Background: Access to advanced histomolecular diagnostic testing for central nervous system(CNS) tumors is limited in low and middle-income countries (LMICs), hindering adequate characterization and failure to reach a WHO CNS 2021 diagnosis. LMICs also lack access to targeted therapies, and even conventional chemotherapy and radiation therapies vary between LMICs and high-income countries. Consequently, whether histomolecular subclassification is clinically beneficial and if it provides prognostic information in an LMIC setting is not clear. Here, we address this question by presenting the first systematic prospective study of CNS glioma patients from Pakistan, examining differences in overall survival (OS) by histomolecular subtype. Methods: A total of 194 patients with CNS tumors were enrolled at a single tertiary-care centerin Karachi, Pakistan. Routine histochemical processing, immunohistochemistry, and molecular testing using fluorescence in situ hybridization analysis, limited targeted-panel next-generation sequencing, and polymerase chain reaction were performed to test for isocitrate dehydrogenase (IDH) 1 and 2, P53, ATRX, Ki-67, 1p/19q co-deletion, and MGMT promoter methylation. Results: The results revealed that IDH status was a significant independent prognostic factor,regardless of age (p=0.016), with a 1-year survival rate of 76% and median OS of 16.15 months in IDH-wildtype high-grade gliomas. Conversely, the 1-year survival rate was 95% for IDH-mutant gliomas. Significant survival differences were observed for ATRX status (retained vs. loss) in IDH-mutant gliomas (p=0.046), P53 mutations in IDH-wildtype high-grade gliomas (p=0.05), and 1p/19q co-deletion in grade 3 gliomas (log-rank p=0.023). Conclusion We provide empirical evidence supporting a role for histo-morphological and limitedmolecular testing in neuro-oncology practice in LMICs.

Epilepsy surgery is a well-established treatment for drug-resistant epilepsy, with awake craniotomy being used in certain cases to remove epileptogenic foci while preserving crucial brain functions. We are presenting the first reported case from Pakistan of a 19-year-old woman who underwent awake epilepsy surgery to treat cortical dysplasia. She had a history of generalized tonic-clonic seizures since her childhood and was referred to our clinic due to an increase in seizure frequency. EEG and MRI identified the epileptogenic focus in the right parieto-temporal region. The patient underwent a neuro-navigation guided awake craniotomy and an excision of the epileptogenic focus in the right parieto-temporal region. The procedure was carried out using a scalp block and dexmedetomidine for conscious sedation, enabling the patient to remain awake throughout the surgery. Intraoperative mapping and electrocorticography were used for complex multidisciplinary care. Post-resection corticography showed no spikes along the resected margins. The patient was discharged without any complications and remained free of symptoms a year after the surgery. Awake epilepsy surgery is a viable option for removing epileptogenic foci while preserving vital cognitive functions. However, it is seldom used in low- and middle-income countries such as Pakistan. The successful outcome of this case underscores the need for greater awareness and availability of epilepsy surgery in resource-limited settings. Cost-effective measures, such as using small subdural strips for intraoperative localization, can be implemented.

Background: The endoscopic endonasal approach (EEA) has been gaining popularity for resection of adult craniopharyngiomas. However, the safety and effectiveness of the procedure in comparison to the traditional transcranial approach (TCA) remains unestablished as previous reviews are outdated. Methods: A literature search without language restriction was conducted in PubMed, Cochrane database, and Web of Science from conception to July 9, 2021. Cohort studies and case series that compared EEA with TCA and assessed postoperative complications, recurrence, and 30-day mortality were included. Articles, where data for adult populations could not be extracted or calculated, were excluded. Article selection and data extraction in a predesigned data extraction form were conducted in duplicate. Pooled participant data were included in a random-effects model. Results: The search yielded 227 articles, from which eight cohort studies containing 11,395 patients were included (EEA: 6,614 patients, TCA: 4,781 patients). Six studies were good quality and two were fair quality according to the Newcastle Ottawa Scale. There were significantly higher rates of cerebrospinal fluid leak (risk ratio [RR]=0.23, 95% confidence interval [CI] 0.17–0.32, p<0.00001, I2 =0%) and lower rates of postoperative hypopituitarism (RR=1.40, 95% CI 1.30–1.51, p<0.00001, I2 =0%), hydrocephalus (RR=6.95, 95% CI 5.78–8.36, p<0.00001, I2 =0%), visual impairment (RR=1.52, 95% CI 1.34–1.73, p<0.00001, I2 =0%), and 30-day mortality (RR=5.63, 95% CI 3.87–8.19, p<0.00001, I2 =0%) after EEA. Non-significant lower rates of postoperative diabetes insipidus (RR=1.12, 95% CI 0.78–1.61, p=0.53, I2 =85%) and recurrence of tumor (RR=2.69, 95% CI 0.35–20.81, p=0.34, I2 =47%) were seen after EEA. Conclusion EEA may be associated with reduced postoperative hypopituitarism, hydrocephalus, visual impairment, and 30-day mortality and higher rates of cerebrospinal fluid leak. These findings do not account for differences in tumor size and extension between the EEA and TCA cohorts. Further research on patients with comparable tumor characteristics is required to fully assess outcomes.