A challenging case of endoscopic third ventriculostomy.

Background: Although controversial, endoscopic third ventriculostomy (ETV) in the management of Myelomeningocele and Chiari type II malformation-related hydrocephalous is gaining wider popularity and use. With variable success rates, it can be proposed as a first or second option after shunt malfunction. ETV in post-infectious hydrocephalus may also be considered as an alternative to shunting. With reported success rates of 50-60%, failure is attributed to anatomical reasons and/or to pathological subarachnoid space scarring that may result from infectious processes. Similarly, ETV in repeated shunt malfunctions is an acceptable option that may offer shunt independency. In all situations, case-by-case selection and discussion are to be considered. Case Description: A 5-year-old boy with a history of surgically treated lumbosacral myelomeningocele and ventriculoperitoneal shunting at six months of age is presented. During the course following the initial surgery, he experienced multiple shunt malfunctions, with two episodes of meningitis, leading to 7 shunt revision surgeries. Lately, the patient presented a large peritoneal cyst formation that needed regular evacuations. With a magnetic resonance imaging (MRI)-scan showing a large bi-ventricular hydrocephalus and a trapped third ventricle with multiple septations, surgical options included either ventriculoatrial shunting or third ventriculostomy. The latter option, offering shunt independency, was chosen after family consent and risk explanation. The expected success rate of the procedure was discussed and evaluated to 40-60% on the ETV success score. The video describes a step-by-step procedure with detailed radiological and correlated anatomical annotations of a completely distorted anatomy of a multifactorial hydrocephalous. No scarring at the prepontine cistern was observed. Shunt independency was achieved. However, the patient died from late postoperative status epilepticus and pulmonary complications. Whether these postoperative events are directly related to the procedure is unclear, although technically and clinically successful in the short term. Conclusion: We believe that ETV should be carefully indicated in selected patients with Chiari II, post-infectious hydrocephalus, by experienced hands, as the surgical anatomy can be extremely complex and misleading.

Asleep-awake-asleep versus hypnosis for low-grade glioma surgery: long term follow-up outcome.

BACKGROUND: Hypnosis-aided craniotomy is a safe alternative to standard asleep-awake-asleep (AAA) surgery in glioma surgery. The impact of these two anesthetic methods on tumor prognosis has never been assessed. OBJECTIVE: This study aimed to evaluate the possible impact of the type of sedation (i.e., hypnosedation vs. standard sedation) on postoperative outcomes in awake surgery for gliomas. METHODS: Adult patients who underwent awake surgery for a diffuse glioma, excluding glioblastomas, between May 2011 and December 2019 at the authors' institution were included in the analysis. Pearson Chi-square, Fisher exact, and Mann-Whitney U tests were used for inferential analyses. RESULTS: Sixty-one (61) patients were included, thirty-one were female (50.8 %), and the mean age was 41.8 years (SD = 11.88). Most patients had IDH mutated tumors (n = 51; 83.6%). Twenty-six patients (42.6%) were hypnosedated while 35 (57.4%) received standard AAA procedure. The overall median follow-up time was 48 months (range: 10 months-120 months). Our results did not identify any significant difference between both techniques in terms of extent of resection (sub-total resection >95% rates were 11.48% vs. 8.20%, OR = 2.2, 95% CI = 0.62-8.44; P = 0.34) and of overall survival (87.5% of patients in the AAA surgery group reach 9 years OS vs. 79% in the hypnosis cohort, cHR = 0.85, 95% CI = 0.12-6.04; P = 0.87). CONCLUSION: Hypnosis for awake craniotomy is rarely proposed although it is a suitable alternative to standard sedation in awake craniotomy for LGGs, with similar results in terms of extent of resection or survival.

Towards a collaborative-integrative model of education and training in neurosurgery in low and middle-income countries.

BACKGROUND: Neurosurgery inequity between High-Income Countries and Low- and Middle-Income Countries is striking. Currently, several models of education and training are available each has advantages and limitations. Our goal is to suggest an integrative model of Education and Training with international collaboration which will assure the most cost-effective Training Model. MATERIALS AND METHODS: The authors reviewed the literature narratively and examined in broad stroke the different existing models of international education and training programs to analyze their strengths, limitations, and cost-effectiveness in addressing the needs of Neurosurgery in Low and middle-Income Countries. RESULTS: Several international institutions have been involved in Education and Training in Global Neurosurgery. The most common models for international education include short-term surgical mission and boot camps, a full residency training program in HICs, and a full residency training Program in Local or regional World Federation of Neurosurgical Societies (WFNS) reference centers in Low and Middle-Income Countries, and online education. In Africa, both Local residency training centers and WFNS reference centers are available and provide full training programs in Neurosurgery. Among them, WFNS Rabat Training Center is the first established center in Africa in 2002. This program is supported by the WFNS Foundation and by the Africa 100 Project. Some of these education models face currently challenges such as sustainability, financial support, and ethical issues. CONCLUSION: Training neurosurgeons from Low and Middle-Income countries in local and regional WFNS Training centers might be the most cost-effective model of training that helps close the gap in neurosurgery. This training Model is duplicable and may be integrated into a global cohesive and collaborative model of education with international institutions.

Glioma dataset from Rabat: Clinicopathological, immunohistochemical and disease progression features of 32 Moroccan patients with diffuse Glioma.

The Moroccan Glioma Dataset contains the clinical data of 32 patients with glioma. The clinical data including demographic data (age, sex), tumor characteristics (tumor location, Glioma type, Karnofsky performance score, mitotic activity, cell density, necrosis, endotheliocapillary vascular proliferation, MRI contrast pick-up, corpus collosum infiltration and Oedema), treatment strategy (subtotal resection, gross resection, biopsy, radiotherapy, chemotherapy), expression pattern of tumor biomarkers (IDH1, HIF-1alpha, P53, Ki-67), and survival data (Kaplan-Meier curves for disease progression). The dataset can be used to relate tumor characteristics to tumor biomarkers and to predict disease progression for a better treatment management. The data were presented, analyzed, and described in the article "Immunohistochemical expression of HIF-1α, IDH1 and TP53: prognostic profile of Moroccan patients with diffuse glioma" published in Journal of Chemical Neuroanatomy [1].

Deep Brain Stimulation in Moroccan Patients With Parkinson's Disease: The Experience of Neurology Department of Rabat.

Introduction: Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is known as a therapy of choice of advanced Parkinson's disease. The present study aimed to assess the beneficial and side effects of STN DBS in Moroccan Parkinsonian patients. Material and Methods: Thirty five patients underwent bilateral STN DBS from 2008 to 2016 in the Rabat University Hospital. Patients were assessed preoperatively and followed up for 6 to 12 months using the Unified Parkinson's Disease Rating Scale in four conditions (stimulation OFF and ON and medication OFF and ON), the levodopa-equivalent daily dose (LEDD), dyskinesia and fluctuation scores and PDQ39 scale for quality of life (QOL). Postoperative side effects were also recorded. Results: The mean age at disease onset was 42.31 ± 7.29 years [28-58] and the mean age at surgery was 54.66 ± 8.51 years [34-70]. The median disease duration was 11.95 ± 4.28 years [5-22]. Sixty-three percentage of patients were male. 11.4% of patients were tremor dominant while 45.71 showed akinetic-rigid form and 42.90 were classified as mixed phenotype. The LEDD before surgery was 1200 mg/day [800-1500]. All patients had motor fluctuations whereas non-motor fluctuations were present in 61.80% of cases. STN DBS decreased the LEDD by 51.72%, as the mean LEDD post-surgery was 450 [188-800]. The UPDRS-III was improved by 52.27%, dyskinesia score by 66.70% and motor fluctuations by 50%, whereas QOL improved by 27.12%. Post-operative side effects were hypophonia (2 cases), infection (3 cases), and pneumocephalus (2 cases). Conclusion: Our results showed that STN DBS is an effective treatment in Moroccan Parkinsonian patients leading to a major improvement of the most disabling symptoms (dyskinesia, motor fluctuation) and a better QOL.

A sacral hydatid cyst mimicking an anterior sacral meningocele.

Hydatid disease is a zoonosis caused by Echinococcus granulosus. It is a progressive disease with serious morbidity risks. Sacral hydatid disease is very uncommon, accounting for < 11% of spinal hydatidosis cases. The diagnosis of a sacral hydatid cyst is sometimes difficult because hydatidosis can simulate other cystic pathologies. The authors report on 9-year-old boy admitted to their service with a paraparesis that allowed walking without aid. The boy presented with a 2-year history of an evolving incomplete cauda equina syndrome as well as a soft cystic mass in the abdomen extending from the pelvis. Radiological examination revealed an anterior meningocele. A posterior approach with laminectomy from L-5 to S-3 was performed. Three lesions with classic features of a hydatid cyst were observed and removed. The diagnosis of hydatid cyst was confirmed histopathologically. Antihelmintic treatment with albendazole (15 mg/kg/day) was included in the postoperative treatment. The patient's condition improved after surgery, and he recovered normal mobility. The unusual site and presentation of hydatid disease in this patient clearly supports the consideration of spinal hydatid disease in the differential diagnosis for any mass in the body, especially in endemic areas.

Long term outcome following mild traumatic brain injury in Moroccan patients.

PRIMARY OBJECTIVES: To describe the symptoms of chronic post-concussion syndrome (PCS) and to investigate the relationship between the persistence of these symptoms and different aspects of social life (return to work, quality of life, sport and leisure activities and family relationships) in Moroccan patients with mild traumatic brain injury (MTBI), one year after the trauma. METHODS: Forty-two adult patients who sustained MTBI were reviewed one year after trauma. We investigated the persistence of PCS by using the "Problem Checklist" questionnaire. We also assessed their quality of life using a visual analogue scale, and noted the changes in employment status, social activities and family relationships. Then, we examined whether there were significant relationships between these different data. RESULTS: More than half of the patients (n=23, 54.8%) were found with persistent post-concussion symptoms at one year post-injury. Chronic PCS was significantly more common in married persons (p=0.008) and significantly related to both non return to work (p≤0.01), and QoL deterioration (p≤0.001). CONCLUSION: In this study, a large proportion of persons who sustained a MTBI experienced persistent symptoms up to one year after trauma. MTBI might have significant and lasting impact on the quality of life, which is to be verified by further studies.