Factors affecting endoscopic third ventriculostomy success in adults.

BACKGROUND: Endoscopic third ventriculostomy (ETV) is a standard treatment in hydrocephalus of certain aetiologies. The most widely used predictive model is the ETV success score. This is frequently used to predict outcomes following ETV in adult patients; however, this was a model developed in paediatric patients with often distinct aetiologies of hydrocephalus. The aim of this study was to assess the predictive value of the model and to identify factors that influence ETV outcomes in adults. METHODS: A retrospective study design was used to analyse consecutive patients who underwent ETV at a tertiary neurosurgical centre between 2012 and 2020. Observed ETV outcomes at 6 months were compared to pre-operative predicted ETV success scores. A multivariable Bayesian logistic regression analysis was used to determine the factors that best predicted ETV success and those factors that were redundant. RESULTS: A total of 136 patients were analysed during the 9-year study. Thirty-one patients underwent further cerebrospinal fluid diversion within 6 months. The overall ETV success rate was 77%. Observed ETV outcomes corresponded well with predicted outcomes using the ETV success score for the higher scores, but less well for lower scores. Location of obstruction at the aqueduct irrespective of aetiology was the best predictor of success with odds of 1.65 of success. Elective procedures were also associated with higher success compared to urgent ones, whereas age under 70, nature and location of obstructive lesion (other than aqueductal) did not influence ETV success. CONCLUSION: ETV was successful in three-quarters of adult patient with hydrocephalus within 6 months. Obstruction at the level of the aqueduct of any aetiology was a good predictor of ETV success. Clinicians should bear in mind that adult hydrocephalus responds differently to ETV compared to paediatric hydrocephalus, and more research is required to develop and validate an adult-specific predictive tool.

Experience with revision craniovertebral decompression in adult patients with Chiari malformation type 1, with or without syringomyelia.

BACKGROUND: Craniovertebral decompression is performed for symptomatic Chiari malformation type 1, with or without syringomyelia. In a few patients the symptoms and/or syrinx persist or recur, in which case revision surgery may be offered. The aim of this study was to examine the cause of failure of primary surgery and to assess the outcomes for revision cranio-vertebral decompression. METHODS: We retrospectively reviewed all revision cranio-vertebral decompressions performed in our centre over an eighteen-year period. A total of 35 patients were identified (23 females; 12 males). Twenty patients had isolated Chiari malformation type 1 and a further fifteen had associated syringomyelia. The mean follow up period was 4-years (range:1-12 years). RESULTS: The mean time to revision was 7 years after the primary surgery. The commonest operative finding was that of dense arachnoid scar tissue, obstructing movement of CSF across the craniovertebral junction. Overall, 32 of the 35 patients reported improvement after surgery, including all 15 patients with syringomyelia. Improvement was maintained in the longer term in more than two thirds of those patients who underwent revision craniovertebral decompression. CONCLUSIONS: Failure of primary craniovertebral decompression for Chiari malformation most often results from the formation dense scar tissue at the operation site, obstructing CSF movement. Revision cranio-vertebral decompression can provide early symptomatic relief in most patients and this benefit is sustained in at least two thirds of cases, in the medium term at least. Patients with concomitant syringomyelia appear to derive most benefit from revision surgery.

Case report: Development of syringomyelia after anatomically successful craniovertebral decompression for Chiari I malformation without syrinx.

An 18 year old female with headaches and radiologically confirmed Chiari I malformation, without syringomyelia, underwent an anatomically and clinically successful craniovertebral decompression. Five years later she returned with extensive syringomyelia. This was treated successfully by division of an arachnoid web at the foramen of Magendie.

Syringomyelia: diagnosis and management.

In the pre-MR era syringomyelia often presented late, as a crippling neurological disorder. Today, most cases are diagnosed earlier, with less pronounced deficits. We are therefore presented with new challenges, including understanding the significance of various presenting symptoms, knowing when surgery might help and being aware of other treatments that could benefit someone living with the effects of syringomyelia, or its underlying cause.

Symptom outcome after craniovertebral decompression for Chiari type 1 malformation without syringomyelia.

BACKGROUND: Specific symptom outcomes after craniovertebral decompression for patients with Chiari type 1 malformation, without accompanying syringomyelia, are not well characterised and poorly reported. METHODS: We performed a retrospective review of all patients diagnosed with Chiari type 1, without syringomyelia, who underwent craniovertebral decompression in our unit. RESULTS: We identified 129 individuals with a minimum of 2 years' follow-up. The most common pre-operative symptoms were pressure dissociation headaches (78%), visual disturbances (33%), dizziness/balance disturbances (24%) and blackouts (17%). The symptoms most likely to respond to surgery included Valsalva-induced headache (74% response, p < 0.0001) and blackouts (86% response, p < 0.001). CONCLUSIONS: After successful craniovertebral decompression, most patients presenting with pressure dissociation headaches and blackouts will improve. However, the large variety of other symptoms patients often present with may not improve after surgery.

Challenges to Neurosurgery During the Coronavirus Disease 2019 (COVID-19) Pandemic.

The coronavirus disease 2019 pandemic has presented a massive burden to most health care systems across the globe. The demand for intensive care unit capacity in particular has increased significantly, and hospitals in most affected regions have struggled to cope. The focus of health care activity has shifted to the pandemic, with a negative impact on the management of other conditions. Neurosurgery, like most specialties, has been drastically affected but, arguably, warrants special considerations because many of the treatments required are time-critical. Lack or delay of appropriate intervention may lead, for an individual patient, to permanent neurologic injury and a significant decline in function and quality of life, or even death. In this report, we consider the challenges that neurosurgeons currently face in relation to the pandemic and are likely to face in the foreseeable future. The challenges are multifaceted with practical, ethical, legal, and other implications. These include re-deployment of staff to areas outside neurosurgery, treatment priority setting, ethical decision-making and risk of moral injury, as well as medicolegal risks, financial uncertainties and implications for training, research, and global health work. As well as patients, these challenges will affect neurosurgeons as doctors and as humans. The international neurosurgical community has a moral duty to contribute to the global response to the COVID-19 crisis, but also to retain a duty to care for individual patients.

The implementation of an external ventricular drain care bundle to reduce infection rates.

Background: The main complication of external ventricular drains (EVD) is infection. Implementation of evidence-based guidelines for central venous catheter (CVC) care resulted in significant declines in infections. We tested a comparable approach to EVD infection rates.Methods: An initial retrospective study evaluated the existing EVD infection rate, and identified contributory risk factors. Based on our results, and in corroboration with existing literature, an EVD care bundle was developed and implemented. A prospective study was then conducted to identify improvement.Results: A total of 275 EVDs (120 pre- and 155 post-EVD care bundle) inserted over a period of 1532 days were included. Pre-care bundle, the infection rate was 27%, with the predominant factor associated with infection being number cerebrospinal fluid sampling episodes. Following introduction of the EVD care bundle, the infection rate declined to 10% (p < 0.001) with the incidence from 21 to 9 cases per 1,000 EVD-days (p = 0.003). The infection rate was not found to be significantly associated with the number of accesses during this period (p = 0.910).Conclusions: Introduction of a well-implemented EVD care bundle can significantly decrease EVD infection rates.

Cerebral mycotic aneurysms secondary to Streptococcus Agalactiae induced infective endocarditis.

Subarachnoid and intraparenchymal haemorrhages due to cerebral mycotic aneurysms are rare and associated with high mortality. Streptococcus agalactiae, is a rare cause of endocarditis and there are no reported cases of cerebral mycotic aneurysms secondary to this organism. We report a rare case of streptococcus agalctiae induced intracranial mycotic aneurysm.

Management and birth outcomes of pregnant women with Chiari malformations: A 14 years retrospective case series.

OBJECTIVE: The management of Chiari malformations in pregnancy is challenging due to the perceived risk of adverse maternal neurological outcomes and raising intracranial pressure during labour. Our aim was to evaluate the management and health outcomes of pregnant women cared for at a regional referral centre and highlight elements of best practice. STUDY DESIGN: A retrospective case series of all pregnant women diagnosed with Chiari malformation over fourteen years (January 2004-June 2018) at the Birmingham Women's Hospital - UK. RESULTS: Twenty-one women (23 pregnancies) with Chiari malformation were included, four had syringomyelia (4/21,19%) and six had previously undergone craniovertebral decompression (6/21, 29%). The median age was 34-years (range 20-41), the median gravidity was two (range 1-8), the median parity was one (range 0-6), and the median extent of tonsillar herniation was 11 mm (range 9-18). The majority of women received their preferred mode of delivery (15 normal vaginal deliveries (15/23, 65.2%) and 6 elective Caesarean sections (6/23, 26.1%)) with two pregnancies ending with an emergency caesarean section for obstetric complications (2/23, 8.7%). Five Caesarean section were performed under general anaesthetic, two under spinal (2/23, 8.7%) and one under epidural anaesthesia (1/23, 4.3%) with no neurological sequelae. There were no adverse neurological outcomes at discharge postnatally. CONCLUSIONS: Offering normal vaginal delivery with effective analgesia, for women with Chiari malformation, appears to be safe. Pregnancy care should be provided by a multi-disciplinary team with experience in managing Chiari malformation.

A qualitative study exploring staff attitudes to maintaining hydration in neurosurgery patients.

AIMS: To explore staff perceptions of the processes and influences on maintaining patients' hydration on a busy neurosurgery ward. BACKGROUND: Dehydration continues to be a major concern in the NHS where its avoidance is hindered by complications arising from clinical conditions, poor assessment and documentation of hydration and a lack of staff time to monitor fluid intake. Recent work has explored patient perceptions of hydration care but there has been little conducted recently that has explored those of staff. METHODS: Semi-structured interviews were conducted with staff working on a neurosurgery ward during 2016. We used open-ended questions to elicit experiences of hydration care and explore factors that influenced the maintenance of hydration in patients. RESULTS: We found that staff were aware of the importance of hydration and saw it as a central aspect of the care they provided. A range of staff are involved in the assessment of patients' hydration requirements and their ability to meet them. Similarly all staff were expected to provide oral fluids for patients able to drink independently. Competing priorities inhibited the time staff could spend providing hydration care which had an impact on the timely and accurate completion of fluid balance charts and meant that relatives were relied on to support patients requiring assistance in drinking.

Are Established Methods of Physiotherapeutic Management for Long-term Neurological Conditions Applicable to 'Orphan' Conditions such as Syringomyelia?

BACKGROUND AND PURPOSE: Syringomyelia is a rare or 'orphan' condition with the potential to cause significant disability and detrimental effects to quality of life. Syringomyelia shares similar symptoms to those common in other long-term neurological conditions, including spinal cord injury and multiple sclerosis. In these more prevalent conditions, physiotherapy is utilized widely and is effective in optimizing physical, psychological and social parameters. Therefore, we theorized that physiotherapy might be transferable to, and beneficial to syringomyelia patients. As a paucity of literature exists in this area, we aimed to evaluate the existing uptake and perceived efficacy of physiotherapy. METHODS: An exploratory, mixed methodology was selected to derive sufficient qualitative data for analysis. Specifically designed questionnaires and semi-structured interviews yielded data on uptake and perceived physiotherapy efficacy. One hundred patients from a National Health Service tertiary syringomyelia service were invited to participate. RESULTS: The questionnaire and interviews were completed by 49 and 20 patients, respectively. Of the small number of patients receiving physiotherapy, the majority reported beneficial effects on pain modulation and quality of life. Stretching and hydrotherapy were deemed effective for relief of pain and stiffness. Additionally, physiotherapy was reported to provide similar benefits to surgical intervention. DISCUSSION: Syringomyelia patients report physiotherapy to provide benefits for symptom management and quality of life. Such findings suggest that established rehabilitation techniques in more common conditions may be transferable to those less prevalent. Uptake of physiotherapy was limited, seemingly because of inadequate information, knowledge and resources. To address these deficiencies, further studies should be planned investigating the effectiveness of physiotherapy modalities, such as hydrotherapy, in parallel or in conjunction with surgery and/or pharmacology. Additionally, syringomyelia could be represented alongside similar pathologies in research trials to initiate further research questions and drivers for funding.

The skull of Chios: trepanation in Hippocratic medicine.

Cranial trepanation is the oldest neurosurgical operation and its roots date back to prehistory. For many centuries, religion and mysticism were strongly linked to the cause of diseases, and trepanation was associated with superstitions such as releasing evil spirits from inside the skull. The Hippocratic treatise "On injuries of the head" was therefore a revolutionary work, as it presented a systematic approach to the management of cranial trauma, one that was devoid of spiritual elements. Unfortunately, there are only a limited number of skeletal findings that confirm that the practice of trepanation was performed as part of Hippocratic medicine. In this historical vignette, the authors present a trepanned skull that was found in Chios, Greece, as evidence of the procedure having been performed in accordance with the Hippocratic teaching. The skull bears a parietal bur hole in association with a linear fracture, and it is clear that the patient survived the procedure. In this analysis, the authors examine the application of the original Hippocratic teaching to the skull of Chios. The rationalization of trepanation was clearly a significant achievement in the evolution of neurosurgery.

Is cerebrospinal fluid shunting in idiopathic intracranial hypertension worthwhile? A 10-year review.

BACKGROUND: The role of cerebrospinal fluid (CSF) diversion in treating idiopathic intracranial hypertension (IIH) is disputed. METHOD: We conducted a 10-year, retrospective case note review to evaluate the effects of CSF diversion in IIH. Symptoms, signs and details of shunt type, complications and revisions were documented at baseline, 6, 12 and 24 months post-operatively. RESULTS: Fifty-three IIH patients were shunted [predominantly lumboperitoneal (92%)]. The most common symptom pre-surgery was headache (96%). Post-operatively, significantly fewer patients experienced declining vision and visual acuity improved at 6 (p = 0.001) and 12 months (p = 0.016). Headache continued in 68% at 6 months, 77% at 12 months and 79% at 2 years post-operatively. Additionally, post-operative low-pressure headache occurred in 28%. Shunt revision occurred in 51% of patients, with 30% requiring multiple revisions. CONCLUSION: We conclude that CSF diversion reduces visual decline and improves visual acuity. Unfortunately, headache remained in the majority of patients and low-pressure headache frequently complicated surgery. Over half of the patients required shunt revision with the majority of these requiring multiple revisions. We suggest that CSF shunting should be conducted as a last resort in those with otherwise untreatable, rapidly declining vision. Alternative treatments, such as weight reduction, may be more effective with less associated morbidity.

The role of lumboperitoneal shunts in the treatment of syringomyelia.

OBJECT The role of thecoperitoneal shunts in the management of syringomyelia is not well defined. In this study, the authors analyze the outcome of lumboperitoneal shunt procedures carried out to treat syringomyelia in their institution. METHODS The authors retrospectively reviewed the medical records of 19 patients who underwent lumboperitoneal shunt procedures for syringomyelia. RESULTS The mean follow-up duration was 25 months (range 3-51 months). Of 16 cases followed up, only 5 patients reported clinical improvement in their preoperative symptoms, but of these, 2 had clear radiological evidence of improvement. Three of 6 patients with syringomyelia due to spinal arachnoiditis improved. CONCLUSIONS Lumboperitoneal shunts may lead to useful improvement in the symptoms of a patient with syringomyelia while avoiding the risk of neurological deterioration inherent in myelotomies required for syrinx shunting procedures.