British Journal of Neurosurgery最新文献

Introduction: Hydrocephalus is commonly treated by diverting cerebrospinal fluid (CSF) from the ventricles through a shunt system to a distal site, such as the peritoneum, right atrium, or pleural space. When CSF diversion to these sites is contraindicated, the gallbladder is an alternative terminus. Ventriculo-biliary shunts, in which the distal tip of the shunt catheter is placed into the gallbladder through the cystic duct, are one such alternative. There are a paucity case reports describing the adverse effects of these shunts.

Case presentation: Here, we describe the case of a 3-year-old child with history of a craniopharyngioma who underwent ventriculo-biliary shunt placement and presented with increased seizures, abdominal distention, hydrocephalus, and imaging consistent with development of a subdural collection. Analysis of the subdural collection was consistent with biliary fluid.

Conclusion: The placement of a valveless system between the brain and biliary system should be carefully considered in highly medically unstable patients. We present the first report of this rare adverse event and describe the diagnostic criteria, prevention, and management options for biliary reflux into the intracranial compartment.

Purpose: Neurosurgery training in the UK has undergone significant changes over the past few years, including the new competency-based curriculum and a reduction of elective operating due to the pandemic. We conducted a comprehensive survey to assess UK neurosurgical trainees' experiences and perceptions to develop targeted action plans.

Methods: An online anonymised survey was developed and distributed amongst the BNTA mailing list. Question types included 10-point Likert scales and free text options. Descriptive statistics, non-parametric testing of Likert scores, and Spearman's rank correlation were used to analyse responses. Pearson's chi-squared test was used for subgroup analysis of categorical data.

Results: A total of 75 trainees with a National Training Number (NTN) responded. Overall trainees feel they are well trained, well supported, and have caught up with training emerging out of COVID. Funding for training varied between deaneries. There is significant concern amongst trainees regarding the workforce crisis. This, as well as financial concerns are leading to more than a quarter of trainees considering quitting. Half of the trainees are considering going OOP. More than one third of the trainees and more than half of the female trainees are considering working Less Than Full Time (LTFT). Most important supportive mechanisms towards completion of training were social support, along with personal satisfaction from work. An independent mentoring scheme is a preferred additional support mechanism.

Conclusions: Overall training experience for neurosurgery trainees in UK and Ireland was positive. There are significant concerns regarding the workforce crisis and costs of training, with a large proportion of neurosurgery trainees considering resigning. OOP and LTFT are popular means of becoming more competitive for consultant posts and to spend time with their families. Deanery experience, senior and peer support does, and will improve trainee experience and protect against attrition.

Introduction: Skull base pathologies in the paediatric population are rare and require treatment by multiple qualified specialists. The endoscopic endonasal approach has revolutionized surgical treatment because it is less invasive than existing treatments.The goal of this study was to retrospectively review our experience with the reconstruction of paediatric skull middle base defects and associated complications.

Materials and methods: We analysed medical records from patients aged ≤ 18 years who were treated at our centre between 2013 and 2021. Patients treated with an endoscopic skull base approach and reconstruction, and who had complete clinical and radiological documentation and a minimum follow-up of 12 months, were included in the analysis. Personal data, reconstructive techniques, and complications were analysed.

Results: A total of 78 patients met the inclusion criteria and were enrolled in the study. Of these patients, 32 were male and 46 were female, and the mean age was 11.5 years. The main signs and symptoms were as follows: bitemporal hemianopsia in 53 cases, visual impairment in 23 cases, and headache in 30 cases. The most frequent aetiologies were craniopharyngioma (38 cases), pituitary adenoma (23 cases), and clivus chordoma (4 cases). All patients were treated via a pure endoscopic approach. For reconstruction, a multilayer technique was used in 18 cases, naso-septal flap in 43 cases, Gasket-Seal technique in 12 cases, and heterologous reconstruction in 5 cases. Only six patients presented a major complication: two had a postoperative cerebral spinal fluid leak, one developed a brain abscess, and three had diabetes insipidus.The mean follow-up period was 23.4 months.There were no statistically significant differences in postoperative CSF leak in relation to different reconstructive techniques.

Conclusion: Endoscopic endonasal skull base surgery is a safe and effective treatment for paediatric middle skull base pathologies. Reconstruction techniques have a high success rate of 96.5-100%, and the rate of associated complications is < 3%.

Although glioblastoma is the commonest primary brain tumour in adults, its location in the cerebellum is extremely rare. We present thirteen cases (3 female, 10 male; median age at presentation 56 [age range 21-77]) of surgically managed, histologically confirmed, primary cerebellar glioblastoma (cGB) over a 17 year period (2005-2022). Pre-operative radiological diagnosis was challenging given cGB rarity, although MRI demonstrated ring enhancement in all cases. Surgical management included posterior fossa craniectomy and debulking in 11 cases and burr hole biopsy in two. CSF diversion was necessary in four cases. No evidence of IDH or ATRX gene mutations was found when tested. Survival ranged from 1 to 22 months after diagnosis (mean 10.9 months). We also seek to understand why glioblastoma is rare in this location and discuss potential reasons for this. We hypothesise that increasing anatomical distance from germinal regions and decreased local endogenous neural stem cell activity (which has been associated with glioblastoma) may explain why glioblastoma is rare in the cerebellum. We hereby seek to add to the limited literature on cGB as this is the largest UK cGB series to date.

Dermoid cysts are ectodermal inclusion lesions which can occur at the bregma, preventing complete closure of the anterior fontanelle. Various management strategies have been suggested for children presenting with such lesions. We describe the experience of managing a series of 13 consecutive patients at the University Hospital of Wales, Cardiff, including pre-operative workup, operative strategy, post operative care and follow up. Referred patients underwent a form of cross-sectional cranial imaging. All patients were given a general anaesthetic and had a small coronial incision over the lesion, large enough only to expose the lesion. Circumferential dissection of the lesion was then performed, taking particular care at the base of the lesion. We found no intra-dural or intra-sinus connection at the base of any lesion. All patients were discharged on the same day of surgery and were seen once in person or via telephone at follow-up prior to discharge. There have been no recurrences of any lesions. We conclude that these patients can be managed safely as day case procedures and discharged after single follow-up. Although a theoretical risk of intra-sinus or intra-dural connection exists, we suspect this is extremely rare.

Background: The National Neurosurgical Audit Programme (NNAP) publishes mortality outcomes of consultants and neurosurgical units across the United Kingdom. It is unclear how useful outcomes data is for patients and whether it influences their decision-making process. Our aim was to identify patients' perceptions and understanding of the NNAP data and its influences.

Materials and methods: This single-centre study was conducted in the outpatient neurosurgery clinics at a regional neurosurgical centre. All adult (age ≥ 18) neurosurgical patients, with capacity, were invited to take part. Native and non-native English speakers were eligible. Statistical analyses were performed on SPSS v28 (IBM). Ethical approval was obtained.

Results: A total of 84 responses were received (54.7% females). Over half (51.0%) of respondents felt that they understood a consultant's mortality outcomes. Educational level determines respondents' understanding (χ²(8) = 16.870; p = .031). Most respondents were unaware of the NNAP (89.0%). Only a third of respondents (35.1%) understood the funnel plot used to illustrate mortality.

Conclusions: Most patients were unaware of the NNAP and most did not understand the data on the website. Understanding of mortality data seemed to be related to respondents' educational level which would be important to keep in mind when planning how to depict mortality data.

Introduction: The Glasgow Coma Scale (GCS) and pupil response to light are commonly used to assess brain injury severity and predict outcomes. The aim of this study was to investigate whether the GCS combined with pupil response (GCS-P), compared to the GCS alone, could be a better predictor of hospital mortality for patients with traumatic brain injury (TBI).

Methods: A retrospective cohort study was undertaken at an adult level one trauma centre including patients with isolated TBI of Abbreviated Injury Scale above three. The GCS and pupil response were combined to an arithmetic score (GCS score (range 3-15) minus the number of nonreacting pupils (0, 1, or 2)), or by treating each factor as separate categorical variables. The association of in-hospital mortality with GCS-P as a categorical variable was evaluated using Nagelkerke's R² and compared using areas under the receiver operating characteristic (AUROC) curve.

Results: There were 392 patients included over the study period of 1 July 2014 and 30 September 2017, with an overall mortality rate of 15.2%. Mortality was highest at GCS-P of 1 (79%), with lowest mortality at a GCS-P 15 (1.6%). Nagelkerke's R² was 0.427 for GCS alone and 0.486 for GCS-P. The AUROC for GCS-P to predict mortality was 0.87 (95%CI: 0.82-0.72), higher than for GCS alone (0.85; 95%CI: 0.80-0.90; p < .001).

Discussion: GCS-P provided a better predictor of mortality compared to the GCS. As both the GCS and pupillary response are routinely recorded on all patients, combination of these pieces of information into a single score can further simplify assessment of patients with TBI, with some improvement in performance.

Background: Surgical treatment of intracranial arachnoid cysts (iACs) is challenging. Microsurgical resection, endoscopic fenestration and cysto-peritoneal shunting are the most frequently used methods, each implying their own drawbacks. Stereotactic-guided cysto-ventricular drainage has been described as an alternative method. Here we describe our experience with this technique and how we conducted volumetric measurements to evaluate the effect of permanent drainage.Methods: Standardized stereotactic planning was performed. The planned trajectory included both the iAC and the ventricle system. The catheter was shortened to the defined length and was further fenestrated along its planned course through the iAC to allow drainage into the ventricular system. Clinical and radiological control was performed on outpatient basis after a mean follow-up of 2 (1-3) months. The overall mean follow-up was 32 months (6-59). The measurement of the cyst volume was conducted by the ABC/2-method.Results: Six patients with symptomatic arachnoid cysts (4 f, 2 m) were treated between 2010 and 2016. The overall postoperative reduction in cyst volume at the first follow-up was 36.04% (at the long-term follow-up: 38.57%). Decrease of the midline-shift was achieved in all cases and averaged 57.83% (long term: 81.88%). Clinical improvement of related symptoms could be achieved in all patients (4 patients were symptom free, two patients had alleviated symptoms). There was no case of over-drainage. The catheter had to be removed after 6 months in one case due to infection.Conclusions: We demonstrate successful symptom control and volume reduction in a small series of iACs by continuous drainage into the CSF-system through stereotactic placed catheters. This method may facilitate a self-regulated egress of entrapped cyst fluid in symptomatic patients without risk of over-drainage. A literature survey of the success rate and the complications of this approach is provided. It is concluded that this minimally- invasive method may be an alternative to established fenestration techniques especially for patients with arachnoid cysts that aren't directly adjacent to a cisternal or ventricular CSF space.

Pilocytic Astrocytomas are generally presenting as WHO grade 1 intracranial masses in the paediatric population with a favourable prognostic. In less common instances they can be found in the spinal cord. There have been rare cases of Anaplastic variants of the Cranial Pilocytic Astrocytomas. We report a rare instance of an adult patient with pilocytic astrocytoma of the cervical cord with anaplastic features. Our patient presented with 6 months history of neck pain and right-hand paraesthesia which partially responded to steroid treatment. MRI of the cervical spine demonstrated marked expansion of the cervical cord with oedema extending cranially to the medulla and caudally to the mid-thoracic cord. Post-gadolinium T1-weighted images showed intense intramedullary enhancement mainly centred at the level of the C3 vertebra. Diffusion Tensor Imaging Tractography showed the central location of the tumour expanding the cord and displacing the tracts circumferentially. Surgical resection was performed in two stages according to the Elsberg and Beer technique that assisted with safe margin tumour debulking. The histological sections revealed a glial lineage tumour with retained ATRX nuclear expression, positive for GFAP, Ki-67 estimated to 10% and a methylation class corresponding to an Anaplastic Pilocytic Astrocytoma. Subsequently, our patient underwent adjuvant radiotherapy and chemotherapy (10 cycles of Temozolamide and 6 cycles of CCNU). Symptomatic progression developed at 18 months from the initial surgery, radiological progression at 34 months and the overall survival was 40 months. We reviewed the literature and found only four other cases with similar histology.

Introduction: Deep brain stimulation (DBS) of the ventral intermediate thalamus (VIM) is a safe and effective treatment of essential tremor (ET). Traditionally microelectrode recording (MER) was used to confirm lead placement in the target structure in the awake state. More recently, lead placement using indirect anatomical targeting with the patient under general anaesthesia has been described and implemented in many centres, and is referred to as 'asleep DBS'. We performed a systematic review of asleep DBS procedures for ET to assess the outcomes of this technique.

Methods: A systematic review was performed looking at all studies utilising asleep DBS for ET according to PRISMA guidelines. PubMed, Web of Science and Cochrane database were searched. Only studies in ET with a VIM target were included.

Results: 229 patients with 406 leads inserted asleep across 9 studies were included with robotic and non-robotic guided insertion. 3 studies had an internal comparison with traditional awake methods with microelectrode recordings (132 patients with 214 leads). Functional improvement ranged from 48% to 71% [weighted mean (wm) 57.62%]. Radial errors across the studies ranged between 0.5 and 1.9 mm (wm 0.83 mm). The percentage of leads passed successfully on first pass ranged from 88.3% to 100%. Complication rates ranged from 0% to 41.7% (wm 7.45%), with haemorrhage rates ranging from 0% to 8.3% (wm 2.19%), infections 0-16.2% (wm 1.89%) and altered mental status from 0% to 24.2% (wm 0.67%). Mean total operative room times ranged from 205 to 333 minutes for bilateral lead insertion only. Mean length of stay ranged from 1.5 to 3 days.

Conclusion: Asleep DBS, targeting VIM, is a safe and effective procedure in the treatment of essential tremor. High levels of precision allow submillimetre target accuracy in many cases. Functional outcomes and complications are comparable to awake procedures performed with MER. Larger randomised control trials directly comparing asleep to awake procedures with MER are desirable.