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.

Background: Cerebellopontine angle (CPA) tumors present surgical challenges due to their proxim-ity to the facial nerve. Despite preservation efforts, facial nerve paresis is a major issue. This study aims to identify key factors affecting facial nerve preservation during microsurgical resection of large CPA tumors in a low- and middle-income countries (LMIC) setting. Methods: This retrospective cross-sectional study, conducted at Aga Khan University, includedpatients who underwent microsurgical resection of large (>3 cm) CPA tumors with House-Brackmann (HB) grades 1–4. Postoperative facial nerve function was assessed using the HB grading system. Data was extracted from medical records and analyzed using SPSS 22. Results: This study analyzed 95 patients (M:F=1:1.16, mean age 44.24±13.71 years) withCPA tumors who underwent microsurgical resection. Common presenting complaints included a complete hearing loss (57.9%), headache (52.6%), and abnormal gait (40%). Preoperative facial nerve function was normal (HB grade I) in 75%, with 19%, 7%, and 2% having HB grades II, III, and IV, respectively. Schwannoma (69.5%), meningioma (16.8%), and epidermoid cyst (10.5%) were the most common diagnoses. Postoperative preservation of facial nerve function was achieved in 73.7% of patients. At six months, HB grades I and II were observed in 64% and 11.5%, respectively, while none had complete facial nerve palsy. On univariate analysis, larger tumor size and higher HB grade correlated with worse facial nerve outcomes (p=0.02). Complications were more frequent in patients with worsened outcomes (72% vs. 38.6%, p=0.004). However, in multivariate analysis, only preoperative HB grade was identified as a predictor. Conclusion Facial nerve preservation during CPA tumor resection is influenced by intrinsic tumorcharacteristics, surgical complexity, and patient-specific factors. Detailed preoperative counseling is crucial to set realistic expectations.

Background: Advancements in surgery, chemotherapy, and radiotherapy have improved survivalfor brain tumor patients, increasing the risk of second primary tumors (SPTs) among long-term survivors. This study examines the types and risks of SPTs in brain tumor patients presenting at a tertiary care hospital. Methods: This single-center, retrospective study explored occurrences of SPTs following prima-ry brain tumors and occurrences of brain tumors as SPTs following primary extra neural tumors. A total of 41 patients were included and analyzed presenting with histologically confirmed SPTs between 1st January 2000 and 31st December 2020. Results: The study included 41 patients with SPTs, primarily female (65.9%). Of these, 20 pa-tients (48.7%) developed SPTs after a primary brain tumor, while 21 patients (51.2%) developed brain tumors as SPTs after extra-neural tumors. Among patients who developed SPTs after brain tumors (n=20), meningioma (n=8, 40.0%) and pituitary adenoma (n=6, 30.0%) were the most prevalent first primary tumors (FPTs) while breast tumors predominated as SPTs (n=4, 20.0%). Survival analysis indicated younger mean age (44.5 years) for patients marked alive, compared to those marked deceased (57.0 years) and those with unknown outcomes (63.0 years). Conclusion Based on this retrospective analysis, the median age at diagnosis was 44.5 years,with a considerable number of patients (36.6%) having uncertain outcomes at follow-up due to incomplete records. These findings highlight the need for improved follow-up data management to better assess long-term survival in patients with SPTs following brain tumors.

Background: Cognitive decline is commonly seen in brain tumor (BT) patients and is associatedwith a worsened prognosis. Cognitive rehabilitation (CR) for cancer-related cognitive dysfunction has been widely studied for non-central nervous system cancers; however, recent emerging research has commenced documenting CR strategies for BT patients and survivors. Our objective was to review the current literature on various CR modalities in patients and BT survivors. Methods: The review was conducted in accordance with the PRISMA guidelines. The studieson CR were searched across 3 databases using a predefined search strategy. After removing duplicates, performing initial and full-text screenings, and applying inclusion criteria, relevant articles were selected. The demographic details, CR technique, cognitive tasks/tests administered, cognitive functions assessed, follow-up time, and outcomes of the intervention were assessed. Results: A total of 15 studies were included in the review. Neuropsychologist-guided trainingsessions to improve memory, attention, and executive functioning are effective in improving the mentioned domains. Younger and more educated patients benefited the most. Holistic mnemonic training and neurofeedback were not shown to affect overall cognitive functioning. Computer-based training programs showed improvements in executive functions of pediatric BT survivors, however, feasibility studies showed conflicting results. Aerobic exercises improved executive functions and decreased symptoms of the tumor. Both yoga and combined aerobic and strength training improved overall cognitive functioning. Active video gaming may improve motor and process skills; however, no effect was seen on cognitive functioning. Conclusion Neuropsychologic training, computer-based programs, and physical exercise havebeen found effective in improving or preventing decline in cognitive functions of BT patients. Given the limited trials and methodological variations, a standardized CR program cannot be established at present. Ongoing trials are expected to provide valuable data in the near future.

Background: Advancements in surgery, chemotherapy, and radiotherapy have improved survivalfor brain tumor patients, increasing the risk of second primary tumors (SPTs) among long-term survivors. This study examines the types and risks of SPTs in brain tumor patients presenting at a tertiary care hospital. Methods: This single-center, retrospective study explored occurrences of SPTs following prima-ry brain tumors and occurrences of brain tumors as SPTs following primary extra neural tumors. A total of 41 patients were included and analyzed presenting with histologically confirmed SPTs between 1st January 2000 and 31st December 2020. Results: The study included 41 patients with SPTs, primarily female (65.9%). Of these, 20 pa-tients (48.7%) developed SPTs after a primary brain tumor, while 21 patients (51.2%) developed brain tumors as SPTs after extra-neural tumors. Among patients who developed SPTs after brain tumors (n=20), meningioma (n=8, 40.0%) and pituitary adenoma (n=6, 30.0%) were the most prevalent first primary tumors (FPTs) while breast tumors predominated as SPTs (n=4, 20.0%). Survival analysis indicated younger mean age (44.5 years) for patients marked alive, compared to those marked deceased (57.0 years) and those with unknown outcomes (63.0 years). Conclusion Based on this retrospective analysis, the median age at diagnosis was 44.5 years,with a considerable number of patients (36.6%) having uncertain outcomes at follow-up due to incomplete records. These findings highlight the need for improved follow-up data management to better assess long-term survival in patients with SPTs following brain tumors.

Background: Cognitive decline is commonly seen in brain tumor (BT) patients and is associatedwith a worsened prognosis. Cognitive rehabilitation (CR) for cancer-related cognitive dysfunction has been widely studied for non-central nervous system cancers; however, recent emerging research has commenced documenting CR strategies for BT patients and survivors. Our objective was to review the current literature on various CR modalities in patients and BT survivors. Methods: The review was conducted in accordance with the PRISMA guidelines. The studieson CR were searched across 3 databases using a predefined search strategy. After removing duplicates, performing initial and full-text screenings, and applying inclusion criteria, relevant articles were selected. The demographic details, CR technique, cognitive tasks/tests administered, cognitive functions assessed, follow-up time, and outcomes of the intervention were assessed. Results: A total of 15 studies were included in the review. Neuropsychologist-guided trainingsessions to improve memory, attention, and executive functioning are effective in improving the mentioned domains. Younger and more educated patients benefited the most. Holistic mnemonic training and neurofeedback were not shown to affect overall cognitive functioning. Computer-based training programs showed improvements in executive functions of pediatric BT survivors, however, feasibility studies showed conflicting results. Aerobic exercises improved executive functions and decreased symptoms of the tumor. Both yoga and combined aerobic and strength training improved overall cognitive functioning. Active video gaming may improve motor and process skills; however, no effect was seen on cognitive functioning. Conclusion Neuropsychologic training, computer-based programs, and physical exercise havebeen found effective in improving or preventing decline in cognitive functions of BT patients. Given the limited trials and methodological variations, a standardized CR program cannot be established at present. Ongoing trials are expected to provide valuable data in the near future.

Background: Advancements in surgery, chemotherapy, and radiotherapy have improved survivalfor brain tumor patients, increasing the risk of second primary tumors (SPTs) among long-term survivors. This study examines the types and risks of SPTs in brain tumor patients presenting at a tertiary care hospital. Methods: This single-center, retrospective study explored occurrences of SPTs following prima-ry brain tumors and occurrences of brain tumors as SPTs following primary extra neural tumors. A total of 41 patients were included and analyzed presenting with histologically confirmed SPTs between 1st January 2000 and 31st December 2020. Results: The study included 41 patients with SPTs, primarily female (65.9%). Of these, 20 pa-tients (48.7%) developed SPTs after a primary brain tumor, while 21 patients (51.2%) developed brain tumors as SPTs after extra-neural tumors. Among patients who developed SPTs after brain tumors (n=20), meningioma (n=8, 40.0%) and pituitary adenoma (n=6, 30.0%) were the most prevalent first primary tumors (FPTs) while breast tumors predominated as SPTs (n=4, 20.0%). Survival analysis indicated younger mean age (44.5 years) for patients marked alive, compared to those marked deceased (57.0 years) and those with unknown outcomes (63.0 years). Conclusion Based on this retrospective analysis, the median age at diagnosis was 44.5 years,with a considerable number of patients (36.6%) having uncertain outcomes at follow-up due to incomplete records. These findings highlight the need for improved follow-up data management to better assess long-term survival in patients with SPTs following brain tumors.

Background: Cognitive decline is commonly seen in brain tumor (BT) patients and is associatedwith a worsened prognosis. Cognitive rehabilitation (CR) for cancer-related cognitive dysfunction has been widely studied for non-central nervous system cancers; however, recent emerging research has commenced documenting CR strategies for BT patients and survivors. Our objective was to review the current literature on various CR modalities in patients and BT survivors. Methods: The review was conducted in accordance with the PRISMA guidelines. The studieson CR were searched across 3 databases using a predefined search strategy. After removing duplicates, performing initial and full-text screenings, and applying inclusion criteria, relevant articles were selected. The demographic details, CR technique, cognitive tasks/tests administered, cognitive functions assessed, follow-up time, and outcomes of the intervention were assessed. Results: A total of 15 studies were included in the review. Neuropsychologist-guided trainingsessions to improve memory, attention, and executive functioning are effective in improving the mentioned domains. Younger and more educated patients benefited the most. Holistic mnemonic training and neurofeedback were not shown to affect overall cognitive functioning. Computer-based training programs showed improvements in executive functions of pediatric BT survivors, however, feasibility studies showed conflicting results. Aerobic exercises improved executive functions and decreased symptoms of the tumor. Both yoga and combined aerobic and strength training improved overall cognitive functioning. Active video gaming may improve motor and process skills; however, no effect was seen on cognitive functioning. Conclusion Neuropsychologic training, computer-based programs, and physical exercise havebeen found effective in improving or preventing decline in cognitive functions of BT patients. Given the limited trials and methodological variations, a standardized CR program cannot be established at present. Ongoing trials are expected to provide valuable data in the near future.

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.