Hypertensive posterior reversible encephalopathy causing obstructive hydrocephalus

Background:

Posterior reversible encephalopathy syndrome (PRES) can occur due to the detrimental effect of malignant hypertension on cerebral autoregulation. Most reported cases describe involvement of the supratentorial areas. Involvement of the posterior fossa structures in conjunction with supratentorial involvement has also been reported; however, PRES affecting the infratentorial structures without supratentorial involvement is a rare phenomenon. Clinical manifestations can involve severe headache, seizures, and reduced consciousness with treatment focused primarily on blood pressure control.

Case Description:

We report a case of PRES with isolated involvement of the infratentorial structures leading to obstructive hydrocephalus. The patient was managed with aggressive control of blood pressure and avoided ventriculostomy or posterior fossa decompression with a good outcome.

Conclusion:

Medical management in the absence of neurological deficit can be associated with a good outcome.

Presentation, management, and outcomes of cauda equina syndrome up to one year after surgery, using clinician and participant reporting: A multi-centre prospective cohort study

Background

Cauda equina syndrome (CES) results from nerve root compression in the lumbosacral spine, usually due to a prolapsed intervertebral disc. Evidence for management of CES is limited by its infrequent occurrence and lack of standardised clinical definitions and outcome measures.

Methods

This is a prospective multi-centre observational cohort study of adults with CES in the UK. We assessed presentation, investigation, management, and all Core Outcome Set domains up to one year post-operatively using clinician and participant reporting. Univariable and multivariable associations with the Oswestry Disability Index (ODI) and urinary outcomes were investigated.

Findings

In 621 participants with CES, catheterisation for urinary retention was required pre-operatively in 31% (191/615). At discharge, only 13% (78/616) required a catheter. Median time to surgery from symptom onset was 3 days (IQR:1–8) with 32% (175/545) undergoing surgery within 48 h. Earlier surgery was associated with catheterisation (OR:2.2, 95%CI:1.5–3.3) but not with admission ODI or radiological compression. In multivariable analyses catheter requirement at discharge was associated with pre-operative catheterisation (OR:10.6, 95%CI:5.8–20.4) and one-year ODI was associated with presentation ODI (r = 0.3, 95%CI:0.2–0.4), but neither outcome was associated with time to surgery or radiological compression. Additional healthcare services were required by 65% (320/490) during one year follow up.

Interpretation

Post-operative functional improvement occurred even in those presenting with urinary retention. There was no association between outcomes and time to surgery in this observational study. Significant healthcare needs remained post-operatively.

Funding

DCN Endowment Fund funded study administration. Castor EDC provided database use. No other study funding was received.

Rapid Growth of a Facet Joint Cyst Mimicking an Aggressive Tumor in the Lumbar Spine

A 67-year-old patient with a history of fully treated bowel carcinoma presented with a short history of unilateral lumbosacral radiculopathy. No neurological deficit was found on examination. Magnetic resonance imaging (MRI) demonstrated initially L4/5 foraminal narrowing that was believed to be the cause for the patient’s symptoms; however, a nerve root block led to no improvement in symptoms. MRI was repeated at 5 months and demonstrated a mass causing compression of the S1 nerve. However, the patient declined surgical decompression. MRI at 14 months subsequently showed rapid growth of the lesion suggestive of an aggressive process such as a metastatic lesion or even a nerve sheath tumor such as a Schwannoma. Open biopsy and decompression revealed the lesion to be a facet joint cyst and the patient recovered well and had satisfactory postoperative imaging at 3 months follow-up. There are no reports in the literature of facet joint cysts growing this quickly and thus mimicking other forms of lesion.

P79 Is length of stay (LOS) equivalent for elective anterior cervical discectomy (ACD) patients in an NHS hospital and as waiting list initiative cases in a private hospital?

Objectives

To investigate if there is a significant difference between the LOS for patients admitted as waiting list initiative patients to a private hospital versus standard care in an NHS hospital.

Design

Retrospective analysis between 2015 and 2017 of all ACD procedures at the two hospitals.

Subjects

674 elective NHS patients were included, 340 were admitted to the NHS hospital and 334 as waiting list initiative patients to the private hospital. Acute patients were excluded.

Methods

Retrospective database search of electronic hospital records for all ACD procedures carried out between 2015 and 2017. The student standard t test analysis was used to compare the difference in LOS.

Results

In both groups 100% were admitted on the day of surgery. The mean NHS LOS was 3.3 (SD=6.34) days and the private hospital was 1.1 (SD=0.97) days. (p<0.001) For the patients admitted to the private hospital 96% of the patients went home with 1 night stay, only 61% of the patients went home in the same period in the NHS hospital.

Conclusions

We found that length of stay is significantly shorter in the private hospital than in the NHS hospital. This could be due to patient selection, a swifter patient pathway or a combination of the two and these factors will be explored.

P76 Skip laminectomy versus cervical laminectomy, an analysis of patient reported outcomes, spinal alignment and re-operation rates: the leeds spinal unit experience (2008–2016)

Objectives

To compare clinical, radiological and complication results between skip laminectomy and cervical laminectomy for posterior cervical decompression for cervical spondylotic myelopathy.

Design

Retrospective single institution cohort study.

Subjects

Subjects underwent primary skip or cervical laminectomy between 2008–2016.

Methods

Statistical analysis compared pre- and post-operative differences in Visual Analogue Scale, Neck Disability Index and radiological differences in sagittal alignment of the vertebral bodies. Analysis of re-operation rates was performed.

Results

A total of 42 and 29 patients had skip and cervical laminectomy respectively. Median follow up was 32±23.1 (Range: 1–325) weeks. Post-operatively there was no difference in patient reported outcomes namely Visual Analogue Scale and Neck Disability Index between skip laminectomy and cervical laminectomy groups compared to pre-operatively (p=0.64, p=0.75). No difference was seen in sagittal alignment between both groups following surgery (p=0.65). Three patients (7.1%) in the skip laminectomy group and two patients (6.9%) in the cervical laminectomy group required revision surgery to the cervical spinal region at a different level to the original surgery. No patients needed further instrumentation.

Conclusions

Both skip laminectomy and cervical laminectomy appear to deliver similar outcomes with regards to patient reported outcomes, preserving sagittal alignment and re-operation rates over this short follow-up period.

TM1-6 Intramedullary spinal cord tumours – a single centre 10 year retrospective review

Objectives

To identify clinically relevant predictors of progression free survival by retrospectively analysing the anatomical location, pre- and post-operative function and histology in intramedullary spinal cord tumours from a single neurosurgical centre over 10 years.

Design

Retrospective review.

Methods

49 patients were identified from a surgical database. Variables collected included pre-and post-operative Frankel Grade and Modified McCormick Scale assessments, tumour histology, extent of resection and length of follow up. Chi-Squared, Kaplan-Mier Survival and Mann-Whitney U-Tests were completed.

Results

There was a statistically significant relationship between identification of the tumour plane and extent of resection (p<0.01), along with the extent of resection and recurrence (p<0.01). Compared to the other histological subtypes, ependymoma’s demonstrated a significantly greater extent of resection (p=0.02). There was a significant relationship between the grade of tumour and progression free survival (p<0.01). We did not find a significant relationship between pre- and post-operative neurological function and survival.

Conclusions

Tumour plane and the extent of tumour resection are significant determinants of progression free survival. Ependymoma, whilst being the commonest histology in our series were also the most resectable. Whilst complete resection reduces the rate of recurrence, tumour grade is the most important predictor of outcome.

Iatrogenic Limb Ischemia Caused by Angiography Closure Devices

Described are 2 cases of lower limb ischemia that resulted after deployment of 2 different arterial closure devices. One patient presented acutely with lower limb ischemia after an Angio-Seal (St Jude Medical, Minnetonka, Minn) device deployed at the conclusion of cerebral artery aneurysm embolization. The second patient, who underwent angioplasty for aortic recoarctation, presented with claudication 1 week after deployment of the Perclose (Perclose, Redwood City, Calif) device. The use of such devices can result in significant complications, and cardiologists, interventional radiologists, and vascular surgeons are advised to have a high index of suspicion for such complications and work in close conjunction to provide prompt and adequate treatment.

Frontal sinus mucocele in association with fibrous dysplasia: review and report of two cases

We present two paediatric cases of fibrous dysplasia (FD) who presented to the craniofacial neurosurgical clinic with ophthalmological symptoms associated with sinus mucoceles. The first patient presented with a history of orbital cellulitis and an increasing bony swelling around the orbit associated with proptosis. Radiological imaging revealed monostotic FD associated with an obstructive mucocele in the frontal sinus with extension into the orbit. The second patient presented with recurrent conjunctivitis, painful proptosis, rhinitis and a bony peri-orbital swelling. Both patients had histological diagnoses of frontal mucoceles invading the orbit in association with FD. They both underwent frontal craniotomies and excision of the mucocele/fibrous dysplastic complex. In summary, mucocele development is an unusual complication of FD, likely to occur secondary to occlusion of the sinus drainage system. Orbital involvement may lead to visual disturbance caused by pressure effects. A multi-disciplinary approach including maxillofacial surgeons, plastic surgeons and neurosurgeons is advocated.

Incomplete cellular depopulation may explain the high failure rate of bovine ureteric grafts

BACKGROUND

The aim was to assess the results of a decellularized bovine ureter graft (SynerGraft) for complex venous access.

METHODS

Bovine ureter conduits were implanted in patients with a failed fistula or access graft in whom native vessels were unsuitable as conduits. Graft histories were obtained from all patients who had undergone this procedure at one institution. Failed grafts were explanted and subjected to histological examination. A sample of fresh bovine ureter was immunostained for galactose (alpha1 --> 3) galactose (alpha-Gal).

RESULTS

Nine patients with a median age of 46 (range 25-70) years underwent complex venous access surgery between August 2004 and November 2006 using a SynerGraft. Graft types included loop superficial femoral artery to stump of long saphenous vein (four patients), loop brachial artery to vein (two), brachial artery to axillary vein (two) and left axillary artery to innominate vein (one). Three grafts developed aneurysmal dilatation and two thrombosed. Histological assessment of the explanted bovine ureters revealed acute and chronic transmural inflammation. Immunostaining of fresh bovine ureter suggested residual cells and the xenoantigen alpha-Gal.

CONCLUSION

Graft failure with aneurysmal dilatation and thrombosis in complex arteriovenous conduits using bovine ureter may be due to residual xenoantigens.

Randomized clinical trial of the effects of methylprednisolone on renal function after major vascular surgery

BACKGROUND

Perioperative renal dysfunction following abdominal aortic aneurysm (AAA) repair is multifactorial and may involve hypotension, hypoxia and ischaemia-reperfusion injury. Studies of cardiac and hepatic transplant surgery have demonstrated beneficial effects on renal function of high-dose methylprednisolone administered before surgery.

METHODS

Twenty patients undergoing elective open AAA repair were randomized to receive either methylprednisolone 10 mg/kg or dextrose (control) before induction of anaesthesia. Blood was analysed for a panel of cytokines representative of T helper cell type 1 and 2 subsets. Urine was analysed for subclinical markers of renal dysfunction (albumin, alpha(1)-microglobulin and N-acetyl-beta-D-glucosaminidase).

RESULTS

Data from 18 patients were analysed. Both groups demonstrated glomerular and proximal convoluted tubular dysfunction that was unaffected by steroid treatment. Steroid administration increased serum levels of urea and creatinine (both P < 0.001). The steroid group had increased interleukin 10 levels (P = 0.005 compared to controls). There were no differences between groups in overall surgical complications, length of intensive care unit (P = 0.821) and hospital (P = 0.719) stay, or 30-day mortality.

CONCLUSION

Methylprednisolone administration altered the cytokine profile favourably but adversely affected postoperative renal function.

Cerebellopontine angle meningioma resulting in middle-ear polyp

Extracranial spread of meningiomas to involve the middle ear is very rare. We present the case of a 43-year-old woman with a known cerebellopontine angle meningioma who subsequently presented with left-sided otalgia and a middle-ear mass extruding through the tympanic membrane due to local invasion of the meningioma. The tumour was excised surgically. A discussion of the relevant literature is also presented.

1,000 forensic outpatients: a descriptive study

The case notes and court reports of 1,000 consecutive outpatient referrals to a regional forensic outpatient service were studied retrospectively. Socio-demographic, psychiatric and forensic information was collected. The sample was predominantly male, Caucasian and relatively young in comparison with a general psychiatric population. The commonest source of referral was from defense solicitors and the commonest reason for referral was for a court report. A wide range of diagnoses and offences were noted. A number of differences were found in the frequency of gender, ethnicity and diagnosis according to the source of, and reason for, referral.

An evaluation of the preoperative information given to patients by intensive care nurses

In many hospitals it is common practice for nurses working in intensive care units to visit patients on the ward when a stay in the intensive care unit is anticipated following elective surgery. The purpose of the preoperative visit is to minimise fear and anxiety by preparing patients for their admission by providing information about the unit, the equipment used and responding to any questions. However, although there is extensive evidence to support the advantages of information--giving prior to stressful events the author could find no evaluation of the type of information given by intensive care staff. The purpose of the study was three fold. Firstly to discover the type of information patients would like to receive. Secondly to use this data in compiling a booklet which could be used to supplement the preoperative visit. Thirdly to evaluate the contents of the booklet. Postoperatively 20 patients evaluated the booklet by means of a self-administered questionnaire. These were completed 48 h after their transfer from the unit. Overall patients were satisfied with the information contained in the booklet but felt they required additional advice about their proposed surgery and needed more time to absorb the information they had been given.

Pharmacokinetics of lithium in patients treated with controlled release lithium formulations

There has long been discussion as to the relative merits of the lithium formulations available in the UK. Two of these have been shown to exhibit similar pharmacokinetics in normal volunteers and both are now marketed as controlled release formulations. In this study the serum lithium profiles of these formulations were compared in patients at two centres during the first 4 h after the dose, and at 24 h. We were unable to show any significant difference between the formulations in respect of maximum serum lithium concentrations or the concentration at each time point.