Single Neurosurgical Center Research Articles

Impact of specialist neurovascular care in subarachnoid haemorrhage

BackgroundThe management of neurosurgical disorders has become increasingly specialised. The care of patients with subarachnoid haemorrhage (SAH) has generally been part of core neurosurgical practice, provided by general neurosurgeons whatever their specialist interest. The aim of this present study therefore is to ascertain if, and to what extent care provided by a dedicated neurovascular team (compared to care provided by a general neurosurgical team) change patient disposition in SAH. MethodsThis is a retrospective analysis of SAH patients, identified from a departmental database of a single neurosurgical centre. In 2008, the service was reorganised such that a neurovascular team cared for all SAH patients. We compared clinical outcome in people admitted prior to this service reorganisation (Period A, 2004-2007) with patients admitted afterwards (Period B, 2009-2011). Survival and recovery were assessed according to the Glasgow Outcome Scale (GOS). Multi-factorial logistic regression analysis was performed to determine the injury and age adjusted incidence of complications, odds of survival at discharge, discharge home, mortality, good recovery (GOS 5) and favourable outcome, by dichotomising GOS (GOS 4-5 vs. GOS 1-3) at 3 months. Results1114 patients were included in the study. The mean age of patients presenting in Period A (n=543) was younger [50 years (SD 13.5)] than those in Period B (n=571) [53 years (SD 13)]. Patients admitted in Period B were more likely to present as poor grade (World Federation of Neurological surgeons (WFNS) grades 4 and 5) compared to Period A (26.5% vs. 21.3%). No statistical differences between the groups in the incidence of pre-operative re-bleeding (3% vs. 5%) or rates of delayed cerebral ischaemia (16.1% vs. 16.1%) were observed.After adjustment for age, sex and injury severity, the odds of patient time to discharge, discharge home and good recovery (GOS 5) were 27% (p<0.001), 45% (p=0.001) and 93% (p<0.001) higher respectively in Period B than Period A. ConclusionsThe data presented here demonstrates that management of SAH by a dedicated neurovascular team improves the potential for patient recovery.

Aneurismal subarachnoid hemorrhage: who remains for surgical treatment in the post-ISAT era?

IntroductionAlthough there have been a number of studies on changes and trends in the management of aneurismal subarachnoid hemorrhage (aSAH) since publication of the International Subarachnoid Aneurysm Trial (ISAT), no data exist on what category of patients still remains for surgical treatment. Our goal was to investigate the changes that occurred in the characteristics of a population of aSAH patients treated surgically in the post-ISAT period in a single neurosurgical center, with limited availability of endovascular service.Material and methodsThe study included 402 aSAH patients treated surgically in our unit between January 2004 and December 2011. Each year, data regarding number of admissions, age, aneurysm location and size, clinical and radiological presentation, outcome and mortality rates were collected and analyzed.ResultsThe annual number of admissions more than halved in the study period (from 69 in 2004 to 32 in 2011). There were no linear trends regarding patients’ mean age, clinical presentation and outcomes, but the number of patients in Fisher grade 4 increased and mortality slightly decreased. An unexpected, statistically significant increase occurred in the incidence of anterior communicating artery aneurysms (from 36.2% to 50%) and medium size aneurysms (from 34.7% to 56.2%) treated surgically, with a corresponding decrease in the incidence of middle cerebral artery aneurysms (from 40.5% to 34.3%) and large aneurysms (from 21.7% to 12.5%).ConclusionsUnexpected trends in characteristics of aSAH patients treated surgically could be related to treatment decision modality. Trend patterns could be properly expressed in the constant availability of endovascular services.

Quantitative study of white matter neurons in human temporal lobe resection with mild malformation of cortical development (MCD) type II

Quantitative study of white matter neurons in human temporal lobe resection with mild malformation of cortical development (MCD) type II

Indications for intracranial reservoirs: A six-year study

Objectives. For patients with intracranial recurrent cysts, reservoir placement can offer symptomatic control at relatively low risk, allowing repeated outpatient aspiration. Predicting which patients will require repeated drainage is not always straightforward. The aim of this study was to examine a series of patients treated with reservoir system placement, and examine the factors that may be relevant to repeated drainage and morbidity. Methods. We retrospectively reviewed all adult patients who had intracranial reservoir placement between 2005 and 2011 at a single neurosurgical centre. Information was gathered on the indications for placement, demographics, diagnosis, imaging, disease characteristics, complications and clinical outcome. Results. Forty-one adult patients had reservoir placement over the 6-year period, of which 31 had cystic lesions, 4 had hydrocephalus, and 6 were for intrathecal therapy. Of the 31 cystic lesions, 14 were high-grade gliomas, 6 craniopharyngiomas, 4 low-grade gliomas, 5 cystic metastases, 1 acoustic neuroma, and 1 arachnoid cyst. The 30 patients with malignant disease had 1–6 postoperative aspirations at a median of 290 days after surgery. In patients with hydrocephalus the reservoir was not used postoperatively. Eighty-three per cent of patients with cystic lesions who had recurrent aspirations (26/36) resulted in clinical improvement. For the three categories of cystic lesions with the most number of aspirations; 100% showed clinical improvement in low-grade lesions, 68.4% in high-grade lesions, and 66.7% in craniopharyngiomas. Four patients experienced complications, including reservoir malfunction (2), infection (1), and misplacement (1). Conclusions. Intracranial reservoirs provide significant clinical improvement when used for recurrent aspiration in patients with cystic tumours. In particular, it is clear that ommaya reservoirs are of significant advantage in high-grade lesions, where the majority of patients undergo recurrent aspirations with clinical improvement.

Prospective observational study of acute postlumbar laminectomy MRI

Patients who develop a lower-extremity neurological deficit after lumbar laminectomy present a diagnostic dilemma. In the setting of a neurological deficit, some surgeons use MRI to evaluate for symptomatic compression of the thecal sac. The authors conducted a prospective observational cohort study in patients undergoing open lumbar laminectomy for neurogenic claudication to document the MRI appearance of the postlaminectomy spine and to determine changes in thecal sac diameter caused by the accumulation of epidural fluid. Eligible patients who were candidates for open lumbar laminectomy for neurogenic claudication at a single neurosurgical center between August 2007 and June 2009 were enrolled. Preoperative and postoperative MRI of the lumbar spine was performed on the same MRI scanner. Postoperative MRI studies were completed within 36 hours of surgery. Routine clinical and surgical data were collected at the preoperative visit, during surgery, and postoperatively. Images were interpreted for the signal characteristics of the epidural fluid and for thecal diameter (region of interest [ROI]) by 2 blinded neuroradiologists. Twenty-four patients (mean age 69.7 years, range 30-83 years) were enrolled, and 20 completed the study. Single-level laminectomy was performed in 6 patients, 2-level in 12, and 3-level in 2. Preoperative canal measurements (ROI) at the most stenotic level averaged 0.26 cm(2) (range 0.0-0.46 cm(2)), and postoperative ROI at that same level averaged 0.95 cm(2) (range 0.46-2.05 cm(2)). The increase in ROI averaged 0.69 cm(2) (range 0.07-1.81 cm(2)). Seven patients (35%) had immediate postoperative weakness in at least 1 muscle group graded at 4+/5. The decline in examination was believed to be effort dependent and secondary to discomfort in the acute postoperative period. Those with weakness had smaller increases in ROI (0.51 cm(2)) than those with full strength (0.78 cm(2), p = 0.1599), but none had evidence of worsened thecal compression. On the 1st postoperative day, 19 patients were at full strength and all patients were at full strength at their 15-day follow-up. The T1-weighted epidural fluid signal was isointense in 19 of the 20 patients. The T2-weighted epidural fluid signal was hyperintense in 9, isointense in 4, and hypointense in 7 patients. Immediately after lumbar laminectomy, the appearance of the thecal sac on MRI can vary widely. In most patients the thecal sac diameter increases after laminectomy despite the presence of epidural blood. In this observational cohort, a reduction in thecal diameter caused by epidural fluid did not correlate with motor function. Results in the small subset of patients where the canal diameter decreased due to epidural fluid compression of the thecal sac raises the question of the utility of immediate postoperative MRI.

Presentation, management and outcomes in acute pituitary apoplexy: a large single‐centre experience from the United Kingdom

To study the presentation, management and outcomes and to apply retrospectively the Pituitary Apoplexy Score (PAS) (United Kingdom (UK) guidelines for management of apoplexy) to a large, single-centre series of patients with acute pituitary apoplexy. Retrospective analysis of casenotes at a single neurosurgical centre in Liverpool, UK. Fifty-five patients [mean age, 52·4 years; median duration of follow-up, 7 years] were identified; 45 of 55 (81%) had nonfunctioning adenomas, four acromegaly and six prolactinomas. Commonest presenting features were acute headache (87%), diplopia (47·2%) and visual field (VF) defects (36%). The most frequent ocular palsy involved the 3rd nerve (81%), followed by 6th nerve (34·6%) and multiple palsies (19%). Twenty-three patients were treated conservatively, and the rest had surgery either within 7 days of presentation or delayed elective surgery. Indications for surgery were deteriorating visual acuity and persistent field defects. Patients presenting with VF defects (n = 20) were more likely to undergo surgery (75%) than to be managed expectantly (25%). There was no difference in the rates of complete/near-complete resolution of VF deficits and cranial nerve palsies between those treated conservatively and those who underwent surgery. Endocrine outcomes were also similar. We were able to calculate the PAS for 46 patients: for the group treated with early surgery mean, PAS was 3·8 and for those managed conservatively or with delayed surgery was 1·8. Patients without VF deficits or whose visual deficits are stable or improving can be managed expectantly without negative impact on outcomes. Clinical severity based on a PAS ≥ 4 appeared to influence management towards emergency surgical intervention.

A single neurosurgical center’s experience of the resolution of cervical radiculopathy after dorsal foraminotomy and ventral discectomy

Monosegmental cervical disc herniation can be removed either by dorsal foraminotomy and sequesterectomy (Frykholm’s method) or by a ventral approach with extensive removal of the affected disc with subsequent segmental fusion (modified Cloward’s method). The choice of method largely depends on the surgeon’s individual preference and experience. We evaluated the neurological outcomes of both surgical methods in a retrospective series of 100 consecutive patients (50 male, 50 female; mean age = 47.7 years) who underwent surgery within a 3-year period. Fifty-one patients (30 male, 21 female; mean age = 50.1 years) underwent a dorsal foraminotomy and 49 patients (20 male, 29 female; mean age = 45.3 years) underwent surgery by the ventral approach with consecutive segmental fusion. We identified demographic data and analysed the postoperative neurological performance (motor and sensory activity) and the resolution of the radiating and local pain during the in-hospital stay. Patients in the Cloward Group recovered significantly better from cervicobrachialgia ( p = 0.02), neck pain ( p = 0.01) and sensory deficits ( p = 0.003). Furthermore, the Cloward Group showed a trend towards better outcomes for paresis. Complete removal of the affected cervical disc via a ventral approach and segmental fusion results in a superior neurological performance in the short-term compared to a dorsal foraminotomy and nerve root decompression by sequestrectomy. However, assessment of the long-term outcome is required and further studies are required to confirm our results.

The incidence of deep brain stimulator hardware infection: the effect of change in antibiotic prophylaxis regimen and review of the literature

The complication of hardware infection related to deep brain stimulator implantation (or revision) varies between 0 and 15.2% in the literature. However, no national guidelines exist at present to define an average or acceptable rate of infection associated with, nor the preferred antibiotic prophylaxis required for, this procedure. The aim of this study was to examine the effect of changing the antibiotic prophylaxis regimen used in a single neurosurgical centre on the incidence and outcome of hardware infection. A prospective cohort of 38 patients undergoing deep brain stimulation (DBS) implantation or internal pulse generator (IPG) replacement and receiving perioperative vancomycin (including intravenous gentamicin on induction) and pouch-installed gentamicin, was compared to a historical cohort of 35 patients receiving perioperative cefuroxime in the same unit. The infection rate over 2 years in the prospective group for DBS surgery was 0 compared to 1 (5.6%) in the historical cohort (p = 0.11, χ2); the infection rate for IPG replacements was 1(3.6%) in the prospective cohort, versus 3 (17.6%) in the historical (p = 0.44, χ2). In this article, we have also systematically reviewed the literature to date and derived an average infection rate of 4.7% (PI 0.9–22%, Random Effects Meta-analysis, Stata) for 35 studies comprising 3550 patients. There is no significant difference in infection rates between DBS procedures that are primarily internalised (n = 9) compared to those in which there is a period of electrode externalisation (n = 23) (p = 0.9, Meta-regression analysis, Stata).

Dural-stabs after wide craniectomy to decompress acute subdural hematoma with severe traumatic brain edema — An alternative technique to open dural flap

The Department of Neurosurgery Sher-i-Kashmir Institute of Medical Sciences (SKIMS) Srinagar, a single neurosurgical centre in Kashmir valley, assessed prospectively, under a uniform protocol, 120 patients of severe traumatic brain edema with acute subdural hematoma by wide decompressive craniectomy with dural-stabs in 60(cases) patients as against conventional dural opening (open dural flap) and removal of acute subdural hematoma in 60(controls) patients during a period of 3 years (June 2006 to June 2009). A free bone flap was elevated and preserved. All patients had GCS (Glassgow Coma Scale) score of 8 and less. The elective ventilation and ICP monitoring was carried out in all patients. Most patients were young and males with a mean age of 30 years in both groups. The overall survival of the dural-stab group (case-study) was 78.3% with good recovery in 43.3% and a mortality of 21.6% (13/60) as compared to 40% survival in open dural flap (control) group with 11.6% good recovery and a mortality of 60% (36/60). The conventional (open dural flap) procedure to remove the clot proved dangerous in a traumatic “vent-searching” and edematous brain, restricted in a rigid cranial vault. This midway-approach, known in SKIMS as “dural-stabs”, between the only decompressive craniectomy and removal of acute subdural clot by open dural flap (conventional) method, proved much effective in increasing survival of low GCS and severe traumatic brain edema with acute subdural hematoma. In conclusion decompressive craniectomy alone is not sufficient and open dural flap is full of risk in such patients.

Non-Conventional Treatments Sought by Patients after Surgery for Intramedullary Spinal Cord Tumors

Despite modern microsurgical techniques and interdisciplinary treatment options, intramedullary spinal cord tumors often lead to profound neurological deficits. Some patients may search for non-scientific or unconventional therapeutic options to treat the symptoms induced by the tumor itself or arising from treatment. The extent of non-scientific therapy use, the rationale behind it, and costs of these forms of therapy are unknown. A questionnaire consisting of 20 questions was sent to 60 patients of a single neurosurgical center who had undergone surgery for an intramedullary spinal cord tumor. A retrospective study was carried out based on this data. Histological findings ranged from ependymoma (52.9%), hemangioblastoma (17.6%), cavernoma (14.7%), astrocytoma (8.8%), oligodendroglioma (2.9%) to ganglioglioma (2.9%). Non-scientific therapy was defined as a method not used in routine clinical practice for the treatment of symptoms induced by intramedullary spinal cord tumors. A total of 38 questionnaires was returned. About 55.3% of the patients claimed to use non-scientific therapies. No significant difference between histological types and the percentage of alternative therapy use was detected. There was a gender difference. One third (non user group) to one fourth (user group) did not feel adequately informed about their disease. The monthly costs for non-scientific therapies ranged from 50 to 500 Euros. The main motive for the use of non-scientific therapies was the wish to try everything possible. In the daily clinical routine, patients' use of non-scientific therapies may be largely overlooked and underestimated. Neurooncologists should be aware of this phenomenon and encourage an open but critical dialogue with their patients.

Is the routine placement of a CSF reservoir following endoscopic third ventriculostomy justified?

Endoscopic third ventriculostomy (ETV) is a well established treatment for selected cases of obstructive hydrocephalus. However, it does carry a significant rate of failure, which can be abrupt and life threatening. The present study analyses the benefits versus the risks of routine CSF reservoir insertion during ETV. Clinical data obtained from the medical records of patients from a single neurosurgical centre who underwent ETV between August 2002 and February 2007 were analysed retrospectively. A total of 34 records were available with follow-up ranging from 3–56 months (Median 26 months) and with patient age range between 6 months – 75 yrs (median 19 years). During this period, one neurosurgeon routinely placed reservoirs in all patients undergoing ETV (n = 34). In all instances of reservoir insertion, Ommaya reservoirs were used. The number of patients in which the reservoir was tapped for diagnostic and/or therapeutic reasons was quantified, and all complications resulting from reservoir placement recorded. ETV success was defined by a lack of subsequent need for cerebrospinal fluid diversion. In total 13 of 34 (38%) reservoirs inserted were tapped at a later date and there were no complications associated with their insertion. Tapping of reservoirs helped determine which patients required subsequent ventriculoperitoneal (VP) shunting. In at least one case reservoir tapping was carried out as an emergency and was a crucial intermediate intervention prior to further surgery. The overall success rate of ETV was 65% (95% CI, 49–81%) with four complications associated with ETV: short-term memory loss, psychosis, and two cases of post-operative seizures. These complications were not attributed to CSF reservoir insertion but the ETV procedure itself. The routine placement of CSF reservoir following ETV thus seems justified with respect to the observed benefits and lack of complications associated with its placement.

Cushing's Disease in Children and Adolescents: 20 Years of Experience in a Single Neurosurgical Center

Cushing's Disease in Children and Adolescents: 20 Years of Experience in a Single Neurosurgical Center

Cushing's Disease in Children and Adolescents: 20 Years of Experience in a Single Neurosurgical Center

This is a retrospective analysis of 25 consecutive pediatric patients with Cushing's disease who underwent transsphenoidal surgery performed by a single neurosurgeon in a specialist center during a 20-year period. This article discusses the presentation of Cushing's disease, the endocrinological investigation with particular reference to bilateral inferior petrosal sinus sampling (BIPSS), the operative management with reference to specific pediatric difficulties of the transsphenoidal approach and the use of intraoperative image guidance, and the analysis of these cases as regards postoperative complications and outcomes of this rare condition in young patients. All patients underwent detailed endocrine investigation and imaging in the form of computed tomography and/or magnetic resonance imaging. BIPSS was performed in 19 patients (76%), with successful lateralization of the side of the microadenoma in 14 (74%) and prediction of a central tumor in four (94% total prediction rate). Surgical removal was via the sublabial, paraseptal, transsphenoidal route. There were 15 male and 10 female patients, with a mean age of 13.4 years (range, 6.6-17.8 yr). Weight gain was the most common presentation (100%), and then growth impairment (96%), fatigue and skin changes (64%), and hypertension (32%). Postoperative complications included growth hormone deficiency (36%), transient diabetes insipidus (12%), panhypopituitarism (4%), and transient cerebrospinal fluid rhinorrhea (4%). The median follow-up period was 59.5 months (range, 6-126 mo). Overall, 15 patients (60%) achieved surgical cure or remission, of which 14 outcomes were obtained using the results of BIPSS. Ten patients (40%) required postoperative radiotherapy to achieve "remission." There were no cases of meningitis, no neurological deficits, no reoperations, and no mortality. Cushing's disease in children and adolescents is a rare illness. The accurate preoperative localization of the adenoma is essential for achieving good results. In this series, BIPSS was far more accurate in localizing the adenoma than computed tomography or magnetic resonance imaging. Imaging, however, is useful for the exclusion of other intracranial problems. Transsphenoidal surgery was safe and efficacious in achieving cure in the majority of cases. The challenge of transsphenoidal surgery in this age group is the small pituitary fossa and the absence of sphenoid sinus aeration in some cases. We found the use of intraoperative neuronavigation to be an excellent aid in overcoming such anatomic difficulties.

Management of Choroid Plexus Tumours in Children: 20 Years Experience at a Single Neurosurgical Centre

Objective: Tumours of the choroid plexus are rare tumours of neuro-ectodermal origin, accounting for less than 1% of all intracranial tumours. Most cases present in children less than 2 years of age. While choroid plexus carcinomas (CPC) are reported to have an extremely poor prognosis, choroid plexus papillomas (CPP) are generally regarded as benign tumours with a very favourable long-term outcome. Management dilemmas are associated with the choice of surgical procedure, tumour vascularity, the treatment of hydrocephalus and the value of adjuvant therapy. The objective of this study was to review our experience with this rare tumour over a 20-year period. Methods: Patients were identified from the Great Ormond Street Neurosurgical Brain Tumour Database. Over a 20-year period (1979–1999), 34 children were identified with a choroid plexus tumour. There were 25 cases of CPP and 9 cases of CPC. A retrospective review of case notes, radiological imaging, operation reports and pathology was performed. Results: The median age at presentation was 17 months (1–138) for CPP and 13 months (2–102) for CPC. There was no sex difference for CPP. However, 8 of the 9 CPCs were male (89%). A complete surgical resection was achieved in all 25 cases of CPP and in 3 cases of CPC (33%). The median survival for CPPs was 75.5 months (2–228), with a median follow-up of 73.5 months (2–228). The median survival for CPCs was 6 months (1–90), with a median follow-up of 6 months (1–90). Conclusion: With modern neurosurgical practise, a cure should be the aim for all children with CPP. There is no evidence that adjuvant therapy has any role in the primary management of these children. However, CPC still has an extremely poor prognosis, and the efficacy of adjuvant therapy remains to be established.

Staging, scoring and grading of medulloblastoma. A postoperative prognosis predicting system based on the cases of a single institute.

Although recently survival of some medulloblastoma patients increased remarkably, it remains a serious diagnosis in others. In order to predict the postoperative prognosis in patients treated for medulloblastoma, a new staging, scoring and grading system was developed. Sixty-six patients operated on microsurgically between 1975 and 1990 at a single neurosurgical center were fully followed-up. No patient was excluded due to a poor postoperative course. Completion of commonly used radiotherapy protocols was attempted in all patients. Survival of patients was evaluated by the Kaplan-Meier method. The following 5 parameters were selected to define subgroups: patients' age, tumour location and histology, degree of resection and presence or absence of metastases. Patients older than 10 years had a better prognosis than individuals aged 10 or less (p < 0.01), patients with lateral tumours had a better prognosis than patients with midline tumours with brain stem infiltration (p < 0.05), patients with complete tumour resection had a more favourable prognosis than individuals with subtotal (p < 0.01) or partial resection (p < 0.001), patients without metastases at the time of diagnosis had a better prognosis than individuals without such evidence (p < 0.001), patients with the desmoplastic tumour variant had a better prognosis than patients with classical tumour histology (p < 0.01). According to the prognosis of a distinct subgroup, scoring points were distributed which correlated with the degree of inter-subgroup significances. The sum of a single patient's scoring points was called the total score. Based on this score, three groups of prognosis were distinguished.(ABSTRACT TRUNCATED AT 250 WORDS)