Variation in outcome after subarachnoid hemorrhage: a study of neurosurgical units in UK and Ireland.

BACKGROUNDS AND PURPOSE: The purpose of the study was to describe the characteristics, management, and outcomes of patients with confirmed aneurysmal subarachnoid hemorrhage and to compare outcomes across neurosurgical units (NSUs) in the UK and Ireland. METHODS: A cohort of patients admitted to NSUs with subarachnoid hemorrhage between September 14, 2001 and September 13, 2002 was studied longitudinally. Information was collected to characterize clinical condition on admission and treatment. Death or severe disability, defined by the Glasgow Outcome Score-Extended, was ascertained at 6 months. RESULTS: Data for 2397 patients with a confirmed aneurysm and no coexisting neurological pathology were collected by all 34 NSUs in the UK and Ireland. Aneurysm repair was attempted in 2198 (91.7%) patients (surgical clipping, 57.7%; endovascular coiling, 41.2%; other repair, 1.0%). Most patients (65.0%) were admitted to the NSU on the same day or the day after their hemorrhage; 32.0% of treated patients had the aneurysm repaired on the day of admission to the NSU (day 0), day 1 or day 2 and a further 39.3% by day 7. Glasgow Outcome Score-Extended at 6 months was obtained for 90.6% of patients (2172), of whom 38.5% had an unfavorable outcome. The median risk of an unfavorable outcome for all patients was 31% (5(th) and 95(th) percentiles, 12% and 83%), depending on prerepair prognostic factors. After adjustment for case-mix, the percentage of patients with an unfavorable outcome in each NSU did not differ significantly from the overall mean. CONCLUSIONS: In this study that collected representative data from the UK and Ireland, there was no evidence that the performance of any NSU differed from the average.

Horizontal stent-assisted coil embolisation of wide-necked intracranial aneurysms with the Enterprise stent--a case series with early angiographic follow-up.

INTRODUCTION: The purpose of the study is to describe our experience in eight cases of horizontal stenting across the circle of Willis in patients with terminal aneurysms. METHODS: Eight patients were treated with horizontal stent placement and aneurysm coiling. All aneurysms had highly unfavourable dome to neck ratios. All patients were followed up with digital subtraction angiography at 3-12 months following treatment. RESULTS: The Enterprise stent was successfully deployed horizontally in vessels of less than 2-mm diameter with no stent occlusion. Neurological complications occurred in one patient. Immediate and follow-up angiographic results were encouraging with six stable occlusions at 6 months. There was one asymptomatic case of in-stent stenosis and one case of late organised in-stent thrombus. CONCLUSIONS: Horizontal deployment of the Enterprise stent to assist coil embolisation of wide-necked terminal aneurysms is feasible. This device can be navigated via relatively small communicating arteries, in cases with favourable anatomy. Early angiographic results were favourable; however, longer-term follow-up will be required.

Spine surgery training and competence of European neurosurgical trainees.

BACKGROUND: Little is known about the nature of spine surgery training received by European neurosurgical trainees during their residency and the level of competence they acquire in dealing with spinal disorders. METHODS: A three-part questionnaire entailing 32 questions was devised and distributed to the neurosurgical trainees attending the EANS (European Association of Neurosurgical Societies) training courses of 2004. RESULTS: Of 126 questionnaires, 32% were returned. The majority of trainees responding to the questionnaire were in their final (6(th)) year of training or had completed their training (60.3% of total). Spinal surgery training in European residency programs has clear strengths in the traditional areas of microsurgical decompression for spinal stenosis and disc herniation (77-90% competence in senior trainees). Deficits are revealed in the management of spinal trauma (34-48% competence in senior trainees) and spinal conditions requiring the use of implants and anterior approaches, with the exception of anterior cervical stabilisation. CONCLUSIONS: European neurosurgical trainees possess incomplete competence in dealing with spinal disorders. EANS trainees advocate the development of a postresidency spine subspecialty training program.

Neurosurgical training in the United kingdom and ireland: assessing progress and attainment.

OBJECTIVE: To review neurosurgical training in the United Kingdom and Ireland in the past decade and the methods used to monitor training and assess trainee competence. METHODS: A database was compiled with data from 1990 to 2000 on behalf of the Specialist Advisory Committee in Neurosurgery from trainee logbook operative totals submitted on achieving accreditation or receiving the Certificate of Completion of Surgical Training. RESULTS: During the 11-year period, 109 trainees achieved accreditation or Certificate of Completion of Surgical Training. The median duration of training, including research, was 6.1 years. The total training duration per year did not change overall, although results suggested an increasing trend in the duration of clinical training (excluding research) from 4.8 to 5.6 years since 1997. The median age at accreditation or at receipt of Certificate of Completion of Surgical Training was 35 years 7 months. At completion of training, the Specialist Advisory Committee used operative totals in addition to reports from trainers to analyze the trainees' competence. Despite changes to the training system and a reduction in hours of work, the quality of training, as reflected by median operative totals, did not change during the decade. The database also permitted assessment of operative experience gained within each training program. CONCLUSION: The duration of training and training standards in terms of operative experience have remained constant during the past decade. Operative totals provide an objective method of assessing trainee progress and attainment and enable a comparison of experience offered by different training programs. An alternative method of assessing trainee operative competence that can be used in conjunction with median operative totals is proposed.

Perimesencephalic nonaneurysmal subarachnoid hemorrhage caused by jugular venous occlusion: case report.

OBJECTIVE: The cause of perimesencephalic nonaneurysmal subarachnoid hemorrhage remains unknown. We describe a patient in whom jugular venous occlusion preceded the occurrence of perimesencephalic nonaneurysmal subarachnoid hemorrhage. This finding supports the theory that the source of the hemorrhage is venous in origin. CLINICAL PRESENTATION: A 25-year-old man presented with sudden onset of headache after his head was held in a headlock during a playful fight 48 hours before the ictus. His computed tomographic (CT) scan on admission demonstrated a perimesencephalic pattern of subarachnoid hemorrhage. CT angiography excluded the presence of an underlying aneurysm or vascular malformation but showed bilateral jugular venous obstruction with hematoma surrounding the right internal jugular vein. Magnetic resonance imaging and a 4-vessel cerebral angiogram confirmed the CT angiographic findings. INTERVENTION: The patient was observed as an inpatient and had no complication of his hemorrhage. Follow-up at 5 months with CT angiography showed resolution of his neck hematoma and reopening of his internal jugular veins. CONCLUSION: The presence of acute jugular venous occlusion as a cause of perimesencephalic nonaneurysmal subarachnoid hemorrhage supports a venous origin of hemorrhage.

The non-invasive detection of intracranial aneurysms: are neuroradiologists any better than other observers?

Can non-neuroradiologists detect intracranial aneurysms as well as neuroradiologists, using CT and MR angiography? Sixty patients undergoing intra-arterial digital subtraction angiography (IADSA) to detect aneurysms also underwent computed tomographic angiography (CTA) and time-of-flight magnetic resonance angiography (MRA). Consensus review of IADSA by two neuroradiologists was the reference standard. Two neuroradiologists, a neurosurgeon, a neuroradiographer and a general radiologist blinded to IADSA, plain CT and clinical data, independently reviewed hard-copy base and reconstructed maximum intensity projection images of the CTA and MRA studies. Thirty patients had a total of 63 aneurysms, 71.4% were