Pediatric fibromyxoid brachial plexus tumor with YWHAZ::PLAG1 gene fusion: a case report

Pediatric fibromyxoid soft tissue tumors may be associated with gene fusions such as YHWAZ::PLAG1, with only three reported cases in the literature. We present the fourth case, a 13-year-old male with a pediatric fibromyxoid brachial plexus tumor with YWHAZ::PLAG1 gene fusion. This is also the first case to be reported in an adolescent, in the brachial plexus, and in the Philippines. The patient presented with a 10-year history of a slowly growing left supraclavicular mass and a 1-year history of intermittent dysesthesia in the left upper extremity. Neurologic examination was unremarkable. Imaging revealed a large left supraclavicular lesion with intrathoracic extension. Surgical excision was performed, and histopathology revealed a fibromyxoid tumor with YWHAZ::PLAG1 gene fusion. Although previous examples of this gene fusion pointed toward lipoblastoma as their primary pathology, our tumor does not completely fulfill the current diagnostic criteria for a lipoblastoma and may represent an intermediate form of the disease. Our case is unique not only because it is the first reported adolescent patient harboring such a lesion but also because of the relatively lengthy natural history exhibited by the tumor prior to its resection. This provided us with valuable information about its behavior, which suggests a more indolent growth pattern. This case also highlights the clinical importance of molecular testing of tumors, where recognition of disease entities can assist clinicians in deciding and advocating for the proper management.

Adult idiopathic bilateral occlusion of foramen of Monro: Systematic review with illustrative case

BACKGROUND

Adult idiopathic occlusion of foramen of Monro (AIOFM) is a rare condition that results in hydrocephalus, and bilateral presentation is even rarer. Here we report a case of idiopathic bilateral stenosis of the foramen of Monro in an adult patient and performed a systematic literature review on the current treatment options and outcomes.

METHODS

We performed a systematic review of SCOPUS, Science Direct, and PubMed databases in accordance with PRISMA guidelines. Data on demographics, clinical presentation, imaging findings, type of AIOFM, treatment, and outcomes were collected.

RESULTS

A total of 22 cases of bilateral AIOFM were identified in the literature, including ours. The median age was 38.5 years (range: 20-53), with no sex predilection. The most common presenting symptoms were headache (n=16, 73%) and vomiting (n=10, 45%). There were 9 cases of Type 1 AIOFM (stenosis) and 13 cases of Type 2 (membrane occlusion). Majority of patients underwent surgical treatment, mostly endoscopic unilateral foraminoplasty and septostomy (59%), followed by ventriculoperitoneal shunt insertion (31%). One patient underwent medical management only to alleviate her presenting symptoms (seizures). The overall outcome was good for majority of patients at a median follow-up of 6 months.

CONCLUSION

Bilateral AIOFM is a rare condition that may easily be missed, so neurosurgeons should be cognizant of this disease entity. Identification of the type of AIOFM may guide surgical decision-making. Treatment options include neuroendoscopic procedures such as septostomy and foraminoplasty, and ventriculoperitoneal shunt insertion.

Transcranial magnetic resonance-guided focused ultrasound pallidothalamic tractotomy for patients with X-linked dystonia-parkinsonism: a study protocol

Transcranial magnetic resonance-guided focused ultrasound (MRgFUS) is a noninvasive method for controlling tremor and has recently been used in patients with X-linked dystonia-parkinsonism (XDP). This study aims to determine the improvement in dystonia and parkinsonism in patients with XDP after MRgFUS pallidothalamic tractotomy. This prospective study will be conducted at the Philippine General Hospital, University of the Philippines Manila. The primary outcome measure is the change in the pre- and post-treatment XDP-Movement Disorder Society of the Philippines Scale scores. In addition, demographic and clinical data will be collected, including the Burke-Fahn-Marsden Dystonia Rating Scale, Part III of the Movement Disorder Society-Unified Parkinson's disease Rating Scale score, XDP clinical and functional stage, the five-level EuroQol five-dimensional questionnaire, Montreal Cognitive Assessment scores, MRgFUS treatment parameters, and adverse events. Patients will be assessed within 24 hours of treatment, then at 2 weeks, 3 months, 6 months, 9 months, and 12 months post-treatment. This protocol was approved by the University of the Philippines Manila Research Ethics Board (UPMREB 2022-0271-01). Data collection began in January 2023. This protocol has been registered with ClinicalTrials.gov: Trial Registration number: NCT05592028.

Cortical mapping in multilinguals undergoing awake brain surgery for brain tumors: Illustrative cases and systematic review

BACKGROUND

Awake brain mapping in multilingual patients with brain tumors presents unique challenges to the neurosurgeon. Knowledge of potential eloquent sites is vital to preserve language function.

METHODS

We present two cases of pars opercularis glioma and perform a systematic review in accordance with PRISMA guidelines.

RESULTS

Our review yielded 7 studies, with a total of 25 multilingual brain tumor patients who underwent awake brain mapping. The age ranged from 25 to 62 years. Majority were female (56.5%). Most (52%) were trilingual, while 20% were quadrilingual and 28% were pentalingual. All tumors were left-sided, mostly in the frontal lobe. These were predominantly gliomas. Extent of resection was gross total in 61%. The brain mapping findings were heterogeneous. Some authors reported a greater number of cortical sites for the first language compared to others. Others found that the first and second languages shared cortical sites whereas the third and subsequent languages were located in distant sites. The peri-Sylvian area was also found to be involved in language that was learned at an earlier age. Subsequent languages thus involved more distant sites. A larger number of cortical areas were also activated for languages that were learned later in life. In terms of language disturbance and recovery, there were mixed results.

CONCLUSION

Cortical mapping in multilingual brain tumor patients showed heterogeneity in terms of the location and number of language areas in the face of pathology. These findings may influence neurosurgical and oncological management of tumors in the speech area but emphasize the need to tailor surgical approaches and intraoperative testing to the patient.

Calvarial metastasis from malignant pheochromocytoma associated with multiple endocrine neoplasia

Background:

Malignant pheochromocytoma is a rare neuroendocrine tumor that may metastasize to the bones, liver, lungs, kidneys, and lymph nodes. Cerebral and skull metastases are even rarer, with only 17 cases reported in the literature. To the best of the authors’ knowledge, this is the first reported case of a purely calvarial metastasis from malignant pheochromocytoma associated with multiple endocrine neoplasia type 2A (MEN2A).

Case Description:

A 31-year-old Filipino man diagnosed with MEN2A was found to have elevated urine metanephrine on routine surveillance, and workup revealed right adrenal and hepatic masses and a focus of intense tracer accumulation on the right frontal bone on metaiodobenzylguanidine I-123 scan. All the newly discovered lesions were resected to achieve tumor control. Histopathology revealed a diagnosis of pheochromocytoma for the calvarial lesion.

Conclusion:

Malignant pheochromocytoma may give rise to indolent metastatic foci that can easily be missed without a thorough examination. Misdiagnosis and delays in management of this disease can be detrimental, resulting in irreversible complications and death.

Resources for Operative Neurosurgical Education Among Trainees in the Philippines

BACKGROUND

Operative neurosurgical skills education is a vital part of neurosurgical training, and these skills are usually obtained through operating room experience and supplemented by textbooks and other resources. We aimed to determine the resources used by trainees in the Philippines, both prior to and after the onset of the coronavirus disease 2019 pandemic.

METHODS

An online survey was sent to neurosurgical trainees in the Philippines from January to March 2021. Data on demographics, educational resources used, and weekly hours spent on each were collected, for both the pre- and post-coronavirus disease 2019 periods.

RESULTS

A total of 37 neurosurgical trainees (60% response rate) participated in the survey. Most respondents were female (70%), in their senior levels (58%), and undergoing training in a public institution (65%). The main resources for operative neurosurgical education were operative experience, online academic resources, and neurosurgical textbooks. After the onset of the pandemic, the overall time spent decreased to 61.2 hours/week from 67.7 hours/week, with a significant reduction in the hours spent on operative experience (27.3 vs. 21.3 hours/week, P < 0.0001) and a significant increase in the time spent on webinars (0 vs. 3.2 hours/week, P < 0.0001) and online resources as a whole (14.9 vs. 16.4 hours/week, P = 0.0003).

CONCLUSIONS

Operative experience, online academic resources, and neurosurgical textbooks were the main resources for operative neurosurgical education among trainees in the Philippines. After the onset of the pandemic, the hours spent on operative experience decreased and online academic resources increased significantly. New avenues of neurosurgical education, particularly webinars, also became available locally.

Patient-reported intraoperative experiences during awake craniotomy for brain tumors: a scoping review

Awake craniotomy (AC) is a neurosurgical procedure that may be used to excise tumors located in eloquent areas of the brain. The techniques and outcomes of AC have been extensively described, but data on patient-reported experiences are not as well known. To determine these, we performed a scoping review of patient-reported intraoperative experiences during awake craniotomy for brain tumor resection. A total of 21 articles describing 534 patients were included in the review. Majority of the studies were performed on adult patients and utilized questionnaires and interviews. Some used additional qualitative methodology such as grounded theory and phenomenology. Most of the evaluation was performed within the first 2 weeks post-operatively. Recollection of the procedure ranged from 0 to 100%, and most memories dealt with the cranial fixation device application, cranial drilling, and intraoperative mapping. All patients reported some degree of pain and discomfort, mainly due to the cranial fixation device and uncomfortable operative position. Most patients were satisfied with their AC experience. They felt that participating in AC gave them a sense of control over their disease and thought that trust in the treatment team and adequate pre-operative preparation were very important. Patients who underwent AC for brain tumor resection had both positive and negative experiences intraoperatively, but overall, majority had a positive perception of and high levels of satisfaction with AC. Successful AC depends not only on a well-conducted intraoperative course, but also on adequate pre-operative information and patient preparation.

Socioeconomic factors affecting survivorship of glioblastoma patients in the Philippines

Glioblastoma (GBM) is the most common malignant primary brain tumor in adults worldwide. However, data on the survivorship of GBM patients in low- and middle-income countries is sparse. We determined whether socioeconomic factors such as marital status, place of residence, educational attainment, employment status, and income affected survival. A retrospective cohort study of surgically managed GBM patients (n = 48) in a single center over a five-year period was conducted using chart review and telephone interview. The mean age was 41 years, with a male predilection (62%). Most patients were married (73%), employed full time (79%), resided in a rural location (56%), completed secondary education (44%), and had a low income (83%). Most of the tumors were > 5 cm at the time of diagnosis (90%) and involved more than one lobe (40%). Majority underwent subtotal resection (56%). Only 15% (n = 7) had adjuvant chemoradiation while 23% (n = 11) had radiotherapy alone. Median overall survival was 7.6 months. Multivariate analysis showed that extent of resection (gross total resection, p = 0.0033; subtotal resection, p = 0.0069) and adjuvant treatment (p = 0.0254) were associated with improved survival, while low income (p = 0.0178) and educational (p = 0.0206) levels and part-time employment (p = 0.0063) were associated with decreased survival. Many GBM patients at our center presented at an advanced stage in their natural history, and majority (62%) did not receive adjuvant treatment after surgery. As such, the median overall survival was less than that reported in developed countries. Of the socioeconomic factors analyzed, low income and educational levels and part-time employment were negatively associated with survivorship.

Isolated Cranial Nerve VI Palsy and Neurosyphilis: A Case Report and Review of Related Literature

An isolated cranial nerve VI palsy is a rare initial manifestation of undiagnosed neurosyphilis. A 33-year-old male presented with a one month history of progressive headache and diplopia. Neurologic examination only revealed an isolated abducens palsy on the left. Cranial imaging was unremarkable. Examination of his cerebrospinal fluid revealed lymphocytic predominant leukocytosis and elevated protein. Microbiologic work-up were all negative. Further work-up revealed the patient to be serum Rapid Plasma Reagin and Enzyme Immunoassay reactive. Enzyme-linked immunosorbent assay for Human Immunodeficiency Virus also tested positive. His cerebrospinal fluid was then sent for Rapid Plasma Reagin to confirm the diagnosis of neurosyphilis. He completed 14 days of intravenous penicillin and was eventually discharged with partial resolution of the abducens palsy. We describe the second case of neurosyphilis presenting only with an isolated cranial nerve VI involvement. On further review, ours was the first case documented on an individual who had an undiagnosed Human Immunodeficiency Virus infection. There are various differentials for an isolated cranial neuritis but infectious causes, particularly neurosyphilis, should be considered among young individuals with known risk factors despite their apparently benign medical history.

Top 100 Most Cited Neurologic and Neurosurgical Articles on COVID-19: A Bibliometric Analysis

Objective

With the exponential growth of literature on coronavirus disease 2019 (COVID-19), we aimed to identify and characterize the 100 most cited COVID-19–related articles in neurology and neurosurgery.

Methods

In March 2021, we performed a title-specific search of the Scopus database using (“neurology” or “neurologic” or “neurosurgery” or “neurosurgical”) and “COVID” as our search query term without date restrictions. The top 100 most cited English-language articles were obtained and reviewed.

Results

Our search yielded 9648 articles published from December 2019 to March 2021. Bibliometric analysis of the top 100 articles found that the most cited article had a citation count of 1741 and was the first to report on the detailed neurologic manifestations of the disease; Neurology had the most number of publications; the majority of the primary authors were neurologists, but 35% were from nonneuroscience specialties; the United States, Italy, the United Kingdom, China, and Germany were the top contributors, with a combined total of 77%; most of the publications were correspondence or editorial articles; and most articles discussed the neurologic manifestations and complications of patients with COVID-19.

Conclusions

This study identified the top 100 most cited neurologic or neurosurgical COVID-19–related articles published to date. This list can be used to identify high-impact studies that will help health care practitioners in clinical decision making and researchers in navigating key areas of study and guiding future research.

Paving the Path to Wellness: A Systematic Review of Wellness Programs for Neurosurgery Trainees

BACKGROUND

Neurosurgical trainees have a heavy workload and poor quality of life, resulting in high rates of burnout and attrition. Consequently, wellness programs have been used by various training institutions to combat this situation.

OBJECTIVE

We aimed to identify and describe wellness programs available for neurosurgical trainees in their training institutions, the outcome measures used to assess them, and their efficacy.

METHODS

A systematic review of the literature was made following PRISMA guidelines.

RESULTS

Six studies were included in the review, describing wellness programs from 9 institutions. All programs except 1 used exercise as the core component. The other components included physical and mental well-being lectures, team-building activities, and cultural excursions. Most institutions used piloted satisfaction and perception questionnaires to assess efficacy. Trainee perceptions of wellness programs were generally positive, but the responses on validated questionnaires and surveys were mixed. Barriers to the program included lack of institutional support, time constraints, fatigue, and feelings of guilt in prioritizing wellness over patient care.

CONCLUSIONS

There is a paucity of literature regarding trainee wellness in neurosurgery. A few training programs have instituted wellness initiatives for trainees, and the feedback was generally positive. However, objective measures of efficacy such as validated questionnaires and scales yielded mixed results.

Coexistence of arteriovenous malformation and meningioma in a single patient: Systematic review and illustrative case

BACKGROUND

The coexistence of intracranial arteriovenous malformation (AVM) and meningioma in a single patient is seldom reported, so the clinical profile, optimal management, and outcomes of these patients are mostly unknown.

METHODS

We performed a systematic review of the SCOPUS and PubMed databases for case reports and case series on patients with both intracranial AVMs and meningiomas. Data on demographics, clinical characteristics, surgical management, and outcomes were collected.

RESULTS

A total of 18 cases were reported in the literature, including the present case. The mean age at presentation was 54 years (range of 15-70 years), with no gender predilection. Most of the meningiomas and AVMs were frontal in location, and more than half of the lesions were contiguous. The most common presenting symptoms were seizures (67%), headache (44%), and weakness (33%). Majority of the patients underwent single stage meningioma and AVM excision (44%), followed by staged meningioma excision then AVM excision (17%) and meningioma excision only (17%). In all, 94% (17/18) of the meningiomas were excised compared to 72% (13/18) of the AVMs. Outcomes were reported in 15 patients; 80% were favorable, but there were 2 deaths and 1 tumor recurrence after 5 years.

CONCLUSION

The coexistence of an intracranial AVM with a meningioma is recognized but rarely reported in the literature. Individualized treatment should be employed in managing patients with concurrent lesions, and outcomes are generally favorable due to the benign nature of both these entities.

Non-Traumatic Intracerebral Hematoma in the Young: Findings from a Tertiary Hospital in the Philippines

BACKGROUND

There is geographic variability in the clinical profile and outcomes of non-traumatic intracerebral hematoma (ICH) in the young, and data for the Philippines is lacking. We aimed to describe this in a cohort from the Philippines, and identify predictors of mortality.

METHODS

We performed a retrospective study of all patients aged 19-49 years with radiographic evidence of non-traumatic ICH admitted in our institution over five years. Data on demographics, risk factors, imaging, etiologies, surgical management, in-hospital mortality, and discharge functional outcomes were collected. Multivariate logistic regression analysis was done to determine factors predictive of mortality.

RESULTS

A total of 185 patients were included, which had a mean age of 40.98 years and a male predilection (71.9%). The most common hematoma location was subcortical, but it was lobar for the subgroup of patients aged 19-29 years. Overall, the most common etiology was hypertension (73.0%), especially in patients aged 40-49. Conversely, the incidence of vascular lesions and thrombocytopenia was higher in patients aged 19-29. Surgery was done in 7.0% of patients. The rates of mortality and favorable functional outcome at discharge were 8.7% and 35.1%, respectively. Younger age (p = 0.004), higher NIHSS score on admission (p=0.01), higher capillary blood glucose on admission (p=0.02), and intraventricular extension of hematoma (p = 0.01) predicted mortality.

CONCLUSIONS

In the Philippines, the most common etiology of ICH in young patients was hypertension, while aneurysms and AVM's were the most common etiology in the subgroup aged 19 - 29 years. Independent predictors of mortality were identified.

Hydranencephaly: Clinical Features and Survivorship in a Retrospective Cohort

OBJECTIVE

Hydranencephaly is a congenital central nervous system disorder characterized by the complete or near-complete absence of the cerebral cortex and basal ganglia. Because of its rarity, data on the clinical features and survivorship remain sparse. We aim to determine the clinical features and survivorship of a cohort of patients with hydranencephaly.

METHODS

We performed a retrospective cohort study of all patients diagnosed with hydranencephaly at our institution from 2008 to 2018. Data on demographics, clinical features, presence of comorbidities, surgical operations performed, and status on last follow-up were collected. Survival curves were generated using Kaplan-Meier analysis.

RESULTS

Fifty patients were included in the cohort, who had a median age at diagnosis of 4 months and a female predilection. The most common clinical manifestations were macrocephaly (92%) and seizures or myoclonic movements. Infection was present in 36% of cases, endocrinopathies in 22%, dysmorphisms in 20%, and cardiac disease in 8%. Twenty patients underwent shunt insertion, with half developing a postoperative complication at a mean follow-up of 14.9 months. The median survival of the cohort was not reached at 7.5 years. Among the patients with follow-up, characteristics were similar between the surgical and nonsurgical groups, except for the greater incidence of infections in the nonsurgical group. The survival curves among the groups were significantly different, with a hazard ratio of 3.731 in the nonsurgical group.

CONCLUSIONS

In this large single-center retrospective cohort of patients with hydranencephaly, novel findings are presented regarding the clinical manifestations and survivorship of this condition.

Tuberculoma of the Peripheral Nerve: Illustrative Case and Systematic Review of the Literature

BACKGROUND

Tuberculomas affecting the peripheral nerve are exceedingly rare. As such, little has been reported about their clinical features, treatment, and outcomes.

METHODS

We report the case of a 10-year-old male patient with histopathologically proven tuberculoma presenting preoperatively as a peripheral nerve tumor. We also performed a systematic review of the SCOPUS and PubMed databases for case reports and case series documenting patients with histopathologically confirmed peripheral nerve tuberculoma and discussed clinical features and treatment outcomes.

RESULTS

A total of 7 cases of peripheral nerve tuberculomas were reported in the literature, including the current case. The mean age was 21.4 years with no sex predilection. The ulnar nerve was involved in all cases. The most common clinical manifestations were hand weakness, atrophy, ulnar clawing, and hypoesthesia. The classic histopathologic features of caseous necrosis, epithelioid granulomas, and Langhans giant cells were seen in all cases, while staining for acid fast bacilli was positive in only one case. All patients underwent nerve exploration and lesion resection, and were given antitubercular treatment lasting between 3 and 18 months. Treatment resulted in complete recovery in 43% of cases and partial improvement of neurologic deficits in 57%.

CONCLUSIONS

Tuberculoma of the peripheral nerve is a rare manifestation of tuberculous disease, with a predilection for the ulnar nerve. Current management includes nerve exploration, lesion resection, and antitubercular treatment, which often results in good neurologic recovery.

Management of Hydrocephalus in Paget's Disease of Bone: Systematic Review and Illustrative Case

OBJECTIVE

Paget's disease of the bone (PDB) is a focal bone disorder characterized by excessive resorption and deposition of pathologic bone. It can involve the skull and cause neurologic dysfunction. Hydrocephalus occurring as a complication has also been reported. However, owing to its rarity, the optimal treatment has not yet been determined.

METHODS

We report the case of a 60-year-old woman with a diagnosis of PDB who had presented with symptomatic hydrocephalus and was successfully treated with ventriculoperitoneal shunt insertion. We also performed a systematic review of the Scopus and PubMed databases for case reports and series documenting patients with PDB complicated by hydrocephalus and discussed the clinical features and therapeutic strategies used.

RESULTS

We found 28 cases of PDB complicated by hydrocephalus in reported studies, including the present case. The median age was 67 years (range, 48-85 years; interquartile range, 7 years), with a female sex predilection. The most common neurologic manifestations were cognitive impairment, gait unsteadiness, urinary incontinence, hearing loss, and headache. Surgery had been performed in 73% of the 28 cases. The most common operation was insertion of a ventriculoperitoneal shunt (63.2%). Cerebrospinal fluid diversion resulted in significant or complete neurologic recovery in 78.9% of the 28 patients. Posterior fossa decompression was performed in 15.8% of operative cases but did not significantly alter the clinical course.

CONCLUSION

Patients with hydrocephalus occurring as a complication of PDB will most commonly present with cognitive impairment, gait unsteadiness, and urinary incontinence. Surgery plays an important role in the treatment, with CSF diversion procedures resulting in significant neurologic recovery in most cases.

Successful management of intraventricular rupture of pyogenic brain abscess (IVROBA): Systematic review and illustrative case

OBJECTIVES

Intraventricular rupture of brain abscess (IVROBA) is one of the most dreaded complications of pyogenic brain abscess due to its high mortality rate. Because of its relative infrequency and poor outcome, the optimal management of this condition remains to be determined.

PATIENTS AND METHODS

We report the case of a 5-year old female with a presumptive diagnosis of IVROBA who was discharged with good neurologic outcome after completing intravenous antibiotic treatment and undergoing insertion of an external ventricular drain (EVD) and later, a ventriculoperitoneal (VP) shunt. We also performed a systematic review of the SCOPUS and PubMed databases for case reports and series documenting patients who survived after undergoing treatment for IVROBA.

RESULTS

A total of 24 cases of IVROBA survivors were reported in the literature, including the present case. The median age was 48.5 years (range: 5-71), with a male predilection (3:1). The most common location of the brain abscesses was temporal while the most common route of spread was hematogenous. Surgery was performed in 92% of cases, with EVD being the most common surgical procedure. Twenty nine percent of cases required a VP shunt. The duration of systemic antibiotic treatment ranged from 31 to 180 days (median: 56 days) while intraventricular antibiotics were given for 8-42 days (median: 14 days).

CONCLUSION

The management of IVROBA in this series varied widely, with surgery playing an important role. Although IVROBA is still a devastating complication of intracranial abscess, a good neurologic outcome may still be possible with treatment.