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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] [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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Plagiarism. Br J Neurosurg 2024; 38:201. [PMID: 38512276 DOI: 10.1080/02688697.2024.2326756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
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Kindness in neurosurgery. Br J Neurosurg 2023; 37:1471-1472. [PMID: 37948536 DOI: 10.1080/02688697.2023.2272417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
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Posterior cervical foraminotomy versus anterior cervical discectomy for Cervical Brachialgia: the FORVAD RCT. Health Technol Assess 2023; 27:1-228. [PMID: 37929307 PMCID: PMC10641711 DOI: 10.3310/otoh7720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Background Posterior cervical foraminotomy and anterior cervical discectomy are routinely used operations to treat cervical brachialgia, although definitive evidence supporting superiority of either is lacking. Objective The primary objective was to investigate whether or not posterior cervical foraminotomy is superior to anterior cervical discectomy in improving clinical outcome. Design This was a Phase III, unblinded, prospective, United Kingdom multicentre, parallel-group, individually randomised controlled superiority trial comparing posterior cervical foraminotomy with anterior cervical discectomy. A rapid qualitative study was conducted during the close-down phase, involving remote semistructured interviews with trial participants and health-care professionals. Setting National Health Service trusts. Participants Patients with symptomatic unilateral cervical brachialgia for at least 6 weeks. Interventions Participants were randomised to receive posterior cervical foraminotomy or anterior cervical discectomy. Allocation was not blinded to participants, medical staff or trial staff. Health-care use from providing the initial surgical intervention to hospital discharge was measured and valued using national cost data. Main outcome measures The primary outcome measure was clinical outcome, as measured by patient-reported Neck Disability Index score 52 weeks post operation. Secondary outcome measures included complications, reoperations and restricted American Spinal Injury Association score over 6 weeks post operation, and patient-reported Eating Assessment Tool-10 items, Glasgow-Edinburgh Throat Scale, Voice Handicap Index-10 items, PainDETECT and Numerical Rating Scales for neck and upper-limb pain over 52 weeks post operation. Results The target recruitment was 252 participants. Owing to slow accrual, the trial closed after randomising 23 participants from 11 hospitals. The qualitative substudy found that there was support and enthusiasm for the posterior cervical FORaminotomy Versus Anterior cervical Discectomy in the treatment of cervical brachialgia trial and randomised clinical trials in this area. However, clinical equipoise appears to have been an issue for sites and individual surgeons. Randomisation on the day of surgery and processes for screening and approaching participants were also crucial factors in some centres. The median Neck Disability Index scores at baseline (pre surgery) and at 52 weeks was 44.0 (interquartile range 36.0-62.0 weeks) and 25.3 weeks (interquartile range 20.0-42.0 weeks), respectively, in the posterior cervical foraminotomy group (n = 14), and 35.6 weeks (interquartile range 34.0-44.0 weeks) and 45.0 weeks (interquartile range 20.0-57.0 weeks), respectively, in the anterior cervical discectomy group (n = 9). Scores appeared to reduce (i.e. improve) in the posterior cervical foraminotomy group, but not in the anterior cervical discectomy group. The median Eating Assessment Tool-10 items score for swallowing was higher (worse) after anterior cervical discectomy (13.5) than after posterior cervical foraminotomy (0) on day 1, but not at other time points, whereas the median Glasgow-Edinburgh Throat Scale score for globus was higher (worse) after anterior cervical discectomy (15, 7, 6, 6, 2, 2.5) than after posterior cervical foraminotomy (3, 0, 0, 0.5, 0, 0) at all postoperative time points. Five postoperative complications occurred within 6 weeks of surgery, all after anterior cervical discectomy. Neck pain was more severe on day 1 following posterior cervical foraminotomy (Numerical Rating Scale - Neck Pain score 8.5) than at the same time point after anterior cervical discectomy (Numerical Rating Scale - Neck Pain score 7.0). The median health-care costs of providing initial surgical intervention were £2610 for posterior cervical foraminotomy and £4411 for anterior cervical discectomy. Conclusions The data suggest that posterior cervical foraminotomy is associated with better outcomes, fewer complications and lower costs, but the trial recruited slowly and closed early. Consequently, the trial is underpowered and definitive conclusions cannot be drawn. Recruitment was impaired by lack of individual equipoise and by concern about randomising on the day of surgery. A large prospective multicentre trial comparing anterior cervical discectomy and posterior cervical foraminotomy in the treatment of cervical brachialgia is still required. Trial registration This trial is registered as ISRCTN10133661. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 21. See the NIHR Journals Library website for further project information.
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Training future reviewers. Br J Neurosurg 2023; 37:961-962. [PMID: 37817374 DOI: 10.1080/02688697.2023.2253615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
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A systematic review of middle meningeal artery embolization for minimally symptomatic chronic subdural haematomas that do not require immediate evacuation. BRAIN & SPINE 2023; 3:102672. [PMID: 38021007 PMCID: PMC10668091 DOI: 10.1016/j.bas.2023.102672] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 08/30/2023] [Accepted: 09/05/2023] [Indexed: 12/01/2023]
Abstract
Introduction Embolization of the Middle Meningeal Artery (EMMA) is an emerging treatment option for patients with Chronic Subdural Haematoma (CSDH). Questions (1) Can EMMA change the natural history of untreated minimally symptomatic CSDH which do not require immediate evacuation? (2) What is the role of EMMA in the prevention of recurrence following surgical treatment? (3) Can the procedure be performed under local anaesthetic? Material and methods Systematic literature review. No randomised clinical trials available on EMMA for meta-analysis. Results Six unique large cohorts with more than 50 embolisations were identified (evidence: 3b-4). EMMA can control the progression of surgically naïve CSDH in 91.1-100% of the patients, in which haematoma expansion is halted, or the lesion decreases and resolves. Treatment failure requiring surgery occurs in 0-4.1% of the patients having EMMA as the primary and only treatment. Treatment failure requiring surgery goes up slightly to 6.8% if post-surgical patients are included. When EMMA is used as postsurgical adjunctive the risk of recurrence is 1.4-8.9% compared to 10-20% in surgical series. EMMA has minimal morbidity and it is feasible under local anaesthesia or slight sedation in the majority of cases. Conclusion There is cumulative low-quality evidence in the literature that EMMA may be able to modify the natural course of the disease. It appears effective in controlling progression of CSDHs in patients having it as a primary standing alone treatment and it reduces the risk of recurrence and the need for surgical intervention in refractory postsurgical cases or as a postsurgical adjunctive treatment with minimal morbidity (recommendation: C).
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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] [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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Fellowship of the British Journal of Neurosurgery. Br J Neurosurg 2023; 37:125-126. [PMID: 36734860 DOI: 10.1080/02688697.2023.2173873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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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] [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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Risk of Aneurysm Rupture (ROAR) study: protocol for a long-term, longitudinal, UK multicentre study of unruptured intracranial aneurysms. BMJ Open 2023; 13:e070504. [PMID: 36927598 PMCID: PMC10030903 DOI: 10.1136/bmjopen-2022-070504] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
INTRODUCTION Unruptured intracranial aneurysms (UIA) are common in the adult population, but only a relatively small proportion will rupture. It is therefore essential to have accurate estimates of rupture risk to target treatment towards those who stand to benefit and avoid exposing patients to the risks of unnecessary treatment. The best available UIA natural history data are the PHASES study. However, this has never been validated and given the known heterogeneity in the populations, methods and biases of the constituent studies, there is a need to do so. There are also many potential predictors not considered in PHASES that require evaluation, and the estimated rupture risk is largely based on short-term follow-up (mostly 1 year). The aims of this study are to: (1) test the accuracy of PHASES in a UK population, (2) evaluate additional predictors of rupture and (3) assess long-term UIA rupture rates. METHODS AND ANALYSIS The Risk of Aneurysm Rupture study is a longitudinal multicentre study that will identify patients with known UIA seen in neurosurgery units. Patients will have baseline demographics and aneurysm characteristics collected by their neurosurgery unit and then a single aggregated national cohort will be linked to databases of hospital admissions and deaths to identify all patients who may have subsequently suffered a subarachnoid haemorrhage. All matched admissions and deaths will be checked against medical records to confirm the diagnosis of aneurysmal subarachnoid haemorrhage. The target sample size is 20 000 patients. The primary outcome will be aneurysm rupture resulting in hospital admission or death. Cox regression models will be built to test each of the study's aims. ETHICS AND DISSEMINATION Ethical approval has been given by South Central Hampshire A Research Ethics Committee (21SC0064) and Confidentiality Advisory Group support (21CAG0033) provided under Section 251 of the NHS Act 2006. The results will be disseminated in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN17658526.
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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] [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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AI, papermills, and challenges for editors. Br J Neurosurg 2023; 37:1-2. [PMID: 36650698 DOI: 10.1080/02688697.2023.2167323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Middle meningeal artery embolisation for chronic subdural haematomas: the first prospective UK study. Br J Neurosurg 2022; 36:786-791. [PMID: 35892289 DOI: 10.1080/02688697.2022.2097200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background/Objectives: MMA embolisation has emerged in recent years as a safe endovascular treatment for chronic subdural haematoma. We report the first UK series of endovascular treatment of chronic subdural haematomas.Design: Prospective case series.Subjects: All adult patients referred with midline shift ≤10 mm and GCS ≥13 were considered. Patients had to be mobile with a standard origin of Middle Meningeal and Ophthalmic arteries. Patients with GCS < 13 or profound weakness (MRC grade ≤ 3) were treated with burr hole drainage and placement of subdural drains.Methods: Patients were recruited over a 14-month period from 25 October 2020 to 25 December 21 through our electronic referral system. Patients' demographics, pre-morbid modified Rankin Score (mRS), symptoms; anticoagulation and co-morbidities were prospectively collected. Suitability for endovascular treatment was discussed with the interventional neuroradiologist and neurosurgeon. SQUID-12 embolic material was used for all MMA embolisations, which was performed under general anaesthetic. Baseline CT/MRI characteristics were collected. Further imaging was obtained at 7, 21, 90 and 180 days. Clinical assessment and mRS was completed at three months.Results: Fifteen patients underwent endovascular embolisation of MMA in the study period. Of these 13 were male, median age was 79 years. Median length of stay was four days. Follow-up CT at three months has demonstrated significant reduction in both midline shift (p = 0.002) and maximum thickness of haematoma (p = 0.001). Nine patients had reached the three months' follow-up period. All of them had complete or near-complete resolution of the CSDH. One patient required surgical rescue at two months post procedure due to progression of CSDH. We report one mortality due to COVID-19.Conclusions: For select patients, MMA embolisation is a safe alternative treatment option for chronic subdural haematoma. As we gain more experience, the procedure could be performed under local anaesthetic.
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Progress in brain research vol 268: Recent advances and controversies in Gamma Knife neurosurgery,. Br J Neurosurg 2022. [DOI: 10.1080/02688697.2022.2151108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Comparison of suspected and confirmed internal EVD-related infections: a prospective multi-centre U.K. observational study. Open Forum Infect Dis 2022; 9:ofac480. [PMID: 36267249 PMCID: PMC9578167 DOI: 10.1093/ofid/ofac480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
Background Diagnosis of internal external ventricular drain (EVD)-related infections (iERI) is an area of diagnostic difficulty. Empiric treatment is often initiated on clinical suspicion. There is limited guidance around antimicrobial management of confirmed versus suspected iERI. Methods Data on patients requiring EVD insertion were collected from 21 neurosurgical units in the United Kingdom from 2014 to 2015. Confirmed iERI was defined as clinical suspicion of infection with positive cerebrospinal fluid (CSF) culture and/or Gram stain. Cerebrospinal fluid, blood, and clinical parameters and antimicrobial management were compared between the 2 groups. Mortality and Modified Rankin Scores were compared at 30 days post-EVD insertion. Results Internal EVD-related infection was suspected after 46 of 495 EVD insertions (9.3%), more common after an emergency insertion. Twenty-six of 46 were confirmed iERIs, mostly due to Staphylococci (16 of 26). When confirmed and suspected infections were compared, there were no differences in CSF white cell counts or glucose concentrations, nor peripheral blood white cell counts or C-reactive protein concentrations. The incidence of fever, meningism, and seizures was also similar, although altered consciousness was more common in people with confirmed iERI. Broad-spectrum antimicrobial usage was prevalent in both groups with no difference in median duration of therapy (10 days [interquartile range {IQR}, 7–24.5] for confirmed cases and 9.5 days [IQR, 5.75–14] for suspected, P = 0.3). Despite comparable baseline characteristics, suspected iERI was associated with lower mortality and better neurological outcomes. Conclusions Suspected iERI could represent sterile inflammation or lower bacterial load leading to false-negative cultures. There is a need for improved microbiology diagnostics and biomarkers of bacterial infection to permit accurate discrimination and improve antimicrobial stewardship.
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Variation, expectations, consent, litigation and GIRFT…. Br J Neurosurg 2022; 36:1-2. [PMID: 35638099 DOI: 10.1080/02688697.2022.2071786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Too many case reports…. Br J Neurosurg 2022; 36:169-170. [PMID: 35706378 DOI: 10.1080/02688697.2022.2075008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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A good and timely review. Br J Neurosurg 2022; 35:687-688. [PMID: 35098836 DOI: 10.1080/02688697.2021.2025648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Treatment of low flow, indirect cavernous sinus dural arteriovenous fistulas with external manual carotid compression - the UK experience. Br J Neurosurg 2020; 34:701-703. [PMID: 32009471 DOI: 10.1080/02688697.2020.1716947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: External manual carotid compression (EMCC) is a treatment option for indirect cavernous sinus dural arteriovenous fistulas (CS-DAVF). The exact mechanism of how this works is unclear but compression of the carotid and jugular produces thrombus in the cavernous sinus (CS). Although compression of the superior ophthalmic vein (SOV) has been described as a treatment option this technique is not always amenable. We studied the clinical features, imaging studies, complications and resolution of CS-DAVF in a series seven patients.Materials and methods: Between 2011 and 2017 we treated 7 patients (4 female, 3 male, age range: 60-86 years) with EMCC for an indirect, low-flow CS-DAVF (Barrow B-D). Patients compressed the cervical carotid artery on the side of the CS-DAVF using the contralateral hand for 5-10 seconds 5-10 times per day. Using gradually increasing pressure they compressed the carotid artery and jugular vein until the pulse was no longer palpable.Results: 6 patients had complete resolution of their CS-DAVF within a range of 5-24 months of symptom onset (median 8 months). 5 of our patients had complete resolution of their clinical symptoms at final follow-up. One patient had a failed endovascular procedure, and subsequently underwent surgery to cannulate the SOV for a transvenous endovascular approach to the fistula but in the meantime she had performed EMCC, which is thought to have resolved the fistula. One patient remains under follow-up and is performing EMCC.Conclusion: EMCC is a safe and low risk technique for low-flow indirect CS-DAVF and should be considered as a first line treatment for patients unable to have endovascular treatment. Although compression of the SOV has been described this can often be difficult to perform in the context of periorbital oedema. EMCC should always be performed using the contralateral hand, because this will ensure that the compressing hand falls away should cerebral ischaemia develop.
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Observed rupture of unruptured intracranial aneurysms. Br J Neurosurg 2019; 34:661-666. [PMID: 31694405 DOI: 10.1080/02688697.2019.1685647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Aim: To study the aneurysms where pre and post-rupture imaging was available to determine the impact of rupture on morphology and size of the aneurysm.Methods: A retrospective case series where all cases of ruptured aneurysms over a 5-year period were evaluated and cases identified where pre and post rupture imaging was available. These were then studied in detail.Results: The actual change in the volume of the aneurysm pre and post rupture was quite small and the underlying shape/morphology did not change at all.Conclusion: Post-rupture morphology of aneurysms can be used as representative of pre-rupture morphology. Further larger studies in collaboration with other neurosurgical centres to corroborate this view would be helpful.
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Meningioma and mood: exploring the potential for meningioma to affect psychological distress before and after surgical removal. Br J Neurosurg 2019; 33:383-387. [PMID: 30829086 DOI: 10.1080/02688697.2019.1571163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Much of the research exploring psychological distress with meningioma stem from studies including several brain tumour types (including malignant tumours) meaning that focus on meningioma is limited and that conclusions are based on small samples. Moreover, contradictory findings have been reported regarding the effects of meningioma on mood. Here, the authors present a study exploring pre and post mood scores in meningioma only patients using a sample size larger than any previous research attempt. Method: The Hospital Anxiety and Depression Scale (HADS) was used as an objective measure of mood in a clinical sample of 184 UK patients pre and post meningioma removal surgery. Repeated measures designs were used to assess for significant differences in depression and anxiety scores before and after surgery, chi-squared analyses were used to establish for clinically significant change. Results: The study revealed a significant decrease, and a medium effect size, in mean depression scores after surgery to remove the meningioma (p = .002, g = 0.35). However, no significant effect was found following meningioma removal and anxiety scores (p = .113, g = 0.17). Discussion: No significant effects were determined between mood and meningioma location. A discussion of the findings, and potential implications, is presented.
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P118 A novel technique for repair of the vertebral artery during cranial surgery. Journal of Neurology, Neurosurgery and Psychiatry 2019. [DOI: 10.1136/jnnp-2019-abn.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
ObjectivesTo demonstrate a novel/alternative technique for repair of the vertebral artery intraoperatively.DesignLeft-sided retromastoid craniotomy in one patient.SubjectsA 61-year-old male patient with meningioma in the foramen magnum encasing the vertebral artery on the left side.MethodsStandard retrosigmoid craniotomy performed with preservation of transverse and sigmoid sinuses. The dura was opened and the cerebellum was retracted with CSF release. The tumour was debulked gradually. The attempt to peel the tumour from the vertebral artery resulted in arterial bleeding. The hole in the artery was sealed using an N-hydroxysuccinimide functionalised polyethylene glycol-coated collagen patch (Hemopatch®, Baxter Healthcare Ltd) as an onlay, applying pressure for 2 minutes. Another patch was applied for further support and the artery checked for haemostasis. The dura was closed with 3–0 vicryl and Hemopatch® onlay after further tumour debulking.ResultsHaemostasis of the vertebral artery was achieved at 140 mmHg SBP and a catheter angiogram found no dissection or false lumen. The patient did not suffer postoperative haemorrhage and after three months of inpatient rehabilitation was discharged with significantly improved cranial nerve function. There was no CSF leak.ConclusionsHaemostasis was successfully achieved in the vertebral artery with this novel technique. It can prove to be important in such scenarios where direct cross-clamping and arterial repair is technically challenging and can lead to brainstem ischemia.
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A young woman with headache and vomiting. BMJ 2019; 364:l216. [PMID: 30700400 DOI: 10.1136/bmj.l216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Percutaneous retrogasserian glycerol rhizotomy for trigeminal neuralgia: an alternative technique. Br J Neurosurg 2018; 32:657-660. [DOI: 10.1080/02688697.2018.1504882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Reducing the radiation exposure from CT scanning in children with shunts: a nationwide survey and a departmental CT protocol. Br J Neurosurg 2018; 32:558-562. [PMID: 30019596 DOI: 10.1080/02688697.2018.1485874] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Low dose ionising radiation such as from CT scans carries a low but cumulative risk of cancer and children are particularly sensitive. Children with VP Shunts often undergo multiple CT scans. We developed a CT protocol with reduced radiation for paediatric patients with shunts and compared it with the current practice in the other neurosurgical units in the UK and ROI by conducting a nationwide survey. METHODS An email questionnaire was send to the superintendent radiographer in every Neurosurgical unit in the UK and the ROI. RESULTS The response rate was 70%. Only 5 (19%) of the responding units used a dedicated CT shunt protocol with reduced radiation. Radiation was reduced by lowering the tube current. In comparison, our protocol uses a combination of less tube current and fewer slices. This reduced the radiation exposure of a CT head significantly with sufficient image quality to make a diagnosis. CONCLUSION Radiation from CT for paediatric shunt patients scans can and should be reduced. This can be achieved by using reduced radiation protocols. A national paediatric CT shunt protocol could lead to significant reduction in effective radiation dose.
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De novo intracerebral arteriovenous malformations and a review of the theories of their formation. Br J Neurosurg 2018; 32:305-311. [DOI: 10.1080/02688697.2018.1478060] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Expansile manubriotomy versus standard approach for accessing ventral cervicothoracic junction disease: Methods to improve the decision-making process. Neurol India 2018; 66:174-175. [PMID: 29322982 DOI: 10.4103/0028-3886.222832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Real-time symptom reporting during elective intracranial pressure monitoring using an interactive handset . Br J Neurosurg 2017; 32:694-696. [PMID: 29183151 DOI: 10.1080/02688697.2017.1409878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Determining whether symptoms are related to abnormal intracranial pressure (ICP) may prove challenging in some cases. We evaluated the utility of an in-house designed interactive handset which allows the real-time recording of symptoms during ICP monitoring. METHODS Adult patients undergoing elective continuous ICP monitoring using the device to investigate symptoms between November 2013 and June 2015 were included in this retrospective observational cohort study. The device allowed the following symptoms to be recorded: mild, moderate and severe headache, visual disturbance and nausea. The corresponding ICP and ICP trend were also recorded. RESULTS Twenty seven patients underwent 29 episodes of ICP monitoring, reporting 383 symptoms (mild 18%, moderate 39%, severe 20% headaches, visual disturbance 15% and nausea 8%) over a median period of 48 hours (IQR 12). The median number of symptoms reported during each episode was 11 (IQR 11). The mean ICP associated with a symptom episode was 7mmHg (Range -10 to 45). Mild, moderate and severe headache complaints were associated with mean ICPs of 5 (-9 to 26), 6 (-10 to 35) and 14 (-10 to 45) mmHg respectively. The majority of complaints (68%) were reported during instances of normal ICP. Following monitoring, non-operative management was employed on 21 occasions (72%) including valve pressure adjustment on two occasions whilst surgical intervention was required on eight occasions (28%; two surgeries for under-drainage and six for over-drainage). CONCLUSIONS The device allows the clinician to accurately match a patient's symptoms with ICP to facilitate management decisions. In most instances, symptoms did not closely correlate with an abnormal ICP. By automating and standardising the collection of symptom data, this device may serve as an efficient adjunct when investigating patients with complex hydrocephalus.
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P12.22 Factors influencing recurrence of atypical meningioma following surgical resection. Neuro Oncol 2017. [DOI: 10.1093/neuonc/nox036.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Is tutobone an efficient alternative to other implants used in anterior cervical discectomy and fusion surgeries? Br J Neurosurg 2017. [PMID: 28637120 DOI: 10.1080/02688697.2017.1297362] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The graft site morbidity following iliac crest harvesting is significant. To overcome this, different bone substitutes like coral dowels, solvent dissolved bovine/human bone substitutes, and carbon fiber/titanium cages have been used. This study was undertaken to assess the postoperative radiological fusion rates and symptom relief in patients who had Tutobone used as an interbody spacer compared to autologous bone graft (ABG), cages, surgibone and coral dowels. METHODS This was a retrospective, observational study. Case notes and post-operative cervical spine radiographs done at two subsequent follow-ups were reviewed. Data were derived from all Anterior Cervical Discectomy and fusion (ACDF) surgeries performed at our centre over a 10-year period for degenerative cervical spine disease. We analysed 530 patients. Exclusion criteria included incomplete notes, complex cervical surgery (both anterior and posterior fixation and vertebrectomies). Patients were divided into 3 groups, patients treated with (1) Autologous bone graft, (2) Tutobone and (3) other implants which include cages, surgibone and coral dowels. RESULTS An analysis of 530 patients who had ACDF with either ABG (n = 328) or tutobone (n = 95) or other implants (n = 90) is presented. A significantly greater number of patients in whom autologous bone was used had more than one level surgery. The median follow-up times were 3 months and 12 months. Rates of fusion and time to fusion with bone substitutes were inferior to ABG in our series, but there was not much to choose amongst them. CONCLUSION The use of ABG in ACDF leads to fusion in a shorter duration and greater proportion of patients, when compared to substitutes. Other implants like Tutobone (cheaper alternative), cages, etc can also be used in ACDF procedures with good efficacy with the added advantage of preventing donor site morbidity. There was no association between fusion rates and symptom relief and between use of plating and fusion.
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Wrong-level spinal surgery - 'never' again? Br J Neurosurg 2016; 30:200-1. [PMID: 26966921 DOI: 10.3109/02688697.2016.1155694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Specialists and survival times. J Neurosurg 2016; 124:887-8. [PMID: 26722861 DOI: 10.3171/2015.6.jns151083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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An Alternative Display Could Lead to Earlier Diagnosis of Intracerebral Pathology with a Hemedex Flow Probe In Situ. World Neurosurg 2015; 84:2079.e1-5. [PMID: 26341435 DOI: 10.1016/j.wneu.2015.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 08/13/2015] [Accepted: 08/14/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To report 2 cases of patients who had an ischemic stroke and an intracerebral hematoma after a superficial temporal artery-middle cerebral artery bypass with a thermal diffusion blood flow probe in situ and emphasize how a change in the way the data are presented could have led to an earlier diagnosis. METHODS Both patients had flow probes within 2 cm of the graft site and were thus close enough to be representative of local or regional rather than global perfusion. Data smoothening was applied to the raw data that were available and displayed on the monitor. Both the smoothed plots and the raw plots were analyzed. RESULTS Good clinical correlation was observed between the flow probe data and the clinical condition of both patients. This was more apparent when viewing the smoothed plots. CONCLUSIONS Although there was good clinical correlation, data displayed on the perfusion monitor can be incorrectly interpreted because the signal-to-noise ratio is small. We therefore suggest an alternative presentation of perfusion data for clinicians to recognize hypoperfusion and to take informed action before a stroke or hematoma is clinically manifest.
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Is local hypoperfusion the reason for transient neurological deficits after STA-MCA bypass for moyamoya disease? J Neurosurg 2015; 122:90-4. [PMID: 25343178 DOI: 10.3171/2014.8.jns132413] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Hyperperfusion is believed to be the cause of transient neurological events (TNEs) in patients with moyamoya disease (MMD) who have undergone an extracranial-to-intracranial (EC-IC) bypass between the superficial temporal artery (STA) and the middle cerebral artery (MCA). The objective of this study was to evaluate this possibility by analyzing cerebral blood flow (CBF) data obtained with thermal diffusion probes used at the authors' center. METHODS The authors examined postoperative cerebral perfusion in 31 patients with MMD who underwent a direct EC-IC STA-MCA bypass. A Hemedex Q500 flow probe was placed in the frontal lobe adjacent to the bypass and connected to a Bowman cerebral perfusion monitor, and CBF data were statistically analyzed using JMP 8.0.2 software. Seven patients experienced a TNE after surgery in the left hemisphere (that is, after left-sided surgery), manifesting as dysphasia approximately 24 hours postoperatively and which had improved by 48 hours. No TNEs were observed after right-sided surgeries. Operative and postoperative CBFs in the left side with the TNE were compared with those in the left side with no TNE and on the right side. RESULTS A detailed analysis of 64,980 minute-by-minute flow observations showed that the initial postbypass CBF was higher on the left side where the TNEs occurred. This CBF increase was followed by a widely fluctuating pattern and a statistically significant and sharp drop in perfusion (p < 0.001, mean difference of CBF between groups, paired t-test) associated with a TNE not observed in the other 2 groups. CONCLUSIONS On the basis of the authors' initial observations, an early-onset altered pattern of CBF was identified. These findings suggest local hypoperfusion as the cause of the TNEs. This hypoperfusion may originate from competing blood flows resulting from impaired cerebral autoregulation and a fluctuating flow in cerebral microcirculation.
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Internal carotid artery surgical revascularization in a pediatric patient with Schimke immuno-osseous dysplasia. J Neurosurg Pediatr 2015; 15:189-91. [PMID: 25431900 DOI: 10.3171/2014.10.peds14141] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Schimke immuno-osseous dysplasia (SIOD) is a rare autosomal recessive disorder characterized by spondyloepiphyseal dysplasia, episodic lymphopenia, renal failure, and cerebrovascular disease secondary to arteriosclerosis and myointimal hyperplasia. In this paper the authors report the first known application of internal carotid artery (ICA) surgical revascularization to relieve a high-grade focal stenosis of the ICA in a pediatric patient, a 6-year-old boy with SIOD. The clinical presentation, imaging features, operative technique, and postoperative course are described and the molecular genetics, pathophysiology, and treatment considerations in SIOD are discussed.
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Temporary Clipping for Unruptured Aneurysms. World Neurosurg 2014; 82:309-11. [DOI: 10.1016/j.wneu.2013.07.094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 07/27/2013] [Indexed: 10/26/2022]
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Routine but risky: a multi-centre analysis of the outcomes of cranioplasty in the Northeast of England. Acta Neurochir (Wien) 2014; 156:1361-8. [PMID: 24752723 DOI: 10.1007/s00701-014-2081-1] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 03/25/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cranioplasty is undertaken as a routine secondary operation following craniectomy. At a time when decompressive craniectomy is being evaluated by several large trials, we aimed to evaluate the morbidity associated with cranioplasty and investigate its potential effect on outcome. METHODS The outcomes of 166 patients undergoing cranioplasty at two centres in the United Kingdom between June 2006 and September 2011 were retrospectively analysed. Outcome measures included mortality, morbidity and functional outcome determined by the modified Rankin score (mRS) at last follow-up. A logistic regression analysis was performed to model and predict determinants related to neurological outcome following cranioplasty. RESULTS Sixty-seven out of 166 patients (40.4 %) experienced at least one complication during a median follow-up time of 15 months (inter-quartile range 5-38 months). Thirty six patients (21.7 %) developed infection requiring antibiotics, with 27 (16.3 %) requiring removal of the cranioplasty. Nine of 25 patients (36 %) with bi-frontal defects developed an infection whereas 21 of the 153 patients (16.4 %) with a defect other than bi-frontal developed an infection (Chi square p = 0.009). Further surgery in the two groups was required in 16.4 % and 11.7, % respectively. Pseudomeningocoele (9 %), seizures (8.4 %) and poor cosmesis (7.2 %) were also commonly observed. Logistic regression analysis identified initial operation (p < 0.03), mRS at the time of cranioplasty (p < 0.0001) and complications (p < 0.04) as being predictive of neurological outcome at last follow-up. Age at the time of cranioplasty and the timing of cranioplasty were not predictive of last mRS score at follow-up. CONCLUSIONS Cranioplasty harbours significant morbidity, a risk that appears to be higher with a bifrontal defect. The complications experienced influence subsequent functional outcome. The timing of cranioplasty, early or late, after the initial operation does not impact on the ultimate outcome. These findings should be considered when making decisions relating to craniectomy and cranioplasty.
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Spinal Cord Stimulation for Visceral Pain Related to Chronic Pancreatitis: Report of 2 Cases. World Neurosurg 2014; 81:651.e17-9. [DOI: 10.1016/j.wneu.2013.09.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Revised: 06/05/2013] [Accepted: 09/19/2013] [Indexed: 01/06/2023]
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Abstract W P370: Is Local Hypoperfusion the Basis of Transient Neurological Deficits After STA-MCA Bypass in Moyamoya Disease? Stroke 2014. [DOI: 10.1161/str.45.suppl_1.wp370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Object:
Hyperperfusion is believed to be the cause of transient neurological deficits in patients who have undergone an STA-MCA bypass for Moyamoya disease (MMD). We evaluated this on the basis of cerebral blood flow data from thermal diffusion probes used at our center.
Methods:
We studied postoperative cerebral perfusion in 31 patients with MMD who underwent a direct STA-MCA bypass. A Hemedex Q500 flow probe (Hemedex, Inc, Cambridge, MA) with a Bowman cerebral perfusion monitor was placed in the frontal lobe adjacent to the bypass, and flow data was analysed using JMP 8.0.2 (SAS Inc., Cary, NC). Seven patients experienced a transient neurological event (TNE) after the left-sided operation, manifesting as dysphasia around 24 hours postoperative and improving by 48 hours. The patterns of median cerebral blood flows with respect to time were plotted for the 3 groups (left side with TNE, the left side with no TNE and the right side) with smoothing by the moving average method. Observations were divided into time blocks (1 = 0-8 hours, 2 = 8-16 hours, 3 = 16-24 hours, 4 = 24-32 hours, 5 = > 32 hours). Differences in median blood flow between various time blocks and between groups were also analysed to evaluate any significant differences. These were correlated with the clinical picture.
Results:
An average of 20 hours (IQR 10-32 hours) of postoperative flow data was available for each patient. A detailed analysis of 64980 minute-by-minute flow observations shows that the initial post-bypass flow was higher on the left side where TNEs occurred, followed by a widely fluctuating pattern and a sharp drop in the perfusion corresponding with a deficit (p < 0.001, mean difference of flow, t-test) when compared to the other groups where deficits were not observed.
Conclusion:
Based on our observations we demonstrate a pattern of blood flow that suggests local hypoperfusion as the cause of the deficit on the backdrop of impaired autoregulation and a fluctuating blood flow, contrary to the traditional view that attributes these to hyperperfusion.
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Temporary artery occlusion in ruptured aneurysms. World Neurosurg 2013; 82:43-5. [PMID: 23920285 DOI: 10.1016/j.wneu.2013.07.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 07/27/2013] [Indexed: 10/26/2022]
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Combined endovascular and microsurgical management of complex cerebral aneurysms. Front Neurol 2013; 4:108. [PMID: 23964263 PMCID: PMC3737456 DOI: 10.3389/fneur.2013.00108] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 07/19/2013] [Indexed: 12/15/2022] Open
Abstract
Cerebral aneurysms are associated with a 50% mortality rate after rupture and patients can suffer significant morbidity during subsequent treatment. Neurosurgical management of both ruptured and unruptured aneurysms has evolved over the years. The historical practice of using microsurgical clipping to treat aneurysms has benefited in the last two decades from tremendous improvement in endovascular technology. Microsurgery and endovascular therapies are often viewed as competing treatments but it is important to recognize their individual limitations. Some aneurysms are considered complex, due to several factors such as aneurysm anatomy and a patient’s clinical condition. A complex aneurysm often cannot be completely excluded with a single approach and its successful treatment requires a combination of microsurgical and endovascular techniques. Planning such an approach relies on understanding aneurysm anatomy and thus should routinely include 3D angiographic imaging. In patients with ruptured aneurysms, endovascular coiling is a well-tolerated early treatment and residual aneurysms can be treated with intervals of definitive clipping. Microsurgical clipping also can be used to reconstruct the neck of a complex aneurysm, allowing successful placement of coils across a narrow neck. Endovascular techniques are assisted by balloons, which can be used in coiling and testing parent vessel occlusion before sacrifice. In some cases microsurgical bypasses can provide alternate flow for planned vessel sacrifice. We present current paradigms for combining endovascular and microsurgical approaches to treat complex aneurysms and share our experience in 67 such cases. A dual microsurgical–endovascular approach addresses the challenge of intracranial aneurysms. This combination can be performed safely and produces excellent rates of aneurysm obliteration. Hybrid angiographic operating-room suites can foster seamless and efficient complementary application of these two modalities.
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Using telephone logs instead of databases to accurately estimate neurosurgical on-call workload. Br J Neurosurg 2012; 27:344-7. [DOI: 10.3109/02688697.2012.743966] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Clip reconstruction of midbasilar aneurysms. World Neurosurg 2012; 79:675-7. [PMID: 23111225 DOI: 10.1016/j.wneu.2012.10.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 10/23/2012] [Indexed: 10/27/2022]
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Abstract
INTRODUCTION We analyse the factors that are associated with the diagnostic yield of needle brain biopsy. MATERIAL AND METHODS We present a retrospective series of 124 consecutive biopsies in a 30-month period. Patients' demographics (age, gender), lesion topography (side, location, depth), lesion characteristics (histology, volume, radiological enhancement), type of biopsy procedure (freehand, ultrasound guided, frameless and frame-based stereotactic) and the use of intraoperative histologic examination were correlated with the diagnostic rate. Descriptive statistics and a nominal logistic regression model were used to evaluate the factors influencing diagnostic yield. RESULTS 63 men and 61 women were included in the study with mean age 59.2 (range: 16-86). 55 were frame-based stereotactic biopsies, 33 were frameless stereotactic biopsies, 29 biopsies were performed under ultrasound guidance and 7 freehand. The diagnostic yield in our series is 93.5%. The gender, lesion topography, biopsy method, use of intraoperative histology and enhancement did not correlate with the diagnostic yield. Younger age had a negative impact on diagnostic yield. 6 out of 8 inconclusive biopsies were in non-glial lesions (p < 0.05). The odds of obtaining a positive diagnosis increased sevenfold with every cc increase in lesion volume. CONCLUSION The age of the patient, the volume and the histology of the brain lesion had an impact on the diagnostic yield of needle biopsy. None of the other factors significantly influenced the diagnostic rate.
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Emergency neurosurgical referrals in the North East of England – trends over four years 2008–2011. Br J Neurosurg 2012; 27:334-9. [DOI: 10.3109/02688697.2012.717979] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Unplanned reoperation rates in pediatric neurosurgery: a single center experience and proposed use as a quality indicator. J Neurosurg Pediatr 2012; 9:665-9. [PMID: 22656260 DOI: 10.3171/2012.2.peds11305] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The pediatric neurosurgery practice over 2 years was reviewed at a tertiary neurosciences center. The intention was to establish the frequency of unplanned reoperations at the center, investigate the factors responsible, and consider using unplanned reoperations as a quality indicator. METHODS All pediatric neurosurgical operations done between January 2008 and January 2010 were reviewed using data from operation theater logs and hospital records. Data were recorded as per the standard requirements of the Society of British Neurological Surgeons for incorporation into the national database. "Unplanned reoperation" was defined as any unscheduled secondary procedure required for a complication resulting directly or indirectly from the index operation or as an unscheduled return to the operating theater for the same condition. Operations were defined as "urgent" if they had to be performed out of hours (that is, outside the hours of 8:00 a.m. to 5:00 p.m.), "emergency elective" if they were included on the emergency list but within working hours, and "routine elective" if they were on the scheduled operations list. Both overall and 30-day unplanned reoperation rates were considered. Factors influencing unplanned reoperations were explored using a logistic regression model. RESULTS Four hundred ten operations were analyzed. The overall unplanned reoperation rate was 28%. The median time to an unplanned reoperation was 9 days. Risk factors for unplanned reoperations included a CSF diversion procedure (OR 7, p < 0.0001) and an urgent procedure (OR 2.5, p = 0.02, higher unplanned reoperations for urgent procedures relative to routine electives). The 30-day unplanned reoperation rate was 17%. Urgent cases composed 32% of all operations. Trainees performed 52% of the urgent operations. Forty-four percent of all operations were related to CSF diversion. Sixty-four percent of patients had reoperations during the course of the study period, and 44% of these reoperations were unplanned. CONCLUSIONS An unplanned return to the operation theater is common in the authors' pediatric neurosurgical practice and is procedure specific. Unplanned reoperation rates may be useful for monitoring quality across hospitals and identifying opportunities for quality improvement. The authors propose the use of this index as a quality indicator and advocate its validation in a prospective multicenter study.
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Subarachnoid hemorrhage patients' fears of recurrence are related to the presence of posttraumatic stress disorder. Neurosurgery 2012; 69:323-32; discussion 332-3. [PMID: 21415779 DOI: 10.1227/neu.0b013e318216047e] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) patients illustrate a chronic fear of recurrence. A third of patients develop posttraumatic stress disorder (PTSD) after SAH, and PTSD after other conditions is associated with a more negative outlook on life. OBJECTIVE We examined whether recurrence fears are related to PTSD and whether this is associated with the patients making more negative health appraisals. We also examined the helpfulness of current treatments. METHODS Two SAH samples were generated. Sample 1 (n = 82) was assessed 13 months after ictus for PTSD, cognition, fear of recurrence, and beliefs concerning future health. Sample 2 (n = 60) was assessed 18 months after ictus for PTSD and to determine how much current treatments increased their confidence about not having another SAH. RESULTS Thirty-four percent of sample 1 had PTSD. Although clinically and cognitively comparable, PTSD patients feared recurrence more and were comparatively more pessimistic about their chances of further SAH. Thirty-six percent of sample 2 had PTSD. These most fearful patients reported finding current treatments the least helpful. CONCLUSION Fear of recurrence after SAH is related to PTSD. Participants with PTSD were more pessimistic about their future health. Treatment for PTSD could alleviate fears of SAH recurrence and promote better outcome.
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