Variation in postoperative outcomes of patients with intracranial tumors: insights from a prospective international cohort study during the COVID-19 pandemic

Background: This study assessed the international variation in surgical neuro-oncology practice and 30-day outcomes of patients who had surgery for an intracranial tumor during the COVID-19 pandemic. Methods: We prospectively included adults aged ≥18 years who underwent surgery for a malignant or benign intracranial tumor across 55 international hospitals from 26 countries. Each participating hospital recorded cases for 3 consecutive months from the start of the pandemic. We categorized patients’ location by World Bank income groups (high [HIC], upper-middle [UMIC], and low- and lower-middle [LLMIC]). Main outcomes were a change from routine management, SARS-CoV-2 infection, and 30-day mortality. We used a Bayesian multilevel logistic regression stratified by hospitals and adjusted for key confounders to estimate the association between income groups and mortality. Results: Among 1016 patients, the number of patients in each income group was 765 (75.3%) in HIC, 142 (14.0%) in UMIC, and 109 (10.7%) in LLMIC. The management of 200 (19.8%) patients changed from usual care, most commonly delayed surgery. Within 30 days after surgery, 14 (1.4%) patients had a COVID-19 diagnosis and 39 (3.8%) patients died. In the multivariable model, LLMIC was associated with increased mortality (odds ratio 2.83, 95% credible interval 1.37–5.74) compared to HIC. Conclusions: The first wave of the pandemic had a significant impact on surgical decision-making. While the incidence of SARS-CoV-2 infection within 30 days after surgery was low, there was a disparity in mortality between countries and this warrants further examination to identify any modifiable factors

Solitary Giant Neurofibroma of the Scalp with Calvarial Defect in a Child

Neurofibroma of the scalp are mostly multiple as part of neurofibromatosis or other phakomatosis. De novo solitary types are less common and rarely erode the skull, unlike the intracranial counterpart. Skull erosion has been reported in adults with longstanding plexiform neurofibromas. We report a giant neurofibroma on the scalp of a five-year-old boy, managed in our center. Although this condition is a rare entity, it should be anticipated and the treatment strategy should include repair of the skull defect

Giant Encephalocele in Sokoto, Nigeria: A 5-Year Review of Operated Cases.

OBJECTIVE: Encephalocele is a common congenital malformation of the central nervous system; however, giant encephaloceles are rare. The use of folic acid supplementation and termination of pregnancies, which are prenatally diagnosed with encephaloceles and other congenital malformation of the central nervous system, has significantly reduced the occurrence of this type of congenital malformation, especially in developed countries. METHODS: This was a retrospective review over a 5-year period from January 2006 to December 2010 at the Department of Neurosurgery, Regional Centre for Neurosurgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria. The records of patients with giant encephalocele were retrieved from the case notes of patients who had excision and repair for encephalocele. RESULTS: Seventy-three patients had excision and repair of encephalocele over the study period. However, the records of only 50 patients were retrieved. Fourteen (28%) of the 50 whose records were retrieved had giant encephalocele. There were 4 male and 10 female patients (1:2.5). Thirteen (92.9%) had the lesion located in the occipital region, whereas in 1 patient (7.1%) the lesion was at the vertex. Three (21%) of the cases had microcephaly, 1 (7.1%) had macrocephaly, and 1 (7.1%) developed postoperative hydrocephalus. The average size of defect was 2.43 cm, and the size of the lesion ranged from 12 × 6 cm to 40 × 50 cm. The average maternal age was 20.3 years (n = 6), and the paternal age was 29 years (n = 4). Four out of 7 (57%) mothers had febrile illness in early pregnancy. Seven out of 10 patients (70%) did not have antenatal care. CONCLUSIONS: This condition is more common in children conceived during the period when farm products are yet to be harvested, and whose mothers did not attend antenatal care visits. It is recommended that mothers should be educated on the necessity of preconception folic acid. Implementation of a national strategy on food fortification is also advised. We recommend surgery after the first month of life to reduce poor early postoperative outcomes. In developing countries and centers with suboptimal pediatric intensive care units, surgical intervention is preferred after the first month of life with good temperature control, adequate fluid replacement following rupture of the sac, blood transfusion availability, and, only if necessary, complex cranial reconstruction

Understanding the neuroprotective effect of tranexamic acid: an exploratory analysis of the CRASH-3 randomised trial

Background: The CRASH-3 trial hypothesised that timely tranexamic acid (TXA) treatment might reduce deaths from intracranial bleeding after traumatic brain injury (TBI). To explore the mechanism of action of TXA in TBI, we examined the timing of its effect on death. Methods: The CRASH-3 trial randomised 9202 patients within 3 h of injury with a GCS score ≤ 12 or intracranial bleeding on CT scan and no significant extracranial bleeding to receive TXA or placebo. We conducted an exploratory analysis of the effects of TXA on all-cause mortality within 24 h of injury and within 28 days, excluding patients with a GCS score of 3 or bilateral unreactive pupils, stratified by severity and country income. We pool data from the CRASH-2 and CRASH-3 trials in a one-step fixed effects individual patient data meta-analysis. Results: There were 7637 patients for analysis after excluding patients with a GCS score of 3 or bilateral unreactive pupils. Of 1112 deaths, 23.3% were within 24 h of injury (early deaths). The risk of early death was reduced with TXA (112 (2.9%) TXA group vs 147 (3.9%) placebo group; risk ratio [RR] RR 0.74, 95% CI 0.58–0.94). There was no evidence of heterogeneity by severity (p = 0.64) or country income (p = 0.68). The risk of death beyond 24 h of injury was similar in the TXA and placebo groups (432 (11.5%) TXA group vs 421 (11.7%) placebo group; RR 0.98, 95% CI 0.69–1.12). The risk of death at 28 days was 14.0% in the TXA group versus 15.1% in the placebo group (544 vs 568 events; RR 0.93, 95% CI 0.83–1.03). When the CRASH-2 and CRASH-3 trial data were pooled, TXA reduced early death (RR 0.78, 95% CI 0.70–0.87) and death within 28 days (RR 0.88, 95% CI 0.82–0.94). Conclusions: Tranexamic acid reduces early deaths in non-moribund TBI patients regardless of TBI severity or country income. The effect of tranexamic acid in patients with isolated TBI is similar to that in polytrauma. Treatment is safe and even severely injured patients appear to benefit when treated soon after injury. Trial registration: ISRCTN15088122, registered on 19 July 2011; NCT01402882, registered on 26 July 2011