Paraganglioma of the cauda equina: a tertiary centre experience and scoping review of the current literature.

Cauda equina paragangliomas are rare benign extra-adrenal neuroendocrine tumours arising from the neural crest cells associated with autonomic ganglia. These tumours are often mistaken preoperatively for ependymomas or schwannomas. Patients present with axial or radicular pain with or without neurological deficits. Recurrence, secretory features and length of follow-up are controversial. We conducted a retrospective cohort study of paraganglioma through searching a prospectively maintained histopathology database. Patient demographics, presentation, surgery, complications, recurrence, follow-up and outcome between 2004 and 2016 were studied. The primary aim was to collate and describe the current evidence base for recurrence and secretory features of the tumour. The secondary objective was to report outcome and follow-up strategy. A scoping review was performed in accordance with the PRISMA-ScR Checklist. Ten patients were diagnosed (M:F 7:3) with a mean age of 53.6 ± 5.1 (range 34-71 years). MRI scans revealed intradural lumbar enhancing lesions. All patients had complete microsurgical excisions without adjuvant therapy with no recurrence with a mean follow-up of 5.1 ± 1.4 years. Tumours were attached to the filum terminale. Electron microscopic images demonstrated abundant neurosecretory granules with no evidence of catecholamine production. A total of 620 articles were screened and 65 papers (including ours) combining 121 patients (mean age 48.8 and M:F 71:50) were included. The mean follow-up was 3.48 ± 0.46 (range 0.15-23 years). Back pain was the most common symptom (94%). Cure following surgery was achieved in 93% of the patients whilst 7% had recurrence. Total resection likely results in cure without the need for adjuvant therapy or prolonged follow-up. However, in certain situations, the length of follow-up should be determined by the treating surgeon.

Management of aneurysmal subarachnoid haemorrhage 17 years after the ISAT trial: a survey of current practice in the UK and Ireland.

Introduction: In the last two decades and driven by the International Subarachnoid Aneurysm Trial (ISAT), the management of aneurysmal subarachnoid haemorrhage (aSAH) has undergone extensive change from predominantly neurosurgical (clipping) to predominantly neuroradiological (coiling) treatment. In 2013, the UK's national Confidential Enquiry into Patient Outcome and Death (NCEPOD) recommended aSAH to be definitively treated within 48h of ictus. The aim of this survey was to assess how this recommendation is being followed across the UK and Ireland 17 years after ISAT and 6 years after the NCEPOD.Methods: An online survey consisting of 9 questions was electronically distributed to neurosurgical consultants and trainees. Missing or ambivalent data was collected or verified by emailing consultant neurosurgeons to ensure the coverage of all 32 neurosurgical units in the UK and Ireland.Results: Only 9 (28%) of units provide 7 days a week interventional neuroradiology service, but all 32 (100%) units have established networks with other neuroradiology centres to provide aSAH treatment within 48h of ictus assuming no delays in patient transfer. For aSAH patients requiring neurosurgical clipping, 27 (84%) of units provide (locally or through networks) aneurysm repair within 48h of ictus, whereas 5 (16%) units may breach this recommendation by keeping the aSAH patients that present after 5PM on Fridays and delaying their clipping to the subsequent Monday.Conclusion: Assuming no delays in patient transfer, 32 (100%) neurosurgical centres in the UK and Ireland meet the <48h ictus-to-treatment target for endovascular coiling and 27 (84%) units for neurosurgical clipping of aSAH.

Management of malignant middle cerebral artery infarction following a cardiac stab wound--the role of early decompressive craniectomy.

We report the presentation, investigation and management of a 22-year-old male who developed a right malignant middle cerebral artery infarct following a cardiac stab wound. This case exemplifies that early identification and timely decompression of young patients with embolic infarcts as a result of penetrating trauma can lead to a favourable clinical outcome.