Medicine and Health Sciences Commons^™

Mr Perfusion Imaging, Techniques And Role In Differentiating Radiation Necrosis And Tumor Recurrence, Raima Zakaria, Fatima Mubarak, Muhammad Shahzad Shamim

Department of Radiology

High grade brain tumours are treated with surgery, chemotherapy and radiation therapy and despite such aggressive treatment, can recur in a short span of time. MRI scan has been the conventional diagnostic modality to diagnose recurrence, although at times it becomes difficult for the neuroradiologists to differentiate between tumour recurrence and radiation necrosis. Herein lies the emergent need to explore the efficacy of functional imaging to assist in this diagnostic challenge. Recent studies have sought to do so with promising implications, which we have attempted to summarize in this review.

Pediatric Brainstem Gliomas: An Institutional Experience, Altaf Ali Laghari, Mirza Zain Baig, Muhammad Ehsan Bari, Aneela Darbar, Naureen Mushtaq, Umme E Hani Abdullah, Daniya Aziz Khan

Section of Neurosurgery

Objective: The aim of this study was to analyze the clinical profiles and outcomes of pediatric brainstem gliomas treated at our institute.
Methodology: We reviewed the files of 18 pediatric age group patients diagnosed with brainstem glioma at our institution. The following variables were recorded: age, sex, duration of symptoms, date of diagnosis, main clinical symptoms, Karnofsky performance status score, magnetic resonance imaging findings, histopathology findings, details of the treatment given, disease progression, and date of mortality/last follow-up. This data were then transferred to SPSS version 23 which was used for further analysis.
Results: The mean age of our cohort …

Interleukin 1 Alpha Administration Is Neuroprotective And Neuro-Restorative Following Experimental Ischemic Stroke, Kathleen E. Salmeron, Michael E. Maniskas, Danielle N. Edwards, Raymond Wong, Ivana Rajkovic, Amanda L. Trout, Abir A. Rahman, Samantha Hamilton, Justin F. Fraser, Emmanuel Pinteaux, Gregory J. Bix

Sanders-Brown Center on Aging Faculty Publications

BACKGROUND: Stroke remains a leading cause of death and disability worldwide despite recent treatment breakthroughs. A primary event in stroke pathogenesis is the development of a potent and deleterious local and peripheral inflammatory response regulated by the pro-inflammatory cytokine interleukin-1 (IL-1). While the role of IL-1β (main released isoform) has been well studied in stroke, the role of the IL-1α isoform remains largely unknown. With increasing utilization of intravenous tissue plasminogen activator (t-PA) or thrombectomy to pharmacologically or mechanically remove ischemic stroke causing blood clots, respectively, there is interest in pairing successful cerebrovascular recanalization with neurotherapeutic pharmacological interventions (Fraser et …

Multiple Sclerosis Outcomes After Cancer Immunotherapy, Catherine R. Garcia, Rani Jayswal, Val R. Adams, Lowell B. Anthony, John L. Villano

Markey Cancer Center Faculty Publications

INTRODUCTION: Neurological immune-related adverse events are a rare but potentially deadly complication after immune checkpoint inhibitor (ICI) treatment. As multiple sclerosis (MS) is an immune-mediated disease, it is unknown how ICI treatment may affect outcomes.

METHODS: We analyzed the United States Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) database for pembrolizumab, atezolizumab, nivolumab, ipilimumab, avelumab, and durvalumab 2 years prior their FDA approval until December 31, 2017, to include all cases with confirmed diagnosis/relapse of MS. We also included cases reported in the literature and a patient from our institution.

RESULTS: We identified 14 cases of MS …

Current Management Of Glioma In Pakistan, Umme E Hani Abdullah, Altaf Ali Laghari, Muhammad Usman Khalid, Huzaifa Bin Rashid, Fatima Ali, Adnan Jabbar, Asim Hafiz, Muhammad Shahzad Shamim, Ather Enam

Section of Neurosurgery

To date, information on the management of specific neurosurgical tumors, such as glioma, in Pakistan remains scattered and scarce. Our review synthesizes the predicaments of glioma management routinely presented to the neurosurgery, medical oncology, radiation oncology, and radiology departments in Pakistan. Expert opinions were integrated from each of the relevant fields in the form of personal citations. The data presented in our review were collected from various PubMed and non-PubMed indexed articles, coupled with various health reports from the Government of Pakistan along with the World Health Organization. Through these data, it was postulated that the utilization of innovative and …

Pituitary Adenoma With Calcifications: A Case Report, Yakoot Khan, Noor Malik, Saba Iqbal Awan, Syed Hassan Khalid, Altaf Ali Laghari

Section of Neurosurgery

Pituitary adenomas and Rathke’s cleft cyst with calcification are rarely seen and craniopharyngioma still remains the common sellar suprasellar space occupying lesion with calcification. Presence of calcification is reported in pituitary adenoma in only 0.2% to 8% cases. The pituitary adenoma with calcification is a rare radiological finding and it must be distinguished from other lesions of the pituitary gland as the management and prognosis differs significantly. We report a case of a 29-year-old gentleman presented electively with the complaints of deterioration of vision for four months. CT-scan without contrast examination revealed pituitary adenoma with calcification. The patient underwent transsphenoidal …

Timing Of Postoperative Magnetic Resonance Imaging (Mri) Following Glioma Resection: Shattering The 72 Hour Window, Syed Sarmad Bukhari, Muhammad Shahzad Shamim, Fatima Mubarak

Section of Neurosurgery

Extent of enhancing tumour resection is correlated with progression free survival following glioma surgery. Historically, a contrast enhanced MRI has been recommended within 72 hours following surgery to evaluate for residual disease. This theoretical window was established amidst conflicting evidence to avoid reactive enhancement. Recent studies with better designs and better imaging quality have sought to challenge this window with a more pragmatic method of evaluating residual disease.

Emergency Care Surveillance And Emergency Care Registries In Low-Income And Middle-Income Countries: Conceptual Challenges And Future Directions For Research, Hani Mowaf, Christine Ngaruiya, Gerard O'Reilly, Olive Kobusingye, Vikas Kapil, Andres Rubiano, Marcus Ong, Juan Carlos Puyana, Akm Fazlur Rahman, Rashid Jooma, Blythe Beecrof, Junaid Razzak

Section of Neurosurgery

Despite the fact that the 15 leading causes of global deaths and disability-adjusted life years are from conditions amenable to emergency care, and that this burden is highest in low-income and middle-income countries (LMICs), there is a paucity of research on LMIC emergency care to guide policy making, resource allocation and service provision. A literature review of the 550 articles on LMIC emergency care published in the 10-year period from 2007 to 2016 yielded 106 articles for LMIC emergency care surveillance and registry research. Few articles were from established longitudinal surveillance or registries and primarily composed of short-term data collection. …

Endoscopic Transsphenoidal Surgery For Cushing's Disease: A Review, Mirza Zain Baig, Altaf Ali Laghari, Aneela Darbar, Umme E Hani Abdullah, Sumiya Abbasi

Section of Neurosurgery

Ever since the 1960s, transsphenoidal surgery has been the modality of choice for treating Cushing's disease. Subsequent visualization of the pituitary fossa and sphenoid sinus may be done either with the operating microscope or with the relatively new endoscope. The endoscope due to its panoramic view allows greater visualization as compared to the operating microscope. It confers greater access to the cavernous sinus, sella, suprasellar, and parasellar regions and accommodates higher magnifications. It is bi-dimensional, however as opposed to the operating microscope that provides a three-dimensional view and allows greater depth perception. This article provides a comprehensive review of the …

Effect Of Pregnancy On Growth Of Intracranial Meningiomas, Ayesha Quddusi, Muhammad Shahzad Shamim, Quratulain Virani

Section of Neurosurgery

Meningiomas are the most common benign primary intracranial tumours in adults. Their rapid growth during pregnancy has been well reported. Moreover, the relationship of increased progesterone expression during pregnancy and extensive tumour growth has been debated. In this review, we discuss not only the effect of progesterone on meningiomal growth but also other mechanisms involved in gestational meningiomas.

Quality Of Life Of Road Traffic Injury Survivors Aged 15-44 Years Suffered From Moderate And Severe Head Injuries In Karachi, Pakistan, S A. Abbasi, Tazeen Saeed Ali, Shafquat Rozi, Uzma Rahim Khan, Rashid Jooma

Community Health Sciences

Background: Most of Road traffic injuries are predicted to be the third leading contributor to the global burden of disease by 2020 and patients end up into head injuries which leave devastating impacts on individual and society. Quality of Life After Brain Injury (QOLIBRI) is a specific tool that measures quality of life in head injury patients.
Methods: This was a cross sectional study among 300 patients aged 15-45 years, attended emergency department of the Aga khan University Hospital. Structured questionnaire included demography, injury details, QOLIBRI, GOSE and WHO Disability Assessment Scale (WHODAS 12 items). Severity of injury was determined …

Initial Management Of Meningiomas: Analysis Of The National Cancer Database, Catherine R. Garcia, Stacey A. Slone, Monica Chau, Janna H. Neltner, Thomas A. Pittman, John L. Villano

Neurology Faculty Publications

BACKGROUND: Meningiomas are the most common central nervous system tumor. We describe current trends in treatment and survival using the largest cancer dataset in the United States.

METHODS: We analyzed the National Cancer Database from 2004 to 2014, for all patients with diagnosis of meningioma.

RESULTS: 201,765 cases were analyzed. Patients were most commonly White (81.9%) females (73.2%) with a median age of 64 years. Fifty percent of patients were diagnosed by imaging. Patients were reported as grade I (24.9%), grade II (5.0%), grade III (0.7%), or unknown WHO grade (69.4%). Patients diagnosed by imaging were older, received treatment in …

Early Versus Delayed Flow Diversion For Ruptured Intracranial Aneurysms: A Meta-Analysis, Rimal Hanif Dossani, Devi P. Patra, Jennifer Kosty, Fareed Jumah, Okkes Kuybu, Nasser Mohammed, Muhammad Waqas, Muhammad Riaz, Hugo Cuellar

Section of Neurosurgery

Objective: The use and timing of flow diversion for aneurysmal subarachnoid hemorrhage is controversial. The objective of this study is to perform a meta-analysis and systematic review to compare overall complication rate between early versus delayed flow diversion for ruptured aneurysms.
Methods: A literature search for all eligible articles was performed using PubMed, Cochrane, and Web of Science databases. The primary outcome was the overall complication rate (any complication in the perioperative period), and secondary outcomes were 1) hemorrhage and 2) stroke/death (all hemorrhagic/ischemic strokes and/or death).
Results: Thirteen articles including 142 patients met inclusion criteria. Eighty-nine (62.7%) patients underwent …

Serum Biomarkers For Glioblastoma Multiforme, Ayesha Quddusi, Muhammad Shahzad Shamim

Section of Neurosurgery

A number of different serum biomarkers are currently being evaluated for their potential use as diagnostic and prognostic biomarkers in Glioblastoma Multiforme. Amongst these, a vast number of different microRNAs have been studied, that are up-regulated or downregulated in relation to Glioblastoma Multiforme. Different studies have found numerous associations of these different microRNAs with recurrence, Karnofsky Performance Score, Progression Free Survival and Overall Survival. Other than microRNAs, serum Glial Fibrillary Acid Protein, cytokines and YLK-40, as well as a number of other candidate serum biomarkers are being studied.More studies, with larger sample sizes are required before these serum biomarkers can …

Freehand Pedicle Screw Fixation: A Safe Recipe For Dorsal, Lumbar And Sacral Spine, Muhammad Junaid, Ali Afzal, Anisa Kalsoom, Syed Sarmad Bukhari

Section of Neurosurgery

Objective: To determine outcome of freehand pedicle screw fixation for dorsal, lumbar and sacral fractures at a tertiary care centre in the developing world.
Methods: A retrospective review was performed of 150 consecutive patients who underwent pedicle screw fixation from January 1, 2012 to 31^st December 2017. A total of 751 pedicle screws were placed. Incidence and extent of cortical breach by misplaced pedicle screw was determined by review of intra-operative and post-operative radiographs and/or computed tomography.
Results: Among the total 751 free hand placed pedicle screws, four screws (0.53%) were repositioned due to a misdirected trajectory towards the …

Enhanced Recovery After Elective Craniotomy For Brain Tumours, Ummey Hani, Saqib Kamran Bakhshi, Muhammad Shahzad Shamim

Section of Neurosurgery

Enhanced recovery after surgery (ERAS) is aimed at accelerated rehabilitation after surgery, and involves a multidisciplinary approach. Significant work has been published on this concept with regards to abdominal surgeries, however, the idea is relatively new for those undergoing neurosurgical procedures. We have reviewed literature on ERAS in patients undergoing craniotomy for brain tumours.

Need Of Physical And Chemical Restraints: Experiences At Inpatient Psychiatric Ward In A Tertiary Care Hospital In Karachi, Pakistan, Humera Saeed, M. Shameel Khan, Syeda Maheen Batool, Asma Akbar Ladak, Nadia Karim, Rabeeka Aftab

Department of Psychiatry

In psychiatry, agitated / aggressive patients are often treated with de-escalation techniques. If this does not work, physical or chemical restrains are required; but in the event of resistance, seclusion is applied. We report the findings of baseline study of experiences of physical and chemical restraints in a tertiary care hospital in Karachi, where 104 files were evaluated retrospectively. The mean age of patients was 32.5 ±14.3 years with 54.8% men, while the average length of stay was 11.5 ±9.3 days. Agitation, violent behaviour, and aggression were the most common indications for restraints. In total, 94.5% of patients had both …

Diffuse Low-Grade Glioma - Changing Concepts In Diagnosis And Management: A Review, Rashid Jooma, Muhammad Waqas, Inamullah Khan

Section of Neurosurgery

Though diffuse low-grade gliomas (dLGGs) represent only 15% of gliomas, they have been receiving increasing attention in the past decade. Significant advances in knowledge of the natural history and clinical diversity have been documented, and an improved pathological classification of gliomas that integrates histological features with molecular markers has been issued by the WHO. Advances in the radiological assessment of dLGG, particularly new magnetic resonance imaging scanning sequences, allow improved diagnostic and prognostic information. The management paradigms are evolving from "wait and watch" of the past to more active interventional therapy to obviate the risk of malignant transformation. New surgical …

Endovascular Coiling Versus Neurosurgical Clipping For Aneurysmal Subarachnoid Hemorrhage: A Systematic Review And Meta-Analysis, Syed Ijlal Ahmed, Gohar Javed, Syeda Beenish Bareeqa, Syeda Sana Samar, Ali Shah, Arwa Giani, Zainab Azam, Abeer Tasleem, Syed Hasham Humayun

Section of Neurosurgery

Background: Aneurysmal subarachnoid hemorrhage is a frequently devastating condition with a reported incidence of between 10 and 15 people per 100,000 in the United States. Currently, according to the best of our knowledge, there are not enough meta-analyses available in the medical literature of the last five years which compare the risks and benefits of endovascular coiling with neurosurgical clipping.
Methods: Twenty-two studies were selected out of the short-listed studies. The studies were selected on the basis of relevance to the topic, sample size, sampling technique, and randomization. Data were analyzed on Revman software.
Results: Mortality was found to be …

Does Surgeon Experience Influence The Amount Of Radiation Exposure During Orthopedic Procedures?: A Systematic Review, Azeem Tariq Malik, Hamid Hussain Rai, Riaz Hussain Lakdawala

Section of Orthopaedic Surgery

With an increasing use of intraoperative fluoroscopy in operating rooms worldwide, the topic of radiation exposure has become a major concern among hospital staff, doctors and patients alike. Since fluoroscopy has become an integral part in orthopedic intraoperative management, we sought to identify whether surgeon grade or experience plays a role in the amount of radiation used and consequently exposed. We performed a systematic review examining the association between surgeon experience and radiation exposure using primary outcome measures (radiation dose and total screening time/fluoroscopy time). To be included in the review, the study population had to compare varying surgeon experience …

Choice Of Therapeutic Anti-Seizure Medication In Patients With Brain Tumour, Altaf Ali Laghari, Syed Ijlal Ahmed, Namra Qadeer, Muhammad Shahzad Shamim

Section of Neurosurgery

Seizures are common in patients with brain tumours, even though prophylactic anti-seizure treatment for all patients with brain tumours is not recommended. Newer anti-epileptic drugs have shown benefits that outweigh the side effects of treatment and can also be given in combination with traditional anti-epileptic drugs. The authors have reviewed the literature on the various combinations of anti-epileptics in patients with seizures and brain tumours.

Dermoid Cyst With No Intracranial Extension: A Case Report And Literature Review, Asra Tanwir, Noor Malik, Gohar Javed, Romana Idress

Section of Neurosurgery

Background: Dermoid cysts are cystic inclusion tumors. They comprise hair follicles, sweat glands, and sebaceous glands. They have lining of stratified squamous epithelium. The most common areas involved are face, lower back, and ovaries. Congenital cystic dermoid involving the anterior fontanelle with no intracranial extension is a rare scalp swelling. We present a case of dermoid cyst with no intracranial extension.
Case description: We report a case of 4-month-old child presented with a history of a scalp swelling since birth. The swelling increased in size progressively. Magnetic resonance imaging of the brain revealed extracranial cystic lesion over anterior fontanelle with …

Motor-Vehicle Crash Patient Injury Patterns From A Level One Trauma Center In A Metropolitan City: A Cross-Sectional Study, Obada Hasan, Sadaf Sheikh, Asad Abbas, Nida Zahid, Naveed Baloch

Section of Orthopaedic Surgery

Introduction: Motorcycles are an inexpensive and popular mode of transportation in Karachi, Pakistan, despite the increasing number of motor vehicle injuries. Although motorcycle-related injuries have been studied previously, to our knowledge, there are no published reports on the orthopedic injuries associated with motorcycles crashes.
Methods: We conducted a cross-sectional study of medical records of patients with motorcycle-related injuries in 2015, at the Aga Khan University in Karachi, Pakistan. We reviewed the patient demographic and medical data, helmet use, the Glasgow coma score, the spectrum of injuries, length of stay, specific injury diagnosis, and final disposition of patients. Data were analyzed …

Surgical Care For All - Much Work To Be Done, Ather Enam, Sadaf Khan

Section of Neurosurgery

No abstract provided.

Primary Trauma Care: A Training Course For Healthcare Providers In Developing Countries, Saqib Kamran Bakhshi, Rashid Jooma

Section of Neurosurgery

Outcomes of injury in low and middle income countries may be compromised by skill deficiencies of healthcare providers. Short subspecialty training courses can be a useful solution to skill-deficits. We report on the Primary Trauma Care programme, a 2-day course designed to train frontline health workers in resuscitation and early management of the injured with limited resources and equipment. Developed for use in weak health systems and now conducted in over 70 countries, the programme is cost-efficient with built-in design sustainability by way of early transfer of ownership to local partners to effect a cascade of trauma courses in their …

Pre-Operative Voriconazole In Patients Undergoing Surgery For Central Nervous System Fungal Infections: Special Report, Ghani Haider, Muhammad Shahzad Shamim, Muhammad Faheem Khan, Muhammad Ehsan Bari, Ather Enam

Section of Neurosurgery

Fungal infections of the central nervous system (CNS) are uncommon. Despite several advancements in diagnosis and treatment of these infections, the mortality rates remain high. The current retrospective study was planned to define the demographic and clinical features of patients with CNS fungal infections. Conducted at Aga Khan University Hospital, Karachi, and comprising CNS fungal infections operated between January 2000 and December 2015. The study analysed whether a short course of pre-operative anti-fungal therapy may improve outcomes in these patients. There were 47 cases confirmed on histopathology and/or microbiology. Outcome measures used were Glasgow coma score (GCS), Glasgow outcome score …

Follow-Up Bibliometric Analysis Of Neurosurgical Publications From Pakistan And Institutional Comparison With Other Countries Using H-Index And I-10 Index, Muhammad Waqas Saeed Baqai, Usman Tariq Siddique, Muhammad Shahzad Shamim

Section of Neurosurgery

Aim: The aim of the study was to analyze the neurosurgical research output of Pakistan and compare it with that of developed countries.
Methodology: We conducted a bibliometric analysis of publically available databases for all neurosurgical publications from Pakistan. All indexed peer-reviewed publications from January 2009 to December 2014 where at least one author was affiliated with any neurosurgical departments in Pakistan and research was conducted in Pakistan were selected. Manual and electronic search was done using MeSH terms to search for articles from Pakistan. Articles were then categorized according to design, subspecialty, region, and year.
Results: Our search identified …

Microrna-133a And Myocardial Infarction, Yi Xiao, Jiling Zhao, Julian P. Tuazon, Cesar V. Borlongan, Guolong Yu

Neurosurgery and Brain Repair Faculty Publications

Myocardial infarction (MI) is the leading cause of morbidity and mortality in the world. The infarcted heart displays typical cell death cascades characterized by a loss of cells and fibrotic scarring in the myocardium. Cardiac hypertrophy and fibrosis largely contribute to ventricular wall thickening and stiffening, altogether defining an adverse cardiac remodeling that ultimately leads to impaired cardiac function and subsequent heart failure. Finding a strategy to promote therapeutic, instead of detrimental, cardiac remodeling may pose as a potent MI treatment. Accumulating evidence shows that microRNAs (miRNAs) may play an essential role in cardiovascular diseases. In particular, microRNA-133a (miR-133a) is …

Gutting The Brain Of Inflammation: A Key Role Of Gut Microbiome In Human Umbilical Cord Blood Plasma Therapy In Parkinson's Disease Model, Jea-Young Lee, Julian P. Tuazon, Jared Ehrhart, Paul R. Sanberg, Cesar V. Borlongan

Neurosurgery and Brain Repair Faculty Publications

Current therapies for Parkinson's disease (PD), including L-3,4-dihydroxyphenylalanine (L-DOPA), and clinical trials investigating dopaminergic cell transplants, have generated mixed results with the eventual induction of dyskinetic side effects. Although human umbilical cord blood (hUCB) stem/progenitor cells present with no or minimal capacity of differentiation into mature dopaminergic neurons, their transplantation significantly attenuates parkinsonian symptoms likely via bystander effects, specifically stem cell graft-mediated secretion of growth factors, anti-inflammatory cytokines, or synaptic function altogether promoting brain repair. Recognizing this non-cell replacement mechanism, we examined here the effects of intravenously transplanted combination of hUCB-derived plasma into the 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-induced rat model of PD. …

Retrospective Case Series Of Traumatic Brain Injury And Post-Traumatic Stress Disorder Treated With Hyperbaric Oxygen Therapy, R. Douglas Shytle, David J. Eve, Soel-Hee Kim, Allan Spiegel, Paul R. Sanberg, Cesar V. Borlongan

Neurosurgery and Brain Repair Faculty Publications

Returning veterans are frequently diagnosed with traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). Considering a recent case-controlled study of hyperbaric oxygen therapy (HBOT) reporting a reduction in suicidal ideation, we investigated retrospectively three veterans with chronic TBI/PTSD symptoms who were treated with multiple rounds of HBOT with neurophysiological testing performed before and after treatment. Improvements were detected on parameters within neurocognitive domains, including reductions in suicide-related symptoms. These findings independently confirm that HBOT may be effective in treating specific symptoms of TBI/PTSD that are not currently addressed with existing therapeutic approaches.