Board (UPMREB 2022-0271-01). Data collection began in January 2023. This protocol has been registered with ClinicalTrials.gov: Trial Registration number: NCT05592028.

Patient-reported intraoperative experiences during awake craniotomy for brain tumors: a scoping review.

Awake craniotomy (AC) is a neurosurgical procedure that may be used to excise tumors located in eloquent areas of the brain. The techniques and outcomes of AC have been extensively described, but data on patient-reported experiences are not as well known. To determine these, we performed a scoping review of patient-reported intraoperative experiences during awake craniotomy for brain tumor resection. A total of 21 articles describing 534 patients were included in the review. Majority of the studies were performed on adult patients and utilized questionnaires and interviews. Some used additional qualitative methodology such as grounded theory and phenomenology. Most of the evaluation was performed within the first 2 weeks post-operatively. Recollection of the procedure ranged from 0 to 100%, and most memories dealt with the cranial fixation device application, cranial drilling, and intraoperative mapping. All patients reported some degree of pain and discomfort, mainly due to the cranial fixation device and uncomfortable operative position. Most patients were satisfied with their AC experience. They felt that participating in AC gave them a sense of control over their disease and thought that trust in the treatment team and adequate pre-operative preparation were very important. Patients who underwent AC for brain tumor resection had both positive and negative experiences intraoperatively, but overall, majority had a positive perception of and high levels of satisfaction with AC. Successful AC depends not only on a well-conducted intraoperative course, but also on adequate pre-operative information and patient preparation.

A meta-analysis on the prevalence of anxiety and depression in patients with unruptured intracranial aneurysms: exposing critical treatment gaps.

Unruptured intracranial aneurysms (UIAs) are a significant cause of anxiety and depression. Though the annual rupture rate is relatively low, ensuing mortality and morbidity may be high. Most published studies have focused on functional outcomes; however, limited studies have explored and reported on psychiatric outcomes, which are equally important. We aimed to review existing data on anxiety and depression in patients with UIAs. We systematically searched the databases of Pubmed, Cochrane, Scopus, EBSCOHOST, and ClinicalTrials.gov for studies that reported on anxiety and depression in patients with UIAs. Where available, we also reported data on aneurysm characteristics, treatment modalities, and functional outcomes of these populations. We performed a meta-analysis of proportions by random-effects modeling to compute the prevalence of anxiety and depression in patients with UIAs. Eighteen studies reporting a total of 1413 patients with UIAs were included in the systematic review. The mean age was 57.8 (range 27-79); 64% of whom were female. Random-effect modeling analysis showed an overall estimated prevalence of 28% [95% CI: 0.17-0.42] for anxiety and 21% [95% CI: 0.13-0.33] for depression among patients with UIAs. No significant difference was found in the prevalence of these conditions between treated vs untreated aneurysms. Our review highlights the heterogeneity of data from existing studies and the lack of standardized methodologies in determining psychiatric outcomes in patients with UIAs. It was also limited by the small sample sizes and patient counseling bias in the included studies. Larger, well-designed epidemiologic studies on patients with UIA should include more representative samples, assess for predictors of psychological outcomes, and explore the most optimal psychiatric assessment tools.

Intraventricular Bone Dust Migration after Endoscopic Third Ventriculostomy: Illustrative Report of 2 Cases.

INTRODUCTION: Autologous bone dust replacement is a commonly used technique to seal a defect created from a burr hole. However, postoperative migration of these bone fragments may occur as an uncommon complication of endoscopic third ventriculostomy (ETV). CASE PRESENTATION: We report 2 cases of intraventricular bone dust migration resulting in acute hydrocephalus from physical obstruction of the stoma and infection. DISCUSSION/CONCLUSION: From our 2 cases as well as other reported cases, the bone dust may have acted as a foreign body and served as a nidus of infection, in addition to causing physical obstruction. A lumbar puncture performed after ETV may have resulted in a suction effect of the bone dust from the burr hole into the ventricular system. Both our cases necessitated urgent surgical intervention to extract the bone fragments and restore CSF flow. Because of its potential complications, we recommend against using autologous bone dust for closure of a burr hole defect after ETV.

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

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

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

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

Neurosurgery in the elderly: Findings from a cohort in the Philippines.

BACKGROUND: Better living conditions and health care advancements have improved life expectancy worldwide, increasing the number of older patients who require neurosurgery. We would like to report our experience with geriatric neurosurgical patients at our institution. METHODS: This is a retrospective study on geriatric patients (aged ≥ 65 years) who underwent neurosurgery at our center between 2015 and 2022. Data on age, sex, comorbidities, pre-morbid status, type of admission, diagnosis, operation, complications, short-term outcome, hospital length of stay (LOS), and 30-day readmission were collected. Descriptive statistics and multiple regression analysis were used. RESULTS: A total of 327 patients were included. The mean age was 70.4 years and 51.3 % were female. Majority (70.6 %) had at least one comorbid condition, most commonly hypertension. Most patients were admitted through emergency systems (80.1 %), with 40.4 % consulting for traumatic brain injury. The top diagnoses were chronic subdural hematoma (35.2 %), ruptured intracerebral aneurysm (15.6 %), and meningioma (10.1 %). The most common procedures were burrhole drainage of hematoma (34.8 %), brain tumor excision (16.7 %), and aneurysm clipping (14.6 %). The post-operative complication rate was 15.2 %, and mean LOS was 16.7 days. Majority of patients (86.9 %) were discharged home, and 2.8 % were readmitted within 30 days. The 30-day mortality rate was 13.1 %. Lower pre-operative GCS, certain comorbidities, and intra- and post-operative complications were significantly associated with mortality and LOS. CONCLUSION: Advanced age alone should not be a contraindication to surgery; other factors such as frailty and comorbid conditions should also be considered. Proper patient selection and preoperative preparation are key to achieving good outcomes.

External ventricular drain migration into the cisterna magna: A case report.

Background: External ventricular drain (EVD) insertion is a common neurosurgical procedure used to treat acute hydrocephalus. In this report, we present a rare case of an EVD that was initially correctly placed within the frontal horn but subsequently migrated to the cisterna magna, the first to be reported in the literature. Case Description: A 46-year-old man with postoperative meningitis and hydrocephalus underwent EVD insertion using an improvised EVD system. The EVD was also used as a route for the administration of intraventricular antibiotics. The patient was restless and agitated during his treatment, causing him to move his head frequently. Serial computed tomography scans showed that the EVD was initially correctly placed within the frontal horn and then migrated to the cisterna magna. Conclusion: Inward catheter migration is a rare complication of EVD insertion and is an important concern since it may cause neurologic deficits and potentially harmful sequelae. We have also highlighted measures that can be taken to prevent a similar event in the future.

Adult idiopathic bilateral occlusion of foramen of Monro: Systematic review with illustrative case.

BACKGROUND: Adult idiopathic occlusion of foramen of Monro (AIOFM) is a rare condition that results in hydrocephalus, and bilateral presentation is even rarer. Here we report a case of idiopathic bilateral stenosis of the foramen of Monro in an adult patient and performed a systematic literature review on the current treatment options and outcomes. METHODS: We performed a systematic review of SCOPUS, Science Direct, and PubMed databases in accordance with PRISMA guidelines. Data on demographics, clinical presentation, imaging findings, type of AIOFM, treatment, and outcomes were collected. RESULTS: A total of 22 cases of bilateral AIOFM were identified in the literature, including ours. The median age was 38.5 years (range: 20-53), with no sex predilection. The most common presenting symptoms were headache (n=16, 73%) and vomiting (n=10, 45%). There were 9 cases of Type 1 AIOFM (stenosis) and 13 cases of Type 2 (membrane occlusion). Majority of patients underwent surgical treatment, mostly endoscopic unilateral foraminoplasty and septostomy (59%), followed by ventriculoperitoneal shunt insertion (31%). One patient underwent medical management only to alleviate her presenting symptoms (seizures). The overall outcome was good for majority of patients at a median follow-up of 6 months. CONCLUSION: Bilateral AIOFM is a rare condition that may easily be missed, so neurosurgeons should be cognizant of this disease entity. Identification of the type of AIOFM may guide surgical decision-making. Treatment options include neuroendoscopic procedures such as septostomy and foraminoplasty, and ventriculoperitoneal shunt insertion.

Challenges and Opportunities in Awake Craniotomy for Brain Tumor Surgery in Low- and Lower-Middle-Income Countries: A Narrative Review and Perspective.

BACKGROUND: Low-income countries (LICs) and lower-middle-income countries (LMICs) are presented with unique challenges and opportunities when performing awake craniotomy (AC) for brain tumors. These circumstances arise from factors that are financial, infrastructural, educational, personnel, and sociocultural in nature. METHODS: We performed a systematic narrative review of series on AC for intra-axial brain tumors in LICs/LMICs using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, focusing on the challenges and opportunities in these settings. The PubMed, Scopus, and Web of Science databases were searched. RESULTS: After initially identifying 74 studies, inclusion-exclusion criteria were applied, leaving a total of 14 studies included in the review. These involved 409 patients who underwent AC in LICs/LMICs. These series were from India, Ghana, Nigeria, Iran, Pakistan, Morocco, the Philippines, and Egypt. The most common pathology encountered were gliomas (10-70%). Most studies (11/14, 78.5%) reported on their technique of cortical-subcortical mapping. All reported on motor mapping and 8 of these performed language mapping. The most common outcomes reported were seizure and neurologic deficits, and longest follow-up was at 1 year. Challenges noted were lack of equipment and trained personnel, need for validated tests for the local setting, and sociocultural factors. Opportunities identified were volume for training, technique innovation, and international collaboration. CONCLUSIONS: There are numerous challenges and opportunities that arise when performing AC in LICs/LMICs. A collaborative approach toward harnessing the opportunities, and seeking creative solutions to address the challenges, would provide an ideal mechanism toward advancing neurosurgical care and specialty worldwide.

Cortical mapping in multilinguals undergoing awake brain surgery for brain tumors: Illustrative cases and systematic review.

BACKGROUND: Awake brain mapping in multilingual patients with brain tumors presents unique challenges to the neurosurgeon. Knowledge of potential eloquent sites is vital to preserve language function. METHODS: We present two cases of pars opercularis glioma and perform a systematic review in accordance with PRISMA guidelines. RESULTS: Our review yielded 7 studies, with a total of 25 multilingual brain tumor patients who underwent awake brain mapping. The age ranged from 25 to 62 years. Majority were female (56.5%). Most (52%) were trilingual, while 20% were quadrilingual and 28% were pentalingual. All tumors were left-sided, mostly in the frontal lobe. These were predominantly gliomas. Extent of resection was gross total in 61%. The brain mapping findings were heterogeneous. Some authors reported a greater number of cortical sites for the first language compared to others. Others found that the first and second languages shared cortical sites whereas the third and subsequent languages were located in distant sites. The peri-Sylvian area was also found to be involved in language that was learned at an earlier age. Subsequent languages thus involved more distant sites. A larger number of cortical areas were also activated for languages that were learned later in life. In terms of language disturbance and recovery, there were mixed results. CONCLUSION: Cortical mapping in multilingual brain tumor patients showed heterogeneity in terms of the location and number of language areas in the face of pathology. These findings may influence neurosurgical and oncological management of tumors in the speech area but emphasize the need to tailor surgical approaches and intraoperative testing to the patient.

Time to Care: Analysis of Time Differences and Outcomes in the Management of Pediatric Traumatic Brain Injury for a High-Income and Lower-Middle-Income Country.

BACKGROUND: Pediatric cranial trauma is the leading cause of acquired death and disability in children worldwide. However, trauma resources vary widely among countries. We sought to compare management and timely access to care between a level 1 U.S. pediatric trauma center and a tertiary referral hospital in a lower-middle-income country to assess whether system and resource differences influence care and outcomes. METHODS: We compared data from 214 pediatric head trauma admissions to Philippine General Hospital (Manila) with 136 children from the TRACK-TBI pediatrics study cohort at Massachusetts General Hospital (MGH). Admitted MGH patients were compared with the Philippine cohort regarding demographics; mechanism of injury; times to neurosurgical consult, imaging, and surgery; in-hospital mortality; and length of hospitalization. RESULTS: Age (9 years), gender distribution (67% male), and presenting Glasgow Coma Scale scores were similar (P = 0.10) between sites. More children had intracranial injury in the Philippine cohort (73% vs. 60%; n = 319) and more underwent neurosurgery (27% vs. 4%). Times to consult, imaging, and surgery were longer in the Philippines (12.3 vs. 6.5, 12.0 vs. 2.8, and 45.4 vs. 5.6 hours, respectively). In-hospital mortality across all admissions was similar between cohorts (3% vs. 0%; P = 0.09), but significantly higher in the most severe Philippines cases (31% vs. 0%, P=0.04). Length of stay was longer (5 vs. 2 days; P < 0.001) in the Philippine cohort. CONCLUSIONS: High-income country status correlated with faster care, shorter hospitalizations, and better outcomes among severe cases. Prompt care through sophisticated trauma system implementation may improve pediatric health in resource-limited settings.

Volume specific response criteria for brain metastases following salvage stereotactic radiosurgery and associated predictors of response.

BACKGROUND: We aimed to derive three-dimensional volume-based (V(3D)) response criteria that approximate those based on Response Evaluation Criteria in Solid Tumours (RECIST) in patients with brain metastases (BM) treated with salvage stereotactic radiosurgery (SRS). MATERIAL AND METHODS: Seventy patients with 178 BM were treated with SRS. Each BM was characterised at baseline and at each follow-up MRI according to its widest diameter and V(3D) using ITK-SNAP image segmentation software. RESULTS: The median tumour diameter was 1.2 cm (range, 0.2-4.5 cm) and V(3D) was 0.73 cm(3) (range, 0.01-22.7 cm(3)). The V(3D) percent changes that best matched RECIST response criteria were: an increase of ≥71.5% for progressive disease, a ≥58.5% decrease for partial response and a <58.5% decrease or increase of <71.5% for stable disease (k =0.85). A baseline diameter >3.0 cm (p =0.006) and a V(3D) >6.0 cm(3) (p =0.043) predicted for local failure, and a baseline cumulative V(3D) of >3.0 cm(3) (p =0.02) was adversely prognostic for survival. CONCLUSIONS: We define 3D volume specific criteria to base response upon for brain metastases treated with salvage SRS. Tumours with a V(3D) of greater than 6 cm(3) are at a higher risk of local failure.

Resources for Operative Neurosurgical Education Among Trainees in the Philippines.

BACKGROUND: Operative neurosurgical skills education is a vital part of neurosurgical training, and these skills are usually obtained through operating room experience and supplemented by textbooks and other resources. We aimed to determine the resources used by trainees in the Philippines, both prior to and after the onset of the coronavirus disease 2019 pandemic. METHODS: An online survey was sent to neurosurgical trainees in the Philippines from January to March 2021. Data on demographics, educational resources used, and weekly hours spent on each were collected, for both the pre- and post-coronavirus disease 2019 periods. RESULTS: A total of 37 neurosurgical trainees (60% response rate) participated in the survey. Most respondents were female (70%), in their senior levels (58%), and undergoing training in a public institution (65%). The main resources for operative neurosurgical education were operative experience, online academic resources, and neurosurgical textbooks. After the onset of the pandemic, the overall time spent decreased to 61.2 hours/week from 67.7 hours/week, with a significant reduction in the hours spent on operative experience (27.3 vs. 21.3 hours/week, P < 0.0001) and a significant increase in the time spent on webinars (0 vs. 3.2 hours/week, P < 0.0001) and online resources as a whole (14.9 vs. 16.4 hours/week, P = 0.0003). CONCLUSIONS: Operative experience, online academic resources, and neurosurgical textbooks were the main resources for operative neurosurgical education among trainees in the Philippines. After the onset of the pandemic, the hours spent on operative experience decreased and online academic resources increased significantly. New avenues of neurosurgical education, particularly webinars, also became available locally.