British Journal of Neurosurgery最新文献

Purpose: Extracranial-intracranial (EC-IC) bypass surgery remains controversial due to high complication rates reported in major trials. This study evaluates whether optimised perioperative protocols and surgical expertise can achieve substantially improved safety profiles in patients with symptomatic chronic internal carotid artery occlusion (CICAO) and chronic middle cerebral artery occlusion (CMCAO), addressing the critical gap between theoretical benefit and clinical reality.

Materials and methods: This retrospective single-centre study analysed 256 consecutive patients with symptomatic CICAO (n = 162) or CMCAO (n = 94) who underwent superficial temporal artery-middle cerebral artery bypass between October 2006 and February 2021. All procedures were performed by a single experienced surgeon using standardised protocols, including continuation of antiplatelet therapy throughout the perioperative period, maintaining baseline blood pressure levels, and strict postoperative blood pressure control below 140 mmHg. Patients underwent comprehensive evaluation with magnetic resonance imaging, digital subtraction angiography, and computed tomography perfusion. Primary outcomes included 30-day stroke or death and recurrent stroke during 24-month follow-up.

Results: The mean temporary intraoperative occlusion time was 23.5 minutes. Remarkably, the 30-day haemorrhagic stroke rate was 0.8% (2/256) with no ischaemic strokes, representing a dramatic improvement over historical controls. During 24-month follow-up, recurrent stroke occurred in 1.5% (4/256) of patients. Patients with CMCAO demonstrated superior outcomes compared to CICAO patients, with total stroke rates of 1.0% versus 3.1%, respectively.

Conclusions: Under expert surgical technique with optimised perioperative protocols, EC-IC bypass achieves exceptional safety profiles with complication rates substantially lower than previous major trials. The dramatic reduction from the historical 15% to 0.8% perioperative stroke rates demonstrates that surgical excellence and protocol optimisation can transform outcomes in cerebral revascularisation. These findings suggest that the poor results in previous trials may reflect technical and management factors rather than fundamental procedure limitations, warranting reconsideration of EC-IC bypass for carefully selected patients, particularly those with CMCAO.

Introduction: The management of intracranial aneurysms (IAs) has undergone a century-long evolution, shifting from vessel ligation to microsurgical clipping and, more recently, to advanced endovascular therapies. This study aims to combine historical milestones with current evidence to clarify the contemporary balance between microsurgical and endovascular approaches within evidence-based practice.

Methods: A review was conducted using PubMed/MEDLINE and Google Scholar from database inception through September 2025. Eligible studies included historical analyses, randomized trials, systematic reviews, meta-analyses, and international guidelines comparing microsurgical clipping with endovascular treatments-coiling, flow diversion, and intrasaccular devices.

Results: The microsurgical era, pioneered by Yasargil and Drake, established durable anatomical reconstructions. Since the 1990s, endovascular advances-from Guglielmi detachable coils to flow diverters-have driven a global paradigm shift. Recent trials (BRAT, Darsaut et al.) and meta-analyses have demonstrated that clipping yields higher long-term occlusion rates and lower retreatment rates, while endovascular approaches offer reduced perioperative morbidity and shorter hospitalization times. Contemporary evidence also supports the importance of aneurysm location and morphology: microsurgery remains superior for large and giant anterior circulation aneurysms, whereas endovascular therapy is often favored for complex posterior circulation territories. Guideline consensus recommends early treatment of ruptured aneurysms (within 24-72 hours) and individualized management of unruptured lesions based on rupture risk, anatomy, and expert judgment.

Conclusions: Modern aneurysm treatment balances surgical durability and endovascular minimalism. Multidisciplinary, evidence-based decision-making ensures optimized, patient-specific management for both ruptured and unruptured aneurysms.

Study design: Retrospective Cohort Study Objectives: To identify factors that could predict metalwork failure in thoracolumbar instrumentation for different indications.

Methods: A retrospective analysis was conducted on patients who underwent thoracolumbar fixation in a single unit between January 2014 to January 2023. Radiological parameters were measured using CT and MRI. The study was analysed in a per-case and a per-screw basis using T-test, Chi-Square test, Logistic regression and ROC analysis.

Results: Over a 9-year period, 444 patients underwent 486 thoracolumbar instrumentation surgeries. Complications were observed in 20% of cases, with post-operative wound infection being the most common (9.7%). Metalwork failure was identified in 31 cases (6.38%). In the per-patient analysis, the presence of wound infection and average pedicle cancellous bone density (<280 HU), were statistically significant factors in predicting metalwork failure. Wound infection was a significant predictor for metal work failure in both degenerative and traumatic indications for spinal fixations. In the per-screw analysis, the screw-to-pedicle area ratio was significantly higher (>0.21) in screws without metalwork failure. For traumatic indications, the screw-to-pedicle area ratio (<0.25) and Charleston Comorbidity Index (CCI) (>0.15) were significant predictors. For degenerative indications, presence of wound infection and total pedicle bone density (<220 HU) were significant predictors. For neoplastic indications, only age (>66 years) was a predictor.

Conclusion: This study highlights the significance of avoiding post-operative wound infection, the use of screws with a larger diameter and higher pedicle cancellous bone density (>280 HU) in the reducing the risk of metalwork failure in thoracolumbar fixation.

Aims: After the relocation of paediatric spinal surgery services between specialist centres within the same region, monetary rebates for spinal procedures declined, despite consistent case volumes. A long-term quality improvement initiative was undertaken to enhance coding accuracy and ensure correct remuneration.

Method: A five-year quality improvement project, consisting of three cycles, was undertaken to assess paediatric spinal procedures and related coding practices. Procedures were reviewed and given "optimal" codes by clinicians from the spinal deformity team, and mock rebates were generated. These were compared to actual codes and rebate values from the new site. Meetings were held with lead coders at the new site, and instruction was provided on how to more accurately code spinal procedures. A spinal coding operation manual with lay descriptions of spinal procedures and coding advice was developed.

Results: Rebate accuracy rose from 82.16% to 98.40% over the course of the project (p = 0.007). The mean difference between actual and optimal coding rebate fell from -£4,243.16 to -£264.42. The overall accuracy of clinical coding rose from 37.8% to 70.0% (p = 0.003).

Conclusions: This long-term quality improvement project significantly increased the accuracy of clinical coding for paediatric spinal procedures and, when extrapolated to a mean of 150 cases per year, has generated an annual saving of approximately £596,811.00 for the site. This methodology can be easily replicated in institutions facing similar issues.

Purpose of article: The role of immediate precipitating activities in aneurysmal subarachnoid hemorrhage (aSAH) remains unclear, lcontributing to uncertainty regarding activity restriction. This systematic review and meta-analysis examined the relative strain of activities preceding spontaneous aSAH using metabolic equivalents of task (METs).

Materials and methods: A systematic search identified studies reporting activities preceding aSAH (categorised as nonstrenuous, MET 1-4, and strenuous, MET ≥5). Associations between activity category and aSAH occurrence were assessed using chi-squared testing, with Fisher's combined method evaluating overall association. Odds of aSAH were evaluated using sleep or rest (MET 1) as the reference.

Results: Six studies (3,285 aSAH cases) were included. aSAH mostly preceded nonstrenuous activities (43.2%) compared with strenuous activities (23.5%). Heavy strain activities (MET 6-8) , preceded 8.9% of cases ,while Valsalva maneuversaccounted for 7.9%. Fisher's combined method showed aSAH occurred less frequently after strenuous activities (p <0.001). Compared with sleep or rest, odds of aSAH were comparable or lower across all other activity categories.

Conclusion: Routine nonstrenuous activities most often preceded aSAH, suggesting high physical exertion may not be a dominant immediate trigger of aneurysm rupture. Other factors, including circadian blood pressure fluctuations and impaired autoregulation, may contribute to rupture risk.

Objective: Various household devices contain magnets or emit electromagnetic fields and it is hypothesised that the strength of these magnets may be enough to affect the settings on programmable cerebrospinal fluid shunt valves. The aim of this study is to identify changes to the valve settings of seven commonly used programmable valves, when they are near common household devices generating a magnetic field.

Methods: Several commonly encountered household devices were used, with and without rotational movement, with reference to seven commonly used programmable valves (the Codman Certas and Hakim, Sophysa SPV and SM8, Medtronic Strata II Regular and Small, and the Miethke M.Blue Plus). The valve settings were checked before and after the interference with the household device, by using either the manufacturers tool kit for reading the settings or x-rays.

Results: We demonstrated that the only valve which was not affected by any of the household devices, regardless of the distance or rotational movement, was the Miethke M. Blue Plus. In addition, the programmable shunts were more likely to experience change to their settings with rotational movement as opposed to no movement, and the two devices most likely to induce this change were a smart watch and kids toy magnets.

Conclusions: Everyday household devices have the potential to affect the settings on programmable shunts, leading to concerns around the maintenance of shunt settings both in and out of hospital due to household and healthcare electromagnetic fields. Surgeons, and other healthcare professionals involved in the care of those with programmable CSF shunts, should be aware of the potential risks and utilise this information when making clinical decisions and advising patients.

Background: Anaplastic large cell lymphoma (ALCL) represents a group of heterogenous CD30+ mature T Cell lymphomas, which vary in their clinical, histological, and molecular characteristics. A majority of ALCL are ALK positive, which is characterised by translocation t(2;5) leading to the fusion of the ALK gene to the nucleophosmin gene. CNS presentations of ALCL are rare and restricted to case reports. A synchronous CNS and systemic presentation in an adult has never been reported.

Case presentation: A 31-year-old woman presented with headache and tonic-clonic seizures. MRI revealed a 15-mm enhancing left frontal convexity lesion with broad dural contact. A left frontal craniotomy was performed, and pathological analysis was conducted. Initially the diagnosis was unclear, with the most likely diagnosis being thought to be ALK-positive histiocytosis, with a differential of ALK-positive ALCL. The patient was treated with a modified MARIETTA protocol (without rituximab) and consolidated with a carmustine-based autologous stem cell transplant. End of treatment PET-CT and MRI brain showed a complete metabolic response. shows complete metabolic response on PET-CT and MRI brain.

Conclusions: This case presents the first successful treatment of a synchronous presentation of CNS and systemic ALK-positive ALCL, and the importance of a multidisciplinary approach for diagnosis.

Objective: Trigeminal neuralgia (TN) is a debilitating craniofacial pain disorder that often necessitates surgical intervention when medical therapy fails. This study evaluates the impact of two Teflon implantation techniques - pledget interposition and shredded Teflon - on clinical outcomes following microvascular decompression (MVD).

Methods: A retrospective analysis was conducted on 121 patients with classical trigeminal neuralgia (TN) who underwent microvascular decompression (MVD) between 2001 and 2020. Patients were grouped based on the Teflon technique used: pledget interposition (n = 55) or shredded Teflon (n = 66). Outcomes were assessed using the Barrow Neurological Institute (BNI) pain scale, Modified Rankin Scale (mRS), and postoperative MRI. Statistical comparisons included Fisher's exact test, chi-square test, and t-tests.

Results: Shredded Teflon was associated with significantly lower recurrence (4.54% vs. 16.36%) and complication rates (9.09% vs. 14.55%) compared to pledget interposition. Reoperation was required in 12.72% of pledget cases, primarily due to implant displacement and arachnoid adhesions; no reoperations were needed in the shredded group. MRI-confirmed recurrent neurovascular compression correlated with clinical recurrence (p = 0.033). Patient satisfaction was significantly higher in the shredded group (87.87% vs. 69.09%, p = 0.001).

Conclusion: MVD using shredded Teflon yields superior long-term outcomes with fewer complications and recurrences compared to pledget interposition. Avoiding direct nerve contact and minimizing implant volume may reduce inflammatory risks. Postoperative MRI is crucial for detecting recurrence and guiding subsequent interventions.