Atypical meningiomas compared to other WHO Grade 2 meningiomas: Histological features and prognosis.

OBJECTIVES: To study each atypical feature in atypical meningioma versus other grade 2 meningiomas and its possible relation to recurrence. METHODS: This is a retrospective study of patients with WHO grade 2 meningioma operated in our institution between 01/2008 and 12/2020. The rate of recurrence, reoperation and readmission were recorded during the follow-up period. A statistical analysis was done to determine the significance of each pathological feature in regard to recurrence. RESULTS: A total of 74 patients were included as WHO grade 2 meningioma with 60 (81%) patients having an AM and 14 (19%) patients with chordoid or clear cell meningioma. The mean age was 51 years±14. The most common location was meningioma abutting the frontal lobe (convexity). Major atypical features were more noted in the AM, however, there was no significant difference between AM and other types of meningioma. Increased Nuclear cytoplasmic ratio and cellularity were found significantly more in AM. The recurrence rate was 16.2%. No specific pathology feature (major or minor) nor the type of Grade 2 meningioma was significantly related to recurrence. CONCLUSION: The types of WHO grade 2 meningiomas have similar prognosis and recurrence rates. There is no significant difference between the atypical features in indicating a more aggressive nature or risk of recurrence in grade 2 meningiomas.

The utility of decompressive craniectomy in severe traumatic brain injury in Saudi Arabia trauma centers.

Background: Decompressive craniectomy (DC) represents an effective method for intracranial pressure (ICP) reduction in cases of severe traumatic brain injury (TBI). However, little is known regarding the attitude of practicing neurosurgeons toward decompressive craniectomy (DC) in Saudi Arabia.Objective: We aimed to explore the perspective on DC among neurosurgeons in Saudi Arabia.Methods: An electronic survey was distributed via e-mail to members of the Saudi Association of Neurological Surgery (SANS).Results: A total of 52 neurosurgeons participated in this survey. The majority of these neurosurgeons practice in a governmental (95.2%), tertiary hospital (75.5%) with academic affiliations (77.6%). Most surgeons (71.4%) agreed that the DC approach for managing refractory ICP is supported by evidence-based medicine. The majority of the participants choose to perform DC on a unilateral basis (80%). Interestingly, DC followed by duraplasty was performed by only 71% of these surgeons, with 29% of the respondents not performing expansive duraplasty.Conclusion: In Saudi Arabia, the utility of DC in cases of TBI with refractory intracranial hypertension has not been clearly defined among practicing neurosurgeons. The development of appropriate, widely adopted TBI guidelines should thus be a priority in Saudi Arabia to reduce variability among TBI care practices. In addition, a national TBI registry should be established for documenting different practices and longitudinal outcomes.

Endoscopic transnasal resection of optic pathway pilocytic astrocytoma.

PURPOSE: Optic pathway gliomas (OPGs) are low-grade neoplasms that primarily affect children. The management of OPGs remains controversial. Reports on the use of the endoscopic endonasal approach (EEA) in OPGs are extremely limited, and no such reports exist on its utility for pediatric OPGs. Here, we report our results and experience with OPGs treated with the EEA. METHODS: We retrospectively reviewed the medical records of OPG patients who were treated surgically via the EEA at our institutions from 2015 to 2017. Data on the demographics, clinical presentation, surgical complications, clinical outcomes, radiological imaging, and visual outcomes were recorded for each patient. RESULTS: Four cases were identified, with visual disturbances being the predominant complaint. The mean patient age was 15.5 years. Three cases showed normal preoperative hormonal profiles, but one patient had hypothyroidism. All tumors identified in this study were World Health Organization grade I pilocytic astrocytomas. Surgical complications included hypopituitarism in two patients, meningitis in two patients, cerebrospinal fluid leak in one patient, and transient diabetes insipidus in one patient. No patient experienced worsening neurological or visual symptoms postoperatively. CONCLUSIONS: Although our data are preliminary, the EEA provides a direct corridor to OPG with acceptable results in terms of tumor resection and visual outcomes. Hypothalamic-pituitary axis dysfunction remains a limitation of any treatment modality for OPGs and should be considered whenever possible. Definitive conclusions are pending as the learning curve of this approach is steep. Further work is needed to understand patient selection for such an approach.

Pediatric intracranial hypertension. Experience from 2 Tertiary Centers.

OBJECTIVE: To review the experience of 2 tertiary centers in Saudi Arabia with intracranial hypertension (IH) in the pediatric population. METHODS: We retrospectively reviewed and analyzed pediatric patients diagnosed with IH from June 2002 to May 2017 in 2 institutes. RESULTS: We identified 53 patients (30 females and 23 males) with a mean age of 7 years at the time of presentation. Among them, 41 patients were younger than 12 years, and 12 were older. Obese and overweight patients constituted 27.00% (n = 14) of all cases, 8 (66.7%) of whom were older than 12 years. The most common presenting feature was papilledema followed by headache. Vitamin D deficiency, which constituted the most common associated condition, was identified in 12 (22.6%) patients. Acetazolamide was the treatment option in 98.11% of patients, and only 5.7% underwent surgical interventions. The length of follow-up ranged from 6 months to 8 years. CONCLUSION: Intracranial hypertension is rare in children and commonly seen in overweight females older than 12 years similar to adults. Patients younger than 12 years tend to develop secondary IH. More studies are needed to characterize the clinical presentation and guide the management plan.

Visual Function Improvement After Optic Nerve Sheath Fenestration in Osteopetrosis Patients with Optic Canal Stenosis: A Report of Two Cases.

The outcome of two patients with visual loss from osteopetrosis who underwent an optic nerve sheath fenestration (ONSF) is reported. A 20-year-old male and 26-year-old female with osteopetrosis had optic nerve edema. Computed tomography and magnetic resonance imaging demonstrated optic canals stenosis. Both patients underwent unilateral ONSF. After ONSF, the patients experienced improvement in visual acuity and optic nerve appearance. Therefore, when papilledema is recognized in osteopetrosis patients, it may be reasonable to start with an ONSF even if the optic canal seems to be stenotic because of the lower morbidity that is associated with this procedure compared with other surgical options.

Hemorrhagic colloid cyst.

Colloid cysts are cystic lesions that are usually located in the anterior portion of the third ventricle near the foramen of Monro. Rarely, hemorrhagic cysts can lead to acute obstructive hydrocephalus or sudden death. We herein report 2 cases and a review literature. We examine a 47-year old male who presented with progressive headache and a 55-year old male who presented with progressive memory disturbance and unsteady gait. Both cases demonstrated typical imaging features of hemorrhagic colloid cyst, and were histopathologically confirmed. Total excision was achieved in both cases with good outcomes. Hemorrhagic colloid cysts are rare; however, bleeding tendencies should be carefully considered in patients with these cysts. The degree of rapidity with which clinical deterioration occurs may play a major role in the preferred treatment approach and subsequent outcomes.

Perioperative lumbar drain utilization in transsphenoidal pituitary resection.

OBJECTIVE: To evaluate lumbar drain (LD) efficacy in transnasal resection of pituitary macroadenomas in preventing postoperative cerebrospinal fluid (CSF) leak, technique safety, and effect on length of hospital stay. METHODS: We conducted a retrospective data review of pituitary tumor patients in our institution who underwent surgery between December 2006 and January 2013. All patients were operated on for complete surgical resection of pituitary macroadenoma tumors. Patients were divided into 2 groups: group 1 received a preoperative drain, while LD was not preoperatively inserted in group 2. In cases of tumors with suprasellar extension with anticipation of high-flow leak, LD was inserted after the patient was intubated and in a lateral position. Lumbar drain was used for 48 hours, and the drain was removed if no leak was observed postoperatively. In documented postoperative CSF leak patients with no preoperative drain, the leak was treated by LD trial prior to surgical reconstruction. Cases in which leak occurred 6 months postoperatively were excluded. RESULTS: Our study population consisted of 186 patients, 99 women (53%) and 87 men (47%), with a mean age of 50.3+/-16.1 years. Complications occurred in 7 patients (13.7%) in group 1 versus 21 (15.5%) in group 2 (p=0.72). Postoperative CSF leak was observed in 1 patient (1.9%) in group 1 and 7 (5%) in group 2 (Fisher exact test=0.3). Length of hospital stay was a mean of 4.7+/-1.9 days in group 1 and a mean of 2.7+/-2.4 days in group 2 (p<001). The most common reason to extend hospital stay was management of diabetes insipidus. CONCLUSION: Although LD insertion is generally considered safe with a low risk of complications, it increases the length of hospitalization. Minor complications include headaches and patient discomfort.

Brainstem encephalitis. A diagnostic dilemma.

Brainstem encephalitis (BE) is a rare, severe, and potentially life-threatening inflammation of the central nervous system. Brainstem encephalitis has multiple etiologies, which vary in treatment and outcomes. The current literature is generally focused on the infectious causes of BE, while little is known about the other entities, including cases with inconclusive diagnoses. Additionally, the outcomes of BE are not well documented. We present a case of an 18-year-old male who presented with progressive symptoms of brainstem involvement. His clinical investigations, including cerebrospinal fluid (CSF) analysis, were normal; magnetic resonance imaging (MRI) of the brain showed an enhancing medullary lesion, while tissue biopsy yielded no specific diagnosis. Multiple empirical treatments to address possible autoimmune and infectious processes were started with no significant improvement. He continued to deteriorate over a period of 12 weeks. Thereafter, following intensive supportive and rehabilitative care, he started to show slow signs of improvement.

Optimizing bevacizumab dosing in glioblastoma: less is more.

Compared to traditional chemotherapies, where dose limiting toxicities represent the maximum possible dose, monoclonal antibody therapies are used at doses well below maximum tolerated dose. However, there has been little effort to ascertain whether there is a submaximal dose at which the efficacy/complication ratio is maximized. Thus, despite the general practice of using Bevacizumab (BEV) at dosages of 10 mg/kg every other week for glioma patients, there has not been much prior work examining whether the relatively high complication rates reported with this agent can be decreased by lowering the dose without impairing efficacy. We assessed charts from 80 patients who received BEV for glioblastoma to survey the incidence of complications relative to BEV dose. All patients were treated with standard upfront chemoradiation. The toxicity was graded based on the NCI CTCAE, version 4.03. The rate of BEV serious related adverse events was 12.5% (n = 10/80). There were no serious adverse events (≥grade 3) when the administered dose was (<3 mg/kg/week), compared to a 21% incidence in those who received higher doses (≥3 mg/kg/week) (P < 0.01). Importantly, the three patient deaths attributable to BEV administration occurred in patients receiving higher doses. Patients who received lower doses also had a better survival rate, although this did not reach statistical significance [median OS 39 for low dose group vs. 17.3 for high dose group (P = 0.07)]. Lower rates of serious BEV related toxicities are noted when lower dosages are used without diminishing positive clinical impact. Further work aimed at optimizing BEV dosage is justified.

Idiopathic intracranial hypertension in males.

Idiopathic intracranial hypertension (IIH) is a neurological condition characterized by increased intracranial pressure without an underlying intracranial pathology. This condition is rarely encountered in men and it predominantly affects obese women of childbearing age. We present an interesting case of IIH in a male patient who presented with acute severe vision loss over 2 weeks and was successfully treated via surgery. Although IIH is less common in men than in women, men are more likely to develop vision loss, which is usually severe and less likely to respond to medical treatment. Therefore, surgical intervention might be considered early in the treatment of men with rapidly progressive visual loss. Further prospective studies are needed to evaluate the role of early surgical intervention in comparison to medical treatment in this group of patients.

Phase II pilot study of single-agent etirinotecan pegol (NKTR-102) in bevacizumab-resistant high grade glioma.

Patients with recurrence of high-grade glioma (HGG) after bevacizumab (BEV) have an extremely poor prognosis. Etirinotecan pegol (EP) is the first long-acting topoisomerase-I inhibitor designed to concentrate in and provide continuous tumor exposure throughout the entire chemotherapy cycle. Here we report results of a Phase 2, single arm, open-label trial evaluating EP in HGG patients who progressed after BEV. Patients age >18 with histologically proven anaplastic astrocytoma or glioblastoma (GB) who previously received standard chemo-radiation and recurred after BEV were eligible. A predicted life expectancy >6 weeks and KPS ≥ 50 were required. The primary endpoint was PFS at 6-weeks. Secondary endpoint was overall survival from first EP infusion. Response was assessed by RANO criteria. Single agent EP was administered IV every 3 weeks at 145 mg/m2. Patients did not receive BEV while on EP. 20 patients (90 % GB) were enrolled with a median age of 50 and median KPS of 70. Three patients with GB (16.7 % of GB) had partial MRI responses. 6-week PFS was 55 %. Median and 6-month PFS were 2.2 months (95 % CI 1.4-3.4 months) and 11.2 % (95 % CI 1.9-28.9 %) respectively. Median overall survival from first EP infusion was 4.5 months (95 % CI 2.4-5.9). Only one patient had grade 3 toxicity (diarrhea with dehydration) attributable to EP. Hematologic toxicity was mild. Three patients had confirmed partial responses according to RANO criteria. These clinical data combined with a favorable safety profile warrant further clinical investigation of this agent in HGG.

Awake craniotomy. A patient`s perspective.

OBJECTIVE: To report the personal experiences of patients undergoing awake craniotomy for brain tumor resection. METHODS: We carried out a qualitative descriptive survey of patients` experiences with awake craniotomies for brain tumor resection. The survey was conducted through a standard questionnaire form after the patient was discharged from the hospital. RESULTS: Of the 9 patients who met the inclusion criteria and underwent awake craniotomy, 3 of those patients reported no recollection of the operation. Five patients had auditory recollections from the operation. Two-thirds (6/9) reported that they did not perceive pain. Five patients remembered the head clamp fixation, and 2 of those patients classified the pain from the clamp as moderate. None of the patients reported that the surgery was more difficult than anticipated. CONCLUSION: Awake craniotomy for surgical resection of brain tumors was well tolerated by patients. Most patients reported that they do not recall feeling pain during the operation. However, we feel that further work and exploration are needed in order to achieve better control of pain and discomfort during these types of operations.

Endoscopic transtubular resection of a colloid cyst.

Colloid cysts, benign outgrowths from the roof of the third ventricle, warrant resection when they become symptomatic. Historically, this has been performed by craniotomy and a transcortical or a transcallosal approach that employs a pair of fixed blade retractors and an operating microscope. Less invasive endoscopic techniques have employed rigid endoscopes with single or dual working channels. We report the use of a tubular retractor as a transcortical port to resect a third ventricular colloid cyst. A 29-year-old woman presented with headache. The brain imaging demonstrated a third ventricular colloid cyst. We describe transcortical, transforaminal resection of a colloid cyst using stereotactically guided placement of a tubular retractor, endoscopic visualization, and bimanual dissection with traditional microinstruments. The increased range of viewing angles of the endoscope within the cylinder of access maintained by the tubular retractor facilitates resection of the cyst through a smaller opening.

Early Displacement of Reconstruction Material is a Predictor of Cerebrospinal Fluid Leak Post Endoscopic Skull Base Surgery.

BACKGROUND: The reconstruction technique and materials used for endoscopic skull base surgery (ESBS) are important factors in preventing cerebrospinal fluid (CSF) leak, a notable complication following this surgery. Visualizing the status of reconstruction early in the postoperative course can help determine the risk of postoperative CSF leak. Here, we aimed to determine if the radiological status of reconstruction post endonasal endoscopic surgery can predict postoperative CSF leak. METHODS: This retrospective study included patients who had undergone ESBS between 2015 and 2020. An early computed tomography (CT) scan (obtained within 24 hours of surgery) was utilized to evaluate the reconstruction and postoperative radiological changes, and its findings were correlated with the occurrence of postoperative CSF leaks. RESULTS: Our study included 11 (12.7%) out of 86 patients with CSF leaks. The type of reconstruction, construction material, and type of nasal packing were not identified as significant risk factors for CSF leaks. The location of the fat graft (placed properly vs. displaced out of the surgical cavity) was significantly associated with CSF leak (P = 0.001). All patients with a displaced solid reconstruction (n = 5), displaced septal flap (n = 6), signs of air continuation (n = 2), or significantly increased amount of air (n = 5) presented with a CSF leak (P < 0.001). CONCLUSIONS: Early postoperative CT scan is predictive of CSF leak. Displacement of the fat graft in early postoperative CT was the most important factor in predicting CSF leak. In this patient group, paying attention to radiological predictors of CSF leaks is important, supported by clinical findings.

A 55-Year-Old Woman Presenting with a Second Diagnosis of Craniopharyngioma Following Diagnosis and Successful Treatment of Craniopharyngioma as a 5-Year-Old Child.

BACKGROUND Craniopharyngioma is a rare, partly cystic embryonic malformation of the sellar and parasellar region and is usually benign. This report is of a 55-year-old woman presenting with a second diagnosis of craniopharyngioma following diagnosis and successful treatment of craniopharyngioma as a 5-year-old child. CASE REPORT Our patient was diagnosed with craniopharyngioma at age 5 when she presented with headaches accompanied by nausea and vomiting, decreased visual acuity, polyurea, and polydipsia for 6 months. She was found to have diplopia and grade II papilledema. A skull X-ray showed separation of the sutures and a calcified mass in the suprasellar region. A pneumoencephalogram showed extension of the tumor into the third ventricle. Surgery was performed via transcallosal approach followed by radiotherapy at 5000 rays. She was followed up clinically and radiologically and had been disease-free until age 55, when she presented with headache and facial numbness. On examination, she had right-eye Horner syndrome, decreased sensation in the right side of the face, diplopia, and grade 2 facial palsy. An MRI revealed interval significant recurrence of the craniopharyngioma at the sellar/suprasellar mass with extension to the right Meckel's cave and the right posterior fossa. On April 6, 2023, she underwent surgical resection through a right-sided craniotomy and Kawase approach. This was followed by CyberKnife radiation therapy. CONCLUSIONS This report has presented a rare recurrence of craniopharyngioma with a 50-year interval and has highlighted the challenges in the diagnosis and the multidisciplinary approach to patient diagnosis and management.

Suprasellar Meningioma Classification: Endoscopic Transnasal Perspective.

Objectives Midline suprasellar meningiomas include planum sphenoidale, tuberculum sellae, and diaphragma sellae meningiomas. Multiple classifications have been previously documented; however, they come with controversies and limitations, including those with surgical implications. The aim of this study was to classify suprasellar meningiomas based on their behavior toward the underlying bone and neurovascular structures. Methods Patients with newly diagnosed suprasellar meningiomas that underwent extended endoscopic transnasal approach between 2015 and 2021 were included in this study. The following parameters were evaluated: chiasmatic sulcus length, location of the optic chiasm and nerves, optic canal involvement, and vascular displacement. Results We identified 40 cases of midline suprasellar meningiomas, 1 diaphragma sellae meningioma (type A), 10 tuberculum sellae meningiomas (type B), 9 chiasmatic sulcus meningiomas (type C), and 10 planum sphenoidale meningiomas (type D). Asymmetrical visual complaints were most common in chiasmatic sulcus meningiomas, followed by tuberculum sellae meningiomas (66 and 50%, respectively). Chiasmatic sulcus meningiomas showed increased separation between the optic chiasm and the A1/A2 complex (8.9 mm) compared with tuberculum sellae (2.7 mm) and planum sphenoidale (1.9 mm) meningiomas. Compared with other types, increased chiasmatic sulcus length was observed in chiasmatic sulcus meningiomas. Conclusion Preoperative evaluation of bone involvement and tumor relation to neurovascular structures can be used to classify suprasellar meningiomas. Chiasmatic sulcus meningioma is a distinct subtype of suprasellar meningiomas. Its unique behavior toward nearby neurovascular structures could be of surgical value during tumor resection.

A Prospective Comparison Between Soft Tissue Dissection Techniques in Pterional Craniotomy: Functional, Radiological, and Aesthetic Outcomes.

BACKGROUND AND OBJECTIVES: Given the complex anatomy of the operative region and individual surgeon preferences, some techniques for soft tissue dissection before pterional craniotomy have gained more popularity than others. This prospective study used subjective and objective measurements to compare the functional, radiological, and aesthetic outcomes of 3 such dissection techniques. METHODS: This multicenter prospective cohort study included all patients who underwent elective pterional craniotomy between 2018 and 2020 at 3 centers in Riyadh, Saudi Arabia. All patients underwent 1 of 3 soft tissue dissection techniques: myocutaneous flap, interfascial, and subfascial dissection techniques. Clinical and radiological assessments were performed upon discharge and at the 3- and 6-month follow-ups. RESULTS: We included 78 patients, with a mean age of 44.9 ± 16.3 years. Myocutaneous flap, interfascial, and subfascial dissections were performed in 34 (43%), 24 (30%), and 20 patients (25%), respectively. The myocutaneous flap method had the shortest opening ( P = .001) and closure ( P = .005) times; tenderness was more evident in this group than in the others ( P = .05). The frontalis muscle was most affected in the interfascial dissection group ( P = .05). The frontalis nerve function was similar in all groups after 6 months ( P = .54). The incidence of temporomandibular joint dysfunction was highest in the myocutaneous flap group (29%). Decreased temporalis muscle thickness at the 6-month postoperative follow-up was most severe in the subfascial dissection group (12.6%), followed by the myocutaneous flap (11.9%) and interfascial dissection (9.9%) groups, with no significant difference ( P = .85). Temporal hollowing was more prominent in the myocutaneous flap group ( P = .03). Cosmetic satisfaction was highest in the interfascial dissection group, with no significant difference ( P = .4). CONCLUSION: This study provides important information for neurosurgeons in weighing the benefits and risks of each technique for their patients.

A New Sarcoma Shortly after Treatment for High-Grade Glioma with Adjuvant Chemoradiation: A Case Report.

Introduction: High-grade gliomas are central nervous system tumors conventionally treated with surgery followed by adjuvant chemoradiotherapy. Secondary cancer due to radiation therapy is a rare yet established phenomenon that typically occurs years after radiation therapy. Case Presentation: In this case, we discuss an early presentation of a second cancer adjacent to the radiation field. This case report is of a 52-year-old male who developed a new scalp sarcoma at the site of primary surgery 8 months after radiation therapy. Genetic testing revealed a heterozygous missense variant in the NF1 gene, a variant of uncertain significance. The report highlights that this case does not conform to the expected criteria for postradiation sarcoma in terms of timing. Conclusion: Secondary cancers may arise earlier than expected, even in phenotypically normal patients, as they may have unmanifested variants of relevant mutations. The question of pre-radiotherapy screening for radiosensitivity syndromes and diseases requires further study, as current data are limited and do not provide enough insight into the significance of different genetic variants.