British Journal of Neurosurgery最新文献

Spinal arteriovenous fistulas represent a heterogenous group of pathologies and are divided into four categories. Type IV fistulas are further stratified into three groups (IVa, IVb and IVc) according to the number and dimensions of the fistulous vessels. Approximately 10% of these fistulas are associated with aneurysms. However, we are not aware of a previously reported case of an aneurysm associated with a Type IVa fistula with an anterior spinal artery (ASA) feeder at the cervico-medullary junction. We therefore describe our experience with a patient presenting with a ruptured aneurysm associated with a fistula in this location.

Colloid cysts (CCs) are usually small, benign lesions located at the foramen of Monro. They usually grow to a size of 1-3 cms. We have described here a giant colloid cyst of size 6 x 5.2 x 4.4 cm with a unique radiological appearance of multiple concentric layers with different intensities which has not been described before. This unusual appearance is most probably due to the variation of hydration between the different layers with gradually decreasing concentration of protein from centre to periphery, which correlated well with intraoperative and histopathological findings.

Background: Cancellation of elective operations during the COVID-19 pandemic has led to a significant increase in the number of patients waiting for treatment. In neurosurgery, treatment for spinal diseases, in particular, has been disproportionately delayed. We aim to describe the waiting list burden at our institution and forecast the time and theatre capacity required to return to pre-pandemic levels.

Methods: A retrospective evaluation of the waiting list records (both cranial and spinal), from January 2015-October 2022, inclusive, was conducted at a high-volume neurosciences centre. The average monthly decrease in the waiting list was calculated for the months since the waiting list was noted to fall consistently during or after the pandemic, as applicable. Five different scenarios were modelled to identify the time required to reduce the waiting list to the pre-pandemic level of December 2019. Data collection and analyses were performed on Excel (Microsoft).

Results: At the pre-pandemic threshold (December 2019), 782 patients were on the waiting list. Between January 2015-January 2020, inclusive, an average of 673 patients were on the waiting list but this has doubled over the subsequent months to a peak of 1388 patients in December 2021. Between December 2021-October 2022, on average, the waiting list reduced by 18 per month. At the current rate of change, the waiting list would fall to the pre-pandemic level by October 2024, an interval of 24 months. A seven-day service would require 18 months to clear the backlog. Doubling or tripling the current rate of change would require 12 months and 8 months, respectively.

Conclusions: Pre-existing, pandemic-related, and new NHS-wide challenges continue to have negative influences on reducing the backlog. Proposals for surgical hubs to tackle this carry the risks of removing staff from hospitals which cannot avoid emergency/urgent operating thereby further reducing those institutions' capacity to undertake elective work.

Background: Although resection of mesial temporal lobe lesions can be achieved with relatively low morbidity, resective surgery is not without risk. Whilst many lesions found in the anterior mesiotemporal lobe are low-grade entities, transforming and high-grade lesions have also been demonstrated. We investigate the feasibility of utilising serial quantitative volumetric imaging, to determine if a strategy of imaging surveillance can be safely employed for the management of radiologically diagnosed anterior mesial temporal low-grade tumours without a confirmed histological diagnosis.

Methods: A retrospective case-note and radiology review design were utilised. The primary presenting symptomatology was recorded together with the efficacy of symptomatic control. Volumetric analysis of MRI images was performed using Brainlab software. Pre- and post-operative neuropsychological data were analysed.

Results: 35 patients were identified with a radiological diagnosis of a low-grade anterior mesial temporal lobe tumour. Of these, 29% (n = 10) underwent surgical resection. For the whole cohort, the mean tumour volume at diagnosis was 6.5cm³, with a mean volumetric expansion of 1.4% per month. A significant difference was found between the volumetric expansion rate of those that underwent surgical treatment and those that did not (4.9% per month vs 0.06% per month, p < .01). Of those cases that did not undergo surgical resection, no significant difference was seen between the initial diagnostic volume and the volume at the time of their most recent interval surveillance scan (p = .97). New onset epilepsy was significantly associated with a requirement for eventual surgical tumour resection; relative risk = 6.25, 95% CI = 1.5-25.9, p = .0114.

Conclusion: Where medical seizure control is adequate, we suggest that conservative management is feasible even in the absence of a confirmed histological diagnosis. However, in patients aged over 50 years with new onset epilepsy, a lower threshold for intervention should be considered.

Background: In awake surgery, cortical mapping may identify the negative motor area (NMA). However, since speech arrest occurs regardless of whether the NMA or the frontal language area (FLA) is stimulated, the presence of speech arrest alone does not distinguish the NMA from the FLA. Furthermore, the exact location and function of the NMA is not well understood. The purpose of this study was to more accurately locate the NMA in a group of cases in which the NMA and FLA could be identified in different brain gyri, and to describe symptoms in cases in which the NMA was removed.

Methods: There were 18 cases of awake surgery at our institution between 2000 and 2013 in which cortical stimulation allowed identification of FLA and NMA in separate brain gyri. In these cases, the pre- and post-removal mapping results were projected onto a 3D model postoperatively. We investigated the symptoms and social rehabilitation in a case in which the tumour invaded the same brain gyrus as the NMA and the NMA had to be resected in combination with the tumour.

Results: In cases where the NMA and FLA could be identified in different brain gyri, NMA was localized inferior to the precentral gyrus in all cases. In four cases where NMA was removed with the tumour, apraxia of speech was observed during the surgery; the same symptoms persisted after it, but it improved within a few months, and the patients were able to return to work.

Conclusion: In cases where NMA and FLA could be identified separately by awake mapping, the NMA was commonly localized inferior to the precentral gyrus. When NMAs were resected in combination with tumour invasion, they did not lead to serious, long-term complications.

Background: Corpus callosotomy is a palliative surgery for medically refractory epilepsy. We aim to analyze the clinical features of patients with seizure freedom and failure after total corpus callosotomy for childhood-onset refractory epilepsy.

Methods: We retrospectively reviewed the clinical courses of patients with childhood-onset refractory epilepsy undergoing total corpus callosotomy between May 2009 and March 2019. Seizure outcome at the last follow-up was the primary outcome. The clinical features of patients with seizure freedom and failure after callosotomy were compared.

Results: Eighty patients with childhood-onset refractory epilepsy underwent total corpus callosotomy; 15 (18.8%) obtained freedom from all seizures and 19 (23.8%) had unworthwhile improvement and failure. The mean ages at seizure onset in patients with seizure freedom and failure after callosotomy were 5.7 and 5.9 years; and mean seizure durations were 9.4 and 11.5 years, respectively. Univariate analysis found epilepsy syndrome (p = 0.047), mental retardation (p = 0.007), previous medical history (p = 0.004), ≥10 seizures per day (p = 0.024), theta waves in the background electroencephalogram (p = 0.024), and acute postoperative seizure (p = 0.000) were associated with failure after callosotomy. Seizure freedom after callosotomy was more common among patients with less than 10 seizures per day.

Conclusions: Total corpus callosotomy is an effective palliative procedure for childhood-onset refractory epilepsy, particularly for patients with specific clinical characteristics. Callosotomy has a high seizure-free rate in well-selected patients.

Background: Central Nervous System (CNS) suppurative infections are serious but rare conditions in the paediatric population. Data on long-term neurocognitive and quality of life outcomes in children recovering from these infections are lacking.

Methods: A retrospective cohort review of children <16 years with non-sinogenic infections undergoing neurosurgery was conducted. Data for patients admitted to Children's Health Ireland at Temple St between 2008-2021 were analysed for clinical and microbiological profiles. Follow-up reviews evaluating neurological and academic sequelae and quality of life were performed. Categorical variables were analysed for unfavourable outcome with a p < 0.05 significance value.

Results: Forty patients were included with a mean age of 4.5 years and equal gender distribution. Fever (68%) and vomiting (58%) were the most common presenting complaints. Only fourteen (35%) patients presented with the classic triad of fever, headache, and focal neurological deficit. Meningitis/Encephalitis was the most common cause of suppurative infection (40%). Predisposing factors included congenital heart disease (18%), prematurity (15%) and immunocompromised status (10%). More patients received an initial Burr hole aspiration (73%) than Craniotomy (27%). The re-operation rate was higher in the craniotomy group (45%) compared to the burr hole group (34%), but this was not statistically significant (p = 0.522). Four patients died (10%) including two intra-hospital deaths (5%). Male gender (p = 0.047) and multiple abscesses (p = 0.041) were associated with unfavourable outcome at discharge. Mobility impairment was the most affected determinant of quality of life.

Conclusion: CNS suppurative infections are associated with long-term neurocognitive sequelae in children. Multiple abscesses and male gender are associated with unfavourable GOS on discharge. Children are still left with mobility impairment (25%), personality changes (23%) and intellectual disability (18%) at an average of 5 years. Long-term follow up with multidisciplinary input is required. Further research should focus on evaluating long-term HRQoL in children.

Background: The increased popularity of cycling is leading to an anticipated increase in cycling-related traffic accidents and a need to better understand the demographics and epidemiology of craniospinal injuries in this vulnerable road user group. This study aims to systematically investigate and characterise cycling-related head and spine injuries seen in the Major Trauma Centre for the Eastern region, which has the highest cycling rates in the UK.

Methods: We performed a retrospective cohort study comparing the incidence, patterns, and severity of head and spine injuries in pedal cyclists presenting to the Major Trauma Centre in Cambridge between January 2012 and December 2020. Comparisons of injury patterns, characteristics, and associations were made according to mechanism of injury, helmet use, patient age and gender.

Results: A total of 851 patients were admitted after being involved in cycling-related collisions over the study period, with 454 (53%) sustaining head or spine injuries. The majority of victims (80%) were male and in mid-adulthood (median age 46 years). Head injuries were more common than spine injuries, with the most common head injuries being intracranial bleeds (29%), followed by skull fractures (12%), and cerebral contusions (10%). The most common spine injuries were cervical segment fractures, particularly C6 (9%), C7 (9%), and C2 (8%). Motorised collisions had a higher prevalence of spine fractures at each segment (p < 0.001) and were associated with a higher proportion of multi-vertebral fractures (p < 0.001). These collisions were also associated with impaired consciousness at the scene and more severe systemic injuries, including a lower Glasgow coma scale (R = -0.23, p < 0.001), higher injury severity score (R = 0.24, p < 0.001), and longer length of stay (R = 0.21, p < 0.001). Helmet use data showed that lack of head protection was associated with more severe injuries and poorer outcomes.

Conclusion: As cycling rates continue to increase, healthcare providers may expect to see an increase in bicycle-related injuries in their practice. The insights gained from this study can inform the treatment of these injuries while highlighting the need for future initiatives aimed at increasing road safety and accident prevention.

Informed consent is an ethical and legal requirement integral to modern surgical practice. Clinicians have a duty to consider, disclose and discuss risks and concerns relevant to an individual patient. With medical advances there are now a significant number of animal-derived products and adjuncts available for use in modern neurosurgical practice, which may be relevant when consenting patients for specific procedures if such products are used. This paper highlights commonly used products in neurosurgery that contain animal-derived constituents with the aim of facilitating an informed discussion between the neurosurgeon and patient. We have reviewed the commonly used products in the centres of the authors and their commercial equivalents. The product information is taken from the manufacturer's instructions or the Federal Drug Administration documents regarding the product. Animal products commonly available to neurosurgeons can be broadly categorised into haemostatic agents, dural substitutes, dural sealants and bone cements. Many products contain a variety of animal (or human) derived products. In order to ensure informed consent and shared decision making, it is important to establish any relevant patient beliefs or views regarding the use of animal-derived products. Given the wide availability and use of neurosurgical adjuncts containing human or animal derived products, coupled with the heterogeneity within ethnic, religious, and social groups, each patient must be approached individually to ensure patient-specific concerns are identified and alternatives offered when appropriate.

Purpose Trochlear nerve schwannomas are rare tumors. So far, only 121 cases have been published. We present four new cases, discuss the imaging characteristics and summarize all previously published cases through a systematic review.Methods Four cases, all treated in AZ Sint-Jan Hospital Brugge-Oostende (Belgium), were collected, including their demographic, clinical and radiological data. All MR imaging was performed with the three-dimensional fluid-attenuated inversion recovery (3D-FLAIR), turbo spin echo T1 high-resolution (TSE T1 HR), three-dimensional balanced fast-field echo (3D b-FFE) and three-dimensional T1 black blood (3D T1 black blood) sequence. We compared our findings with the present literature through a systematic literature review in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines.Results Screening with routine unenhanced 3D-FLAIR imaging could identify all schwannomas as hyperintense lesions on the course of the trochlear nerve. The use of 3D T1 black blood sequences was superior in depicting the lesions, while high-resolution 3D b-FFE images enabled us to visualize the anatomic boundaries of the lesions in detail. Most trochlear schwannomas are located in the ambient cistern, at or just below the free edge of the tentorium.Conclusion The majority of trochlear nerve schwannomas are located cisternal and display variable enhancement on contrast administration. 3D-FLAIR imaging is superior in detecting these lesions. Comparison with data collected from previous cases demonstrates the importance of early diagnosis and treatment. Generally, patients with trochlear nerve schwannomas have a good prognosis.