Feasibility of awake craniotomy for brain arteriovenous malformations: A scoping review.

Background: Brain Arteriovenous Malformations (AVMs) located in proximity to eloquent brain regions are associated with poor surgical outcomes, which may be due to higher rates of postoperative neurological deterioration. Current treatment protocols include stereotactic radiosurgery, transarterial embolization, and surgical resection under general anesthesia. Awake Craniotomy (AC) allows intraoperative mapping of eloquent areas to improve post-operative neurologic outcomes. Objectives: We reviewed the current literature reporting surgical outcomes and assessed the feasibility of AC for AVM resection. Methods: The PRISMA guidelines were utilized as a template for the review. Three databases including PubMed, Scopus, and Cochrane Library were searched using a predefined search strategy. After removing duplicates and screening, full texts were analyzed. Outcomes including the extent of resection, intra-operative and post-operative complications, and long-term neurologic outcomes were assessed. Results: 12 studies were included with a total of 122 AVM cases. Spetzler-Martin grading was used for the classification of the AVMs. The asleep-awake-asleep protocol was most commonly used for AC. Complete resection was achieved in all cases except 5. Intraoperative complications included seizures (n = 2) and bleeding (n = 4). Short-term post-operative complications included hemorrhage (n = 3), neurologic dysfunctions including paresis (n = 3), hemiplegia (n = 10), dysphasia/aphasia (n = 6), cranial nerve dysfunction (n = 3), and pulmonary embolism (n = 1). Almost all neurological deficits after surgery gradually improved on subsequent follow-ups. Conclusion: AVMs may shift the anatomical location of eloquent brain areas which may be mapped during AC. All studies recommended AC for the resection of AVMs in close proximity to eloquent areas as mapping during AC identifies the eloquent cortex thus promoting careful tissue handling which may preserve neurologic function and/or predict the postoperative functional status of the patients We, therefore, conclude that AC is a viable modality for AVMs resection near eloquent language and motor areas.

Redundant nerve roots indicate higher degree of stenosis in lumbar spine stenotic patients.

OBJECTIVES: Redundant Nerve Root (RNR) is a tortuous and elongated radiological appearance of cauda equina on Magnetic Resonance Imaging (MRI) in Lumbar Spinal Canal Stenosis (LSCS) patients. This study evaluated preoperative spinal morphometry associated with the development of RNR. METHODS: The retrospective cohort was conducted at The Aga Khan University Hospital, and included patients undergoing decompressive spinal surgery secondary to degenerative LSCS in 2015. The patients were divided into two groups with respect to the presence of preoperative RNR. Spinal morphometry was defined by several radiological parameters, including areas of dural sac (DSA), spinal canal, spinal foramen, facets, and spinal joints, and bilateral angles based on vertebral anatomy. RESULTS: A total of 55 patients were enrolled with a mean age of 57.1 years, in which 22 (40%) expressed RNR in their MRI. The RNR group had significantly lower mean DSA (59.64 vs 84.01 mm2; p = 0.028), bilateral posterior facet angle (Right: 33.84 vs 46.21, p = 0.004; Left: 36.43 vs 43.80, p = 0.039) and higher bilateral anterior facet angles (Right: 54.85 vs 44.57, p = 0.026; Left: 55.27 vs 46.36, p = 0.050) compared to the non-RNR group. The other bidimensional and angular parameters did not observe any statistical difference between the two groups. CONCLUSION: RNR was associated with a higher degree of stenosis in patients with LSCS. Bilateral anterior and posterior facets angles contribute to its development, indicating particular spinal morphology to be vulnerable to the stenotic disease.

Craniotomy or Craniectomy for Acute Subdural Hematoma? Difference in Patient Characteristics and Outcomes at a Tertiary Care Hospital.

Objective This article compares the outcomes of patients with traumatic acute subdural hemorrhage (SDH) managed either with craniotomy (CO) or with decompressive craniectomy (DC). Methods In this single-center, retrospective analysis we included all adult patients with acute traumatic SDH who were treated either using CO or DC. Sixteen-year hospital data was reviewed for patient demographics, injury details, and hospital course. Outcomes were noted in terms of intraoperative blood loss, intensive care unit stay, need for tracheostomy, post-surgery Glasgow Coma Score (GCS; calculated immediately after surgery), delayed GCS (DGCS; calculated 1 week after surgery), and delayed Glasgow Outcome Score (DGOS) after 6 months of surgery. Postoperative complications were noted during hospital stay, while mortality was noted within 6 months of surgery for each patient. Results Patients who underwent DC were younger (mean age 34.4 ± 16.8 years vs. 42.4 ± 19.9 years in the CO group) ( p = 0.006). Patients who underwent DC also had worst degree of traumatic brain injury as per Marshall grade (62.4% patients with Marshall grade 4 in the DC group vs. only 41.2% patients in the CO group) ( p = 0.037). Mean size of hematoma was 23.8 ± 24.6 mm in the DC group versus 11.3 ± 8.2 mm in the CO group ( p = 0.001). Mean postop GCS was lower in the DC group; 8.0 ± 4 versus 10.8 ± 4 in the CO group ( p < 0.001). However, there was no significant difference in DGCS and DGOS between the DC and CO groups ( p = 0.76 and 0.90, respectively). Mortality rate was 24 (30.8%) in the DC group versus 18 (20.7%) in the CO group ( p = 0.14). Conclusion The patients who underwent DC were younger, had larger size hematoma, and poor Marshall grade. We did not find any significant difference in the outcomes of CO and DC for management of subdural hematoma.

Intramedullary schwannoma - A case report.

Background: Schwannomas are benign but clinically progressive tumors. Mostly, they present as intradural extramedullary lesions. They are quite rare in the intramedullary (IM) region. We report a case of IM schwannoma. Case Description: A 52-year-old gentleman presented with a history of gait instability and numbness in bilateral lower limbs. He had clinical signs of myelopathy. His magnetic resonance imaging (MRI) dorsal spine was done that showed an intradural IM lesion at the level of D11, with one differential of ependymoma. Near total resection of lesion was done and histopathology reported it schwannoma. Conclusion: Preoperative radiologic assessment for IM spinal lesions is difficult and high degree of suspicion should be present when approaching a patient with somatic pain and IM lesion on MRI, keeping in mind one differential of IM schwannoma.

Spinal Radiology associated with Redundant Nerve Roots of cauda equina in lumbar spine stenosis.

OBJECTIVES: Redundant Nerve Roots (RNR) is a common radiological observation of elongated tortuous appearance of cauda equina nerve roots in sagittal MRI. It is considered a poor prognostic factor, but the associated spinal morphometry remains unfamiliar. METHODS: A retrospective cohort study was conducted at the Aga Khan University Hospital, Pakistan. Patients, aged 18 or above, undergoing decompressive spinal surgery due to degenerative Lumbar Spinal Canal Stenosis (LSCS) in 2015 were included. Patients were divided in groups as per presence of RNR and assessed for spinal morphometric parameters. RESULTS: Fifty-two patients, aged 57.52 ± 12.08 years, were enrolled in the study. The patients in RNR group were older than those in non-RNR group (p = 0.023). RNR was significantly associated with sedimentation sign (15 vs 11; p = 0.011), as well as L2/L3 (12 vs 9; p = 0.043) and L3/L4 (18 vs 18; p = 0.034) stenosis. Ligamentum flavum hypertrophy at the most stenotic level was more common in the RNR group (20 vs 19; p = 0.006). The only quantitative parameter statistically associated with RNR was lower ligamentous interfacet distance (5.07 ± 1.95 vs 8.07 ± 4.26 mm; p = 0.010). All other parameters did not contribute to the development of RNR in LSCS patients. The multivariate model revealed significant contribution of age, male sex, ligamentous interfacet distance and disc bulge to develop RNR. CONCLUSION: Certain spinal morphometric parameters contribute towards RNR formation, which represents higher degree of spinal stenosis. These parameters, along with RNR, should be regularly reported for preoperative consideration of LSCS management.

Current Management Trends for Surgical Site Infection After Posterior Lumbar Spinal Instrumentation: A Systematic Review.

OBJECTIVE: The objective of this systematic review is to determine the fate of spinal implants when patients develop postoperative wound infection after posterior instrumental fusion in a degenerative spine. METHODS: A systematic review of the English-language literature (published between January 2001 and July 2020) was undertaken to identify articles documenting the management strategy for surgical site infections (SSIs) after posterior lumbar spinal fusion. Studies on pedicle screw fixation after trauma, immunocompromised, metastatic spine disease, and combined anterior/posterior approach were excluded. Two independent reviewers assessed the level of evidence quality using the criteria set by the North American Spine Society, and disagreements were resolved by consensus. RESULTS: Of the 3071 citations identified, 49 met the criteria to undergo full-text review. Outcomes after SSIs were studied from a combined pool of 1150 patients who had undergone instrumental spinal fusion. The collected data showed that 456 patients (39.97%) had undergone spinal implant removal after SSI while 694 patients (60.03%) had their implants retained until the resolution of SSI. There was an absolute risk reduction (ARR) of 29% (-0.292) and a relative risk reduction (RRR) of 50.3% (-0.503) of implant removal if the patient underwent wound debridement following SSI. The number needed to treat (NNT) for wound debridement was calculated at 3.31 from our pooled cohort. The ARR in implant removal following vacuum-assisted closure (VAC) therapy was 16.6% and RRR was noted at 40.4%. This led to a high value of NNT at 6.0 patients. There was an ARR of 33.5% and a RRR of 70.7% was estimated in patients undergoing continuous irrigation. CONCLUSIONS: Our review of the literature suggests that surgeons prefer early wound debridement with or without negative pressure wound therapy under antimicrobial coverage for eradication of SSI after posterior lumbar spinal fusion. Implant removal is generally reserved for cases refractory to the other treatment modalities.

Conducting the Pakistan brain tumour epidemiology study - report on the methodology.

Objectives: To combat the lack of brain tumour registries, the Pakistan Brain Tumour Epidemiology Study (PBTES) was conducted without any funding from an external source. METHODS: A retrospective analysis of patient data, including patients of all age groups diagnosed with all histopathological types of brain tumours from all over Pakistan, was performed. For this, Pakistan Brain Tumour Consortium (PBTC) was established, including 32 neurosurgical centres from around the country. Data was collected online through a proforma that included variables such as patient demographics, clinical characteristics, operative details, postoperative complications, survival indices, and current functional status. The data collection and analysis team included principal investigators, core leads, regional leads, regional associates, and student facilitators. Despite logistical concerns and lack of resources, the PBTES was conducted successfully, and a formal brain tumour surveillance database was formed without any external funding, which remains unheard of. CONCLUSIONS: The methods applied in this study are reproducible and can be employed not just to develop more robust brain tumour and other cancer registries but also to study the epidemiology of communicable and non-communicable diseases in resource-limited settings, both locally and globally.

Role of redundant nerve roots in clinical manifestations of lumbar spine stenosis.

BACKGROUND: Redundant nerve roots (RNRs) are defined as elongated, thickened, and tortious appearing roots of the cauda equina secondary to lumbar spinal canal stenosis (LSCS). The study compared the clinical and radiological features of patients with LSCS with versus without RNR. METHODS: This retrospective study was performed on 55 patients who underwent decompressive surgery for degenerative LSCS. Patients were divided into two groups based on the presence of RNR in their preoperative magnetic resonance imaging, as evaluated by a radiologist blinded to the study design. Medical records were reviewed for basic demographic, clinical MR presentation, and outcomes utilizing Japanese Orthopaedic Association (JOA) scores. RESULTS: The mean age of enrolled patients was 57.1, with mean follow-up of 4.0 months. RNR was found in 22 (40%) of patients with LSCS. These patients were older than those patients without RNR (62.2 vs. 53.7). Interestingly, there were no statistically significant differences in clinical presentations, duration of symptoms, and outcomes using JOA scores between the two groups. CONCLUSION: RNR is a relatively common radiological finding (i.e., 40%) in patients with LSCS. It is more likely to be observed in older patients. However, no significant differences were noted in clinical presentation and functional outcomes with respect to the presence or absence of RNR.

Modifications in lumbar facet joint are associated with spondylolisthesis in the degenerative spine diseases: a comparative analysis.

BACKGROUND: Magnetic resonance imaging (MRI) is important in the assessment of degenerative spine disease. However, its role is limited in the identification of spinal instability; therefore, weight-bearing and dynamic studies like X-rays are required. The supine position eliminates the gravitational pull, corrects the vertebral slippage, and opens the facet joints leading to the collection of the synovial fluid into the joint space, which is detected on the MRI and can serve as a marker for instability. We aim to compare the facet fluid, facet hypertrophy, facet angle, and disc degenerative changes among the patients presenting with degenerative spondylolisthesis (DS) and those without. METHODS: We performed a retrospective review for all the patients treated at our institution from January 2015 to December 2016. Facet Fluid Index (FFI) (ratio of facet fluid width and facet joint width) was calculated to assess the joint fluid. The percentage of spondylolisthesis was measured on X-rays. Each radiological parameter was compared between the two groups, i.e., patients with DS and patients without DS. A p value < 0.05 was considered significant. RESULTS: In total, 61 patients, 28 with DS and 33 without DS, were enrolled. Baseline characteristics were similar in the two groups (p > 0.05). The average values of FFI, facet fluid width, and the difference between the superior and inferior facet were significantly higher in the group with instability (p < 0.05). Multivariate analysis demonstrated a 4.44 (95% confidence interval [CI] 2.03-5.365) times increase in the odds of instability with a unit increase in FFI, p < 0.0001. CONCLUSIONS: We report a positive linear correlation between the facet joint effusion and facet hypertrophy on MRI and the percentage of vertebral translation on X-ray. Prospective studies will determine if these markers can play a role in predicting spinal instability.

Work-life balance amongst residents in surgical and non-surgical specialties in a tertiary care hospital in Karachi.

OBJECTIVE: To assess work-life balance among medical residents at a tertiary hospital. METHODS: The cross-sectional study was conducted from September to December 2016 at a private-sector tertiary care hospital in Karachi, and comprised medical residents working at the facility. A standardised, self-administered questionnaire was developed on the basis of Canadian Mental Health quiz and a study in literature. The questions aimed at assessing satisfaction with work as well as emotional and personal life of residents in various medical and surgical specialties. SPSS 20 was used for data analysis. RESULTS: Of the 275 residents, 129(46.9%) were males and 146(53.1%) were females. The overall mean age was 28.19±2.194 years. Of the total, 13(4.7%) participants thought they had work-life balance; 165(60%) felt their job had negatively affected their private lives; 118(42.9%) felt worn out; 109(39.6%) expressed moderate dissatisfaction with work-related factors; 119(43.3%) were dissatisfied with life outside work; and 93(33.8%) were dissatisfied their health. CONCLUSIONS: There was minimal work-life balance among the residents.

Value of Routine Preoperative Tests for Coagulation Before Elective Cranial Surgery. Results of an Institutional Audit and a Nationwide Survey of Neurosurgical Centers in Pakistan.

BACKGROUND: Routine preoperative blood testing has become a dogma. The general practice is to order preoperative workup as a knee-jerk response rather than individualize it for each patient. The fact that the bleeding brain tends to swell, which coupled with limited options for proximal control, packing, and overall hemostasis, leads to an overemphasis on the preoperative coagulation profile. MATERIAL AND METHODS: This is a retrospective review of the medical records of patients admitted at Aga Khan University Hospital from January 2010 to December 2015 for an elective craniotomy. The hospital registry was used to identify files for review. Data were collected on a predefined proforma. A nationwide survey was performed, and 30 neurosurgery centers were contacted across Pakistan to confirm the practice of preoperative workup. RESULTS: The survey revealed that all centers had a similar practice of preoperative workup. This included complete blood count, serum electrolytes, and coagulation profile, including prothrombin time, activated partial thromboplastin time (aPTT), and international normalized ratio (INR). A total of 1800 files were reviewed. Nine (0.5%) patients were found to have deranged clotting profile without any predictive history of clotting derangement; 56% were male and 44% were female. Median age was 32 years with an interquartile range of 27 years. Median aPTT was (40.8 with 20.8 IQR). Median INR was (1.59 with 0.48 IQR). Median blood loss was (400 with 50 IQR). No significant association between coagulation profile (aPTT, INR) and blood loss was found (P = 0.85, r = -0.07). CONCLUSIONS: We conclude that patients without a history of coagulopathy and normal physical examination do not require routine coagulation screening before elective craniotomy.

Role of extent of resection on quality of life in patients with newly diagnosed GBM.

Glioblastomas known for their adverse outcomes are most reportedly managed by surgical resection. Studies on the impact of (Extent of Resection) EOR against Quality of Life (QOL) are very limited. We have collected data from recent studies in this review to extract a general consensus among the neurosurgeons regarding the EOR. Key parameters like functional independence, neurocognitive improvements and global health status have been explored in the context of QOL. The currently available data suggests that an increased EOR may help improve QOL in GBM patients. With the help of recent advancements it may be possible to attain a better extent of resection while operating on GBMs.

Survival benefit of surgery in recurrent glioblastoma multiforme.

There is an ongoing debate regarding role of surgery for recurrent glioblastoma multiforme (GBM). Older literature hinted at only modest survival benefits with surgery and a high rate of morbidity. However, more recent literature suggests better survival that may be attributed to better surgical techniques and better options in adjuvant treatment. Herein the authors review recent literature with regards to the possible role of surgery in recurrent GBM and also look into the key factors impacting second surgery. .

Intrathecal and intraventricular antibiotics for postoperative Gram-negative meningitis and ventriculitis.

BACKGROUND: Postoperative meningitis is a growing cause of concern, especially with the evolution of multidrug-resistant organism. The authors evaluate the use of intraventricular/intrathecal (IVT/IT) antibiotics for postoperative gram-negative meningitis in patients whom intravenous antibiotics were ineffective. METHODS: Medical records were retrospectively reviewed and neurosurgery patients with gram-negative postoperative infection meningitis/ventriculitis were enrolled in the study. Their demographics, hospital course, and outcomes were recorded in a pro forma and analyzed using Statistical Package for the Social Sciences, version 19. RESULTS: The review identified 21 patients with postneurosurgical gram-negative meningitis/ventriculitis who were treated with IVT or IT antibiotics. The most common organism was Acinetobacter species (n = 14; 66%). Amikacin was used in 7 patients, polymyxin B in 9 patients, and colistin in 5 patients. A combination of antibiotics was used in one patient. Cerebrospinal fluid sterility was achieved in all patients with no incidence of relapse. There was a single death, though that was not related to the infectious process as the patient had a massive pulmonary embolism. CONCLUSION: The findings of this study suggest that IVT and IT antibiotic therapy is a useful option in patients who are nonresponsive to standard intravenous therapy with little or no side effects.

Quality of Life in Individuals Surgically Treated for Congenital Hydrocephalus During Infancy: A Single-Institution Experience.

BACKGROUND: Congenital hydrocephalus (CH) is a frequently encountered birth anomaly that can hinder long-term neurologic maturity and social well-being of affected children. This study was undertaken to assess quality of life (QOL) 10-15 years after surgical treatment for primary CH during infancy at a tertiary care hospital in a developing country. METHODS: This retrospective cohort study included individuals who presented to Aga Khan University Hospital, Karachi, Pakistan, between 1995 and 2005 at <1 year old and underwent surgery for primary CH. The Hydrocephalus Outcome Questionnaire was used to assess outcomes with respect to QOL. RESULTS: Of 118 patients, 90 patients participated in the study. Mean age at first admission was 6.2 months. Mean length of follow-up was 5.4 years. Of these, 28 patients had died after surgery. Shunt infection (P = 0.012) and delayed milestones (P = 0.003) were found to be statistically significant factors affecting mortality in the patients who died. The mean overall health score was 0.67 ± 0.30. Age <6 months at the time of first surgery was a poor predictor of overall health on the Hydrocephalus Outcome Questionnaire (P = 0.039). CONCLUSIONS: In our analysis, we assessed the QOL associated with CH. We hope that these results will provide insight for future prospective work with the ultimate goal of improving long-term QOL in children with CH.

Awake craniotomy for brain tumours in Pakistan: An initial case series from a developing country.

Awake craniotomy offers safe resection of brain tumours in eloquent area. Aga Khan University Hospital, Karachi, recently started the programme in Pakistan, and the current study was planned to assess our experience of the first 16 procedures. The retrospective study comprised all such procedures done from November 2015 to May 2016. Pre-operative and post-operative variables were analysed. Of the 16 patients, 11(68.75%) were males and 5(31.25%) were females. The overall median age was 37 years (interquartile range[IQR]: 23-62 years). The most common presenting complaint was seizures 8(50%), followed by headache6(38%). The common pathologies operated include oligodendroglioma and glioblastoma. Pre-operative mean Karnofsky Performance Status score was 76±10, which increased to 96±7 post-operatively at discharge. Besides, 2(12.5%) intra-operative complications were observed, i.e. seizure and brain oedema, in the series. The study had median operative time of 176 minutes (IQR: 115-352) and median length of stay of 4 days (IQR: 3-7).Awake craniotomy was highly effective in maintaining post-operative functionality of the patient following glioma resection. It was also associated with shorter hospital course and so lower cost of management.

Primary anaplastic pleomorphic xanthoastrocytoma in adults. Case report and review of literature.

BACKGROUND: Pleomorphic xanthoastrocytoma (PXA) classified as a low Grade (WHO II) astrocytic neoplasm. It is known for its relatively favorable prognosis. It most commonly occurs in young adults. Malignant progression in PXA has been frequently reported since its first description in 1979; however, the presentation of a primary anaplastic PXA tumor with an aggressive clinical course in adults is rare especially in the later age group. CASE DESCRIPTION: We present a case of primary anaplastic PXA in a 53 year old male that manifested with an early recurrence pattern at 9 weeks. Treatment performed was surgical excision and external beam radiotherapy. The aforementioned tumor followed an aggressive clinical course. Tumor cells exhibited the characteristic expression of GFAP (Glial fibrillary acidic protein), higher proliferative index (8-10%) on Ki-67 staining along with the presence of increased mitoses ( >5/10hpf). A review of previously reported primary anaplastic pleomorphic xanthoastrocytoma cases in adults with histological features was also done. CONCLUSION: Our review of all reported cases of APXA in adults concludes that the clinical behavior of this tumor varies considerably from its benign variant. Early disease recurrence in anaplastic pleomorphic xanthoastrocytomas is associated with fatal outcomes. As per our review of literature it is seen that anaplastic variant of PXA shows histological characteristics as well as clinical course comparable with Grade III astrocytomas. We recommend further evaluation of PXA with anaplastic features regarding their genetic characteristics to understand the origin as well as behavior of this tumor.

Cerebellopontine angle primitive neuroectodermal tumor mimicking trigeminal schwannoma.

BACKGROUND: Primitive neuroectodermal tumors (PNETs) comprise a group of aggressive, poorly differentiated embryonal tumors occurring in central nervous system as well as in peripheral locations. Primary cerebellopontine angle (CPA) PNET is an extremely rare entity. It is important to have knowledge of this pathology and to be able to differentiate it from other commonly occurring CPA tumors, such as vestibular and trigeminal schwannomas. This distinction is essential because of the difference in the overall treatment plan and prognosis. CASE DESCRIPTION: This report describes a case of a young male presenting with diplopia and numbness of face; magnetic resonance imaging showed a CPA mass. With a provisional diagnosis of trigeminal schwannoma, the patient underwent surgery. Histopathology provided a diagnosis of PNET. CONCLUSION: We discuss the importance of recognizing this rare condition and how this entity differs from the commonly occurring tumors.

Providing Care Beyond the Hospital: Perspective of a Tertiary Care Hospital from a Developing Country.

BACKGROUND: Neurorehabilitation is an important aspect of continuing care for neurosurgical patients with functional disability. In developing countries, where formal home nursing frequently is unavailable, ensuring care after discharge is a difficult task. Training attendants to provide nursing care is an alternate option. In this study, we compared the outcomes of patients nursed by family members versus those looked after by a professional nurse. METHODS: This was a retrospective observational study conducted at the Aga Khan University Hospital Karachi. The study consisted of 2 groups. Group 1 (consisting of patients cared for by a professional nurse) included 94 patients and group 2 (patients cared for by family members) included 102. All these patients had activity of daily living score of ≥3. Glasgow Outcomes Scale score, time to decannulation, development/worsening of bedsores, and mortality were recorded and compared between the groups at follow-up. RESULTS: The study included 196 patients. Traumatic brain injury was the most common diagnosis. Nursing requirements were similar between the 2 groups and included tracheostomy care, percutaneous endoscopic gastrostomy tube care, peripherally inserted central catheter line care, care of patients with no bone flap, and log-rolling. The outcomes of the 2 groups were comparable and included bedsore development/worsening of grade, Glasgow Outcomes Scale score at follow-up, time to decannulation, and 30-day mortality. CONCLUSIONS: There was no statistically significant difference in outcomes of patients nursed by family members compared with the patients looked after by professional nurses.

Ependymal tumors with oligodendroglioma like clear cells: Experience from a tertiary care hospital in Pakistan.

BACKGROUND: Ependymal tumors with oligodendroglioma like clear cells have never been reported from Pakistan. We aimed to see the features and outcomes of this rare entity. METHODS: It was retrospective cohort conducted at the Department of Neurosurgery, Aga Khan University from 2003 to 2013. The medical records and radiology of patients with proven histopathology were reviewed. Analysis was done on SPSS 20. RESULTS: Eleven cases of ependymal tumors with clear cells were found, which equated to 1.5% of the total tumor burden in 11 years. The median age was 49 years. Most common presenting symptom was headache 54.5%. Out of 11 patients, 9 patients had a supratentorial tumor. Magnetic resonance imaging showed hypointense signals on T1 and hyperintense signals on T2-weighted images in all cases. Contrast enhancement was found in 9 patients (77.8%), necrosis and hemorrhage was found in 4 (36%) and 3 (27%) patients, respectively. Immunohistochemistry showed glial fibrillary acidic protein and epithelial membrane antigen positivity in all cases. Ki-67 showed high proliferative index in 6 patients. According to the World Health Organization grading of ependymal tumors, 2 patients had Grade II tumors, and 9 patients had Grade III tumors with clear cells. Gross total resection was achieved in 6 (54.5%) and subtotal resection in 5 patients (45.4%). Recurrence was observed in 9 patients. Six patients died of the disease. Median progression-free survival and overall survival was 8 months and 10 months, respectively. CONCLUSION: Ependymal tumors with clear cells presented more commonly in Grade III lesions and were more aggressive in behavior with poorer outcome compared to similar studies.