Post-haemorrhagic hydrocephalus is associated with poorer surgical and neurodevelopmental sequelae than other causes of infant hydrocephalus.

PURPOSE: This retrospective cohort study aimed to investigate the surgical and neurodevelopmental outcomes (NDO) of infant hydrocephalus. We also sought to determine whether these outcomes are disproportionately poorer in post-haemorrhagic hydrocephalus (PHH) compared to other causes of infant hydrocephalus. METHODS: A review of all infants with hydrocephalus who had ventriculoperitoneal (VP) shunts inserted at Great Ormond Street Hospital (GOSH) from 2008 to 2018 was performed. Demographic, surgical, neurodevelopmental, and other clinical data extracted from electronic patient notes were analysed by aetiology. Shunt survival, NDO, cerebral palsy (CP), epilepsy, speech delay, education, behavioural disorders, endocrine dysfunction, and mortality were evaluated. RESULTS: A total of 323 infants with median gestational age of 37.0 (23.29-42.14) weeks and birthweight of 2640 g (525-4684 g) were evaluated. PHH was the most common aetiology (31.9%) and was associated with significantly higher 5-year shunt revision rates, revisions beyond a year, and median number of revisions than congenital or "other" hydrocephalus (all p < 0.02). Cox regression demonstrated poorest shunt survival in PHH, related to gestational age at birth and corrected age at shunt insertion. PHH also had the highest rate of severe disabilities, increasing with age to 65.0% at 10 years, as well as the highest CP rate; only genetic hydrocephalus had significantly higher endocrine dysfunction (p = 0.01) and mortality rates (p = 0.04). CONCLUSIONS: Infants with PHH have poorer surgical and NDO compared to all other aetiologies, except genetic hydrocephalus. Research into measures of reducing neurodisability following PHH is urgently required. Long-term follow-up is essential to optimise support and outcomes.

Influence of biases in numerical magnitude allocation on human prosocial decision making.

Over the past decade neuroscientific research has attempted to probe the neurobiological underpinnings of human prosocial decision making. Such research has almost ubiquitously employed tasks such as the dictator game or similar variations (i.e., ultimatum game). Considering the explicit numerical nature of such tasks, it is surprising that the influence of numerical cognition on decision making during task performance remains unknown. While performing these tasks, participants typically tend to anchor on a 50:50 split that necessitates an explicit numerical judgement (i.e., number-pair bisection). Accordingly, we hypothesize that the decision-making process during the dictator game recruits overlapping cognitive processes to those known to be engaged during number-pair bisection. We observed that biases in numerical magnitude allocation correlated with the formulation of decisions during the dictator game. That is, intrinsic biases toward smaller numerical magnitudes were associated with the formulation of less favorable decisions, whereas biases toward larger magnitudes were associated with more favorable choices. We proceeded to corroborate this relationship by subliminally and systematically inducing biases in numerical magnitude toward either higher or lower numbers using a visuo-vestibular stimulation paradigm. Such subliminal alterations in numerical magnitude allocation led to proportional and corresponding changes to an individual's decision making during the dictator game. Critically, no relationship was observed between neither intrinsic nor induced biases in numerical magnitude on decision making when assessed using a nonnumerical-based prosocial questionnaire. Our findings demonstrate numerical influences on decisions formulated during the dictator game and highlight the necessity to control for confounds associated with numerical cognition in human decision-making paradigms.NEW & NOTEWORTHY We demonstrate that intrinsic biases in numerical magnitude can directly predict the amount of money donated by an individual to an anonymous stranger during the dictator game. Furthermore, subliminally inducing perceptual biases in numerical-magnitude allocation can actively drive prosocial choices in the corresponding direction. Our findings provide evidence for numerical influences on decision making during performance of the dictator game. Accordingly, without the implementation of an adequate control for numerical influences, the dictator game and other tasks with an inherent numerical component (i.e., ultimatum game) should be employed with caution in the assessment of human behavior.

The Application of Guideline-Based Care for Traumatic Brain and Spinal Cord Injury in Low- and Middle-Income Countries: A Provider-Based Survey.

Objective: Neurosurgical guidelines have resulted in improved clinical outcomes and more optimized care for many complex neurosurgical pathologies. As momentum in global neurosurgical efforts has grown, there is little understanding about the application of these guidelines in low- and middle-income countries. Methods: A 29-question survey was developed to assess the application of specific recommendations from neurosurgical brain and spinal cord injury guidelines. Surveys were distributed to an international cohort of neurosurgeons and neurotrauma stakeholders. Results: A total of 82 of 222 (36.9%) neurotrauma providers responded to the survey. The majority of respondents practiced in low- and middle-income countries settings (49/82, 59.8%). There was a significantly greater mean traumatic brain injury volume in low-income countries (56% ± 13.5) and middle-income countries (46.5% ± 21.3) compared with high-income countries (27.9% ± 13.2), P < 0.001. Decompressive hemicraniectomy was estimated to occur in 61.5% (±30.8) of cases of medically refractory intracranial pressure with the lowest occurrence in the African region (44% ± 37.5). The use of prehospital cervical immobilization varied significantly by income status, with 36% (±35.6) of cases in low-income countries, 52.4% (±35.5) of cases in middle-income countries, and 95.2% (±10) in high-income countries, P < 0.001. Mean arterial pressure elevation greater than 85 mm Hg to improve spinal cord perfusion was estimated to occur in 71.7% of cases overall with lowest occurrence in Eastern Mediterranean region (55.6% ± 24). Conclusions: While some disparities in guideline implementation are inevitably related to the availability of clinical resources, other differences could be more quickly improved with accessibility of current evidence-based guidelines and development of local data.

Far Lateral Approaches: C1 Meningioma With Vertebral Artery Involvement: 3-Dimensional Operative Video.

Tumors around the cervicomedullary junction are rare and constitute 5% of spinal tumors and 1% of cranial tumors. The approach to these lesions is difficult because of the close proximity of the medulla and cervical spinal cord, lower cranial nerves, and vertebral artery (VA) as well as the complex articulation between occipital condyle, C1 and C2. Cervicomedullary junction meningiomas are commonly classified based on their origin in relation to the dentate ligament, but the relationship to the VA typically plays an important role in deciding the surgical approach. For lesions located dorsal to the dentate ligament and not involving the VA, a midline approach is typically sufficient. However, when the VA is involved a far lateral approach is preferred as it offers better access to the V4 segment. We describe a case of a 55-yr-old man who presented with accessory nerve palsy and mild upper motor neuron signs and was found to have a C1 meningioma encasing and narrowing the VA at the V3/V4 segment. Informed consent was obtained. The patient was treated with a right far lateral approach with limited condylectomy to gain access to the V4 segment. We described the steps used for safe resection of the tumor around the VA from distal to proximal. We demonstrate the relationship of the tumor to the VA and the need to completely skeletonize the VA to achieve a gross total resection. We supplement the discussion with a 3D surgical video.

Far Lateral Approaches: Dural Arteriovenous Fistulae at the Hypoglossal Canal: 3-Dimensional Operative Video.

Cognard type V dural arteriovenous fistulae (dAVF) are typically located at the foramen magnum. Their presentation often mimics that of cervical myelopathy, and they can be easily misdiagnosed even if spinal vascular imaging is undertaken. Treatment typically involves endovascular embolization or surgery when embolization is not possible. We describe a case of a 67-yr-old man who presented with progressive symptoms of cervical myelopathy with a significant reduced ambulation and upper motor neuron signs. Imaging disclosed upper cervical cord edema, and angiography confirmed a Cognard type V dAVF with drainage into the perimedullary and spinal venous system. The dAVF was supplied by the hypoglossal division of the ascending pharyngeal artery. Endovascular treatment was believed to pose a risk of ischemic injury to the hypoglossal nerve, and therefore, surgery was offered. Informed consent was obtained. A far lateral approach was used to access the fistulous point. We describe the relevant vascular anatomy and the benefits of the far lateral approach for this lesion. We also demonstrate a tailored inferior condylectomy to gain access to the intracranial part of the hypoglossal canal, where the draining vein is expected to be found. We supplement the discussion with a 3D surgical video.

Current state of global neurosurgery activity amongst European neurosurgeons.

BACKGROUND: The expanding field of global neurosurgery calls for a committed neurosurgical community to advocate for universal access to timely, safe, and affordable neurosurgical care for everyone, everywhere. This study aims to (i) assess the current state of global neurosurgery activity amongst European neurosurgeons and (ii) identify barriers to involvement in global neurosurgery initiatives. METHODS: Cross-sectional study through dissemination of a web-based survey, from September 2019 to January 2020, to collect data from European neurosurgeons at various career stages. Descriptive analysis was conducted on respondent data. RESULTS: Three hundred and ten neurosurgeons from 40 European countries responded. 53.5% regularly follow global neurosurgery developments. 29.4% had travelled abroad with a global neurosurgery collaborative, with 23.2% planning a future trip. Respondents from high income European countries predominantly travelled to Africa (41.6%) or Asia (34.4%), whereas, respondents from middle income European countries frequently traversed Europe (63.2%) and North America (47.4). Cost implications (66.5%) were the most common barrier to global neurosurgery activity, followed by interference with current practice (45.8%), family duties (35.2%), difficulties obtaining humanitarian leave (27.7%) and lack of international partners (27.4%). 86.8% would incorporate a global neurosurgery period within training programmes. CONCLUSIONS: European neurosurgeons are interested in engaging in global neurosurgery partnerships, and several sustainable programmes focused on local capacity building, education and research have been established over the last decade. However, individual and system barriers to engagement persist. We provide insight into these to allow development of tailored mechanisms to overcome such barriers, enabling European neurosurgeons to advocate for the Global Surgery 2030 goals.

Barriers to neurotrauma care in low- to middle-income countries: an international survey of neurotrauma providers.

OBJECTIVE: Delays along the neurosurgical care continuum are associated with poor outcomes and are significantly greater in low- to middle-income countries (LMICs), with timely access to neurotrauma care remaining one of the most significant unmet neurosurgical needs worldwide. Using Lancet Global Surgery metrics and the Three Delays framework, the authors of this study aimed to identify and characterize the most significant barriers to the delivery of neurotrauma care in LMICs from the perspective of local neurotrauma providers. METHODS: The authors conducted a cross-sectional study through the dissemination of a web-based survey to neurotrauma providers across all World Health Organization geographic regions. Responses were analyzed with descriptive statistics and Kruskal-Wallis testing, using World Bank data to provide estimates of populations at risk. RESULTS: Eighty-two (36.9%) of 222 neurosurgeons representing 47 countries participated in the survey. It was estimated that 3.9 billion people lack access to neurotrauma care within 2 hours. Nearly 3.4 billion were estimated to be at risk for impoverishing expenditure and 2.9 billion were at risk of catastrophic expenditure as a result of paying for care for neurotrauma injuries. Delays in seeking care were rated as slightly common (p < 0.001), those in reaching care were very common (p < 0.001), and those in receiving care were slightly common (p < 0.05). The most significant causes for delays were associated with reaching care, including geographic distance from a facility, lack of ambulance service, and lack of finances for travel. All three delays were correlated to income classification and geographic region. CONCLUSIONS: While expanding the global neurosurgical workforce is of the utmost importance, the study data suggested that it may not be entirely sufficient in gaining access to care for the emergent neurosurgical patient. Significant income and region-specific variability exists with regard to barriers to accessing neurotrauma care. Highlighting these barriers and quantifying worldwide access to neurotrauma care using metrics from the Lancet Commission on Global Surgery provides essential insight for future initiatives aiming to strengthen global neurotrauma systems.

Longitudinal Changes in Size of Conservatively Managed Flow-Related Aneurysms Associated with Brain Arteriovenous Malformations.

BACKGROUND: Flow aneurysms (FAs) associated with brain arteriovenous malformations (AVMs) are thought to arise from increased hemodynamic stress due to high-flow shunting. This study aims to describe the changes in conservatively managed FAs after successful AVM treatment. METHODS: Patients with symptomatic AVMs and associated FAs who underwent successful treatment of the AVM between 2008 and 2017 were included. FA dimensions were measured on surveillance angiography to assess longitudinal changes. RESULTS: Thirty-two patients were identified with 48 FAs. Sixteen (33%) FAs were treated endovascularly; 18 (38%) FAs were treated surgically; and 14 (29%) FAs (11 patients) were monitored. FAs demonstrated a decrease in size from 5.0 mm to 3.8 mm (24%; P = 0.016) and 4.9 mm to 3.6 mm (27%; P = 0.013) in height and width, respectively, over a median 35 months. However, on subgroup analysis, only class IIb aneurysms demonstrated a significant decrease in size (51% reduction in largest diameter, P = 0.046) and only 3 FAs (21%) resolved. There were no hemorrhages observed during follow-up. CONCLUSIONS: While conservatively managed FAs demonstrated a reduction in size after the culprit AVM was treated, this was only significant in FAs located close to an AVM nidus (class IIb). There were no hemorrhages during the median 35 months' follow-up; however, long-term data are lacking. Our data support close observation of all conservatively managed aneurysms and a tailored approach based on the proximity to the nidus and observed changes in size.

Medical students' experience of the hidden curriculum around primary care careers: a qualitative exploration of reflective diaries.

OBJECTIVES: Primary healthcare internationally is facing a workforce crisis with fewer junior doctors choosing general practice (GP) as a career. In the UK, a national report on GP careers highlighted adverse influences during medical school on students' career choices. The authors explored these influences in two urban UK medical schools, both with relatively low numbers of students entering GP training. DESIGN: Using a phenomenological approach, the authors thematically analysed the reflective diaries of four medical students who were recruited as 'participant researchers' over a period of 10 months. These students made regular reflexive notes about their experiences related to GP career perceptions in their academic and personal environments, aiming to capture both positive and negative perceptions of GP careers. The research team discussed emerging data and iteratively explored and developed themes. SETTING: Two UK medical schools PARTICIPANTS: Undergraduate medical students RESULTS: Seven key themes were identified: the lack of visibility and physicality of GP work, the lack of aspirational GP role models, students' perceptions of a GP career as default, the performativity of student career choice with the perceptions of success linked to specialism, societal perceptions of GP careers, gender stereotyping of career choices and the student perception of life as a GP. CONCLUSIONS: Students overwhelmingly reflected on negative cues to GP careers, particularly through their experience of the hidden curriculum. Three recommendations are made: the need for increased representation of GP role models in clinical curricula content delivery and senior leadership; ensuring GP clerkships involve an active and authentic student role with patients, enabling students to experience GP's 'work' including managing complexity, uncertainty and risk. Finally, institutions need to consider students' experiences of the hidden curriculum and the effect this can have on students' perception of careers, alongside the challenges of rankings and perceived hierarchical positioning of disciplines.

Optimal Timing of External Ventricular Drainage after Severe Traumatic Brain Injury: A Systematic Review.

External ventricular drainage (EVD) may be used for therapeutic cerebrospinal fluid (CSF) drainage to control intracranial pressure (ICP) after traumatic brain injury (TBI). However, there is currently uncertainty regarding the optimal timing for EVD insertion. This study aims to compare patient outcomes for patients with early and late EVD insertion. Following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, MEDLINE/EMBASE/Scopus/Web of Science/Cochrane Central Register of Controlled Trials were searched for published literature involving at least 10 severe TBI (sTBI) patients from their inception date to December 2019. Outcomes assessed were mortality, functional outcome, ICP control, length of stay, therapy intensity level, and complications. Twenty-one studies comprising 4542 sTBI patients with an EVD were included; 19 of the studies included patients with an early EVD, and two studies had late EVD placements. The limited number of studies, small sample sizes, imbalance in baseline characteristics between the groups and poor methodological quality have limited the scope of our analysis. We present the descriptive statistics highlighting the current conflicting data and the overall lack of reliable research into the optimal timing of EVD. There is a clear need for high quality comparisons of early vs. late EVD insertion on patient outcomes in sTBI.

The management and referral of iliofemoral deep venous thrombosis in North West London.

BACKGROUND: Post-thrombotic syndrome is a common complication of iliofemoral deep venous thrombosis (IFDVT). Existing evidence and National Institute for Health and Care Excellence guidelines suggest that this can be reduced by prompt thrombolytic therapy or thrombectomy. We aimed to evaluate the characteristics of IFDVT patients and to identify whether patients are being offered the recommended treatment pathway. METHODS: A multicenter cross-sectional study was conducted across eight hospital sites in the North West London region, of which two were hub hospitals in their local vascular service networks. Patients with proximal DVT were identified using International Classification of Diseases, Tenth Revision coding during a 1-year period. Data on demographics, diagnostic methods used, interventions, and referrals were extracted from electronic and paper medical records. RESULTS: During the study period, 132 patients with IFDVT were identified (mean age, 59.4 years; 55% female); 75% of these patients had an IFDVT. In this cohort, the biggest predisposing factors were previous DVT (n = 35), malignant disease (n = 35), and immobility (n = 20). In total, 104 patients were administered anticoagulation, and 88 of these patients received anticoagulation within 24 hours. The cases of 45 patients were either discussed with or promptly referred to a vascular service, after which 20 patients were treated solely with anticoagulation, whereas 20 patients received thrombolysis of varying methods. CONCLUSIONS: A significant proportion (56%) of symptomatic IFDVT patients are not being appropriately referred to or discussed with vascular services. Of these, 43% would have been eligible for consideration of early thrombus removal. Adherence to the National Institute for Health and Care Excellence guidelines could be improved by increasing awareness among emergency department colleagues.

Interhemispheric control of sensory cue integration and self-motion perception.

Spatial orientation necessitates the integration of visual and vestibular sensory cues, in-turn facilitating self-motion perception. However, the neural mechanisms underpinning sensory integration remain unknown. Recently we have illustrated that spatial orientation and vestibular thresholds are influenced by interhemispheric asymmetries associated with the posterior parietal cortices (PPC) that predominantly house the vestibulo-cortical network. Given that sensory integration is a prerequisite to both spatial orientation and motion perception, we hypothesized that sensory integration is similarly subject to interhemispheric influences. Accordingly, we explored the relationship between vestibulo-cortical dominance - assessed using a biomarker, the degree of vestibular-nystagmus suppression following transcranial direct current stimulation over the PPC - with visual dependence measures obtained during performance of a sensory integration task (the rod-and-disk task). We observed that the degree of visual dependence was correlated with vestibulo-cortical dominance. Specifically, individuals with greater right hemispheric vestibulo-cortical dominance had reduced visual dependence. We proceeded to assess the significance of such dominance on behavior by correlating measures of visual dependence with self-motion perception in healthy subjects. We observed that right-handed individuals experienced illusionary self-motion (vection) quicker than left-handers and that the degree of vestibular cortical dominance was correlated with the time taken to experience vection, only during conditions that induced interhemispheric conflict. To conclude, we demonstrate that interhemispheric asymmetries associated with vestibulo-cortical processing in the PPC functionally and mechanistically link sensory integration and self-motion perception, facilitating spatial orientation. Our findings highlight the importance of dynamic interhemispheric competition upon control of vestibular behavior in humans.

Composite Grafts for Pediatric Fingertip Amputations: A Retrospective Case Series of 100 Patients.

BACKGROUND: Fingertip amputations are common. This study reports on the outcomes of composite grafts used for fingertip amputations in children, measuring graft take, predictors of graft take, complications, and patient-reported outcomes. METHODS: A retrospective case series of consecutive patients (≤ 16 years) undergoing composite grafts for fingertip amputations in a tertiary pediatric hospital, January 06 to December 16, was performed. Information was collected on amputations, graft take, and complications. Logistic regression was used to analyze factors predicting graft take (partial/complete or failure) including age; amputation level; mechanism and time delay to surgery. Patients were contacted via post or telephone to ask about functional and cosmetic outcomes and their perception of graft take. RESULTS: One hundred patients [57 (57%) males; mean age, 4.41 ± 3.98 years], presenting with 100 fingertip amputations, met the inclusion criteria. Amputation mechanism was crush in 75 (75%), avulsion in 13 (13%), and laceration in 12 (13%). Thirteen (13%) composite grafts survived completely, 46 (46%) partially, and 41 (41%) failed. Graft survival was higher in children under 4 years (P = 0.016). Seventeen (17%) grafts became infected, 9 (9%) required a reoperation, 9 (9%) had wound healing complications, and 4 (4%) patients developed psychological complications. Patient-reported survival was 33% higher than medical-reported survival. Cosmetic issues were the commonest complication reported by patients. Patients rated fingertips looking 3.5/5 normal, and that they were 4/5 satisfied with the appearance. Most patients were using their fingers normally by 2-6 months. CONCLUSIONS: Composite grafts for fingertip amputations mostly only partially survive, but morbidity is low, patient satisfaction is high, and acceptable cosmetic and functional outcomes are achieved.