British Journal of Neurosurgery最新文献

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.

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.