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Background Surgical resection of insular gliomas is a challenge. TO resection is considered more versatile and has lower risk of vascular damage. In this study, we aimed to understand the factors that affect resection rates, ischemic changes and neurological outcomes and studied the utility of IONM in patients who underwent TO resection for IGs. Methods Retrospective analysis of 66 patients with IG who underwent TO resection was performed. Results Radical resection was possible in 39% patients. Involvement of zone II and the absence of contrast enhancement predicted lower resection rate. Persistent deficit rate was 10.9%. Although dominant lobe tumors increased immediate deficit and fronto-orbital operculum involvement reduced prolonged deficit rate, no tumor related factor showed significant association with persistent deficits. 45% of patients developed a postoperative infarct, 53% of whom developed deficits. Most affected vascular territory was lenticulostriate (39%). MEP changes were observed in 9/57 patients. 67% of stable TcMEPs and 74.5% of stable strip MEPs did not develop any postoperative motor deficits. Long-term deficits were seen in 3 and 6% patients with stable TcMEP and strip MEPs respectively. In contrast, 25% and 50% of patients with reversible strip MEP and Tc MEP changes respectively had persistent motor deficits. DWI changes were clinically more relevant when accompanied by MEP changes intraoperatively, with persistent deficit rates three times greater when MEP changes occurred than when MEPs were stable. Conclusion Radical resection can be achieved in large, multizone IGs, with reasonable outcomes using TO approach and multimodal intraoperative strategy with IONM.

BackgroundMaximizing resection is an oft-sought-after albeit challenging goal in diffuse gliomas. Microsurgical technique remains the mainstay.MethodBy virtue of their pattern of growth and spread, gliomas respect anatomical boundaries like the pia. Using subpial dissection, en bloc resections provide the most optimal surgical technique. This paper revisits this technique and describes the rationale and basic principles integrating it in the modern multimodal glioma surgery workflow.ConclusionSubpial resection is a very useful and “anatomical” technique for en bloc resection of diffuse gliomas which is easy to master and execute and optimizes the extent of resection and minimizes complications effectively.

Background Gliomas are among the most typical brain tumors tackled by neurosurgeons. During navigation for surgery of glioma brain tumors, preoperatively acquired static images may not be accurate due to shifts. Surgeons use intraoperative imaging technologies (2-Dimensional and navigated 3-Dimensional ultrasound) to assess and guide resections. This paper aims to precisely capture the importance of preoperative parameters to decide which type of ultrasound to be used for a particular surgery. Methods This paper proposes two bagging algorithms considering base classifier logistic regression and random forest. These algorithms are trained on different subsets of the original data set. The goodness of fit of Logistic regression-based bagging algorithms is established using hypothesis testing. Furthermore, the performance measures for random-forest-based bagging algorithms used are AUC under ROC and AUC under the precision-recall curve. We also present a composite model without compromising the explainability of the models. Results These models were trained on the data of 350 patients who have undergone brain surgery from 2015 to 2020. The hypothesis test shows that a single parameter is sufficient instead of all three dimensions related to the tumor ( p < 0.05 ). We observed that the choice of intraoperative ultrasound depends on the surgeon making a choice, and years of experience of the surgeon could be a surrogate for this dependence. Conclusion This study suggests that neurosurgeons may not need to focus on a large set of preoperative parameters in order to decide on ultrasound. Moreover, it personalizes the use of a particular ultrasound option in surgery. This approach could potentially lead to better resource management and help healthcare institutions improve their decisions to make the surgery more effective.

Background Intraoperative imaging is increasingly being used in resection of brain tumors. Navigable three-dimensional (3D)-ultrasound is a novel tool for planning and guiding such resections. We review our experience with this system and analyze our initial results, especially with respect to malignant gliomas. Methods A prospective database for all patients undergoing sononavigation-guided surgery at our center since this surgery’s introduction in June 2011 was queried to retrieve clinical data and technical parameters. Imaging was reviewed to categorize tumors based on enhancement and resectability. Extent of resection was also assessed. Results Ninety cases were operated and included in this analysis, 75 % being gliomas. The 3D ultrasound mode was used in 87 % cases (alone in 40, and combined in 38 cases). Use of combined mode function [ultrasound (US) with magnetic resonance (MR) images] facilitated orientation of anatomical data. Intraoperative power Doppler angiography was used in one-third of the cases, and was extremely beneficial in delineating the vascular anatomy in real-time. Mean duration of surgery was 4.4 hours. Image resolution was good or moderate in about 88 % cases. The use of the intraoperative imaging prompted further resection in 59 % cases. In the malignant gliomas (51 cases), gross-total resection was achieved in 47 % cases, increasing to 88 % in the “resectable” subgroup. Conclusions Navigable 3D US is a versatile, useful and reliable intraoperative imaging tool in resection of brain tumors, especially in resource-constrained settings where Intraoperative MR (IOMR) is not available. It has multiple functionalities that can be tailored to suit the procedure and the experience of the surgeon.

Background Seizures are common in patients with brain tumors, impacting daily life and healthcare burden. In contemporary neuro-oncology practice, levetiracetam is the most commonly prescribed anti-seizure medication (ASM). Although the practice is widely variable, levetiracetam is usually used for 2–3 years following surgery to prevent further seizures. However, the incidence of seizures post antitumoral treatment is relatively low, and the duration of use is not well defined. To address this knowledge gap, the current randomized controlled non-inferiority trial will be conducted comparing a shorter regimen of levetiracetam with the standard long-term schedule. Methods and analysis Patients with newly diagnosed primary brain tumors (brain metastasis excluded) in the supratentorial compartment with a prior history of seizure will be eligible for the study. Adults (> 18 years), within 1 year from surgery, and controlled on levetiracetam monotherapy for 6 months will be randomized in a 1:1 ratio to either standard arm (long course: additional 2 years levetiracetam) or experimental arm (short course: tapered of levetiracetam and stopped). Stratification factors include tumor location, seizure type, histology, grade, and adjuvant therapy. The primary endpoint is 2-year seizure-free survival (SFS); secondary endpoints include seizure impact, quality of life, progression-free survival (PFS), and overall survival (OS). Assuming a 2-year SFS rate of 80%, a total of 431 patients (167 events) will be needed to prove the non-inferiority of the experimental arm (non-inferiority margin of 8%, α = 0.05, power = 80%). Considering an attrition rate of 40% (25% accounting for death and 15% lost to follow-up), the final sample size is 604. Discussion The trial will provide level 1 evidence on the optimal duration of ASM use in primary brain tumors with a history of seizures. If short-term ASM use is non-inferior, it will reduce drug utilization, lower neurotoxicity, improve quality of life, and optimize resource usage. Ethics and dissemination The trial has been approved by the Institutional Ethics Committee of Tata Memorial Centre, Mumbai. Registration Registered with CTRI/2024/06/069498, Clinicaltrials.gov: NCT06442748.

Introduction Craniospinal irradiation (CSI) forms an integral role in the management of primary brain tumors like embryonal tumors (medulloblastoma), non-seminomatous germ cell tumors, metastatic ependymoma, etc. The cranial component with radiation of whole brain and boost can lead to decline in neurocognitive function. Memantine is an NMDA receptor antagonist with an established role in reducing radiation-induced neurocognitive decline in patients treated with whole brain radiotherapy, but the benefit in pediatric and adults treated with CSI remains unclear. Methods This is a phase 3 open-label, randomized controlled trial. Pediatric and young adults (5 to 39 years) treated with CSI will be eligible for the study. Patients will be randomized in 1: 1 accounting for stratification factors such as age, CSI dose, location of tumor boost, and use of chemotherapy. Patients in the experimental arm will receive memantine 5 mg once daily for 1 week, 5 mg twice daily for 1 week, and finally escalated to 10 mg twice daily for 6 months. The primary endpoint will be cognitive deterioration-free survival (CDFS) at 2 years, with secondary endpoints being safety and compliance of memantine, slope of decline of neurocognitive scores, and survival. To demonstrate the improvement of 2-year CDFS of 75% in memantine arm compared to 50% in standard arm, 84 patients need to be evaluated (alpha 0.05 and power 80%). Considering an attrition of 20%, a total of 101 patients will be randomized. Discussion If trial results are positive memantine will be established as a new standard of care to be used with CSI. Trial registration The trial is registered on ClinicalTrials.gov (study identifier NCT06275035) and Clinical Trial Registry India (CTRI/2024/02/062273).

The primary objective of this review is to examine the demographic and nutrition transition in India in relation to its contribution to the emerging epidemic of chronic non-communicable diseases in this country. India, the country as a whole and its different states with a population exceeding 1 billion in 2001. The review examines demographic changes in the population with consequent effects on the population pyramid, the rapidity and rates of urbanisation with striking variations in chronic disease patterns and the trends in obesity between rural and urban communities, attempting to relate their prevalence with the diet and lifestyle changes accompanying them. The review is based largely on representative large-scale surveys in the country and other reliable documented data on population characteristics. It also includes a review of the published literature. The results indicate that the demographic changes, rates of urbanisation and changes in dietary patterns are contributing to the changing trends in chronic disease in India. There is clear evidence of a demographic, epidemiological and nutrition transition in India that is fuelling the epidemic of chronic diseases and obesity, particularly in the urban areas.

This study aimed to evaluate concurrent laparoscopic totally extraperitoneal (TEP) inguinal hernia repair and transurethral resection of the prostate (TURP) with determination of outcomes. This retrospective study was conducted at our hospital, from June 2011 to June 2020. Over 9 years, 17 patients with co-existing uncomplicated unilateral or bilateral inguinal hernia (primary/recurrent) and significant benign prostatic hypertrophy were operated in the same sitting. The following outcomes were compared: duration of the surgery, conversion to open hernia surgery, intraoperative and post-operative complications, duration of hospital stay, recurrence, time taken to resume normal activity and cost of the treatment. This study included 17 patients with a mean age of 65 years (range of 50-87 years). The average time taken for the surgery was 115 min with no conversion to open hernia repair. The mean post-operative stay was 3.7 days. There were four patients (23.5%) with seromas identified at day 10, only two remained at 6 weeks and none at 12 weeks. None had significant bleeding intraoperatively or postoperatively. There was no superficial or deep wound infection (including mesh infection). There was no recurrence of inguinal hernia. Two patients (11.7%) developed post-TURP urethral stricture and underwent cystoscopic stricturoplasty, 3 and 2.5 months after the initial procedure. The time taken to resume normal activity was 7 (±1) days. The hospital cost is reduced by 25% as compared to the sum of costs when both the operations are done separately. Concurrent TEP inguinal hernia repair and TURP is a practical, safe and cost-effective procedure.