Idiopathic intracranial hypertension VISION (venous intervention versus shunting in IIH for optic nerve disc swelling) trial: patient perspective questionnaire.

INTRODUCTION: Headaches, visual problems and tinnitus are symptoms of Idiopathic Intracranial Hypertension (IIH) which resolve with reduction of CSF pressure. Impaired cranial venous outflow has been implicated in the pathogenesis and there is evidence of good treatment results in IIH using venous sinus stenting. We are currently initiating a multi-centre randomised controlled trial, the VISION study (Venous Intervention versus Shunting in IIH for Optic Disc Swelling) comparing radiological (venous sinus stenting) to surgical intervention (CSF shunting). As part of the preparations for VISION we made a basic questionnaire available to members of the website IIH UK ( www.iih.org.uk ). METHODS: 10-point questionnaire pertaining to IIH diagnosis, symptoms and management using www.surveymonkey.com . RESULTS: 250 questionnaires were returned. 95.6% of respondents were female, mostly ≤40 years of age. 70% were diagnosed in the last 5 years, but only 35% were diagnosed less than a year after onset of symptoms. 59.4% of patients had not undergone any radiological/surgical intervention, 34.9% had had CSF diversion, 3.6% venous stenting and 2.0% had stent plus shunt. 16.8% indicated their lives were most affected by tinnitus and 18.1% by visual problems, but 49.6% said they were most affected by their headaches. 81% of patients indicated they would be happy to participate in a randomised trial comparing the two treatment options of venous stenting and CSF shunting. CONCLUSION: IIH patients want to be actively involved in their treatment and are favourably disposed towards clinical research. Variation exists in treatment modalities offered. There are individual differences regarding impact of symptoms.

Symptomatology following traumatic brain injury in a multidisciplinary clinic: experiences from a tertiary centre.

BACKGROUND: Physical, cognitive and emotional sequelae in patients with traumatic brain injury (TBI) have been identified; some as late as two years post-injury. To aid in the specialist management of such patients, a multidisciplinary neurotrauma clinic was initiated at a tertiary centre.  Aim: This study sought to describe the clinical features of patients who attended the clinic. METHODS: Patient data was collected under several categories: basic demographics, mechanism and severity of injury, initial CT findings and management, hospital stay and discharge details, symptoms in clinic and actions performed by clinic staff (medication changes, referrals to other services, etc.). RESULTS: Three hundred and five patients met the inclusion criteria. Mean age was 47.5 and most patients were male (72.1%). Commonest mechanism of injury was falls (53.1%). 17.4% of injuries were classed as mild, 68.2% moderate and 14.1% severe. Commonest injury locations were frontal (21.6%) and temporal (16.1%) with contusions (37.4%) and subdural hematomas (27.9%) the commonest type of injury on initial CT scan. The most frequent physical complaints were headache (47.9%) and memory problems (42.0%). 7.9% complained of new seizures since TBI. 41.6% were referred to further services: most frequently psychology (19.3%) and neuropsychiatry (18.4%). Of 184 known to be employed before their injury, 48.4% of these returned to work before their last appointment. 28.5% were unable to continue driving. CONCLUSION: Our study provides an insight into the reality of long term sequelae of TBI, especially those at the more severe end of the spectrum, who are likely to present to tertiary or specialist services. Information gathered in this study about characteristics of the TBI population and their outcomes allows for better targeting of suitable patients for referral to a multidisciplinary clinic and improved resource planning.

Intradural migration of cervical posterior fixation rods.

BACKGROUND: Instrumented spinal fixations are an important tool in the management of traumatic conditions and delayed complications are rare. CASE REPORT: We present a case of open reduction and fixation of traumatic C5/6 facet fracture dislocation with late complication in the form of intradural hardware migration. CONCLUSION: To our knowledge, this is the first report of an intradural rod migration distant to the initial surgery in a patient without posterior decompression. This highlights the need for long-term follow-up of patients with spinal instrumentation.

The management of minor head trauma (GCS 15-13) across a Trauma Network.

OBJECTIVES: To determine the variations in the management of patients with minor head injuries across a Trauma Network. METHODS: An 18-point questionnaire covering aspects of hospital care and follow-up of patients with minor head injuries was sent out to 19 wards in 10 different trauma units within our network. RESULTS: Fifty-eight percent of wards routinely admitting patients with minor head injuries have no management protocol in place. Mild head injury patients stay for 24-48 h as in-patients. Fifty percent of wards use GCS as the only assessment tool. Seventy-four percent of wards give post-head injury advice to their discharged patients with mild head injuries, but only 26% follow their patients up locally and 16% refer minor head injury patients to the specialist neurotrauma clinic. Twenty one percent of wards give information to their head injury patients regarding supporting organisations and charities. Seventy-four percent of ward staff report being confident in looking after head injury patients. All wards would welcome a head injury study day or an in-house education event. CONCLUSION: Management of minor head injury patients in trauma units should be standardised and neurosurgical units within Major Trauma Centres (MTC) need to lead in protocol based management of these patients across their network. NICE currently provide guidance detailing local management of head injuries not requiring immediate admission to the MTC. We believe it is the role of the neurosurgical centre to work with trauma units and provide guidelines and standards of practice to ensure optimal management of this vulnerable population group. In addition, the neuroscience centre has a role in ensuring staff education and on-going professional development across Trauma Networks.

Case Report: Traumatic Carotid-Cavernous Fistula.

Carotid-cavernous fistulae (CCFs) are a rare complication of head trauma, with potentially serious consequences. We report the case of a 45-year-old male patient who presented with posttraumatic CCF 2 months after sustaining a head injury. Appropriate imaging in the form of computed tomography of the head, magnetic resonance imaging of the head, and digital subtraction angiography of the intracranial vessels was performed, and the CCF was successfully coil embolized. This resulted in good resolution of the patient's symptoms. We discuss the cause, presentation, diagnosis, and treatment of CCFs. Carotid-cavernous fistulae are a rare sequela of craniofacial trauma; therefore, a high index of suspicion must be maintained to establish a diagnosis and prevent serious consequences.

History of neurosurgery at the Royal Free Hospital in London.

The recent move of the neurosurgical services from The Royal Free London NHS Foundation Trust in Hampstead to The National Hospital for Neurology and Neurosurgery at Queen Square signified the end of an era of neurosurgery in North London. It also represents also another chapter in the history of the remarkable North London hospital that is The Royal Free Hospital. This short article looks at the history of the Department of Neurosurgery at The Royal Free Hospital and the factors contributing to the reorganisation of neurosurgical services in North London.

COVID-19 and Spontaneous Resolution of Lumbar Disk Prolapse: A Retrospective Cohort Study of Patients Awaiting Microdiscectomy.

BACKGROUND: Between individual patients with lumbar disk prolapse (LDP), the natural course of disease is significantly variable. Spontaneous resolution is reported to occur in up to 70% of cases. However, we currently cannot predict for whom and when this will occur. Neurosurgical intervention is indicated for LDP patients with nontolerable pain after at least 8 to 12 weeks of conservative management, or significant neurologic deficit. Channeling essential resources in the National Health Service (NHS) to fight the COVID-19 pandemic led to the postponement of most elective operations, including microdiskectomy. This left many LDP patients previously considered to be surgical candidates with conservative-only options in the interim. To our knowledge, we are the first center to report the specific impact of the peri- and postpandemic period on waiting list times, delayed elective microdiskectomy, and the incidence of spontaneous LDP resolution. METHODS: Retrospective case series of a prospectively collected electronic departmental database identified LDP patients who would have been impacted by the COVID-19 pandemic at some point in their care pathway (March 2020-February 2022). Further information was obtained from electronic patient records. RESULTS: In total, 139 LDP patients were listed for elective microdiskectomy at the time of postponement of elective surgery. Over a third of LDP patients (n = 47, 33.8%), in shared decision with the responsible neurosurgeon, had their rescheduled microdiskectomy canceled due to clinical improvement (14.1%), radiologic regression (6.5%), or both (12.2%). CONCLUSION: Our single-center retrospective analysis revealed that for over a third of LDP patients, the prolonged postpandemic waiting list times for elective microdiskectomy resulted in their surgery not taking place either due to spontaneous clinical improvement or proven radiologic regression. Considering this, a prolonged conservative approach to LDP may be appropriate in some patients, allowing time for natural resolution, while avoiding perioperative risks.

Apoptotic cells and clonally expanded cytotoxic T cells in bone marrow trephines of patients with myelodysplastic syndrome.

AIMS: There is increasing evidence that autoimmunity is involved in the pathogenesis of myelodysplastic syndromes (MDS). We examined the number of apoptotic cells, and analysed the T cells and the T cell receptor gene rearrangements in bone marrow trephines of patients with low-grade MDS [refractory anaemia (RA), refractory anaemia with ringed sideroblasts (RAS) and refractory cytopenia with multilineage dysplasia (RCMD)] to investigate the correlation between T cells and apoptosis. METHODS AND RESULTS: Bone marrow trephines from 30 patients with RA, seven patients with RCMD, four patients with RAS and 11 normal bone marrow donors were stained for CD3 and for apoptotic cells using immunohistochemistry and terminal deoxynucleotidyl transferase 2'-deoxyuridine, 5'-triphosphate (dUTP) nick end labelling (TUNEL) technique, respectively. The positive cells were quantified by computer-assisted image analysis. In addition, CD 8 and T cell-restricted intracellular antigen-1 (TIA-1)-positive cells were analysed by single staining and evaluated semiquantitatively by light microscopy. Junctional diversity of the T cell receptor (TCR) α-, ß- and γ-chains were analysed in 24 cases of RA and RCMD by reverse transcription-polymerase chain reaction (RT-PCR). In all cases of RA, RCMD and RAS an increase of apoptotic cells was accompanied by an increase of T cells, when compared to normal donors (P < 0.001). Expression of TIA-1 was found in 33 of 41 patients with low-grade MDS. In contrast, normal controls showed either no or only very weak expression. Furthermore, 14 of 24 cases with low-grade MDS showed clonal TCR gene rearrangement. CONCLUSION: These findings provide evidence that increased apoptosis in low-grade MDS correlates with increased numbers of cytotoxic T cells. A considerable proportion of the MDS cases showed clonal TCR rearrangement suggesting an antigen-driven selection of the T cells. We therefore speculate that cases of MDS can be accompanied by a presumably autoreactive T cell-mediated apoptosis induction in bone marrow cells.

Spontaneous resolution of a symptomatic synovial cyst of the lumbar spine.

We present a case of spontaneous resolution of a lumbar intraspinal synovial cyst. We discuss the management options, including conservative management.

Intracranial Hypertension Secondary to Cervical Dural Arteriovenous Fistula.

Idiopathic intracranial hypertension (IIH) is a disease of mainly unknown etiology. Latest theories as to the pathogenesis have postulated a final common pathway of cerebral venous hypertension secondary to venous outflow impairment leading to decreased cerebrospinal fluid absorption. We present the case of a 42-year-old female who was treated for several years for headache and for approximately 12 months for IIH until appropriate imaging showed a right-sided cervical dural arteriovenous fistula (AVF) at the level of C4. The patient's IIH symptoms resolved following surgical excision of the fistula. We suggest that the cranial venous outflow impairment secondary to the cervical AVF was responsible for intracranial hypertension and that complete investigation of IIH patients should include imaging of the neck vasculature.

Case report: Angiosarcoma of the cervical spine.

Angiosarcomas (ASs) are rare malignant vascular tumours, which only occasionally occur in the spine. The prognosis is generally poor due to rarity of the condition as well as lack of data of treatment options. We present the case of a 75-year old man with a primary angiosarcoma of C2 and C3 who underwent occipito-cervical (to C6) fixation. A first biopsy did not result in a diagnosis and a further anterior approach with repeat biopsy had to be undertaken. The patient received adjuvant radiotherapy and at 6-month follow-up there was no radiological progression of the angiosarcoma. ASs are a rare condition and due to paucity of data relating to management cases should be reported to aid understanding and development of guidelines for diagnosis and treatment.

Cerebral aneurysms and accelerated atherosclerosis in Russell-Silver syndrome: a new subtype? Case report.

The authors describe the case of a 32-year-old woman known to have Russell-Silver syndrome who presented with repeated aneurysmal subarachnoid hemorrhage. Multiple intracranial aneurysms and advanced peripheral vascular disease were demonstrated. The authors postulate a link between these vascular features and the patient's genetic condition.

Impact of brain biopsy on the management of patients with nonneoplastic undiagnosed neurological disorders.

OBJECTIVE: We sought to assess the diagnostic yield, complication rates, and therapeutic impact of open brain biopsy and serial stereotactic brain biopsy in the management of patients with nonneoplastic neurological conditions in which conventional investigations did not yield a definitive diagnosis. METHODS: A retrospective case note analysis was undertaken in consecutive patients undergoing brain biopsy at The Walton Centre for Neurology and Neurosurgery during a 15-year period. The diagnostic yield, prebiopsy diagnostic category, biopsy technique (open versus stereotactic), complication rates, and impact on clinical management were assessed. Biopsies were grouped into one of five categories: diagnostic, suggestive, nonspecific, normal, or nondiagnostic. RESULTS: Thirty-nine patients underwent biopsy. The diagnostic yield (combined diagnostic and suggestive) of targeted serial stereotactic biopsy was 64% (seven of 11 patients); in the open brain biopsy group, the diagnostic yield was 46% (13 of 28 patients). The prebiopsy diagnosis was confirmed in 100% (three of three patients) stereotactic biopsy patients and 75% (nine of 12 patients) of open biopsy patients. Two patients (7%) in the open biopsy group had short-term complications. The clinical impact was similar in both groups: nine of 28 (32%) open biopsy patients and four of 11 (36%) stereotactic biopsy patients. CONCLUSION: Despite the low clinical impact, diagnostic brain biopsy should be considered in patients with nonneoplastic undiagnosed neurological disorders. Patients with neuroimaging abnormalities should preferentially undergo targeted biopsy.

CSF diversion in benign intracranial hypertension using a lumbo-atrial shunt.

An obese woman with benign intracranial hypertension had been managed for several years with lumbo-peritoneal shunting. Following a bilopancreatic procedure performed for management of her obesity dense peritoneal adhesions caused repeated shunt failure. The shunt system was successfully converted to a lumbo-atrial system.

Predisposing conditions and risk factors for development of symptomatic meningioma in adults.

BACKGROUND: Risk factors and predisposing factors for the development of symptomatic meningioma during adult life are not well known. METHODS: Data from 306 consecutive patients with primary meningioma were collected retrospectively in a hypothesis-generating study. Factors studied included localisation of tumours, blood group typing, and risk factors, such as diabetes mellitus, coronary arterial disease, hypertension, rheumatoid arthritis, bronchial asthma, smoking, obesity, and second primary tumour. Case-control analysis of putative risk factors was carried out using a control data set from the German East-West Health Survey (n=7466, age range 25-69 years). Patients and controls were matched for age, gender, geographic area, and time of data collection. RESULTS: Rh(D) positive cases were significantly less frequent in the patient group compared to controls (p=0.01). Pre-existing diabetes was associated with meningioma in middle-aged (40-69 years) patients (odds ratio, OR 13.94-4.30, p=0.001-0.05). In female patients, arterial hypertension was significantly associated with occurrence of meningioma in the age group 60-69 years (OR=2.23, p=0.041). Rheumatoid arthritis had a negative association with meningioma in both males and females in the age groups above 50 years (OR 0.19-0.27, p=0.02-0.034). Bronchial asthma, smoking, and obesity were not significantly associated with meningioma. A second primary tumour was present in 12 cases. The most frequent combination was meningioma and breast cancer (5/12). CONCLUSIONS: This study shows statistically significant association of some co-morbidities with symptomatic meningioma in adults. Areas of interest have been identified where further research would be necessary.