Decompressive craniectomy in children: indications and outcome from a tertiary centre.

INTRODUCTION: The role of decompressive craniectomy (DC) is as a rescue therapy for the treatment of intracranial hypertension. The indications for the DC are variable. METHODS: The clinical details, imaging, operative findings and follow-up data of children less than or equal to 18 years of age were reviewed for more information on the children who underwent DC in the last 5 years. RESULTS: During the study period, a total of 128 children underwent DC. The trauma cases were 66, and the non-trauma cases were 62. The common indication for DC was pure acute subdural hematoma 33 (50%), followed by contusion 10 (15%) in the trauma group, and in non-trauma, arterial infarction in 20 (32%) and cerebral venous thrombosis in 17 (27%). Hemicraniectomy was done in 114 (89%), and bifrontal craniectomy was done in 7 (5.4%) cases. The median duration follow-up was 7 months in non-trauma and 6 months in trauma. GCS was less than 8, the motor score was less than 3, and pupillary asymmetry, hypotension and basal cistern effacement were factors related to an unfavourable outcome in the non-trauma group. In regression analysis, only a motor score of less than three was associated with the non-trauma group. Age less than 10 years, GCS less than 8, motor score less than three and preoperative infarction were the predictive factors in univariate analysis, and only GCS less than 8 was the predictive factor for unfavourable factors in regression analysis in the trauma group. CONCLUSION: The DC is performed as a lifesaving procedure. The unfavourable outcome is slightly higher in non-trauma cases compared to trauma cases. However, the mortality rate is high in trauma cases.

Incidence, predictors, and impact of acute post-operative pain after cranial neurosurgery: A prospective cohort study.

Objectives: Pain is common after craniotomy. Its incidence and predictors in developing nations are not adequately studied. We aimed to assess the incidence, predictors, and impact of acute post-operative pain after intracranial neurosurgeries. Materials and Methods: This prospective observational study was conducted in adult patients undergoing intracranial neurosurgeries. After patient consent, ethics committee approval, and study registration, we assessed the incidence of post-operative pain using numerical rating scale (NRS) score. Predictors and impact of pain on patient outcomes were also evaluated. Results: A total of 497 patients were recruited during 10-month study period. Significant (4-10 NRS score) post-operative pain at any time-point during the first 3 days after intracranial neurosurgery was reported by 65.5% (307/469) of patients. Incidence of significant pain during the 1st post-operative h, on the 1st, 2nd, and 3rd post-operative days was 20% (78/391), 50% (209/418), 38% (152/401), and 24% (86/360), respectively. Higher pre-operative NRS score and pain during the 1st h post-operatively, predicted the occurrence of pain during the first 3 days after surgery, P = 0.003 and P < 0.001, respectively. Pain was significantly associated with poor sleep quality on the first 2 post-operative nights (P < 0.001). Patient satisfaction score was higher in patients with post-operative pain, P = 0.002. Conclusion: Every two in three patients undergoing elective intracranial neurosurgery report significant pain at some point during the first 3 postoperative days. Pre-operative pain and pain during 1st post-operative h predict the occurrence of significant post-operative pain.

Association between patient characteristics and dissatisfaction after cranial neurosurgery: A prospective observational study.

Objectives: Patient satisfaction is an indicator of the quality of healthcare. It can improve treatment adherence and health outcomes. This study aimed to determine the incidence, predictive factors, and impact of post-operative patient dissatisfaction with perioperative care after cranial neurosurgery. Materials and Methods: This was a prospective observational study conducted in a tertiary care academic university hospital. Adult patients undergoing cranial neurosurgery were assessed for satisfaction 24 h after surgery using a five-point scale. The data regarding patient characteristics that may predict dissatisfaction after surgery were collected along with ambulation time and hospital stay. Shapiro-Wilk test was used to assess normality of data. Univariate analysis was performed using Mann-Whitney U-test and significant factors were entered into binary logistic regression model for identifying predictors. The level of significance was set at P < 0.05. Results: Four hundred and ninety-six adult patients undergoing cranial neurosurgery were recruited into the study from September 2021 to June 2022. Data of 390 were analyzed. The incidence of patient dissatisfaction was 20.5%. On univariate analysis, literacy, economic status, pre-operative pain, and anxiety were associated with post-operative patient dissatisfaction. On logistic regression analysis, illiteracy, higher economic status, and no pre-operative anxiety were predictors of dissatisfaction. The patient dissatisfaction did not impact ambulation time or duration of hospital stay after the surgery. Conclusion: One in five patients reported dissatisfaction after cranial neurosurgery. Illiteracy, higher economic status, and no pre-operative anxiety were predictors of patient dissatisfaction. Dissatisfaction was not associated with delayed ambulation or hospital discharge.

Effect of Helicopter Transportation of Acute Ischemic Stroke Patients on Mortality and Functional Outcomes: A Systematic Review and Meta-Analysis.

OBJECTIVE: The "time is brain" concept denotes the importance of the expedited transfer of patients to stroke care centers. Helicopter emergency medical services (HEMS) can reduce the time to definitive care, which could improve neurologic prognosis and reduce mortality. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, a search for randomized controlled trials, nonrandomized controlled trials, and prospective and retrospective cohort studies was performed through specific databases from inception to February 2020. Helicopter, acute stroke, and their synonyms (according to Medical Subject Headings) were included in this search. The Newcastle-Ottawa Scale was used to assess the quality of the included studies, and the Egger test was used to assess for publication bias. RESULTS: A total of 8 studies matched the inclusion criteria and were included for meta-analysis. The overall number recruited for helicopter transportation was 1,372, and for emergency standard transportation, it was 8,587. The association among HEMS and mortality was not statistically significant (odds ratio [OR] = 0.7; 95% confidence interval [CI], 0.60-1.06; P = .12). There was a significant association between good outcomes and HEMS (OR = 2; 95% CI, 1.79-2.34; P ≤ .001), and the overall poor neurologic outcome was reduced (OR = 0.52; 95% CI, 0.46-0.60; P ≤ .001). CONCLUSION: A good neurologic outcome was higher with HEMS compared with emergency standard transportation. The mortality rate was less in the emergency standard transportation group after pooled analysis but was not significant; the reduction in a poor outcome was statistically significant.

Pilocytic astrocytoma with spontaneous malignant transformation with intracranial and skeletal dissemination: case report and review of the literature.

Pilocytic astrocytoma is a benign low-grade tumor with a favorable prognosis. We present a 47-year-old- lady with a posterior fossa pilocytic astrocytoma who underwent surgical decompression. She developed multiple early local recurrences Along with malignant transformation of the cranial lesion she developed skeletal dissemination within a very short time frame. There were no features or family history of neurofibromatosis 1. She did not receive radiotherapy or chemotherapy prior to the recurrences.

When the Bone Flap Expands Like Bellows of Accordion: Feasibility Study Using Novel Technique of Expansile (Hinge) Craniotomy for Severe Traumatic Brain Injury.

BACKGROUND: Decompressive craniectomy (DC) is a rescue operation performed for reduction of intracranial pressure due to progressive brain swelling, mandating the need for cranioplasty. OBJECTIVE: To describe expansile craniotomy (EC) as a noninferior technique that may be effectively utilized in situations requiring standard DC. MATERIALS AND METHODS: A decision to perform DC or EC was taken by consecutively allocation to either of the procedures. The bone flap was divided into three pieces, which were tied loosely to each other and to the skull using silk threads. The primary outcome included functional assessment using Glasgow outcome scale (GOS) score at 1 year. RESULTS AND CONCLUSIONS: Total 67 patients were included in the analyses, of which, 31 underwent EC and 36 underwent DC. Both the cohorts were matched in terms of baseline determinants for age, Glasgow coma scale, and Rotterdam score at admission. There was no significant difference in GOS scores and the extent of volume expansion obtained by EC as compared to DC. Complication rates though less in EC group did not differ significantly between the groups. EC appears to be the safe and effective alternative to DC in the management of brain swelling due to TBI with a potential to obviate the need of cranioplasty.

Cysticercal brain abscess: a distinct entity mimicking pyogenic brain abscess in the colloidal vesicular stage.

Cysticercal brain abscess is a rare entity with the clinical presentation and radiological findings closely mimicking a pyogenic abscess. We report three cases of cysticercal abscess presenting as solitary lesion in the brain with radiological appearance like an abscess. All the patients underwent excision of the lesion with histopathological diagnosis of cysticercal brain abscess with evidence of cysticerci in the colloidal vesicular stage. The clinical outcome was satisfactory after surgical excision. Cysticercal abscess, though rare, should be considered as a differential diagnosis of a solitary rim-enhancing lesion, mainly if the patients belong to the endemic zone of neurocysticercosis. Surgical excision with or without a short course of the anti-parasitic agent is the treatment of choice for the intracranial mass lesion with evidence of mass effect For the small lesion of cysticercal brain abscess or early stage of abscess, anti-parasitic medication and steroids can be considered.

Management Options for Suprasellar Cystic Craniopharyngioma: Endoscopic Transventricular Approach and Microsurgical Approach.

Objective The treatment of cystic craniopharyngioma in children is varied. The treatment ranges from radical excision to direct radiotherapy. As the morbidity of excision is high, more conservative approaches are used. Transventricular endoscopy is a minimally invasive treatment for cystic craniopharyngiomas. The objective of this study is to compare the outcome of microscopic versus endoscopic transventricular approach for cystic craniopharyngioma. Methods This is a retrospective study of series of children managed with microscopic excision and endoscopic transventricular approach for suprasellar cystic craniopharyngiomas. Operative details, visual outcome, endocrinological outcome, tumor-related cyst recurrence rate, and complication were compared between microscopic and endoscopic groups. Results A total of 28 children underwent microscopic excision and 14 children underwent endoscopic procedure. The anesthesia time was significantly lower with endoscopic as compared to microscopic group ( p = 0.0001) as well as blood loss during surgery ( p = 0.0001). Hospital stay after surgery was shorter in endoscopic group. Incidence of diabetes insipidus was more in microscopic group (25%) compared to endoscopic group (7.14%). Visual outcome was almost same with approaches. Requirement of hormone replacement was more in microscopic group than in endoscopic group ( p = 0.006). Incidence of cyst recurrence was more in microscopic (39.3%) compared to endoscopic group (7.7%). Conclusion Endoscopic transventricular approach is a safe alternative for initial treatment of suprasellar cystic craniopharyngioma in children.

Development of a Prognostic Model to Predict Mortality after Traumatic Brain Injury in Intensive Care Setting in a Developing Country.

Objectives We aimed to develop a prognostic model for the prediction of in-hospital mortality in patients with traumatic brain injury (TBI) admitted to the neurosurgery intensive care unit (ICU) of our institute. Materials and Methods The clinical and computed tomography scan data of consecutive patients admitted after a diagnosis TBI in ICU were reviewed. Construction of the model was done by using all the variables of Corticosteroid Randomization after Significant Head Injury and International Mission on Prognosis and Analysis of Clinical Trials in TBI models. The endpoint was in-hospital mortality. Results A total of 243 patients with TBI were admitted to ICU during the study period. The in-hospital mortality was 15.3%. On multivariate analysis, the Glasgow coma scale (GCS) at admission, hypoxia, hypotension, and obliteration of the third ventricle/basal cisterns were significantly associated with mortality. Patients with hypoxia had eight times, with hypotensions 22 times, and with obliteration of the third ventricle/basal cisterns three times more chance of death. The TBI score was developed as a sum of individual points assigned as follows: GCS score 3 to 4 (+2 points), 5 to 12 (+1), hypoxia (+1), hypotension (+1), and obliteration third ventricle/basal cistern (+1). The mortality was 0% for a score of "0" and 85% for a score of "4." Conclusion The outcome of patients treated in ICU was based on common admission variables. A simple clinical grading score allows risk stratification of patients with TBI admitted in ICU.

Predictors of Quality of Life at 3 Months after Treatment for Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Patients with aneurysmal subarachnoid hemorrhage (SAH) have a low quality of life (QOL) despite diagnostic and therapeutic advancements. Less than half of the survivors can return to their previous jobs and have difficulty in being a functional part of society. Our study aimed to understand the overall outcome and QOL of these patients and to identify the predictive factors determining the same. METHODS: The clinical and radiological data were recorded at presentation, subsequent intervals at the hospital, and during discharge. Patients were interviewed telephonically or in the clinic subsequently at 3 months after treatment with following outcome assessment tools: Modified Rankin Scale (mRS), Barthel Index (BI), QOL after Brain Injury Overall Scale (QOLIBRI-OS), and Short Form 36 (SF 36) QOL scale. RESULTS: Out of the total patients (n = 143), 124 patients survived, of which 106 patients could be interviewed. The mRS, QOLIBRI-OS, BI, and SF36 had a good correlation with each other. Only 4.7% had moderate to severe disability on the mRS scale, and 2.8% had severe disability according to the Barthel index. Nearly one-third of patients had deteriorated QOL. The mental health domain was worst affected. The major determinant of QOL was GCS at presentation (mean P value 0.01), a course in the ward (0.0001), GCS at discharge (0.001). CONCLUSION: Though fewer of the patients had a severe disability, a majority of them had deterioration in QOL.

Management of choroid plexus tumours: A comprehensive study from a tertiary hospital.

OBJECTIVE: Choroid plexus tumours (CPT) are rare intraventricular tumours representing less than 0.5 % of brain tumours. The tumour is commonly located in the supratentorial region, but the location varies depending on the age. We present our experience of managing these tumours in a tertiary hospital. METHODS: Retrospectively, we reviewed our operative database and recruited 80 cases of CPT who underwent surgical treatment in our institute from 1995 to 2018. We analysed the factors affecting the outcome and the perioperative complications of the choroid plexus tumour. RESULTS: A total of 80 choroid plexus tumours were recruited in our retrospective review, of which 44 were choroid plexus papilloma (CPP), 13 were atypical choroid plexus tumours (ACPP), 23 were choroid plexus carcinomas (CPC). The mean age was 16.75 (SD 16.71) in the overall cohort. Males were found to be predominant in all tumour groups (M/F: 46/34). Headache was the most common symptom (52.5 %). Hydrocephalus was seen in 53.8 % of cases. The median overall survival was 89.88 months. Gross total resection was achieved in 62.5 % cases (n = 50/80), and near-total resection in 27. 5 % cases (n = 22/80). The median overall survival was 89.88 months. The median overall survival for CPP, ACPP, CPC was 106.83, 37.37, 36.19 months, respectively. Median Event-free survival was 65.83 months. A Cox regression analysis of predictors of overall survival of atypical CPP and CPC was done, in which age, sex, location, size, the extent of the resection, and complications were considered. The extent of the resection (p = 0.01) and the size (p = 0.02) were related to overall survival CONCLUSION: CPT's are the rare intraventricular tumours, which requires aggressive resection strategies. The extent of resection offers survival benefit based on the histological grades.

Heart Rate Variability as a Predictor of Mortality in Traumatic Brain Injury: A Systematic Review and Meta-Analysis.

OBJECTIVE: To systematically review the medical literature to determine the utility of heart rate variability in predicting mortality for moderate to severe traumatic brain injury. METHODS: A search for randomized controlled trials, nonrandomized trials, and prospective and retrospective cohort studies was carried out using PubMed, SCOPUS, Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE. Reference lists of included studies were also searched to identify potentially eligible studies. RESULTS: Five articles comprising 542 patients met inclusion criteria. Heart rate variability as low-frequency/high-frequency ratio (area under the curve [AUC] receiver operating characteristic [ROC]) for predicting mortality was found to be statistically significant (AUC ROC 0.810, P < 0.001) with high heterogeneity (I2 = 61.98%, P = 0.032). Meta-analysis of low-frequency/high-frequency ratio, High frequency peak, and total power were statistically significant for predicting mortality. Odd's ratio for predicting mortality for LF/HF ratio, HF peak, and TP were 16.17, 19.09, 22.59 respectively. High-frequency peak in predicting mortality showed an AUC ROC of 0.986 (P ≤ 0.001) with a low level of heterogeneity. Total power (TP) showed an AUC ROC of 0.93 (P < 0.001) in predicting mortality with a high level of heterogeneity (I2 = 83.16%, P = 0.002). Funnel plot analysis to assess the presence of publication bias for TP showed a high level of heterogeneity and asymmetry among studies. CONCLUSIONS: This meta-analysis predicted high mortality based on odds ratio for variables low-frequency/high-frequency ratio, high-frequency peak, and TP. However, the statistical analysis was weakened owing to the high level of heterogeneity in the included studies. Further research is needed to generate high-quality recommendations regarding heart rate variability as a predictor of mortality after traumatic brain injury.

A scoping review to understand the indications, effectiveness, and limitations of cabergoline in radiological and biochemical remission of prolactinomas.

Cabergoline has long been used in the medical management of prolactin-secreting pituitary adenomas. However, there is contradicting and inadequate evidence on the efficacy of cabergoline in achieving radiological and biochemical remission in prolactinoma. This article presents scoping review of evidence in cabergoline achieving radiological and biochemical remission in cases of prolactinoma. We have used a recommended scoping review methodology to map and summarize existing research evidence and identify knowledge gaps. The review process was conducted according to the PRISMA-ScR guidelines (Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews). The selection of studies was based on the criteria defined. Essential information such as reference details, study characteristics, topics of interest, main findings, and the study author's conclusion are presented in text and tables. With the study selection process, eight publications were finally included-one systematic review and meta-analysis, one RCT, and six primary studies. Cabergoline is effective in achieving biochemical and radiological remission in cases of prolactinoma. We identified several knowledge gaps with the scoping review and directions for future studies. Future studies, including randomized studies, will help address challenging questions associated with the management of prolactinoma.

Distal anterior cerebral artery aneurysm with bilateral fetal posterior cerebral arteries and trifurcation of anterior cerebral artery.

Developmental vascular anomalies of brain are non-modifiable risk factors for the development of aneurysms and are prone for rupture. We report one such association in a 44-year-old gentleman who succumbed to subarachnoid hemorrhage (SAH) secondary to ruptured distal anterior cerebral artery aneurysm associated with vascular anomalies in the anterior and posterior circulation that included trifurcation of anterior cerebral artery and bilateral fetal posterior cerebral arteries. We identified multiple anomalies in circle of Willis that could have contributed to the formation of aneurysm and early rupture. Knowledge of these variations is essential to plan early and optimum management with close follow-up.

Conventional and Advanced Magnetic Resonance Imaging Features of Supratentorial Extraventricular Ependymomas.

OBJECTIVE: To describe the magnetic resonance imaging characteristics of supratentorial ependymomas. METHODS: The magnetic resonance imaging and computed tomography imaging characteristics of 49 cases of supratentorial ependymomas were analyzed retrospectively. The location, size, degree of perilesional edema, gross appearance, computed tomography attenuation characteristics, T1 and T2 signal intensity characteristics, degree of diffusion restriction, presence of calcification, and hemorrhage were documented for each lesion. The intratumoral susceptibility scores (ITSS), apparent diffusion coefficient (ADC) values, relative cerebral blood volume, and choline/N-acetyl aspartate ratios were documented where available. RESULTS: The frontal lobe was the most common location with a mean size of 6.37 × 4.8 cm. Severe perilesional edema was evident in 30%. Heterogenous, solid-cystic appearance was present in 96% lesions, with 95% of extraventricular lesions extending from pial surface to the ventricular margin. Calcification was seen in 55% of cases. The ITSS was 3 in 85.7% of lesions. The mean ADC value calculated was 600 × 10 mm/s. The mean relative cerebral blood volume on dynamic susceptibility contrast perfusion was 4.83. The mean choline/N-acetyl aspartate ratio was 5.87. Leptomeningeal dissemination was demonstrable in 5 lesions. Four lesions were abutting the dura with frank dural invasion in one. One patient presented with disseminated disease without evidence of a primary lesion. CONCLUSIONS: A large lesion with relatively well-defined margins, heterogeneous solid cystic appearance, extending from the pial surface to the ventricular margin, presence of calcification, and ADC values approaching those of white matter should raise a suspicion of supratentorial ependymoma. High ITSS, MR perfusion parameters, and magnetic resonance spectroscopy characteristics are similar to those of other high-grade gliomas.

Bilateral anomalous origin of ophthalmic artery from middle meningeal artery and coincidence of bilateral carotid artery aneurysm: Case report and literature review.

Ophthalmic artery (OA) is known for anomalous origin and aberrant course probably attributable to its complex embryology. Anomalous origin of OA can be associated with intracranial aneurysm. Anomalous origins have been reported from middle meningeal artery (MMA), cavernous carotid, posterior communicating, anterior cerebral and basilar artery. Even though bilateral anomalous origin of OA from MMA is a rare finding, to the author's best knowledge, association of above condition with bilateral internal carotid artery aneurysms has not been described in the literature. We present a case of such anomalous bilateral OA originating from MMA and associated with bilateral internal carotid artery aneurysms. We have also reviewed the pertinent literature regarding anomalous OA origin.

Atypical presentation of extraspinal neurofibroma presenting with acute-onset monoparesis and Horner's syndrome: Case report and review of literature.

The clinical presentation of spinal or extraspinal neurofibroma is radiculopathy or myelopathy, pain, and motor weakness. Extraspinal neurofibroma presenting with acute-onset monoparesis and Horner's syndrome is very rare. We report the case of a 55-year-old female who presented with acute-onset monoparesis of the left upper limb along with left-side drooping of the eyelid. Imaging revealed C6-D2 extraspinal solitary mass lesion lateral to spinous process with bleed without intraspinal component. The patient underwent an anterior cervical approach and excision of the tumor. Final biopsy report was a neurofibroma. At 3-year follow-up, she recovered from motor weakness, and Horner's syndrome subsided. Extraspinal neurofibroma can present with acute bleed, and surgical outcome is superior in early intervention.

The Correlation of Endothelial Nitric Oxide Synthase (eNOS) Polymorphism and Other Risk Factors with Aneurysmal Subarachnoid Hemorrhage: A Case-Control Study.

OBJECTIVE: Endothelial nitric oxide synthase gene (eNOS) polymorphism is an association with cerebral aneurysm formation, rupture, and vasospasm and plays a role in the a functional outcome. PATIENTS AND METHODS: The aim of the study was to evaluate the role of eNOS gene polymorphism and further assess the predictors of outcome in the aneurysmal subarachnoid hemorrhage (aSAH). A prospective case-control study was conducted from 2009 to 2012 among those who presented with aSAH. A serum sample was collected from aSAH patients along with age and sex-matched healthy controls. The frequency of polymorphism of eNOS gene and other factors (demographic and aneurysmal) were correlated with functional outcome at six month of follow-up. RESULTS: 100 patients with aSAH and 100 healthy controls were enrolled in the cohort. The mean age of the patient group was 51.61 years and control group was 45.81 years with a male:female ratio of 1:1.38 and 1:1.08 for patients and controls, respectively. Among all eNOS polymorphisms, 4BB (65%) 24-VNTR, TT (71%) of T-786C, and GG (71%) of G947T were the most common and frequency was similar in the control group. The occurrences of hypertension, smoking, diabetes were 32%, 37%, and 7% respectively in the patient group. Maximum patients were in WFNS grade 1 (53%) followed by 23% grade 2 and only 10% in grade 4. Fisher grade 3 (57%) was the most common followed by Fisher grade 4 (28%). Most aneurysms (97%) were in anterior circulation. 83% of the aneurysms were clipped and 10% underwent coiling. Size-wise most of the aneurysms were in the middle group (6-9 mm) followed by bigger group (>10 mm) (37%); only 6% aneurysms were in the small aneurysm (<6 mm) group. 33% of the patients had evidence of vasospasm. TT of G894T polymorphism (60%) had the highest incidence of vasospasm. Univariate analysis showed smoking (OR: 3.19, CI: 1.19-8.84, P = 0.01), 4AA (OR: 12.15, CI: 1.13-624.9, P = 0.03) variety of 24-VNTR polymorphism, CC (OR: 15.39, CI: 1.60-762.8, P = 0.01) variety of T786C polymorphism, Fisher grade 4 (OR: 3.43, CI: 1.24-9.68, P = 0.01), WFNS grade (poor vs. good) (OR: 3.42, CI: 1.17-10.12, P = 0.02), vasospasm (OR: 3.84, CI: 1.42-10.75, P = 0.006), intraoperative rupture (OR: 4.77, CI: 1.55-15.27, P = 0.004) were significantly related with unfavorable outcome at 6 months follow-up. In regression analysis, smoking (CI: 0.06-0.69, P = 0.01), Fisher grade 4 (CI: 0.09-1.00, P = 0.05), and intraoperative rupture (CI: 0.05-0.89, P = 0.03) were correlated with an unfavorable outcome at 6 months follow-up. CONCLUSION: The eNOS gene polymorphism, smoking, clinical grade (WFNS), Fisher grade, intraoperative rupture, and vasospasm play a role in functional outcome after the treatment of cerebral aneurysms.

Factors Influencing Survival of Children with Atypical Teratoid/Rhabdoid Tumors: A Single-Institute Experience in a Developing Country.

BACKGROUND: We evaluated the factors influencing overall survival (OS) and event-free survival (EFS) in children with atypical teratoid/rhabdoid tumors (ATRTs). METHODS: We performed a retrospective study of children aged <16 years and tumor histological diagnosis of ATRT. Univariate and multivariate analyses were performed to determine the effect of individual and interdependent variables and survival. RESULTS: A total of 34 children had undergone surgery, with a male/female ratio of 1.8:1. On univariate analysis, the factors with statistically significant influence on OS and EFS were the extent of resection (P = 0.012 and P = 0.015, respectively), adjuvant therapy (P ≤ 0.001 and P = 0.001, respectively), and rhabdoid cell percentage (P = 0.004 and P = 0.005, respectively). On survival analysis, the median OS and EFS were better for those who had completed adjuvant therapy versus those who had not received adjuvant therapy (OS, 22.7 months vs. 3.5 months; EFS, 10.9 months vs. 3.5 months), those who had undergone gross total resection versus those who had undergone partial decompression (OS, 10.9 months vs. 2 months; EFS, 8.9 months vs. 2.5 months), and those with <50% rhabdoid cells in the biopsy specimen versus those with >50% rhabdoid cells (OS, 10.9 months vs. 3.7 months; EFS, 8.9 months vs. 3.5 months). On multivariate analysis, only the extent of resection and adjuvant therapy status had a significant influence on OS and EFS. CONCLUSION: Achieving gross total resection should be the aim of surgery, depending on the tumor location, and these children should undergo upfront adjuvant treatment.