Proposed novel classification of circumscribed Lower-Grade Gliomas (cLGG) vs. infiltrating Lower-Grade Gliomas (iLGG): Correlations of radiological features and clinical outcomes.

Purpose: We hypothesize that lower grade gliomas (LGG) can be identified and classified into two distinct subtypes: radiologically circumscribed Lower-Grade Gliomas (cLGG) and infiltrating Lower-Grade Gliomas (iLGG) based on radiological parameters and that these two different subtypes behave differently in terms of clinical outcomes. Methods: We conducted a retrospective cohort study on surgical patients diagnosed with lower grade glioma over five years. Patient records and MRIs were reviewed, and neurosurgeons classified tumors into cLGG and iLGG groups. Results: From the 165 patients in our cohort, 30 (18.2%) patients were classified as cLGG and 135 (81.8%) patients were classified as iLGG Mean age in cLGG was 31.4 years while mean age in iLGG was 37.9 years (p = 0.004). There was significant difference in mean blood loss between cLGG and iLGG groups (270 and 411 ml respectively, p = 0.020). cLGG had a significantly higher proportion of grade II tumors (p < 0.001). The overall mean survival time for the iLGG group was 14.96 ± 1.23 months, and 18.77 ± 2.72 months for the cLGG group. In univariate cox regression, the survival difference between LGG groups was not significant (HR = 0.888, p = 0.581), however on multivariate regression cLGG showed a significant (aHZ = 0.443, p = 0.015) positive correlation with survival. Intense contrast enhancement (HZ = 41.468, p = 0.018), blood loss (HZ = 1.002, p = 0.049), and moderately high Ki-67 (HZ = 4.589, p = 0.032) were also significant on univariate analyses.Conclusion: cLGG and iLGG are radiologically distinct groups with separate prognoses, surgical experience, and associations.

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.

Awake Surgery for Lesional Epilepsy in Resource-Limited Settings: Case Report and Review of Literature.

Epilepsy surgery is a well-established treatment for drug-resistant epilepsy, with awake craniotomy being used in certain cases to remove epileptogenic foci while preserving crucial brain functions. We are presenting the first reported case from Pakistan of a 19-year-old woman who underwent awake epilepsy surgery to treat cortical dysplasia. She had a history of generalized tonic-clonic seizures since her childhood and was referred to our clinic due to an increase in seizure frequency. EEG and MRI identified the epileptogenic focus in the right parieto-temporal region. The patient underwent a neuro-navigation guided awake craniotomy and an excision of the epileptogenic focus in the right parieto-temporal region. The procedure was carried out using a scalp block and dexmedetomidine for conscious sedation, enabling the patient to remain awake throughout the surgery. Intraoperative mapping and electrocorticography were used for complex multidisciplinary care. Post-resection corticography showed no spikes along the resected margins. The patient was discharged without any complications and remained free of symptoms a year after the surgery. Awake epilepsy surgery is a viable option for removing epileptogenic foci while preserving vital cognitive functions. However, it is seldom used in low- and middle-income countries such as Pakistan. The successful outcome of this case underscores the need for greater awareness and availability of epilepsy surgery in resource-limited settings. Cost-effective measures, such as using small subdural strips for intraoperative localization, can be implemented.

Utilization of an ultra-low-field, portable magnetic resonance imaging for brain tumor assessment in lower middle-income countries.

Background: Access to neuroimaging is limited in low-middle-income countries (LMICs) due to financial and resource constraints. A new, ultra-low-field, low-cost, and portable magnetic resonance imaging (pMRI) device could potentially increase access to imaging in LMICs. Case Description: We have presented the first brain tumor case scanned using an Ultra-low-field pMRI at Aga Khan University Hospital in Karachi, Pakistan. Conclusion: The imaging results suggest that the pMRI device can aid in neuroradiological diagnosis in resource-constrained settings. Further, research is needed to assess its compatibility for imaging other neurological disorders and compare its results with conventional MRI results.

Intraoperative use of ultra-low-field, portable magnetic resonance imaging - first report.

Background: Intraoperative use of portable magnetic resonance imaging (pMRI) has become a valuable tool in a surgeon's arsenal since its inception. It allows intraoperative localization of tumor extent and identification of residual disease, hence maximizing tumor resection. Its utility has been widespread in high-income countries for the past 20 years, but in lower-middle-income countries (LMIC), it is still not widely available due to several reasons, including cost constraints. The use of intraoperative pMRI may be a cost-effective and efficient substitute for conventional MRI machines. The authors present a case where a pMRI device was used intraoperatively in an LMIC setting. Case Description: The authors performed a microscopic transsphenoidal resection of a sellar lesion with intraoperative imaging using the pMRI system on a 45-year-old man with a nonfunctioning pituitary macroadenoma. Without the need for an MRI suite or other MRI-compatible equipment, the scan was conducted within the confinements of a standard operating room. Low-field MRI showed some residual disease and postsurgical changes, comparable to postoperative high-field MRI. Conclusion: To the best of our knowledge, our report provides the first documented successful intraoperative transsphenoidal resection of a pituitary adenoma using an ultra-low-field pMRI device. The device can potentially enhance neurosurgical capacity in resource-constrained settings and improve patient outcomes in developing country.

Glioblastoma imitating a cavernoma radiologically: A unique image report.

Background: Glioblastoma is the most common primary malignant brain tumor with characteristic radiological features in most cases. Case Description: We highlight an unusual case of a 54-year-old woman, neurologically intact, with a diagnostically challenging lesion. The patient's magnetic resonance imaging revealed a left frontal lesion with surrounding edema and a hemosiderin ring, misleading it to be a cavernoma. Intraoperatively, the lesion was found to be a solid tumor with hematoma and was confirmed to be glioblastoma on histopathology. Conclusion: The dilemma associated with our patient's radiological findings and longstanding history of epilepsy is rare and a diagnostic challenge.

Quality of life in survivors of pediatric medulloblastoma: a systematic review and meta-analysis.

INTRODUCTION: Medulloblastoma (MB) is the most common malignant pediatric brain tumor. The mainstay of treatment is maximum surgical resection and craniospinal radiation, which may be followed by chemotherapy. The debilitating effect of the tumor and the intensive treatment approaches in MB lead to long-term neuropsychological, physical, and chronic medical problems. We conducted a systematic review to assess the quality of life (QoL) in the long-term survivors of MB and the factors leading to compromised QoL. METHODS: We utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for our review. A comprehensive literature search was performed using PubMed, Cochrane Library, Digital Commons Network, and Wiley Online Library databases to search for articles having quality of life, medulloblastoma, and pediatric survivors in title or abstract. We removed duplicates and screened through titles, and full texts. Twelve articles were included in our study. Articles using and reporting all domains of PaedsQL were included in the meta-analysis. The PaedsQL scores of survivors and their caregivers were compared. Subgroup analysis was conducted for craniospinal and proton radiotherapy groups. RESULTS: As compared to other posterior fossa tumors, MB survivors have the lowest QoL scores. There is a difference in the perception of QoL of survivors between caregivers and survivors themselves with survivors rating themselves higher in several domains. The overall PaedsQL scores were significantly different for both groups (p < 0.001). Subgroup analysis showed that the difference between those who were treated with craniospinal or proton radiation was not significant (p = 0.76). For the subscales, physical (p = 0.005), psychosocial (p = 0.0003), and school (p = 0.03) perceptions were significantly different for the survivors and their caregivers; however, psychosocial (p = 0.80) and emotional (p = 0.93) scales were not different for the survivors or caregivers. Patient characteristics related to a worse QoL included disease severity, metastatic disease, lesser family income, smaller current ventricle size, need for permanent hydrocephalus treatment, and lesser age at diagnosis. CONCLUSION: An analysis of various studies, using different measures of QoL, concludes that QoL is compromised in all pediatric survivors of MB; however, the perception of QoL of the survivors is better than objective or caretaker-rated QoL.

Factors affecting cognitive functions of patients with high-grade gliomas: a systematic review.

BACKGROUND: Gliomas make up approximately 26.5% of all primary CNS tumors and 80.7% of malignant tumors. They are classified according to histology, location, and genetics. Grade III and IV gliomas are considered high-grade gliomas (HGGs). The cognitive signs and symptoms are attributed to mass defects depending on location, growth rapidity, and edema. Our purpose is to review the cognitive status of patients diagnosed with HGGs; the effect of treatments including surgical resection, radiotherapy, and chemotherapy; and the predictors of the cognitive status. METHODS: We utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines as a template for the methodology. A comprehensive literature search was performed from three databases (PubMed, ScienceDirect, and Cochrane Library) for clinical trials and longitudinal studies on patients diagnosed with HGGs assessing their cognitive status. RESULTS: Thirteen studies were selected among which 9 assessed cognitive function before and after treatment. One assessed the consistency of cognitive complaints and objective cognitive functioning. Three reported factors affecting disease progression and cognitive status. Most HGG patients have impairment in at least one cognitive domain. Treatments including surgical resection or radio-chemotherapy did not impair cognitive status. DISCUSSION: The cognitive status could be used to assess sub-clinical tumor progression. Factors correlated to cognitive status were tumor location, edema, and grade. Patient characteristics correlated were pre-operative epilepsy, corticosteroid use, and age at the time of diagnosis. CONCLUSION: Assessment of the cognitive status of HGG patients indicates sub-clinical tumor progression and may be used to assess treatment outcomes.

Recent management trends of subependymal giant cell astrocytoma associated with tuberous sclerosis complex.

Subependymal giant cell astrocytomas (SEGA) are benign cranial tumours typically found in patients with tuberous sclerosis complex (TSC). Surgical resection has been the standard treatment for SEGA, however, medical management through mTOR inhibitors has now predominantly replaced surgery as the primary treatment modality. Additionally, newer treatment modalities have emerged with the hopes of providing safer methods for treating the tumour such as laser interstitial thermal therapy (LITT). However, very few reports have addressed these newer methods and analysed the results.

Clinical factors affecting post-operative seizure control after supratentorial low-grade glioma resection in adults.

Up to 88% of patients with low grade glioma (LGG) experience seizures during the course of their disease. In patients who undergo surgery for supratentorial low grade glioma (SLGG), post-operative seizures can impact their quality of life and complicate the post-operative management course. Evidence suggests that epileptic activity can be related to tumour progression. In addition to the extent of resection, recent studies have investigated the possible patient and tumour factors which can influence post-operative seizure control in patients with SLGG.

Case Report: Recurrent pediatric cavernous malformation of the trigeminal nerve.

Background: Most cavernous malformations (CM) usually involve the parenchyma and rarely occur in cranial nerves. Recurrence of CM associated with cranial nerves after surgical resection has not been previously reported. Case description: This paper describes the case of an 11-year-old girl who presented with left otalgia and headache because of a left trigeminal cavernous malformation. She underwent radical resection via a left retrosigmoid approach while sparing the trigeminal nerve. Surveillance imaging at 18 months demonstrated recurrence along the length of the trigeminal nerve into Meckel's cave with significant extension into the middle cerebellar peduncle. Subsequent re-operation via an extended middle fossa approach with anterior petrosectomy enabled complete resection with division of the trigeminal nerve. Postoperatively, she had a transient left facial paresis, and right hemiparesis that resolved within 48 h. Conclusion: This case highlights the importance of close postoperative surveillance in CM associated with cranial nerves as recurrence after nerve-sparing resection is possible. Surgical treatment due to the morphology of significant recurrence required the use of a complex skull base approach through a new corridor to achieve optimal clinical outcome.

Intraoperative Seizures During Awake Craniotomy for Brain Tumours.

Awake craniotomy (AC) is becoming increasingly popular for brain tumour surgery. The procedure allows better preservation of eloquent cortex and helps achieve greater tumour resection. However, a potential problem with the procedure is intraoperative seizures (IOS) that may affect the mapping and monitoring of awake patients and may even lead to abandoning of the awake procedure.

Comparison of Glioblastoma Outcomes in Two Geographically and Ethnically Distinct Patient Populations in Disparate Health Care Systems.

Introduction Variations in glioblastoma (GBM) outcomes between geographically and ethnically distinct patient populations has been rarely studied. To explore the possible similarities and differences, we performed a comparative analysis of GBM patients at the University of Kentucky (UK) in the United States and the Aga Khan University Hospital (AKUH) in Pakistan. Methods A retrospective review was conducted of consecutive patients who underwent surgery for GBM between January 2013 and December 2016 at UK, and July 2014 and December 2017 at AKUH. Patients with recurrent or multifocal disease on presentation and those who underwent only a biopsy were excluded. SPSS (v.25 IBM, Armonk, New York, United States) was used to collect and analyze data. Results Eighty-six patients at UK (mean age: 58.8 years; 37 [43%] < 60 years and 49 [57%] > 60 years) and 38 patients at AKUH (mean age: 49.1 years; 30 (79%) < 60 years and 8 (21%) > 60 years) with confirmed GBM were studied. At UK, median overall survival (OS) was 11.5 (95% confidence interval [CI]: 8.9-14) months, while at AKUH, median OS was 18 (95% CI: 13.9-22) months ( p = 0.002). With gross-total resection (GTR), median OS at UK was 16 (95% CI: 9.5-22.4) months, whereas at AKUH, it was 24 (95% CI: 17.6-30.3) months ( p = 0.011). Conclusion Median OS at UK was consistent with U.S. data but was noted to be longer at AKUH, likely due to a younger patient cohort and higher preoperative Karnofsky's performance scale (KPS). GTR, particularly in patients younger than 60 years of age and a higher preoperative KPS had a significant positive impact on OS and progression-free survival (PFS) at both institutions.

Neuropsychiatric disorders after awake craniotomy for brain tumour.

Awake-craniotomy (AC) allows maximum tumour resection while reducing the risk of permanent postoperative neurological deficits without compromising the outcomes of the treatment. AC is a potentially stressful procedure for the patients, which may lead to long-term effects on patients' psychology, and may lead to post-traumatic stress. However, there is a scarcity of data suggesting actual association of any neuropsychiatric conditions after AC. Therefore, we sought to review the neuropsychiatric conditions post awake craniotomy.

Quality of Life in Paediatric Survivors of Medulloblastoma.

Medulloblastoma (MB) is among the most common malignant paediatric brain tumours usually arising in the cerebellum. The treatment is surgical resection followed by craniospinal radiation with or without chemotherapy. We assessed the current literature on survivors of MB and their quality of life (QoL). The QoL of MB survivors is significantly compromised in terms of decreased neurocognitive functions, Intelligence Quotient (IQ), and social functioning. These also lead to a compromised overall performance, school performance, lack of employment, social isolation, and caregiver burden. The survivors often self-reported better performances as compared to objective performance and that rated by the caregivers. The predictors of worse QoL include earlier age at diagnosis, hydrocephalus, shunt placement, altered mental status at diagnosis, incomplete/subtotal resection of the tumour, and metastatic disease.

Endoscopic surgical treatment for primary spinal lesions.

Primary spinal cord tumours are infrequently encountered CNS neoplasms and can be broadly classified into intradural intramedullary and intradural extramedullary lesions. Resection of these lesions was traditionally done via open surgical access almost always with microscope assistance. With the advent of minimally invasive surgical techniques, endoscopic excision of these lesions has been attempted for selected tumours. Available literature mainly deals with retrospective reviews on small number of patients; therefore, extensive research is required to establish safety and efficacy of endoscopic approach for excision of primary spinal tumours.

Primary leptomeningeal melanoma in association with neurocutaneous melanosis: A case report.

Background: Primary melanocytic tumors of the central nervous system accounts for approximately 1% of all melanoma with a peak incidence in the fourth decade. The tumor originates from leptomeningeal melanocytes with a variable degree of belligerence. The proliferation of these melanocytes in large amounts in the dermis and nervous system can raise suspicion of neurocutaneous melanosis (NCM), which is an association between malignant melanoma and the presence of a giant intradermal nevus. Case Description: We present a case of a 62-year-old South Asian male with a large congenital melanocytic nevus (>20 cm in size) in the left hemifacial, and head region who presented with complaints of a single episode of grand-mal seizure followed by neuropsychiatric symptoms. The patient was thoroughly evaluated both clinically and surgically leading to a rare diagnosis of primary leptomeningeal melanoma of the left temporal lobe. The patient subsequently underwent a neuronavigation guided left temporal craniotomy with gross total resection of the lesion. Conclusion: Primary leptomeningeal melanoma with a clinical association with NCM is rarely ever reported within the literature. To date, our case is one of the very few instances where such an association is being reported in this age group along with rare neuropsychiatric symptoms.

Unusual presentation in syndrome of trephined - A unique case observation.

Background: Syndrome of trephined (SoT) is a well-recognized complication of decompressive craniectomy (DC). The understanding of SoT has improved more recently with the increasing utilization of DC for severely raised intracranial pressure. It usually presents after a period of weeks or months with a cluster of adverse neurological symptoms, most commonly with worsening of motor strength. Case Description: An elderly gentleman with traumatic brain injury underwent DC. He later developed a sinking flap and unexplained agitation which responded to cranioplasty by returning to a state of calm. His cognitive function further improved over a period of 6 months. This is an unusual observation reported in this case. Conclusion: Timely recognition of the cognitive complications of craniectomy that may respond to early cranioplasty promises to decrease the length of hospital stay and enhance rehabilitation in such patients.

Quality of Life in Children Treated for Craniopharyngiomas.

Craniopharyngiomas are common but complex paediatric brain lesions that present interesting management challenges. Quality of life is an important consideration while choosing management options. In this review, we have discussed the existing literature on various aspects of quality of life in patients treated for craniopharyngioma, assessed by variety of measurement tools.

Surgical outcomes of intramedullary spinal cord ependymomas.

Intramedullary Spinal Cord Ependymomas (ISCE) are uncommon pathologies that need to be aggressively managed before clinical deterioration sets in. Novel application of different therapeutic strategies is being assessed for improving long-term outcomes in patients presenting with these rare neoplasms. In this review, we have discussed the existing literature on ISCEs, and the role of surgery in determining outcomes in terms of neurological status, progression-free survival (PFS) and overall survival (OS).