Cranial Nerve Deficits Research Articles

Comparing neuroendocrine recovery between surgical and conservative management in pituitary apoplexy patients: a propensity score-matched analysis.

Pituitary apoplexy is a rare and potentially life-threatening clinical syndrome. Patients may present with severeneuro-ophthalmologic or endocrine symptoms. Current evidence is unclear whether conservative or surgicalmanagement leads to the best neuroendocrine outcomes. This study aimed to compare neuroendocrine outcomesbetween surgical and conservative treatments in a single center. Cases of patients with pituitary apoplexy whoreceived transsphenoidal surgery or conservative management in Songklanagarind Hospital between January 1,2005 and December 31, 2022 were retrospectively reviewed. A propensity score matching method was used toadjust bias from treatment selection (surgery or conservative treatment). Differences in visual field, visual acuity,cranial nerve, and endocrine outcomes between the surgical and conservative treatment groups were analyzedusing logistic regression analysis. This study included 127 patients, with 98 and 29 patients in the surgical and theconservative treatment group, respectively. The optimal matching method was used for propensity score matching.Compared to the conservative group, the surgically treated patients had a significantly higher rate of visual fieldrecovery (odds ratio (OR): 12.89, P = 0.007). However, there were no statistical differences in the recovery rate ofpreoperative visual acuity, cranial nerve, and endocrine deficits between the groups. Transsphenoidal surgery wasassociated with a higher rate of visual field recovery when compared to the conservative treatment for pituitaryapoplexy patients. Careful selection of appropriate treatment based on the patient's presentation andneuroendocrine status will result in the best outcomes while avoiding unnecessary surgical intervention.

Predictors of syrinx presentation and outcomes in pediatric Chiari malformation type I: a single institution experience of 218 consecutive syrinx patients.

Chiari I malformation (CM-I) in pediatric patients can impose substantial neurologic and functional impairment. Additionally, the presence of syrinx is often a harbinger of clinical compromise, but little attention has been devoted to identifying features associated with syrinx development and the clinical impact of syrinx resolution. Therefore, this study aims to identify clinical and radiographic variables associated with preoperative syrinx presence and postoperative syrinx reduction in pediatric patients with CM-I and determine the relationship between postoperative syrinx reduction and clinical symptom improvement. The authors performed a retrospective analysis of 435 consecutive pediatric patients who underwent surgical treatment of CM-I from 2001 to 2021 at a single tertiary pediatric medical center. All patients underwent pre- and postoperative MRI, and clinical and radiographic variables were recorded and subject to inferential analysis. Syrinx at presentation was independently associated with symptoms of spinal cord dysfunction at presentation (OR 2.17 (95% CI 1.05-4.48); p = 0.036), scoliosis (OR 5.33 (2.34-10.86); p = 0.001), and greater pB-C2 (posterior basion to C2 distance) measurement length (OR 1.14 (95% CI 1.01-1.30); p = 0.040). Syrinx at presentation was inversely associated with tussive headaches at presentation (OR 0.27 (95% CI 0.16-0.47); p = 0.001) and cranial nerve deficits at presentation (OR 0.49 (95% CI 0.26-0.92); p = 0.025). Postoperatively, patients with radiographic evidence of syrinx improvement had greater rates of symptom improvement (93.1% vs 82.1%; p = 0.049), better CCOS scores (15.4 vs 14.2; p = 0.001), and decreased rates of readmission (6.0% vs 25.0%, p = 0.002) and reoperation (0.5% vs 35.7%; p = 0.001). The difference in syrinx resolution was similar but not statistically significant (10.3% vs 16.7%; p = 0.251). AO joint anomaly (OR 0.20, 95% CI 0.04-0.95; p = 0.026) and foramen magnum diameter (OR 1.12, 95% CI 1.00-1.25; p = 0.049) were the only independent predictors of syrinx improvement, and surgical technique was the only predictor for syrinx resolution (OR 2.44, 95% CI 1.08-5.50; p = 0.031). Patients that underwent tonsil reduction surgery whose syrinx improved had a wider foramen magnum diameter than those whose did not improve (34.3 vs 31.7; p = 0.028). Radiographic syrinx improvement is associated with greater rates of symptom improvement and less readmissions and reoperations for CM-I. AO joint anomalies and narrower foramen magnums were independent risk factors for the lack of syrinx improvement. These novel insights will help guide preoperative patient counseling, pre- and intraoperative surgical decision-making, and postoperative clinical prognostication in the treatment of pediatric CM-I.

Long-term outcome of primary clival chordomas: a single-center retrospective study with an emphasis on the timing of recurrences based on the primary treatment.

This study aimed to provide data on extended outcomes in primary clival chordomas, focusing on progression-free survival (PFS) and overall survival (OS). A retrospective single-center analysis was conducted on patients with clival chordoma treated between 1987 and 2022 using surgery, stereotactic radiosurgery, or proton radiation therapy (PRT). The study included 100 patients (median age 44 years, 51% male). Surgery was performed using the endoscopic endonasal approach in 71 patients (71%). Gross-total resection (GTR) or near-total resection (NTR) was attained in 39 patients (39%). Postoperatively, new cranial nerve deficits occurred in 7%, CSF leak in 4%, and meningitis in none of the patients. Radiation therapy was performed in 79 patients (79%), with PRT in 50 patients (50%) as the primary treatment. During the median follow-up period of 73 (interquartile range [IQR] 38-132) months, 41 recurrences (41%) and 31 deaths (31%) were confirmed. Patients with GTR/NTR had a median PFS of 41 (IQR 24-70) months. Patients with subtotal resection or biopsy had a median PFS of 38 (IQR 16-97) months. The median PFS of patients who received radiation therapy was 43 (IQR 26-86) months, while that of patients who did not receive radiation therapy was 18 (IQR 5-62) months. The Kaplan-Meier method showed that patients with GTR/NTR (p = 0.007) and those who received radiation therapy (p < 0.001) had longer PFS than their counterparts. The PFS rates following primary treatment at 5, 10, 15, and 20 years were 51%, 25%, 17%, and 7%, respectively. The OS rates at the same intervals were 84%, 60%, 42%, and 34%, respectively. Multivariate Cox regression analysis showed that age < 44 years (p = 0.02), greater extent of resection (EOR; p = 0.03), and radiation therapy (p < 0.001) were associated with lower recurrence rates. Another multivariate analysis showed that age < 44 years (p = 0.01), greater EOR (p = 0.04), and freedom from recurrence (p = 0.02) were associated with lower mortality rates. Regarding pathology data, brachyury was positive in 98%, pan-cytokeratin in 93%, epithelial membrane antigen in 85%, and S100 in 74%. No immunohistochemical markers were associated with recurrence. In this study, younger age, maximal safe resection, and radiation therapy were important factors for longer PFS in patients with primary clival chordomas. Preventing recurrences played a crucial role in achieving longer OS.

Preservation of cranial nerve function in large and giant trigeminal schwannoma resection: a case series.

Trigeminal schwannomas (TSs) are intracranial tumors that can cause significant brainstem compression. TS resection can be challenging because of the risk of new neurologic and cranial nerve deficits, especially with large (≥ 3cm) or giant (≥ 4cm) TSs. As prior surgical series include TSs of all sizes, we herein present our clinical experience treating large and giant TSs via microsurgical resection. This was a retrospective, single-surgeon case series of adult patients with large or giant TSs treated with microsurgery in 2012-2023. Seven patients underwent microsurgical resection for TSs (1 large, 6 giant; 4 males; mean age 39 ± 14years). Tumors were classified as type M (middle fossa in the interdural space; 1 case, 14%), type ME (middle fossa with extracranial extension; 3 cases, 43%), type MP (middle and posterior fossae; 2 cases, 29%), or type MPE (middle/posterior fossae and extracranial space; 1 case, 14%). Six patients were treated with a frontotemporal approach (combined with transmastoid craniotomy in the same sitting in one patient and a delayed transmaxillary approach in another), and one patient was treated using an orbitofrontotemporal approach. Gross total resection was achieved in 5 cases (2 near-total resections). Five patients had preoperative facial numbness, and 6 had immediate postoperative facial numbness, including two with worsened or new symptoms. Two patients (28%) demonstrated new non-trigeminal cranial nerve deficits over mean follow-up of 22months. Overall, 80% of patients with preoperative facial numbness and 83% with facial numbness at any point experienced improvement or resolution during their postoperative course. All patients with preoperative or new postoperative non-trigeminal tumor-related cranial nerve deficits (4/4) experienced improvement or resolution on follow-up. One patient experienced tumor recurrence that has been managed conservatively. Microsurgical resection of large or giant TSs can be performed with low morbidity and excellent long-term cranial nerve function.

A Staged Approach for Surgical Management of Basilar Invagination.

Patients with basilar invagination (BI) can be treated with several surgical options, ranging from simple posterior decompression to circumferential decompression and fusion. Here, we aimed at examining the indications and outcomes associated with these surgical strategies to devise a staged algorithm for managing BI. We conducted a retrospective cohort study in 2 neurosurgical centers and included patients with a BI, as defined by a position of the dens tip at least 5 mm above the Chamberlain line. Other craniovertebral junction anomalies, such as atlas assimilation, platybasia, and Chiari malformations, were documented. C1-C2 stability was assessed with a dynamic computed tomography scan. We included 30 patients with BI with a mean follow-up of 56 months (min = 12, max = 166). Posterior decompression and fusion (n = 8) was only performed in cases of obvious atlanto-axial instability (eg, increased atlanto-dental interval or hypermobility on flexion/extension), while anterior decompression (transoral or transnasal) was reserved to patients with lower cranial nerves deficits (eg, swallowing dysfunction) and irreducible anterior compression (n = 9). Patients with posterior signs (eg, Valsalva headaches) or myelopathy but without C1-C2 instability nor anterior signs were managed with an isolated foramen magnum decompression, with or without duraplasty (n = 13). Complications were more frequent for combined procedures, including neurological deterioriation (n = 4) and tracheostomy (n = 2), but reinterventions were more likely in patients undergoing posterior decompression alone (n = 3). Patient selection is key to determine the appropriate surgical strategy for BI: In our experience, combined approaches are only needed for patients with irreducible and symptomatic anterior compression, while fusion should be restricted to patient with obvious signs of atlanto-axial instability. Other BI patients can be managed by foramen magnum decompression alone to minimize surgical morbidity.

Takotsubo cardiomyopathy in Guillain-Barré syndrome.

Takotsubo cardiomyopathy (TCM) is a serious autonomic complication of Guillain-Barré syndrome (GBS). However, the association between TCM and GBS has not been investigated in detail. We investigated the characteristics of GBS patients with TCM (GBS-TCM). Clinical features and anti-ganglioside antibody between the GBS-TCM patients and 62 classical GBS patients without TCM as control patients were compared. Eight GBS-TCM patients were identified, in whom TCM was diagnosed at a mean of 6.5 [range 3-42] days after the onset of GBS. The age at onset of GBS was elder in the GBS-TCM patients than in the control GBS patients (76.5 [56-87] vs. 52 [20-88] years, p < 0.01). Notably, cranial nerve deficits, particularly in the lower cranial nerves, were observed in all GBS-TCM patients (100% vs. 41.9%, p < 0.01). Additionally, the GBS-TCM patients showed a higher GBS disability score at nadir (5 [4-5] vs. 4 [1-5], p < 0.01), and lower Medical Research Council sum scores at admission and nadir (37 [30-44] vs. 48 [12-60] at admission, p < 0.05, and 20 [12-44] vs. 40 [0-60] at nadir, p < 0.05, respectively). Mechanical ventilation was more frequently required in the GBS-TCM patients (62.5% vs. 11.3%, p < 0.01). Three GBS-TCM patients were positive for anti-ganglioside antibodies. TCM occurred at a relatively early phase of GBS. The characteristics of GBS-TCM were the elder, lower cranial nerve involvements, severe limb weakness, and respiratory failure.

Sphenoid plasmacytoma as initial presentation of multiple myeloma—case report

Abstract Plasmacytoma is a rare plasma cell neoplasm. Whether solitary or associated with multiple myeloma (MM), it rarely involves the skull base, particularly the sphenoid bone. We present a unique case of sphenoid bone plasmacytoma secondary to MM, highlighting diagnostic and therapeutic challenges. A 56-year-old female presented with headaches, vomiting, epistaxis, and cranial nerve deficits. Cerebral imaging revealed a 65-mm tumor infiltrating the sphenoid bone and adjacent structures. Subtotal resection was performed using an endoscopic nasal approach. Histopathology revealed plasmacytoma, and diagnostic workup confirmed MM. By the end of biological exploration, relapse of the sphenoid plasmacytoma was observed, and the patient was successfully treated with radiotherapy, immunochemotherapy, and autologous stem cell transplantation. After 18-month follow-up, sustained complete remission was confirmed. Although rare, the diagnosis of plasmacytoma should be considered in cases of skull base tumors. This localization is highly predictive of MM, warranting comprehensive investigations to initiate prompt and adequate management.

Association of hemorrhage-to-treatment time with outcomes in patients with brainstem cavernous malformations: a nationwide cohort study.

Brainstem cavernous malformations (BSCMs) often present with haemorrhage, but the optimal timing for microsurgical intervention remains unclear. This study aims to explore how intervention timing relates to neurological outcomes in haemorrhagic BSCM patients undergoing microsurgery, offering insights for clinical decisions. A total of 293 consecutive patients diagnosed with BSCMs, who underwent microsurgery were identified between March 2011 and January 2023 at two comprehensive centres in China, with a postoperative follow-up duration exceeding 6 months. Utilizing logistic regression models with restricted cubic splines, distinct time groups were identified. Subsequently, matching weight analysis compared these groups in terms of outcomes, new haemorrhage rates, cranial nerve deficits, and perioperative complications. The primary outcome was an unfavourable outcome, which was defined as a mRS score greater than 2 at the latest follow-up. Among the 293 patients, 48.5% were female, median age was (39.9±14.3) years, and median haemorrhage-to-treatment time was 42 days. Patients were categorized into acute (≤21days), subacute (22-42days), and delay (>42days) intervention groups. After matching, 186 patients were analyzed. Adjusted analysis showed lower unfavourable outcome rates for acute [adjusted odds ratio (OR), 0.73; 95% CI, 0.65-0.82; P<0.001] and subacute (adjusted OR, 0.83; 95% CI, 0.72-0.95; P=0.007) groups compared to the delay group. Subacute intervention led to fewer cranial nerve deficits (adjusted OR, 0.76; 95% CI, 0.66-0.88, P<0.001). New haemorrhage incidence didn't significantly differ among groups. For haemorrhagic BSCMs patients, delayed microsurgical intervention that exceeded 42 days after a prior haemorrhage were associated with an increased risk of unfavourable neurological outcomes.

Transorbital neuroendoscopic surgery for treatment of sphenoid wing meningiomas extending to the cavernous sinus: clinical implications and a technical illustration.

The aim of this study was to evaluate the efficacy and safety of transorbital neuroendoscopic surgery (TONES) in the management of sphenoid wing meningiomas (SWMs) with cavernous sinus and orbital invasion. The authors conducted a retrospective review of 32 patients with SWMs treated at Gazi University using TONES from October 2019 to May 2023. The study includes clinical applications to elucidate the endoscopic transorbital approach. Surgical techniques focused on safe subtotal resection, aiming to minimize residual tumor volume for subsequent radiosurgery. Data were collected on patient demographics, tumor characteristics, surgical procedures, complications, and postoperative outcomes, including radiological imaging and ophthalmological evaluations. Surgical dissections delineated a three-phase endoscopic transorbital approach: extraorbital, intraorbital, and intracranial. In the clinical application, gross-total resection was not achieved in any patient because of planned postoperative Gamma Knife radiosurgery. The mean follow-up period was 16.3 months. Of 30 patients with preoperative proptosis, 25 experienced postoperative improvement. No new-onset extraocular muscle paresis or visual loss occurred postoperatively. The average hospital stay was 1.15 days, with minimal complications and no significant morbidity or mortality. Total resection of SWMs invading the cavernous sinus and orbit is associated with substantial risks, particularly cranial nerve deficits. TONES offers a minimally invasive alternative, reducing morbidity compared with transcranial approaches, and represents a significant advancement in the surgical management of SWMs, especially those extending into the cavernous sinus and orbit. The approach provides a safe, effective, and patient-centric approach, prioritizing subtotal resection to minimize neurological deficits while preparing patients for adjunctive radiosurgery. This study positions TONES as a transformative surgical technique, aligning therapeutic efficacy with neurovascular preservation and postoperative recovery.

Alpha-chloralose poisoning in 25 cats: clinical picture and evaluation of treatment with intravenous lipid emulsion.

The aims of this study were to describe the clinical picture and progression in cats with alpha-chloralose (AC) intoxication and to determine if treatment with intravenous (IV) lipid emulsion (ILE) influenced either the serum concentration of AC or the clinical signs. Cats with suspected AC poisoning admitted to a university small animal hospital were included. The cats were randomised into two groups: one receiving 20% ILE at a dose of 300 mg/kg as a 2 min bolus, followed by a 1500 mg/kg continuous rate infusion over 30 mins (IL+ group) and the other receiving IV fluid therapy with Ringer's acetate (IL- group). Serum samples were drawn at 0, 2, 12 and 24 h after admission. Samples were tested for AC with a novel validated, quantitative, ultra-high-performance liquid chromatography-tandem mass spectrometry method. Vital and predefined clinical signs were noted at the times of sampling and patients were scored using a previously described intoxication severity score. Telephone interviews were conducted after discharge to assess outcome. A total of 25 cats were enrolled: 13 cats in the IL+ group and 12 in the IL- group. The most common clinical signs at presentation were tremor (n = 22, 88.0%), cranial nerve deficits (n = 20, 80.0%) and bradycardia (n = 19, 76.0%). No significant difference in AC concentration or change in intoxication score over time was found between the IL+ and IL- groups at any time point (P >0.05). All cats recovered within 72 h. ILE did not have any effect on the AC serum concentration or clinical signs in AC-poisoned cats. All cats survived until follow-up. In cats with an acute onset of the described neurological signs, AC intoxication is an important differential diagnosis with an excellent prognosis.

308 Improvement in Cranial Nerve Neuropathies Following Treatment of Intracranial Aneurysms With Flow Diverters: Institutional Outcomes and Meta-analysis of Literature

INTRODUCTION: Cranial nerve (CN) neuropathies are rare presenting symptoms of intracranial aneurysms. Ophthalmological outcomes for symptomatic aneurysms treated with flow diversion are not well established. METHODS: We conducted a retrospective review of our institutional database for patients with intracranial aneurysms presenting with CN neuropathies who underwent treatment with flow diversion between 2015 and 2023. Systematic review of the literature was performed using Medline, EMBASE, Cochrane, and manual citation searches. Random effects meta-analysis was used. RESULTS: Twelve out of 136 studies were included in this meta-analysis, totaling 261 patients. The results were combined with our institutional data. The pooled rate of improvement in any CN neuropathies following flow diversion was 76% (95% CI, 67%-84%, n = 272). Patients presenting with CNII deficits were less likely to improve following treatment compared to other CN neuropathies (pooled OR [pOR] 0.32, 95% CI, 0.16-0.63, n = 224). The pooled rate of clinical improvement was 53% in CNII deficits (95% CI, 42%-65%, n = 80) and 80% in other CN deficits (95% CI, 71%-88%, n = 106). Intervention within one month of presentation was associated with improvement (pOR 6.53, 95% CI, 1.34-31.81, n = 33). Adjunctive coiling did not demonstrate effect on the improvement rate (pOR 0.38, 95% CI, 0.07-2.13, n = 31). Near total occlusion (Raymond Roy Occlusion Classification of 1 or 2, or O'Kelly-Marotta scale of C or D) was associated with symptomatic improvement (pOR 5.29, 95% CI, 1.66-16.90, n = 118), but not total occlusion (pOR 2.83, 95% CI, 0.97-8.23, n = 118). CONCLUSIONS: Flow diversion improves CN outcomes in patients with symptomatic intracranial aneurysms. These results support the theory that CN neuropathies depend more on the pulsatility of the aneurysm sac rather than mass effect. The inferior rate of improvement in CNII deficits compared to other CN symptoms may imply an additional, more irreversible mechanism contributing to CNII visual deficits.

Giant Meningiomas Invading the Cavernous Sinus: The “Inevitable Ones”

Abstract Introduction Giant meningiomas invading the cavernous sinus (GMICSs) are a subgroup of challenging tumors due to their volume and the extent of neurological impairment. Preserving quality of life is one of the most relevant aspects of treating patients with GMICS. Methods A retrospective study was conducted for surgeries performed between 2012 and 2022, including 33 patients presenting meningiomas with the largest diameter of at least 5 cm invading the cavernous sinus. The data from surgical intervention, Simpson grade of resection, tumor location, and morbimortality related to the surgeries were reviewed. Results The group comprised 25 women and 8 men with a median age of 56 years. The mean follow-up period was 52 months. The tumors were in the sphenoid wing, anterior clinoid, spheno-orbital, spheno-petroclival, petroclival, and Meckel's cave. Simpson grade I, II, and III were obtained in 70% of cases. The meningiomas were classified as WHO grade 1 in 94%, grade 2 in 3%, and grade 3 in 3%. The overall mortality was 3%. Permanent cranial nerve deficits occurred in 21%, transient cranial nerve deficits in 42%, cerebrospinal fistula in 15%, and hemiparesis in 18%. The recurrence/regrowth rate was 6%. The Karnofsky Performance Status score of 100 and 90 was 82%. Conclusions The surgical treatment of GMICS is an effective treatment modality with acceptable morbimortality and good long-term control. Involvement of the internal carotid artery is essential to determine the extent of resection inside the cavernous sinus, and training in the microsurgical laboratory is mandatory for safe surgical treatment.

Enigmatic echoes: Exploring brainstem neurenteric cysts - A case series and literature review

Introduction and importanceNeurenteric cysts (NCs) are rare congenital anomalies within the central nervous system, originating from the endodermal layer due to inappropriate embryonic notochordal plate and endoderm separation. Despite constituting a minute fraction of CNS tumors, their diverse clinical presentations and brainstem occurrence pose diagnostic challenges. Case presentationThis study presents a series of three brainstem NCs, detailing demographics, clinical presentations, radiological features, and operative findings. Patients aged 2–40 years exhibited varied symptoms including headaches, vomiting, cranial nerve deficits, and motor/sensory deficits. Literature review of 27 cases showed a mean age of 26.8 years, predominantly in females, with diverse cystic characteristics on MRI. Surgical intervention achieved mostly complete resection, with varying outcomes including recurrence and malignant transformation. Clinical discussionThis study sheds light on the rare entity of brainstem NCs, emphasizing their diagnostic complexity. NCs, though constituting a minute fraction of CNS tumors, present a diagnostic challenge due to their diverse clinical presentations and rarity in the brainstem. ConclusionThis study provides insights into brainstem NCs, emphasizing diagnostic complexity and the importance of MRI in accurate diagnosis and surgical intervention. Enhanced collaboration is needed to refine management strategies for these intriguing lesions.

Bilateral vision loss with cranial nerve paralysis, revealing ischaemic pituitary apoplexy and acromegaly: A case report

Pituitary Apoplexy (PA) is a potentially fatal clinical condition resulting from ischaemic or haemorrhagic infarction of the pituitary gland. The ischaemic subtype is even rarer and more severe. We present the case of a 26-year-old female patient who presented with headache, acute bilateral visual loss, fever, confusion, asthenia with classic features of acromegaly, and pupils with bilateral areactive mydriasis without light perception bilaterally with cranial nerve involvement. Magnetic Resonance Imaging (MRI) confirmed the presence of a pituitary macroadenoma, and endocrine investigations revealed panhypopituitarism. The patient underwent transsphenoidal evacuation and the diagnosis of ischaemic PA was confirmed by histology. Three months later, a follow-up MRI showed an empty bowel with remission of acromegaly, diabetes and mild unilateral visual recovery. Our case highlights the importance of considering ischaemic PA among the possible aetiologies of sudden cranial nerve deficits then early diagnosis and treatment are essential to improve outcome.

Long-term radiographic and endocrinological outcomes of stereotactic radiosurgery for recurrent or residual nonfunctioning pituitary adenomas.

Stereotactic radiosurgery (SRS) is used for the treatment of residual/recurrent nonfunctional pituitary adenoma (NFPA). The aim of this study was to evaluate the factors related to long-term tumor control and delayed endocrinopathies following SRS. This retrospective, multicenter study included patients with recurrent/residual NFPA treated with single-fraction SRS; they were then divided into two arms. The first arm included patients with at least 5 years of radiographic follow-up and all patients with local tumor progression. The second arm included patients with at least 5 years of endocrinological follow-up and all patients who developed endocrinopathy. Study endpoints were tumor control and new or worsening hypopituitarism after SRS and were analyzed using Cox regression and Kaplan-Meier methodology. There were 360 patients in the tumor control arm (median age 52.7 [IQR 42.9-61] years, 193 [53.6%] males) and 351 patients in the hypopituitarism arm (median age 52.5 [IQR 43-61] years, 186 [53.0%] males). The median follow-up in the tumor control evaluation group was 7.95 (IQR 5.7-10.5) years. Tumor control rates at 5, 8, 10, and 15 years were 93% (95% CI 90%-95%), 87% (95% CI 83%-91%), 86% (95% CI 82%-90%), and 69% (95% CI 59%-81%), respectively. The median follow-up in the endocrinopathy evaluation group was 8 (IQR 5.9-10.7) years. Pituitary function preservation rates at 5, 8, 10, and 15 years were 83% (95% CI 80%-87%), 81% (95% CI 77%-85%), 78% (95% CI 74%-83%), and 71% (95% CI 63%-79%), respectively. A margin dose > 15 Gy (HR 0.8, 95% CI 0.7-0.9; p < 0.001) and a delay from last resection to SRS > 1 year (HR 0.9, 95% CI 0.7-0.9; p = 0.04) were significant factors related to tumor control in multivariable analysis. A maximum dose to the pituitary stalk ≤ 10 Gy (HR 1.1, 95% CI 1.09-1.2; p < 0.001) was associated with pituitary function preservation. New visual deficits after SRS occurred in 7 (1.94%) patients in the tumor control group and 8 (2.3%) patients in the endocrinopathy group. Other new cranial nerve deficits post-SRS occurred in 4 of 160 patients with data in the tumor control group and 3 of 140 patients with data in the endocrinopathy group. SRS affords favorable and durable tumor control for the vast majority of NFPAs. Post-SRS hypopituitarism occurs in a minority of patients, but this risk increases with time and warrants long-term follow-up.

Intraventricular Ependymoma in Pediatric Patients: A Systematic Review of Demographics, Clinical Characteristics, and Outcomes

Background: Intraventricular neoplasms are rare occurrences observed in 5 – 7% of all primary pediatric brain tumors. Pediatric intraventricular ependymomas are a complex subset of these tumors, poorly discussed across the current literature. Although surgery is generally the accepted treatment of choice, information on clinical course and outcomes is limited to heterogeneous case reports and small case series focusing on specific histologic subtypes or ventricular locations. We conducted a systematic review on pediatric intraventricular ependymomas to survey the patient population, tumor characteristics, management strategies, and associated outcomes.&#x0D; Project Methods: PubMed, Scopus, Web-of-Science, and Cochrane were searched upon the PRISMA guidelines to include studies reporting pediatric patients with intraventricular ependymomas. Clinical characteristics, treatment protocols, and outcomes were analyzed.&#x0D; Results: A total of 9 studies with 70 patients were included. Most patients were male (54%), diagnosed at a mean age of 7 years (range, 0.2-17), and frequently exhibited nausea and vomiting (38%), headache (31%), and ataxia (25%). Tumors were predominantly located in the fourth ventricle (79%) and most tumors were WHO grade 2 (73%). Mean tumor volume was 3 cm3 (range, 0.1-13.2). Management included surgical resection (96%), radiotherapy (87%), and chemotherapy (38%). Gross total resection was achieved in 69% of cases. Cranial nerve deficit was the most common post-surgical complication (71%). Most common combination of treatment included surgical resection and radiotherapy (53%). Mean overall survival was 50 months in these patients.&#x0D; Conclusion/Impact: Pediatric intraventricular ependymomas are rare tumors with limited information on management strategies. The mainstay of treatment is complete surgical resection. Compared to ependymomas, intraventricular ependymomas appear to have a worse overall prognosis.

Comparing redo surgery and stereotactic radiosurgery for recurrent, residual, and/or tumors showing progression in nonfunctioning pituitary adenomas: A systematic review and meta-analysis.

Non-functioning pituitary adenomas (NFPAs) are well-differentiated benign tumors originating from the adenohypophyseal cells of the pituitary gland. They present with headaches, visual disorders, or cranial nerve deficits. NFPAs can recur, progress, or present as residual tumors. We, therefore, conducted this review to compare the effects of both revision surgery and stereotactic surgery on tumor size, visual status, endocrine status, and complications. A systematic review of published literature on recurrent, residual, or progressing NFPAs that underwent redo surgery or stereotactic radiosurgery from the inception till June 2020 was conducted as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Thirteen records (1209 patients) were included, and risk ratio (RR) and 95% confidence intervals (CIs) estimated from each study were pooled using a random-effects meta-analysis model. Redo surgery was the preferred intervention in patients presenting with larger tumor sizes and was more effective in reducing the tumor size as compared to stereotactic radiosurgery (SRS) (risk ratio [RR] 56.14; 95% CI, 16.45-191.58). There was more visual loss with revision surgery as compared to SRS (risk ratio [RR] 0.08; 95% CI, 0.03-0.20). However, SRS was associated with fewer complications, such as new diabetes insipidus, as compared to the redo surgery (risk ratio [RR] 0.01; 95% CI 0.01-0.03). Redo surgery is the superior choice in the treatment of recurrent/residual or progressing NFPAs if the tumor size is large and an immediate reduction in tumor burden through debulking is warranted. However, redo surgery is associated with a higher risk of visual loss, new endocrinopathies, and other complications, in contrast to SRS.

Craniocervical instability in patients with Ehlers-Danlos syndromes: outcomes analysis following occipito-cervical fusion

Craniocervical instability (CCI) is increasingly recognized in hereditary disorders of connective tissue and in some patients following suboccipital decompression for Chiari malformation (CMI) or low-lying cerebellar tonsils (LLCT). CCI is characterized by severe headache and neck pain, cervical medullary syndrome, lower cranial nerve deficits, myelopathy, and radiological metrics, for which occipital cervical fusion (OCF) has been advocated. We conducted a retrospective analysis of patients with CCI and Ehlers-Danlos syndrome (EDS) to determine whether the surgical outcomes supported the criteria by which patients were selected for OCF. Fifty-three consecutive subjects diagnosed with EDS, who presented with severe head and neck pain, lower cranial nerve deficits, cervical medullary syndrome, myelopathy, and radiologic findings of CCI, underwent open reduction, stabilization, and OCF. Thirty-two of these patients underwent suboccipital decompression for obstruction of cerebral spinal fluid flow. Questionnaire data and clinical findings were abstracted by a research nurse. Follow-up questionnaires were administered at 5–28 months (mean 15.1). The study group demonstrated significant improvement in headache and neck pain (p < 0.001), decreased use of pain medication (p < 0.0001), and improved Karnofsky Performance Status score (p < 0.001). Statistically significant improvement was also demonstrated for nausea, syncope (p < 0.001), speech difficulties, concentration, vertigo, dizziness, numbness, arm weakness, and fatigue (p = 0.001). The mental fatigue score and orthostatic grading score were improved (p < 0.01). There was no difference in pain improvement between patients with CMI/LLCT and those without. This outcomes analysis of patients with disabling CCI in the setting of EDS demonstrated significant benefits of OCF. The results support the reasonableness of the selection criteria for OCF. We advocate for a multi-center, prospective clinical trial of OCF in this population.

Surgical Management of Foramen Magnum Meningiomas: Clinical Insights and Outcomes

Objective: This retrospective study aimed to provide a comprehensive analysis of the surgical management of foramen magnum meningiomas (FMMs), focusing on patient characteristics, surgical approaches, complications, and postoperative outcomes. Materials and Methods: The study included 23 patients diagnosed with anterior or anterolateral FMMs who underwent surgical treatment between 2014 and 2022. The study encompassed clinical records, neurological assessments, radiological findings, and surgical approaches, with a focus on the far lateral approach (FLA). Evaluation of outcomes included Karnofsky Performance Scale (KPS) scores and The Neck Disability Index (NDI) scores. Surgical approaches and postoperative care strategies were detailed. The study also examined the relationship between tumor location and surgical techniques. Results: The analysis revealed that patients with FMMs presented with various clinical symptoms, including lower cranial nerve deficits, pyramidal tract syndrome, and sensory disturbances. The retrocondylar far lateral approach was predominantly utilized, resulting in various Simpson resection grades. Postoperative complications were observed, including cranial nerve deficits, cerebrospinal fluid leakage, and infections. Also, the study found patient KPS scores remained stable, and NDI scores showed no significant increases before and after surgery. Conclusion: Surgical management of FMMs is a complex task requiring meticulous planning, individualized approaches, and close attention to neurovascular structures. The study emphasized the diverse clinical presentations and surgical techniques associated with FMMs and highlighted the importance of ongoing research and collaborative efforts to enhance patient care in this challenging field.

Lessons learned from a fatal case of Tuberculosis Meningitis: A case report

BACKGROUND In 2023, 10 million cases of Tuberculosis were reported by the WHO. Tuberculous meningitis (TBM) may be the sole manifestation of Tuberculosis (TB) and does not require prior pulmonary or extrapulmonary disease[1]. Approximately one-half of all TBM infections lead to severe neurological disability with a mortality rate of 30% with death in 6 months and 50% overall[2-4]. Despite being inarguably the most devastating clinical presentation of TB, frequent diagnostic delays are common due to low clinical suspicion or misdiagnosis as current diagnostic tests still have a limited yield[5]. The best way to reduce mortality and morbidity associated with TBM is by maintaining a high index of suspicion, timely diagnosis and initiation of treatment. This case report aims to highlight the clinical presentation, imaging findings, and diagnostic pitfalls in the diagnosis of TBM. CASE PRESENTATION A 36-year-old Indian man with no significant medical, social, or travel history initially sought treatment at a private hospital in Abu Dhabi for fever, intermittent headaches, and confusion. Investigations at the hospital included a negative QuantiFERON TB gold (QTF) test and a negative cerebrospinal fluid (CSF) culture, but the CSF analysis was not included in the provided reports. Consequently, he received acyclovir treatment for suspected viral encephalitis but was discharged without complete symptom resolution. Following discharge, he experienced worsening confusion over three days. Upon presentation to our Emergency Department (ED), he was febrile, disoriented, and difficult to rouse, with a GCS score of 11/15, displaying terminal neck stiffness. There were no signs of lateralization, cranial nerve deficits, or cerebellar abnormalities. A computerized tomography (CT) scan conducted in the ED revealed hydrocephalus with diffuse leptomeningeal enhancement. Laboratory results indicated significant hyponatremia at 121 mmol/L. He was started on broad-spectrum antibiotics and anti-tuberculosis medication empirically based on the clinical scenario and CT findings. During his Intensive Care Unit (ICU) stay, a CSF analysis suggested TB meningitis, and a positive Mycobacterium tuberculosis polymerase chain reaction (MTB-PCR) confirmed the diagnosis. An MRI of the brain showed meningoencephalitis with tuberculoma formation in the left cerebellar hemisphere. Unfortunately, despite treatment, his condition deteriorated, necessitating endotracheal intubation, multiple EVD revisions, and ventriculoperitoneal shunt placement. A follow-up MRI revealed worsening hydrocephalus and cerebral vessel thromboses, ultimately leading to his unfortunate demise in the ICU. CONCLUSION This case highlights that Tuberculous meningitis is a highly lethal, under-recognized disease with characteristic clinical and imaging features in which delay in diagnosis and subsequent treatment can lead to fatal consequences. Emergency Medicine physicians should maintain a high index of suspicion for TBM in patients with fever and vomiting and signs of altered mental status and keep in mind that a normal CXR, negative QuantiFERON test, and the absence of TB exposure history does not exclude TBM from the differential when clinical and Brain imaging findings raise concern. Prompt identification prevents delay in initiation of management and ultimately may lead to better long-term outcomes.