A single centre's experience of managing spheno-orbital meningiomas: lessons for recurrent tumour surgery.

BACKGROUND: Spheno-orbital meningiomas are complex tumours involving the sphenoid wing and orbit. Various surgical strategies are available but treatment remains challenging and patients often require more than one surgical procedure. This study evaluated whether smaller surgical approaches and newer reconstructive methods impacted the surgical and clinical outcomes of patients undergoing repeat surgery. METHODS: We retrospectively analysed the medical records of consecutive patients who underwent surgery for a spheno-orbital meningioma at a single tertiary centre between 2005 and 2016. We recorded procedural details and analysed complications, postoperative visual status and patient-reported cosmetic outcome. RESULTS: Thirty-four procedures were performed in 31 patients (M:F 12:22, median age 49 years) including 19 (56%) primary operations and 15 (44%) repeat procedures. Seven patients (20.5%) had a pterional craniotomy, 19 (56%) had a standard orbitozygomatic craniotomy and 8 (23.5%) underwent a modified mini-orbitozygomatic craniotomy. Calvarial reconstruction was required in 19 cases with a variety of techniques used including titanium mesh (63%), PEEK (26%) and split calvarial bone graft (5%). Total tumour resection (Simpson grade I-II) was significantly higher in patients undergoing primary surgery compared with those having repeat surgery (41% and 0%, respectively; p = 0.0036). Complications occurred in 14 cases (41%). Proptosis improved in all patients and visual acuity improved or remained stable in 93% of patients. Cosmetic outcome measures were obtained for 18 patients (1 = very poor; 5 = excellent): 1-2, 0%; 3, 33%; 4, 28%; 5, 39%. Tumour recurrence requiring further surgery occurred in four patients (12%). There was no significant difference in clinical outcomes between patients undergoing primary or repeat surgery. CONCLUSION: Spheno-orbital meningiomas are highly complex tumours. Surgical approaches should be tailored to the patient but good clinical and cosmetic outcomes may be achieved with a smaller craniotomy and custom-made implants, irrespective of whether the operation is the patient's first procedure.

Has the survival of patients with glioblastoma changed over the years?

BACKGROUND: Over the last decade, the approach to the management of brain tumours and the understanding of glioblastoma tumour biology has advanced and a number of therapeutic interventions have evolved, some of which have shown statistically significant effects on overall survival (OS) and progression-free survival in glioblastoma. The aim of this study is to compare survival in glioblastoma patients over a 10-year period (1999-2000 and 2009-2010). METHODS: A retrospective cohort study was performed. Identification of all histologically confirmed glioblastoma in a single centre in years 1999, 2000, 2009 and 2010, and production of survival analysis comparing 1999-2000 and 2009-2010 were achieved. RESULTS: A total of 317 patients were included in the analysis (133 in year 1999-2000, and 184 in year 2009-2010). Cox regression analysis showed that the survival was significantly longer in patients in years 2009-2010 than those in 1999-2000 at P<0.001 with HR=0.56, confidence interval (CI) (0.45-0.71). The 1- and 3-year survival rates were 20.7% and 4.4%, respectively, for patients in 1999-2000, improving to 40.0% and 10.3%, respectively, for patients in 2009-2010. The comparisons between the two groups in survival at 1, 2 and 3 years are all statistically significant at P<0.001, respectively. The median OS was 0.36 and 0.74 in 1999-2000 and 2009-2010 groups, respectively. CONCLUSIONS: Over this period, OS from glioblastoma has increased significantly in our unit. We believe this is due to the institution of evidence-based surgical and oncological strategies practised in a multidisciplinary setting.

Neurobehavioural changes in patients following brain tumour: patients and relatives perspective.

PURPOSE: Patients and relatives experiences of behavioural and personality changes following brain tumour were assessed to determine whether these changes are more prominent in the experience of patients with frontal tumours and their relatives as a first step to evaluate the need to develop appropriate support and management of such changes, which have a substantial impact on social functioning, and ultimately to improve quality of life. METHODS: Patients and relatives rated the patients' current levels of apathy, disinhibition and executive dysfunction on the Frontal Systems Behaviour Scale. Patients also completed the Hospital Anxiety and Depression Scale. The data from 28 patients with frontal tumours and 24 of their relatives, and 27 patients with nonfrontal tumours and 25 of their relatives, were analysed. RESULTS: Patients with frontal tumours rated themselves significantly higher than patients with nonfrontal tumours on all frontal systems-related behaviours. The number of patients reporting clinical levels of difficulty was significantly greater in patients with frontal tumours for disinhibition. The ratings of relatives of patients with frontal tumours were significantly higher than those of relatives of patients with nonfrontal tumours for apathy. Clinically significant levels of apathy and executive dysfunction were however reported by at least 40 % of patients and relatives regardless of tumour location. Clinical levels of anxiety were reported by significantly more patients with frontal tumours than those with nonfrontal tumours. CONCLUSION: Support and management of behavioural and personality change for patients with brain tumours and their relatives, regardless of tumour location, would be most appropriate.

Identifying functional cortical plasticity after spinal tumour resection using navigated transcranial magnetic stimulation.

Our aim was to investigate the effectiveness of navigated transcranial magnetic stimulation (nTMS) brain mapping to characterise preoperative motor impairment caused by an intradural extramedullary (IDEM) tumour and postoperative cortical functional reorganisation. Preoperative and 1-year follow-up clinical, radiological and nTMS data from a case of thoracic spinal meningioma that underwent surgical resection of the lesion were collected and compared. A 67-year-old patient presented with severe progressive thoracic myelopathy (hypertonic paraparesis, clonus, insensate urinary retention) secondary to an IDEM tumour. Initial nTMS assessment showed bilateral upper limb representation with no positive responses for both lower limbs. He underwent successful surgical resection for his IDEM (meningioma WHO grade 1). At 1-year follow-up, the patient's gait was improved and his bladder function normalised. nTMS documented positive responses for both upper and lower limbs and a decrease in the area (right side: 1.01 vs 0.39cm2; left side: 1.92 vs 0.81cm2) and volume (right side: 344.2 vs 42.4uVcm2; left side: 467.1 vs 119uVcm2) of cortical activation for both upper limbs, suggesting a functional reorganisation of the motor areas after tumour resection. nTMS motor mapping and derived metrics can characterise preoperative motor deficit and cortical plasticity during follow-up after IDEM resection.

Neurenteric cyst in an adult: a diagnosis in a quinquagenarian.

Neurenteric cysts are congenital lesions of the spine usually diagnosed in children. There are few reports of diagnosis in adults. The abnormality is thought to arise during embryonic life and can be associated with other congenital deformities. We describe a case where the diagnosis occurred in a 54-year-old woman, whose symptoms improved following surgical excision of the cyst. We postulate that the cyst contributed to symptoms of cord tethering rather than cord compression and that the lateness of presentation was due to age-related spinal degeneration.

A randomized trial of nimodipine in severe head injury: HIT I. British/Finnish Co-operative Head Injury Trial Group.

We studied the efficacy of nimodipine in severely head-injured patients in a randomized study. Of 176 patients who received nimodipine, 2 mg/h iv for 2 day, 53% had a favorable outcome (moderate or good recovery). Of 175 control patients, 49% had a favorable outcome. This difference was not statistically significant but does not exclude the possibility that a study of a larger number of patients could show a clinically useful benefit.

Posterior lumbar interbody fusion for revision disc surgery: review of 50 cases in which carbon fiber cages were implanted.

OBJECT: The authors undertook a study to assess the value of posterior lumbar interbody fusion (PLIF) in which carbon fiber cages (CFCs) were placed in patients undergoing revision disc surgery for symptoms suggesting neural compression with low-back pain. METHODS: The authors followed their first 50 patients for a maximum of 5 years and a minimum of 6 months after implantation of the CFCs. Patients in whom magnetic resonance (MR) imaging demonstrated "simple" recurrent herniation did not undergo PLIF. Surgery was performed in patients with symptoms of neural root compression, tension signs, and back pain with focal disc degeneration and nerve root distortion depicted on MR imaging compatible with clinical signs and symptoms. In 40 patients (80%) pedicle screws were not used. Clinical outcome was assessed using the Prolo Functional Economic Outcome Rating scale. Fusion outcome was assessed using an established classification. Symptoms in 46 patients (92%) improved after surgery, and given their outcomes, 45 (90%) would have undergone the same surgery again. Two thirds of patients experienced good or excellent outcomes (Prolo score > or = 8) at early and late follow up. There was no difference in clinical outcome between those in whom pedicle screws were and were not implanted (p = 0.83, Mann-Whitney U-test). The fusion rate at 2 years postsurgery was 95%. There were minimal complications, and no patients fared worse after surgery. No patient has undergone additional surgical treratment of the fused intervertebral space. CONCLUSIONS: In this difficult group of patients the aim remains to improve symptoms but not cure the disease. A high fusion rate is possible when using the CFCs. Clinical success depends on selecting patients in whom radiological and clinical criteria accord. Pedicle screws are not necessary if facet joints are preserved, and high fusion rates and clinical success are possible without them.

Transfacial access for neurosurgical procedures: an extended role for the maxillofacial surgeon. I. The upper cervical spine and clivus.

A variety of osteoplastic flaps have been devised for transoral or extraoral access to the base of skull and the upper anterior cervical spine. Part I of this two-part review will describe access to the clivus and upper anterior cervical spine. Part II will describe access to the middle cranial fossa, the infratemporal fossa and the pterygoid (retromaxillary) "space".

Transfacial access for neurosurgical procedures: an extended role for the maxillofacial surgeon. II. Middle cranial fossa, infratemporal fossa and pterygoid space.

A variety of osteoplastic flaps have been devised for transoral or extraoral access to the base of skull and the upper anterior cervical spine. Part I of this two-part review describes access to the clivus and upper anterior cervical spine. Part II will describe access to the middle cranial fossa, the infratemporal fossa and the pterygoid (retromaxillary) "space".

Diarrhea and Fecal Incontinence.

In brief Two endurance athletes developed diarrhea and fecal incontinence each time they exercised strenuously. Such gastrointestinal difficulties are usually benign, but physicians determined that the disorders were an unusual presentation of lumbar spondylolisthesis in a runner and of jejunal diverticulosis in a cyclist. The runner's diarrhea and incontinence resolved when she avoided activities that precipitated her symptoms, and the cyclist's condition resolved with oral tetracycline.

Primary reconstruction of pelvic floor defects following sacrectomy using Permacol graft.

AIMS: The large pelvic floor defect following sacrectomy for sacral masses leaves the challenging problem of primary closure and herniation. We present the outcome of primary repair using Permacol, a biomaterial made of acellular porcine cross-linked dermal collagen and with similar tensile strength to polypropylene mesh. It is non-allergenic and possibly less likely than synthetic mesh to cause inflammation leading to small bowel adherence; fistula formation and graft extrusion. Following implantation, Permacol is colonized by host cells and resists degradation by host enzymes. METHODS: Three patients had sacrectomy with primary repair of pelvic floor defects between March 2004 and August 2005. Two had excision of sacral chordomas and one excision of a sacrococcygeal teratoma. Repair of the defect was carried out using the Permacol graft, suturing to the sacrum, anococcygeal raphe and ischial spines. Two suction drains were placed superficial to the mesh. RESULTS: All patients had gross en-bloc tumour resections and over a median follow-up period of 1year (range 8-25months), there were no complications related to primary repair. CONCLUSION: Primary closure of a large defect following sacrectomy using a Permacol graft, in our early experience seems to be convenient and safe without the development of herniation.

Paraganglioma of the cauda equina: a case report.

This case report describes a paraganglioma of the cauda equina in a 63 year old woman. Very few examples of paraganglioma have been recorded in this site. Histologically these neoplasms may have considerable similarity with ependymoma, the most common neoplasm of the lower spinal cord, and the diagnosis can be easily missed unless special techniques are employed. The clinical and pathological data obtained from this and the other reported examples suggests that paragangliomas of the cauda equina are benign, slowly growing neoplasms. In contrast to ependymomas and to paragangliomas elsewhere, they are well circumscribed, amenable to complete resection and have an excellent prognosis.

Local anaesthesia for laminectomy surgery.

Neurosurgical patients presenting for laminectomy surgery may have premorbid pathology that either contraindicates general anaesthesia or at least represents a significant risk to the patient. We present a sample case from a series of ten patients in whom laminectomy surgery was performed under local anaesthesia. The mean duration of surgery was 98 minutes and the average dose of lignocaine used was 1.91 mg/kg and, therefore, within safe limits. One patient was converted to a general anaesthetic. We believe that local anaesthesia can offer a safe and satisfactory alternative, in patients who may otherwise be denied surgery. The additional advantage of awake neuro-monitoring, may also reduce the risk of inadvertant spinal cord injury.

Modification of the standard pterional approach for aneurysms of the anterior circle of Willis.

A modification of the standard pterional approach for aneurysms of the anterior circulation is described. Our technique utilizes a smaller curvilinear skin incision, splitting the temporalis and a limited craniectomy. Reduced tissue dissection results in a smoother postoperative course and improves cosmesis without compromising neurological recovery. Minimal brain retraction is required as the technique allows the surgeon to make full use of the basal opening without temporalis muscle obscuring the view.

Spinal neurofibroma presenting as atlanto-axial subluxation in von Recklinghausen neurofibromatosis.

A patient with von Recklinghausen neurofibromatosis (NF-1) developed spinal cord compression from atlanto-axial subluxation caused by a neurofibroma involving the odontoid peg. His case is discussed and the relevant literature reviewed.