Ahmad M. S. Ali

Background: Glioblastoma (GB) carries a dismal prognosis, with survival outcomes particularly poor in older patients. With the fastest-growing global demographic being those aged over 65, the incidence of GB is expected to rise. Objective: To evaluate predictors of survival in patients aged ≥70 years with histologically confirmed GB, focusing on surgical resection, adjuvant therapy, and comorbidities. Methods: A retrospective review was performed of all patients aged ≥70 undergoing index surgery for GB between January 2021 and March 2025 at a single tertiary neurosurgical centre. Demographics, pre-operative fitness scores (Karnofsky Performance Status [KPS]., Charlson Comorbidity Index [CCI].), tumour characteristics, extent of resection, adjuvant treatment, and survival were analysed. Tumour volume was estimated using the ABC/2 method. Survival outcomes were assessed using Kaplan–Meier curves and multivariable Cox proportional hazards regression. Results: A total of 124 patients aged ≥70 years (median 74 years, range 70–86) were included. Median overall survival was 8 months (IQR 4–15). On multivariable analysis, adjuvant chemoradiotherapy (HR = 0.30, 95% CI 0.17–0.52; p < 0.001) and gross total resection (GTR) (HR = 0.41, 95% CI 0.20–0.86; p = 0.019) were independently associated with improved survival. Smoking history was associated with increased hazard of death (HR = 2.02, 95% CI 1.07–3.81; p = 0.029), an effect robust to multiple sensitivity analyses. No significant associations were found for age, pre-operative KPS, comorbidity index, tumour volume, or methylation status (all p > 0.10). Tests for non-proportional hazards indicated that the survival benefit of adjuvant therapy diminished over time (interaction p = 0.0002), with early post-operative benefit (HR ≈ 0.35 at 1 month) that attenuated towards unity by 6–12 months. The effects of GTR and smoking were time-invariant. RMST analysis suggested a modest, non-significant absolute survival advantage of GTR over STR (mean difference = 2.0 months at 18 months; p = 0.11). After exclusion of early post-operative deaths (p < 0.001) and GTR (HR = 0.33; p = 0.005) remained independent predictors of improved survival. Conclusions: Among patients aged ≥70 years with glioblastoma, adjuvant therapy and extent of resection remain key independent predictors of survival, while smoking is associated with poorer outcomes. The survival benefit of adjuvant chemoradiotherapy is strongest in the early post-operative period and diminishes over time, underscoring the importance of early multidisciplinary intervention. These findings highlight that aggressive multimodal treatment may confer survival advantage even in older patients.

BACKGROUND AND OBJECTIVES: Spinal cord stimulation (SCS) is an effective neuromodulatory tool for various chronic pain conditions. Traditionally, the SCS procedure involved an open approach with laminotomy for paddle implants. The minimally invasive percutaneous lead placement has largely replaced open paddles. However, percutaneous leads are prone to migration and may be unfeasible in patients with preexisting epidural scarring, necessitating open paddle placement. An endoscopic approach to the spine would offer reduced morbidity with the stimulation benefits and security of open paddle. We therefore aimed to develop this technique. METHODS: An endoscopic method for SCS paddle implantation was developed initially in a cadaveric laboratory. We tested an anterograde and retrograde method of implantation. The retrograde method of implantation was chosen and subsequently used in 5 patients. A retrospective review of electronic medical records was subsequently undertaken to compare these endoscopic cases with consecutive concurrent open and percutaneous cases. RESULTS: The retrograde method of implantation was chosen because of reduced bony and soft tissue dissection required. In addition, more secure implantation was possible with this approach. We describe the endoscopic technique in detail. Five endoscopic cases were compared with 20 percutaneous and 13 open cases. Postoperative analgesia requirements for the endoscopic and percutaneous cases were similar, and both were significantly lower than for open cases ( P < .001). Operative time was expectantly longer for endoscopic cases. Same-day programming was possible with endoscopic cases, and with modified anesthetic and programming protocols, same-day discharge was possible for our last endoscopic case. With 6-month follow-up, we did not have any wound-related problems or hardware migration in these cases. CONCLUSION: Our findings indicate that endoscopic SCS implantation is a safe and feasible option that combines key advantages of both open and percutaneous standard approaches for SCS implantation.

Background: Repetitive transcranial magnetic stimulation (rTMS) is established for depression and rehabilitation after stroke and is emerging for cognitive rehabilitation. We sought to evaluate patient and carer perceptions toward rTMS for rehabilitation after neurosurgery. Methods: Two surveys were undertaken. Group 1: Patients who received 7 days of rTMS for motor or language rehabilitation for severe postoperative deficits following lesional resection were prospectively surveyed on the last day of their rTMS treatment, as well as their next of kin. Group 2: Patients who had previously been diagnosed with glioma but did not receive rTMS were retrospectively surveyed through two brain tumor charities, including next of kin. Results: Group 1: Twenty-one responses. Eleven patients, 10 next of kin. The commonest pathology was WHO Grade 4 glioma (n = 3). Group 2: 24 responses. Sixteen patients, 8 next of kin. The commonest pathology was WHO Grade 2 glioma (n = 7). Most Group 1 respondents reported a positive experience of rTMS (15/21). Patients experienced subjective improvements in gross motor functions of arm and leg weakness and purposeful movement (9/11). Lack of subjective motor improvement was associated with adverse symptoms (e.g., headaches; p = .01). Group 2 respondents were supportive of rTMS. Key priorities included motor and cognitive rehabilitation. They were accepting of longer and more frequent rTMS sessions than Group 1 (p = .028 and <.001, respectively). Commonest concerns pertained to side effects are seizures and headaches. Conclusions: rTMS for rehabilitation was well-tolerated by patients with side effects being commoner in those with no subjective motor improvements. Nontreated patients and their next of kin would find longer and more sessions acceptable but have concerns about potential side effects.

Study design: Systematic review. Objectives: Primary Spinal Intradural Tumours (PSITs) are rare pathologies that can significantly impact quality of life. This study aimed to review patient reported outcomes (PROs) in PSITs. Methods: A systematic search of Pubmed and Embase was performed to identify studies measuring PROs in adults with PSITs. PRO results were categorised as relating to Global, Physical, Social, or Mental health. Outcomes were summarised descriptively. Results: Following review of 2382 records, 11 studies were eligible for inclusion (737 patients). All studies assessed surgically treated patients. Schwannoma was the commonest pathology (n = 190). 7 studies measured PROs before and after surgery, the remainder assessed only post-operatively. For eight studies, PROs were obtained within 12 months of treatment. 21 PRO measurement tools were used across included studies, of which Euro-Qol-5D (n = 8) and the pain visual/numerical analogue scale (n = 5) were utilised most frequently. Although overall QoL is lower than healthy controls in PSITs, improvements following surgery were found in Extramedullary tumours (EMT) in overall physical, social, and mental health. Similar improvements were not significant across studies of Intramedullary tumours (IMT). Overall QoL and symptom burden was higher in IMT patients than in brain tumour patients. No studies evaluated the effect of chemotherapy or radiotherapy. Conclusion: Patients with PSITs suffer impaired PROs before and after surgery. This is particularly true for IMTs. PRO reporting in PSITs is hindered by a heterogeneity of reporting and varied measurement tools. This calls for the establishment of a standard set of PROs as well as the use of registries.

Introduction: Assessment of the pupillary light reflex (PLR) is a key part of intensive care monitoring of neurosurgical patients, particularly for detecting abnormalities in intracranial pressure (ICP). Quantitative pupillometry using a handheld pupillometer is a reliable method for assessing the PLR. However, many variables are derived from such devices. We therefore aimed to assess the performance of these variables at monitoring ICP. Methods: Sedated patients admitted to a neurocritical care unit in a tertiary neurosurgical centre with invasive ICP monitoring were eligible for inclusion. Hourly measurement of ICP, subjective pupillometry (SP) using a pen torch device, and quantitative pupillometry (QP) using a handheld NeuroOptics NPi-200 Pupillometer system were performed. Results: 561 paired ICP, SP and QP pupillary observations from nine patients were obtained, amounting to 1122 pupillary observations in total. SP and QP had a moderate concordance for measuring pupillary size (κ = 0.62). SP performed poorly at detecting changes in pupillary size (sensitivity = 24%). In 40 (3.6%) observations, SP failed to detect a pupillary response whereas QP did. Moderate correlations against ICP were detected for maximum constriction velocity (MCV), dilation velocity (DV), and percentage change in pupillary diameter (%C). Discriminatory ability at an ICP threshold of > 22mmHg was moderate for MCV (AUC = 0.631), DV (AUC = 0.616), %C (AUC = 0.602), and pupillary maximum size (AUC = 0.625). MCV and %C values were significantly different at different ICP thresholds on ANOVA testing. Conclusion: QP is superior to SP at monitoring pupillary reactivity and changes to pupillary size. Although effect sizes were moderate to weak across assessed variables, our data indicates MCV and %C as the most sensitive variables for monitoring ICP. Further study is required to validate these findings and to establish normal range cut-offs for clinical use.

Purpose For patients with a new lesion on CT head (CTH) suspected to be a brain tumor, a staging chest, abdomen, and pelvis CT (CTCAP) is only warranted if a metastatic lesion is suspected. Unnecessary CTCAPs are often performed too early in a patient’s journey due to poor patient selection. We sought to create a protocol to guide the selection of patients for CTCAPs based on their CTH findings. Methods Patients with suspected new brain tumors discussed at the neuro-oncology MDT at a tertiary neurosurgical center were reviewed. Patient demographics and CTH features were collected. For protocol creation, data was collected from July to December 2020, and predictor variables were identified using multivariate logistic regression. Candidate protocols were assessed in a protocol testing stage using similar data collected from January to June 2021. Sensitivity, specificity, and area under the curve (AUC) were computed for each protocol. Results Variables from the protocol creation stage (222 patients) were assessed in the protocol testing stage (216 patients). The most sensitive variables predicting metastatic disease were a previous history of cancer, multiple lesions, lesion < 4 cm, and infratentorial location. A protocol recommending a CTCAP based on the presence of one of these features has a sensitivity of 99.1% (AUC 0.704). Conclusions Unnecessary CTCAPs are reduced if performed only if a patient has one of the four identified predictor variables.

Introduction The response throughout the National Health Service (NHS) to the first wave of coronavirus disease 2019 (COVID-19) was substantial. With repeat winter waves of COVID-19 or other viral pathogens in the future being likely, we sought to review the impact of the response to the first wave on the delivery and training of neurosurgery in a large tertiary neurosurgical centre. Methods We performed a retrospective review over the three-month period of 8th March to 7th June 2020 as indicative of the peak of the pandemic in the UK. For referrals, our online referral portal was reviewed (ORION). For admissions and operations, electronic patient records were reviewed (EPIC systems). Trust wide update emails and policies were also reviewed. Results In response to the pandemic, neurosurgical service provision was severely restricted in the early days of the pandemic in the form of reduced beds, medical and nursing staff and theatres. This was rapidly realised to be unsustainable, and resources were slowly reopened although not to pre-COVID-19 levels. Although referrals did not substantially reduce, the number of elective and emergency admissions, length of stay, theatre efficiency and operative numbers (by pathology and grade of operating surgeon) did significantly reduce except for emergencies performed by consultants. If similar trainee operating numbers would have persisted, this would lead to a significant delay to completion of training. Conclusions All aspects of neurosurgical provision were detrimentally affected due to the rapid response to the first wave of COVID-19 in our institution. Such repeated reductions in acute services such as neurosurgery would be unsustainable. It is pertinent to re-visit these effects in preparation for future infection waves to better protect acute neurosurgical services.