British Journal of Neurosurgery最新文献

Introduction: Normal pressure hydrocephalus (NPH) is a reversible cause of dementia which may be treated with CSF diverting shunts. Identification of specific barriers to diagnosis and treatment may allow for formation of targeted programs to increase rates of accurate, timely diagnosis to restore functional status and independence.

Methods: 135 patients with a confirmed diagnosis of NPH were reviewed for symptom onset, demographic characteristics, presence of comorbidities as well as time to treatment.

Results: Patients undergoing ventriculoperitoneal shunt (VPS) placement for NPH were slightly more likely to be male (42% vs 58%), with an overall median age of 76 years old (median of 78 years for men and 76 years for women; p-value 0.90). Median time to treatment from symptoms onset reported by the patients was 24 months (range 4-72 months). However, median time to treatment was lower for women than for men (12 vs 24 months; p-value: 0.056), but statistically significant in multivariate regression using a Gamma distribution when controlling for demographic variables (p-value: 0.004).

Conclusion: Although men and women report symptoms onset at a similar age, there appears to be a delay in time to diagnosis or treatment among men and rural inhabitants with no difference in age at surgery.

Objective: This study aimed to compare the long-term pain control outcomes between microvascular decompression (MVD) and radiofrequency rhizotomy (RFR) in patients with idiopathic trigeminal neuralgia (TN) with a neurovascular contact without root distortion after first-time surgical treatment, as there is no clear recommendation for choosing between these surgical modalities for this patient group.

Methods: This retrospective study evaluated patients diagnosed with idiopathic TN with a neurovascular contact without root distortion. Patients treated with MVD or RFR as first-time surgical treatment were included.

Results: A total of 26 patients were included, with 20 treated with MVD and 6 with RFR. Patients treated with MVD exhibited a longer median time until pain recurrence compared to those treated with RFR (median 24 months [CI 9.38-38.62] vs. 5 months [CI 0-11], p = 0.05). Further subanalysis revealed that these differences were primarily seen in a specific subgroup: patients in the MVD group with a preoperative symptom duration of <5 years (PSD < 5Y). This subgroup demonstrated a significantly lower risk of pain recurrence compared to those treated with RFR, with a Hazard ratio of 7.791 (95% CI 1.379-44.013; p = 0.02).

Conclusion: MVD resulted in superior pain control compared to RFR in patients with idiopathic TN with a neurovascular contact without root distortion and with a PSD < 5Y, after initial surgical treatment. However, caution should be exercised in interpreting these findings due to study limitations, including its retrospective design and small sample size. Further research is warranted to validate these results.

Purpose: Recurrent tethered cord syndrome (TCS) with split cord malformation (SCM) is a rare presentation with distinct surgical challenges to successful patient outcomes. SCMs are rare and can progress to cause significant neurological deficits including pain, weakness, sensory disturbance, bowel and/or bladder dysfunction. In these circumstances, surgical management of TSC with SCM is indicated. Reoperation for recurrent TCS, particularly in the context of retained or regrown bony septa and prior spinal instrumentation, is technically demanding and carries elevated risk.

Illustrative case: This case presents a 26-year-old woman with recurrent TCS and SCM Type I who previously underwent multiple spinal surgeries, including posterior spinal fusion and partial resection of a bony septum. She developed progressive radiculopathy, neurogenic bladder, and recurrent urinary tract infections despite conservative therapy. Advanced imaging revealed a recurrent bony septum and tethered neural elements. A two-stage surgical approach was undertaken: first, anterior spinal hardware was removed via thoracoabdominal exposure due to impingement on the hemicord; second, a complex posterior tethered cord release (TCR) was performed with resection of the recurrent bony septum, microsurgical detethering, and resection of the medial dura between hemicords. Intraoperative neuromonitoring and careful neuroanatomic dissection were critical to preserve function and minimize risk. Postoperatively, the patient demonstrated marked improvement in lower extremity pain, mobility, and bladder control.

Conclusions: This case underscores the complexity of managing recurrent TCS with SCM Type I, particularly when prior surgery is incomplete or complicated by spinal instrumentation. Key technical considerations include removal of the bony septum, resection of the medial dura to prevent recurrence, and careful dissection through scarred neural tissue. Preoperative planning with multidisciplinary coordination and intraoperative neurophysiological monitoring is essential to optimize outcomes. This report contributes to the limited literature on recurrent SCM management in adults and reinforces the importance of complete initial intervention and longitudinal follow-up in complex spinal dysraphisms.

Ossification of the posterior longitudinal ligament (OPLL) is a progressive disorder characterized by abnormal ectopic bone formation along the posterior longitudinal ligament, often leading to spinal canal stenosis and cervical myelopathy. OPLL is increasingly recognized worldwide due to advancements in imaging technology. Surgical management remains the mainstay of treatment for symptomatic patients, but the optimal approach continues to be debated. This review aims to provide a practical workflow based on the current evidence on the pathophysiology, classification, diagnostic imaging, and the surgical management of OPLL, while highlighting the advantages, limitations, and outcomes of anterior, posterior, and combined approaches. Evidence indicates that surgical management significantly improves neurological function in symptomatic patients. Anterior approaches provide direct decompression and correction of cervical alignment but are associated with higher complication rates such as CSF leaks and dysphagia. Posterior approaches allow for indirect decompression and wider canal expansion, though they may predispose to kyphosis and OPLL progression. Laminoplasty offers motion preservation but carries a risk of disease progression. Patient selection guided by factors such as canal occupancy ratio, cervical alignment, and K-line status is critical in optimizing outcomes. However, surgical decision-making in OPLL must be individualized, balancing disease severity, anatomical considerations, and long-term risks. Further prospective studies are warranted to refine surgical guidelines and improve long-term outcomes, especially when new technologies such as robotics or augmented reality are used.

Background: Cerebral venous sinus thrombosis (CVT) is a rare condition that, in severe cases, can cause refractory intracranial hypertension. Despite limited evidence, decompressive craniectomy (DC) is endorsed as a rescue treatment. We aimed to describe indications, surgical characteristics, and outcomes of DC for severe CVT in a near-nationwide Swedish cohort.

Methods: This multicentre retrospective case-series included all CVT patients treated with DC (n = 13) at five Swedish neurosurgical centres between 2008-2022. Demographic, clinical, radiological, and surgical variables, and six-month modified Rankin Scale (mRS) were extracted from medical records and radiological imaging. Favourable outcome was defined as mRS 0-3.

Results: Median age was 53 years (IQR 32-62), and 77% were female. At admission, the median GCS Motor score (GCS M) was 6 (5-6) and all patients had reactive pupils. Preoperatively, GCS M declined to 5 (1-5), and only 46% had reactive pupils. Midline shift was 9 mm (6-11) and all patients had compressed basal cisterns before DC. Postoperatively, midline shift decreased to 2 mm (0-5), and basal cisterns were open in 85% of cases. Eleven patients (85%) developed external brain herniation, one patient (8%) had subdural hygroma requiring surgery, and 4 (31%) developed a postoperative intracranial haematoma, one of which (8%) was evacuated. No postoperative infections or reoperations due to DC-extension occurred. At follow-up, 62% had recovered favourably, while 15% were deceased.

Conclusions: DC was an effective last-tier treatment of intracranial hypertension in selected severe CVT cases. Most patients recovered favourably, with low mortality and complication rates.

Background: This multi-centre study aimed to describe indications and outcomes in spontaneous supratentorial intracerebral haemorrhage (ICH) patients treated with decompressive craniectomy (DC).

Methods: All patients undergoing DC for spontaneous ICH at five Swedish neurosurgical centres between 2008 and 2022 were included (n = 45). Clinical, radiological, and outcome data were extracted. Outcome at six months was assessed using the modified Rankin Scale (mRS), dichotomized as favourable vs. unfavourable (mRS 0-3 vs. 4-6), and survival vs. mortality (mRS 0-5 vs. 6).

Results: Based on estimated ICH incidence, DC was performed in approximately 1.5 per 1000 cases. Median age was 47 years and the median ICH volume was 51 mL. Eighty-nine percent underwent ICH evacuation. DC performed as a primary procedure without ICP monitoring in 33%, whereas 67% underwent secondary DC due to refractory ICP elevation. Preoperative midline shift (median 11 mm) and basal cistern compression (present in 96%) significantly improved postoperatively (p < 0.001). Reoperation occurred in <10%. At follow-up, 28% were deceased and 40% had recovered favourably.

Conclusions: DC performed in a highly selected ICH population resulted in significant mass effect reduction and a relatively high rate of favourable outcome. Patient selection remains crucial but challenging, and larger prospective studies are warranted.

Introduction: Anastomosing haemangiomas are rare benign vascular tumours. Their occurrence within the skull is exceptionally rare, with few documented cases in the literature.

Case report: We present a case of a large intraosseous anastomosing haemangioma arising from the skull vault with associated neurological symptoms. A 30-year-old male presented with transient right-sided hemiparesis and dysarthria lasting approximately 30 minutes. Neuroimaging revealed a large extra-axial mass in the left frontoparietal region causing local mass effect. The patient underwent simultaneous craniotomy and gross total resection of the tumour and cranioplasty. The final histopathological diagnosis was an anastomosing haemangioma. The patient recovered well postoperatively and has had no further neurological symptoms during follow-up.

Conclusion: This case highlights the rare presentation of an intraosseous anastomosing haemangioma of the skull with neurological manifestations. Complete excision remains the treatment of choice. Margin involvement necessitates close follow-up. Consideration of this rare entity in the differential diagnosis of vascular bone tumours of the skull is important in neurosurgical practice.

Cerebral blood flow (CBF) is under homeostatic control via cerebral autoregulation, maintaining a constant blood supply to brain parenchyma by integrating myogenic, metabolic, and neurogenic inputs across the neurovascular unit to stabilise perfusion despite physiological variations in cerebral perfusion pressure. While the mechanisms that underpin the control of CBF have been extensively investigated, this narrative review aims to holistically synthesise key findings for clinicians and researchers across healthy and diseased states. We first summarise autoregulatory inputs, cellular effectors, and typical stimuli/responses (with practical caveats including non-linearity, frequency dependence, and pressure-passivity). We then discuss monitoring approaches for assessing CBF and contrast cross-sectional techniques with portable bedside modalities, highlighting what each primarily measures (perfusion, velocity, oxygenation proxy, or flow index), their typical applications, and key constraints (radiation exposure, invasiveness, operator dependence, penetration depth, quantification). For historical context, we briefly note invasive monitors that remain selectively indispensable within multimodal neurocritical care. Looking forward, we outline emerging directions that prioritise non- and minimally-invasive solutions, including photoacoustic imaging, functional ultrasound, diffuse optical methods, speckle-based optics, and machine learning-enhanced post-processing, alongside hybrid multimodal integration. Collectively, these developments aim to improve accuracy, repeatability, and scalability of CBF monitoring and to support individualised decision-making across the clinical neurosciences.