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Eriksson M, Hayat R, Kinsella E, Lewis K, White DCS, Boyd J, Bullen A, Maclean M, Stoddart A, Phair S, Evans H, Noakes J, Alexander D, Keerie C, Linsley C, Milne G, Norrie J, Farrar N, Realpe AX, Donovan JL, Bunch J, Douthwaite K, Temple S, Hogg J, Scott D, Spallone P, Stuart I, Wardlaw JM, Palmer J, Sakka E, Mukerji N, Cirstea E, Davies S, Giannakaki V, Kadhim A, Kennion O, Islam M, Ferguson L, Prasad M, Bacon A, Richards E, Howe J, Kamara C, Gardner J, Roman M, Sikaonga M, Cahill J, Rossdeutsch A, Cahill V, Hamina I, Chaudhari K, Danciut M, Clarkson E, Bjornson A, Bulters D, Digpal R, Ruiz W, Taylor M, Anyog D, Tluchowska K, Nolasco J, Brooks D, Angelopoulou K, Welch B, Broomes N, Fouyas I, MacRaild A, Kaliaperumal C, Teasdale J, Coakley M, Brennan P, Sokol D, Wiggins A, MacDonald M, Risbridger S, Bhatt P, Irvine J, Majeed S, Williams S, Reid J, Walch A, Muir F, van Beijnum J, Leach P, Hughes T, Makwana M, Hamandi K, McAleer D, Gunning B, Walsh D, Wroe Wright O, Patel S, Gurusinghe N, Raza-Knight S, Cromie TL, Brown A, Raj S, Pennington R, Campbell C, Patel S, Colombo F, Teo M, Wildman J, Smith K, Goff E, Stephens D, Borislavova B, Worner R, Buddha S, Clatworthy P, Edwards R, Clayton E, Coy K, Tucker L, Dymond S, Mallick A, Hodnett R, Spickett-Jones F, Grover P, Banaras A, Tshuma S, Muirhead W, Scott Hill C, Shah R, Doke T, Hall R, Coskuner S, Aslett L, Vindlacheruvu R, Ghosh A, Fitzpatrick T, Harris L, Hayton T, Whitehouse A, McDarby A, Hancox R, Auyeung CK, Nair R, Thomas R, McLachlan H, Kountourgioti A, Orjales G, Kruczynski J, Hunter S, Bohnacker N, Marimon R, Parker L, Raha O, Sharma P, Uff C, Boyapati G, Papadopoulos M, Kearney S, Visagan R, Bosetta E, Asif H, Helmy A, Chapas L, Tarantino S, Caldwell K, Guilfoyle M, Agarwal S, Brown D, Holland S, Tajsic T, Fletcher C, Sebyatki A, Ushewokunze S, Ali S, Preston J, Chambers C, Patel M, Holsgrove D, McLaughlan D, Marsden T, Colombo F, Cawley K, Raffalli H, Lee S, Israni A, Dore R, Anderson T, Hennigan D, Mayor S, Glover S, Chavredakis E, Brown D, Sokratous G, Williamson J, Stoneley C, Brodbelt A, Farah JO, Illingworth S, Konteas AB, Davies D, Owen C, Kerr L, Hall P, Al-Shahi Salman R, Forsyth L, Lewis SC, Loan JJM, Neilson AR, Stephen J, Kitchen N, Harkness KA, Hutchinson PJA, Mallucci C, Wade J, White PM. Medical management and surgery versus medical management alone for symptomatic cerebral cavernous malformation (CARE): a feasibility study and randomised, open, pragmatic, pilot phase trial. Lancet Neurol 2024; 23:565-576. [PMID: 38643777 DOI: 10.1016/s1474-4422(24)00096-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND The highest priority uncertainty for people with symptomatic cerebral cavernous malformation is whether to have medical management and surgery or medical management alone. We conducted a pilot phase randomised controlled trial to assess the feasibility of addressing this uncertainty in a definitive trial. METHODS The CARE pilot trial was a prospective, randomised, open-label, assessor-blinded, parallel-group trial at neuroscience centres in the UK and Ireland. We aimed to recruit 60 people of any age, sex, and ethnicity who had mental capacity, were resident in the UK or Ireland, and had a symptomatic cerebral cavernous malformation. Computerised, web-based randomisation assigned participants (1:1) to medical management and surgery (neurosurgical resection or stereotactic radiosurgery) or medical management alone, stratified by the neurosurgeon's and participant's consensus about the intended type of surgery before randomisation. Assignment was open to investigators, participants, and carers, but not clinical outcome event adjudicators. Feasibility outcomes included site engagement, recruitment, choice of surgical management, retention, adherence, data quality, clinical outcome event rate, and protocol implementation. The primary clinical outcome was symptomatic intracranial haemorrhage or new persistent or progressive non-haemorrhagic focal neurological deficit due to cerebral cavernous malformation or surgery during at least 6 months of follow-up. We analysed data from all randomly assigned participants according to assigned management. This trial is registered with ISRCTN (ISRCTN41647111) and has been completed. FINDINGS Between Sept 27, 2021, and April 28, 2023, 28 (70%) of 40 sites took part, at which investigators screened 511 patients, of whom 322 (63%) were eligible, 202 were approached for recruitment, and 96 had collective uncertainty with their neurosurgeon about whether to have surgery for a symptomatic cerebral cavernous malformation. 72 (22%) of 322 eligible patients were randomly assigned (mean recruitment rate 0·2 [SD 0·25] participants per site per month) at a median of 287 (IQR 67-591) days since the most recent symptomatic presentation. Participants' median age was 50·6 (IQR 38·6-59·2) years, 68 (94%) of 72 participants were adults, 41 (57%) were female, 66 (92%) were White, 56 (78%) had a previous intracranial haemorrhage, and 28 (39%) had a previous epileptic seizure. The intended type of surgery before randomisation was neurosurgical resection for 19 (26%) of 72, stereotactic radiosurgery for 44 (61%), and no preference for nine (13%). Baseline clinical and imaging data were complete for all participants. 36 participants were randomly assigned to medical management and surgery (12 to neurosurgical resection and 24 to stereotactic radiosurgery) and 36 to medical management alone. Three (4%) of 72 participants withdrew, one was lost to follow-up, and one declined face-to-face follow-up, leaving 67 (93%) retained at 6-months' clinical follow-up. 61 (91%) of 67 participants with follow-up adhered to the assigned management strategy. The primary clinical outcome occurred in two (6%) of 33 participants randomly assigned to medical management and surgery (8·0%, 95% CI 2·0-32·1 per year) and in two (6%) of 34 participants randomly assigned to medical management alone (7·5%, 1·9-30·1 per year). Investigators reported no deaths, no serious adverse events, one protocol violation, and 61 protocol deviations. INTERPRETATION This pilot phase trial exceeded its recruitment target, but a definitive trial will require extensive international engagement. FUNDING National Institute for Health and Care Research.
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Loan JJM, Bacon A, van Beijnum J, Bhatt P, Bjornson A, Broomes N, Bullen A, Bulters D, Cahill J, Chavredakis E, Colombo F, Danciut M, Digpal R, Edwards RJ, Ferguson L, Forsyth L, Fouyas I, Ganesan V, Grover P, Gurusinghe N, Hall PS, Harkness K, Harris LS, Hayton T, Helmy A, Holsgrove D, Hutchinson PJ, Israni A, Kinsella E, Lewis S, Majeed S, Mallucci C, Mukerji N, Nair R, Neilson AR, Papadopoulos MC, Radatz M, Rossdeutsch A, Raza-Knight S, Stephen J, Stoddart A, Teo M, Turner C, Wade J, Walsh D, White D, White P, Wildman J, Wroe Wright O, Uff C, Ushewokunze S, Vindlacheruvu R, Kitchen N, Al-Shahi Salman R. Feasibility of comparing medical management and surgery (with neurosurgery or stereotactic radiosurgery) with medical management alone in people with symptomatic brain cavernoma - protocol for the Cavernomas: A Randomised Effectiveness (CARE) pilot trial. BMJ Open 2023; 13:e075187. [PMID: 37558454 PMCID: PMC10414059 DOI: 10.1136/bmjopen-2023-075187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/29/2023] [Indexed: 08/11/2023] Open
Abstract
INTRODUCTION The top research priority for cavernoma, identified by a James Lind Alliance Priority setting partnership was 'Does treatment (with neurosurgery or stereotactic radiosurgery) or no treatment improve outcome for people diagnosed with a cavernoma?' This pilot randomised controlled trial (RCT) aims to determine the feasibility of answering this question in a main phase RCT. METHODS AND ANALYSIS We will perform a pilot phase, parallel group, pragmatic RCT involving approximately 60 children or adults with mental capacity, resident in the UK or Ireland, with an unresected symptomatic brain cavernoma. Participants will be randomised by web-based randomisation 1:1 to treatment with medical management and with surgery (neurosurgery or stereotactic radiosurgery) versus medical management alone, stratified by prerandomisation preference for type of surgery. In addition to 13 feasibility outcomes, the primary clinical outcome is symptomatic intracranial haemorrhage or new persistent/progressive focal neurological deficit measured at 6 monthly intervals. An integrated QuinteT Recruitment Intervention (QRI) evaluates screening logs, audio recordings of recruitment discussions, and interviews with recruiters and patients/parents/carers to identify and address barriers to participation. A Patient Advisory Group has codesigned the study and will oversee its progress. ETHICS AND DISSEMINATION This study was approved by the Yorkshire and The Humber-Leeds East Research Ethics Committee (21/YH/0046). We will submit manuscripts to peer-reviewed journals, describing the findings of the QRI and the Cavernomas: A Randomised Evaluation (CARE) pilot trial. We will present at national specialty meetings. We will disseminate a plain English summary of the findings of the CARE pilot trial to participants and public audiences with input from, and acknowledgement of, the Patient Advisory Group. TRIAL REGISTRATION NUMBER ISRCTN41647111.
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Affiliation(s)
- James J M Loan
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | | | | | - Nicole Broomes
- University Hospital Southampton NHS Foundation Trust Wessex Neurological Centre, Southampton, UK
| | - Alistair Bullen
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Diederik Bulters
- University Hospital Southampton NHS Foundation Trust Wessex Neurological Centre, Southampton, UK
| | - Julian Cahill
- National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, UK
| | | | | | | | - Ronneil Digpal
- University Hospital Southampton NHS Foundation Trust Wessex Neurological Centre, Southampton, UK
| | | | | | - Laura Forsyth
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Ioannis Fouyas
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Vijeya Ganesan
- Developmental Neurosciences Department, Great Ormond Street Hospital for Children, London, UK
| | - Patrick Grover
- The National Hospital for Neurology & Neurosurgery, London, UK
| | | | - Peter S Hall
- Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | | | | | - Tom Hayton
- Queen Elizabeth Hospital, Birmingham, UK
| | - Adel Helmy
- Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge, UK
| | - Daniel Holsgrove
- Centre for Clinical Neurosciences, Salford Royal Hospital Manchester, Salford, UK
| | - Peter J Hutchinson
- Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge, UK
| | - Anil Israni
- Alder Hey Children's Hospital, Liverpool, UK
| | - Elaine Kinsella
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Steff Lewis
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | | | | | | | | | - Aileen R Neilson
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | | | - Matthias Radatz
- National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, UK
| | | | | | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Andrew Stoddart
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Mario Teo
- Department of Neurosurgery, Southmead Hospital, Bristol, UK
| | - Carole Turner
- Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge, UK
| | - Julia Wade
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, UK
| | - Daniel Walsh
- King's College Hospital, London, UK
- Institute of Psychiatry Psychology & Neuroscience, King's College London, London, UK
| | | | - Phil White
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Jack Wildman
- Department of Neurosurgery, Southmead Hospital, Bristol, UK
| | | | | | | | | | - Neil Kitchen
- The National Hospital for Neurology & Neurosurgery, London, UK
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
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Hall S, Abouharb A, Anderson I, Bacon A, Bahl A, Brydon H, Dow G, Fouyas I, Galea J, Ghosh A, Gurusinghe N, Kamel M, Minhas P, Mitchell P, Mowle D, Mukerji N, Nair R, Norris J, Patel H, Patel J, Patel K, St George J, Teo M, Toma A, Trivedi R, Uff C, Visca A, Walsh DC, White E, Whitfield P, Bulters D. A survey of the radiological follow-up of unruptured intracranial aneurysms in the United Kingdom. Br J Neurosurg 2023; 37:163-169. [PMID: 34738491 DOI: 10.1080/02688697.2021.1995587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Unruptured intracranial aneurysms (UIA) are common. For many the treatment risks outweigh their risk of subarachnoid haemorrhage and patients undergo surveillance imaging. There is little data to inform if and how to monitor UIAs resulting in widely varying practices. This study aimed to determine the current practice of unruptured UIA surveillance in the United Kingdom. METHODS A questionnaire was designed to address the themes of surveillance protocols for UIA including when surveillance is initiated, how frequently it is performed, and when it is terminated. Additionally, how aneurysm growth is managed and how clinically meaningful growth is defined were explored. The questionnaire was distributed to members of the British Neurovascular Group using probability-based cluster and non-probability purposive sampling methods. RESULTS Responses were received from 30 of the 30 (100.0%) adult neurosurgical units in the United Kingdom of which 27 (90.0%) routinely perform surveillance for aneurysm growth. Only four units had a unit policy. The mean patient age up to which a unit would initiate follow-up of a low-risk UIA was 65.4 ± 9.0 years. The time points at which imaging is performed varied widely. There was an even split between whether units use a fixed duration of follow-up or an age threshold for terminating surveillance. Forty percent of units will follow-up patients more than 5 years from diagnosis. The magnitude in the change in size that was felt to constitute growth ranged from 1 to 3mm. No units routinely used vessel wall imaging although 27 had access to 3T MRI capable of performing it. CONCLUSIONS There is marked heterogeneity in surveillance practices between units in the United Kingdom. This study will help units better understand their practice relative to their peers and provide a framework forplanning further research on aneurysm growth.
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Affiliation(s)
- Samuel Hall
- Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Ashraf Abouharb
- Department of Neurosurgery, Belfast Health and Social Care Trust, Belfast, UK
| | - Ian Anderson
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Andrew Bacon
- Sheffield Centre for Neurosurgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Anuj Bahl
- Department of Neurosurgery, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Howard Brydon
- Department of Neurosurgery, University Hospital of North Midlands NHS Trust, Stoke on Trent, UK
| | - Graham Dow
- Department of Neurosurgery, Queens Medical Centre, Nottingham, UK
| | - Ioannis Fouyas
- Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, UK
| | - James Galea
- Department of Neurosurgery, Cardiff and Vale University Health Board, Cardiff, UK
| | - Anthony Ghosh
- Department of Neurosurgery, Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - Nihal Gurusinghe
- Department of Neurourgery, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | | | - Pawan Minhas
- Department of Neurosurgery, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Patrick Mitchell
- Department of Neurosurgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - David Mowle
- Department of Neurosurgery, Ninewells Hospital and Medical School, Dundee, UK
| | - Nitin Mukerji
- Department of Neurosurgery, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Ramesh Nair
- Department of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
| | - John Norris
- Hurstwood Park Neurosciences Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Hiren Patel
- Department of Neurosurgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Jash Patel
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Krunal Patel
- Department of Neurosurgery, University Hospitals Coventry and Warwickshire, Coventry, UK
| | | | - Mario Teo
- Department of Neurosurgery, North Bristol NHS Trust, Bristol, UK
| | - Ahmed Toma
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Rikin Trivedi
- Department of Neurosurgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Chris Uff
- Department of Neurosurgery, Barts Health NHS Trust, London, UK
| | - Anna Visca
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Daniel C Walsh
- Department of Neurosurgery, King's College Hospital NHS Trust, London, UK
| | - Edward White
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Peter Whitfield
- Department of Neurosurgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Diederik Bulters
- Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
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Hannan CJ, Islim AI, Alalade AF, Bacon A, Ghosh A, Dalton A, Abouharb A, Walsh DC, Bulters D, White E, Chavredakis E, Kounin G, Critchley G, Dow G, Patel HC, Brydon H, Anderson IA, Fouyas I, Galea J, St George J, Bal J, Patel K, Kamel M, Teo M, Fanning N, Mukerji N, Grover P, Mitchell P, Whitfield PC, Trivedi R, Crockett MT, Brennan P, Javadpour M. Radiological follow-up of endovascularly treated intracranial aneurysms: a survey of current practice in the UK and Ireland. Acta Neurochir (Wien) 2023; 165:451-459. [PMID: 36220949 DOI: 10.1007/s00701-022-05379-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/27/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Due to the risk of intracranial aneurysm (IA) recurrence and the potential requirement for re-treatment following endovascular treatment (EVT), radiological follow-up of these aneurysms is necessary. There is little evidence to guide the duration and frequency of this follow-up. The aim of this study was to establish the current practice in neurosurgical units in the UK and Ireland. METHODS A survey was designed with input from interventional neuroradiologists and neurosurgeons. Neurovascular consultants in each of the 30 neurosurgical units providing a neurovascular service in the UK and Ireland were contacted and asked to respond to questions regarding the follow-up practice for IA treated with EVT in their department. RESULTS Responses were obtained from 28/30 (94%) of departments. There was evidence of wide variations in the duration and frequency of follow-up, with a minimum follow-up duration for ruptured IA that varied from 18 months in 5/28 (18%) units to 5 years in 11/28 (39%) of units. Young patient age, previous subarachnoid haemorrhage and incomplete IA occlusion were cited as factors that would prompt more intensive surveillance, although larger and broad-necked IA were not followed-up more closely in the majority of departments. CONCLUSIONS There is a wide variation in the radiological follow-up of IA treated with EVT in the UK and Ireland. Further standardisation of this aspect of patient care is likely to be beneficial, but further evidence on the behaviour of IA following EVT is required in order to inform this process.
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Affiliation(s)
| | | | | | - Andrew Bacon
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, UK
| | - Anthony Ghosh
- Department of Neurosurgery, Queen's Hospital Romford, Romford, UK
| | - Arthur Dalton
- Department of Neurosurgery, Charing Cross Hospital, London, UK
| | - Ashraf Abouharb
- Department of Neurosurgery, Royal Victoria Hospital, Belfast, UK
| | | | - Diederik Bulters
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
| | - Edward White
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Emmanouil Chavredakis
- Department of Neurosurgery, The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - George Kounin
- Department of Neurosurgery, Hull Royal Infirmary, Hull, UK
| | - Giles Critchley
- Department of Neurosurgery, University Hospitals Sussex, Brighton, UK
| | - Graham Dow
- Department of Neurosurgery, Queen's Medical Centre, Nottingham, UK
| | - Hiren C Patel
- Manchester Centre for Clinical Neurosciences, Manchester, UK
| | - Howard Brydon
- Department of Neurosurgery, Royal Stoke University Hospital, Stoke, UK
| | - Ian A Anderson
- Department of Neurosurgery, Leeds General Infirmary, Leeds, UK
| | - Ioannis Fouyas
- Department of Neurosurgery, Western General Hospital, Edinburgh, UK
| | - James Galea
- Department of Neurosurgery, University Hospital Wales, Cardiff, UK
| | - Jerome St George
- Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Jarnail Bal
- Department of Neurosurgery, Royal London Hospital, London, UK
| | - Krunal Patel
- Department of Neurosurgery, University Hospital Coventry, Coventry, UK
| | - Mahmoud Kamel
- Department of Neurosurgery, Cork University Hospital, Cork, Ireland
| | - Mario Teo
- Department of Neurosurgery, Southmead Hospital, Bristol, UK
| | - Noel Fanning
- Department of Neurosurgery, Cork University Hospital, Cork, Ireland
| | - Nitin Mukerji
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Patrick Grover
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Patrick Mitchell
- Department of Neurosurgery, Royal Victoria Infirmary, Newcastle, UK
| | - Peter C Whitfield
- South West Neurosurgery Centre, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Rikin Trivedi
- Department of Neurosurgery, Addenbrookes Hospital, Cambridge, UK
| | | | - Paul Brennan
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Mohsen Javadpour
- Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
- School of Medicine, Trinity College Dublin, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
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Gew J, Sokol D, Gallo P, Kandasamy J, Keston P, Downer J, Fouyas I, Kaliaperumal C. De novo distal middle cerebral artery aneurysm post-excision of intracerebral arteriovenous malformation in an 8-year old. Childs Nerv Syst 2019; 35:2211-2218. [PMID: 31401680 DOI: 10.1007/s00381-019-04328-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 07/28/2019] [Indexed: 11/27/2022]
Abstract
Cerebral arteriovenous malformations (AVMs) are frequently associated with concurrent aneurysms. These aneurysms are commonly haemodynamically related to the AVM and can be classified into extranidal or intranidal in reference to the AVM nidus. An aneurysm arising from an artery that does not angiographically contribute to the blood flow to the AVM is uncommon. A distal middle cerebral artery (dMCA) aneurysm itself is also a rare presentation, especially in paediatric population. We present a rare case of dMCA aneurysm that was noted after successful surgical management of a ruptured AVM in an 8-year-old child and its management. BACKGROUND: About 10-30% of patients with cerebral arteriovenous malformation (AVM) have an associated artery aneurysm. The majority of these aneurysms are flow-related to the malformation. These aneurysms can be classified into extranidal or intranidal in reference to the AVM nidus Rammos et al Am J Neuroradiol 37:1966-1971, [1]. An aneurysm arising from a different artery that does not angiographically contribute to the blood flow associated with the AVM is less common and would generally be regarded as unrelated to the AVM. Distal cerebral artery aneurysm itself is also a rare presentation, comprising of 1-7% of all middle cerebral artery aneurysm. In children, mycotic infection and dissection are the two most common causes for aneurysm in this location. Unlike in adults, berry aneurysms are uncommon in children. We describe a young patient who was found to have distal middle cerebral artery (dMCA) aneurysm in follow-up DSA (Digital Subtraction Angiogram) after the initial successful surgical treatment for a cerebral frontal AVM. In this particular case, endovascular repair is thought to be the best strategy to treat the aneurysm. However, there still remains a lack of consensus of the best management strategy (surgery or endovascular) in treating flow-related aneurysms in general. This is usually based on an individual case scenario and the treatment is tailored depending on various factors including the expertise of the treating team.
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Kalyvas AV, Hughes M, Koutsarnakis C, Moris D, Liakos F, Sakas DE, Stranjalis G, Fouyas I. Efficacy, complications and cost of surgical interventions for idiopathic intracranial hypertension: a systematic review of the literature. Acta Neurochir (Wien) 2017; 159:33-49. [PMID: 27830325 DOI: 10.1007/s00701-016-3010-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 10/27/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND To define the efficacy, complication profile and cost of surgical options for treating idiopathic intracranial hypertension (IIH) with respect to the following endpoints: vision and headache improvement, normal CSF pressure restoration, papilloedema resolution, relapse rate, operative complications, cost of intervention and quality of life. METHODS A systematic review of the surgical treatment of IIH was carried out. Cochrane Library, MEDLINE and EMBASE databases were systematically searched from 1985 to 2014 to identify all relevant manuscripts written in English. Additional studies were identified by searching the references of retrieved papers and relative narrative reviews. RESULTS Forty-one (41) studies were included (36 case series and 5 case reports), totalling 728 patients. Three hundred forty-one patients were treated with optic nerve sheath fenestration (ONSF), 128 patients with lumboperitoneal shunting (LPS), 72 patients with ventriculoperitoneal shunting (VPS), 155 patients with venous sinus stenting and 32 patients with bariatric surgery. ONSF showed considerable efficacy in vision improvement, while CSF shunting had a superior headache response. Venous sinus stenting demonstrated satisfactory results in both vision and headache improvement along with the best complication profile and low relapse rate, but longer follow-up periods are needed. The complication rate of bariatric surgery was high when compared to other interventions and visual outcomes have not been reported adequately. ONSF had the lowest cost. CONCLUSIONS No surgical modality proved to be clearly superior to any other in IIH management. However, in certain contexts, a given approach appears more justified. Therefore, a treatment algorithm has been formulated, based on the extracted evidence of this review. The traditional treatment paradigm may need to be re-examined with sinus stenting as a first-line treatment modality.
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Jensen Ang WJ, Hopkins ME, Partridge R, Hennessey I, Brennan PM, Fouyas I, Hughes MA. Validating the use of smartphone-based accelerometers for performance assessment in a simulated neurosurgical task. Neurosurgery 2014; 10 Suppl 1:57-64; discussion 64-5. [PMID: 23756748 DOI: 10.1227/neu.0000000000000010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Reductions in working hours affect training opportunities for surgeons. Surgical simulation is increasingly proposed to help bridge the resultant training gap. For simulation training to translate effectively into the operating theater, acquisition of technical proficiency must be objectively assessed. Evaluating "economy of movement" is one way to achieve this. OBJECTIVE We sought to validate a practical and economical method of assessing economy of movement during a simulated task. We hypothesized that accelerometers, found in smartphones, provide quantitative, objective feedback when attached to a neurosurgeon's wrists. METHODS Subjects (n = 25) included consultants, senior registrars, junior registrars, junior doctors, and medical students. Total resultant acceleration (TRA), average resultant acceleration, and movements with acceleration >0.6g (suprathreshold acceleration events) were recorded while subjects performed a simulated dural closure task. RESULTS Students recorded an average TRA 97.0 ± 31.2 ms higher than senior registrars (P = .03) and 103 ± 31.2 ms higher than consultants (P = .02). Similarly, junior doctors accrued an average TRA 181 ± 31.2 ms higher than senior registrars (P < .001) and 187 ± 31.2 ms higher than consultants (P < .001). Significant correlations were observed between surgical outcome (as measured by quality of dural closure) and both TRA (r = .44, P < .001) and number of suprathreshold acceleration events (r = .33, P < .001). TRA (219 ± 66.6 ms; P = .01) and number of suprathreshold acceleration events (127 ± 42.5; P = .02) dropped between the first and fourth trials for junior doctors, suggesting procedural learning. TRA was 45.4 ± 17.1 ms higher in the dominant hand for students (P = .04) and 57.2 ± 17.1 ms for junior doctors (P = .005), contrasting with even TRA distribution between hands (acquired ambidexterity) in senior groups. CONCLUSION Data from smartphone-based accelerometers show construct validity as an adjunct for assessing technical performance during simulation training.
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Affiliation(s)
- Wei Jie Jensen Ang
- *College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, Midlothian, United Kingdom; ‡Department of Paediatric Surgery, Alder Hey Children's Hospital, Liverpool, Merseyside, United Kingdom; §Division of Clinical Neurosciences, Western General Hospital, Edinburgh, Midlothian, United Kingdom
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Loan JJM, Jamjoom AAB, Fouyas I. Brainstem abscess presenting with lateral gaze palsy in a healthy adolescent patient. Br J Hosp Med (Lond) 2013; 74:700-1. [PMID: 24326722 DOI: 10.12968/hmed.2013.74.12.700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- James J M Loan
- 5th Year Medical Student in the College of Medicine, Chancellors Building, University of Edinburgh, Edinburgh
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Walkden A, Shekhar H, Fouyas I, Gibson R. The diagnostic dilemma of cerebellopontine angle lesions: re-evaluating your diagnosis. Case Reports 2013; 2013:bcr-2012-008358. [DOI: 10.1136/bcr-2012-008358] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Abstract
The authors present an unusual case of a healthy young male who developed a spontaneous subdural haematoma. Headache was followed by blurring of vision and left upper limb symptoms. The diagnosis was made from a CT scan. Symptoms resolved with surgical decompression. The authors explore the risk factors and pathophysiology implicated in this condition. The authors demonstrate that apparently 'healthy' pursuits can have significant consequences, but the physician must also exclude serious underlying risk factors for bleeding, which the authors discuss.
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Affiliation(s)
- Paul M Brennan
- Deparment of Clinical Neurosciences, Western General Hospital, Edinburgh, Midlothian, UK.
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Sammon PM, Gibson R, Fouyas I, Hughes MA. Intra-operative localisation of spinal level using pre-operative CT-guided placement of a flexible hook-wire marker. Br J Neurosurg 2011; 25:778-9. [PMID: 21707263 DOI: 10.3109/02688697.2011.584987] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Confident intra-operative localisation of thoracic spinal pathology remains challenging. Several strategies are routinely employed, including intra-operative fluoroscopy and pre-operative image-guided skin marking. These techniques are limited both by potential inaccuracy and inconvenience. Here we present a novel, efficient and accurate technique for intra-operative localisation of thoracic spinal pathology using pre-operative CT-guided placement of a flexible hook-wire marker.
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Affiliation(s)
- Peter M Sammon
- Department of Clinical Neurosciences, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK.
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12
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Abstract
Although uncommon, vertebral artery pseudoaneurysms harbour significant risk of embolic stroke and their presence should be considered in cases of blunt cervical trauma. We illustrate a case of a traumatically ruptured vertebral artery pseudoaneurysm treated with coil embolisation.
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Affiliation(s)
- Ian Coulter
- Department of Neurosurgery, Western General Hospital, Edinburgh, UK.
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