Outcomes of central nervous system tuberculosis in Saudi Arabia: a multi-center study.

OBJECTIVES: Central nervous system tuberculosis (TB) (CNS-TB) can occur in several forms, including intracranial tuberculoma, tuberculous brain abscess, TB meningitis (TBM), and spinal TB. Early treatment can save lives and prevent severe neurological complications. This study aimed to describe the characteristics and post-treatment outcomes of patients with CNS-TB and identify factors associated with poor outcomes. To the best of our knowledge, this is the largest CNS-TB study till date published in Saudi Arabia. METHODS: This retrospective cohort study included all patients diagnosed with CNS-TB in three tertiary centers in Saudi Arabia (King Abdulaziz Medical City in Jeddah, King Abdulaziz Medical City in Riyadh, and Al-Noor Specialist Hospital in Makkah) between 2009 and 2019. Data of patients' demographics, co-morbidities, presenting symptoms, type of CNS-TB, medical and surgical treatments, and outcome after completion of treatment were obtained from medical records. Treatment outcomes were categorized using the modified Rankin Scale for neurological disability. RESULTS: A total of 140 participants were included in this study from 2009 to 2019. Good outcomes were achieved in approximately 65% of cases, whereas 35% had poor outcomes based on the modified Rankin Scale. Glasgow Coma Scale score ≤10 at presentation and TBM/tuberculoma were significantly associated with poor outcomes. Moreover, the use of corticosteroids, more than three anti-TB medications, and surgical interventions were not significantly associated with good or poor outcomes. DISCUSSION: CNS-TB is associated with a high burden of long-term neurological morbidity. Early detection and treatment are crucial to prevent serious complications and decrease morbidity and mortality.

Extracranial metastasis of brain glioblastoma outside CNS: Pathogenesis revisited.

BACKGROUND: The most prevalent malignant tumor of the CNS in adults is glioblastoma. Despite undergoing surgery and chemoradiotherapy, the prognosis remains unfavorable, with a median survival period ranging between 15 and 20 months. The incidence of glioblastoma metastasis outside CNS is uncommon with only 0.4%-2% reported rate, compared to other tumors that exhibit a 10% incidence rate of metastasis to the brain. On average, it takes about 11 months from the time of initial diagnosis for the tumor to spread beyond CNS. Consequently, the prognosis for metastatic glioblastoma is grim, with a 6-month survival rate following diagnosis. FINDINGS: The rarity of extracranial metastasis is attributed to the blood-brain barrier and lack of a lymphatic drainage system, although rare cases of hematogenous spread and direct implantation have been reported. The possible mechanisms remain unclear and require further investigation. Risk factors have been widely described, including previous craniotomy or biopsies, ventricular shunting, young age, radiation therapy, prolonged survival time, and tumor recurrence. Due to the lack of understanding about extracranial metastasis of glioblastoma pathogenesis, no effective treatment exists to date. Aggressive chemotherapies are not recommended for metastatic glioblastoma as their side effects may worsen the patient prognosis. CONCLUSION: The optimal treatment for extracranial metastasis of glioblastoma requires further investigation with a wide inclusion of patients. This review discusses the possible causes, factors, and underlying mechanisms of glioblastoma metastasis to different organs.

Major Histocompatibility Class-I (MHC-I) downregulation in glioblastoma is a poor prognostic factor but not a predictive indicator for treatment failure.

BACKGROUND: MHC-I expression is a crucial factor in cancer immunity, and its regulations can impact tumor progression and recurrence. The mechanism through which glioblastoma use MHC-I to avoid immunosurveillance has been rarely investigated. METHODS: A retrospective cohort of 35 patients with IDH-mutant WHO-Grade 4 astrocytoma and IDH-wildtype glioblastoma were examined for MHC-I using protein and gene expression assays. The association between IDH mutation, TP53 mutation, and MHC-I expression with recurrence-free interval were investigated. RESULTS: The average patients' age was 49.6 year. IDH was wildtype in 13 tumors. MHC-I protein expression was absent in 30 tumors, faint in 4 tumors, and membrane bound dense expression in single tumor. MHC-I expression was upregulated in 10 tumors and 25 tumors showed MHC-I downregulation. P53 was positively expressed in 19 cases and lost in 13 cases. A significant statistical difference was observed in the RFI between tumors with distinct MHC-I expression and IDH-mutation [p-value = 0.008]. IDH-wildtype tumors with upregulated MHC-I expression showed late tumor recurrence compared to IDH-wildtype tumors with downregulated MHC-I expression. There was insignificant statistical difference in RFI among patients with varying degree of MHC-I expression, who received TMZ or TMZ and other chemotherapies [P-value = 0.44] CONCLUSIONS: Glioblastoma with upregulated MHC-I showed a delayed tumor recurrence in comparison to those with downregulated MHC-I expression. However, downregulated MHC-I may not necessarily be an indicator of poor problems.

Dynamic interplay between corticosteroid treatment and the role of SRC-1 gene dysregulation in the progression of WHO-Grade 4 Astrocytoma.

BACKGROUND: Corticosteroid is commonly used before surgery to control cerebral oedema in brain tumours and is frequently continued throughout treatment. Its long-term effect of on the recurrence of WHO-Grade 4 astrocytoma remains controversial. The interaction between corticosteroid, SRC-1 gene and cytotoxic T-cells has never been investigated. METHODS: A retrospective cohort of 36 patients with WHO-Grade 4 astrocytoma were examined for CD8 + T-cell and SRC-1 gene expressions through IHC and qRT-PCR. The impact of corticosteroid on CD8+T-cells infiltration, SRC-1 expression, and tumour recurrence was analyzed. RESULTS: The mean patients age was 47-years, with a male to female ratio 1.2. About 78% [n = 28] of the cases showed reduced or no CD8+T-cell expression while 22% [n = 8] of cases have showed medium to high CD8+T-cell expression. SRC-1 gene was upregulated in 5 cases [14%] and 31 cases [86%] showed SRC-1 downregulation. The average of total days and doses of administered corticosteroid from the preoperative period to the postoperative period was at range of 14-106 days and 41-5028 mg, respectively. There was no significant statistical difference in RFI among tumours expressing high or low CD8+T-cells when corticosteroid was administered in recommended or exceeded doses [p-value = 0.640]. There was a significant statistical difference in RFI between CD8+T-Cell expression and SRC-1 gene dysregulation [p-value = 002]. Tumours with high CD8+T T-cell expression and SRC-1 gene downregulation had late recurrence. CONCLUSIONS: Corticosteroid treatment can directly affect the SRC-1 gene regulation but does not directly influence cytotoxic T-cells infiltration or tumor progression. However, SRC-1 gene downregulation can facilitate late tumor recurrence.

Remote Cerebellar Hematoma Following Supratentorial Craniotomy: A Case Report.

Remote cerebellar hemorrhage (RCH) is a rare complication following supratentorial craniotomies with unclear pathophysiology, predisposing factors, and clinical outcomes. This is a case of a 46-year-old female who presented to the emergency room with a complaint of severe headache associated with nausea. MRI studies demonstrated right frontal lesions consistent with low-grade glioma. She underwent a right frontal craniotomy, and the tumor was resected successfully. She developed a severe headache on postoperative day five, and CT scans showed ipsilateral cerebellar hematoma. She was managed conservatively and made a complete recovery within five days. Although rare, RCH requires prompt recognition, neurological monitoring, and management. Medical management and observation may be considered for patients without mass effect or acute hydrocephalus.

Primary spinal epidural rhabdomyosarcoma: A case report.

Background: Rhabdomyosarcoma (RMS) is a malignant childhood tumor that most commonly involves the skeletal muscles of the head and neck, genitourinary tract, limbs, and, rarely, the spine. Case Description: A 19-year-old male presented with cauda equina symptoms. Magnetic resonance imaging showed a C7/T1 homogeneously enhancing lesion, causing pathological fracture of the T1. Similar lesions were found on T3 and S1-S2 levels. CT-guided biopsy and immunohistochemistry confirmed the diagnosis of highly malignant alveolar RMS. He underwent multi-level laminectomies with partial tumor debulking but was paraplegic postoperatively. Conclusion: Spinal RMS rarely involves the soft tissues of the spine and should be surgically resected if feasible. Nevertheless, the long-term prognosis is poor regarding tumor recurrence and metastases.

The Top-100 most cited articles on dural arteriovenous fistula: A bibliometric analysis.

OBJECTIVE: Dural arteriovenous fistula (DAVF) is a rare pathological vascular lesion with variable clinical manifestations. Since 1968, several articles have been published to address spinal and cranial DAVFs. The aim of this study is to identify, analyse, and review the pertinent literature of the top-100 most cited articles on DAVFs published to date. METHODS: A title-specific, keyword-based search with no time restriction was performed in June 2020. The Scopus database was used to identify the top-100 most cited articles on DAVFs. The term "dural arteriovenous fistula" was used as a search keyword. The search results were arranged in descending order based on the total citation count. The top-100 articles were categorized into ten categories. RESULTS: Between 1968 and 2020, a total of 2298 articles were published on DAVFs. The top-100 most cited articles were published between 1983 and 2012. The total number of citations for the top-100 articles was 12393 (123 citations/article). Most articles (34%) were investigating the clinical aspect of DAVFs. The country contributing to the most impactful and highest volume of publications (46%) was the United States. The Mayo Clinic was the most active institute in contribution. Most articles (29%) were published by the Journal of Neurosurgery. CONCLUSIONS: In the top-100 most cited articles on DAVF, most studies were published in neurosurgery/neuroradiology-dedicated journals. This bibliometric analysis identifies the publication trends and provides a comprehensive overview of the most influential articles addressing DAVFs.

Assessment of Different Modalities and Their Impact on Patients with Ruptured Intracranial Arteriovenous Malformation Treated in King Abdulaiziz Medical City in Jeddah, Saudi Arabia.

Background Intracranial arteriovenous malformation (AVM) is a rare congenital disease that is characterized by an abnormal tangle of blood vessels where arteries abnormally shunt into veins with no intervening capillary bed. Several treatment modalities, such as microsurgical removal, embolization, and stereotactic radiosurgery (SRS), are used to treat AVM either solely or in combination. We aimed to assess and compare the effect, morbidity, and mortality outcomes of mono-treatment with embolization and combined treatment for AVM obliteration. Methodology This retrospective cohort study was conducted in the National Guard Hospital Jeddah and reviewed all the AVM patients that visited the center between 2008 and 2017. We assessed presenting symptoms at diagnosis and any co-morbidities as the clinical characteristics and the patients' AVM and Spetzler-Martin grade as the morphological characteristics. Moreover, we performed a three-year follow-up on suitable patients and assessed their outcomes using the modified Rankin Scale. In addition, we performed follow-up imaging on the patients to evaluate AVM obliteration after any of the procedures. Results We included 29 patients treated in our hospital (72.4%, males; 27.6%, females; mean age 40 years). About 65% of the patients underwent mono-therapy consisting of one or more embolization sessions while about 34% underwent combined treatment (embolization + surgery or embolization + SRS). We found more cases of complete obliteration among patients who underwent mono-therapy (52.6%) than among those who underwent combined treatment (30%). Patients who underwent mono-therapy showed better outcomes compared to those who underwent combined therapy; however, the difference did not reach statistical significance. Conclusions Embolization mono-therapy appears to be more effective with regards to the obliteration rate and outcome compared to combined therapy with either SRS or surgery in patients treated in our center.

Smoking behaviour after enforcement of a 100% tax on tobacco products in Saudi Arabia: a cross-sectional study.

BACKGROUND: Raising the prices of cigarettes is a common intervention to control tobacco use. In June 2017, Saudi Arabia imposed a 100% excise tax on tobacco products and energy drinks. AIMS: This study aimed to evaluate the impact of the increase in prices on tobacco products and the resulting cigarette smoking behaviour in Jeddah, Saudi Arabia before and after the increase in tobacco product prices. METHODS: This cross-sectional study was conducted between December 2017 and March 2018 in Saudi Arabian smokers aged 18 years and more. A validated questionnaire was distributed to a convenience sample in public places and through Twitter. The McNemar matched pairs chi-squared test was used to evaluate the self-reported difference in cigarette smoking before and after the tax came into effect. Binary logistic regression analysis was done to identify the socioeconomic and health factors associated with stopping smoking. RESULTS: In all, 376 participants (80.0% men) completed the questionnaire. A large proportion of the participants (39.6%) reported no change in their smoking behaviour after the tax was imposed, whereas 29.8% switched to cheaper brands. Before the tax, 154 participants smoked 15 cigarettes or more a day; this figure decreased to 134 after the tax (McNemar test, P < 0.001). Respondents who were married, unemployed, had a higher income or who rated their health as fair were significantly more likely to have stopped smoking after the tax. CONCLUSION: The sharp increase in cigarette prices in Saudi Arabia has led to a statistically significant reduction in smoking. Future research should assess the long-term effects of this intervention on smoking onset, prevalence and relapse.

A case report of retrograde intussusception 3 years post Roux-en-Y gastric bypass.

Retrograde jejuno-jejunal intussusception is a rare complication of bariatric surgeries. It causes acute sudden symptoms that require immediate surgical intervention. We report a case of a 46-year-old female who underwent Roux-en-Y gastric bypass (REYGP) 3 years prior. The patient presented to the emergency department with acute sudden abdominal pain, nausea and vomiting. Laparoscopically, intussuscepting small bowel segment was found gangrenous, and it was resected and end-to-end anastomoses were fashioned. The postoperative course was uneventful, and the patient remained asymptomatic for the 12 months of follow-up. Patients with retrograde intussusception experience an intolerable severe pain that necessitates surgical intervention. The etiology of intussusception as a complication after REYGP is unclear, yet theoretically some possible etiologies exist. The initial diagnosis of retrograde intussusception is made based on abdominal computed tomography. Early intervention significantly reduces morbidity and mortality.