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.

Dosimetric effects of embolization material artefacts in arteriovenous malformations stereotactic radiosurgery on treatment planning calculation.

Background and Purpose: Stereotactic Radiosurgery (SRS) is a specialized radiotherapy treatment technique for Arteriovenous Malformations (AVM) in which Computed Tomography (CT) images are used for dose calculations. The purpose of this study was to investigate CT image distortions caused by embolic agents and quantify the influence of these distortions on dose calculations. Methods: Eight AVM patients administered embolic agents prior to SRS were included. Original plans were compared to new recalculated plans using two sets of images. The first set was created by masking the embolic material and artefacts, the second was the diagnostic CT images. In addition, treatment plans were created for an anthropomorphic phantom with water inserts, then with known volumes of embolic materials to study the dosimetric effect of each material. Results: Relative to patients' original plans, maximum Monitor Unit (MU) difference was -4.4% with whole brain masking, -1.3% with artefact masking, -4.1% with embolic masking, and -4.5% with artefact-free diagnostic images. Calculated dose differences were within ± 3.5% for all plans. In phantom, Gamma pass rate was 96% for both embolic agents with conformal fields and 99.9% with dynamic arcs. Dose and MU differences in phantom plans were negligible. Conclusion: Relative dose differences between the original plans and the corrected ones were not clinically remarkable. We recommend evaluating the effect of embolic materials on individual patients' plans. The whole brain corrected planning CT images or diagnostic CT images could be utilized to calculate the magnitude of dose reduction caused by embolic materials and correct it if necessary.

Medial Extension of Medial Sphenoid Wing Meningioma from the Anterior Clinoid Line: Does It Truly Affect the Surgical Outcome?

Background Medial sphenoid wing meningiomas (MSWMs) account for approximately 20% of all meningiomas that are known for their critical relation to neurovasculture structures. Objective The purpose of this study is to examine the relation between the maximum diameter of the MSWM medial to the anterior clinoidal line (AC line) and surgical outcome. Methods This is a retrospective cohort study investigating all surgically resected MSWM cases at our institution over 10 years. The patients were divided into groups A and B based on the average ratio between the maximum medial extension of the MSWM from the AC line to the maximum diameter of the tumor, that is, value I = 0.42 (group A ≤ 0.42 and group B > 0.42). And into groups C and D based on the average medial extension of the tumor, that is, 14 mm (group C ≤ and D group D > 14 mm). These measurements were correlated with patients' demographics, preoperative symptoms, and postoperative assessment. Results Among 150 patients, 51patients had MSWM that fulfilled the inclusion criteria. Among them, 76.47% were females with a median age of 48 years (standard deviation [SD] = 47.75 ± 15.11). Also, 92% of the cases were World Health Organization (WHO) grade I. The follow-up period was 0.5 to 10 years. Among them, 40% of group C had gross total resection (GTR), whereas 43% in group D. In group B, 70% had GTR, whereas 48% had GTR in group A. None of the patients developed statistically significant postoperative complications. There is no statistically significant difference in the risk complication with medial extension in all groups. Conclusion The degree of medial extension of MSWM from the AC line has no statistically significant correlation with major postoperative complications, extent of resection, or clinical outcome.

A potential new brainstem reflex: The oculoglossal phenomenon.

BACKGROUND: A synchronized involuntary movement of the tongue to the same side as voluntary movements of the eyes, termed the oculoglossal phenomenon, has been observed. A description of the hypothesized pathway of this phenomenon could guide the development of a rapid clinical evaluation of the long segment of the brainstem and help facilitate further studies to establish a new reflex, if possible. The aim of this study is to describe and propose the simple concept of this pathway/phenomenon, the oculoglossal phenomenon. METHODS: This is an observational study. Of a newly observe brainstem phenomenon evaluated on a subject at the National Neuroscience Institute in king Fahad Medical City (KFMC), Riyadh, Saudi Arabia. After being observed incidentally in a single patient, 60 participants were tested between January and March 2020 to confirm the presence of the phenomenon. Each subject was instructed to protrude the tongue and then move their eyes horizontally to the side. If the tongue simultaneously and involuntarily moved to the same side as the eyes, the test was deemed confirmatory. A literature review was performed, and possible anatomical pathway was proposed. RESULTS: The oculoglossal reflex was present in most (50/60, 83.3%) of the subjects. Our proposed pathway begins at the frontal cortex, followed by a projection to the paramedian pontine reticular formation, then to the contralateral medial longitudinal fasciculus and bilaterally to the hypoglossal nuclei. CONCLUSION: An accurate description of this phenomenon could lead to additional studies and possibly establishing it as a legitimate reflex, thus conceivably adding a new tool in the neurological examination to evaluate the brainstem's integrity.

How Reliable Is the Intraoperative Computed Tomography Angiography in Assessing Complete Surgical Resection of Cerebral Arteriovenous Malformations?

BACKGROUND: Digital subtraction angiography (DSA) is still considered the gold standard test to evaluate arteriovenous malformation's (AVM) residual after microsurgical resection. OBJECTIVE: To evaluate the safety and reliability of intraoperative computed tomography angiography (iCTA) as an immediate method of evaluating the surgical results of AVM resection. METHODS: We performed a retrospective review for all cases of cerebral AVMs at our institute from January 2015 to April 2020 who underwent surgical resection of cerebral AVM and had iCTA. All included patients underwent a postoperative DSA, and the results were compared with iCTA. RESULTS: Twenty-eight cases were included. All cases showed complete resection (100%) in the iCTA, and the results were consistent with the postoperative DSA results. The sensitivity of iCTA was 100%. The added operative time ranged from 25 to 30 min. There were no complications related to the use of iCTA. CONCLUSION: Intraoperative assessment of AVMs surgical results with an iCTA is safe and reliable. The sensitivity of iCTA following AVM resection merits further investigations.

Atorvastatin in combination with radiotherapy and temozolomide for glioblastoma: a prospective phase II study.

Glioblastoma is a fast-growing primary brain tumor observed in adults with the worst prognosis. Preclinical studies have demonstrated the encouraging anticancer activity of statins. This study evaluated the efficacy of atorvastatin in combination with standard therapy in patients with glioblastoma. In this prospective, open-label, single-arm, phase II study, patients were treated with atorvastatin in combination with the standard glioblastoma therapy comprising radiotherapy and temozolomide. The primary endpoint was progression-free survival (PFS) at 6 months (PFS-6). Among 36 patients enrolled from January 2014 to January 2017, the median age was 52 (20-69) years; 22% of the patients were aged ≥60 years, and 62% were male. Patients received atorvastatin for a median duration of 6.2 (0.3-28) months. At a median follow-up of 19 months, the PFS-6 rate was 66%, with a median PFS of 7.6 (5.7-9.4) months. In terms of Grade ≥ 3 hematological adverse events, thrombocytopenia and neutropenia occurred in 7% and 12% of patients, respectively. In multivariate analyses, high baseline low-density lipoprotein levels were associated with worse survival (P = 0.046). Atorvastatin was not shown to improve PFS-6. However, this study identified that high low-density lipoprotein levels are an independent predictor of poor cancer-related outcomes. Future clinical trials testing statins should aim to enroll patients with slow-growing tumors.Clinical trial information: NCT0202957 (December 12, 2013).

Bibliometric Analysis of the Top 100 Most Cited Articles on Cerebral Vasospasm.

OBJECTIVE: Bibliometric analysis reflects the scientific recognition and influential performance of a published article within its field. Our aim is to identify and analyze the top 100 most-cited articles on cerebral vasospasm. METHODS: A title-specific search was carried out using the Scopus database. The top 100 cited articles including the keywords "Cerebral Vasospasm" AND "Vasospasm" were retrieved and stratified in a descending order: title, authors, institution, publishing journal, country of origin, year of publication, and topic of each article were studied. RESULTS: The top 100 articles have an accumulative citation count of 20,972, with 209 average citations per article. Publication dates ranged from 1968 to 2012, with the most productive years between 1998 and 2005. Clinical studies are the most frequent category, followed by pathophysiology. The list includes 7 clinical trials, which received accumulative citations of 1525. The top cited article had received 2109 citations, with 52.7 citations per year. The top 100 articles were published across 14 countries, with most originating from the United States. The lead research institution was the University of Alberta. The most used journal was Journal of Neurosurgery. CONCLUSIONS: Bibliometric analysis has garnered major interest in recent years. It shows the publication trends, knowledge evolution, and evidence-based practice throughout the years. The collection of highly cited articles may assist physicians in gaining a better understanding of the nature of cerebral vasospasm and optimize their clinical practice.

Classification of internal carotid artery injuries during endoscopic endonasal approaches to the skull base.

BACKGROUND: Internal carotid artery (ICA) injuries are a major complication of endoscopic endonasal approaches (EEAs), which can be difficult to manage. Adding to the management difficulty is the lack of literature describing the surgical anatomical classification of these types of injuries. This article proposing a novel classification of ICA injuries during EEAs. METHODS: The classification of ICA injuries during EEAs was generated from the review of the literature and analysis of the main author observation of ICA injuries in general. All published cases of ICA injuries during EEAs in the literature between January 1990 and January 2020 were carefully reviewed. We reviewed all patients' demographic features, preoperative diagnoses, modes of injury, cerebral angiography results, surgical and medical management techniques, and reported functional outcomes. RESULTS: There were 31 papers that reported ICA injuries during EEAs in the past three decades, most studies did not document the type of injury, and few described major laceration type of it. From that review of the literature, we classified ICA injuries into three main categories (Types I-III) and six sub-types. Type I is ICA branch injury, Type II is a penetrating injury to the ICA, and Type III is a laceration of the ICA wall. The functional neurological outcome was found to be worse with Type III and better with Type I. CONCLUSION: This is a novel classification system for ICA injuries during EEAs; it defines the patterns of injury. It could potentially lead to advancements in the management of ICA injuries in EEAs and facilitate communication to develop guidelines.

Efficacy of routine post-operative head computed tomography on cranial surgery patients outcome.

OBJECTIVE: To identify the role of routine postoperative head CT in changing postoperative management after elective craniotomies. METHODS: We conducted a retrospective study on adult patients who underwent cranial surgery. Exclusion criteria includes cranial CTs done postoperatively for urgent clinical indications, pediatric patients, CSF diversion procedures and sedated patients. Patients were placed into "positive" group if the physical assessment changed from the baseline in the form of clinical deterioration, and the "negative" group if the exam did not change. The data then were analyzed to identify which patients needed further medical or surgical management based on CT findings only with "negative" physical examination. RESULTS: Total of 222 were included in the study. 151 patients had negative physical examination. Only 8 out of 151 patients had positive CT findings. Two patients out of 222 (0.9%) had a negative physical exam and positive CT findings that required additional action that wouldn`t be done urgently without routine postoperative brain CT. Only one patient out of 222 (0.4%) who was re-operated urgently based CT findings only and negative physical examination. CONCLUSION: Routine postoperative routine brain CT did not alter the course of medical management, even in the presence of significant radiological findings.

Radiation Induced Multiple Skin Neoplasms Following Craniospinal Irradiation for Medulloblastoma. A Case Report.

BACKGROUND Following craniospinal irradiation in children with medulloblastoma, secondary neoplasms are among the most serious long-term sequelae that include leukemias and solid tumors of the urinary or digestive tracts, thyroid, skin, and central nervous system. Furthermore, in children with Gorlin syndrome following craniospinal irradiation for medulloblastoma, there is a rising incidence of skin and non-skin malignancies. CASE REPORT The patient in the present study was a 19-year-old female who was treated with craniospinal irradiation and chemotherapy following gross total resection (GTR) for medulloblastoma at the age of 4 years. Fifteen years later, she developed a primary adnexal tumor at the medial aspect of her left thigh, glomangioma at the skin of her upper abdomen, dermatofibrosarcoma protruberans at the skin of her upper back, and Kaposiform hemangioendothelioma of the upper abdomen. All these tumors were successfully managed with radical resection without further adjuvant treatment. CONCLUSIONS Metachronous of development of 4 histopathologically different skin tumors following craniospinal irradiation for medulloblastoma in long-term survivors has not previously been reported. The present case warrants a detailed dermatological periodic inspection in such patients.

Familial hypercholesterolemia with bilateral cholesterol granuloma: A case series.

INTRODUCTION: Cholesterol granuloma is a benign mass that commonly involves the petrous apex but rarely affects other structures, such as the mastoid cavity. It is diagnosed histologically by the presence of giant cells, and Its management is individualized based on some factors such as the size and location of the lesion. PRESENTATION OF CASE: The first case was a 33-year-old man who presented to the outpatient clinic with a two-year history of right-sided pulsatile tinnitus, hearing loss, and vertigo. Upon investigations, a large, destructive mass in the tympanomastoid region was found and managed surgically. The other case was for a 41-year-old man who presented to the emergency department with loss of consciousness. Urgent CT was done and revealed an aggressive hypodense posterior fossa mass destroying the right temporal bone that was managed surgically. DISCUSSION: In this report, we describe two patients with familial hypercholesterolemia who developed bilateral cholesterol granuloma that were managed surgically. CONCLUSION: These cases are reported because of their rare location and presentation since few cases of bilateral cholesterol granuloma have been reported in the literature.

Minimally Invasive Syringe Brain Port for Deep-Seated Lesions: How to Make the System and Surgical Video.

Brain retraction is crucial for adequate exposure during many intracranial procedures. It facilitates the access to the area of interest inside the brain and gives the surgeon the ability to create a corridor to visualize the deeply seated lesions. Retraction-related injury is a well-known complication. A minimally invasive retraction system has been invented and modified to improve the downside of retraction and overcome the complications. The syringe brain port system is a transtubular system composed of simple tools that are available in all medical facilities. It can help the neurosurgeons to achieve brain retraction in a safe, simple, and cost-effective technique. We are presenting a video of how to make this system. Also, we are demonstrating an intraoperative application of this system in a case of a 36-year-old male with deep-seated recurrent right frontal glioblastoma multiforme grade IV.

Supratentorial Craniotomies with or without Dural Closure-A Comparison.

BACKGROUND: Dural closure is a routine surgical step in neurosurgery. The benefit of suturing the dura to achieve watertight closure-with or without the use of dural substitutes-has been questioned in supratentorial craniotomy. We performed a retrospective study to examine the possible benefits and harms of suturing the dura compared with no dural closure and the occurrence of postoperative infection, cerebrospinal fluid (CSF) leak, and postcraniotomy headaches. METHODS: We performed a retrospective study to compare the incidence of CSF leak, infection, surgical site swelling, and postcraniotomy headaches between patients with watertight dural closure (closed group) and patients without watertight dural closure (open group). Any method used to close the dura and to achieve watertight closure was included, whether primary or secondary closure (with or without using suturable dural substitute). RESULTS: Overall, 216 patients were included in the present study, with 112 patients in the open group and 114 in the closed group. The open group experienced a greater incidence of infection and CSF leak (6 in the open group vs. 2 in the closed group), but without statistical significance (P = 0.15). We found no difference in surgical site swelling (P = 0.29). However, the closed group showed a greater association with the development of postcraniotomy headaches (P = 0.001). CONCLUSION: We found no difference in the occurrence of CSF leak, infection, or surgical site swelling between the closed and open groups. The incidence of postcraniotomy headaches was greater in the closed group, and the difference was statistically significant.

Meningioma Consistency: Correlation Between Magnetic Resonance Imaging Characteristics, Operative Findings, and Histopathological Features.

INTRODUCTION: Intracranial meningiomas account for 30% of all primary intracranial tumors. Surgical resection remains the mainstay of the treatment for meningiomas. The magnetic resonance of intracranial meningiomas has been largely discussed in many reports of the radiological and neurosurgical literature. To date, a few studies have been attempted to differentiate the tumor characteristics of meningiomas based on magnetic resonance imaging (MRI) studies. OBJECTIVE: The objective of the study is to evaluate the relationship between MRI signal characteristics of intracranial meningiomas and consistency of tumor using objective measures. MATERIALS AND METHODS: A prospective study included all the patients who were admitted for surgery with an MRI finding suggestive of meningioma. All patients were subjected to routine radiological investigations. Surgical resection was performed for patients eligible for surgery using cavitron ultrasonic aspirator (CUSA). The relationship and correlation between the radiological, intraoperative measurements and the histopathological diagnosis were studied. The tumor consistency was measured using mean CUSA level. Intensity on T2, fluid-attenuated inversion recovery (FLAIR), and diffusion-weighted imaging (DWI) was measured using circular regions of interest (ROI) on the MRI. Multiple ROIs were placed initially on the lesions avoiding the obvious blood vessels, if any, then on the brain cortex to avoid the vasogenic edema. The mean ROI (mROI) results from the lesion were subtracted from the mean ROI from the brain cortex for each lesion to achieve normalized ratio. The results of lesion mROI-cortex mROI were compared to the operative and histopathology results using Pearson's correlation test and linear regression test. RESULTS: The total number of patients was seventy. The mean age of the patients was 51 ± 14.8, with 72% of them being females and 28% males. There was a strong statistically significant (P = 0.046) and (P = 0.003) correlation between mean CUSA and FLAIR mROI difference or T2 mROI difference, respectively. On the other hand, there was an inversely proportional relationship between mean CUSA and FLAIR mROI difference and mean CUSA and T2 mROI difference. The value of the regression test (r) shows that there was a slight linear relationship between FLAIR mROI difference or T2 mROI difference and mean CUSA values, in which the mean CUSA value = 50.1 + (-0.088) × FLAIR mROI difference (r = -0.273, P = 0.046) or mean CUSA value = 50.8 + (-0.055) × T2 mROI difference (r = 0.4, P = 0.003). There was no statistical significance in the relation between CUSA values and tumor histological subtypes, DWI values, age, or gender. CONCLUSION: This study presents a new objective method to measure the consistency of intracranial meningiomas based on a simple algorithmic formula. Such information will aid in planning surgery and assessing the resectability of the tumor. To date, this is the first objective measurement of meningioma consistency based on MRI studies and objective intraoperative evaluation.

Atypical Teratoid/Rhabdoid Tumor of the Sellar Region in an Adult With Long Survival: Case Report and Review of the Literature.

Atypical teratoid/rhabdoid tumor (AT/RT) is a highly malignant central nervous system neoplasm usually diagnosed in young children, although it can occur in adults. Prognosis for AT/RT is poor, with a median survival of 10 - 11 months. We report a rare case of adult sellar and suprasellar AT/RT in a 36-year-old female patient. She was treated with multi-modalities including surgery, chemotherapy and radiation. She markedly improved following treatment with no recurrence in 3 years follow-up. To our knowledge, this is the 11th case of an adult-onset AT/RT in the sellar or suprasellar region with favorable long-term outcome.

Familial Intracranial Aneurysms in Saudi Arabia: What Do We Need To Do?

Aneurysmal subarachnoid hemorrhage (SAH) is a devastating event with significant morbidity and mortality. The incidence of SAH might be influenced by environmental factors but genetic predisposition is evolving as an important effector in the risk of development of intracranial aneurysms and rupture of aneurysms. This requires strategies for effective screening of family members at risk of developing such a phenotype, in order to deliver preventive treatment to these target lesions. We discuss the potential for implementing these strategies in the Saudi Arabian health system and the future implications on our care for such a vulnerable group of subjects.

The impact of size and location on rupture of intracranial aneurysms.

OBJECTIVE: For effective management of patients with unruptured intracranial aneurysms, prognostic criteria for rupture, of which aneurysm size, location, and multiplicity are key factors. The aim of this study is to determine the correlation between the aneurysm size, location, and multiplicity, and their effect on aneurysmal rupture. MATERIALS AND METHODS: Eighty one patients with diagnosis of intracranial aneurysms were managed at our center from January 2008 through July 2011. The characteristics of aneurysms, such as size, location, multiplicity, and presentation were retrospectively reviewed from their charts and radiological findings. RESULTS: Eighty one patients harboring 104 aneurysms were diagnosed, of them 45 were males (55.5%) and 36 were females (44.5%). Seventy-six patients (94%) presented with subarachnoid hemorrhage (SAH) due to ruptured aneurysm. Thirty-three patients who were presented with SAH (43%) had their ruptured aneurysm located at the anterior communicating artery with a mean size 5.8 mm. Most of the small (<7 mm) ruptured aneurysms were located at the anterior communicating artery, distal anterior cerebral arteries, posterior communicating arteries, and internal carotid artery bifurcation (51%, 13%, 11%, and 11%), respectively. There were 24 small unruptured aneurysms, 10 of them (42%) located at the middle cerebral arteries, while only 2 of them (8%) located at the anterior communicating artery. CONCLUSIONS: The aneurysm size and location play a substantial role in determining the risk of rupture. The most common location of rupture of small aneurysms was the anterior communicating artery, while the middle cerebral artery was the commonest site for small unrupured aneurysms.

Factors that predict hydrocephalus following intraventricular hemorrhage.

OBJECTIVE: To evaluate potential risk factors that can predict the development of hydrocephalus (HCP) in adult patients with intraventricular hemorrhage (IVH). METHODS: Retrospective analysis of all adult patients presented to King Fahad Medical City between 2004 and 2011 with intraventricular hemorrhage to evaluate different variables and their association with HCP. RESULTS: A total of 31 patients were included in the study, 14 patients (45.16%) developed HCP. Seventy-four percent of HCP patients (10 out of 14) had Graeb classification of ≥6 and/or had IVH affecting all ventricles, while 76% of the patients without HCP (13 out of 17) had a Graeb classification of <6 and/or had IVH only in the lateral ventricles (8 out of 17) or lateral ventricles and either third or fourth ventricle (5 out of 17). Statistical analysis showed that HCP is significantly associated with both Graeb classification of 6 or greater number of IVH affecting all ventricles and 3 versus 1-2 affected ventricles; (OR (95% CI, p value), respectively, 19.3(2, >20), p value<0.05; 8.5 (1.6, >30), p value<0.05. CONCLUSION: HCP following IVH is present in approximately half of all IVH cases. In the present retrospective study, it was found that patients with higher grades of IVH and/or a greater number of affected ventricles had a greater risk of developing HCP.

Primary burkitt lymphoma of the fourth ventricle in an immunocompetent young patient.

Primary Burkitt lymphoma of the central nervous system (CNS) is rare, with only few cases reported in the literature. An 18 year-old immunocompetent male presented with multiple cranial nerves palsies and was found to have a mass predominantly in the 4th ventricle of the brain. Tumor was surgically removed and showed morphological and immunohistochemical features consistent with Burkitt lymphoma. The patient responded very well to anthracycline based chemotherapy with high dose methotrexate (HD MTX) and intrathecal (IT) chemotherapy delivered by Ommaya reservoir. Primary Burkitt lymphoma of the CNS is a rare entity that poses differential diagnostic challenge with other small round blue cell tumors.