AUCTORES
Globalize your Research
Research Article | DOI: https://doi.org/10.31579/2578-8868/329
Department of Neurosurgery and Gamma Knife Center, International Medical Center (IMC), 42 km. Ismailia Desert Road, Cairo, Egypt.
*Corresponding Author: Raef F.A. Hafez, Osama M. Fahmy, Hamdy T. Hassan., (2024), A single institution retrospective study of efficacy and complications perspective of Gamma Knife Radiosurgery for benign skull base meningioma: A 12-year follow-up, J. Neuroscience and Neurologic
Citation: Raef F.A. Hafez, Osama M. Fahmy, Hamdy T. Hassan., (2024), A single institution retrospective study of efficacy and complications perspective of Gamma Knife Radiosurgery for benign skull base meningioma: A 12-year follow-up, J. Neuroscience and Neurological Surgery, 14(6); DOI:10.31579/2578-8868/329
Copyright: ©, 2024, Raef F.A. Hafez. This is an open-access article distributed under the terms of The Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Received: 25 June 2024 | Accepted: 12 July 2024 | Published: 26 July 2024
Keywords: cranial nerve; gamma knife radiosurgery; meningioma; stereotactic radiosurgery; skull base
Background and Objectives: Gamma knife radiosurgery (GKRS) has established its role as an effective treatment modality for inaccessible, recurrent, and residual benign skull base meningioma. Therefore, it is necessary to study the outcome in the long term. The current retrospective study aims to analyze and report the clinical and radiological outcomes after long-term follow-up of GKRS for skull base meningiomas >= 12 years.
Patients and methods: The present study was conducted on 106 consecutive patients harboring benign skull base meningiomas treated by GKRS at our IMC center between 2005 and 2012 and was followed till the end of 2023.
Results: After a median follow-up of 13 years (3.6-18 years), a tumor control rate was reported in 88.7% of patients (n 94/106). Recurrences and tumor progression occurred in 11.3% (n 12/106) at a median follow-up period of 5.4 years (3–10.3 years). The 3, 5-, 10-, 12-and 15-year actuarial tumor control rate was 100%, 95.3%, 89.7%, 88.7%, and 78.1% respectively.
Conclusions: The current retrospective study provides a long-term 12-year follow-up and comprises one of the longest follow-up studies of GKRS-treated benign skull base meningiomas. The current series documents a persistent long-term high local tumor control and an acceptable low incidence of neurological deficits. Benign skull base meningioma volume variant at the time of GKRS is a statistically significance predictor factor for tumor control at long-term outcomes.
Meningiomas are the most common intracranial tumor, comprise 37.6% of all primary central nervous system tumors. They are mostly benign tumors, derived from the arachnoid cap cells of the leptomeninges. One-third of intracranial meningiomas arise from the skull base. Surgery is the primary management option for symptomatic meningioma patients as it provides long-term disease-free survival for more than 90% of patients. [1, 2, 3, 4, 5, 19, 20] However, the proximity of these tumors to critical neurovascular structures makes complete surgical removal extremely difficult. [12, 13, 33, 36, 38]
Skull base meningiomas are often impossible to remove completely. Despite advances in microsurgical techniques, anesthetic management, and postoperative intensive care, surgical access to skull base meningiomas remains a challenge, and the related mortality and morbidity rates are still high. Therefore, surgery alone cannot be the ideal long -term solution to treat all skull base meningiomas. [8, 9, 14, 15, 16]
Gamma knife radiosurgery (GKRS) has been reported as a potentially effective alternative to surgical removal of small-to moderate-sized meningiomas especially at the skull base, and as an adjuvant treatment modality for recurrent and postoperative residual meningioma’s that achieves high rate of tumor control with a lower risk of complications [13,34]. The goal of GKRS, whether used as primary therapy or adjuvant therapy after surgery is to prevent tumor growth, and maintain or improve neurological function. Meningiomas are considered an ideal tumor type for GKRS due to their clear demarcation from the normal brain, and accurate localization with today's advanced neuroimaging techniques. [10, 11, 12]
The concept of planned surgical/GKRS cooperation for skull base meningioma has become more solidified where the need for aggressive tumor resection is reduced as GKRS offered a documented long-term tumor control with acceptable risks of complications. [7, 19, 25, 37]
Objective; The current retrospective consecutive cohort study reports the =>12-year follow-up of skull base meningioma patients treated with Gamma Knife radiosurgery according to current clinical and technical standards. Because of the known slowly growing benign skull base meningioma natural course, this study aims precisely to the report the long-term outcome efficacy and complication of GKRS treatment for these tumors.
Patients’ population; All records of the studied consecutive 106 patients with symptomatic benign meningioma at the skull base undergoing Gamma Knife radiosurgery between January 2005 and January 2012 at the Department of Gamma Knife Radiosurgery (GKRS) / International Medical Center (IMC)-Cairo-Egypt, were thoroughly retrospectively reviewed, analyzed and reported. These patients were included in a long-term =>12-year follow-up. Patients with anaplastic or atypical meningiomas, multiple meningiomas, with history of cancer, neurofibromatosis-II, and those without complete radiological and clinical data were excluded from the current study. GKRS-treated benign skull base meningiomas in the current study had been classified histologically according to WHO grade I in 28 patients and based on radiological criteria in 78 patients (Based on typical imaging findings, including a clear definition of the lesion, wide dural base, extra-axial location, uniform contrast enhancement, and sometimes intratumor calcification).
The anatomical locations reported of treated skull base meningiomas were cavernous sinus and parasellar meningioma in 31.1 (n 33/106, cerebellopontine angle meningioma in 20.8% (n 22/106), petro-clival &petrous apex in 13.2% (n 14/106), sphenoidal ridge in 12.3% (n 13/106), anterior clinoid meningioma 10.4% (n 11/106), olfactory groove (n 5/106), foramen magnum meningioma (n 3/106), suprasellar (n 3/106), tuberculum sellae and intra-orbital meningioma each in 1 patient. [Table I]
*cc=cubic centimeter
Table 1: Patient's population, tumors characters, and GKRS parameters
Neurological and cranial nerve deficits pre-GKRS were reported, including intermittent headache in 36 patients, diplopia and ocular movement disorders in 26 patients, trigeminal nerve affection in 22 patients (trigeminal neuralgia in 8 and trigeminal paresthesia in 14 patients, visual acuity and visual field deterioration in 18 patients, hearing deterioration in 14, motor weakness in 4 patients and 5 patients presented with seizures activity. [Table 2]
| No. of patients Pre -GKRS | No. of patients Post- GKRS | |||
| Neurological and cranial nerve deficits | Improved | Stable | Neurological and cranial nerve deficits post-GKRS | |
Headache
| 36 | 12 | 22 | No new agonizing persistent headache |
| Ocular movement disorders | 26 | 15 | 11 | - |
| visual acuity and visual field defect | 18
| 4 | 14 | 2 Permanent |
| Trigeminal Paresthesia | 14 | 4 | 10 | 5
|
| Trigeminal neuralgia | 8 | 2 | 6 | 1 Controlled |
| Facial nerve palsy | 3
| - | 3 | 1 partial |
| Hearing affection up to loss | 14 | 2 | 12 | 2 Permanent |
Bulbar symptoms
| 2 | - | 5 | - |
| Motor weakness | 4 | 1 | 3 | -
|
Ataxia
| 7 | 2 | 5 | - |
| Seizure activity | 5
| - | 5 | 2 Controlled |
Anosmia
| 4 | - | 4 | - |
| Exophthalmos | 3
| - | 3 | - |
| Dizziness | 11 | 5
| 6 | - |
Table 2. Pre. and post-GKRS neurological and cranial nerve deficits
Gamma knife procedure
The treatment was carried out using a 201 source Cobalt-60 Leksell Gamma Knife Model B and Model 4C-APS (Elekta AB, Stockholm, Sweden). In all cases, a stereotactic frame was applied under local anesthesia followed by a gadolinium-enhanced stereotactic MRI scan 1.5 Tesla. The tumor outline was delineated on the T1-weighted scans (Axial and or coronal acquisition), which were imported into the planning software (Leksell Gamma Plan). The tumor margins including critical anatomical structures were outlined, and the dose plan was created with isodoses, prescription doses, and maximum doses being determined by the responsible neurosurgeon and a medical physicist. The contrast-enhancing dura adjacent to the meningioma, dural tail, usually included within the GKRS treatment field within the prescription isodose whenever feasible.
Follow-up
Follow-up Clinical and radiological follow-up information was gathered by retrospective review of detailed patient records and attendance. MRI and clinical data were reviewed retrospectively as part of the clinical routine. Following GKRS, all patients underwent a clinical evaluation with accompanying imaging follow-up annual MRI in the first 5 years after GKRS and with bi-annual MRI thereafter or whenever needed. All follow-up MRI images were reviewed by neurosurgeons and neuroradiologists. The tumor size measured on the images was classified as tumor control (TC) i.e. (Regressed or stable) or lost tumor control (LTC), i.e. progressed. The images were also assessed for central necrosis or transient swelling.
These images as well as the radiological reports were used for the assessment of local tumor control after radiosurgery. The median (±SD) radiological and clinical follow-up period after the initial GKRS was 13 ± 3.29 years (3.6–18 years).
Statistical analysis
Kaplan-Meier plots were used to estimate the actuarial tumor control rates by applying the Med Calc-version 22.021. Descriptive statistics were calculated for all variables, including mean, median, standard, and frequency distributions as appropriate. Multivariate analysis was carried out using the Cox proportional hazards regression analysis including multiple covariates for assessing prognostic factors including patient age, tumor volume, peripheral prescription dose, maximum dose, conformity index of Lomax (CI Lomax) [40], and if there was pre-GKRS surgery.
In the present study skull base meningioma represented 43.6% (n 106-243) of all GKRS-treated meningioma patients in the same period of follow-up. During the observation period, 5 patients were re-treated with additional Gamma Knife sessions due to tumor progression.
The median age (±SD) at initial Gamma Knife treatment was 48 ± 10.64 years (25–75 years). There were 79 female and 27 male patients. The median tumor volume (±SD) at the time of radiosurgery was 4.65±3.59cc (range 0.7–16.4 cc). The median (±SD) prescription dose was 15.000 ± 1.23Gy (12-16Gy), the median maximum dose was 40.00±5.46Gy (24-42.9Gy), and the median CI Lomax was 0.95 ± 0.037 (0.84-0.99).
Before radiosurgery, 26.4 % of patients (28/106) had undergone an open tumor resection in various neurosurgical centers including ours.
Post-GKRS tumor Control: The overall tumor volume control was achieved in 88.7% (n =94) of patients at the last MRI control images. Tumor reduction was confirmed in (n 18/94pateints) 19.2% and stationary tumor size was observed in 80.8% (n 76/94). At the last follow-up, tumor progression was documented in 11.3% (n 12/106).
Seventy-eight patients (73.6%) had GKRS as a primary treatment with no previous surgical resection. Within this group, tumor control was attained in 88.5% (n 69/78 patients). In these patients who underwent a previous surgical resection 26.4%, (n 28/106), tumor control was attained in 89.3% (n 25/28). This difference between the groups did not reach statistical significance (P < 0>
Figure 1. Kaplan-Meier curve presenting the 3, 5-, 10-, 12-and 15-year actuarial tumor control rate was 100%, 95.3%, 89.7%, 88.7%, and 78.1% respectively.
Figure 2. (A&B) T1-weighted contrast axial and coronal stereotactic MRI images of right petro-cavernous meningioma in a 40-year-old woman of 2.8 cc tumor volume presenting with right 6th nerve palsy and trigeminal pain treated with GKRS with 15Gy marginal dose at 50% isodose curve with 98% tumor coverage. (C&D) 14 years Post GKRS follow-up axial and coronal MRI showing local tumor control with evident decreased of treated tumor volume. The patient showed improvement clinical condition.
Figure 3. (A&B) T1-weighted contrast axial and coronal stereotactic MRI images of 1.9 cc right cavernous sinus meningiomas in a 27-year-old woman, presenting with right 3rd nerve palsy, ptosis, and right facial numbness treated with GKRS with 15Gy marginal dose at 50% isodose curve with 98% tumor coverage. (C&D) 5 years Post GKRS follow-up axial and coronal MRI confirmed lost tumor control LTC (tumor progress in Y&Z coordinates), the patient was retreated with GKRS
Post-GKRS clinical control: A total of 87.7% of patients (93/106) confirmed an unchanged or improved clinical status at the last follow-up. A later clinical deterioration associated with the treated skull base meningioma occurred eventually in 12.3% (n 13/106). In 8 out of 13 patients with later clinical deterioration, the symptoms were related to tumor recurrence and progression. None of the patients developed adverse radiation complications through the follow-up period.
A new onset of trigeminal neuralgia developed in one patient, additional trigeminal paresthesia in 5, deterioration of serviceable hearing in 2, and progressive deterioration of visual field in 2 patients with anterior clinoidal meningiomas. One developed new facial nerve palsy and one had motor weakness. Transient peritumoral edema was detected in 4 cases post-treatment; two of them developed a new onset of seizure activity. [Table 2]
A combined outcome parameter, favorable outcome, defined as a combination of tumor volume control and clinical neurological improvement or stability at the last evaluation, was attained in 85% of patients (n 90/106).
Skull-base meningioma typically presents many treatment challenges related to tumor location, patient age, comorbidities, recurrence after incomplete resection, and risks of neurological morbidity with microsurgery. The options available for the management of skull base meningiomas include observation with serial imaging studies, SRS, and surgical resection. For patients with small, asymptomatic tumors, observation can be considered. [4, 10] However, owing to the proximity of these tumors to critical neurovascular structures, tumor growth will often be associated with neurological deficits. [12, 13, 17, 38]
Complete tumor removal can be achieved in nearly all meningiomas located over the hemispheres. However, management in skull base meningioma is complicated by the proximity to neurovascular critical structures, thus an incomplete tumor resection as a surgical result is more frequent. [4, 7, 8, 33] With large Petro clival meningioma, tumor progression was observed in 15% of patients who had reportedly undergone complete tumor resection as reported by Natarajan et al. [18]
Surgery for skull base meningiomas faces a tough decision between performing an aggressive tumor resection, which carries a high risk of neurological complications, or partial removal which has a lower morbidity rate but a higher chance of tumor progression. Therefore, it is important to have additional adjunctive treatment of the tumor's remnant particularly when planned surgical/GKRS cooperation is considered, to optimize the GKRS option by reducing the size of the tumor mass [14, 17, 44, 45, 62]
Stereotactic GKRS is considered the most effective option for patients with small to moderately sized meningiomas, typically those that are less than 3 cm in diameter or <10>
In a large meta-analysis series of 2065 patients with cavernous sinus meningioma, Sughrue et al.2010, reported that those who had undergone primary stereotactic radiosurgery (SRS) demonstrated greater tumor control rates compared with patients who had undergone either complete or partial resection. In addition, the rate of postoperative cranial nerve deficits was greater in the patients with previous resection compared with primary stereotactic radiosurgery [21]
Although previous publications have found that radiosurgery was associated with favorable tumor control rates and acceptable morbidity in the first 5 years after GKRS, insufficient long-term outcome data exist. [3,9,14,22,23,24,25, 28, 37,39]
We report a tumor control rate at the last follow-up of 88.7% (n 94/106) at a median follow-up of 13 years and a median treated tumor volume of 4cc (range 0.7-10 cc). Lost tumor control and progression were reported in 11.3% (12/106) patients at a median follow-up period of 5.4 years (range 4-10) and a median treated tumor volume of 11.9cc (range 8.7-16.4). Multivariate analysis was carried out using the Cox proportional hazards regression analysis including multiple covariates confirmed tumor volume as a significant prognostic tumor control predictive factor of a P value (<0>
Skull base meningioma volume is a significantly complicated issue for stereotactic radiosurgery as larger tumors are associated with a higher risk for radiation-induced edema, hence tumor volume is generally seen as the most complicating factor in stereotactic radiosurgery. A recurring question concerns the largest possible volume that can be treated with stereotactic radiosurgery safely. This volume may differ depending on the tumor's location. Petro-clival meningiomas with volumes of 8cc and larger showed a significantly increased risk for tumor progression. [8] In cavernous sinus meningioma, the complication rate was considerably higher (21% vs. 3%) in meningiomas larger than 9.4 cc [31]. DiBiase and colleagues [20] reported a 91.9% 5-year disease-free survival for patients with meningiomas less than 10 cm3 as opposed to 68% for larger tumors.
Excellent tumor control rate with stereotactic radiosurgery has been reported by Kondziolka et al, for meningiomas up to a diameter of 3.0 cm or a volume of 7.5 cm3.[32] Likewise, other authors have found excellent local control and fewer radiation-related complications associated with the treatment of smaller meningiomas. [29, 30, 35, 36, 46, 47, 59]
Tumor Control: In the current study tumor reduction was reported in 19.1 % (n 18/94) and unchanged in 80.9% (n 76/94) of patients. Tumor progression was observed in 12 patients (11.3%) and was detected at a median of 5.4 years (range 4-10.3) after GKRS. The analysis of 3768 meningiomas in the European retrospective multicenter meningioma study documented five-and 10-year progression-free survival rates were 95.2% and 88.6%, respectively. [49]
Kondziolka et al. 2016 reported 53% of patients had residual or recurrent tumors after initial surgical resection at an interval of 10 or more years after GKRS, long-term tumor control rates were sustained. [42] This finding supports the present study's conclusion that tumor progression despite radiosurgery will typically be detected in the first decade after the procedure.
The North American Gamma Knife Consortium published actuarial progression-free survival rates of 84% at 10 years after Gamma Knife treatment of Petro clival meningiomas in a multicenter study of 254 patients [61].
Cohen-Inbar in a study of 189 parasellar meningioma patients treated with GKRS reported local tumors control in 88.1% in a series with a median follow-up of 8.5 years [1].
The documented local tumor control rate following GKRS treatment for benign skull base meningioma reported in this study was 88.7% at a median follow-up period of 13 years, which is slightly lower than control rates that have been published with a shorter observation time [46, 47, 50, 51], most probably because of the longer duration of follow-up. Generally, local control rates are slightly lower in series with long observation periods [1, 2, 4, 34] and are close similar to the tumor control rate (88.7%) after =>12 years follow-up found in the present study.
Clinical Outcomes and Complications: Clinical control (Improvement and unchanged) in pre-existing neurological and cranial nerve deficits was documented in 87.7% of patients (93/106). Clinical improvement was in the majority of patients who had achieved tumor reduction in the last control MRI (n 16/18 patients). Flannery et al. [8] argued that the pressure relief associated with tumor regression was a possible mechanism explaining the observed improvements.
In our study diplopia was the most common symptom to improve in 60% n (n 15/25) reporting improvement of pre-existing diplopia. Moreover, trigeminal symptoms improved in 27% (n 6/22). Nicolato et al. [45] reported that 60.5% of their patients who had undergone adjuvant SRS reported improvements in CN deficits. Hasegawa et al. [26] reported symptom improvement in 34% of their patients who had undergone adjuvant GKRS. In a long-term study after Gamma Knife treatments, Kondziolka reported that 94% of asymptomatic patients remained asymptomatic [42].
We observed a new onset of trigeminal neuralgia developed in one patient, additional trigeminal paresthesia in 4, deterioration of serviceable hearing in 2, and progressive deterioration of visual field in 2 patients with anterior clinoidal meningiomas. One patient developed new facial nerve palsy, one had increased motor weakness, and one developed an ataxic gait. Transient peritumoral edema was detected in 4 cases post-treatment, two of them developed a new onset of seizure activity. In 8 out of 13 patients who developed later clinical deterioration, the symptoms were related to tumor recurrence and progression.
The present data revealed a clinical long-term management risk of 12.3% (which was slightly higher than reported in comparable series with short-term follow-up), but the majority of side effects (8/13) were unrelated to the GKRS treatment and appeared to be associated with tumor recurrences. Long-term follow-up usually unveiled late complications and treatment-related morbidity of GKRS as radiation treatment modality. Similar to the present study, Starke et al. reported that tumor progression was present in 64% of patients with new or worsening neurological decline [61]
The limitations in the present study; include those inherent to the nature of retrospective data collection and the small studied number of patients. The current analysis comprises one of the longest available follow-up investigations in a larger series after stereotactic radiosurgery of skull base meningioma. It documents a persistent high local tumor control after Gamma Knife treatment, which is slightly lower than in published observations with shorter follow-ups.
The current retrospective study provides => 12-year follow-up and comprises one of the long-term follow-up studies of GKRS-treated skull base meningiomas. Tumor control from GKRS can accomplished with an acceptable low incidence of neurological deficits and related neuropathies. In a planned surgical/GKRS cooperation, the need for aggressive tumor resection could be reduced as stereotactic radiosurgery provides a documented long-term control of tumor residuals. Tumor volume at the time of GKRS is statistically significance and a reliable long-term predictor factor of tumor control. The long natural history of benign skull base meningioma's slow progression and unpredictable growth necessitates a long observation before any final conclusion regarding GKRS treatment outcome.
(cc) Cubic centimeter, (CN) cranial nerve, (GKRS) Gamma Knife Radiosurgery, (PPD) Peripheral prescription dose, (SRS) Stereotactic Radiosurgery, (TV) Tumor volume, (WHO) World Health Organization.
Ethics approval, consent to participate and consent for publication. ‘Not applicable'
Availability of data and material. Patient’s retrospective data are available
Retrospective study for this type of study formal consent is not required, it does not contain any studies with human participants"
Competing interests: The authors declare that they have no competing interests, and certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial in the matter or materials discussed in this manuscript. We declare that this is an original article.
No funding was received for this research.
All authors read and approved the manuscript.
Not applicable
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
