De Novo Skull Base Atypical Meningioma: Incidence and Outcome

Objective  Atypical meningiomas are uncommon in skull base practice and present a management challenge. We aimed to review all de novo atypical skull base meningioma cases within a single unit to analyze presentation and outcome. Methods  A retrospective review of all patients undergoing surgery for intracranial meningioma identified consecutive cases of de novo atypical skull base meningioma. Electronic case records were analyzed for patient demographics, tumor location and size, extent of resection, and outcome. Tumor grading is based on the 2016 WHO criteria. Results  Eighteen patients with de novo atypical skull base meningiomas were identified. The most common tumor location was the sphenoid wing in 10 patients (56%). Gross total resection (GTR) was achieved in 13 patients (72%) and subtotal resection (STR) in 5 patients (28%). There was no tumor recurrence recorded in patients who had undergone GTR. Patients with tumors >6 cm were more likely to undergo a STR as opposed to a GTR ( p  < 0.01). Patients who had undergone a STR were more likely to have postoperative tumor progression and be referred for radiotherapy ( p  = 0.02 and <0.01, respectively). On multiple regression analysis, tumor size is the only significant factor correlating with overall survival ( p  = 0.048). Conclusion  The incidence of de novo atypical skull base meningioma is higher in our series than currently published data. Tumor size was a significant indicator for patient outcome and extent of resection. Those undergoing a STR were more likely to have tumor recurrence. Multicenter studies of skull base meningiomas with associated molecular genetics are needed to guide management.

414 Are Lumbar Drains Necessary in Endoscopic Transellar Surgery with an Intraoperative High Flow Leak? a Systematic Review

Aim

Perioperative lumbar drains have been used to facilitate healing of the dura and prevent postoperative cerebrospinal fluid (CSF) leaks. However, the use of perioperative lumbar drains is controversial and has primarily been left to the surgeon's preferences. Through the use of meta-analysis, we aim to find out whether lumbar drains effectively reduce the risk of postoperative CSF leak in the context of a high flow intraoperative leak.

Method

A systematic review was conducted using PRISMA guidelines. Databases used in literature searching include PubMed, Ovid (including Embase and Medline), Scopus and Cochrane Library. Articles published in 2006 or later were searched. The random-effects model was used in statistical analysis.

Results

A total of 2623 articles were identified. After screening and full-text reviews, 21 studies were included. From the quantitative data analysis, lumbar drains did not significantly lower the rates of postoperative CSF leaks. In addition, lumbar drains were associated with complications as well as a lengthier hospital stay.

Conclusions

Modern and rigorous repair techniques after endoscopic transsellar surgery are sufficient, and the use of lumbar drains is not necessary.

245 Changing Demographics of Head Injury During the COVID-19 Pandemic

Introduction

Studies have shown that men are more likely to sustain head injuries (HI) due to a higher likelihood of participation in high-risk behaviours. However, the COVID-19 lockdown caused substantial alterations to the daily routines of the Welsh population. We aimed to describe the demographical changes of HI patients caused by this large-scale restriction of public social activity.

Method

A retrospective review of our neurosurgical referral database was performed between 1/1/19 to 31/12/20 to extract patient demographics and referral outcomes (admission/advice only) of adult head injury patients. Referrals during lockdown in Wales (26/3/20 – 1/6/20 and 31/10/20 and 2/12/20) were compared with non-lockdown periods in 2019 and 2020.

Results

There was no significant difference in HI referral volume in 2019 (n = 1228) vs 2020 (n = 1179) (OR: 0.71; 95% CI: 0.53 – 0.96, p = 0.02). Women were less likely to be admitted in 2019 (OR: 0.60, 95%CI: 0.39 – 0.91, p = 0.02) and 2020 (OR: 0.52, 95%CI: 0.31–0.88, p = 0.01). We observed evidence of interaction by age and sex in lockdown vs non-lockdown (p = 0.02). Most strikingly, there was higher odds of admission in women aged 40–70 years during lockdown (OR: 10.4, 95%CI: 1.13 – 95.8, p = 0.04).

Conclusions

We observed significant demographical shifts in HI during lockdown periods, with striking increases in admission rates of men under 40 years and women aged 40–70. The cause of these substantial changes need clarification and have important public health implications. Given likely reduced road traffic accidents during lockdown, other factors such as alcohol or assault need considering.

P47 30 day readmission is not an accurate measure of morbidity in cranial meningioma surgery

Objectives

30 day readmission rate is a widely adopted marker of quality and performance of acute care, but validity is not well demonstrated. We analysed readmission data following cranial meningioma surgery to assess risk factors for readmission.

Design

Retrospective cohort study.

Subjects

All adult patients who underwent cranial meningioma resection from January 2015 to December 2017 in a single institution.

Methods

Using Welsh Clinical Portal electronic data to identify readmission within and beyond 30 days to both the index hospital and regional hospitals. Causes of readmission were recorded.

Results

160 patients were included (76% female, median age 58). 28 cases were emergency admissions, median length of initial admission 7 days. 26% had seizures at presentation. Total readmission rate was 13.5% (median age 54.5, pre-operative seizure rate 40.1%, median length of readmission 9 days). 13 (59%) patients presented within 30 days and 9 (41%)>30 days. Readmission causes were seizure, neurological deficit, thromboembolic, infection, CSF, bleeding and social. Causes after 30 days were the same except social or neurological deficit.

Conclusions

Readmission rates are not associated with age, admission route or initial length of stay. Those who have had seizures are more likely to be readmitted. 41% of readmissions presented outside of the 30 day post-operative time. 30 day readmission rates may not be the most suitable method to demonstrate neurosurgical unit performance in meningioma surgery.

P55 The neurosurgical physician: a new role in the UK

Objectives

With reduction in numbers of junior doctors and strict deanery requirements for training opportunities, the provision of ward cover and continuity has consistently fallen. Various methods of addressing this have been implemented in the UK, including increased nurse practitioners and physician associates. We introduced a new position of GP with a specialist neuroscience interest in line with the North American model of hospitalist and review the impact on patients and trainees.

Design

Qualitative descriptive study.

Subjects

14 core and speciality trainees.

Methods

Retrospective review of the impact of a permanent neurosurgical physician on ward care and provision of training with a qualitative study of trainee experience. Saturation was reached at 14 interviews.

Results

A neurosurgical physician role was instituted in 2013, enabling a formal training rota to fulfil deanery requirements for core training and provide continuity of care at senior medical level, reducing medical ward consults to zero, improved communication with relatives and reduced the need for ST ward rounds. Qualitative assessment revealed a senior medical presence aided trainees own knowledge, resulted in better rapport and communication with patients and improved patient care through knowledge of best medical practice guidelines.

Conclusions

The addition of the neurosurgical physician role has positively impacted on the quality of patient care and junior doctor training. Senior medical care is provided with continuity, in contrast to other models.

TM1-2 Diffuse low grade glioma after the 2016 WHO update, seizure characteristics, imaging correlates and outcomes

Objectives

Seizures are a common presenting symptom in patients with low grade glioma (LGG). Exact mechanisms of epileptogenesis are unknown and the influence of radiological and histological characteristics are not well studied, particularly after the 2016 WHO reclassification of gliomas. We aimed to define predictors of seizure development and outcome in patients with LGG.

Design

Retrospective single institution case series.

Subjects

63 patients who underwent resection of supratentorial LGG in a single institution, 45 presented with seizures.

Methods

Retrospective analysis of patient records to assess seizure outcome and other demographics including radiological variables, tumour characteristics, type of surgery and histology based on the 2016 WHO update.

Results

After surgery, 33 patients (73%) who presented with seizures were Engel class I at median follow up of 43 months. Complete and near total resection were associated with improved Engel class compared to subtotal resection. Awake craniotomy gave improved seizure outcomes compared to under general anaesthesia (84% vs 65%). Molecular genetics did not predict seizure outcome. Updated histology did not predict seizures at diagnosis, only tumour heterogeneousity on initial MRI (p=0.043). Tumour volume at presentation impacted EOR but not seizure outcome.

Conclusions

Seizure outcome is directly related to EOR. Tumour histology based on molecular genetics did not predict seizure development or outcome. Use of awake craniotomy results in greater EOR and improved Engel class.

P44 Is restoration of pituitary function a realistic goal in endoscopic pituitary surgery?

Objectives

The ability to restore pituitary function after endoscopic transsphenoidal surgery (ETSS) in pituitary tumours causing hypopituitarism remains unclear. This study analyses patients that required steroid replacement therapy prior to ETSS, and reviews endocrine function postoperatively.

Methods

A prospectively held pituitary database was retrospectively analysed from May 2011 – July 2017 at a tertiary university hospital. Patients requiring steroids for hypopituitarism pre-operatively were included. Patient demographic data, tumour characteristics, and tumour hormonal profile were recorded.

Results

From a database of 156 patients, 28 (18%) were hypoadrenal pre-operatively and were included in the study. All patients underwent ETSS by a single neurosurgeon. The median age of patients was 56 years (range 17–81), whilst median follow-up was 48 months (range 6–78). 20 male patients and 8 female patients were included. All patients were established on steroid therapy preoperatively with either hydrocortisone (26 patients) or prednisolone (2 patients). 5 (18%) patients were able to stop steroid replacement postoperatively. The median time to cessation of steroid therapy was 4 months (range 2–16 months).

Conclusions

Restoration of pituitary function following ETSS surgery was only successful in a small number of patients despite meticulous gland preservation. Our results suggest that restoration of function in all patients undergoing ETSS is an unrealistic goal and patients should be counselled accordingly.

Pituitary xanthogranulomas: clinical features, radiological appearances and post-operative outcomes

BACKGROUND

Xanthogranulomas are inflammatory masses most commonly found at peripheral sites such as the skin. Sellar and parasellar xanthogranulomas are rare and present a diagnostic challenge as they are difficult to differentiate from other sellar lesions such as craniopharyngiomas and Rathke's cleft cysts pre-operatively. Their radiological imaging features are yet to be clearly defined, and clinical outcomes after surgery are also uncertain. This study reviews clinical presentation, radiological appearances, and clinical outcomes in a cohort of patients with pituitary xanthogranulomas.

METHODS

A prospectively maintained pituitary surgery database was screened for histologically confirmed pituitary xanthogranulomas between May 2011-December 2016. Retrospective case note assessments were then performed by three independent reviewers. Patient demographics, clinical presentations, imaging, and clinical outcomes were analysed.

RESULTS

During the study period 295 endoscopic endonasal pituitary surgeries were performed. Six patients had confirmed pituitary xanthogranulomas (2%). Patients most commonly presented with visual field deficits and/or endocrine dysfunction. Common imaging features included: a cystic consistency, hyperintensity on T1-weighted MR images, and contrast enhancement either peripherally (n = 3) or homogenously (n = 3). The most common pre-operative endocrine deficits were hyperprolactinaemia and hypoadrenalism (at least one of which was identified in 4/6 patients; 66%). Thirty-three percent (2/6) of patients presented with diabetes insipidus. The most common post-operative endocrinological deficits were adrenocortical dysfunction (66%) and gonadotropin deficiency (66%). Visual assessments normalised in all six patients post-operatively. Gross total resection was achieved in all patients, and at median follow up of 33.5 months there were no cases of tumour recurrence.

CONCLUSIONS

The prevalence of pituitary xanthogranulomas in our series is higher than that suggested in the literature. Surgery restored normal vision to all cases, however four patients (67%) required long-term hormonal replacement post-operatively. Imaging features such peripheral rim enhancement, a suprasellar tumour epicentre, and the absence of both calcification or cavernous sinus invasion were identified as potential indicators that together should alert clinicians to the possibility of pituitary xanthogranuloma when assessing patients with cystic sellar and parasellar tumours.

How have changes to out-of-hours primary care services since 2004 affected emergency department attendances at a UK District General Hospital? A longitudinal study

BACKGROUND

The delivery of out-of-hours primary medical care in the United Kingdom has changed substantially since 2004, and there has been little examination of the effect that this has on secondary care.

AIM

The authors aimed to quantify the change in patient type presenting to our emergency department.

METHODS

In this study, routinely collected coding data before, during and after the changes were analysed. Each September and October between 1999 and 2006 were included.

RESULTS

There was a steady increase in all attendances at our emergency department. The number and proportions of patients with non-traumatic conditions rose steadily throughout the study period. The number of patients presenting with traumatic conditions stayed the same. The number of patients presenting with non-traumatic conditions out-of-hours rose after the changes were implemented.

INTERPRETATION

The changes to the provision of out-of-hours primary care have been associated with an increase in patients with non-traumatic attendances presenting to our emergency department. This effect is most marked outside of office hours.

Short communication: Genetic and nongenetic factors influencing Ostertagia ostertagi antibodies in UK Holstein-Friesian cattle

The purpose of this study was to estimate and discuss the genetic variation, heritability, and effects of nongenetic factors on the ability of Holstein-Friesian cows to produce an immune response by producing IgG antibodies to Ostertagia ostertagi. Total IgG (IgG(1) and IgG(2)) antibody levels were determined using an ELISA and measured using optical density ratio (ODR=OD(sample) - OD(negative control)/OD(positive control) - OD(negative control)) from milk samples collected from 1,276 Holstein-Friesian cattle in 229 commercial dairy farms from 2002 to 2004 during their first (82%) and other (2 to 12) lactations. A sire (n=461) model was fitted to the ODR data using ASREML software, and variance components were estimated. The ability to produce O. ostertagi antibodies as measured by ODR had a heritability of 0.13+/-0.12, and both season of sample and herd had a significant effect on total IgG levels. To conclude, this study has ascertained that genetic variation is present in the ability of dairy cows to mount an immune response to the parasite O. ostertagi. Inasmuch as evidence exists that IgG is linked to protective immunity against the parasite via a reduction in its reproductive ability, this trait may be of potential interest to genetic selection programs as an aid to reduce the effect of O. ostertagi in dairy herds.

Stereotactic radiosurgery and vestibular schwannoma: hydrocephalus associated with the development of a secondary arachnoid cyst. A report of two cases and review of the literature

Stereotactic radiosurgery for vesibular schwannoma requires long-term follow-up with complete MR imaging. We report two cases of a large secondary arachnoid cyst developing in the cerebellopontine angle following stereotactic radiosurgery. In one case this was associated with progressive ventriculomegaly and the onset of symptomatic hydrocephalus requiring emergency treatment. The second patient had ventriculomegaly at diagnosis, but developed an arachnoid cyst following treatment. Although both arachnoid cysts and hydrocephalus may also occur spontaneously in patients with vestibular schwanomma, the incidence is higher after stereotactic radiosurgery. As both complications may be associated with sudden clinical deterioration, follow-up with full cranial T1 and T2 weighted MR imaging is required to reveal these complications, in addition to assessing tumour response.

Metabolic Regulation in Danish Bull Calves and the Relationship to the Fertility of Their Female Offspring

The objective of this work was to estimate the genetic variation of free fatty acids (FFA), glucose, growth hormone (GH), and insulin in juvenile male dairy calves and to assess the relationships, if present, with the fertility of their female offspring. This study used data from 1,498 (269.5 d of age +/- 11.1) male calves from a multiple ovulation and embryo transfer breeding scheme (data collected from 1997 to 2002). Calves were Danish Holstein (n = 1,047), Danish Jersey (n = 200), and Red Dane (n = 251), and were sampled following an overnight fast at approximately 9 mo of age. Plasma samples were assayed for basal FFA, glucose, GH, and insulin. Estimated breeding values of female fertility (high values indicating better fertility), based on progeny-test results for approximately 100 daughters per sire, were available for a subset (n = 810) of the male calves as adult sires. Data from Danish Holstein alone or Danish Holstein, Red Dane, and Danish Jersey combined (all breeds) were analyzed for each trait. In both data sets, the estimates of heritabilities of glucose (0.27 +/- 0.06), FFA (0.11 +/- 0.05), and insulin (0.21 +/- 0.06) were moderate, and that of GH (0.09 +/- 0.05) was low. Correlations of estimated breeding values for fertility traits with glucose and FFA breeding values were negative, indicating that male calves with high glucose or FFA had female offspring with reduced fertility. Selection for bull calves with lower concentrations of glucose and FFA following an overnight fast could result in female offspring with genetically better fertility. Glucose and FFA may therefore be of interest to enhance selection for improved female fertility, as a measurement in young bulls.

The role of endoscopic third ventriculostomy in the management of hydrocephalus associated with cerebellopontine angle tumours

BACKGROUND

Progressive hydrocephalus secondary to cerebellopontine angle tumours has been traditionally managed with ventriculo-peritoneal shunting. Endoscopic third ventriculostomy provides an alternative treatment option and the success rate in this patient group has not previously been reported.

METHODS

We report a retrospective series of 11 patients with cerebello-pontine angle tumours who presented with symptomatic hydrocephalus, or developed hydrocephalus following radiosurgery, who underwent endoscopic third ventriculostomy.

RESULTS

Seven patients (63.6%) remain shunt free. There were no complications following endoscopy in any patient. Where the ventriculostomy failed there was no additional morbidity.

CONCLUSIONS

Endoscopic third ventriculostomy is a low morbidity procedure, which avoids the inherent problems of shunts, particularly infection and should be considered for patients with hydrocephalus and cerebello-pontine angle tumours.

Can a senior house officer's time be used more effectively?

OBJECTIVES

To determine the amount of time senior house officers (SHO) spent performing tasks that could be delegated to a technician or administrative assistant and therefore to quantify the expected benefit that could be obtained by employing such physicians' assistants (PA).

METHODS

SHOs working in the emergency department were observed for one week by pre-clinical students who had been trained to code and time each task performed by SHOs. Activity was grouped into four categories (clinical, technical, administrative, and other). Those activities in the technical and administrative categories were those we believed could be performed by a PA.

RESULTS

The SHOs worked 430 hours in total, of which only 25 hours were not coded due to lack of an observer. Of the 405 hours observed 86.2% of time was accounted for by the various codes. The process of taking a history and examining patients accounted for an average of 22% of coded time. Writing the patient's notes accounted for an average of 20% of coded time. Discussion with relatives and patients accounted for 4.7% of coded time and performing procedures accounted for 5.2% of coded time. On average across all shifts, 15% of coded time was spent doing either technical or administrative tasks.

CONCLUSION

In this department an average of 15% of coded SHOs working time was spent performing administrative and technical tasks, rising to 17% of coded time during a night shift. This is equivalent to an average time of 78 minutes per 10 hour shift/SHO. Most tasks included in these categories could be performed by PAs thus potentially decreasing patient waiting times, improving risk management, allowing doctors to spend more time with their patients, and possibly improving doctors' training.

Elevated, straight-arm traction for supracondylar fractures of the humerus in children

Between January 1995 and December 2000, 112 children with a closed displaced supracondylar fracture of the humerus without vascular deficit, were managed by elevated, straight-arm traction for a mean of 22 days. The final outcome was assessed using clinical (flexion-extension arc, carrying angle and residual rotational deformity) and radiographic (metaphyseal-diaphyseal angle and humerocapitellar angle) criteria. Excellent results were achieved in 71 (63%) patients, 33 (29%) had good results, 5 (4.4%) fair, and 3 (2.6%) poor. All patients with fair or poor outcomes were older than ten years of age. Elevated, straight-arm traction is safe and effective in children younger than ten years. It can be effectively used in an environment that can provide ordinary paediatric medical care and general orthopaedic expertise. The outcomes compare with supracondylar fractures treated surgically in specialist centres.

Elevated, straight-arm traction for supracondylar fractures of the humerus in children

Between January 1995 and December 2000, 112 children with a closed displaced supracondylar fracture of the humerus without vascular deficit, were managed by elevated, straight-arm traction for a mean of 22 days. The final outcome was assessed using clinical (flexion-extension arc, carrying angle and residual rotational deformity) and radiographic (metaphyseal-diaphyseal angle and humerocapitellar angle) criteria. Excellent results were achieved in 71 (63%) patients, 33 (29%) had good results, 5 (4.4%) fair, and 3 (2.6%) poor. All patients with fair or poor outcomes were older than ten years of age.

Elevated, straight-arm traction is safe and effective in children younger than ten years. It can be effectively used in an environment that can provide ordinary paediatric medical care and general orthopaedic expertise. The outcomes compare with supracondylar fractures treated surgically in specialist centres.