British Journal of Neurosurgery最新文献

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.

Background: Cerebrospinal fluid (CSF) leaks pose significant risks to post-operative neurosurgical patients. has been limited investigation into post-operative CSF leak in trauma patients. The current study aims to provide an overview of the experience at a Canadian Level 1 Trauma Centre with neurosurgically managed traumatic brain injury (TBI) to improve understanding of prognostic factors for development of CSF leak and mortality among these patients.

Methods: A retrospective cohort study was performed at Hamilton General Hospital, a Level 1 Trauma Centre in Hamilton, Ontario. Univariate analyses were performed to determine potential prognostic factors for CSF leak and mortality. A multivariable analysis was conducted to determine prognostic factors for mortality among this cohort.

Results: A total of 211 patients were included in the analyses. Of these, 16 patients developed post-operative CSF leak. Univariate analyses determined fracture repair, presence of subdural haematoma or depressed skull fracture, penetrating injuries, mild TBI, increasing pre-operative midline shift, and re-operation were found to independently increase the risk of CSF leak. In-hospital mortality in our cohort was 36%. In univariate analyses increasing age, presence of subdural haematoma, pedestrian versus vehicle collision as mechanism of injury, and TBI severity were independently associated with mortality. In the multivariable analysis, only age and presenting GCS were found to significantly increase odds of mortality among our population. CSF leak was associated with a nearly 4-fold increase in odds of death, however this finding was not statistically significant.

Conclusion: Age and severity of TBI are important predictors of mortality in neurosurgically managed TBI patients. CSF leak may be an important predictor of mortality, warranting further investigation.

Introduction: Dystonia, a rare neurologic disorder causing involuntary muscle contractions, significantly impacts quality of life. While deep brain stimulation (DBS) of the globus pallidal internus (GPi) is an established treatment, limitations have led to exploring the Subthalamic nucleus (STN) as an alternative. Previous studies suggest STN DBS is effective, but evidence is limited due to uncontrolled designs. The multicentre, randomised, double-blind, sham-controlled trial aims to determine the effectiveness and safety of STN DBS. The study will enrol 38 patients with isolated segmental or generalised dystonia. Following lead implantation, participants will be randomly assigned to active or sham STN DBS for 6 months. The primary outcome measures the proportion of patients with ≥30% improvement in movement score on the BFMDRS. Secondary outcomes include safety, tolerability, and impact on quality of life, mental, motor, and cognitive status at multiple intervals. Results will be analyzed using logistic regression and other statistical models. The study will follow the Helsinki Declaration and has received ethical approval from five centres. Findings will be disseminated through peer-reviewed journals and conferences.

Trial registration number: NCT04650958.

Introduction: Deep brain stimulation (DBS) is an established treatment for movement disorders. However, there remains a wide variation in practice of surgical technique, such as the use of a stereotactic frame, robotic guidance, awake or asleep surgery, intraoperative imaging, and microelectrode recording (MER).

Research question: This report aims to share the surgical workflow and outcomes of the first 50 patients undergoing DBS at our institution.

Material and methods: This is a retrospective descriptive study including all patients who underwent DBS for movement disorders from November 2021 until November 2024. A description of the perioperative and intraoperative workflow is given. Patient demographics, pathology, surgical targets, and implant brands used are reported. Outcome measures including robotic registration accuracy, frequency of lead placement error requiring lead adjustment, complications, degree of symptom improvement following programming sessions, and neuropsychiatric and quality of life outcomes are reported.

Results: 50 consecutive patients were included in this study. 62% had a diagnosis of Parkinson's disease (PD), 28% dystonia, and 10% essential tremor (ET). 30% of patients required intraoperative adjustments to their lead placement, with 47% of these adjustments requiring adjustment to the trajectory. Patients with Globus Pallidus internus (GPi) targets had a higher odds of requiring an intraoperative adjustment to electrode depth, possibly to avoid the visual side effects from stimulation of the optic tracts. All patients had symptomatic improvement, and most patients with PD had improvements in mood and quality of life following DBS. 9 patients with PD had transient delirium post operatively, and 11 had small reductions in cognition at 6 months follow up that correlated with advanced age. There were no haemorrhagic complications, one patient required a reoperation for infection, and one patient required a reoperation due to late lead migration.

Discussion and conclusion: DBS surgery employing our workflow is safe, effective, and versatile.

Introduction: Primary spinal extradural cavernous haemangiomas (ECHs) are histologically benign but can behave aggressively by eroding the spine or compress neural elements. They are rare and can be mis-interpreted for other more common epidural lesions. Surgery is the gold standard in management. In this report, we highlight the diagnostic and intraoperative technical considerations needed to achieve a good clinical outcome. In addition, a comprehensive literature review was conducted.

Results: We report three cases (two males and one female) with an average age of 40 years. Two patients presented with radiculopathy and one patient presented with thoracic myelo-radiculopathy. The ECH location was cervico-thoracic in two patients and sacral in one. Pre-operative working radiological diagnosis of the cervico-thoracic lesion with homogenous contrast enhancement was haemangioma, while the other two were schwannoma. Two patients underwent pre-operative CT-guided biopsy, and the diagnosis was confirmed in one. Two patients underwent pre-operative catheter angiography, and embolisation was performed in one. All three patients had complete tumour resection with no recurrence on follow-up imaging (mean 33 months). The histology in all three cases confirmed cavernous haemangioma.

Conclusion: Although a rare entity, spinal ECH should be considered in the differential diagnosis of large extradural lesions that extend through the neural foramina. From a surgical viewpoint, wide bony exposure facilitates complete removal of these benign tumours and is associated with better outcomes. Whilst not mandatory, en bloc excisions can help reduce significant blood loss.