British Journal of Neurosurgery最新文献

The impact of Covid-19 on surgical patients worldwide has been substantial. In the United Kingdom (UK) and the Republic of Ireland (RoI), the first wave of the pandemic occurred in March 2020. The aims of this study were to: (1) evaluate the volume of neurosurgical operative activity levels, Covid-19 infection rate and mortality rate in April 2020 with a retrospective cross-sectional cohort study conducted across 16 UK and RoI neurosurgical centres, and (2) compare patient outcomes in a single institution in April-June 2020 with a comparative cohort in 2019. Across the UK and RoI, 818 patients were included. There were 594 emergency and 224 elective operations. The incidence rate of Covid-19 infection was 2.6% (21/818). The overall mortality rate in patients with a Covid-19 infection was 28.6% (6/21). In the single centre cohort analysis, an overall reduction in neurosurgical operative activity by 65% was observed between 2020 (n = 304) and 2019 (n = 868). The current and future impact on UK neurosurgical operative activity has implications for service delivery and neurosurgical training.

Background: Ventriculomegaly is common in aneurysmal subarachnoid haemorrhage (aSAH). An imaging measure to predict the need for cerebrospinal fluid (CSF) diversion may be useful. The bicaudate index (BCI) has been previously applied to aSAH. Our aim was to derive and test a threshold BCI above which CSF diversion may be required.

Methods: Review of prospective registry. The derivation group (2009-2015) included WFNS grade 1-2 aSAH patients who deteriorated clinically, had a repeat CT brain and underwent CSF diversion. BCI was measured on post-deterioration CTs and the lower limit of the 95% confidence interval (95%CI) was the hydrocephalus threshold. In a separate test group (2016), in WFNS ≥ 2 patients, we compared BCI on diagnostic CTs with CSF diversion within 24 hours.

Results: The derivation group (n = 62) received an external ventricular (n = 57, 92%) or lumbar drain (n = 5, 8%). Mean post-deterioration BCI was 0.19 (95%CI 0.17-0.22) for age ≤49 years, 0.22 (95%CI 0.20-0.23) for age 50-64 years and 0.24 (95%CI 0.22-0.27) for age ≥65 years. Hydrocephalus thresholds were therefore 0.17, 0.20 and 0.22, respectively. In the test group (n = 105), there was no significant difference in BCI on the diagnostic CT between good and poor grade patients aged ≤49 years (p = 0.31) and ≥65 years (p = 0.96). 30/66 WFNS ≥ 2 patients underwent CSF diversion, although only 15/30 (50%) exceeded BCI thresholds for hydrocephalus.

Conclusion: A significant proportion of aSAH patients may undergo CSF diversion without objective evidence of hydrocephalus. Our threshold values require further testing but may provide an objective measure to aid clinical decision making in aSAH.

Objectives: This study was a retrospective study to investigate factors related to difficult tracheostomy decannulation, and to evaluate outcomes of tracheostomized neurosurgical patients.

Methods: All consecutive tracheostomized neurosurgical patients in the Prince of Wales Hospital between 1st September 2016 and 31st August 2019 were reviewed retrospectively. Patients were grouped into easy decannulation and difficult decannulation groups using 3 months as cut-off time. Risk factors were analysed and outcomes were compared.

Results: One hundred thirty-one patients were included. In univariate analyses, male gender, GCS less than or equal to 8 on admission, the presence of vocal cord palsy at 3 months, and pneumonia within 1-month post-tracheostomy were associated with difficult decannulation. In multivariable logistic regression for difficult decannulation, GCS on admission, the presence of vocal cord palsy at 3 months, and the presence of pneumonia within 1-month post-tracheostomy remained statistically significant. The easy decannulation group had a shorter length of in-patient stay, higher survival rate, and more favourable neurological outcome (GOS 4-5) than the difficult decannulation group at both 6 months and 1 year. The majority of easy decannulation group patients (54%) were discharged to home, while the majority of the difficult decannulation group (42%) of patients were discharged to the infirmary.

Conclusion: GCS less than or equal to 8 on admission, the presence of vocal cord palsy, and the presence of pneumonia were associated with difficult tracheostomy decannulation in neurosurgical patients. Difficult decannulation is associated with a longer length of in-patient stay and poor neurological outcomes.

Introduction: Although rare, injury to the internal carotid artery (ICA) during pituitary surgery may result in serious morbidity such as stroke or death. This case series explores a single centre's incidence and outcomes of ICA injury during endoscopic transsphenoidal pituitary surgery, discusses the current management options, and introduces the 'muscle wonton' (morcellised muscle wrapped in a single sheet of Surgicel^®) as being a viable repair option.

Methods: All patients undergoing pituitary operations from January 2010 to December 2019 at the Queen Elizabeth Hospital, Birmingham, UK were included. Primary outcome was number of internal carotid artery injuries during pituitary surgery. Secondary outcome measures included pre-operative (demographic, risk factors such as previous radiotherapy, number of previous operations, imaging available), operative (intra-operative image guidance, intra-operative doppler ultrasound, which side ICA was damaged, repair technique) and post-operative result (death, cranial nerve VI palsy, or stroke).

Results: 7 out of 893 patients (0.8%) were identified as having an ICA injury. Four of the injuries were left sided. Average age was 54 years old, five were male. In four of the ICA injuries intra-operative navigation imaging was used, and a further two concurrently used ultrasound doppler. Three of the seven cases resulted in permanent morbidity (stroke). There were no other consistent demographic, pre-operative, operative, or post-operative similarities. The two patients with muscle wonton repair suffered no permanent serious complication of ICA injury (i.e. death, abducens nerve palsy, stroke).

Discussion: Our findings resemble the current literature, with left sided ICA injury being more common. Different methods for repairing ICA injury exist, however morcellised muscle patches have shown significant promise in animal models, and the perforated Surgicel^® helps create an easy delivery method. The muscle wonton is a viable surgical option for repairing ICA injuries during pituitary surgery.

Ganglioglioma is a rare primary tumour of the central nervous system, which characteristically contain both neuronal and glial neoplastic components mainly in children and adolescents. The most common clinical presentation is refractory epilepsy. The imaging findings of ganglioglioma are obvious and varied. However, ganglioglioma with normal neuroimaging is rare. We report a 12-year-old boy presented with intractable focal epilepsy with normal CT and almost negative MRI. The epileptogenic focus was found to be located in the left posterior superior temporal gyrus by comprehensive evaluation including PET-CT imaging and stereo electroencephalography monitoring. The epileptogenic focus was resected, and the histological examination of the surgical specimen confirmed ganglioglioma. He was seizure-free at last follow-up 14 months after surgery.

Background and importance: One of the most feared and devastating complications of carotid revascularization procedures is hyperperfusion hemorrhage. The acute onset of an ipsilateral mydriatic pupil following carotid endarterectomy (CEA) or carotid artery stenting (CAS) should prompt immediate neurosurgical evaluation to rule out hyperperfusion injury.

Clinical presentation: We describe a case of benign, transient ipsilateral mydriasis following CAS. After undergoing right common and internal carotid artery (ICA) angioplasty and stenting with distal embolic protection, the patient developed anisocoria with a right-sided 5 mm minimally reactive pupil. Imaging demonstrated no acute pathology, and the mydriasis resolved spontaneously within 48 hours. We hypothesise that the pathophysiologic mechanism is secondary to transient ischemia of parasympathetic structures within the petrous/cavernous ICA from arterial ostium occlusion that occurred during device placement. Alternatively, sympathetic stimulation during angioplasty is also plausible.

Conclusions: Although an ipsilateral mydriatic pupil following carotid revascularization necessitates evaluation, it may represent a self-limiting process especially in the absence of other focal neurologic deficits.

Programmable variable pressure valves were introduced in the 1980s, providing a non-invasive solution to post-operative alterations of the valve opening pressure to address problems of under or overdrainage. Since their increased use in the treatment of hydrocephalus, there have been case reports of unintentional alterations of the valve opening pressure following exposure to magnetic fields in everyday environments, from televisions to rollercoasters. Here we describe two cases of patients' programmable valves being altered following audiology assessments. We subsequently discuss some of the available research on the safety of these valves in various magnetic field strengths, alongside interim and updated recommendations made by the British Society of Audiologists with regards to testing of children with programmable shunts in place.

Background: This study investigated the influence of periprocedural hemorrhage and clinical outcomes with an endovascular therapeutic strategy for cerebellar arteriovenous malformations (cAVMs).

Methods: From December 2006 to January 2018, 125 cAVMs were classified as types I-IV and received endovascular embolization via Onyx or Glubran 2. The risk factors of hemorrhage were analyzed using univariate and multivariate logistic analyses. A modified Rankin Scale (mRS) score was used to evaluate the neurological function before and 1 year after the operation. Results Of 125 patients, 63 had type I cAVMs, 2 type II cAVMs, 48 type III cAVMs, and 12 type IV cAVMs. A total of 88 (70.4%) patients had clinical manifestations of intracranial hemorrhage. Multivariate logistic regression analysis showed that age (OR, 2.276; 95% CI, 1.132 - 5.663), flow-related aneurysm (OR, 2.845; 95% CI, 1.265 - 6.248), lesion size (OR, 3.005; 95% CI, 1.119 - 5.936), and the number of feeding arteries (OR, 0.105; 95% CI, 0.081 - 0.312) were still the significant independent risk factors of intracranial hemorrhage. During a 1-year follow-up, 109 patients (87.2%) had good outcomes (mRS 0 - 2), 12 patients (9.6%) had poor outcomes (mRS 3 - 4), 4 patients (3.2%) died, and 3 patients had intracranial hemorrhage due to the incomplete embolization of cAVMs.

Conclusions: Endovascular embolization is a feasible treatment for cAVMs. Age, flow-related aneurysm, lesion size, and the number of feeding arteries are the significant risk factors of periprocedural hemorrhage. Moreover, the lesion characteristics must be given full consideration when using Onyx or Glubran 2 before cAVMs embolization.

This case study presents a 47-year-old male who was diagnosed with Gorham-Stout syndrome (GSS) 10 years ago in the occipitocervical junction. The pathology caused the resorption of the suboccipital bone, clivus, foramen magnum, and C1-C3 laminae. After his first fusion attempt in 2010 using occipital plate-cervical lateral mass screws, he needed many revision surgeries either for the progression of the pathology or for instrumentation failure and wound healing problems. Eventually, a new occipital plate and cervical pedicle screws were applied to obtain the exact solution. The involvement of the craniovertebral junction in GSS may be challenging for spinal surgeons due to the inadequate bone reserve for stabilization. As lateral mass screws cannot provide a strong pull-out force, cervical pedicular screws may be used as the first choice for unstable cervical GSS cases.