Surgical treatment of long-standing overt ventriculomegaly in adults (LOVA)

Background Longstanding overt ventriculomegaly in adults (LOVA) is characterised by chronic hydrocephalus presumed to begin during infancy, but arresting before becoming clinically detectable. Later in life clinical features of hydrocephalus ensue, typically in the 5th or 6th decades. Only a relatively small number of LOVA case series have been published, and ambiguity remains regarding optimal management. This case series describes a series of patients with LOVA treated successfully at a single neurosurgical institution using endoscopic third ventriculostomy (ETV). Methods A series of 14 patients were diagnosed with LOVA using established clinical and radiological criteria. All patients underwent an ETVand their clinical conditions were followed up for up to 5 years post-operatively. Results Fourteen patients (100 %) reported either improvement or halt of progression in their presenting symptoms 3 months after ETV; 93 % of patients (n = 13) did not require any further surgical intervention. One patient (7 %) reported deterioration in symptoms beyond 3 months post-operatively, which necessitated further surgery (ventriculoperitoneal shunt). These promising outcomes after ETV are mirrored in numerous other LOVA case series. Other works have analysed the value of CSF shunting procedures in LOVA, with mixed results. A direct, prospective comparison of outcomes after shunt procedures and ETV, with a specific focus on LOVA patients, is yet to be completed. A minority of patients fail to respond, or develop recurrence of symptoms, months or years after initial surgical interventio

Invest to progress? a survey of the cost of postgraduate training prior to specialty applications in the United Kingdom

Aim: Clinical training is expensive. This survey of foundation doctors across four UK foundation deaneries (Severn, Wales, South Thames and Scotland) identifies that highly variable sums of money were spent by foundation doctors applying for specialty training. Place and Duration of Study: Bristol Royal Infirmary and University Hospital of Wales, between September 2015 and July 2016. Methodology: A total of 1506 foundation year two (FY2) doctors were invited to participate in the online survey. Participants were canvassed via ten questions pertaining to their involvement in four groups of career enhancing activities: training courses; postgraduate examinations; qualifications, and conference attendances. The survey was closed after a ‘live’ period of 5 months. 100 FY2 doctors had completed the survey at the time of its closure. Results: Of the 100 participants, 89 (89.0%) had undertaken at least one career enhancing activity, with a mean expenditure of £1460 per respondent. Surgical and academic programme applicants spent on average over double the amount of those for anaesthetics (p = 0.01) and medicine (p = 0.001) and ten times that of applicants to general practice (p = 0.0001). Conclusions: These results have potential implications for training expectations, allocation of study budgets and specialty application processes as a whole

Biomarkers for traumatic brain injury

Traumatic brain injury (TBI) poses a major public health problem. It is amongst the leading causes of mortality in young people in developed countries, and many survivors of TBI suffer from persistent disabilities. As a result, there remains an unmet clinical need for the development of more robust diagnostic and prognostic indicators of TBI. Axonal injury is a key driver of the ongoing pathological process following TBI, causing chronic neurological deficits and disability, and has been the focus of research in this area to date. A popular approach has been the investigation of body fluid (serum, CSF and saliva) biomarkers to assess axonal injury in the acute setting. Biomarkers can be any quantifiable product serving as a marker of physiological insult, and recent studies have highlighted several substances that appear both promising and clinically relevant. However, it is likely that eventually the optimal model for assessing axonal injury in TBI is likely to involve multi-faceted components, including multiple biomarkers and select advanced neuroimaging modalities. If successful, early and reliable identification of axonal injury post-TBI has the potential to enhance current care by increasing speed and accuracy of diagnosis, providing prognostic information, allowing patient stratification and efficient allocation of rehabilitation services, and providing better understanding if the underlying pathology, and discovery of potential therapeutic targets. In this article, we review three studies investigating candidate serum biomarkers of TBI, with a focus on their potential relationship with clinical outcomes within both human and animal models

Surgical management of life-threatening thyroid haematoma following occult blunt neck trauma.

A 42-year-old man arrived at the emergency department in severe respiratory distress, requiring immediate intubation and ventilation. An emergency computed tomography (CT) neck scan identified a substantial haematoma within a multinodular goitre, necessitating an emergency total thyroidectomy. It was later discovered that the patient had been the victim of an assault involving blunt trauma to the anterior neck. Five days postoperatively the patient was extubated and was well enough to self-discharge the following day. Pathology revealed the lesion to be a ruptured follicular adenoma within his multinodular goitre. Signs of this rare but life-threatening condition may be subtle on initial presentation, particularly if the patient is obtunded. Patients with suspected blunt neck trauma should be observed for signs of respiratory distress. If this develops, the patient should be intubated to facilitate CT scan, and if thyroid haematoma is confirmed, emergency thyroidectomy is the definitive treatment

Olfactory outcomes after resection of tuberculum sella and planum sphenoidale meningiomas via a transcranial approach

Objectives Controversy exists surrounding the optimal approaches to tuberculum sella meningioma (TSM) and planum meningioma (PM). Olfaction is infrequently considered within this context but is nonetheless an important quality of life measure. The evolution of olfactory outcomes following contemporary transcranial surgery remains unclear. This study reviews olfactory outcomes after supraorbital craniotomy for TSM or PM and defines temporal trends in its recovery. Study Design A prospective study of a patients who underwent a minimally invasive supraorbital craniotomy for TSM or PM was conducted at a single neurosurgical center. Participants & Main Outcome Measures All patients were questioned about olfaction at presentation 3 months postoperatively, 12 months postoperatively, and annually thereafter (median follow-up = 37 months). The olfactory status of patients was categorized as normosmia, anosmia, hyposmia, parosmia, (altered perception of odours), or phantosmia, (olfactory hallucinations). Results Twenty-two patients were included in the study analysis, (range = 27–76). Precisely, 3 months after surgery, seven patients had normal olfaction (32%). Six patients were anosmic, (27%) four hyposmic, (18%), three parosmic, (14%), and two were phantosmic (9%). At 1-year follow-up, almost half of patients (10; 48%) were normosmic, while two patients (9.5%) were anosmic. There were no further improvements in olfaction between 1 year and long-term follow-up. Conclusion Subfrontal transcranial approaches for TSM or PM appear to be associated with changes in olfaction that can improve with time; these improvements occur within the first year after surgery. Impacts upon olfaction should be considered when selecting a surgical approach and patients counseled appropriately

High mobility group box protein 1 and white matter injury following traumatic brain injury: perspectives on mechanisms and therapeutic strategies

Traumatic brain injury (TBI) is a major cause of morbidity and mortality worldwide. Despite significant medical advances over recent decades, many survivors of TBI develop long term neuro-cognitive deficits. Previously, only moderate and severe injuries were thought to account for the devastating consequences of TBI. However, there is increasing evidence that even milder injuries may result in problematic lifelong cognitive and affective disturbances. TBI is typically characterized by an an acute physical injury followed by a protracted innate neuro-inflammatory response. These reponses, mediated via neuronal, astrocyte and microglial cells, amongst others, and may result in widespread neuronal death and a micro-environment that is not conducive to brain repair (Manivannan et al., 2021). Whilst the primary physical injury often evades intervention from a medical perspective, the subsequent neuro-inflammatory response offers a potential therapeutic target. Nonetheless, effective pharmacological strategies continue to elude clinicians and scientists due to the complex underlying pathogenesis and difficulties of modelling such a heterogeneous disease. However, the majority of research to date has focused on investigating the effects of post-traumatic neuro-inflammation on grey matter injury rather than the consequences upon white matter (WM), which contributes greatly to cognitive dysfunction across many neurological diseases (Filly and Kelly, 2018). Herein, we will briefly discuss: (i) high mobility group box protein 1 (HMGB1) as a potential therapeutic target; (ii) the relevance of WM injury in TBI and current understanding of WM repair following injury; and (iii) perspectives on how HMGB1 may play a role

Clinical features associated with the development of hydrocephalus following TBI in the paediatric age group

IntroductionPredictive factors for post-traumatic hydrocephalus (PTH) in adults have been elucidated but remain uncertain for children. We aimed to identify the prevalence of PTH in paediatric patients and identify clinical/radiological factors which may increase the probability of children developing PTH.MethodsThis was a retrospective study of all patients < 16 years old admitted to our unit with traumatic brain injury (TBI) between March 2013 and June 2018, 108 patients in total. Patients were classified as mild (13–15), moderate (9–12) or severe (3–8) TBI based on admission GCS. Three independent reviewers collected data from case notes. CT scans were reviewed for hydrocephalus using Evan’s index. Two-tailed Fisher’s exact tests with a p value < 0.05 were considered statistically significant.ResultsMedian patient age was 7 years, and 65% were males (n = 70). PTH wasn’t identified in any patients with mild/moderate TBI (n = 79). In cases of severe TBI (n = 29), three patients developed PTH requiring ventriculoperitoneal shunting (10%; p = 0.02). Radiological features which were significantly more common in the PTH group were intraventricular haemorrhage (p = 0.05) and subarachnoid haemorrhage (p = 0.03). There was also a trend towards a statistically significant association with subdural haematoma (p = 0.07). The need for other neurosurgical procedures, such as fracture elevation and craniotomy, did not increase the probability of developing with PTH (p = 0.08).DiscussionThe prevalence of PTH in our study is 2.7%. Factors which may be associated with a higher probability of developing PTH may include IVH, SAH, severity of TBI, and subdural haematoma. We propose a national prospective multicentre database of paediatric PTH. The data collected on prevalence, presentation, risk factors, and management could guide contemporary management and improve the outcomes of children with PTH

Outcomes of ventriculoperitoneal shunt insertion in the management of idiopathic intracranial hypertension in children

Purpose The ventriculoperitoneal (VP) shunt has become the procedure of choice for treatment of idiopathic intracranial hypertension (IIH). We aimed to assess the efficacy of frameless stereotactic placement of VP shunts for the management of medically resistant IIH in children and to assess the role of gender and obesity in the aetiology of the condition. Methods This is a retrospective analysis of the case notes of 10 patients treated surgically at the University Hospital of Wales in Cardiff, from May 2006 to September 2012. Results VP shunts were successful in relieving headache, papilloedema and stabilising vision. No sex predilection was identified, and increased BMI was a feature throughout the population, regardless of age. Conclusions Neuronavigated VP shunt insertion is an effective mode of treatment for medically resistant IIH in children. The aetiological picture in children does not seem to be dominated by obesity, as in adults. Literature on childhood IIH is sparse, and larger scale, comparative studies would be of benefit to treating clinicians

Pituitary xanthogranulomas: clinical features, radiological appearances and post-operative outcomes

Background Xanthogranulomas are inflammatory masses most commonly found at peripheral sites such as the skin. Sellar and parasellar xanthogranulomas are rare and present a diagnostic challenge as they are difficult to differentiate from other sellar lesions such as craniopharyngiomas and Rathke’s cleft cysts pre-operatively. Their radiological imaging features are yet to be clearly defined, and clinical outcomes after surgery are also uncertain. This study reviews clinical presentation, radiological appearances, and clinical outcomes in a cohort of patients with pituitary xanthogranulomas. Methods A prospectively maintained pituitary surgery database was screened for histologically confirmed pituitary xanthogranulomas between May 2011–December 2016. Retrospective case note assessments were then performed by three independent reviewers. Patient demographics, clinical presentations, imaging, and clinical outcomes were analysed. Results During the study period 295 endoscopic endonasal pituitary surgeries were performed. Six patients had confirmed pituitary xanthogranulomas (2%). Patients most commonly presented with visual field deficits and/or endocrine dysfunction. Common imaging features included: a cystic consistency, hyperintensity on T1-weighted MR images, and contrast enhancement either peripherally (n = 3) or homogenously (n = 3). The most common pre-operative endocrine deficits were hyperprolactinaemia and hypoadrenalism (at least one of which was identified in 4/6 patients; 66%). Thirty-three percent (2/6) of patients presented with diabetes insipidus. The most common post-operative endocrinological deficits were adrenocortical dysfunction (66%) and gonadotropin deficiency (66%). Visual assessments normalised in all six patients post-operatively. Gross total resection was achieved in all patients, and at median follow up of 33.5 months there were no cases of tumour recurrence. Conclusions The prevalence of pituitary xanthogranulomas in our series is higher than that suggested in the literature. Surgery restored normal vision to all cases, however four patients (67%) required long-term hormonal replacement post-operatively. Imaging features such peripheral rim enhancement, a suprasellar tumour epicentre, and the absence of both calcification or cavernous sinus invasion were identified as potential indicators that together should alert clinicians to the possibility of pituitary xanthogranuloma when assessing patients with cystic sellar and parasellar tumours

Online patient information on Vagus Nerve Stimulation: How reliable is it for facilitating shared decision making?

Purpose This study evaluates the quality of information available on the internet for carers of children with epilepsy considering treatment with Vagus Nerve Stimulation (VNS). Methods Selected key phrases were entered into two popular search engines (Google™, Yahoo™). These phrases were: “Vagus nerve stimulator”, alone and in combination with “childhood epilepsy”, “paediatric epilepsy” and “epilepsy in childhood”; “VNS”, and “VNS epilepsy”. The first 50 hits per search were then screened. Of 600 identified sites, duplicated (262), irrelevant (230) and inaccessible (15) results were excluded. 93 websites were identified for evaluation using the DISCERN instrument, an online validation tool for patient information websites. Results The mean DISCERN score of all analysed websites was 39/80 (49%; SD 13.5). This equates to Fair to borderline Poor global quality, (Excellent = 80–63; Good = 62–51; Fair = 50–39; Poor = 38–27; Very poor = 26–15). None of the analysed sites obtained an Excellent quality rating. 13% (12) obtained a Good score, 40% (37) obtained an Average score, 35% (33) obtained a Poor score, and 12% (11) obtained a Very poor score. The cohort of websites scored particularly poorly on assessment of whether reliable, holistic information was presented, for instance provision of reliable sources, (28%, SD 18) and discussion of alternative treatments, (30%, SD 14). Conclusion To facilitate patient-centred shared decision-making, high quality information needs to be available for patients and families considering VNS. This study identifies that such information is difficult to locate on the internet. There is a need to develop focussed and reliable online patient resources for VNS