Mostafa Shahein

Background: Brain perfusion imaging is a radiological technique used to study cerebral microvasculature. One type of magnetic resonance imaging (MRI) perfusion is arterial spin labelling (ASL), which has been utilised in the pre-operative evaluation of brain tumours. Microvessel density (MVD) is an important histological feature that influences the behaviour of brain tumours. In this study, we aimed to investigate whether there is a positive correlation between the perfusion of brain tumours, as measured by ASL and MVD, as assessed by histopathology using CD34 immunohistochemistry, irrespective of the tumour’s location within the brain. Patients and methods: This study included 37 patients who were newly diagnosed with primary brain tumours. Patients with recurrent brain tumours or metastases and those who previously received chemotherapy or radiotherapy were excluded from the study. All patients underwent pre-operative evaluation by ASL, calculating both mean tumour blood flow (mTBF) directly within the lesion and relative tumour blood flow (rTBF) by normalising the perfusion of the lesion to the contralateral cortical grey matter using a standard 50 mm ² ROI. The tumour MVD was evaluated by histopathology following either operative excision of the lesion or stereotactic biopsy using the CD34 immune marker. Results: There was a statistically significant positive correlation between rTBF and MVD ( p -value = 0.001, r  = 0.742) and between mTBF and MVD ( p -value = 0.001, r  = 0.378), which was confirmed after applying Bonferroni correction, as the p-value was less than the corrected p -value (0.025). Although there was a borderline positive correlation between the rTBF and tumour grade for the intra-axial tumour group ( p -value = 0.046, r  = 0.504), this value was not statistically significant after applying Bonferroni correction, as the p-value was greater than the corrected p -value ( p  = 0.016). No statistically significant positive correlation was found between rTBF and extra-axial ( p -value = 0.872, r  = 0.045) or posterior fossa and skull base ( p  = 0.407, r  = 0.420) tumour grade. Conclusion: Arterial spin labelling perfusion parameters demonstrate a strong correlation with MVD in brain tumours, regardless of their location. ASL is a promising non-invasive method for the assessment of brain tumour angiogenesis, but it needs further validation with larger homogeneous cohorts. The value of ASL in the pre-operative grading of brain tumours requires further validation.

Arterial spin labelling (ASL) is one of the new cerebral perfusion magnetic resonance imaging (MRI) studies that provides useful information about the intracranial lesional perfusion through the measurement of cerebral blood flow (CBF). Tumours and tumour-like lesions are associated with alterations in the CBF. The identification of these perfusion changes can help predict the tumour grade as well as differentiate true brain neoplasms from their mimics. Furthermore, ASL is a valuable tool for monitoring tumour treatment and tracking tumour progression. This case-based review aims to illustrate the role of ASL as a problem-solving tool in the assessment and management of intra-axial and extra-axial brain tumours. It also highlights the importance of ASL in the evaluation of intracranial tumour-like lesions.

Epilepsy is a common neurological disease that is treated with medications; however, patients with drug-resistant epilepsy, commonly intractable temporal lobe epilepsy, tend to have better control with surgical treatment. While the mainstay of surgical treatment is anterior temporal lobectomy, it carries risk of potential adverse effects hence minimally invasive techniques are now being used as an alternative to open surgery. This systematic review and meta-analysis compare the efficacy and safety of three of the most used techniques: laser interstitial thermal therapy (LITT), radiofrequency ablation (RFA) and stereotactic radiosurgery (SRS). Multiple databases were searched and PRISMA guidelines were followed to make an indirect meta-analysis using the currently available studies for the three techniques in terms of seizure freedom, risk of major complications and reoperations. Further subgroup analyses were carried out for LITT in terms of follow up periods and seizure freedom in patients with or without hippocampal sclerosis. A total of 42 papers were included in this study with a total of 1675 patients (1303 treated by LITT, 188 treated by RFA and 184 treated by SRS). LITT had the highest rate of seizure freedom (55.0%, CI 51.5 − 58.5%, P = 0.148), and the lowest rates of major complications (2.3%, CI 1.2 − 3.5%, P = 0.070), and reoperations (14.3%, CI 10.4 − 18.3%, P = 0.042) compared to RFA and SRS which had seizure freedom of 46.3% (CI 18.8 − 73.7%, P = 0.000) and 53.8% (CI 44.4 − 63.3%; I^2 = 40.4%, P = 0.098), major complication rate of 3.9% (CI 0.7 − 7.0%; I^2 = 0%, P = 0.458) and 14.3% (CI 3.1 − 25.5%, P = 0.000) and reoperation rate of 28.6% (CI -4.3 − 61.5%, P = 0.000) and 15.4% (CI 6.1 − 24.8%; I^2 = 0%, P = 0.392) respectively. In conclusion, LITT showed the highest rate of seizure freedom and the lowest rate of major complications and reoperations compared to RFA and SRS in single-arm studies of intractable mesial temporal lobe epilepsy. However, the lack of direct comparisons between treatment modalities limits definitive conclusions. Despite this, LITT appears to offer a favorable safety profile, warranting further prospective, comparative studies to validate these findings.

Background: Giant sacral and presacral schwannomas are very rare conditions and their prevalence is estimated to account for only 0.3 to 3.3% of overall schwannomas. Current published literature about these tumors is limited to case reports and small case series. In this paper we systematically reviewed and analyzed the available literature on giant sacral schwannomas focusing on identifying the presenting symptoms, Klimo type, surgical approach, recurrence rate and postoperative complications. Methods: Following the PRISMA guidelines, we conducted a literature search on electronic databases to obtain the relevant studies until March 2024. We included reports of surgically managed giant sacral schwannomas; either involving tumor of at least 2 adjacent vertebra or had a maximum diameter of 5 cm or more. Presenting symptoms, tumor size, morphology, surgical approach and postoperative complications were reported. Results: A total of 102 studies with 201 unique patients were included in our analysis (mean age 45.4 ± 9.8, 49.7% females). The most common presenting symptoms were lower extremity radicular pain (19.5%), lower back pain (14.1%), lower extremity numbness or paresthesia (9%), and constipation (7.6%). Most surgeries used an open posterior approach (40.1%) or open anterior approach (33.5%). Postoperative complications occurred in (29.3%) of patients and 10% had local recurrence or progression of their tumor. On linear regression the volume of the tumor could significantly predict the estimated amount of blood loss (P = 0.03). We found that an anterior approach was far more likely to be used in patients with Klimo type III, (P < 0.001). Similarly, posterior approach was mostly used for Klimo type I and type II (P < 0.001). Conclusion: The management approach of giant sacral and presacral schwannomas are mainly tailored according to the tumor size and location. Due to the benign nature and the overall recurrence rate of the tumor, frequent imaging follow-up is required after safe resection with adequate clean margins.

Background: Traumatic brain injury (TBI) is a major medical and social concern in developing countries. TBI-related morbidity and mortality statistics in Egypt are lacking and do not reflect the actual magnitude of the problem. Objectives: To overview the incidence of moderate and severe head trauma in a heavily populated developing country and document the outcome of moderate and severe TBI associated with skull base fracture (SBF). Methodology: Data of patients admitted to our center with moderate and severe TBI associated with skull base fracture (SBF) were reviewed in the period between January 2019 and March 2023. Results: The most common type of trauma was road traffic accidents in 54.2% of the patients; 91.2% had Single SBF (middle cranial fossa fracture was predominant 58.5%). 25.5% had an initial GCS of ≤ 8. Periorbital ecchymosis was the most common presenting sign in 36.3%. The most frequent complication (37.3%) was pneumocephalus. The presence of skull base fracture inversely affected the Glasgow outcome scale extended GOSE (P = 0.001, r = 0.674). Higher initial GCS scores were positively correlated with good GOSE (GOSE) (P = 0.001, r =− 0.222). Conclusions: RTA represents a significant cause for moderate and severe TBI in young male population. SBF is associated with poor outcome in moderate and severe TBI. Higher initial GCS score was positively correlated with good GOSE. It is important to have an overview of different types of TBI in Egypt.

BACKGROUND: Proper skull base reconstruction after endoscopic endonasal pituitary surgery is of great importance to decrease the rate of complications. OBJECTIVE: To assess the safety and efficacy of reconstruction with materials other than fat graft and naso-septal flaps (NSF) to avoid their associated morbidities. METHODS: The authors’ institutional database for patients who underwent endoscopic endonasal approach for pituitary adenoma was reviewed. Exclusion criteria included recurrence, postradiation therapy, and reconstruction by fat graft or NSF. They were divided into group A, where collagen matrix (CM) (DuraGen^® Plus Matrix, Integra LifeSciences Corporation, Plainsboro, New Jersey) alone was used; group B, where CM and simple mucoperiosteum graft were used and group C, which included cases without CM utilization. RESULTS: The study included 252 patients. No age, gender, or body mass index statistically significant difference between groups. Group B included the largest tumor size (23.0 mm) in comparison to groups A (18.0 mm) and C (13.0 mm). Suprasellar extension was more frequently present (49.4%) in comparison to groups A (29.8%, P = .001) and C (21.2%, P < .001). Postoperative cerebrospinal fluid (CSF) leak rate was 0%, 2.9%, and 6% in groups A, B, and C, respectively. In group B, the CSF leak rate decreased from 45.9% intraoperatively to 2.9% postoperatively (P < .001). In group A, the CSF leak reduction rate was almost statistically significant (P = .06). CONCLUSION: Utilization of CM and simple mucosperiosteal graft in skull base reconstruction following pituitary adenoma surgery is an effective method to avoid the morbidities associated with NSF or fat graft.

Object Resection of lesions located within the third ventricle presents a surgical challenge. Several approaches have been developed in an attempt to obtain maximal resection, while minimizing brain retraction. In this work, we assess the surgical exposure and maneuverability of the endoscopic supraorbital translaminar approach (ESTA), a potential alternative to fenestrate the lamina terminalis and approach the third ventricle by using the endoscope through a keyhole supraorbital-eyebrow craniotomy. Methods Five cadaveric heads were used to assess the corridor depth, area of exposure, and viewing angles offered by the ESTA. One additional utilized specimen provided a stepwise dissection of the approach. Results The ESTA was successfully performed in all specimens. Depth of the surgical corridor from the craniotomy to the ipsilateral internal carotid artery (ICA), lamina terminalis, and contralateral carotid were 70.7 ± 2.9 mm, 73.2 ± 2.9 mm, and 78.9 ± 4.1 mm, respectively. Viewing angle referenced to the ipsilateral ICA was 6.5 ± 4.2°, while the viewing angle for the lamina terminalis was 25.8 ± 4.3°. The surgical exposure provided by the ESTA was 1655 ± 255 mm². Conclusions The ESTA provides a wide surgical view of the lamina terminalis and may be potentially used to approach lesions located in the anterior third of the third ventricle. As a pure endoscopic approach, the ESTA requires minimal brain retraction, while affords good visualization of targeted lesions around the lamina terminalis. The ESTA uses an anterolateral approach and so provides a short and straightforward approach to these structures.