Multidisciplinary consensus guideline for the diagnosis and management of spontaneous intracranial hypotension

BACKGROUND

We aimed to create a multidisciplinary consensus clinical guideline for best practice in the diagnosis, investigation and management of spontaneous intracranial hypotension (SIH) due to cerebrospinal fluid leak based on current evidence and consensus from a multidisciplinary specialist interest group (SIG).

METHODS

A 29-member SIG was established, with members from neurology, neuroradiology, anaesthetics, neurosurgery and patient representatives. The scope and purpose of the guideline were agreed by the SIG by consensus. The SIG then developed guideline statements for a series of question topics using a modified Delphi process. This process was supported by a systematic literature review, surveys of patients and healthcare professionals and review by several international experts on SIH.

RESULTS

SIH and its differential diagnoses should be considered in any patient presenting with orthostatic headache. First-line imaging should be MRI of the brain with contrast and the whole spine. First-line treatment is non-targeted epidural blood patch (EBP), which should be performed as early as possible. We provide criteria for performing myelography depending on the spine MRI result and response to EBP, and we outline principles of treatments. Recommendations for conservative management, symptomatic treatment of headache and management of complications of SIH are also provided.

CONCLUSIONS

This multidisciplinary consensus clinical guideline has the potential to increase awareness of SIH among healthcare professionals, produce greater consistency in care, improve diagnostic accuracy, promote effective investigations and treatments and reduce disability attributable to SIH.

A Novel Neurosurgery Referral Course: Feasibility, Validation, and Inferences for Patient Care

OBJECTIVE

The speciality of neurosurgery is under-represented in the majority of medical school curriculums, and those rotating within this specialty tend to be those with career aspirations within this field. Consequently, few emergency medicine trainees are exposed to this specialty. The aim of this educational project was to develop and validate a neurosurgery referral course for the target audience of emergency medics.

DESIGN

Development of a single day neurosurgery referral course, developed with accreditation from the Royal College of Surgeons England. The curriculum covered commonly referred pathologies. Content validity was assessed using a 5-point Likert Scale. Median Likert scores were compared to "indifferent" (3) (indifferent = 3 in this study Likert scale) using the Wilcoxon matched-pairs signed-rank test. Construct validity was assessed using a standardized pre and postcourse 10-single best answer exam and results compared using paired t tests.

SETTING

A pilot "Neurosurgery for Emergency Medics" referral course, hosted at a single UK based neurosurgery unit.

PARTICIPANTS

A cohort of 19 delegates, working in emergency departments various regions within the UK.

RESULTS

The subjective feedback showed significantly higher than the expected median Likert scale satisfaction scores (p = 0.0001). Construct validity was confirmed, with significant improvement in proportion of students getting the answers in the single best answer exam after the days training course (p = 0.017).

CONCLUSIONS

We demonstrate feasibility, content, and construct validity and conclude that this pilot "Neurosurgery for Emergency Medics" course was beneficial. Integration of this 1-day course into local doctor's induction programmes for emergency medicine and neurosurgery may advance both local and national standards for referrals and consults alike, with the ultimate goal of improving patient care.

Extradural Compressive Spinal Cerebrospinal Fluid Leak in Ehlers-Danlos Syndrome

Ehlers-Danlos syndrome can be associated with cerebrospinal fluid (CSF) disturbances including recurrent CSF leak and Chiari I malformations. Persistent pseudomeningoceles are known to be associated with raised intracranial pressure. We present an unusual case of a compressive epidural CSF collection occurring after a computed tomography-guided L5 nerve root block and describe an effective management strategy.

Syringomyelia secondary to "occult" dorsal arachnoid webs: Report of two cases with review of literature

In a certain group of patients with syringomyelia, even with the advent of sophisticated magnetic resonance imaging (MRI), no associated abnormality or cerebrospinal fluid (CSF) block is easily identified. This type of syringomyelia is often termed idiopathic. Current literature has less than 10 reports of arachnoid webs to be the causative factor. We present our experience in the management of two cases of syringomyelia secondary to arachnoid webs. Both our patients presented with progressive neurological deterioration with MRI scans demonstrating cervical/thoracic syrinx without Chiari malformation or low-lying cord. There was no history of previous meningitis or trauma. Both patients underwent myelography that demonstrated dorsal flow block implying CSF obstruction. Cord displacement/change in caliber was also noted and this was not evident on MRI scans. Both patients underwent thoracic laminectomy. After opening the dura, thickened/abnormal arachnoid tissue was found that was resected thus widely communicating the dorsal subarachnoid space. Postoperatively at 6 months, both patients had significant symptomatic improvement with follow-up MRI scans demonstrating significant resolution of the syrinx. In patients with presumed idiopathic syringomyelia, imaging studies should be closely inspected for the presence of a transverse arachnoid web. We believe that all patients with idiopathic symptomatic syringomyelia should have MRI CSF flow studies and/or computed tomography (CT) myelography to identify such arachnoid abnormalities that are often underdiagnosed. Subsequent surgery should be directed at the establishment of normal CSF flow by laminectomy and excision of the offending arachnoid tissue.

Inadvertent insertion of nasogastric tube into the brain

An unusual case of a nasogastric (Ryle's) tube inserted in the brain in a patient having severe head injury with skull base fractures is reported here along with a brief review of literature. A 35 years male was referred from a peripheral institute following head trauma with endotracheal tube and nasogastric tube in situ. A CT scan of the brain showed multiple skull base fractures and a high parietal extradural hematoma. It also revealed that the nasogastric tube had inadvertently found its way into the brain through the lamina cribrosa of the ethmoid bone. The tube was removed under aseptic conditions in the operation theatre but the patient expired on day 2 of admission due to the head injuries sustained.