British Journal of Neurosurgery最新文献

Background: A temporo-sphenoidal encephalocoele occurs when temporal lobe herniates through a defect in the greater wing of the sphenoid bone into the sphenoid air sinus. The natural history is not well-understood, though presentation in adulthood with CSF rhinorrhoea and/or meningitis is typical. Lateral pneumatisation of the sphenoid sinus and elevated BMI may be contributory.

Aims: We explored the feasibility of a transorbital approach (TOA) for repair, using a combination of 3D modelling and simulation. We then successfully deployed this technique in vivo.

Methods: CT imaging for three patients who had previously undergone transcranial repair of lateral temporo-sphenoidal encephalocoele was used to generate data allowing 3D printed models of the skull base to be produced. The transorbital approach was simulated by performing a lateral orbitotomy followed by drilling of the sphenoid wing to expose the antero-basal middle fossa. 3D object scanning was used to create virtual models of the skull base post-surgery, from which surgical access was quantified in two ways: the area (mm²) of the middle fossa exposed by the TOA and the vertical attack angle.

Results: The mean surface area of the cranial access window achieved by simulated TOA was 325mm². The mean vertical attack angle was 25°. One patient was subsequently treated successfully via TOA with no recurrence of their CSF leak, no orbital morbidity, excellent cosmesis, but resolving V2 numbness (follow-up 7 months).

Conclusions: We have shown that the transorbital approach provides adequate surgical access. In our single case, surgical repair of a lateral temporo-sphenoidal encephalocoele via TOA was feasible, safe, and effective. This approach may offer some advantages compared with transcranial or endonasal approaches.

We present an illustrative case series in which high spatial resolution black blood (BB) MRI sequences were used as an adjunct in the acute management of intracranial aneurysms with diagnostic uncertainty regarding rupture status. Several acute management dilemmas are discussed including the surveillance of previously treated ruptured intracranial aneurysms, identifying culprit lesion(s) amongst multiple ruptured intracranial aneurysms, and risk stratifying incidental unruptured intracranial aneurysms. We present our experience which supports the evaluation of this vessel wall imaging technique in larger multi-centre observational studies. MR imaging was performed on a 3.0 Tesla Siemens Somatom Vida system and sequences used included: Susceptibility Weighted Imaging, Diffusion Weighted Imaging & 3D T1 pre- and post-contrast-enhanced BB sequences.

Background: CNS ganglioneuroblastoma in an extremely rare embryonal tumour, specifically in the pediatric population. Bad prognosis is documented due to aggressiveness and absence of protocolized treatment at the moment.

Clinical description: We present the case of a 5-year-old boy who presented with sudden loss of consciousness. CT scan was performed showing a large posterior fossa lesion with several intraventricular focal lesions, suggesting metastases, the largest one located inside the III ventricle. The patient underwent a posterior fossa resection of the lesion and a subtotal resection of the III ventricle lesion, with adjuvant chemotherapy. The evolution was poor and the patient finally died 3 months after diagnosis.

Conclusion: Ganglioneuroblastoma is extremely likely to recur quickly and extensively. There is little knowledge about treatment options but is documented that gross total resection followed by adjuvant radiotherapy and chemotherapy is the best management in these patients.

Objective: Spinal cerebrospinal fluid (CSF) leaks are common, and their management is heterogeneous. For high-flow leaks, numerous studies advocate for primary dural repair and CSF diversion. The LiquoGuard7® allows automated and precise pressure and volume control, and calculation of patient-specific CSF production rate (prCSF), which is hypothesized to be increased in the context of durotomies and CSF leaks.

Methods: This single-centre illustrative case series included patients undergoing complex spinal surgery where: 1) a high flow intra-operative and/or post-operative CSF leak was expected and 2) lumbar CSF drainage was performed using a LiquoGuard7®. CSF diversion was tailored to prCSF for each patient, combined with layered spinal wound closure.

Results: Three patients were included, with a variety of pathologies: T7/T8 disc prolapse, T8-T9 meningioma, and T4-T5 metastatic spinal cord compression. The first two patients underwent CSF diversion to prevent post-op CSF leak, whilst the third required this in response to post-op CSF leak. CSF hyperproduction was evident in all cases (mean >/=140ml/hr). With patient-specific CSF diversion regimes, no cases required further intervention for CSF fistulae repair (including for pleural CSF effusion), wound breakdown or infection.

Conclusions: Patient-specific cerebrospinal fluid drainage may be a useful tool in the management of high-flow intra-operative and post-operative CSF leaks during complex spinal surgery. These systems may reduce post-operative CSF leakage from the wound or into adjacent body cavities. Further larger studies are needed to evaluate the comparative benefits and cost-effectiveness of this approach.

Objectives: To describe the epidemiology, microbiology and clinical outcomes of adult patients (aged ≥16 years) diagnosed with bacterial intracranial abscesses in the Republic of Ireland.

Methods: A 12-year retrospective analysis from 2010 to 2021 was conducted in the Republic of Ireland's two neurosurgical centres. Radiological, microbiological, and medical records of adult patients with confirmed intracranial abscesses were analysed.

Results: Of 192 patients, 127 were male (66.2%); mean age at diagnosis was 54 years (SD = 10.5). Community-acquisition occurred in 183 (95.3%) cases. The highest annual case number was recorded in 2020 (n = 32). A preceding or concurrent sinusitis, mastoiditis, or dental infection was identified in 39.1% (n = 75), prior neurosurgical procedure in 14.6% (n = 28), and infective endocarditis in 14.6% (n = 28). Solitary abscesses were present in 82.3% (n = 158), with frontal lobe abscesses predominating (38.6% [61/158]). Neurosurgical drainage was performed in 90.6% (n = 174). A single organism was cultured in 84 patients; Streptococcus intermedius most commonly (n = 35). Polymicrobial infection was identified in 27.9% (n = 48), culturing S. intermedius (n = 16), anaerobes (n = 33) and Gram-negative organisms. Of 40 culture-negative specimens, an organism was detected in 10 cases by 16S rRNA gene PCR. In-hospital mortality was 3.1%.

Conclusion: This first national cross-site study on intracranial abscess in the Republic of Ireland highlights the predominance of S. intermedius, reflecting a shift from Staphylococcus aureus. In-hospital mortality appears lower than previously reported internationally underscoring the need for continued surveillance and robust outcome data collection.

Introduction: Neurovascular compression (NVC) often drives trigeminal neuralgia (TGN) pathology. This study examines the incidence, diagnostic accuracy, and role of NVC.

Methods: We conducted a retrospective review of patients ≥18 years with medically refractory TGN who underwent MRI, plus a secondary cohort of medically responsive patients. All had ≥1-year follow-up. MRI scans were interpreted by a general radiologist (initial) and neuroradiologist (final), with the latter used to determine NVC. Patients were grouped as: no NVC (NC), NVC on symptomatic side (SC), and bilateral NVC (BC). Statistical tests included Shapiro-Wilk, paired T-test, ANOVA, and Log-Rank; The Barrow-Neurological Institute (BNI) scale quantified severity.

Results: Among 459 patients, 168, 213, and 78 had NC, SC, and BC respectively. Interpretation congruence on the symptomatic side was significantly different (p < 0.01). BC patients had lower median BNI at diagnosis (BNI = 3, p = 0.0018) and more frequent sensory deficits (50%, p = 0.0006). KM analysis showed significant differences in median recurrence: NC (7.1 months), SC (9.0 months), BC (10.0 months), AC (15.8 months). SC patients were less likely to have refractory TGN (OR = 0.6622, p = 0.0064), while NC patients were more likely (OR =1.469, p = 0.0091).

Conclusion: Findings reveal interpretation errors and suggest increased blinding. NC patients had more refractory TGN; BC patients had reduced severity.

Background: The objective was to explore factors associated with early outcomes in patients with spinal dural arteriovenous fistulae (sDAVF) treated by open surgery (Open) or endovascular procedures (Endo).

Methods: Data sources: MEDLINE, Web of Science, and Ovid to March 9, 2024. Study selection: adult sDAVF cohorts with ≥11 patients reporting on at least one of the outcomes of interest. Data extraction and synthesis: PRISMA guidelines were used to screen studies/extract data. Fistula closure rates, complication rates, and prevalence of the affected spine segments were analysed based on summary data. The post- vs. pre-procedural difference in clinical disability was based on individual patient data. Main Outcome(s) and Measure(s): (1) fistula closure rate; (2) early complications rate; (3) clinical disability; (4) prevalence of sDAVF across spine segments/levels.

Results: We identified 115 cohorts. Odds of closure (106 reports on Open, 82 on Endo, adjusted for covariates) were higher with Open vs. Endo (OR = 7.68, 95%CI 5.48-11.0). Odds of complications (59 reports on Open, 48 on Endo, adjusted) were similar for Open vs. Endo (OR = 1.02, 0.77-1.35, prediction 0.77-1.35). With adjustment (21 reports with individual patient data, 288 Open and 134 Endo procedures), reduction in disability scores was larger with Open vs. Endo (difference= -0.55, 95%CI -0.95, -0.15), consistently across the spinal segments, age, and sex. All estimates were resistant to bias (E-values = 4.99, 2.00, and 2.70).

Conclusions: Compared to Endo, Open is more likely to result in fistula closure and reduction of disability, with a similar probability of complications.

Background: Chronic subdural haematoma (CSDH) is common in the elderly, with approximately 40% of patients with CSDH taking anti-thrombotic medications. Surgery necessitates temporary cessation. The optimal time of postoperative antithrombotic resumption is not known, with the risk of recurrence balanced against the risk of thrombosis.

Methods: A systematic review was carried out (registration number:CRD42023427275). Medline and EMBASE databases were searched. The primary outcome of this study was recurrence. Late and early resumption was defined by study authors - a final definition was not possible given the heterogeneity amongst papers.

Results: 7 studies were included in the final analysis (3,195 patients total). Generally, studies reported higher risk of thromboembolic events in patients in late resumption groups (n = 4). On meta-analysis, there was no increased risk of recurrence in the early vs late groups (OR 0.61, 95% CI [0.016; 2.40], I² = 0%, p = 0.26). Most studies reported that early resumption was not associated with increased adverse events. Definitions of early and late varied by study (earliest range <3 days to <30 days).

Conclusions: We found no significant difference in rates of recurrence, or thromboembolic events in those receiving early or late resumption of antithrombotic medication. Prospective studies with consensus definitions are required to inform clinical decision making and guidelines.

Introduction: The Risk of Aneurysm Rupture (ROAR) study is a UK multicentre natural history study to determine the risk of rupture from a known unruptured intracranial aneurysm (UIA). It will use national healthcare databases for patient follow up which will need to identify events of UIA treatment for censoring patients. This study was to establish the sensitivity of different codes to identify these treatments.

Method: Patients were identified at a single neurosurgery unit from records dated 2006-2020 and linked to the Hospital Episode Statistics - Admitted Patient Care (HES-APC) database. All cases underwent case note review to identify UIA treatments during that time. All HES episodes containing an OPCS4 code for aneurysm treatment underwent further individual case note review, recalling records from external providers as required.

Results: 318 instances of elective UIA treatment were identified, of which 310 were found in the HES-APC database. The sensitivity of HES-APC for identifying elective UIA treatment is 95.6%, and the estimated sensitivity of combining HES-APC with neurosurgery unit electronic patient records, as will be done in the ROAR Study, is 99.88%. The L33 or O01-4 OPCS4 codes were used for 93.8% of elective aneurysm treatments in HES-APC.

Discussion: The HES-APC database is an effective source for identifying elective UIA treatments, and its high sensitivity makes it ideal for long-term follow-up in the ROAR Study.