British Journal of Neurosurgery最新文献

Spontaneous intracranial hemorrhage (ICH) is the second most common form of stroke and represents a life-threatening neurological emergency. The clinical course of an intracerebral hematoma varies widely, ranging from stable clot containment to progressive hematoma expansion with resulting neurological deterioration and increased mortality. Conversely, rapid resorption of acute hematomas is an uncommon phenomenon that typically unfolds over several days. The association between cirrhosis and spontaneous ICH remains controversial, and the factors influencing hematoma evolution in cirrhotic patients are poorly understood. We present the case of a 41-year-old man with a history of liver cirrhosis, chronic alcohol use, and occasional cocaine abuse, who arrived with a sudden severe headache, vomiting, and a Glasgow Coma Scale score of 12. Imaging revealed a large spontaneous left temporo-parietal intraparenchymal hemorrhage, which was managed conservatively. Remarkably, a follow-up CT scan performed 20 h after symptom onset demonstrated complete resolution of the hematoma without surgical intervention. A systematic review of the literature was conducted to explore potential pathophysiological mechanisms underlying this rare and rapid hematoma resorption. To the authors' knowledge, this represents the first documented case of ultra-early spontaneous resolution of ICH, both in the general population and specifically in a patient with cirrhosis. We hypothesize that this phenomenon may reflect a complex interplay between cirrhosis-associated coagulopathy and alterations in the fibrinolytic system, suggesting novel insights into ICH pathophysiology that could inform future therapeutic approaches. Further research is warranted to validate these findings and elucidate underlying mechanisms.

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.

Purpose: We present our analysis of the existing Paediatric High Dependency Unit (HDU) admission policy at our institution and discuss our thoughts for its revision in the context of paediatric supratentorial tumour surgery.

Materials and methods: We screened our prospectively maintained database of all children undergoing supratentorial craniotomy for resection of paediatric brain tumours over a fifteen-year period. The post-operative course of each patient was reviewed, assessing the number of patients who had true HDU needs in the immediate post-operative period, and the relative depth of input from paediatric HDU specialists that each patient received.

Results: Forty-three patients underwent craniotomy for supratentorial tumour resections during the study period. The median age of the children was 8 years old. Forty-two patients in the study cohort did not require any HDU-level monitoring or treatment post-operatively; all these patients were able to be discharged from HDU to a standard ward bed very rapidly post-operatively. Only one patient (2%) from the study cohort had any tangible HDU needs in the acute post-operative period, comprising of invasive cardiovascular monitoring and repeated blood transfusions. This child's tumour was known to be large, highly vascular, and invasive pre-operatively.

Conclusions: We would advocate a rational and nuanced approach with regards to predicting which children are most likely need paediatric HDU care following supratentorial craniotomy for resection of a brain tumour. This rationalisation could improve resource availability and reduce financial burdens upon paediatric neurosurgical units.

Introduction: Paediatric brain tumours (PBT) are the most common cause of death among all childhood cancers. The neutrophil to lymphocyte ratio (NLR) has been shown to prognosticate many adult cancers. There is a paucity of literature on the NLR in PBTs. This study aims to study the link between PBTs and the NLR by comparing the preoperative serum NLR in children under 16 with brain tumours with their outcome in terms of grade of brain tumour and overall survival.

Methods: This is a retrospective case control study. The NLRs were compared between patients with benign or malignant PBTs and patients who were alive or dead. Receiver-operating characteristic (ROC) curve analyses were performed and Youden indexes were calculated to evaluate the predictive potential of the NLR. A cut-off point of NLR > 4 was selected for the calculation of odds ratios.

Results: A total of 515 patients were included in this study. 53.8% were male. 66.2% had benign PBTs. 81.0% were alive at the time of the study. Patients with malignant PBTs had a higher NLR compared to patients with benign PBTs (p = 0.0066**). There was no difference in the NLR between patients who were dead compared to those who were alive (p = 0.1682 ns). The NLR had a Youden's index of 0.1567 to predict malignant PBTs and 0.1285 to predict survival.

Conclusion: A high NLR was associated with an increased odds of having a malignant PBT but a reliable cut-off point was not identified and the underlying mechanisms for this remain unknown. The NLR is a poor diagnostic biomarker due to its poor overall sensitivity and specificity. More research is required to further study the role of immunity in PBTs.

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.

Introduction: A chronic subdural haematoma (cSDH) is an encapsulated collection of fluid and blood degradation products in the subdural space. It is increasingly common, affecting older people and those living with frailty. Currently, no guidance exists to define optimal care from onset of symptoms through to recovery. This paper presents the first consensus-built recommendations for best practice in the care of cSDH, co-designed to support each stage of the patient pathway.

Methods: Guideline development was led by a multidisciplinary Steering Committee with representation from diverse clinical groups, professional associations, patients, and carers. Literature searching to identify relevant evidence was guided by core clinical questions formulated through facilitated discussion with specially convened working groups. A modified Delphi exercise was undertaken to build consensus on draft statements for inclusion in the guideline using survey methodology and an in-person meeting. The proposed guideline was subsequently endorsed by the Society for British Neurological Surgeons, Neuroanaesthesia and Critical Care Society, Association of Anaesthetists, British Association of Neuroscience Nurses, British Geriatric Society, and Centre for Perioperative Care.

Results: We identified that high quality evidence was generally lacking in the literature, although randomised controlled trial (RCT) data were available to inform specific recommendations on aspects of surgical technique and use of corticosteroids. The final guideline represents the outcome of synthesising available evidence, consensus-built expert opinion and patient involvement. The guideline comprises 67 recommendations across eight major themes, covering: presentation and diagnosis, neurosurgical triage and shared decision-making, non-operative management, perioperative management (including anticoagulation), timing of surgery, intraoperative and postoperative care, rehabilitation and recovery.

Conclusions: We present the first multidisciplinary guideline for the care of patients with cSDH. The recommendations reflect a paradigm shift in the care of cSDH, recognising and formalising the need for multidisciplinary and collaborative clinical management, communication and decision-making delivered effectively across secondary and tertiary care.

Purpose: National Institute of Clinical Excellence (NICE) guidelines advise that paediatric patients with linear skull fractures do not require admission in the absence of intracranial injury. Despite this, a period of inpatient neuro-observation has become the standard advice and practice in the UK for fear of deterioration. Our experience is that these children rarely deteriorate or require neurosurgical intervention. The primary aim of this study was to describe the incidence of neurological deterioration in patients referred to our paediatric neurosurgery unit with linear skull fractures.

Methods: We identified all patients with a linear skull fracture referred to neurosurgery at a paediatric major trauma centre between 2018 and 2023. Patients with intracranial injury, skull base fracture or major trauma were excluded. Demographic and clinical data were collected. The primary outcome was deterioration which was defined as drop in Glasgow Coma Scale (GCS) score, unplanned repeat cranial imaging, neurosurgical intervention performed, or the patient died.

Results: Two hundred and ninety-four patients were identified in our referral database. Infants were the age group most commonly referred (44.2%) and falls from under 2 m in height the most common mechanism of injury (71.4%). Ninety-seven children had specific advice documented regarding neuro-observation; of these, the majority (n = 53) were advised 24 hours of inpatient observation. No patients experienced deterioration.

Conclusions: This is the largest cohort of linear skull fractures in children described in the UK. None of our patients experienced neurological deterioration, mirroring findings from international studies and supporting current NICE guidance. In addition, at a cost of £360 per 24-hour admission, this has a cost implication for a resource-scarce NHS. We propose that UK trauma networks should devise protocols to support the safe discharge from ED of such patients without the need for discussion with a neurosurgical department.