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Review Article | DOI: https://doi.org/10.31579/2768-2757/076
Neurosurgery Service, Guemes Sanatorium, CABA, Argentina.
*Corresponding Author: Torres, Pilar, Neurosurgery Service, Guemes Sanatorium, CABA, Argentina.
Citation: Pilar T., Guido B., Martina A., Jeronimo M., Fedra S., Sebastian B., (2023), Factors Influencing the Degree of Resection and Proposed Preoperative Scale for the Management of Skull Base Meningiomas, Journal of Clinical Surgery and Research, 4(3); DOI:10.31579/2768-2757/076
Copyright: © 2023, Torres, Pilar. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 09 May 2023 | Accepted: 18 May 2023 | Published: 26 May 2023
Keywords: meningioma; skull base; Simpson; scale; unicentric study; statistical analysis
Objectives: to identify factors involved in the degree of resection of skull base meningiomas and to propose a scale to calculate the probability of total resection.
Materials and methods: unicenter, observational, retrospective study of patients operated on in the period 06/2018 – 06/2022. The following variables were used: age, clinic, location, size, previous embolization, perilesional edema, intertumoral calcium, characteristics in T2 and T1 and bone invasion. The degree of resection was measured with the traditional Simpson classification and was also divided into total (Simpson I, II and III) and subtotal (Simpson IV and V) resection. With the results, a scale was proposed taking into account the variables with statistical significance (p < 0.05). A literature review of the topic was conducted.
Results: A total of 23 patients were operated. They were statistically significant associated with Simpson's grade, location (p 0.002) and size (p 0.001). Associated with total and subtotal resection, bone invasion (p 0.013). For the scale we use: location (anterior 1 point, posterior 2 points, medial 2 points and medial involving cavernous sinus 3 points), size (<5 cm 1 point, >5 cm 2 points) and bone invasion (not 1 point and if 2 points). We performed an inferential analysis and an association was observed between the scale performed and the degree of resection (p 0.005).
Conclusion: In our study, an association was observed between bone size, location and invasion with the degree of resection achieved. We proposed a scale to measure the probability of total resection.
Meningiomas are the most common primary CNS tumor. They originate from meningothelial cells found in the arachnoid layer of the meninges, may be associated with the dura mater or choroid plexus, and account for 36% of all CNS 1 tumors. They grow along the outer surface of the brain, spinal cord or, less commonly, within the ventricular system. There are 3 grades based on WHO criteria. 80% are grade [1], benign and slow growing; 20 - 25% are grade 2 with higher probability of recurrence; and 1-6% are grade 3, malignant with metastatic potential [2]. They occur at an average age of 65 years. 66% of cerebral meningiomas occur in women, rising to 90% when they are located in the spinal cord [3]. Cases may occasionally occur in the pediatric population, and are generally associated with genetic syndromes or infant radiation [4]. The base of the skull is a complex anatomical region that forms the floor of the cranial cavity. There are several neoplastic processes that can manifest in the skull base, with different distribution depending on their location is anterior, middle or posterior. Meningiomas can develop in any of their locations.Surgery is the first-line treatment for most benign and malignant skull base tumors [5]. Gross total resection is the therapeutic paradigm that is intended to be reached when we diagnose a meningioma. Based on tumor resection, its residual remnant and infiltrated dura mater, Simpson introduced in 1957 a prognostic classification for the extent of resection, which has been widely applied in neurosurgical practice [6]. Simpson Grades I, II, and III can be defined as gross total resection and were associated with lower recurrence compared to Grade IV and V, defined as subtotal resection [7,8]. The surgical challenge of this type of tumor, which as we have mentioned are usually benign lesions in its great majority, is due to the difficult accessibility given the anatomy and its proximity to critical neurovascular structures. To avoid Complications, it is often necessary to perform a subtotal resection and preserve the patient's functional status [9]. Therefore, presurgical planning and the establishment of the objectives of tumor resection are essential parts, and they must be individualized, to provide an adequate surgical result. It is very useful to identify predictive factors obtained in the preoperative assessment that influence the degree of surgical resection. The objective of this study is to identify these factors taking into account characteristics, either patient or tumor, that intervene in the degree of resection of skull base meningiomas, and propose a scale to assess the probability of total resection.
An observational, retrospective study was conducted, collecting data from clinical histories of patients operated with transcranial approach of skull base meningiomas during the period 6/2018 to 6/2022 by our neurosurgical team of the Güemes Sanatorium, CABA, Argentina. Patients older than 18 years, without previous operations and with preoperative contrast MRI and brain tomography were included. Patients younger than 18 years of age, with previous surgical interventions and with incomplete presurgical studies were excluded. Epidemiological and clinical characteristics of the patient were analyzed, as well as characteristics of the tumor, whether location, size, imaging and whether he has previous embolization or not. The degree of resection was measured with the traditional Simpson classification and was also divided into total (Simpson I, II and III) and subtotal (Simpson IV and V) resection (Figure 1).
Figure 1: Representative images of patients operated on for meningioma of the anterior skull base of olfactory groove. A: T1 sequence with magnetic resonance contrast, axial slice. B: Same lesion coronal cut C: coronal Cort of postoperative imaging. D: approach and craniotomy performed.
Then, with the results obtained, a scale was proposed to graduate the probability of total or subtotal respectability of meningioma, taking into account the variables that had statistical significance (p < 0.05). Finally, a literature review was conducted in order to compare results with other series.
Protocols and definitions of the variables studied
Patients were analyzed according to age in three cohorts: <40> 60 years. For the clinic, patients were divided into those asymptomatic at the time of diagnosis and symptomatic. Meningiomas of anteromedial localization were defined as those of the olfactory sulcus, sphenoid planum and tuberculum sellae. The anterolaterals are those that arise from the sphenoid wing, including those of the inner segment or clinoidal, those of the medial segment or wings and those of the lateral segment or pterional 10. Those of medial location were those of the cavernous sinus. And those of posterior location the petroclival meningiomas and the cerebellar ponto angle. For the size, the highest value obtained in any of its diameters was taken into account and divided into <3> 5 cm. Among the characteristics we obtained from the imaging studies, we collected whether or not intratumoral calcium was observed, if they had perilesional edema, if they had bone invasion, and their characteristics in sequence T1 and T2. Information was also obtained on whether or not preoperative embolization was performed. Thedegree of resection was categorized according to the Simpson scale based on the intraoperative observation of the surgeon and its description in the surgical part; also comparing the results with resonance with gadolinium postoperative control. Simpson being grade I total removal of meningioma and dura mater, grade II total tumor removal and dura mater coagulation, grade III total tumor removal without dura mater coagulation, grade IV partial resection and grade V decompression or biopsy. We speak of total resection when a Simpson I, II and III was achieved, and subtotal resection with Simpson IV and V.
Taking the results of the variables studied of categorical type and with the database obtained, an analysis was carried out using frequent descriptive statistics and inferential statistics with chi square. SPSS version 25 or JAMOVI was used.
Patient characteristics
A total of 23 patients with skull base meningiomas were operated on during the study period (Table 1). Of these, 95% (n 22) were female. With respect to age, 21.7% (n:5) were younger than 40 years, 39.1% (n:9) between 40 and 60 years old and 39.1% (n:9) were older than 60 years. 73.9% (n:17) had clinical manifestation and 26% were asymptomatic at the time of diagnosis.
Tumor characteristics
The most frequent location was anterolateral with 47.8% (n:11), then posterior with 30.4% (n:7), anteriomedial 17.4% (n:4) and finally medial 4.3% (n:1). 4.3% (n:1) of tumors were smaller than 3 cm, 78.3% (n:18) measured between 3 and 5 cm, and 17.4% (n:4) were smaller than 5 cm; being less than 5 cm 82.6% (n:19).73.9% (n:17) of tumors did not have embolization prior to surgery
Imaging features of the tumor
52.2% (n:12) of meningiomas had perilesional edema and 17.4% (n:4) had intratumoral calcium. Bone invasion was found in 8.7% (n:2). A 34.8% (n: 8) were hyperintense in T2, 43.5% (n: 10) isointense and characteristic heterogenies 21.7% (n:5). Regarding its behavior in sequence T1 30.4% (n: 7) was hypointense and 69.6% (n: 16) isointense.
Degree of exeresis
Simpson I resection was achieved in 4.3% (n:1) of patients, Simpson II in 47.8% (n:11) of patients, Simpson III and IV in 21.7% (n:5) respectively, and Simpson V in 4.3% (n:1).
| Frecuencia | Porcentaje | |
| CLINICA | ||
| Sintomático | 17 | 73,9 |
| Asintomático | 6 | 26,1 |
| EDAD | ||
| <40> | 5 | 21,7 |
| 40-60 | 9 | 39,1 |
| >60 | 9 | 39,1 |
| LOCALIZACION | ||
| Anteromedial | 4 | 17,4 |
| Anterolateral | 11 | 47,8 |
| Medial | 1 | 4,3 |
| Posterior | 7 | 30,4 |
| TAMAÑO | ||
| <3> | 1 | 4,3 |
| 3-5 cm | 18 | 78,3 |
| >5 cm | 4 | 17,4 |
| EMBOLIZACION | ||
| No | 17 | 73,9 |
| Si | 6 | 26,1 |
| EDEMA PERILESIONAL | ||
| No | 11 | 47,8 |
| Si | 12 | 52,2 |
| CALCIO | ||
| no | 19 | 82,6 |
| Si | 4 | 17,4 |
| INVASIONOSEA | ||
| No | 21 | 91,3 |
| Si | 2 | 8,7 |
| T2 | ||
| Hiper | 8 | 34,8 |
| Iso | 10 | 43,5 |
| heterogeneo | 5 | 21,7 |
| T1 | ||
| Iso | 16 | 69,6 |
| Hipo | 7 | 30,4 |
| GRADO DEEXERESIS | ||
| I | 1 | 4,3 |
| II | 11 | 47,8 |
| III | 5 | 21,7 |
| IV | 5 | 21,7 |
| V | 1 | 4,3 |
Table 1: Frequency and percentage of variables.
Regarding inferential results, two types of analysis were performed using the Chi-square test. On the one hand, the study variables were associated with the degree of excision measured with the Simpson scale taking the different five levels I, II, III, IV and V (Table 2). Only associations with location and size were found, with moderate and high effect sizes (Crammer's V).
| (p) | |
| Localización | 0,002 |
| Edad | 0,238 |
| Clínica | 0,487 |
| Tamaño | 0,001 |
| Embolización | 0,724 |
| Edema | 0,172 |
| Calcio | 0,600 |
| Invasión ósea | 0,096 |
| T2 | 0,427 |
| T1 | 0,213 |
Table 2: Association of variables with Simpson's degree.
On the other hand, the variables were associated with the measures of the Simpson scale divided as total resection (I, II and III) partial resection (grade IV and V) (Table 3). Thus, associations were found between bone invasion and grade, with moderate and high effect sizes (Crammer's V). No associations were found between the rest of the variables with the Simpson scale (p > .05).
| (p) | |
| Edad | 0,814 |
| Clínica | 0,091 |
| Localización | 0,131 |
| Tamaño | 0,089 |
| Embolización | 0,638 |
| Edema | 0,408 |
| Calcio | 0,231 |
| Invasión ósea | 0,013 |
| T2 | 0,705 |
| T1 | 0,226 |
Table 3: association with total or subtotal resection.
Proposed scale
Given the results objectified and described above, three variables with statistical significance were found from the inferential analysis: tumor size, location and bone invasion.
For the scale we decided to use the three variables: location (anterior 1 point, posterior 2 points, medial 2 points and medial involving cavernous sinus 3 points), size (<5>5 cm cm 2 points) and bone invasion (not 1 point but 2 points) (Table 4).
| Localización | anterior | 1 |
| posterior | 2 | |
| medial | 2 | |
| medial(C) | 3 | |
| Tamaño | < 5 cm | 1 |
| > 5 cm | 2 | |
| Invasión ósea | No | 1 |
| Si | 2 |
Table 4: Presurgical scale
The minimum score is 3 and the maximum is 7. The probability of total resection with a score of 3, moderate with a score of 4 and low with a score of 5 or more was considered high (Table 5).
| Grado | Puntaje |
| Alto | 3 |
| Moderado | 4 |
| Bajo | >5 |
Table 5: scale score.
Of the total of our series (Table 6) 11 had a score of 3 points and all had total resection (Simpson I, II and III); 10 patients scored 4, 6 of them with total resection and 4 with subtotal resection. Finally, 2 patients had a score of 5 and both had subtotal resection (Figure 2).
| Total (n) | Resección total | Resección subtotal | |
| 3 puntos | 11 | 1 | 0 |
| 4 puntos | 10 | 6 | 4 |
| 5 puntos | 2 | 0 | 2 |
Table 6: Patient score from our study.
Figure 2: patients with different degrees of excision measured in Simpson and their relationship with the score obtained from our scale.
When performing an inferential analysis, an association was observed between the scale performed and the degree of resection (p: 0.005) (Table 7 and 8).
| Significación asintótica (bilateral) | |
| Chi- cuadrado de Pearson | 0,005 |
Table 7 and 8: association between proposed scale and degree of resection.
In our series, 23 patients were operated on in the period 06/2018 - 06/2022; Within the variables analyzed, we found that both the location, size and bone invasion of the meningioma were related to the degree of resection. Of the total number of patients studied, a complete exeresis (Simpson I, II and III) was achieved in 73.8%. In different publications, a correlation was shown between the location of meningiomas and the degree of excision achieved, with the skull base being the site where less complete resection is achieved11. Meling. et al. in a study of 1148 patients, they found that in 68% of skull base meningiomas achieved total excision, compared to 89?hieved in tumors of another location [12]. In our study, anteromedial and anterolateral skull base meningiomas (which together form the anterior skull base) were the ones with the best degree of exeresis obtained, measured on the Simpson scale. There are currently reviews that describe more resectability in tumors of anterior base compared to those of medium or posterior base [13]. Although when we talk about anterior skull base, we cannot ignore the progress of the endoscopic transnasal approach for the management of this pathology, and although there are still controversies, there are studies in which an increase in the degree of resection has been observed in the transcranial approach and lower comorbidities compared to the endoscopic approach [14]. However, in small patients, the transnasal endoscopic approach for many neurosurgical teams is usually the primary indication [15]. In our series, the size of the meningioma was related to the degree of excision, more than 78% of tumors smaller than 5 cm had a complete resection. Several. Studies took 5 cm as a cut to talk about large meningiomas and described that, especially at the skull base, size influences the degree of excision [16,17,18] Bone invasion may be a preoperative predictor of the extent of surgical resection [19]. A series that incorporated data from 1469 meningiomas and analyzed predictive factors related to the surgical extent of resection concluded that clinic, location at the base of the skull and bone invasion were significant predictors of a low degree of resection (Simpson IV and V) [20]. In our sample, an association was observed between bone invasion and degree of excision, all patients with invasion (8%) had a subtotal resection. Different studies described that in elderly patients’ unfavorable postoperative outcomes are more related to previous functional status and comorbidities and not so much to the degree of excision measured in Simpson [21,22,23]. However, the main predictor of a poor postoperative functional outcome is the intraoperative complications themselves, which are observed in a higher percentage in elderly patients [24]. Therefore, subtotal resection with adequate debulking in exchange for greater safety for meningiomas located near complex neurovascular structures is usually preferable in these patients. In our study, no relationship was observed between Simpson's grade and age. Although in this study no relationship was observed between the patient's clinic, that is, whether he is symptomatic or asymptomatic at the time of diagnosis, with the degree of excision; In a recent study [20] symptomatic patients achieved a lower degree of exeresis compared to asymptomatic patients. In our results, preoperative embolization was not related to the degree of resection. The review did not find any direct benefit associated with the degree of excision of embolized meningiomas before the operation [25]. There have been attempts to objectify the best indication for preoperative embolization and its benefits according to the size and vascularization of the meningioma. A vascularization index has recently been performed by measuring the flow vacuum of the meningioma obtained from a volumetric T2, and better bleeding control was observed in patients with high index and with previous embolization compared to those not embolized [26]. According to the literature, between 38% and 67% of meningiomas have perilesional edema [27]. We found no relationship between the degree of excision and the presence of edema in tumors within our work. Vignes et al in a study of 30 patients where he relates edema and prognosis in meningioma surgery, concludes that the presence of edema affects the surgical prognosis and confers a higher risk of morbidity and postoperative complications, but did not make a direct correlation between meningiomas with perilesional edema and degree of excision [28]. If it has been observed that a high volume of edema correlates with a higher incidence of recurrence, regardless of biological type and histological grade [29]. Approximately 15% of meningiomas may have different patterns of calcification. Zhang et al [30] in a report of 58 cases achieved a Grade III Simpson resection in 52 cases and III in 6. Calcification was associated with high-grade meningiomas and it has been shown that non-calcified tumors may have a greater proliferative potential than calcified tumors [31]. In our study, no relationship was observed between the degree of resection and intertumoral calcium. Given the importance of knowing the type of tumor consistency when addressing this pathology, attempts have been made to predict it in presurgical studies, as well as intraoperative scores have been proposed [32]. There are several studies that related hyperintensity in T2 with soft tumors; It may be related to higher water content. While the lower signal in T2 for hard tumors could be due to less water and more collagen and calcium content. Although there are several articles that show the indication of the T2 signal to predict consistency, it is not yet a validated method [33]. Likewise, in most of the studies reviewed, it has not been found that there is an association between T1 and meningioma consistency. However, Hoover et al found that meningiomas that were hyperintense at T2 and hypointense at T1 were more likely to be soft, while those that were hypointense at T2 and isointense at T1 were probably firm [34]. Elastography is a new technique that takes advantage of the fact that a pathological process alters the elastic properties of the affected tissue. This change in elasticity is detected and visualized by MRI using transverse waves to assess tissue displacement in all directions [35]. Elastography proved to have a good degree of accuracy in predicting the consistency of meningiomas as well as other types of tumors [36]. Although it is not yet available, it is a tool to be taken into account when its accessibility is no longer limited [37]. In our analysis, hyperintensity at T2 or hypointensity at T1 did not correlate with the degree of excision; and then analyzing patients in which hyperintensity in T2 and hypointensity in T1 were combined, no relationship was observed with resection. Since the prognosis and survival of the patient differs markedly if the meningioma is WHO grade I, II or III, it is important to know that many factors that complicate total resection are also factors that are associated with suspected malignancy. Clinic, size, perilesional edema, irregularity and heterogeneity, as well as imaging aspects based on ADC, were shown to be factors that increase the probability of meningioma malignancy; as well as the location outside the skull base [38,39,40]. Among the different characteristics, size is the only one that had statistical significance at the time of subtotal resection in our series [41]. It was observed that the recurrence of meningiomas, regardless of their location, varies according to the degree of malignancy only from a Simpson IV resection. Although we proposed a scale with presurgical data, the contribution of histomolecular studies gives us a more adequate prognosis, so it is necessary to take them into account. Studies focusing on factors predicting meningioma recurrence after subtotal resection suggest that minimizing residual tumor volume of less than 4 to 5 cm3 may be associated with increased recurrence-free survival. The goal should be to minimize the residual volume so that it is amenable to postoperative radiosurgery. Some authors have even shown that the combination of radiotherapy with subtotal resection is associated with recurrence-free and overall survival rates similar to those of total resection [42]. After the statistical analysis we proposed a preoperative graduation scale, with which according to the total score obtained we can infer the probability of total excision. For the scale we used location, size and bone invasion as parameters (Figure 3, 4 and 5). Within location, cavernous sinus meningiomas had a higher score (3 points). The justification for this particularity is based on the fact that, given the difficulty and complications involved in surgery, the current trend is decompression followed by radiosurgery [43]. Different scales have been tried previously [44].
Figure 3: Patient with anteromedial skull base meningioma (AM) (1 point), size less than 5 cm (1 point), no bone invasion (1 point), total score: 3, high probability of total resection. A: location of lesion at the base of the skull. B: 3D reconstruction with approach. C: resonance with presurgical sagittal cut contrast. D: postsurgical sagittal cut contrast resonance with total resection.
Figure 4: Patient with anterolateral skull base meningioma (LA) (1 point), size more than 5 cm (2 points) without bone invasion (1 point), total: 4 points, moderate probability of total resection. A: location of lesion at the base of the skull. B:
Resonance with presurgical sagittal cut contrast. C: intraoperative image showing meningioma with arachnoid plane. D: emptying and reducing size with scalpel blade 11. E: resection partial dura mater and coagulation of the same. F: surgical lodge without tumor remnant, Simpson resection 2. Postsurgical sagittal cut with subtotal resection of lesion.
Figure 5: Patient with petroclival skull base meningioma (PC) (2 points), in its maximum diameter measured 5 cm (2 points) without bone invasion, total: 5 points, low probability of total resection. A: location of lesion at the base of the skull. B: combined approach. C: resonance with presurgical sagittal cut contrast. D: resonance with contrast.
One of the most widespread is that of Magitll. and col. of the meningiomas of tuberculum sellae. They proposed a score based on tumor size, optic canal invasion, and arterial encapsulation that could predict EOR (extent of resection) and postoperative visual outcomes. Like us, they used tumor size, but they observed that a smaller tumor size was significantly associated with better or stable vision after the operation, but not with the extent of resection [45]. Although with the particularities of the tumor that make us reach a low or high score it can already be deduced whether or not the surgery will provide a total resection; We think that, with a simple scale, easy to perform and with information that is obtained without much complexity within the presurgical evaluation, the expected result can be dichotomized quickly and thus plan the surgery taking into account realistic objectives. It can also help us to know what tools, whether diagnostic, intrasurgical and post-surgical may be required. In order to provide the patient with adequate treatment and with the least possible morbidity.
Among the most complex procedures of the neurosurgical specialty, without a doubt, are the surgeries of the skull base meningiomas. Achieving the highest degree of resection with the lowest postoperative morbidity remain the objectives pursued in this type of surgery. Taking into account the different particularities of the tumor, as well as that of the patient and its comorbidities, it is often not only necessary but beneficial to perform a subtotal resection. To obtain good results by providing individualized planning, it is important to take into account the different characteristics that influence surgery and that allow us to predict the degree of excision, and thus anticipate surgical results and the requirement for adjuvant treatment. Our study showed a statistically significant relationship between the location (0.002), size (0.001) and bone invasion (0.013) of the meningioma with the degree of excision achieved. We proposed a simple scale to measure the possibility of total resection taking into account these variables
Given the low number of patients (n23) because it is a rare pathology, the associations between variables may be biased, leading to a high probability of committing type II error (that there are differences, but cannot be detected by inferential analyses), and a low statistical power. Together, we understand its limitations as it is a retrospective observational study.
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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.
I would like to offer my testimony in the support. I have received through the peer review process and support the editorial office where they are to support young authors like me, encourage them to publish their work in your esteemed journals, and globalize and share knowledge globally. I really appreciate your journal, peer review, and editorial office.
Dear Agrippa Hilda- Editorial Coordinator of Journal of Neuroscience and Neurological Surgery, "The peer review process was very quick and of high quality, which can also be seen in the articles in the journal. The collaboration with the editorial office was very good."
I would like to express my sincere gratitude for the support and efficiency provided by the editorial office throughout the publication process of my article, “Delayed Vulvar Metastases from Rectal Carcinoma: A Case Report.” I greatly appreciate the assistance and guidance I received from your team, which made the entire process smooth and efficient. The peer review process was thorough and constructive, contributing to the overall quality of the final article. I am very grateful for the high level of professionalism and commitment shown by the editorial staff, and I look forward to maintaining a long-term collaboration with the International Journal of Clinical Case Reports and Reviews.
To Dear Erin Aust, I would like to express my heartfelt appreciation for the opportunity to have my work published in this esteemed journal. The entire publication process was smooth and well-organized, and I am extremely satisfied with the final result. The Editorial Team demonstrated the utmost professionalism, providing prompt and insightful feedback throughout the review process. Their clear communication and constructive suggestions were invaluable in enhancing my manuscript, and their meticulous attention to detail and dedication to quality are truly commendable. Additionally, the support from the Editorial Office was exceptional. From the initial submission to the final publication, I was guided through every step of the process with great care and professionalism. The team's responsiveness and assistance made the entire experience both easy and stress-free. I am also deeply impressed by the quality and reputation of the journal. It is an honor to have my research featured in such a respected publication, and I am confident that it will make a meaningful contribution to the field.
"I am grateful for the opportunity of contributing to [International Journal of Clinical Case Reports and Reviews] and for the rigorous review process that enhances the quality of research published in your esteemed journal. I sincerely appreciate the time and effort of your team who have dedicatedly helped me in improvising changes and modifying my manuscript. The insightful comments and constructive feedback provided have been invaluable in refining and strengthening my work".
I thank the ‘Journal of Clinical Research and Reports’ for accepting this article for publication. This is a rigorously peer reviewed journal which is on all major global scientific data bases. I note the review process was prompt, thorough and professionally critical. It gave us an insight into a number of important scientific/statistical issues. The review prompted us to review the relevant literature again and look at the limitations of the study. The peer reviewers were open, clear in the instructions and the editorial team was very prompt in their communication. This journal certainly publishes quality research articles. I would recommend the journal for any future publications.
Dear Jessica Magne, with gratitude for the joint work. Fast process of receiving and processing the submitted scientific materials in “Clinical Cardiology and Cardiovascular Interventions”. High level of competence of the editors with clear and correct recommendations and ideas for enriching the article.
We found the peer review process quick and positive in its input. The support from the editorial officer has been very agile, always with the intention of improving the article and taking into account our subsequent corrections.
My article, titled 'No Way Out of the Smartphone Epidemic Without Considering the Insights of Brain Research,' has been republished in the International Journal of Clinical Case Reports and Reviews. The review process was seamless and professional, with the editors being both friendly and supportive. I am deeply grateful for their efforts.
To Dear Erin Aust – Editorial Coordinator of Journal of General Medicine and Clinical Practice! I declare that I am absolutely satisfied with your work carried out with great competence in following the manuscript during the various stages from its receipt, during the revision process to the final acceptance for publication. Thank Prof. Elvira Farina
Dear Jessica, and the super professional team of the ‘Clinical Cardiology and Cardiovascular Interventions’ I am sincerely grateful to the coordinated work of the journal team for the no problem with the submission of my manuscript: “Cardiometabolic Disorders in A Pregnant Woman with Severe Preeclampsia on the Background of Morbid Obesity (Case Report).” The review process by 5 experts was fast, and the comments were professional, which made it more specific and academic, and the process of publication and presentation of the article was excellent. I recommend that my colleagues publish articles in this journal, and I am interested in further scientific cooperation. Sincerely and best wishes, Dr. Oleg Golyanovskiy.
Dear Ashley Rosa, Editorial Coordinator of the journal - Psychology and Mental Health Care. " The process of obtaining publication of my article in the Psychology and Mental Health Journal was positive in all areas. The peer review process resulted in a number of valuable comments, the editorial process was collaborative and timely, and the quality of this journal has been quickly noticed, resulting in alternative journals contacting me to publish with them." Warm regards, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. I appreciate the journal (JCCI) editorial office support, the entire team leads were always ready to help, not only on technical front but also on thorough process. Also, I should thank dear reviewers’ attention to detail and creative approach to teach me and bring new insights by their comments. Surely, more discussions and introduction of other hemodynamic devices would provide better prevention and management of shock states. Your efforts and dedication in presenting educational materials in this journal are commendable. Best wishes from, Farahnaz Fallahian.
Dear Maria Emerson, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. I am delighted to have published our manuscript, "Acute Colonic Pseudo-Obstruction (ACPO): A rare but serious complication following caesarean section." I want to thank the editorial team, especially Maria Emerson, for their prompt review of the manuscript, quick responses to queries, and overall support. Yours sincerely Dr. Victor Olagundoye.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews. Many thanks for publishing this manuscript after I lost confidence the editors were most helpful, more than other journals Best wishes from, Susan Anne Smith, PhD. Australian Breastfeeding Association.
Dear Agrippa Hilda, Editorial Coordinator, Journal of Neuroscience and Neurological Surgery. The entire process including article submission, review, revision, and publication was extremely easy. The journal editor was prompt and helpful, and the reviewers contributed to the quality of the paper. Thank you so much! Eric Nussbaum, MD
Dr Hala Al Shaikh This is to acknowledge that the peer review process for the article ’ A Novel Gnrh1 Gene Mutation in Four Omani Male Siblings, Presentation and Management ’ sent to the International Journal of Clinical Case Reports and Reviews was quick and smooth. The editorial office was prompt with easy communication.
Dear Erin Aust, Editorial Coordinator, Journal of General Medicine and Clinical Practice. We are pleased to share our experience with the “Journal of General Medicine and Clinical Practice”, following the successful publication of our article. The peer review process was thorough and constructive, helping to improve the clarity and quality of the manuscript. We are especially thankful to Ms. Erin Aust, the Editorial Coordinator, for her prompt communication and continuous support throughout the process. Her professionalism ensured a smooth and efficient publication experience. The journal upholds high editorial standards, and we highly recommend it to fellow researchers seeking a credible platform for their work. Best wishes By, Dr. Rakhi Mishra.
Dear Jessica Magne, Editorial Coordinator, Clinical Cardiology and Cardiovascular Interventions, Auctores Publishing LLC. The peer review process of the journal of Clinical Cardiology and Cardiovascular Interventions was excellent and fast, as was the support of the editorial office and the quality of the journal. Kind regards Walter F. Riesen Prof. Dr. Dr. h.c. Walter F. Riesen.
Dear Ashley Rosa, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews, Auctores Publishing LLC. Thank you for publishing our article, Exploring Clozapine's Efficacy in Managing Aggression: A Multiple Single-Case Study in Forensic Psychiatry in the international journal of clinical case reports and reviews. We found the peer review process very professional and efficient. The comments were constructive, and the whole process was efficient. On behalf of the co-authors, I would like to thank you for publishing this article. With regards, Dr. Jelle R. Lettinga.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, I would like to express my deep admiration for the exceptional professionalism demonstrated by your journal. I am thoroughly impressed by the speed of the editorial process, the substantive and insightful reviews, and the meticulous preparation of the manuscript for publication. Additionally, I greatly appreciate the courteous and immediate responses from your editorial office to all my inquiries. Best Regards, Dariusz Ziora
Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation, Auctores Publishing LLC, We would like to thank the editorial team for the smooth and high-quality communication leading up to the publication of our article in the Journal of Neurodegeneration and Neurorehabilitation. The reviewers have extensive knowledge in the field, and their relevant questions helped to add value to our publication. Kind regards, Dr. Ravi Shrivastava.
Dear Clarissa Eric, Editorial Coordinator, Journal of Clinical Case Reports and Studies, Auctores Publishing LLC, USA Office: +1-(302)-520-2644. I would like to express my sincere appreciation for the efficient and professional handling of my case report by the ‘Journal of Clinical Case Reports and Studies’. The peer review process was not only fast but also highly constructive—the reviewers’ comments were clear, relevant, and greatly helped me improve the quality and clarity of my manuscript. I also received excellent support from the editorial office throughout the process. Communication was smooth and timely, and I felt well guided at every stage, from submission to publication. The overall quality and rigor of the journal are truly commendable. I am pleased to have published my work with Journal of Clinical Case Reports and Studies, and I look forward to future opportunities for collaboration. Sincerely, Aline Tollet, UCLouvain.
Dear Ms. Mayra Duenas, Editorial Coordinator, International Journal of Clinical Case Reports and Reviews. “The International Journal of Clinical Case Reports and Reviews represented the “ideal house” to share with the research community a first experience with the use of the Simeox device for speech rehabilitation. High scientific reputation and attractive website communication were first determinants for the selection of this Journal, and the following submission process exceeded expectations: fast but highly professional peer review, great support by the editorial office, elegant graphic layout. Exactly what a dynamic research team - also composed by allied professionals - needs!" From, Chiara Beccaluva, PT - Italy.
Dear Maria Emerson, Editorial Coordinator, we have deeply appreciated the professionalism demonstrated by the International Journal of Clinical Case Reports and Reviews. The reviewers have extensive knowledge of our field and have been very efficient and fast in supporting the process. I am really looking forward to further collaboration. Thanks. Best regards, Dr. Claudio Ligresti
Dear Chrystine Mejia, Editorial Coordinator, Journal of Neurodegeneration and Neurorehabilitation. “The peer review process was efficient and constructive, and the editorial office provided excellent communication and support throughout. The journal ensures scientific rigor and high editorial standards, while also offering a smooth and timely publication process. We sincerely appreciate the work of the editorial team in facilitating the dissemination of innovative approaches such as the Bonori Method.” Best regards, Dr. Matteo Bonori.
I recommend without hesitation submitting relevant papers on medical decision making to the International Journal of Clinical Case Reports and Reviews. I am very grateful to the editorial staff. Maria Emerson was a pleasure to communicate with. The time from submission to publication was an extremely short 3 weeks. The editorial staff submitted the paper to three reviewers. Two of the reviewers commented positively on the value of publishing the paper. The editorial staff quickly recognized the third reviewer’s comments as an unjust attempt to reject the paper. I revised the paper as recommended by the first two reviewers.
Dear Maria Emerson, Editorial Coordinator, Journal of Clinical Research and Reports. Thank you for publishing our case report: "Clinical Case of Effective Fetal Stem Cells Treatment in a Patient with Autism Spectrum Disorder" within the "Journal of Clinical Research and Reports" being submitted by the team of EmCell doctors from Kyiv, Ukraine. We much appreciate a professional and transparent peer-review process from Auctores. All research Doctors are so grateful to your Editorial Office and Auctores Publishing support! I amiably wish our article publication maintained a top quality of your International Scientific Journal. My best wishes for a prosperity of the Journal of Clinical Research and Reports. Hope our scientific relationship and cooperation will remain long lasting. Thank you very much indeed. Kind regards, Dr. Andriy Sinelnyk Cell Therapy Center EmCell
Dear Editorial Team, Clinical Cardiology and Cardiovascular Interventions. It was truly a rewarding experience to work with the journal “Clinical Cardiology and Cardiovascular Interventions”. The peer review process was insightful and encouraging, helping us refine our work to a higher standard. The editorial office offered exceptional support with prompt and thoughtful communication. I highly value the journal’s role in promoting scientific advancement and am honored to be part of it. Best regards, Meng-Jou Lee, MD, Department of Anesthesiology, National Taiwan University Hospital.
Dear Editorial Team, Journal-Clinical Cardiology and Cardiovascular Interventions, “Publishing my article with Clinical Cardiology and Cardiovascular Interventions has been a highly positive experience. The peer-review process was rigorous yet supportive, offering valuable feedback that strengthened my work. The editorial team demonstrated exceptional professionalism, prompt communication, and a genuine commitment to maintaining the highest scientific standards. I am very pleased with the publication quality and proud to be associated with such a reputable journal.” Warm regards, Dr. Mahmoud Kamal Moustafa Ahmed
Dear Maria Emerson, Editorial Coordinator of ‘International Journal of Clinical Case Reports and Reviews’, I appreciate the opportunity to publish my article with your journal. The editorial office provided clear communication during the submission and review process, and I found the overall experience professional and constructive. Best regards, Elena Salvatore.
Dear Mayra Duenas, Editorial Coordinator of ‘International Journal of Clinical Case Reports and Reviews Herewith I confirm an optimal peer review process and a great support of the editorial office of the present journal
Dear Editorial Team, Clinical Cardiology and Cardiovascular Interventions. I am really grateful for the peers review; their feedback gave me the opportunity to reflect on the message and impact of my work and to ameliorate the article. The editors did a great job in addition by encouraging me to continue with the process of publishing.
Dear Cecilia Lilly, Editorial Coordinator, Endocrinology and Disorders, Thank you so much for your quick response regarding reviewing and all process till publishing our manuscript entitled: Prevalence of Pre-Diabetes and its Associated Risk Factors Among Nile College Students, Sudan. Best regards, Dr Mamoun Magzoub.
International Journal of Clinical Case Reports and Reviews is a high quality journal that has a clear and concise submission process. The peer review process was comprehensive and constructive. Support from the editorial office was excellent, since the administrative staff were responsive. The journal provides a fast and timely publication timeline.
Dear Maria Emerson, Editorial Coordinator of International Journal of Clinical Case Reports and Reviews, What distinguishes International Journal of Clinical Case Report and Review is not only the scientific rigor of its publications, but the intellectual climate in which research is evaluated. The submission process is refreshingly free of unnecessary formal barriers and bureaucratic rituals that often complicate academic publishing without adding real value. The peer-review system is demanding yet constructive, guided by genuine scientific dialogue rather than hierarchical or authoritarian attitudes. Reviewers act as collaborators in improving the manuscript, not as gatekeepers imposing arbitrary standards. This journal offers a rare balance: high methodological standards combined with a respectful, transparent, and supportive editorial approach. In an era where publishing can feel more burdensome than research itself, this platform restores the original purpose of peer review — to refine ideas, not to obstruct them Prof. Perlat Kapisyzi, FCCP PULMONOLOGIST AND THORACIC IMAGING.
Dear Grace Pierce, International Journal of Clinical Case Reports and Reviews I appreciate the opportunity to review for Auctore Journal, as the overall editorial process was smooth, transparent and professionally managed. This journal maintains high scientific standards and ensures timely communications with authors, which is truly commendable. I would like to express my special thanks to editor Grace Pierce for his constant guidance, promt responses, and supportive coordination throughout the review process. I am also greatful to Eleanor Bailey from the finance department for her clear communication and efficient handling of all administrative matters. Overall, my experience with Auctore Journal has been highly positive and rewarding. Best regards, Sabita sinha
Dear Mayra Duenas, Editorial Coordinator of the journal IJCCR, I write here a little on my experience as an author submitting to the International Journal of Clinical Case Reports and Reviews (IJCCR). This was my first submission to IJCCR and my manuscript was inherently an outsider’s effort. It attempted to broadly identify and then make some sense of life’s under-appreciated mysteries. I initially had responded to a request for possible submissions. I then contacted IJCCR with a tentative topic for a manuscript. They quickly got back with an approval for the submission, but with a particular requirement that it be medically relevant. I then put together a manuscript and submitted it. After the usual back-and-forth over forms and formality, the manuscript was sent off for reviews. Within 2 weeks I got back 4 reviews which were both helpful and also surprising. Surprising in that the topic was somewhat foreign to medical literature. My subsequent updates in response to the reviewer comments went smoothly and in short order I had a series of proofs to evaluate. All in all, the whole publication process seemed outstanding. It was both helpful in terms of the paper’s content and also in terms of its efficient and friendly communications. Thank you all very much. Sincerely, Ted Christopher, Rochester, NY.
