A survey of the radiological follow-up of unruptured intracranial aneurysms in the United Kingdom.

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.

Prognostic factors following resection of intracranial metastases.

Background: The aim of this study was to identify prognostic factors associated with resection of intracranial metastases. Methods: A retrospective case series including patients who underwent resection of cranial metastases from March 2014 to April 2021 at a single center. This identified 112 patients who underwent 124 resections. The median age was 65 years old (24-84) and the most frequent primary cancers were nonsmall cell lung cancer (56%), breast adenocarcinoma (13%), melanoma (6%), and colorectal adenocarcinoma (6%). Postoperative MRI with contrast was performed within 48 hours in 56% of patients and radiation treatment was administered in 41%. GraphPad Prism 9.2.0 was used for the survival analysis. Results: At the time of data collection, 23% were still alive with a median follow-up of 1070 days (68-2484). The 30- and 90-day, and 1- and 5-year overall survival rates were 93%, 83%, 35%, and 17%, respectively. The most common causes of death within 90 days were as follows: unknown (32%), systemic or intracranial disease progression (26%), and pneumonia (21%). Age and extent of neurosurgical resection were associated with overall survival (P < 0.05). Patients aged >70 had a median survival of 5.4 months compared with 9.7, 11.4, and 11.4 for patients <50, 50-59, and 60-69, respectively. Gross-total resection achieved an overall survival of 11.8 months whereas sub-total, debulking, and unclear extent of resection led to a median survival of 5.7, 7.0, and 9.0 months, respectively. Conclusion: Age and extent of resection are potential predictors of long-term survival.

Primary pituitary granulomatosis with polyangiitis and the role of pituitary biopsy, case report and literature review.

BACKGROUND: Pituitary dysfunction (PD) in granulomatosis with polyangiitis (GPA) is a rare manifestation of the disease with an incidence of 2% and tends to occur as the disease progresses. On very rare occasions, PD can be the initial presentation of GPA. From our literature review, only 6 such cases were documented. CASE PRESENTATION: We present a rare case of GPA in a 57-year-old female who primarily presented with PD and visual disturbance without any other systemic features of GPA. Her initial ANCA screen was negative and her MRI scan showed an enlarged pituitary gland with cystic changes. A pituitary biopsy confirmed the diagnosis and she was started on immunosuppressants. After completing her immunotherapy, her diabetic insipidus subsided and her vision markedly improved. LITERATURE REVIEW: A literature search on Pubmed, Cochrane, Open Grey, and SciELO with keywords 'granulomatosis', 'polyangiitis', and 'pituitary' was performed. A total of 72 articles were reviewed. 6 articles were identified where PD was the presenting complaint of GPA without other systemic involvement. DISCUSSION: Secondary hypophysitis in GPA indicates pituitary inflammation resulting from systemic disease or pituitary near-lying lesions. PD in GPA tends to occur with concomitant active disease at other sites. Headache seemed to be a common presenting feature with diabetic insipidus being the most common type of PD. Tissue biopsy is essential to confirm diagnosis. Pituitary biopsy is rarely required as other organ involvement is available for safer tissue sampling. However, in our case, pituitary biopsy had a role in confirming diagnosis and avoiding treatment delay. CONCLUSION: PD as a primary manifestation in GPA without systemic involvement is very rare and poses a diagnostic challenge. Pituitary biopsy can aid in diagnosis, allowing prompt treatment and prevention of long-term complications of untreated GPA such as permanent pituitary dysfunction. Nevertheless, the risk and benefit of pituitary surgery in each case should be weighted.

CSF rhinorrhoea after endonasal intervention to the anterior skull base (CRANIAL): proposal for a prospective multicentre observational cohort study.

BACKGROUND: The endonasal transsphenoidal approach (TSA) has emerged as the preferred approach in order to treat pituitary adenoma and related sellar pathologies. The recently adopted expanded endonasal approach (EEA) has improved access to the ventral skull base whilst retaining the principles of minimally invasive surgery. Despite the advantages these approaches offer, cerebrospinal fluid (CSF) rhinorrhoea remains a common complication. There is currently a lack of comparative evidence to guide the best choice of skull base reconstruction, resulting in considerable heterogeneity of current practice. This study aims to determine: (1) the scope of the methods of skull base repair; and (2) the corresponding rates of postoperative CSF rhinorrhoea in contemporary neurosurgical practice in the UK and Ireland. METHODS: We will adopt a multicentre, prospective, observational cohort design. All neurosurgical units in the UK and Ireland performing the relevant surgeries (TSA and EEA) will be eligible to participate. Eligible cases will be prospectively recruited over 6 months with 6 months of postoperative follow-up. Data points collected will include: demographics, tumour characteristics, operative data), and postoperative outcomes. Primary outcomes include skull base repair technique and CSF rhinorrhoea (biochemically confirmed and/or requiring intervention) rates. Pooled data will be analysed using descriptive statistics. All skull base repair methods used and CSF leak rates for TSA and EEA will be compared against rates listed in the literature. ETHICS AND DISSEMINATION: Formal institutional ethical board review was not required owing to the nature of the study - this was confirmed with the Health Research Authority, UK. CONCLUSIONS: The need for this multicentre, prospective, observational study is highlighted by the relative paucity of literature and the resultant lack of consensus on the topic. It is hoped that the results will give insight into contemporary practice in the UK and Ireland and will inform future studies.

Percutaneous ultrasound-guided insertion of ventriculo-atrial shunts.

Ventriculo-atrial (VA) shunts have been in use for >60 years but less frequently so of late. This is due to a combination of the risk of cardiac complications, lack of expertise and a lengthy operation. We present our consecutive prospective series of 10 VA shunts inserted using a percutaneous method employing the Sonowand Invite™ neuronavigation system for both the distal and proximal catheters, over a 13-month period. We had two complications of cases needing revision, but our series highlights a safe and reproducible method of inserting a VA shunt. About 30% of the procedures were carried out by a trainee as the primary surgeon. This technique does not necessarily require the expertise of a complex hydrocephalus surgeon and is thus able to be in the armoury of any neurosurgeon needing to do a VA shunt procedure. The indications, operative data and outcomes of our patients are discussed.

Blue rubber bleb naevus syndrome and Chiari malformation: high risk of peroperative haemorrhage.

Blue rubber bleb naevus syndrome is an uncommon disorder whereby patients possess cutaneous vascular malformations. Cranial malformations have been rarely reported in the literature. We report the first ever case of a patient with blue rubber bleb naevus syndrome (BRBNS), who was found to have a symptomatic Chiari malformation and prominent subcutaneous vascular malformations in communication with the intracranial venous sinuses. In our case, a routine operation for Chiari malformation was complicated by significant blood loss. The operative hazards are presented along with suggested peri-operative management strategies when carrying out neurosurgical operations on patients with BRBNS. A brief literature review is included.

Novel use of intrathecal baclofen drug delivery system for periodic focal dystonia in a teenager.

INTRODUCTION: Focal dystonia, often affecting part of a limb, is a manifestation of complex regional pain syndrome (CRPS). This can be difficult to diagnose and treat. Furthermore, there may be significant latency between the onset of dystonia after the diagnosis of CRPS. We present the case of a 15-year-old girl with periodic focal dystonia who has been successfully treated with an intrathecal baclofen pump. MATERIALS AND METHODS: The patient had sustained a minor ankle fracture four years prior to presentation. Despite radiologic evidence of adequate bony union, the patient continued to complain of spasms and pain in her left foot leading to dystonic posturing of the foot. Multiple therapies including subcutaneous morphine infusion, ankle splinting, physiotherapy, and local botulinum injections had not provided adequate relief. Intrathecal baclofen on three separate occasions resulted in successful temporary resolution of the dystonia. A placebo double-blinded injection of intrathecal saline at a separate setting however did not resolve the dystonia. RESULTS: We then proceeded with permanent delivery of baclofen by implantation of an intrathecal drug delivery pump, which resulted in resolution of the dystonia. The patient also was able to receive bolus doses of intrathecal baclofen. The patient is now able to partake in sporting and dancing activities. A detailed history of the patient, along with the difficulties in diagnosis and management, is presented. CONCLUSION: Intrathecal baclofen therapy can be effective in the management of focal dystonia after rigorous preoperative testing and counseling of adolescents with CRPS.

Rapid brain shift, remote site hemorrhage, and a spinal hematoma after craniotomy for a large arachnoid cyst.

Arachnoid cysts are prevalent among the general population. The management options of symptomatic arachnoid cysts each have their own merits and disadvantages. We report a case where a large arachnoid cyst was treated by open fenestration and marsupialization that was complicated by remote intraparenchymal and spinal subdural hemorrhage. The potential physiological changes underlying these complications as well as the related literature are reviewed.

Management of infratentorial subdural hygroma complicating foramen magnum decompression: a report of three cases.

Decompression of the foramen magnum for symptomatic Chiari malformation attends a small but significant risk of infratentorial subdural extra-arachnoid hygroma when an arachnoid-sparing procedure is attempted. We present three cases whereby an arachnoid-sparing procedure was carried out and resulted in infratentorial subdural hygroma and hydrocephalus. The complication was managed by re-exploration of the posterior fossa and wide arachnoidotomy. In cases whereby the decision has been made to open the dura, we recommend routine arachnoidotomy in foramen magnum decompression, avoiding the risks of infratentorial subdural hygroma. In cases where arachnoid-sparing procedures have been attempted and subdural hygroma subsequently develops, we advocate re-exploration of the posterior fossa rather than cerebrospinal fluid diversion.