British Journal of Neurosurgery最新文献

Background: Goal directed fluid therapy (GDFT) may be a rational approach to adopt in neurosurgical patients, in whom intravascular volume optimization is of utmost importance. Most of the parameters used to guide GDFT are derived invasively. We postulated that the total volume of intraoperative intravenous fluid administered during elective craniotomy for supratentorial brain tumours would be comparable between two groups receiving GDFT guided either by the non-invasively derived plethysmography variability index (PVI) or by stroke volume variation (SVV).

Methods: 60 ASA category 1, 2 and 3 patients between 18 and 70 years of age were randomized to receive intraoperative fluid guided either by SVV (SVV group; n = 31) or PVI (PVI group; n = 29). The total volume of fluid administered intraoperatively was recorded. Serum creatinine was measured before the surgery, at the end of the surgery, 24 h after surgery and on the fifth post-operative day. Arterial cannulation was performed before induction in all patients. Serum lactate was measured before induction, once in 2 h intraoperatively, at the end of the surgery and 24 h after the surgery. Brain relaxation score was assessed by the surgeon during dural opening and dural closure. Patients were followed up till discharge or death. The duration of mechanical ventilation and the duration of hospital stay was noted for all patients.

Results: The volume of fluid given intraoperatively was significantly higher in the SVV group (p = 0.005). The two groups were comparable with respect to serum lactate and serum creatinine measured at pre-determined time intervals. Brain relaxation score was also comparable between the groups. SVV and PVI displayed moderate to strong correlation intraoperatively. The duration of mechanical ventilation and the length of the hospital stay were comparable between the two groups.

Conclusions: PVI and SVV are equally effective in guiding GDFT in adults undergoing elective craniotomy for supratentorial brain tumours.

The massa intermedia (MI) or interthalamic adhesion (ITA) is a band of tissue connecting the medial surfaces of the thalami and is present in the majority of healthy individuals. Its enlargement as well as its absence have been associated with some pathological states.We describe the first case report of a 3-year-old child presenting with obstructive hydrocephalus in the context of an enlarged massa intermedia. The patient's symptoms abated following an endoscopic third ventriculostomy.

Background: Setting minimum annual volume thresholds for pituitary surgery in England is seen as one way of improving outcomes for patients and service efficiency. However, there are few recent studies from the UK on whether a volume-outcome effect exists, particularly in the era of endoscopic surgery. Such data are needed to allow evidence-based decision making. The aim of this study was to use administrative data to investigate volume-outcome effects for endoscopic transsphenoidal pituitary surgery in England.

Methods: Data from the Hospital Episodes Statistics database for adult endoscopic transsphenoidal pituitary surgery for benign neoplasm conducted in England from April 2013 to March 2019 (inclusive) were extracted. Annual surgeon and trust volume was defined as the number of procedures conducted in the 12 months prior to the index procedure. Volume was categorised as < 10, 10-19, 20-29, 30-39 and ≥40 procedures for surgeon volume and < 20, 20-39, 40-59, 60-79 and ≥80 procedures for trust volume. The primary outcome was repeat ETSPS during the index procedure or during a hospital admission within one-year of discharge from the index procedure.

Results: Data were available for 4590 endoscopic transsphenoidal pituitary procedures. After adjustment for covariates, higher surgeon volume was significantly associated with reduced risk of repeat surgery within one year (odds ratio (OR) 0.991 (95% confidence interval (CI) 0.982-1.000)), post-procedural haemorrhage (OR 0.977 (95% CI 0.967-0.987)) and length of stay greater than the median (0.716 (0.597-0.859)). A higher trust volume was associated with reduced risk of post-procedural haemorrhage (OR 0.992 (95% CI 0.985-0.999)), but with none of the other patient outcomes studied.

Conclusions: A surgeon volume-outcome relationship exists for endoscopic transsphenoidal pituitary surgery in England.

Background: We assessed the accuracy and performed a directional analysis of robot-assisted implantation of stereoelectroencephalography (SEEG) depth electrodes in children using the frameless neurolocate 3D registration module.

Methods: Thirteen children with epilepsy undergoing stereotactic robot-assisted insertion of SEEG electrodes were included. Six children were operated on with standard frame-based registration while 7 with the use of the frameless neurolocate registration module. Accuracy and directional analysis of orthogonal and oblique electrodes were assessed by calculating the absolute error, the radial error, the angle error, and the Euclidean distance.

Results: Of 172 electrodes 89 were implanted in the 6 standard frame-based mode patients and 83 in the 7 neurolocate patients. The overall mean age was 12.2 ± 4.4 years (range 2-17). The mean number of electrodes in each patient was 13.2 ± 2.04 (range 9-17). The median radial error of electrode placement in the neurolocate patients (1.08 mm, [IQR: 1.26]) was significantly less when compared with standard frame-based mode patients (1.49 mm, [IQR 1.25)]; p = 0.04). The same applies to the median angle error which was in the neurolocate group 1.61° [IQR: 1.46] and in the standard frame-based group 2.16° [IQR: 2.09]; p = 0.019. Directional analysis of electrode trajectories in the neurolocate group showed that in the x-axis the median absolute error of orthogonal electrodes (0.4 mm, [IQR: 0.475]) was less when compared with oblique electrodes (0.7 mm, [IQR: 1.2]; p = 0.007). In the standard frame-based mode group in the y-axis, the median absolute error of orthogonal electrodes (0.7 mm, [IQR: 1.3]) was less compared with oblique electrodes (1.25 mm, [IQR: 1.6]; p = 0.03).

Conclusion: In paediatric patients, robot-assisted SEEG depth electrode implantation with the non-invasive and easy-to-use frameless neurolocate registration module is a consistent and accurate procedure.

Background: Despite the availability of safe and effective surgical treatments for chronic SI joint pain, many clinicians find the diagnosis of SI joint pain challenging. Misdiagnosis can lead to misdirected surgery, which has important consequences. The study's goal was to determine whether a combination of clinical examination, joint block, and selected radiographic imaging can distinguish patients with SI joint pain from those with other causes of chronic low back pain.

Methods: Prospective diagnostic accuracy study with evaluation of 364 consecutive patients seeking advice in a neurosurgical clinic for chronic low back pain. Participating patients underwent comprehensive clinical examination (medical history items, specific physical examination manoeuvres, and selected radiographic tests) followed by SI joint block. Block was used to confirm or exclude SI joint pain. Logistic regression with LASSO (least absolute shrinkage and selection operator) penalty was used to calculate the accuracy of diagnosis when looking at (1) medical history items only, (2) medical history plus radiographic testing, and (3) medical history, radiographic testing, and physical examination testing.

Results: 150 patients had a positive response (>50% acute pain relief) to SI joint block, 214 had no response to SI joint block, and 37 had minimal (<50% improvement) in pain. Diagnostic accuracy for SI joint pain was lowest with medical history only (85-86%), slightly higher when radiographic testing was added (87%), and highest when physical examination testing was included (96%).

Conclusion: Comprehensive clinical examination (including SI joint block where relevant and selected imaging procedures) is accurate in distinguishing the SI joint from non-SI joint causes of chronic low back pain.

Trial registration: https://www.clinicaltrials.gov/study/NCT04381208.

Objective: To present a new technique for the management of subdural empyema to promote resolution and prevent recurrence.

Background: Classic treatment for subdural empyema (SDE) has consisted of antibiotics and surgical treatment with either craniotomy or burrholes. There are still several complications that persist after current treatment, including relatively high rates of morbidity and mortality. In this case report, we present a technique that utilises a novel irrigating-draining catheter to provide a minimally invasive approach for empyema resolution with continuous antibiotic irrigation.

Methods: In this example case, a 24-year-old male presented to the hospital for new onset headache, lethargy, confusion, and extremity tremors. Initial imaging demonstrated a left frontal extra-axial collection, treated with emergent craniotomy for evacuation of subdural empyema. The subsequent hospital course was complicated by the development of bilateral subdural empyemas which were surgically treated with use of novel irrigating-draining catheters.

Results: The patient tolerated the procedure well without any complications. He was subsequently discharged to rehab with no deficits or recurrence at a 4-month follow-up visit.

Conclusions: This minimally invasive novel approach for SDEs can be both safe and effective. Future work should further elucidate the effect of this technique on empyema recurrence and long-term outcomes compared to traditional surgical approaches.

Purpose: Many patients with skull base meningiomas (SBMs) develop cranial neuropathies, though there is a paucity in literature regarding cranial neuropathy improvement following treatment. This is even more profound when isolating for patients who received stereotactic radiotherapy (SRT) as their primary treatment without additional open surgery. Our goal was to investigate the effect of SRT on cranial neuropathies secondary to SBMs and identify predictors of favourable treatment response.

Materials and methods: A single-center retrospective case-control study was performed assessing factors associated with cranial neuropathy improvement in patients with SBMs treated with SRT alone. Patients diagnosed with SBMs, having a cranial neuropathy, and treatment with radiation monotherapy were included. Patients without SBMs or who underwent surgery treatments were excluded. Patients with olfactory and vestibulocochlear neuropathies were ultimately excluded due to sample sizes. Subgroup analysis was performed assessing predictors of improvement for optic, extraocular, and trigeminal neuropathy. Statistical analysis was completed using R version 4.0 (R Foundation for Statistical Computing, Vienna, Austria).

Results: Eighty-five patients met the inclusion criteria of SBMs treated with SRT alone. Forty-five patients (52.9%) had improvement in their symptoms. Among the entire cohort, there was no significant difference between gender, age, tumour location, type of neuropathy, duration of symptoms, tumour volume, total radiation dose, or follow-up duration between those who did and those who did not improve. Subgroup analysis demonstrated significant improvement with younger age at diagnosis of optic neuropathy (50.7 vs 59.6 years, p = 0.04), shorter duration of symptoms prior to radiation in those with extraocular neuropathy (3.0 vs 11.5 months, p = 0.02), and lower radiation dose in those with trigeminal neuropathy (50.0 vs 54.0 Gy, p = 0.01).

Conclusions: This study demonstrates that SRT alone resulted in cranial neuropathy improvement in more than half of patients with SBM and identifies factors predictive of symptom resolution.

We report a fairly rare case of postoperative acute subdural hygromas without concurrent hydrocephalus complicating foramen magnum decompression (FMD) for Chiari malformation type I (CM-I). Full resolution of subdural hygromas was achieved through therapeutic lumbar puncture releasing bloody cerebrospinal fluid which has been scarcely advocated in managing post-FMD subdural hygromas. This outcome suggests that bloody cerebrospinal fluid may be related to the formation of subdural hygromas after FMD for CM-I and therapeutic lumbar puncture may provide an effective treatment modality in such conditions.

Background: Brain abscess (BA) is a rare, but severe infection and experimental BA animal models may prove crucial for advances in treatment. This review describes the development of experimental BA models and the clinical advances obtained from these, in a historical perspective.

Material and methods: Experimental BA studies from inception until June 15, 2022, were included by searching the PubMed and Embase databases. Inclusion required the use of an experimental BA animal model. Non-bacterial BA models, in vitro studies, veterinarian case-reports, and articles written in non-English language were excluded. Bias was not systematically assessed, and the review was not registered at the PROSPERO.

Results: 79 studies were included. The majority of animal BA models have been based on small rodents using Staphylococcus aureus. The models have delineated the natural development of BA and provided detailed descriptions of the histopathological characteristics consisting of a necrotic centre surrounded by layers of inflammatory cells and fibroblasts encapsulated by a dense collagenous layer. Radiological studies of animal BA have been shown to correlate with the corresponding stages of human BA in both computed tomography and magnetic resonance imaging and may guide diagnosis as well as the timing of neurosurgical intervention. Moreover, pharmacokinetic studies of the intracavitary penetration of various antimicrobials have helped inform medical treatment of BA. Other studies have examined the diverse effects of corticosteroids including decreased cerebral oedema, intracranial pressure, and intracavitary drug concentration, whereas concerns on decreased or weakened capsule formation could not be confirmed. Finally, studies on the immunological response to BA have highlighted potential future immunomodulatory targets.

Conclusions: Animal models have been vital for improvements in the management of BA. Experimental BA models resembling human disease including polymicrobial infection by oral cavity flora in large animals are needed.

Background: The tumor invasion of the skull base structures is very frequent in spheno-orbital meningiomas. The aim of the present study is to evaluate the invasion rate of skull base structures and the best surgical approach and management.

Methods: The surgical series of 80 spheno-orbital meningiomas was reviewed. The tumors were classified according to the intraorbital location with respect to the optic nerve axes into three types: I-lateral: II-medial; III-diffuse. The invasion of the orbital apex, optic canal, superior orbital fissure, anterior clinoid, ethmoid-sphenoid sinuses, and infratemporal fossa was evaluated. The rate and extension of involvement of these structures was correlated with the intraorbital location and the surgical approach. The preoperative ophtalmological symptoms and signs and their outcome were also evaluated.

Results: Proptosis was found in 79 patients (97%), variable decrease of the visual function in 47 patients (59%), and deficits of the eye movements in 28(35%). The invasion of the optic canal (74%), superior orbital fissure (65%), anterior clinoid (60%), and orbital apex (59%) was more frequently found, whereas the tumor extension into the ethmoid-sphenoid sinuses (4%) and infratemporal fossa (4%) was rare. Types II and III meningiomas showed significantly higher involvement of the skull base structures than type I ones, which only had 15% invasion of the optic canal. Remission or significant improvement of the visual function occurred postoperatively in 24 among 47 cases (51%), with a higher rate for type I meningiomas vs. other types (p = 0.021, p = 0.019) and worsening in 7 (15%).

Conclusions: Spheno-orbital meningiomas growing in the lateral orbital compartment show no involvement of the skull base structures excepting the optic canal as compared to those growing medially or diffusely. The surgical resection of tumor invading the skull base structures should be more extensive as possible, but the risk of optic and oculomotor deficits must be avoided.