British Journal of Neurosurgery最新文献

Background: Intracranial dural metastases from extracranial malignancies, including prostate adenocarcinoma are rare, but they pose significant challenges due to atypical clinical presentations, unusual radiographic characteristics, and poor prognosis.

Case presentations: We present two patients with prostate adenocarcinoma who developed subdural hematoma (SDH) in association with dural metastatic disease. The first patient, a 58-year-old man, suffered a traumatic SDH that was initially managed with middle meningeal artery (MMA) embolization but presented with recurrent SDH requiring craniotomy and further MMA embolization, and ultimately craniectomy and mesh cranioplasty after documentation of a dural-based metastatic tumor at the chronic hematoma site. The second patient, a 63-year-old man with stage IV prostate cancer and known osseous metastases, was found to have a subacute SDH concomitant with a dural metastatic mass; he underwent craniectomy, and tumor resection . These cases illustrate two distinct presentations of dural metastasis with SDH - one appearing after a traumatic hemorrhage and one presenting as a hemorrhagic collection from bleeding of the underlying dural mass.

Conclusions: Prostate cancer dural metastasis can mimic or exacerbate SDHs, demanding a high index of suspicion in patients with known malignancy or atypical SDH features. Early use of contrast-enhanced MRI is crucial for diagnosis, and definitive management often requires a multidisciplinary approach.

Objective: Both prone and lateral position could be used to operate supratentorial cerebral pathologies in posterior regions.This study aimed to evaluate whether one position offers superior outcomes or whether the choice should be guided by patient/pathology characteristics.

Methods: Retrospective study including 58 patients with posterior supratentorial cerebral pathologies operated in either the prone (32) or lateral (26) position. Patient data (age, comorbidity, BMI) and pathology characteristics (location, volume, depth, histology) were collected. Outcomes:extent of resection, surgical complications, positioning-related complications. Statistical analyses were performed to assess whether patient or pathology factors influenced outcomes according to surgical position.

Results: No significant differences were found between the two groups in terms of patient or pathology characteristics. Resection rates and complication rates were similar, none of the evaluated factors significantly influenced surgical outcomes according to the position used. Extra-axial pathologies attached to the falx appeared easier to manage in the prone position due to facilitated interhemispheric dissection, whereas the lateral position may facilitate larger craniotomies by allowing wider exposure of the hemicranium.

Conclusion: Prone and lateral positioning showed comparable clinical outcomes. No specific patient/pathology characteristics clearly favored one position over the other. Positioning choice should therefore rely mainly on surgical strategy and team experience.

Purpose: Percutaneous pedicle screw fixation has become a widely adopted technique for treating thoracolumbar burst fractures without neurological deficit, though optimal strategies - particularly regarding anterior support - remain debated. Our objective is to compare kyphotic angle evolution over six months in patients treated with pedicle screws alone versus those receiving additional anterior support via vertebroplasty or kyphoplasty.

Methods: We retrospectively analysed 34 neurologically intact patients with thoracolumbar burst fractures treated percutaneously at our institution over the past five years. Patients were divided into two groups: pedicle screw fixation only (n = 15) and screw fixation with anterior support (n = 19). Segmental kyphosis was measured at diagnosis, 24 hours post-op, 3 months, and 6 months. Secondary outcomes included age, sex, visual analog scale (VAS) scores, opioid use, hospital stay, and complications.

Results: Both techniques were effective. At 3 months, mean kyphosis was 7.9° in the screw-only group and 6.6° in the anterior support group. At 6 months, kyphosis converged (7.9° vs. 7.73°, respectively). The only significant difference was observed 24 hours post-op, with greater correction in the anterior support group (p = 0.026). VAS scores improved similarly in both groups, and opioid requirements were low.

Conclusions: While anterior support provided superior immediate radiological correction, this benefit diminished by six months. Both techniques demonstrated comparable long-term outcomes in preserving sagittal alignment and controlling pain in neurologically intact thoracolumbar burst fractures.

Tarlov cysts are frequently identified during magnetic resonance imaging of the lumbosacral spine, although the majority carry no clinical relevance. A smaller but important subgroup causes symptoms through deformation or irritation of the sacral nerve roots. These patients often experience prolonged diagnostic pathways, and many are assessed by several specialities (often appropriately) before neurosurgical review is considered. Referral patterns remain inconsistent, in part because many specialists are uncertain which symptom profiles reliably indicate sacral nerve dysfunction. In this connection, the aim of this review is to provide a structured and clinically grounded framework for identifying symptomatic Tarlov cysts, emphasising the importance of symptom pattern recognition, correlation with anatomical level, exclusion of differential diagnosis and careful interpretation of radiological findings. Sitting intolerance and sacral or perineal sensory change, represent particularly discriminating features of sacral root involvement. Radiological markers such as dorsal root ganglion displacement and sacral foraminal remodelling strengthen the case for clinical relevance, although cyst size alone is not predictive. This framework also outlines differential diagnoses that merit consideration, including gynaecological, urological and colorectal causes of pelvic or perineal symptoms. The role of pelvic neurophysiology in selected cases is discussed, as well as the occasional use of single photon emission computed tomography (SPECT-CT) when pain localisation is uncertain. The proposed structure is intended to assist multi-disciplinary clinicians and neurosurgeons, in determining when specialist referral is appropriate. This review draws on the authors' experience within a tertiary neurosurgical referral practice as well as select evidence from the published literature.

Background: Middle meningeal artery embolisation (MMAE) is a potential adjunct/alternative to conventional treatment of chronic subdural haematoma (cSDH) and is associated with reduced rates of recurrence and surgical rescue. However, real world reporting outcomes in older people with frailty have not yet been extensively described.

Methods: We undertook an observational analysis of all cSDH patients requiring intervention between November 2019 and December 2024. Patients received either MMAE (standalone/adjunctive) or burr holes alone.

Results: Ninety patients underwent MMAE (median age: 81, IQR: 76-86); 222 underwent burr holes alone (median age: 80, IQR: 74-85). MMAE was adjunctive in 64.4% of cases; these patients had more severe neurological impairment, larger haematoma depth, and greater degree of midline shift than patients undergoing standalone MMAE. 52.2% of MMAE patients had frailty. MMAE was associated with significantly reduced cSDH recurrence (7.8% vs. 19.8%, p = 0.009, OR 0.341 (95% CI 0.136-0.745)), and antithrombotic therapy was resumed earlier in patients treated with MMAE (8.5 vs. 14 days, p < 0.001). Adverse events following MMAE were low (1.1%).

Conclusions: In a real-world UK healthcare setting, including patients with frailty, MMAE is associated with reduced rates of clinically significant cSDH recurrence and may facilitate safer, earlier reintroduction of antithrombotic therapy.

Objective: Cauda equina is an uncommon target for neuromodulation. We present a long-term follow-up of a patient who underwent spinal cord stimulator (SCS) insertion at the level of cauda equina for chronic pelvic pain (CPP).

Methods: This is a case report of a 44-year-old female who underwent SCS placement over the cauda equina roots in 2012.

Results: The patient experienced long-term benefits of the therapy.On top of the pain relief evidenced by improvement in pain score and mobility and reduction in pain medication, the patient reported subjective improvement in urinary symptoms.

Conclusions: According to our knowledge, this is the first report of a cauda equina stimulation for pelvic pain. This case is significant as it shows that the cauda equina roots could be used as a target for neuromodulation in the treatment of pain located within the pelvic region, as well as challenges in using this target and the potential role of paraesthesia-free modalities. It also suggests that this treatment could potentially improve autonomic symptoms.

Background: Moyamoya disease (MMD) was first described in Japan and is primarily recognized in East Asia. Although rare, it is increasingly diagnosed in Western countries. A Western phenotype - characterized by a lower risk of hemorrhage - has been proposed in a previous review article in this journal.

Objectives: This narrative review explores MMD from a Western perspective.

Results: Drawing partly on studies from a Danish MMD cohort, the author suggests that MMD exhibits similar features across different regions. Nordic national registries and well-maintained clinical records provide valuable data for gaining a deeper understanding of this disease.

Conclusions: In our data, the overall Kaplan-Meier 5-year stroke risk was 10%. We observed a trend toward higher stroke risk in females and in those with angiographic progression.

Purpose: Fusiform intracranial aneurysms (IA) are rare vascular lesions with limited data on natural history and management. We assessed long-term outcomes of fusiform IAs, including progression, rupture, and treatment-related morbidity.

Methods: We retrospectively studied all fusiform IAs diagnosed and managed at our institution between January 2010 and December 2021. Demographics, aneurysm features, clinical course, and treatment outcomes were analysed. Logistic regression identified predictors of progression and neurological complications.

Results: We identified 100 patients (median age 52.7 years; 53% female). At diagnosis, 73/100 were unruptured. Locations included the middle cerebral artery (30%), vertebral artery (17%), internal carotid artery (14%), and basilar artery (11%). Over a median 74-month follow-up, 9/73 (13%) of unruptured aneurysms progressed and 1/73 (1.4%) ruptured. 48 aneurysms were treated with flow diversion (36%), parent vessel occlusion (29%), stent-assisted coiling (23%), or surgery (12%). Aneurysm occlusion was achieved in 96% of imaged treated cases. Permanent neurological deficit occurred in 23% of treated patients.

Conclusions: Treatment of fusiform IAs achieved high occlusion rates but carried substantially higher morbidity than typically reported for saccular aneurysms. Given the low rupture rate and modest progression risk, treatment may be best reserved for ruptured or progressing lesions.

Objective: External ventricular drain (EVD) insertion can be performed using a freehand technique or by the use of intraoperative image guidance. The aim of this study was to analyse whether implementation of real-time ultrasound-guided EVD insertion using high-fidelity surgical simulation was associated with improved accuracy of transfrontal EVD placement.

Methods: Departmental mandatory real-time intraoperative ultrasound-guided EVD placement training using a high-fidelity surgical simulator was delivered. Retrospective analysis of operative records and medical notes was performed for all primary transfrontal EVDs 7 months before and 7 months after the provision of simulated ultrasound training. A modified Kakarla grading system was used to classify the accuracy of EVD placement. Misplacement was defined as the entire EVD tip being placed within the brain parenchyma.

Results: A total of 126 EVDs were included in the analysis. Pre-training 63.6% (42/66) of EVDs were placed with grade 1A/1B accuracy (optimal) whilst post-training this improved to 73.3% (44/60, p = 0.257). 21.2% (14/66) of EVDs were placed with grade-2 (suboptimal) accuracy pre-training compared to 26.7% (16/60) post-training (p = 0.533). 15.2% (10/66) of EVDs were misplaced pre-training. Post-training no EVDs were misplaced, which reached statistical significance (p = 0.002). There was no significant difference in the number of passes required to place the EVD using the landmark technique compared to real-time intraoperative ultrasound guidance (p = 0.378). The median operative duration prior to ultrasound training was 43 minutes (IQR: 23), whilst post-ultrasound training it was 40.5 minutes (IQR: 17), but this difference was not significant (p = 0.313).

Conclusions: A high-fidelity training simulator was used to train neurosurgeons to use real-time intraoperative ultrasound to place EVDs. There was a significant improvement in the accuracy of EVD placement without a significant difference in operative duration.

Background and study aims: In 2013, Balain et al. proposed a scoring system, the Oswestry Spinal Risk Index (OSRI), to predict survival in patients with spinal metastases (SM) and hence aid treatment decisions. This study aims to externally validate the OSRI for patients treated exclusively with radiotherapy, and assess its relevance in emergency decision making in the age of nomograms and machine learning.

Materials and methods: Data from 150 patients with spinal metastases (SM) treated at our Regional Cancer Centre over a four-year period were retrospectively analysed. OSRI scores were calculated for each patient, and actual survival duration from diagnosis was determined to enable comparison with predicted survival. The cohort, selected over a decade ago, ensured complete survival data for all included patients.

Results: Spearman's rank correlation demonstrated a strong positive relationship between actual and OSRI-predicted survival (r = 0.706, p < 0.001). The Mantel-Cox log-rank test revealed statistically significant differences in survival curves across OSRI risk groups (p < 0.001), with lower OSRI scores associated with longer survival. Paired sample t-tests further confirmed this correlation (one-sided p = 0.009; two-sided p = 0.017). Kaplan-Meier survival plots were similar to those of the original study.

Conclusions: This study is the first to externally validate the Oswestry Spinal Risk Index (OSRI) specifically in patients treated exclusively with radiotherapy. Unlike previous validations, which included patients managed surgically or with combined modalities, our cohort focused solely on radiotherapy. We found a strong correlation between predicted and actual survival, highlighting the OSRI's simplicity, accuracy and its practical value for rapid decision-making in emergency settings.