Neurosurgery Unit Research Articles

P18.39.A SEIZURE PROPHYLAXIS IN GLIOMA SURGERY (SPRING): A MULTI-CENTRE, UNBLINDED, RANDOMISED TRIAL

Abstract BACKGROUND 50-80% of all glioma patients will suffer from seizures during their lifetime. Over half of these patients will have drug resistant seizures. Seizure risk is increased peri-operatively, at tumour progression, and shortly before death. Current guidelines do not support routine use of prophylactic peri-operative anti-epileptic drugs (AED) in seizure naïve patients; despite this, levetiracetam is frequently prescribed for this indication. The aim of this trial was to determine the clinical and cost effectiveness of prophylactic levetiracetam in seizure naïve patients undergoing surgery for a glioma at reducing the risk of seizures. MATERIAL AND METHODS Seizure naïve patients with newly diagnosed glioma undergoing surgery (biopsy or resection) were randomised (1:1) to receive 12 months prophylactic levetiracetam or no prophylaxis at 14 neurosurgery and neuro-oncology units in the UK. Participants received standard of care neurosurgery and neuro-oncology treatment and were followed until death or for a maximum of one year. The primary outcome was one year risk of first seizure analyzed using a logistic regression model and intention to treat analysis. Outcomes were analyzed by intention-to-treat. The target accrual was 804 participants. This trial was registered with ISRCTN 49474281. RESULTS Between Oct 10, 2019 and Aug 30, 2022, we randomised 96 patients, from 24 to 79 years of age, to levetiracetam (n=49) or no prophylaxis (n=47). Due to slow accrual during the Covid-19 pandemic the trial closed early. In the levetiracetam group there were 43 high grade glioma (HGG) and 6 low grade glioma (LGG), and in the no prophylaxis group there were 43 HGG and 4 LGG. Seventeen (35%) of 49 patients randomised to levetiracetam had a seizure, compared to 15 (32%) of 47 patients randomised to no prophylaxis (OR 1.25, 95%CI 0.49-3.21, p=0.64). Median time to first seizure was 4.8 months in the levetiracetam group and 3.0 months in the no prophylaxis group. In the levetiracetam group 20 (41%) of 49 patients died within 12 months (median overall survival 6.8 months; range 0.2-11.9), and in the no prophylaxis group 15 (32%) of 47 patients died within 12 months (median 4.7 months; range 0.1-12.0). There were no serious adverse events or suspected unexpected serious adverse events related to levetiracetam. CONCLUSION Due to poor accrual caused by the Covid-19 pandemic the SPRING trial closed early and is therefore underpowered. Based on the limited data there was no difference in the 12 month seizure risk in the prophylaxis and no prophylaxis patients undergoing surgery for newly diagnosed glioma. The role of prophylactic anti-epileptic drugs remains undefined.

Antibiotic use in surgical infections at a tertiary teaching hospital in Ghana.

The study aimed to assess antibiotic prescribing and use patterns at the Department of Surgery, Korle Bu Teaching Hospital. A cross-sectional study design was employed in this study. The study was conducted at the Department of Surgery, Korle Bu Teaching Hospital. Forty-two prescribers out of 63 (67%) at the Department of Surgery responded to questionnaires. Over the study period, prescriptions and medical records of 1715 patients from the general surgery, neurosurgery, and urology units were reviewed. Percentage of prescriptions with antibiotics, percentage of prescribers using guidelines for antibiotic prescriptions, and percentage using culture and sensitivity to inform antibiotic prescriptions. Of the 1715 prescriptions assessed, 75% (1294/1715) were from inpatients, and 45% (772/1715) included an antibiotic. Ciprofloxacin and metronidazole constituted 54% of antibiotic prescriptions from general surgery. Amoxicillin/clavulanic acid and ceftriaxone constituted 64.7% of antibiotic prescriptions from neurosurgery, and ceftriaxone and ciprofloxacin made up 37.7% of antibiotic prescriptions from urology. Microbiology testing was done for only 14.5% (9/62) of inpatients who received antibiotics for treatment. The choice of antibiotics was influenced mainly by doctors' previous experience (37/42, 88.1%). Antibiotics are widely used. About half of all prescriptions had antibiotics, with ciprofloxacin and metronidazole constituting more than half of antibiotic prescriptions from general surgery. Doctors mainly based their antibiotic prescriptions on previous experience and occasionally on microbiological investigations. None declared.

CP-14. VOLUMETRIC ANALYSIS OF PAEDIATRIC CRANIOPHARYNGIOMAS: CLINICAL-RADIOLOGICAL CORRELATION STUDY

Abstract BACKGROUND Craniopharyngioma are heterogeneous hypothalamopituitary tumours with solid and cystic components which have a distinct natural history. Neuroimaging follow-up and the definition of progressive disease is challenging due to unpredictable growth of the inflammatory cystic component. METHODS This multicentre retrospective observational study aimed to describe the clinical-radiological correlation of craniopharyngiomas at two paediatric neurosurgery units (GOSH,UK and USP,Brazil). Craniopharyngiomas treated over a 20-year period were identified and standardized clinical outcomes recorded. Baseline MRIs were reviewed and volumetric T1-weighted images segmented by a board-certified paediatric neuroradiologist. RESULTS Of 123 patients, 92 baseline MRIs were available for image analysis (USP=32; GOSH=60). No differences between series were identified in either demography (mean age: USP=9.2±4.6; GOSH=8.2±4.1 years) or tumour characteristics, with tumours being predominantly cystic (USP=75%; GOSH=76%), localised to the sellar/suprasellar region (USP=84%; GOSH: 88%), and on pre-chiasmatic (USP=34%; GOSH=22%) or retro-chiasmatic (USP=59%; GOSH=67%) locations. Pre-chiasmatic tumours were associated with an increased prevalence of visual symptoms at presentation (p=0.006) and worse recovery of visual acuity at long-term follow-up (p=0.021). Regarding volumetric analysis, mean volumes were 16.6±25.1cm3 for the cystic component and 38.3±10cm3 for the solid component. Volumes of the solid and cystic components had no correlation with each other. Larger cystic tumour volumes were correlated with a greater prevalence of diabetes insipidus at presentation (p=0.06). Larger solid tumours were significantly related to younger ages (p=0.02) and had worse PFS in our series. In terms of long-term outcomes, high volume cystic tumours were related to worse hypothalamic outcomes. In multivariate analysis (n=92), Paris classification did not predict long-term outcomes. CONCLUSIONS Volumetric analysis of craniopharyngiomas showed significant correlation with the onset of diabetes insipidus and hypothalamic long-term outcomes. Larger cystic craniopharyngioma were more common in younger patients. The Paris classification did not predict long-term outcomes in multivariate analysis.

CP-15. LONG-TERM OUTCOMES OF PAEDIATRIC CRANIOPHARYNGIOMAS: MULTI-CENTRE COMPARATIVE STUDY

Abstract BACKGROUND Craniopharyngioma (CP) account for 80% of childhood hypothalamopituitary tumours and, though benign, their proximity to the visual pathways, hypothalamus, and pituitary incurs significant long-term neurologic and endocrine morbidity. Informed surgical decision-making has the potential to reduce morbidity and improve outcomes. METHODS This multicentre retrospective observational study aimed to compare long-term outcomes of CP at two paediatric neurosurgery units (GOSH, UK, and USP, Brazil), delineating management paradigms associated with better prognosis. CP treated over a 20-year period were identified and standardized clinical outcomes recorded for comparative analysis. RESULTS 123 patients were identified (USP=52; GOSH=71). No demographic differences were identified between series (mean age: USP=9.2±4.6; GOSH=8.2±4.1 years). Headaches (USP=75%; GOSH=62%) and visual deficits (USP=46%; GOSH=38%) were the most common presenting symptoms. Growth hormone deficiency at presentation was more common in the USP cohort (USP=62.5%; GOSH=35%; p=0.009). There was significantly more hypothalamic invasion in the GOSH cohort (Paris grade 2: GOSH=67.0%; USP=37.5%; p=0.026), but significantly larger cystic volumes in the USP cohort (USP=27.5±37cm3; GOSH=10.5±8.9cm3;p=0.004). These differences led to different surgical approaches, with more subtotal resections at USP (78%) and more cyst aspirations at GOSH (62%). 80% of patients at GOSH received RT compared to 32% at USP. Mean follow-up at GOSH was 7.5±4.8 years compared to 10.1±5.6 years at USP. Cognitive outcome did not vary. GOSH cohort presented higher rates of levothyroxine replacement (USP=67%; GOSH=86%;p=0.017). GOSH exhibited better hypothalamic outcomes (p=0.08) and better visual outcomes (field deficits: GOSH=44%; USP=66%;p=0.01). In multivariate analysis (n=123), subtotal/gross-total resection (OR0.17; 95%CI:0.05-0.55;p<0.01) and older age at diagnosis (OR0.91, 95%CI:0.82-0.99;p=0.04) were associated with longer progression-free survival. CONCLUSIONS Comparative analysis of two large craniopharyngioma series identified different paradigms of surgical management driven by clinical-radiological presentation with similar long-term outcomes. Subtotal/gross-total resection was not related to worse clinical outcome or better progression-free survival.

Posttraumatic Hydrocephalus Following Decompressive Craniectomy in Traumatic Brain Injury: Proportion and Risk Factors

Abstract Background Posttraumatic hydrocephalus (PTH) is an important cause of morbidity after decompressive craniectomy (DC) following traumatic brain injury (TBI). Early diagnosis and treatment of PTH can prevent further neurological compromise in patients who are recovering from TBI. Objective The aim of this study was to assess the proportion of patients who develop hydrocephalus after undergoing DC and to identify the factors associated with PTH requiring surgical treatment in patients undergoing DC for TBI. Methods Data of patients undergoing DC for TBI in the Trauma Neurosurgery Unit, Medical College Hospital, Trivandrum, between June and December 2020 were collected prospectively. Results A total of 48 patients who underwent DC were studied. Six (12.5%) patients developed PTH. The patients were divided into two groups: PTH (patients who developed hydrocephalus) and non-PTH (patients who did not develop hydrocephalus). Age, sex, mode of injury, severity of injury, and preoperative radiological findings were not associated with the development of PTH. A distance of craniectomy margin from the midline of less than 2.5 cm was found to be statistically significant. No statistical difference was found in the outcome among the PTH and non-PTH groups. Conclusion Craniectomy with a superior limit too close to the midline can predispose patients undergoing DC to the development of hydrocephalus. We therefore suggest performing wide DCs with the superior limit greater than 25 mm from the midline.

High prevalence of morphometric vertebral fractures opportunistically detected on thoracic radiograms in patients with non-functioning pituitary adenoma.

Vertebral fractures (VFs), the hallmark of skeletal fragility, have been reported as an emerging complication in patients with pituitary diseases associated with hormonal excess and/or deficiency, independently from bone mineral density. Non-functioning pituitary adenoma (NFPA) is amongst the most frequent pituitary adenomas; however, skeletal health in this context has never been investigated. We aimed at assessing the prevalence and the determinants of morphometric VFs in patients with NFPA. We enrolled 156 patients (79M/77F, mean age 55.75 ± 12.94years) at admission in Neurosurgery Unit before trans-sphenoidal surgery and compared them with an age and sex-matched control group of subjects with neither history/risk factors for secondary osteoporosis nor pituitary disorders. We performed a vertebral morphometric evaluation of the thoracic spine on pre-operative X-ray images (MTRx) and collected biochemical, demographic, and clinical data from the entire cohort. The prevalence of thoracic VFs in patients with NFPA was significantly higher than the control group (26.3% vs. 10.3%; p < 0.001). In the NFPA group, 20 patients (48.8% of the fractured patients) showed multiple VFs, 14 (34.1% of them) showed moderate/severe VFs. Patients with VFs were significantly older and had lower serum free triiodothyronine (fT3) levels than non-fractured ones (p = 0.002 and p = 0.004; respectively). The prevalence of secondary male hypogonadism was higher among men with VFs as compared to those with no VFs (72% vs. 48.1%; p = 0.047). Consistently, total testosterone levels in males were significantly lower in fractured patients than in non-fractured ones (p = 0.02). The prevalence of gonadotroph adenomas was significantly higher among patients with VFs (p = 0.02). In multiple logistic regression analysis, older age and lower serum fT3 levels were independent factors predicting the risk for VFs. For the first time, we reported a high prevalence of thoracic radiological VFs in patients with NFPAs. Our data should prompt clinicians to proceed with a clinical bone fragility evaluation already during the diagnostic work-up, particularly in those with concomitant hypogonadism, or in those with older age and/or with lower fT3.

An “epileptic scent”: Olfactory auras in tumor-related epilepsy

ObjectivesTo characterize a profile for patients with tumor-related epilepsy presenting olfactory auras. Materials and MethodsWe conducted a monocentric, retrospective study on patients who underwent surgery in the Neurosurgery Unit of Udine University Hospital (Udine, Italy), between the 1st of January 2010 and the 1st of January 2019, for primary brain tumors (PBTs) involving the temporal lobe and the insula. All patients were affected by tumor-related epilepsy; the study group presented olfactory auras as well. We collected neuroradiological, neuropsychological and neurophysiological data from patients’ medical charts. ResultsThe subtraction analysis of MRI data shows maximum lesion overlay in left olfactory cortex, left and right hippocampus, left amygdala, right rolandic operculum, right inferior frontal gyrus and right middle temporal gyrus. The presence of olfactory auras did not influence seizure outcome (p = 0.500) or tumor recurrence after surgery (p = 0.185). The type of auras (elementary vs. complex), also, did not influence seizure control (p = 0.222). DiscussionIn presence of olfactory auras, anterior and mesial temporal regions are mainly involved, such as olfactory cortex, amygdala, and anterior hippocampus, together with right rolandic operculum, right inferior frontal gyrus and right middle temporal gyrus, suggesting their possible role in the genesis of olfactory auras. Post-surgical seizure outcome and disease relapse are not influenced by neither the presence nor the type of olfactory auras. ConclusionsOlfactory auras are rare event, however they may be often underestimated by the patients and under-investigated by the clinicians, even when their occurrence can represent a useful localizing tool.

Prognostic variables predict clinical outcome after decompressive craniectomy: A single institute experience; A retrospective study.

Decompressive craniectomy (DC) is a well-established neurosurgical intervention in patients with high intracranial pressure who fail to respond to medical treatment. Data on predictive factors for functional outcomes in patients with DC who have malignant middle cerebral artery (MCA) infarction as opposed to intracranial hemorrhage (ICH) are scarce. Eighty-four patients who underwent DC treatment for ICH and malignant MCA infarction were examined. All patients underwent surgery in the Bahrain Salmaniya Medical Complex Neurosurgery Unit between January 2017 and June 2021. To determine whether any of these demonstrated a link to the functional outcome, radiographic factors were compared with clinical data. The postsurgical midline shift (MLS) (ICH group) showed the strongest correlation (ρ = 0.434; P = .006), as in the MCA infarction group as well (ρ = 0.46; P = .005). Further analyses using binary logistic regression with postsurgical basal cistern status and ∆ MLS, and it was observed to be statistically significant (odds ratios: 0.067, 95% CI: 0.007, 0.67; P = .021). The initial Glasgow coma scale, postsurgical MLS, basal cistern status, and ∆ are Measurable variables that can be used to predict outcomes in the groups with ICH and MCA infarction.

Challenges of establishing a neurosurgery unit and working as a neurosurgeon in Karnali, a remote province of Nepal

Challenges of establishing a neurosurgery unit and working as a neurosurgeon in Karnali, a remote province of Nepal

Analysis of Fall Incidence Rate and Risk Factors at a Tertiary Care Hospital Setting for Inpatient Neurological Care using the Morse Fall Scale: A Prospective Study

Introduction: Falls are the most common adverse events related to a patient safety in healthcare institutions. Falls during hospitalisation, particularly in inpatient rehabilitation facilities, are a common phenomenon among hospitalised individuals. The rationale of the present study is to reduce the incidence of falls by early identification of fall risk using an outcome measure. Aim: The aim of this study is to identify the fall incidence rate and associated factors responsible for falls in inpatients with neurological diseases using the Morse Fall Scale (MFS). Materials and Methods: This prospective study included 128 patients hospitalised in the Medicine and Neurosurgery Units of Justice KS Hegde Charitable Hospital in Mangaluru, Karnataka, Southern India. The study was conducted from March 2022 to March 2023. Factors were analysed through direct patient interviews, and fall risk scores were identified using the MFS during admission and discharge. Categorical variables were presented as frequency and percentage, while descriptive variables were presented as Mean±Standard Deviation. The pre-post comparison of the outcome measure was conducted using the Z-test. Results: The fall incidence rate in neurological inpatients was found to be 15 (11.7%), and the majority of the population belonged to moderate to high-risk of falls. During the hospitalisation period, 99 (77.3%) individuals had a fear of falling, while 29 (22.7%) did not have any fear of falling. Among the study population, 113 (88.3%) had no falls during their hospitalisation, while 15 (11.7%) experienced falls. The majority of subjects had a moderate risk of falls: 63 (49.2%) upon admission and 68 (53.1%) at discharge. There was a significant difference in the MFS scores between admission and discharge (p-value=0.024). Conclusion: The present study concludes that the MFS enables the identification of individuals at risk of falling. The variables related to these findings were the use of continuous medications, balance issues, fear of falling, followed by other factors such as age, length of hospital stay, previous hospitalisation, and sensory disorders.

Incidence of infection in carpal tunnel surgery with and without the use of local antibiotics.

To compare the infection rate in patients who underwent carpal tunnel surgery with and without instilling local antibiotics into the surgical wound. The retrospective cohort study was conducted at the Department of Surgery, Unit of Neurosurgery, Government Naseer Ullah Babar Memorial Hospital, Peshawar, Pakistan, and comprised data from July 2019 to July 2021 related to non-diabetic patients without any comorbidity who had undergone fresh carpal tunnel surgery. The cases had been operated by two surgeons having a different approach to preventing infection in carpal tunnel surgery cases. The surgeon in group A did not use any local antibiotics after completing the surgery, while the surgeon in group B instilled local gentamicin in the open wound for 3 minutes after completing the nerve release. All patients were put on oral antibiotics for a period of 5 days after the procedure in both the cohorts, and were assessed fortnightly for any infection and removal of stitches. Demographics of the patients, use of antibiotics and the occurrence of infection were recorded on a proforma. Data was analysed using SPSS 20. Of the 177 patients operated during the period, 13(7.3%) were discarded owing to missing data. Of the 164(92.7%) patients analysed, 138(84.14%) were females and 26(15.85%) were males. The overall mean age was 32.46±8.97 years. The total surgeries conducted were 176; 96(54.54%) in group A and 80(45.45%) in group B. Infections were found in 3(1.7%) patients; all in group A (p=0.160). Although not statistically significant, instillation of local antibiotics may play a role in preventing surgical site infections in carpal tunnel surgery cases.

Promoting the Singular Therapeutic Project in a public hospital

The objective this study was to report the application of the Singular Therapeutic Project (STP) in a public hospital. For five weeks, five multiprofessional residents were allocated in a medical clinic and neurosurgery unit, where they selected patients for the development of STP. 10 STP were performed, most with patients with complex clinical conditions, unable to answer for themselves, with no companions during hospitalization or with family members with low levels of education. Among the challenges encountered, there was difficulty in sharing decisions with the medical team regarding hospital discharge, which sometimes did not consider the subject's totality, also the lack of understanding of the clinical staff regarding the need for some pharmacological measures and the lack of psychological support to the patients during hospitalization. In contrast, the medical team observed the rapid evolution of the clinical condition of the patients involved in the STP, and began to request multiprofessional follow-up for other patients. Despite the challenges, the development of the STP provided an understanding of the importance of each profession and of humanized patient care. The reception, qualified listening and continuity of care, made a difference in the physical, psychological well-being and in the evolution of the clinical condition of those involved.

Identifying brain tumor patients' subtypes based on pre-diagnostic history and clinical characteristics: a pilot hierarchical clustering and association analysis.

Central nervous system (CNS) tumors are severe health conditions with increasing incidence in the last years. Different biological, environmental and clinical factors are thought to have an important role in their epidemiology, which however remains unclear. The aim of this pilot study was to identify CNS tumor patients' subtypes based on this information and to test associations with tumor malignancy. 90 patients with suspected diagnosis of CNS tumor were recruited by the Neurosurgery Unit of IRCCS Neuromed. Patients underwent anamnestic and clinical assessment, to ascertain known or suspected risk factors including lifestyle, socioeconomic, clinical and psychometric characteristics. We applied a hierarchical clustering analysis to these exposures to identify potential groups of patients with a similar risk pattern and tested whether these clusters associated with brain tumor malignancy. Out of 67 patients with a confirmed CNS tumor diagnosis, we identified 28 non-malignant and 39 malignant tumor cases. These subtypes showed significant differences in terms of gender (with men more frequently presenting a diagnosis of cancer; p = 6.0 ×10-3) and yearly household income (with non-malignant tumor patients more frequently earning ≥25k Euros/year; p = 3.4×10-3). Cluster analysis revealed the presence of two clusters of patients: one (N=41) with more professionally active, educated, wealthier and healthier patients, and the other one with mostly retired and less healthy men, with a higher frequency of smokers, personal history of cardiovascular disease and cancer familiarity, a mostly sedentary lifestyle and generally lower income, education and cognitive performance. The former cluster showed a protective association with the malignancy of the disease, with a 74 (14-93) % reduction in the prevalent risk of CNS malignant tumors, compared to the other cluster (p=0.026). These preliminary data suggest that patients' profiling through unsupervised machine learning approaches may somehow help predicting the risk of being affected by a malignant form. If confirmed by further analyses in larger independent cohorts, these findings may be useful to create potential intelligent ranking systems for treatment priority, overcoming the lack of histopathological information and molecular diagnosis of the tumor, which are typically not available until the time of surgery.

Need to Incorporate Endovascular Neurosurgery in Neurosurgery Curriculum in India: Stay Abreast or be Left Behind.

Endovascular neurosurgery is one of the most rapidly evolving subspecialties in the field of neurosurgery. Since its inception, it has taken up almost 50%-60% of the cerebrovascular workload. Various specialties are competing to claim this field; still, no one can argue against a neurosurgeon's suitability in performing endovascular techniques. Currently, the field is shared between neurosurgeons and neuroradiologists, each getting different pie shares in various parts of the world. However, in India, barring a few residency programs, most neurosurgery programs offer little or no exposure to endovascular techniques. There is an urgent need for endovascular neurosurgery to be incorporated in the neurosurgery training curriculum in the country. Performing DSAs is the first step toward starting an endovascular neurosurgery unit. We have presented here the data of the DSAs done by a single neurosurgeon over almost 3 years. We have discussed our experience in the hope that fellow neurosurgeons across the country find it useful.

OTHER-06 EPIDEMIOLOGY OF BRAIN AND SPINE TUMOURS – A SINGLE CENTRE DESCRIPTIVE RETROSPECTIVE STUDY

Abstract Brain and spine tumours are of significant public health concern and lead to severe morbidities and mortalities. The incidence is on the rise, ranking as the fifth (5th) leading cause of cancer-related deaths in Africa. Treatment and prognosis depend on age, tumour location, functional neurological status, extent of tumour resection and histological subtype of tumour. This study aims to describe the patient demographics, clinical presentation, and histological subtypes of central nervous system (CNS) tumours in the Korle-Bu Teaching Hospital. A retrospective review of the medical records and histopathology reports (reports presented to the unit) of all patients with CNS tumours operated upon in the Neurosurgical Unit, Department of Surgery, Korle-Bu Teaching Hospital over the past 17years (2007-2023) was collated. The patients without definitive histopathological diagnosis were excluded from the study. Epidemiological data retrieved include clinical presentation, histological subtype, patient age and sex and the spatial distribution. A total of 327 tumour were recorded in the Neurosurgery unit: 85.3% were Brain Tumours. 178 (54.4%) were females and 149 (45.6%) males. Overall Meningiomas were the commonest CNS tumour encountered forming 32.1% followed by Gliomas, Glioneuronal and Neuronal tumours with 29.4% then Tumours of the Sella region, 19.6%. The commonest Meningioma subtype was Meningothelial (33%). Of the Gliomas, Low grade gliomas formed 69%. The commonest symptom for brain cases were headaches (59.1%) followed by visual impairment (33.0%). Of the spine cases, the prevalent symptom was paraparesis (46.2%) followed with low back pain and bowel and bladder dysfunction at 23.1% respectively. We concluded that Low grade tumours predominate in our setting. It is prudent that we channel efforts towards prompt diagnosis and treatment of such cases.

OTHER-09 RATES AND PATTERNS OF CENTRAL DIABETES INSIPIDUS AFTER SURGERY FOR SELLAR AND PARASELLAR TUMORS AT THE KENYATTA NATIONAL HOSPITAL

Abstract BACKGROUND Central Diabetes Insipidus (DI) is a common post operative complication after procedures for sellar and parasellar tumors. It is associated with increased morbidity, mortality and prolonged hospital stay. It is diagnosed clinically by symptoms of polyuria and polydipsia and measuring serum sodium and osmolality as well as urine osmolality and specific gravity (SG). There is limited data on rates and patterns of post operative central DI for tumors in this anatomically complex region even with increasing number surgeries being done for these tumors. OBJECTIVE To determine the rates and patterns of post-operative central Diabetes Insipidus in patients with sellar and parasellar tumors at the (Kenyatta National Hospital) KNH. STUDY DESIGN This was a descriptive cross-sectional study. Study Setting: The study was conducted at KNH Neurosurgery units and critical care units. Methodology: This study involved 24 participants following surgery for sellar and parasellar tumors. Informed consent was obtained from the participants. Clinical assessment for presence polyuria and polydipsia and laboratory measurement of serum sodium and urine SG for features for central DI was done. DATA RESULTS The mean age of the patients was 28.69 years, 70.8% were female and 29.2% were male. The most common tumor as confirmed by histology was craniopharyngioma seen in 33.3% of the patients. With regards to age craniopharyngioma, pilocytic astrocytoma and arachnoid cyst was seen in paediatric age group predominantly while meningioma and pituitary adenoma was more common in adults. Polyuria and polydipsia were the main clinical features seen post operatively in patients with Central DI. 69.2% presented with both polyuria and polydipsia, 30.8% presented with polyuria alone without polydipsia. The rate of post operative Central DI after surgery for sellar and parasellar tumors was 54.2%. The most common pattern was transient type occurring in 76.9% of the cases. Biphasic pattern was seen in 23.1%.

Transcallosal approach and post-operative subdural collections: 12-year paediatric neurosurgery tertiary centre experience.

Following transcallosal surgery for tumour resection, the formation of convexity or interhemispheric subdural cerebrospinal fluid collections may lead to clinical deterioration and may influence decision-making with regards to additional interventions. The aim of this study was to determine the incidence, risk factors, and management of subdural collections following the transcallosal approach in a paediatric cohort. A retrospective case note and radiological review of all children who underwent transcallosal surgery for intraventricular and thalamic tumours was carried out covering a 12-year period (2012-2023) in a single-centre tertiary paediatric neurosurgery unit. Parameters including demographics and clinical information including lesion location, pathology, extent of resection, need for and type of shunt required, as well as depth, laterality, and location of the collection were analysed prior to shunting, and at approximately 3 weeks, 3 months, and latest follow-up available post-operatively in order to further elucidate the natural history of these subdural collections and their clinical significance. Sixty-four cases satisfied the inclusion criteria of transcallosal surgery for tumour resection; 13 did not have adequate post-operative imaging and were excluded. Of the remaining 51 cases, there were 32 children (63%) with post-operative CSF subdural collections, of which 59% were ipsilateral, with the remainder showing bilateral distribution. The overall shunt insertion rate was 25.5% (12 ventriculoperitoneal and 1 subdural-peritoneal shunt) at 3 months, with a mean time to shunting of 19 days post-operatively. Children who developed post-operative subdural collections had a higher rate of shunting, at 37.5%, compared to 5.2% in those who did not. Pre- and post-operative hydrocephalus and subtotal resection were identified as risk factors for development of subdural collections post-operatively. Subdural collections showed a natural course of reduction and regression over follow-up, with the exception of 3 children where they persisted or increased over time; although none of these required shunting. Those children who underwent shunt insertion showed greater regression in the size of the subdural collection over time compared to the non-shunted group. In this paediatric cohort, 25.5 % of children required insertion of a shunt by 3 months following transcallosal surgery. Pre- and post-operative hydrocephalus and subtotal tumour resection were risk factors for development of subdural collections post-operatively.

Surgical Treatment of Upper Cervical Spine Trauma: Experience in a Regional Neurosurgery Unit in a Country with Limited Health Care Resources-About 22 Consecutives Cases.

Objectives Representing approximately 22% of cervical spine injuries, upper cervical spine injuries are becoming more frequent with the increase in road traffic accidents. The purpose of our study is to evaluate the results of our surgical series and to compare them with the literature. Materials and Methods In this monocentric retrospective study of over three years (June 2019-May 2022), all the patients with traumatic injuries of the upper cervical spine with a surgical treatment and a minimum of 12 months follow-up were included. Results The average age was 32.7 years, with a predominance of young patients. The predominant cause of injury was road traffic accident (86.3%). The clinical symptoms were cervical pain, associated with a motor deficit in two cases. Jefferson fracture associated with odontoid fracture was the most frequent injury (36.3%), followed by Hangman fracture (22.7%). Ten patients were treated with the Harms technique, four with occipitocervical C0-C2-C3 fixation, two with anterior screw insertion of the odontoid, and six with anterior C2-C3 arthrodesis. The average duration of follow-up was 12.2 months. The outcome was favorable in 21 cases and average in 1 case. Surgical morbidity and mortality were inexistent. Conclusion This short series shows the effectiveness of surgical treatment in the managing traumatic injuries of the upper cervical spine and in the regression of the pain with a low risk of surgical morbidity and mortality.

Thalamopeduncular Tumors in Pediatric Age: Advanced Preoperative Imaging to Define Safe Surgical Planning: A Multicentric Experience.

Background: Thalamopeduncular tumors are challenging lesions arising at the junction between the thalamus and the cerebral peduncle. They represent 1-5% of pediatric brain tumors, are mainly pilocytic astrocytoma and occur within the first two decades of life. To date, the optimal treatment remains unclear. Methods: We retrospectively reviewed pediatric patients who underwent surgery for thalamopeduncular tumors in the Academic Pediatric Neurosurgery Unit of Padova and Verona from 2005 to 2022. We collected information on age, sex, symptoms, preoperative and postoperative neuroradiological studies, histological specimens, surgical approaches, and follow-up. Results: We identified eight patients with a mean age of 9 years. All lesions were pilocytic astrocytoma. The main symptoms were spastic hemiparesis, cranial nerve palsy, headache, and ataxia. The corticospinal tract was studied in all patients using diffusion-tensor imaging brain MRI and in two patients using navigated transcranial magnetic stimulation. The transsylvian approach was the most frequently used. A gross total resection was achieved in two patients, a subtotal resection in five and a partial resection in one. In three patients, a second treatment was performed due to the regrowth of the tumor, performing an additional surgery in two cases and a second-look surgery followed by adjuvant therapy in one. After the surgery, four patients maintained stability in their postoperative neurological exam, two patients improved, and two worsened but in one of them, an improvement during recovery occurred. At the last follow-up available, three patients were disease-free, four had a stable tumor residual, and only one patient died from the progression of the disease. Conclusions: Advanced preoperative tools allow one to define a safe surgical strategy. Due to the indolent behavior of thalamopeduncular tumors, surgery should be encouraged.

Selective dorsal rhizotomy in non-ambulant children with cerebral palsy: a multi-center prospective study

PurposeAssess the effects of selective dorsal rhizotomy (SDR) on motor function and quality of life in children with a Gross Motor Function Classification System (GMFCS) level of IV or V (non-ambulatory).MethodsThis is a prospective, observational study in three tertiary neurosurgery units in England, UK, performing SDR on children aged 3–18 with spastic diplegic cerebral palsy, and a GMFCS level of IV or V, between 2012 and 2019. The primary outcome measure was the change in the 66-item Gross Motor Function Measure (GMFM-66) from baseline to 24 months after SDR, using a linear mixed effects model. Secondary outcomes included spasticity, bladder function, quality of life, and pain scores.ResultsBetween 2012 and 2019, 144 children who satisfied these inclusion criteria underwent SDR. The mean age was 8.2 years. Fifty-two percent were female. Mean GMFM-66 score was available in 77 patients (53.5%) and in 39 patients (27.1%) at 24 months after SDR. The mean increase between baseline and 24 months post-SDR was 2.4 units (95% CI 1.7–3.1, p < 0.001, annual change 1.2 units). Of the 67 patients with a GMFM-66 measurement available, a documented increase in gross motor function was seen in 77.6% (n = 52). Of 101 patients with spasticity data available, mean Ashworth scale decreased after surgery (2.74 to 0.30). Of patients’ pain scores, 60.7% (n = 34) improved, and 96.4% (n = 56) of patients’ pain scores remained the same or improved. Bladder function improved in 30.9% of patients.ConclusionsSDR improved gross motor function and reduced pain in most patients at 24 months after surgery, although the improvement is less pronounced than in children with GMFCS levels II and III. SDR should be considered in non-ambulant patients.