British Journal of Neurosurgery最新文献

Purpose: Traumatic Brain Injury (TBI) is a leading cause of morbidity and mortality in adults, with a substantial number managed in non-specialist trauma units. Despite national guidance, variability persists in inpatient TBI management. This study aimed to evaluate the impact of a newly developed regional guideline for the inpatient care of adult TBI patients.

Materials and methods: A multidisciplinary team developed a structured inpatient guideline addressing neurological observation, medication safety, imaging, escalation to neurosurgery, and discharge criteria. The guideline was disseminated across 12 Trauma Units in the East of England Trauma Network. The launch of the guideline was conducted over Microsoft Teams, with invitations sent to all specialties and disciplines across the Trauma Network. To assess its perceived impact, an online survey evaluating confidence, knowledge, and current practice was conducted among clinicians pre- and post-guideline implementation.

Results: A total of 64 clinicians responded to the initial survey. Prior to the launch of the guideline, 39% of respondents reported the lack of clear guidance on when to perform repeat CT imaging for TBI, 78% were unsure of restarting anticoagulation, 55% were unclear on discharge criteria, and 83% were unaware of local neurorehabilitation pathways. Only 19% reported confidence in prescribing anti-epileptic drugs, and 8% in reversing anticoagulation. While GCS and pupil checks were commonly used, only 58% assessed limb power-a key sign of neurological deterioration. Overall, 90% supported the introduction of a structured inpatient guideline.

Conclusions: The findings highlight substantial gaps in clinician confidence and variability in practice for TBI patients managed in trauma units. The implementation of a regionally tailored inpatient guideline was well-received and has the potential to improve safety, consistency, and quality of TBI care outside specialist centres.

Aim: A case of Eustachian tube dysfunction following percutaneous balloon compression (PBC) of the trigeminal ganglion led us to investigate aural complications of PBC and similar procedures. We aimed to clarify both the physiological effects of compression of the trigeminal ganglion on aural function and the possibility of puncture of the Eustachian tube during placement of the needle.

Methods: We reviewed the anatomy of the Eustachian tube in relation to the foramen ovale and the aural structures supplied by the trigeminal nerve through cadaveric study. Following CT scanning, neuronavigation was used to guide a needle into Meckel's cave of a cadaver. Dissection was subsequently carried out with the needle in-situ to assess the proximity of the needle to the Eustachian tube and other structures. A literature review of aural complications of foramen ovale procedures using Ovid Medline, PubMed, and Google Scholar databases was undertaken.

Results: Our literature review summarises the relationship of the Eustachian tube to the foramen ovale, the nerve supply of aural structures from the trigeminal nerve and examines previously reported post-operative aural complications. From our anatomical study, at its closest point, the needle was 7 mm from the Eustachian tube.

Conclusion: The trigeminal nerve supplies both the tensor tympani and tensor veli palatini muscles and percutaneous procedures may, therefore, lead to aural symptoms. Also, the path of the needle is close to the Eustachian tube and can be punctured during these procedures. The authors recommend discussing aural complications during consent for these procedures.

Background: Trigeminal neuralgia is a very painful condition that may require a surgical approach as treatment, which is typically retrosigmoid craniotomy followed by microvascular decompression. Due to the limited margin for error when operating in the small triangular window of the cerebellopontine angle and the infrequency of this condition, the operating room can present a difficult learning environment for surgical trainees. Our aim is to create a synthetic, low-cost, high-fidelity, and largely reusable simulation model that will enable neurosurgical trainees to practice these procedural steps in a safe learning environment.

Materials and methods: Design-based research was employed to develop the model through iterative micro-cycles, with expert evaluation from an educational and clinical team. The model was made from easy to source materials without advanced technology where sustainability, reproduction at scale and cost where significant considerations.

Results: Our model effectively simulates a retrosigmoid craniotomy and microvascular decompression of the trigeminal nerve. The model consists of two distinct parts that are made of synthetic materials. Part A is a single-use, moulded portion of the skull, while part B depicts the cerebellopontine angle and some of its internal anatomical and pathological structures crucial to carrying out all the steps to this procedure. Part A sits ergonomically flush on top of Part B, with both parts subsequently clamped to the table.

Conclusions: As a proof of concept, we report the development and utilisation of a novel, low-cost, replicable retrosigmoid craniotomy and microvascular decompression of the trigeminal nerve simulation model.

Background: Ambulatory anterior cervical discectomy and fusion (ACDF) is a promising method, but not common in Poland.

Objective: That is why the purpose of this study was to demonstrate the experience of performing ACDF in patients with degenerative spinal diseases.

Methods: This study at the Spine Centre involved a single-center, multi-surgeon evaluation of 100 patients undergoing ACDF.

Results: Outcomes assessed included pain severity, measured by the visual analogue scale, which improved from 4.28 ± 0.76 preoperatively to 1.11 ± 0.59 one month postoperatively. The Core Outcome Measures Index-neck (COMI-neck) scale also showed significant improvement: before surgery, 30% of patients scored their condition severity between 4-6, and 70% scored 7-10; 6 months postoperatively, the scores were 0-3 for 55% of patients, 4-6 for 45%, and 7-10 for none. Only 2% of patients experienced moderate, temporary complications, with no serious complications or postoperative hematomas observed.

Conclusion: The study supports the feasibility, safety, and efficacy of performing ACDF in an ambulatory setting, suggesting that with appropriate patient selection and surgical protocols, ambulatory ACDF can be more broadly implemented.

Neurobrucellosis is a rare complication of brucella infection which presents as meningitis, meningoencephalitis, subdural empyema, brain abscess, myelitis, and radiculo- neuritis. We report the first case of neurobrucellosis presenting as an infected cerebellopontine cistern epidermoid cyst in a young immunocompetent male who presented with fever and acute raised intracranial pressure. MRI brain showed an extra-axial mass in the right cerebellopontine angle cistern with peripheral rim enhancement and diffusion restriction. Emergency surgery unveiled a well-encapsulated lesion containing thick pus and keratinous material, confirming an infected epidermoid cyst. Intriguingly, the culture revealed Brucella infection, but the source of the infection remained unclear.

Background: Cardiac myxoma is a rare, benign tumour that commonly originates in the left atrium and may lead to embolic events. Parenchymal brain metastases represent a rare neurological manifestation. While surgical intervention is commonly used, there is limited information on long-term outcomes after radiotherapy treatment. This report describes a case of successful treatment of haemorrhagic brain metastases with radiotherapy and offers a literature review of long-term results after radiotherapy treatment.

Case report: A 49-year-old woman presented with multiple haemorrhagic brain lesions and a cardiac mass. Surgical removal of the cardiac mass and the symptomatic brain lesion confirmed metastatic cardiac myxoma. Post-surgery, she experienced fatigued and neurocognitive impairment and was closely monitored. However, the metastases progressed. She subsequently received whole-brain radiotherapy, resulting in complete response. Seven years later, she remains in remission, although with enduring neurocognitive impairment.

Conclusions: Whole-brain radiotherapy can provide long-term control of haemorrhagic brain metastases arising from cardiac myxoma. Radiotherapy dose and treatment volume need careful consideration to reduce toxicity.

Background: Bilateral, biventricular lesions present a challenging scenario in neurosurgery, often requiring complex surgical techniques for management. Gangliogliomas (GG), while typically indolent, can manifest as anaplastic variants (AGG), necessitating comprehensive treatment strategies. This case study explores a unique surgical approach for a patient with bilateral, intra-extraventricular lesions infiltrating the corpus callosum, highlighting the complexities of managing such cases.

Methods: A 63-year-old female presented with a progressive intraventricular lesion infiltrating the left frontal lobe, diagnosed initially as a ganglioglioma. Following resection and histological examination, the lesion was confirmed as a WHO Grade 1 ganglioglioma. Subsequently, a contralateral lesion emerged, necessitating a novel surgical approach to achieve maximal safe resection while minimising neurological deficits. The technique involved extending the surgical corridor contralaterally along the tumour route, guided by neuronavigation and fluorescence imaging.

Results: The surgical approach enabled maximal safe resection of the lesion, with postoperative imaging confirming complete resection in most sites except for a known infiltration in the right posterior lateral ventricle. Histological examination revealed AGG, prompting subsequent adjuvant radiotherapy due to its aggressive nature.

Conclusion: The management of bilateral, biventricular lesions such as AGG requires innovative surgical approaches tailored to individual patient characteristics. The case highlights the efficacy of a transtumoral approach in achieving maximal safe resection while minimising neurological sequelae. Moreover, it underscores the importance of comprehensive treatment strategies, including adjuvant therapies, in addressing aggressive histological variants of gangliogliomas.

Background: Primary pituitary lymphoma (PPL) is a rare finding in immunocompetent patients, with only 54 patients reported to date (including ours). It presents most often with headache and hypopituitarism, with MRI findings comparable to more common pituitary tumours, making the diagnosis challenging. There is no consensus on the ideal management for these lesions with the role of surgical resection not clearly established.

Case report: We present here a 49-year-old female who presented with acute vision loss and was found to have PPL of diffuse large B-cell lymphoma, non-germinal centre type. The radiologic findings were distinct from prior cases with haemorrhagic components and perilesional edoema in the bilobed sellar mass. Surgical resection was halted when a diagnosis of lymphoma was suspected. This decision was based on the guidelines for the treatment of primary CNS lymphoma (PCNSL) and the lack of evidence to support surgical resection of PPL specifically. Our patient lacked mutations commonly associated with a poor prognosis in DLBCL, such as TP53 and BCL6. She remains in remission with normal vision nearly two years after treatment with minimal resection, MR-CHOP, and consolidation radiotherapy.

Conclusion: We highlight here the clinical and diagnostic features of PPL to guide clinicians to early recognition and diagnosis. Surgical resection should be limited to what is necessary to obtain a diagnosis and critical decompression; otherwise, these lesions respond excellently to steroids and typical chemoradiation regimens.