Evolution of RANO in Assessing Brain Tumour Outcomes.

Assessing treatment response is extremely important in management of brain tumours. Response assessment in neuro-oncology (RANO) was introduced in 2008 for the purpose of making recommendations for it by addressing and countering the limitations in previously reported response criteriae. Subsequently, multiple RANO working groups have been formed to cater to different tumour types and to update their previous recommendations to counter the limitations in their criteria. Herein we have a summarized list of RANO criteria for adult brain tumours.

Photodynamic Therapy in Adult Intra-axial Brain Tumours.

The management of high-grade gliomas is challenging considering their infiltrative nature, involvement of the eloquent cortex, and high recurrence rate. Photodynamic therapy (PDT) is an emerging modality that selectively destroys tumour cells while preserving normal brain tissue. Its safety, and the concurrent use with surgery, radiation, and chemotherapy, is some of its appealing tenets. Here, we present a review of the literature regarding the mechanism, safety, and efficacy of PDT.

Prognostic Value of BRAF Mutation in Glioblastoma.

With advances in molecular genetics, exploring targetable mutations for treating glioblastoma (GBM) patients, has become a centre of interest in modern day neuropathology. BRAF mutation has been extensively reported in several brain tumours. Recent studies report identification of BRAF mutation in GBM patients, especially isocitrate dehydrogenase wildtype glioblastomas (IDH-WT GBM), and its potential role in patient outcomes. Here we discuss the existing literature on the prognostic value of BRAF mutation in GBM.

A brief review of skull base chordomas.

Skull base chrodomas are slow growing neoplasms usually located along the midline. They display a locally invasive nature with possibilities of extracranial metastasis. Presentation is usually late and depends upon the location and extent of the tumour. Management aims at gross total resection via open microsurgical or endoscopic approach followed by adjuvant radiotherapy. Prognosis may be good for the classical and chondroid subtypes but remains poor for de-differentiated type.

Spinal Schwannomas; Classification, Management And Outcomes.

Schwannomas are benign tumours of the peripheral nerve sheath. When they occur in spine, they are most commonly found in intradural-extramedullary location. Surgery is the mainstay of treatment. Radiation has a limited role in the management of residual or recurrent lesions not suitable for surgery. Here we discuss the existing literature on the outcomes of spinal schwannoma after surgery.

Intramedullary Subependymoma Of Lower Thoracic Cord.

Spinal subependymoma (SSE) is a rare intramedullary, benign tumour. Surgical excision isthe preferred approach. However, the interwoven pattern of neural tissue within the tumour dictates the extent of resection. Where gross total resection is linked with possible neurological deficits, subtotal resection or close observation may support better functional outcomes. The evidence for the management of SSE is based mostly on case reports. Herein, we review the existing literature regarding treatment options and clinical outcomes of spinal subependymoma.

Exploring the 'January effect' at a university hospital in Pakistan: a retrospective cohort study investigating the impact of trainee turnover on patient care quality outcomes.

OBJECTIVE: There are reports of a potential rise in a teaching hospital's morbidity and mortality rates during the trainee turnover period, i.e., with the induction of new residents and house staffs, and the changeover of clinical teams. The published literature displays mixed reports on this topic with lack of reproducible observations. The current study was conducted to explore existence of any such phenomenon (January effect) in Pakistan. METHODS: This retrospective cohort study was conducted at Aga Khan University Hospital, Karachi, Pakistan. Five-year (2013-2018) record of all the patients in all age groups related to these outcomes was retrieved and recorded in specifically designed questionnaire. Different outcome measures were used as indicators of patient care and change in these outcomes at the time of new induction was related to possible January effect. RESULTS: During the five-year study period, more than 1100 new trainees were inducted into the post graduate medical education program (average of 237 per year) with more than 22,000 inpatient admissions (average of 45,469 per year). Some patterns were observed in frequencies of surgical site infections, medication errors, sentinel events, patient complaints, and adverse drug reactions. However, these were not consistently reproducible and could not be directly attributed to the trainee turnover. All other indicators did not show any pattern and were considered inconclusive. No effect of overlap was observed. CONCLUSIONS: Inconsistency in the patient care quality indicators do not favor existence of January effect in our study. Further research is recommended to establish our results.

The Role Of 18F-FDG PET/CT In Evaluation Of Primary CNS Lymphoma: The Path Less Travelled.

Primary central nervous system lymphoma (PCNSL) is a rare but highly aggressive lymphoma with increasing incidence in immunocompromised patients. MRI is the modality of choice in evaluating brain lesions. However, MRI is often challenging in the detection of early recurrence, assessing residual disease and response evaluation in PCNSL. 18F-FDG PET/CT has superior diagnostic performance compared with body CT in the evaluation of lymphoma. 18F-FDG PET-CT is helpful in evaluating evaluation of disease extent and differentiating primary CNS lymphoma from systemic lymphoma. Besides diagnostic and prognostic value in primary CNS lymphoma, it might also be helpful in response assessment. The role of FDG-PET in PCNSL is not fully defined. In this article we have reviewed the potential role of 18F-FDG PET/CT in initial diagnosis, baseline staging, restaging, evaluation of treatment response, prognostication, and survival analysis of PCNSL.

Geographical Distribution of Neurosurgeons and Emergency Neurosurgical Services in Pakistan.

BACKGROUND AND OBJECTIVE: According to the World Federation of Neurosurgical Societies (WFNS), a minimum neurosurgery workforce density should be 1 per 200,000 population for optimum access to neurosurgical care. Pakistan lags behind in the number of neurosurgeons, and disproportionate geographical distribution further increases disparity. Our objective was to geographically map the density of neurosurgeons and emergency neurosurgical services (ENS) in Pakistan. METHODS: This survey was circulated among 307 neurosurgeons. Data were analyzed using SPSS v21. The number of neurosurgeons and ENS were plotted on the population density map using ArcGIS Pro 3.0.0 software. RESULTS: Three hundred and seven neurosurgeons working at 74 centers responded to our survey (93.3% coverage). The current density of neurosurgeons in Pakistan is 0.14/100,000. The 2 more populous provinces, Punjab and Sindh, have 42.3% (130) and 35.8% (110) neurosurgeons, respectively. They also housed nearly 3 quarters of all the neurosurgery centers in urban districts. Karachi and Lahore accommodate 135 (44%) of all the country's neurosurgeons, having 0.29 and 0.51 neurosurgeons/100,000 respectively. Management of traumatic brain injury is offered at 65 centers (87.8%). Nearly all centers are equipped with computed tomography (CT) scan machine (74; 97%), but magnetic resonance imaging (MRI) facility is available at 55 (72%) centers and 37 (49%) centers have angiography suites. Sixty nine centers (93.2%) have C-arm fluoroscopes available. CONCLUSIONS: The geographical mapping of neurosurgeons and neurosurgical facilities is highly skewed towards urban centers, increasing disparity in access to timely neurosurgical emergency services. Four times more neurosurgeons are required in Pakistan to bridge the gap in neurosurgical workforce.

Intraoperative Seizures During Awake Craniotomy for Brain Tumor Resection.

Background Intra-operative seizures (IOS) can occur during awake craniotomies (AC) for brain tumors. They can potentially result in an increased risk of morbidity; however, literature is scarce on IOS, its risk factors, and predictors. This study aims to ascertain the frequency of IOS in patients undergoing AC and determine possible IOS predictors. Methods In this retrospective study, we reviewed the records of all patients who underwent AC for tumor resection at a single university hospital between January 2016 and December 2020. IOS was defined as any seizure, including partial or generalized, experienced by any patient at any time from the beginning of the procedure till the end of surgery. Results Two hundred patients underwent AC during the study period. Seven (3.5%) patients experienced IOS. Compared to the non-seizure group, no significant correlation existed with any demographic variable. No significant difference was seen between the initial complaints presented by the two groups. In addition, the post-operative course of the seizure group did not significantly differ from the non-seizure group. Due to the low frequency of IOS in our cohort, an extensive analysis to determine predictors could not be performed. Conclusion In this study, we observed a low frequency of IOS (3.5%) during AC. The possible predictors and risk factors must be further investigated in large cohorts; to help limit the consequences of this possible intraoperative complication.

Low-field magnetic resonance imaging in a boy with intracranial bolt after severe traumatic brain injury: illustrative case.

BACKGROUND: Conventional magnetic resonance imaging (cMRI) is sensitive to motion and ferromagnetic material, leading to suboptimal images and image artifacts. In many patients with neurological injuries, an intracranial bolt (ICB) is placed for monitoring intracranial pressure (ICP). Repeated imaging (computed tomography [CT] or cMRI) is frequently required to guide management. A low-field (0.064-T) portable magnetic resonance imaging (pMRI) machine may provide images in situations that were previously considered contraindications for cMRI. OBSERVATIONS: A 10-year-old boy with severe traumatic brain injury was admitted to the pediatric intensive care unit, and an ICB was placed. Initial head CT showed a left-sided intraparenchymal hemorrhage with intraventricular dissection and cerebral edema with mass effect. Repeated imaging was required to assess the brain structure because of continually fluctuating ICP. Transferring the patient to the radiology suite was risky because of his critical condition and the presence of an ICB; hence, pMRI was performed at the bedside. Images obtained were of excellent quality without any ICB artifact, guiding the decision to continue to manage the patient conservatively. The child later improved and was discharged from the hospital. LESSONS: pMRI can be used to obtain excellent images at the bedside in patients with an ICB, providing useful information for better management of patients with neurological injuries.

68Ga-DOTA-peptide PET/CT for radiotherapy planning and evaluating treatment response in the management of meningiomas.

Meningiomas overexpress somatostatin receptors (SSTR). PET imaging with SSTR ligands such as 68Ga-DOTA-peptide has recently shown high diagnostic accuracy in identification of meningiomas due to lack of normal bone and brain activity. PET-derived parameters, especially gross tumour volume (GTV) delineation improves inter-observer variability and appears to be particularly promising for RT planning. The potential strength of 68Ga-DOTA in the ongoing assessment of treatment response and disease progression in meningioma, particularly in the post-surgical and post-radiation settings is encouraging. More prospective randomized studies with large cohorts of patients are required to define the effective role of this modality.

Spinal meningiomas: Management and outcomes.

Spinal meningiomas are relatively rare, benign, intradural, extramedullary tumours, that are typically slow-growing and well-defined. Surgery is always the first line for treating spinal meningiomas. Here, we have discussed the existing literature on spinal meningiomas and the role of surgery in determining the outcomes.

The effect of preoperative steroids for at least 10 days on complications following craniotomy for tumor resection: A database, retrospective cohort study.

Introduction: The effect of chronic steroid therapy on postoperative outcomes after craniotomy for tumor resection remains understudied. Research question: This study aimed to fill this gap and to identify risk factors of postoperative morbidity and mortality among patients on chronic steroid use undergoing craniotomy for tumor resection. Materials and methods: Data from the American College of Surgeons National Surgical Quality Improvement Program were used. Patients who underwent craniotomy for tumor resection between 2011 and 2019 were included. Perioperative characteristics and complications were compared among patients with and without chronic steroid therapy, defined as steroid use for at least 10 days. Multivariable regression analyses were conducted to assess the impact of steroid therapy on postoperative outcomes. Subgroup analyses involving patients on steroid therapy were conducted to explore risk factors of postoperative morbidity and mortality. Results: Of 27,037 patients, 16.2% were on steroid therapy. On regression analyses, steroid use was significantly associated with any postoperative complication, infectious complication, urinary tract infection, septic shock, wound dehiscence, pneumonia, non-infectious, pulmonary, and thromboembolic complications, cardiac arrest, blood transfusion, unplanned reoperation, readmission, and mortality. On subgroup analysis, risk factors for postoperative morbidity and mortality among patients on steroid therapy included older age, higher American Society of Anesthesiology physical status, functional dependence, pulmonary and cardiovascular comorbidities, anemia, dirty/infected wounds, prolonged operative time, disseminated cancer, and a diagnosis of meningioma. Discussion and conclusion: Preoperative brain tumor patients on steroids for 10 or more days are at a relatively high risk of postoperative complications. We recommend a judicious use of steroids in brain tumor patients, both in terms of dosage and duration of treatment.

Quality of life in children operated for spina bifida; low- and middle-income country perspective.

INTRODUCTION: Spina bifida is a potentially disabling congenital condition and affects the quality of life (QOL). We aimed to assess clinical outcomes and QOL in children who underwent spina bifida repair at our hospital. METHODS: This was a retrospective cohort study on children who underwent spina bifida repair at our hospital over 10 years. Phone calls were made to parents of the children, and the Health Utility Index Mark 3 (HUI 3) score was used to assess QoL, and degree of disability. Demographics and clinical data were obtained from the medical chart review. Statistical analysis was done using SPSS (version 21). RESULTS: Eighty children with a median age of 1.1 months (IQR 0.03-2.0) at the time of presentation, were included in this study. The mean follow-up period was 6.04 ± 2.54 years and the median HUI-3 score was 0.64 (IQR: 0.40 - 0.96) on a scale of 0 (dead) to 1 (perfectly healthy). Based on the severity of disability, 12 (23.1%) children had mild disability, 4 (7.7%) had moderate disability, and 23 (44.2%) had severe disability. Factors including a leaking spina bifida and paraplegia at presentation; radiological findings of hydrocephalus and Chiari malformation, were associated with a significantly low QOL. Children who required CSF diversion (EVD/ VP shunt) during the repair or at a later stage also had significantly low QOL. CONCLUSION: In LMIC, children with myelomeningocele (MMC) born with lower limb weakness, hydrocephalus, Chiari malformation, and those presenting with leaking MMC, have a significantly low QoL at a mean follow-up of 6 years.

Intracranial metastasis of testicular germ cell tumours.

Brain metastasis from testicular germ cell tumour (TGCT) is rare and represents only 2% of metastatic brain tumours. Although TGCTs have a good survival rate, the prognosis of brain metastasis is poor. Due to the rarity of the diagnosis, there are limited studies on the topic and a standardized treatment protocol does not exist. Surgical management has long been considered a positive prognostic factor; however, recent studies have investigated the impact of chemotherapy and radiotherapy in these patients. Current literature suggests multiplicity of brain lesions and treatment with chemotherapy or radiotherapy alone can have a poor impact on the prognosis of the disease. However, studies with larger cohorts are required to understand and develop the optimal treatment protocol for patients with brain metastasis from TGCT.

Psychosocial factors influencing quality of life in patients with primary brain tumors in Pakistan: an analytical cross-sectional study.

OBJECTIVE: Despite quality of life (QoL) being recognized as an important outcome in neuro-oncology, there is a lack of research from Pakistan where sociocultural differences may influence QoL. This study aimed to measure the QoL in patients with primary brain tumors (PBTs) and assess its association with mental health outcomes and social support. RESULTS: Our study included a total of 250 patients, with a median age of 42 years (range 33-54 years). The commonest brain tumors were glioma (46.8%) and meningioma (21.2). The mean global QoL of the sample was 75.73 ± 14.9. The majority of patients had high social support (97.6%) and were not depressed (90%) or anxious (91.6%). On multivariable linear regression, global QoL was inversely associated with no or low income (beta coefficients: -8.75 to -11.84), having hypertension (-5.53), currently using a urine catheter (-13.55), having low social support (-28.16) suffering from mild (-15.31) or symptomatic (-23.84) depression, or mild anxiety (-13.22).

Factors affecting well-being in brain tumor patients: An LMIC perspective.

Introduction: Brain tumor is a devastating and often fatal diagnosis; quality of life and patient well-being are important goals of treatment. This study addresses the gap in culture-specific literature exploring the needs and coping strategies of brain tumor patients within an LMIC setting. Methodology: A qualitative approach was undertaken using an exploratory descriptive study design. In-depth interviews were conducted to capture the perspective of 250 brain tumor patients at a private tertiary center followed by extensive content analysis to identify major themes and sub-themes across responses. Results: The analysis identified three major themes: (i) Factors affecting the lives of brain tumor survivors (BTSs) and their impact (ii) What works to improve QoL according to the survivors' perspectives, and (iii) Coping tactics & fostering healthy relationships. The need for financial navigation strategies improved patient-physician relationships, and reinforcing positive coping strategies were emphasized. Conclusion: In our population, family support and spiritual connection played an important role in helping patients mitigate the psychosocial burden of illness. However, financial concerns were pervasive and need to be addressed for better overall well-being.

Primary Cardiac Sarcomas: Risk of Brain Metastases and Management.

Primary cardiac neoplasms are very rarely encountered, and the most common type of malignant tumours occurring primarily in the heart are sarcomas. These carry a lethal prognosis on account of their late presentation and aggressive spread. They have a high propensity for cerebral metastases. Such cases are exceptionally uncommon, and till date only a few examples are available. Currently, there is no standard protocol for the management of primary cardiac sarcoma with brain metastases.

Effect of post-operative infections on glioblastoma outcomes.

Glioblastoma multiforme (GBM) is the most aggressive primary brain tumour with a poor prognosis. The risk of developing a post-operative infection after craniotomy is the highest in GBM patients. Historical beliefs suggest that post-operative infections render a survival advantage in GBM patients, however recent clinical neurosurgical reports involving large multicentric patient cohorts do not support this claim. Nonetheless, the relationship has not been extensively studied which poses the need for further large, scaled studies to determine the association between post-operative infections and survival benefit in GBM patients.