A cross-sectional survey of patient perceptions of the National Neurosurgical Audit Programme (NNAP).

BACKGROUND: The National Neurosurgical Audit Programme (NNAP) publishes mortality outcomes of consultants and neurosurgical units across the United Kingdom. It is unclear how useful outcomes data is for patients and whether it influences their decision-making process. Our aim was to identify patients' perceptions and understanding of the NNAP data and its influences. MATERIALS AND METHODS: This single-centre study was conducted in the outpatient neurosurgery clinics at a regional neurosurgical centre. All adult (age ≥ 18) neurosurgical patients, with capacity, were invited to take part. Native and non-native English speakers were eligible. Statistical analyses were performed on SPSS v28 (IBM). Ethical approval was obtained. RESULTS: A total of 84 responses were received (54.7% females). Over half (51.0%) of respondents felt that they understood a consultant's mortality outcomes. Educational level determines respondents' understanding (χ2(8) = 16.870; p = .031). Most respondents were unaware of the NNAP (89.0%). Only a third of respondents (35.1%) understood the funnel plot used to illustrate mortality. CONCLUSIONS: Most patients were unaware of the NNAP and most did not understand the data on the website. Understanding of mortality data seemed to be related to respondents' educational level which would be important to keep in mind when planning how to depict mortality data.

In-House Intraoperative Monitoring in Neurosurgery in England - Benefits and Challenges.

BACKGROUND: Intraoperative neurophysiological monitoring (IOM) is a valuable adjunct for neurosurgical operative techniques, and has been shown to improve clinical outcomes in cranial and spinal surgery. It is not necessarily provided by NHS hospitals so may be outsourced to private companies, which are expensive and at cost to the NHS trusts. We discuss the benefits and challenges of developing an in-house service. METHODS: We surveyed NHS neurosurgical departments across England regarding their expenditure on IOM over the period January 2018 - December 2022 on cranial neurosurgery and spinal surgery. Out of 24 units, all responded to our Freedom of Information requests and 21 provided data. The standard NHS England salary of NHS staff who would normally be involved in IOM, including physiologists and doctors, was also compiled for comparison. RESULTS: The total spend on outsourced IOM, across the units who responded, was over £8 million in total for the four years. The annual total increased, between 2018 and 2022, from £1.1 to £3.5 million. The highest single unit yearly spend was £568,462. This is in addition to salaries for staff in neurophysiology departments. The mean NHS salaries for staff is also presented. CONCLUSION: IOM is valuable in surgical decision-making, planning, and technique, having been shown to lead to fewer patient complications and shorter length of stay. Current demand for IOM outstrips the internal NHS provision in many trusts across England, leading to outsourcing to private companies. This is at significant cost to the NHS. Although there is a learning curve, there are many benefits to in-house provision, such as stable working relationships, consistent methods, training of the future IOM workforce, and reduced long-term costs, which planned expansion of NHS services may provide.

Variations in the Neurosurgical Management of Depressed Skull Fractures in Adults: An International Cross-Sectional Survey.

BACKGROUND: Depressed skull fractures have been well described since antiquity, yet its management remains controversial. Contentious issues include the use of prophylactic antibiotics and antiepileptics, the role of nonoperative management, and the replacement/removal of bone fragments. Our objective was to explore the management patterns of closed and open depressed skull fractures across the world. METHODS: A 23-item, web-based survey was distributed electronically to the members of national neurosurgical associations, and on social media platforms. The survey was open for data collection from December 2020 to April 2021. RESULTS: A total of 218 respondents completed the survey, representing 56 countries.With regard to open fractures, most respondents (85.8%) treated less than 50 cases annually. Most respondents (79.4%) offered prophylactic antibiotics to all patients with open fractures, with significant geographical variation (p < 0.001). Less than half of the respondents (48.2%) offered prophylactic antiepileptics. Almost all respondents (>90%) reported the following indications as important for surgical management: (1) grossly contaminated wound, (2) dural penetration, (3) depth of depression, and (4) underlying contusion/hematoma with mass effect. Most respondents treated less than 50 cases of closed depressed skull fractures annually. Most European respondents (81.7%) did not offer prophylactic antiepileptics in comparison to most Asian respondents (52.7%; p < 0.001). Depth of depression, an underlying hematoma/contusion with mass effect, and dural penetration were the most important surgical indications. CONCLUSIONS: There remains a great degree of uncertainty in the management strategies employed across the world in treating depressed fractures, and future work should involve multinational randomized trials.

Specialist healthcare services for concussion/mild traumatic brain injury in England: a consensus statement using modified Delphi methodology.

OBJECTIVE: To establish a consensus on the structure and process of healthcare services for patients with concussion in England to facilitate better healthcare quality and patient outcome. DESIGN: This consensus study followed the modified Delphi methodology with five phases: participant identification, item development, two rounds of voting and a meeting to finalise the consensus statements. The predefined threshold for agreement was set at ≥70%. SETTING: Specialist outpatient services. PARTICIPANTS: Members of the UK Head Injury Network were invited to participate. The network consists of clinical specialists in head injury practising in emergency medicine, neurology, neuropsychology, neurosurgery, paediatric medicine, rehabilitation medicine and sports and exercise medicine in England. PRIMARY OUTCOME MEASURE: A consensus statement on the structure and process of specialist outpatient care for patients with concussion in England. RESULTS: 55 items were voted on in the first round. 29 items were removed following the first voting round and 3 items were removed following the second voting round. Items were modified where appropriate. A final 18 statements reached consensus covering 3 main topics in specialist healthcare services for concussion; care pathway to structured follow-up, prognosis and measures of recovery, and provision of outpatient clinics. CONCLUSIONS: This work presents statements on how the healthcare services for patients with concussion in England could be redesigned to meet their health needs. Future work will seek to implement these into the clinical pathway.

Reducing the neurosurgical waiting list burden: is it a futile endeavour?

BACKGROUND: Cancellation of elective operations during the COVID-19 pandemic has led to a significant increase in the number of patients waiting for treatment. In neurosurgery, treatment for spinal diseases, in particular, has been disproportionately delayed. We aim to describe the waiting list burden at our institution and forecast the time and theatre capacity required to return to pre-pandemic levels. METHODS: A retrospective evaluation of the waiting list records (both cranial and spinal), from January 2015-October 2022, inclusive, was conducted at a high-volume neurosciences centre. The average monthly decrease in the waiting list was calculated for the months since the waiting list was noted to fall consistently during or after the pandemic, as applicable. Five different scenarios were modelled to identify the time required to reduce the waiting list to the pre-pandemic level of December 2019. Data collection and analyses were performed on Excel (Microsoft). RESULTS: At the pre-pandemic threshold (December 2019), 782 patients were on the waiting list. Between January 2015-January 2020, inclusive, an average of 673 patients were on the waiting list but this has doubled over the subsequent months to a peak of 1388 patients in December 2021. Between December 2021-October 2022, on average, the waiting list reduced by 18 per month. At the current rate of change, the waiting list would fall to the pre-pandemic level by October 2024, an interval of 24 months. A seven-day service would require 18 months to clear the backlog. Doubling or tripling the current rate of change would require 12 months and 8 months, respectively. CONCLUSIONS: Pre-existing, pandemic-related, and new NHS-wide challenges continue to have negative influences on reducing the backlog. Proposals for surgical hubs to tackle this carry the risks of removing staff from hospitals which cannot avoid emergency/urgent operating thereby further reducing those institutions' capacity to undertake elective work.

Surgical decompressions for cauda equina syndrome during COVID-19.

BACKGROUND: The novel coronarvirus disease (COVID-19) has had a major impact on provision of spinal neurosurgery across the world, especially in the UK, with a significant fall in operating and patient volumes, and elective clinical activities. It is unclear whether the pandemic has affected the volume of urgent spinal procedures in the UK, especially surgical decompressions for cauda equina syndrome (CES). METHODS: Therefore, we conducted a retrospective analysis of theatre records and electronic operation notes at our institution to identify all procedures performed for CES before (December 2019 to February 2020) and during (March 2020 to May 2020) the COVID-19 pandemic. Statistical analyses were performed on SPSS v22 (IBM). RESULTS: Forty-four patients underwent surgical decompressions during the study period. Over half (54.5%) were female and the median age was 45 years (range = 22-78 years). Three in four procedures were performed at L4-5 and L5-S1 levels (79.5%). There was no statistically significant difference in the number of decompressions performed each month [χ2(5)=1.818; p = 0.874]. On the other hand, the number of referrals for suspected or confirmed CES fell by 81.8% between December 2019 and April 2020. CONCLUSIONS: Our results did not show any statistically significant decline in the volume of surgical decompressions performed for CES despite the considerable fall in electronic referrals for CES and degenerative spinal conditions. This suggests that patients with critical neurological symptoms continued to present and were treated appropriately despite the restrictions imposed on spinal surgeons during the pandemic.

Bypassing the nearest emergency department for a more distant neurosurgical centre in traumatic brain injury patients.

BACKGROUND AND OBJECTIVE: Major trauma triage within regional trauma networks (RTN) select patients with suspected TBI for bypass to specialist neuroscience centres (SNC), expediting neurosurgical care but may delay resuscitation. This comparative effectiveness study assessed the impact of this strategy on the risk adjusted hospital survival rates of patients confirmed to have intracranial injury on brain computed tomography (CT) scan. METHOD: A retrospective cohort study was conducted using Trauma Audit and Research Network trauma registry data. Adult patients with a TBI on CT scan were included if they presented between June 2015 to February 2016 to SNCs or non-specialist acute hospitals (NSAH) in the North of England (South Cumbria, Lancashire and the North East Region). Patients were identified as having bypassed a nearer NSAH emergency department (ED) to a SNC using google maps. Their standardised excess survival rate was compared to TBI patients who received primary treatment at a NSAH. A multivariate logistic regression model predicting 30-day survival after TBI (Ps14n)1 was used to adjust for variation in casemix between cohorts. STUDY DESIGN AND RESULTS: 355 patients met the study inclusion criteria, with 89/355 (25%) of TBI patients bypassing a nearer NSAH to a SNC, and 266/355 (75%) receiving primary treatment at an NSAH. The median severity of intracranial injury was equivalent (median Head Abbreviated Injury Scale 4 (IQR 4-5) in each group. There was no statistically significant difference in the standardised excess survival rate between the two cohorts; +6.15% for bypass (95% CI -1.24% to +13.55%) versus -1.12% for non-bypass (95% CI -4.51% to +2.25%). CONCLUSION AND FUTURE RESEARCH: No statistically significant survival benefit was identified for TBI patients who bypassed the nearest ED to attend a SNC compared to those receiving treatment at the nearest NSAH, however a clinically significant 7% excess survival rate merits a larger study.

Neurosurgical Referral Patterns During the Coronavirus Disease 2019 Pandemic: A United Kingdom Experience.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a severe respiratory viral illness that has spread rapidly across the world. However, the United Kingdom has been particularly affected. Evidence has suggested that stroke, cardiac, and spinal presentations decreased during the pandemic as the public avoided seeking care. The effect on neurosurgical presentations and referrals during COVID-19 is unclear. Our aim, therefore, was to describe the referral patterns to a high-volume neurosurgical department in the United Kingdom during the COVID-19 pandemic. METHODS: Electronic referrals were identified from the referrals database from January 1, 2020 to May 31, 2020, inclusive, with January used as the baseline. The demographic data and referral diagnoses were captured on Excel (Microsoft, Redmond, Washington, USA). Statistical analyses were performed using SPSS, version 22 (IBM Corp., Armonk, New York, USA). Differences between referral volumes were evaluated using χ2 goodness-of-fit tests. RESULTS: A total of 2293 electronic referrals had been received during the study period. The median age was 63 years. Overall, the referrals had decreased significantly in volume during the study period [χ2(4) = 60.95; P < 0.001]. We have described the patterns in the daily referrals as the pandemic progressed. The reduction in the volume of referrals for degenerative spine cases and traumatic brain injuries was statistically significant (P < 0.001). CONCLUSIONS: The referrals for degenerative spine and traumatic brain injuries decreased significantly during the pandemic, which can be explained by the lower vehicular traffic and patient avoidance of healthcare services, respectively. The risk of neurological deterioration and increased morbidity and mortality, as a consequence, is of concern, and neurosurgeons worldwide should consider the optimal strategies to mitigate these risks as the pandemic eases.

Survival outcomes following craniotomy for intracranial metastases from an unknown primary.

INTRODUCTION: Management of patients with intracranial metastases from an unknown primary tumor (CUP) varies compared to those with metastases of known primary tumor origin (CKP). The National Institute for Health and Care Excellence (NICE) recognizes the current lack of research to support the management of CUP patients with brain metastases. The primary aim was to compare survival outcomes of CKP and CUP patients undergoing early resection of intracranial metastases to understand the efficacy of surgery for patients with CUP. METHODS: A retrospective study was performed, wherein patients were identified using a pathology database. Data was collected from patient notes and trust information services. Surgically managed patients during a 10-year period aged over 18 years, with a histological diagnosis of intracranial metastasis, were included. RESULTS: 298 patients were identified, including 243 (82.0%) CKP patients and 55 (18.0%) CUP patients. Median survival for CKP patients was 9 months (95%CI 7.475-10.525); and 6 months for CUP patients (95%CI 4.263-7.737, p = 0.113). Cox regression analyses suggest absence of other metastases (p = 0.016), age (p = 0.005), and performance status (p = 0.001) were positive prognostic factors for improved survival in cases of CUP. The eventual determination of the primary malignancy did not affect overall survival for CUP patients. CONCLUSIONS: There was no significant difference in overall survival between the two groups. Surgical management of patients with CUP brain metastases is an appropriate treatment option. Current diagnostic pathways specifying a thorough search for the primary tumor pre-operatively may not improve patient outcomes.

Perampanel and decanoic acid show synergistic action against AMPA receptors and seizures.

Perampanel is an adjunctive treatment for epilepsy that works through the direct inhibition of AMPA receptors. The same molecular mechanism has recently been shown for a fatty acid, decanoic acid, prescribed in the medium chain triglyceride ketogenic diet for the treatment of patients with drug-resistant epilepsy. Because each compound has been proposed to act through a distinct AMPA receptor binding site, we predicted that perampanel and decanoic acid would act synergistically against AMPA receptors and, consequently, seizures. Here, we show a synergistic interaction between perampanel and decanoic acid in direct AMPA receptor inhibition, in an ex vivo model of seizure activity, and against seizure-induced activity in human brain slices. These data support a potential role for combination treatment using perampanel and dietary decanoic acid to provide enhanced seizure control.

Bypassing nearest hospital for more distant neuroscience care in head-injured adults with suspected traumatic brain injury: findings of the head injury transportation straight to neurosurgery (HITS-NS) pilot cluster randomised trial.

OBJECTIVE: Reconfiguration of trauma services, with direct transport of patients with traumatic brain injury (TBI) to specialist neuroscience centres (SNCs)-bypassing non-specialist acute hospitals (NSAHs), could improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) may worsen outcomes when compared with selective secondary transfer from nearest NSAH to SNC. We conducted a pilot cluster randomised controlled trial to determine the feasibility and plausibility of bypassing suspected patients with TBI -directly into SNCs-producing a measurable effect. SETTING: Two English Ambulance Services. PARTICIPANTS: 74 clusters (ambulance stations) were randomised within pairs after matching for important characteristics. Clusters enrolled head-injured adults-injured nearest to an NSAH-with internationally accepted TBI risk factors and stable ABC. We excluded participants attended by Helicopter Emergency Medical Services or who were injured more than 1 hour by road from nearest SNC. INTERVENTIONS: Intervention cluster participants were transported directly to an SNC bypassing nearest NSAH; control cluster participants were transported to nearest NSAH with selective secondary transfer to SNC. OUTCOMES: Trial recruitment rate (target n=700 per annum) and percentage with TBI on CT scan (target 80%) were the primary feasibility outcomes. 30-day mortality, 6-month Extended Glasgow Outcome Scale and quality of life were secondary outcomes. RESULTS: 56 ambulance station clusters recruited 293 patients in 12 months. The trial arms were similar in terms of age, conscious level and injury severity. Less than 25% of recruited patients had TBI on CT (n=70) with 7% (n=20) requiring neurosurgery. Complete case analysis showed similar 30-day mortality in the two trial arms (control=8.8 (2.7-14.0)% vs intervention=9.4(2.3-14.0)%). CONCLUSION: Bypassing patients with suspected TBI to SNCs gives an overtriage (false positive) ratio of 13:1 for neurosurgical intervention and 4:1 for TBI. A measurable effect from a full trial of early neuroscience care following bypass is therefore unlikely. TRIAL REGISTRATION NUMBER: ISRCTN68087745.

Iatrogenic syringomyelia secondary to lumboperitoneal shunt altered by the raised intra-abdominal pressure of pregnancy.

We report a case of a 37 year old female with syringomyelia secondary to lumboperitoneal (LP) shunt. Syrinx regression occurred with raised intra-abdominal pressure due to pregnancy and subsequently redeveloped after parturition. To our knowledge a case of pregnancy associated syringomyelia regression has not been previously reported.

Outcome after craniotomy for recurrent cranial metastases.

OBJECTIVE: To investigate the outcomes of patients with recurrent/progressive cranial metastases who underwent re-do craniotomy and to assess the utility of surgery as a treatment option. METHODS: A retrospective study was conducted assessing survival after re-do craniotomy for recurrent or progressive cranial metastases. 29 patients were identified between January 2006 and December 2013. Data was gathered from a prospective pathology database, patients' notes and electronic records. The diagnosis of cranial metastasis was obtained through pathological analysis at the time of tumour resection. Results were analysed with Cox regression tests and converted into a Kaplan-Meier curve. RESULTS: Median patient age was 57 years old (range 24-74 years) at diagnosis of brain metastases. Two patients had serious complications after re-do surgery. Five patients had >2 craniotomies for recurrent disease. Median survival after the first craniotomy was 18 months (range 4.1-50.9 months). Median survival after re-do craniotomy was 7.6 months (range 0.2-31.3 months). 90% of patients survived at least 3 months after re-do surgery, 65.5% survived at least 6 months. CONCLUSION: This study suggests that re-do surgery is a viable treatment option for patients with recurrent cranial metastases.

Pure endoscopic expanded endonasal approach for olfactory groove and tuberculum sellae meningiomas.

The expanded endoscopic endonasal (EEE) approach for the removal of olfactory groove (OGM) and tuberculum sellae (TSM) meningiomas is currently becoming an acceptable surgical approach in neurosurgical practice, although it is still controversial with respect to its outcomes, indications and limitations. Here we provide a review of the available literature reporting results with use of the EEE approach for these lesions together with our experience with the use of the endoscope as the sole means of visualization in a series of patients with no prior surgical biopsy or resection. Surgical cases between May 2006 and January 2013 were retrospectively reviewed. Twenty-three patients (OGM n=6; TSM n=17) were identified. In our series gross total resection (GTR) was achieved in 4/6 OGM (66.7%) and 11/17 (64.7%) TSM patients. Vision improved in the OGM group (2/2) and 8/11 improved in the TSM group with no change in visual status in the remaining three patients. Post-operative cerebrospinal fluid (CSF) leak occurred in 2/6 (33%) OGM and 2/17 (11.8%) TSM patients. The literature review revealed a total of 19 OGM and 174 TSM cases which were reviewed. GTR rate was 73% for OGM and 56.3% for TSM. Post-operative CSF leak was 30% for OGM and 14% for TSM. With careful patient selection and a clear understanding of its limitations, the EEE technique is both feasible and safe. However, longer follow-ups are necessary to better define the appropriate indications and ideal patient population that will benefit from the use of these newer techniques.

Cauda equina syndrome secondary to intradural renal cell carcinoma metastasis haemorrhage.

Intradural renal cell carcinoma (RCC) metastasis is rare. We report a case of an 81-year-old female presenting with acute cauda equina syndrome (CES), secondary to intradural RCC metastasis haemorrhage. To our knowledge this is the first case of CES secondary to acute haemorrhage within an intradural RCC metastasis.

Extensive cartilaginous metaplasia of recurrent posterior fossa ependymoma: case report and review of the literature.

Cartilaginous metaplasia in ependymomas is extremely rare and only few cases have been reported in the literature. We describe a case of a 5-year-old patient with a 5th recurrence of 4th ventricle ependymoma. He was previously treated with 4 resections, chemotherapy and radiotherapy. Histopathology revealed well-differentiated chondroid tissue occupying almost the entire lesion. Near total resection was achieved for the 5th time, but the patient died 3 months later achieving a total survival of 48 months, the 3rd longest reported in literature. Multiple resections of tumour recurrence provided a new insight in this very rare tumour, as it gave us the opportunity to observe the progression of tumour aggressiveness from grade II to grade III and finally to chondroid metaplasia. Cartilaginous metaplasia in posterior fossa ependymomas is a very atypical and challenging tumour with poor overall prognosis.

Patients' perception of error during craniotomy for brain tumour and their attitudes towards pre-operative discussion of error: a qualitative study.

INTRODUCTION: Medical error can result in significant morbidity and even mortality. Public and media attention remains focussed on its incidence and causes. Appreciation of patient perception of medical error in the neurosurgical setting is limited. This study investigated patients' perceptions of potential medical error during craniotomy for brain tumour and whether this influenced their decision to consent. MATERIALS AND METHODS: This study utilised qualitative research methodology. Thirty-five patients who had undergone craniotomy for brain tumour were interviewed using a semi-structured questionnaire. Interviews were transcribed and subjected to thematic analysis. RESULTS: Analysis revealed seven overarching themes: (i) views on what constituted medical error were well formed; (ii) to err is human; (iii) protocols exist to prevent error; (iv) trust in one's surgeon is important; (v) patients' belief that they can influence the likelihood of error was variable; (vi) concern with treating the disease trumps worry over possible errors; and (vii) the usefulness of discussing potential error was variable. CONCLUSIONS: Patients had a good understanding of medical error and it's potential causes. The usefulness of pre-operative, pre-consent discussion of error was varied. It may empower clinicians and patients to talk about such issues, though this should avoid exacerbating a patient's anxiety.

Neuropsychologic impact of treatment modalities in subarachnoid hemorrhage: clipping is no different from coiling.

OBJECTIVE: This study assesses the impairment in activities of everyday life using a novel test battery following subarachnoid hemorrhage (SAH) and its treatment. METHODS: A one-off neuropsychologic assessment was conducted for all patients who agreed to participate in the study. The date of the interview was at least 12 months after the ictus. The aspects tested included attention, memory, mood, and executive functions. Thirty normal subjects were also assessed using the same battery of tests to act as controls. The data was analyzed using JMP, version 8.0.2. The project was approved by the local research ethics committee and was performed under the tenets of the Helsinki declaration. RESULTS: Analysis from 77 patients and 30 controls is presented. Patients in the SAH group had significant deficits of sustained attention and attentional switching and executive functions when compared to normal controls (P < 0.05, χ(2)). Within the SAH patient group, the deficits were independent of the subgroup to which the patients belonged (coiled, clipped, and perimesencephalic hemorrhage, P > 0.05, χ(2)). The perimesencephalic hemorrhage group had fewer deficits as compared to the coiled and clipped groups, but because there were very few patients in this group, statistical significance was not achieved for these results. CONCLUSION: Our results reflect a change in UK practice in treating aneurysms, the majority being treated with endovascular coiling. After more than 12 months postictus, attention and executive functions were found to be significantly impaired. Significant deficits remain in various cognitive domains following an SAH, but these appear to be independent of the treatment modality according to our data.

Emergency head CT scans: can neurosurgical registrars be relied upon to interpret them?

Neurosurgical registrars are frequently called upon by A&E staff and physicians to interpret emergency head CT (computed tomography) scans out of hours. This appears to reflect the reduced threshold for scanning patients and the nonavailability of a radiologist to report these scans. This study was undertaken to assess the safety of such practices. Five neurosurgical registrars, blinded to each other and to the radiology reports, interpreted 50 consecutive emergency head CT scans (both trauma and nontrauma) from the hospital's imaging system as a pilot study. These were initially graded as normal or abnormal. Abnormal scans were assessed for the presence of an intracranial bleed, pneumocephalus, skull fractures, cerebral contusions, mass effect, midline shift, ischaemia or hydrocephalus. The agreement of the observers' recordings with the report issued or approved by a consultant radiologist was evaluated using SPSS Version 13.0. Four of the five registrars assessed a further 150 scans in a similar manner to complete the study. There was a good general agreement between the formal reports and the neurosurgical registrars' identification of normal scans (average Kappa 0.79). The radiology reports and the registrars also agreed well on the presence or absence of intracranial blood, contusions and pneumocephalus (Kappa value > 0.70). The agreement was poorer for ischaemia, mass lesions (other than intracranial haematomas), grey white differentiation, evidence of raised intracranial pressure and midline shift (Kappa < 0.5). Neurosurgical registrars compared well with radiologists when it came to assessing emergency head CT scans as normal or detecting a surgical lesion. The agreement was poorer on subtle abnormalities. The practice of neurosurgical registrars informally 'reporting' on emergency head CT scans cannot be recommended.

Co-existing cholesteatoma and vestibular schwannoma.

A 69-year-old man presented with a cholesteatoma in the right mastoid process and a vestibular schwannoma at the left internal acoustic meatus. Cholesteatoma co-existing with a vestibular schwannoma has not been documented previously in the contemporary literature. The clinical dilemma in the management of his progressive bilateral hearing loss is discussed. He presented with dizziness and bilateral hearing loss worse on the right side. Pressure over the mastoid process elicited vertigo and nystagmus. He had no history of previous operation or infection in the ear canal. Audiograms confirmed high-tone hearing loss. Radiological investigations revealed a symptomatic cholesteatoma on the right side and an incidental vestibular schwannoma on the left. We have elected to manage both lesions conservatively. Bilateral cholesteatoma and bilateral vestibular schwannomas have been previously reported. Co-existing lesions, as in our patient have, however, not been reported previously. The management options of his hearing loss are discussed.