Higher Orexin A levels in lumbar compared to ventricular CSF: a study in idiopathic normal pressure hydrocephalus

Orexin A (ORX-A) is implicated in the regulation of various physiological processes, including sleep/wake cycles and reward/motivation. The hypothalamic ORX-A neurons project throughout the brain and spinal cord. In the present study we established and compared ORX-A levels in lumbar and ventricular cerebrospinal fluid (CSF) samples, drawn from idiopathic normal pressure hydrocephalus (INPH) patients, during respectively, lumbar puncture and shunt placement. Ventricular and lumbar CSF levels of total protein and of the dopamine, serotonin and norepinephrine metabolites HVA, 5-HIAA and MHPG respectively, were also estimated. ORX-A was quantified using a commercially available radioimmunoassay kit. Neurotransmitter metabolites were quantified by high performance liquid chromatography. Expectedly, HVA and 5-HIAA levels were significantly higher and total protein levels lower in ventricular compared to lumbar CSF while there were no differences in MHPG levels. However, in contrast to HVA and 5-HIAA and similar to total protein, lumbar ORX-A levels were significantly higher than ventricular levels. The higher lumbar compared to ventricular ORX-A levels may reflect elevated contributions from the spinal cord. The finding of a ventriculo-lumbar difference for ORX-A should be considered in studies utilizing its CSF levels in assessing Orexin system status.

Serum levels of S-100B after recreational scuba diving

Recreational scuba diving is a sport of increasing popularity. Previous studies indicating subtle brain injury in asymptomatic divers imply a cumulative effect of minor neural insults in association with diving for professional and/or recreational purposes, over the long-term. This is the first study to investigate putative neural tissue burden during recreational scuba diving by measuring circulating levels of S-100B, a sensitive biomarker of brain injury. 5 male divers performed 3 consecutive dives under conservative recreational diving settings (maximum depth 15 m, duration of dive 56 min, ascend rate 1.15 m/min) with an interval of 12 h between each session. Although a small increase in serum S-100B levels after each dive was apparent, this increase did not quite reach statistical significance (p=0.057). Moreover, no abnormal S-100B values were recorded (mean baseline: 0.06 μg/L, mean post-dive: 0.086 μg/L) and no effect of the 3 consecutive dives on changes in S-100B levels was detected. These results suggest that under the experimental conditions tested, diving does not seem to have a discernible and/or cumulative impact on central nervous system integrity. The extent to which variable diving settings and practices as well as individual susceptibility factors underlie putative neural tissue burden in asymptomatic divers, remains to be established.

Trigonal cavernous angioma: a short illustrated review

PURPOSE

Intraventricular cavernomas are rare. Even more rare are those presenting in the trigone of the lateral ventricles.

METHODS

We performed a search of the literature of the last 30 years and identified all cases of intraventricular cavernous angiomas. Trigonal cavernomas were separately identified and analysed. Our search yielded a total of 13 trigonal cavernomas.

RESULTS

Of a total of 61 intraventricular cases, 13 were located in the trigone of the lateral ventricles. The most prominent presenting symptom was intracranial hypertension (68.9%), followed by seizures (18.2%) and hemorrhage (13.1%).The literature review revealed a trend of intraventricular cavernomas to present with intracranial hypertension rather than seizures or focal neurologic deficit, unlike their intraparenchymal counterparts. We feel that this difference has received little attention in the international literature. We discuss a possible pathogenetic mechanism for the presence of intracranial hypertension and address different aspects of diagnosis and treatment of this benign lesion.

CONCLUSIONS

Trigonal cavernomas are benign lesions that have an excellent outcome after radical excision. Symptoms and signs of intracranial hypertension and hydrocephalus may be the prominent initial presentation of this rare ailment.

Occult traumatic dissection of vertebral artery with an excellent outcome

We present the case of a young male with severe head injury, cervico-thoracic fractures, and an initially unrecognized brainstem infarct due to unilateral dissection of vertebral artery, who made an unusually excellent recovery. This report stresses the importance of prompt clinico-imaging diagnosis and prophylactic anticoagulant treatment in such cases.

Cervical disc, mimicking nerve sheath tumor, with rapid spontaneous recovery: a case report

The study design includes a case report and clinical discussion. The potential of acute disc herniations to regress spontaneously has been previously reported. However, the initial radiological presentation can be misleading, leading to therapeutic pitfalls, especially when the presence of myelopathy calls for early intervention. We present the case of a 46-year-old woman with a cervical intraspinal enhancing mass, associated enhancement of the C6 root and myelopathy, leading to the presumptive diagnosis of a nerve sheath tumor. The patient was offered surgery, which she denied. The patient returned 7 weeks later with significant clinical improvement. A subsequent magnetic resonance imaging depicted a herniated cervical disc and regression of myelopathy. Although spontaneous regression of disc prolapse and myelopathy have been previously reported, the initial radiological presentation and the short period of regression in this case highlight the need for a thorough understanding of the natural course of cervical disc herniations. Nonsurgical conservative observation should be considered an option for treatment for some cervical disc herniations that are likely to regress for very specific and predictable reasons.

Intracranial Hemorrhagic Arachnoid Cyst: The Role of Diffusion-Weighted Imaging

The majority of hemorrhagic arachnoid cysts are correlated with trauma or aneurysmal rupture. We report on a 35-year-old woman with acute headache and an intracranial mass lesion that was hyperdense in CT and hyperintense in conventional MRI images. The history and imaging were negative for trauma or vascular anomaly. Diffusion-weighted imaging (DWI) clearly demonstrated a large right anterior and middle cranial fossa arachnoid cyst with associated subacute intracystic hemorrhage without subdural hematoma. DWI offers invaluable information for the differential diagnosis of hemorrhagic arachnoid cysts from other extra-axial space-occupying lesions.

The current range of neuromodulatory devices and related technologies

The pace of technology dictates changes in every aspect of human life. Medical profession is not an exception. The development of sophisticated electronic devices has radically influenced diagnosis and therapy. Today neurosurgical science is revolutionized with numerous implanted and non-implanted devices that modulate and stimulate the nervous system. Physicians, patients and non-technical experts involved in this field need to understand the core mechanisms and the main differences of this technology so that they can use it effectively. It will take years until clinicians reach a "consensus" about the use of these devices, but in the course of action objective information about the current status of the methods and equipment, and the technical, biological, and financial complications that arise in practice will speed up their public approval and acceptance.

Arachnoiditis ossificans with progressive syringomyelia and spinal arachnoid cyst

We present a 30-year-old man with progressive spastic paraparesis. Spinal imaging revealed extensive calcification of the thoracic cord and cauda equina arachnoid, an intradural extramedullary cyst and evidence of rapidly progressing syringomyelia. Radiological diagnosis was arachnoiditis ossificans and an attempt at surgical decompression was made because of progressive neurologic deterioration. Due to tenacious adhesion of the calcified plaques to the cord and roots, only cyst drainage was achieved; the patient had no clinical improvement. A literature review revealed only two other cases reported in the literature with co-existence of arachnoiditis ossificans and syringomyelia. In none of the previous cases was there an intradural extramedullary arachnoid cyst, nor did the syrinx progress in such a rapid fashion. An attempt is made to explain possible pathophysiological mechanisms leading to this unusual pathology.

Giant dumbbell-shaped middle cranial fossa trigeminal schwannoma with extension to the infratemporal and posterior fossae

We present a 38-year-old female with a giant dumbbell-shaped trigeminal neurinoma originating primarily in the middle cranial fossa, extending to the infratemporal and posterior fossae through the foramen ovale and Meckel's cave, respectively. Because of the large tumour extension into the Infratemporal Fossa, a combined skull base approach (zygomatic infratemporal - transmandibular) was utilised for tumour removal, with a subsequent excellent outcome. An extensive literature review since 1935, revealed 580 cases of surgically treated trigeminal neurinomas. Among these, only three were located in three distinct compartments, making this the rarest developmental pattern for trigeminal neurinomas.

The prognostic value of serum S-100B protein in spontaneous subarachnoid haemorrhage

BACKGROUND

Despite the major progress in neurophysiological monitoring, there are still difficulties in the early identification and quantification of cerebral damage after a stroke. In this prospective study we examined the associations between serum S-100B protein, a serum marker of brain injury, and initial neurological-neuroimaging severity, secondary deterioration, external ventricular drainage (EVD: therapeutic intervention) and outcome in patients with subarachnoid haemorrhage (SAH).

METHOD

We recorded all pertinent clinical data of 52 patients with SAH and measured S-100B serum levels on admission and every 24 h for a maximum of 9 consecutive days. Mann-Whitney U-test and Kruskal Wallis analysis were employed to assess the association of S-100B levels with all variables of interest. Log-rank test was used to evaluate survival and Cox's proportional hazard regression analysis to define the significant predictors of survival rate.

FINDINGS

Admission S-100B was statistically significantly associated with initial neurological status, neuroimaging severity, and one-year outcome (p = 0.0002, 0.001, and 0.017, Kruskal Wallis analysis). Admission S-100B above 0.3 microg/L predicted unfavourable outcome (p < 0.0001, log rank test) and constituted an independent predictor of short-term survival (p = 0.035 Cox's proportional hazard regression analysis) with a hazard ratio of 2.2 (95% C.I.: 1.06-4.6) indicating a more than doubling of death probability. Secondary neurological deterioration associated with S-100B increase (p < 0.0001) and external ventricular drainage (EVD) with S-100B reduction (p = 0.003, Wilcoxon signed rank test).

CONCLUSIONS

Serum S-100B protein seems to be a useful biochemical indicator of neurological - neuroimaging severity, secondary deterioration, EVD (therapeutic intervention), and outcome in patients with SAH.

Serum S-100B Protein as A Biochemical Marker of Brain Injury: A Review of Current Concepts

S-100 protein, described initially by Moore, constitutes a large family of at least 20 proteins with calcium binding ability. It is found as homo- or hetero-dimers of two different subunits (A and B). Types S-100AB and S-100BB are described as S-100B protein and are shown to be highly specific for nervous tissue. It is present in the cytosol of glial and Schwann cells, and also in adipocytes and chondrocytes, although in very low concentrations in the latter two. The role of protein S-100B is not yet fully understood. It is suggested that it has intracellular and extracellular neurotropic as well as neurotoxic function. At nanomolar levels, S-100B stimulates neurite outgrowth and enhances survival of neurons. However, at micromolar levels it stimulates the expression of inflammatory cytokines and induces apoptosis. Recently, serum S-100B protein has been proved to be an attractive surrogate marker of primary severe brain injury and secondary insults. It can be measured in the arterial and venous serum; it is not affected by haemolysis and remains stable for several hours without the need for immediate analysis. Its short half-life makes measurements crucial in the emergency and intensive care settings. This review summarises published findings on S-100B regarding its role as a serum biochemical marker of brain injury, i.e., after severe, moderate or mild neuro-trauma, subarachnoid haemorrhage, thrombo-embolic stroke, cerebral ischaemia and brain tumours, as well as extracranial trauma, neurodegenerative and psychiatric disorders.

Spontaneous subarachnoid haemorrhage in the era of transition from surgery to embolization. A study of the overall outcome

The aim of the investigation was to evaluate the outcome of spontaneous subarachnoid haemorrhage, in the era of new techniques, patient centralization and subspecialization, by taking into account the local conditions in Greece. A prospective observational study was conducted during a 4-year period. All patients with a first-ever spontaneous subarachnoid haemorrhage were enrolled. Clinical, management and outcome data were recorded. Two-hundred-and-eighteen consecutive patients with an 81% good, medium clinical grade (Hunt & Hess I-III) were identified. Rebleed and rebleed leading to death rates were 22 and 11%, respectively. Permanent deficit or death from vasospasm was 15%. Twenty-eight per cent of the study population died early, were unsuitable for further management (poor clinical status, advanced age) or declined angiography or treatment, and another 22% had a negative angiogram. The remaining 50% underwent intervention (neurosurgical/endovascular), for obliteration of an aneurysm. The overall favourable 6-month outcome was 59%, whereas the favourable outcome of the intervention group was 70%. Our results confirm the findings of previous series. The relatively worse results are due to delayed referral, and lack of availability of surgical or endovascular management in the early post-haemorrhage period (28% of the patients), particularly in potentially salvageable cases. On the basis of these observations, we recommend early intervention (surgery or embolization) and centralization/subspecialization, in order to improve the outcome.

Selection of cranial site for shunting debilitated patients

BACKGROUND/OBJECTIVE

The optimum cranial site for ventricular catheter insertion in CSF shunts is still under debate and there has been no general consensus as far as surgical technicalities are concerned. Furthermore, there have been no reports dealing with appropriate cranial site selection in debilitated patients. The aim of this report is to stress the need to utilize a frontal approach when dealing with patients who are likely to remain bed-bound for long periods and to emphasize the well-known prerequisites such as meticulous surgical technique and peri-operative general and local care.

METHOD

A retrospective analysis of all shunt operations and revisions performed in our department during the last 6 years.

FINDINGS

This analysis revealed 8 long-term recumbent patients with late valve extrusion (N1 = 5) or primary wound breakdown (N2 = 3), all through the occipital area. Extended periods of bed rest due to neurological disease combined with poor nursing and dietary intake had led to either chronic valve extrusion or wound breakdown. Shunt revision was performed successfully by a frontal approach in 5 whereas 2 tolerated shunt removal and one died of meningitis.

CONCLUSION

In debilitated patients or those who are likely to remain bed-bound for long periods, a frontal approach for proximal catheter insertion may help prevent immediate postoperative wound breakdown or late valve extrusion.

Peritumoural haematoma and meningioma: a common tumour with an uncommon presentation

Spontaneous peritumoural haemorrhage in meningiomas is a rare but serious complication with a grave prognosis. It occurs at the interface between the tumour and the parenchyma, either from the tumour surface or the cortical vessels in association with it. Although several pathophysiologic mechanisms for this complication have been proposed, they all remain speculative. We report a 72-year-old female who presented with sudden onset of headache and a left homonymous hemianopia. Neuroimaging revealed a parasagittal meningioma at the posterior third of the superior sagittal sinus with peritumoural intracerebral haematoma, 1 cm away from the tumour. An uncomplicated gross total excision of the meningioma and aspiration of the haematoma was achieved through a craniotomy. The postoperative course was uneventful with an excellent clinical outcome. Possible mechanisms for this unusual complication are discussed. We emphasise the importance of prompt diagnosis and simultaneous excision of the tumour and aspiration of the haematoma as prerequisites for a favourable outcome.

CT-guided stereotactic biopsies of brain stem lesions: personal experience and literature review

Appropriate therapy of brain stem lesions should be guided by an accurate diagnosis. Clinical evaluation combined with modern neuroimaging techniques may nowadays approach the diagnosis but not always with accuracy, thus leading to erroneous treatment. We report a series of 11 patients who underwent stereotactic biopsy for brain stem lesions. In 8 patients, the lesion was approached transfrontally. In the remaining 3 patients, the lesion was approached via the suboccipital transcerebellar route. There was no surgical mortality. Precise histological diagnosis was achieved in all patients. Three patients (27.2%) suffered complications attributed to the procedure and were successfully treated conservatively. Histological results were in accordance with preoperative diagnosis in 9 patients (81.8%). Despite the limited number of patients, our data suggest that stereotactic biopsy of brain stem lesions is a safe technique that can obtain adequate tissue for histological diagnosis, thus providing each patient with the best available treatment.

Stereotactic biopsy in the era of advanced neuroimaging. Does the minimal therapeutic gain justify its current wide use?

OBJECTIVE

This study reviewed the contribution of stereotactic brain biopsy in the management and final outcome of a series of patients with presumed inoperable lesions.

PATIENTS AND METHODS

Sixty-nine consecutive patients underwent a CT-guided lesion biopsy (n = 67) or abscess/cyst aspiration (n = 2) using the Cosman-Roberts-Wells (CRW) frame.

RESULTS

A definitive specific diagnosis was made in 53 of 67 patients (79 %). The remaining procedures did not provide a diagnosis because of failure to obtain appropriate specimen (11 patients), findings consistent with non-specific inflammation (2 patients) or uneventful surgical complication requiring termination of the procedure (1 patient). A total of 55 patients (80 %) died due to the malignant nature of the lesion, most within six months after the biopsy. The preoperative imaging diagnosis was consistent with the histological diagnosis in 60 patients (87 % accuracy). The perioperative morbidity and mortality were nil and most of the patients were discharged within twenty-four hours.

CONCLUSIONS

The stereotactic biopsy did not alter either the therapeutic management or the mortality due to the natural course of the lesion. These findings indicate that the current principle of mandatory histological diagnosis in virtually all non-resectable brain lesions should be re-evaluated taking into account parameters such as: age, medical/neurological status, neuroimaging characteristics, patients' best interest and health care financial shortages.

Development of neurosurgery in Greece: past, present, and future

In this study the authors examine the historical tradition as well as current features of neurosurgery in Greece and compare the available data with international standards. In particular, they describe the organizational structure of neurosurgery with reference to manpower, unit distribution, training, and qualification. They discuss problems such as overproduction of neurosurgeons and the poor control of training and qualification procedures in the neurosurgical profession. The findings are examined in a critical way and solutions are proposed that could improve the present situation.

Dorsal root entry zone lesion performed with Nd:YAG laser

Thermocoagulation of the dorsal root entry zone (DREZ) is the current surgical management of deafferentation pain syndromes. It is usually performed with the assistance of specially designed lesion generators. We report a patient who underwent a DREZ lesion with a Nd:YAG laser as an alternative to standard thermocoagulation technique. A 62-year-old woman with a 5-year history of bilateral dysaesthetic (burning) type of leg pain, after a crush fracture of the fourth thoracic vertebra and complete cord transection, was managed by inducing a bilateral dorsal root entry zone lesion at T2-T5 myelotomes using a Nd:YAG laser, which was used as an alternative to the conventional electrically generated thermocoagulation. A significant reduction of deafferentation type of pain was achieved.

Ruptured cerebral aneurysm: influence of specialist and trainee-performed operations on outcome

The results of a series of 160 consecutive patients operated on for ruptured cerebral aneurysm in relation to the surgeon's seniority were studied. The outcome, as measured by the Glasgow Outcome Scale at six months, shows a difference between specialist-neurosurgeon and resident-performed ruptured cerebral aneurysm obliterations, although this difference does not reach statistical significance.

The overproduction of neurosurgeons jeopardizes future neurosurgical care

In some areas of the world the next generation of neuro-surgeons is facing a serious problem. The training of an inappropriately large number of neurosurgeons will lead to underemployment/unemployment, which will have a direct impact on the quality of neurosurgical care. The following statistical data relate to local phenomena but reflect dilemmas to be considered by the international neurosurgical community since they exist in many countries.

Continuous assessment of relative cerebral blood volume in transient ischemia using steady state susceptibility-contrast MRI

The utility of a noninvasive steady state susceptibility-contrast MRI technique for continuous measurement of relative cerebral blood volume (rCBV) during global transient ischemia and subsequent hyperemia in a feline ischemia model is demonstrated. The measurements were obtained during a 10-min period of occlusion and 1-h period of reperfusion. Maximal hyperemic responses in gray matter, basal ganglia, and white matter (observed at 7,7, and 5 min, respectively) were 1.9 +/- 0.5, 1.8 +/- 0.3, and 1.7 +/- 0.6 times greater than baseline CBV (mean +/- SEM). Thirty to forty minutes after onset of reperfusion, CBV returned to normal. Thereafter, it decreased below baseline, nearing the control level by 1 h after onset of reperfusion. Steady state susceptibility-contrast MRI permits continuous, in vivo mapping of alterations in CBV.

Functional outcome in patients after excision of extracanalicular acoustic neuromas using the suboccipital approach

An audit of surgery for acoustic neuroma was carried out to determine the frequency and nature of postoperative symptoms and their impact upon the patient's quality of life and vocation. Fifty-six patients were interviewed between 6 months and 5 years (mean 26 months) after surgical excision of an acoustic neuroma. The objective surgical results in these patients are good, with normal or near normal functional preservation rates of 80% for the facial nerve (House-Brackmann grade I/II), and 27.3% for a previously functioning acoustic nerve. Despite this there was no significant overall reduction in the reported occurrence of balance problems, tinnitus, headache and other neurological sequelae of the tumour after surgical excision. In 20% of the patients persistent symptoms, including deafness and facial weakness, had prevented the resumption of former social activities. As a result of these symptoms 8.6% of the patients were certified medically unfit for work, but of those employed preoperatively over 70% had returned to their jobs. The success of neuro-otological surgical management of acoustic neuroma is offset by some degree of chronic morbidity. Our patients expressed the need to know whether their symptoms would resolve, but were often too afraid to ask. Patients can be reassured that the majority resume their former social and vocational activities, but should be advised that some symptoms can persist or occur de novo after surgery. Our data suggest that early intervention would reduce the incidence of these troublesome sequelae.

The outcome of surgery of aneurysmal subarachnoid haemorrhage

Aneurysmal subarachnoid haemorrhage is a challenging pathology which remains a cause of considerable mortality and morbidity. To demonstrate to general practitioners the results of surgery for this condition a retrospective study of 160 consecutive cases who had undergone aneurysmal surgery was carried out. On admission 57% of cases had a good Hunt and Hess grade (grades I and II) and 43% a poor grade (grades III, IV and V). Twelve per cent of cases had a pre-existing hypertension and 73% of cases were treated with nimodipine. Angiography was performed from 0 to 73 days (median 3 days) after the bleed. Early surgery (within the first three days after the bleed) was performed in 41% of cases. Twenty-two per cent of cases rebled before surgery from 1 to 69 days after initial presentation (median seven days). Delayed cerebral ischaemia was diagnosed in 38% of cases, but only 15% of cases had evidence of low density on the CT scan. The outcome was determined at six months using the 'Glasgow outcome scale'. Fifty-five per cent of cases made a good recovery (back to normality), 15% a fair recovery (moderately disabled but independent), 15% a poor recovery (severely disabled and dependent), and 15% died. The significant poor prognostic factors were: a poor pre-operative Hunt and Hess grade, the presence of an intracerebral haematoma or angiographic spasm, evidence of rebleeding and early surgery without treatment with nimodipine. Other factors which did not reach a statistical significance include: age, presence of subarachnoid and intraventricular blood on CT, timing of surgery, history of long-standing hypertension, intraoperative rupture, and the development of hydrocephalus or delayed ischaemia.

Successful removal of intramedullary spinal cord metastasis: case report

Intramedullary metastatic disease accounts for 5% of CNS metastases. This report describes a 47-year-old female with the simultaneous presentation of primary breast carcinoma and a solitary brain metastasis, both treated surgically. She represented with an increasing hemiparesis due to a spinal cord metastasis 4 years later. The cord lesion was removed microsurgically using a CO2 laser. Postoperatively she made a good recovery and lived independently for 2 years. The rationale for aggressive surgical treatment is discussed.

MRI in the diagnosis of spinal extradural angiolipoma

We report the case of a 68-year-old woman with a 1-year history of progressive spastic paraparesis, due to an extradural angiolipoma of the mid-thoracic spine. The MRI appearance of the angiolipoma is reported here for the first time. This appearance is characteristic, allows preoperative diagnosis and assists planning of the surgical approach.

Outcome following surgical evacuation of traumatic intracranial haematomas in the elderly

In order to determine the factors influencing outcome following craniotomy for trauma in patients over the age of 65 and to establish criteria for surgical intervention, the authors carried out a retrospective analysis of the hospital and general practice records of all head injury patients over the age of 65 who underwent a craniotomy for evacuation of a post-traumatic haematoma within 7 days of injury at Frenchay Hospital during a 10-year period (1980-89). Outcome was measured using the Glasgow Outcome Scale and patients were allotted to a good outcome group (good recovery or moderate disability but independent) or a poor outcome group (severe disability, vegetative state of death). There were 35 men and 31 women with a mean age of 72.5 years (range 65-85 years). The mortality rate was 61% and 9% of patients survived in a severely disabled or vegetative state. All 20 (30%) patients with a good outcome had a Glasgow Coma Score (GCS) of 5 or more immediately before surgery. All 18 (27%) patients with a GCS of 4 or less and all 22 (33%) patients with unilateral or bilateral pupillary dilatation had a poor outcome. Outcome was significantly worse in the older patients (75-85 years) compared with the younger patients (65-74 years) and in those patients requiring craniotomy within 24 hours of injury, but the mechanism of injury (fall or road traffic accident), the presence or absence of skull fractures and limb fractures and the pre-operative CT scan appearances did not influence outcome. This study confirms the high probability of poor outcome following surgical evacuation of traumatic intracranial haematomas for elderly head-injured patients with pupillary dilatation or extensor motor responses. Craniotomy under these circumstances is not justified.

The value of autopsies in neurosurgery

Many previous studies have reported the value of autopsy in assessing clinical diagnostic accuracy. None of them however, assessed the value of autopsies in a specific clinical speciality. The authors reviewed the findings of 123 consecutive neurosurgical autopsies with reference to the premortem clinical diagnoses. The study showed that 7% of cases had a wrong clinical diagnosis and in 9% of cases the clinical diagnosis was incomplete. Only in 5% of all cases knowledge of the autopsy findings would have led to a change in management and outcome. The autopsies also confirmed that 11% of cases died following a surgical complication and in 3% of cases the primary cause of death was non-neurosurgical. The latter was a previously unrecognised finding in 8% of autopsies. The autopsy will remain a valuable means of clinical audit and the increasing financial pressures to reduce the number of autopsies should be resisted.