A cross-sectional survey of patient perceptions of the National Neurosurgical Audit Programme (NNAP).

BACKGROUND: The National Neurosurgical Audit Programme (NNAP) publishes mortality outcomes of consultants and neurosurgical units across the United Kingdom. It is unclear how useful outcomes data is for patients and whether it influences their decision-making process. Our aim was to identify patients' perceptions and understanding of the NNAP data and its influences. MATERIALS AND METHODS: This single-centre study was conducted in the outpatient neurosurgery clinics at a regional neurosurgical centre. All adult (age ≥ 18) neurosurgical patients, with capacity, were invited to take part. Native and non-native English speakers were eligible. Statistical analyses were performed on SPSS v28 (IBM). Ethical approval was obtained. RESULTS: A total of 84 responses were received (54.7% females). Over half (51.0%) of respondents felt that they understood a consultant's mortality outcomes. Educational level determines respondents' understanding (χ2(8) = 16.870; p = .031). Most respondents were unaware of the NNAP (89.0%). Only a third of respondents (35.1%) understood the funnel plot used to illustrate mortality. CONCLUSIONS: Most patients were unaware of the NNAP and most did not understand the data on the website. Understanding of mortality data seemed to be related to respondents' educational level which would be important to keep in mind when planning how to depict mortality data.

A systematic review of middle meningeal artery embolization for minimally symptomatic chronic subdural haematomas that do not require immediate evacuation.

Introduction: Embolization of the Middle Meningeal Artery (EMMA) is an emerging treatment option for patients with Chronic Subdural Haematoma (CSDH). Questions: (1) Can EMMA change the natural history of untreated minimally symptomatic CSDH which do not require immediate evacuation? (2) What is the role of EMMA in the prevention of recurrence following surgical treatment? (3) Can the procedure be performed under local anaesthetic? Material and methods: Systematic literature review. No randomised clinical trials available on EMMA for meta-analysis. Results: Six unique large cohorts with more than 50 embolisations were identified (evidence: 3b-4). EMMA can control the progression of surgically naïve CSDH in 91.1-100% of the patients, in which haematoma expansion is halted, or the lesion decreases and resolves. Treatment failure requiring surgery occurs in 0-4.1% of the patients having EMMA as the primary and only treatment. Treatment failure requiring surgery goes up slightly to 6.8% if post-surgical patients are included. When EMMA is used as postsurgical adjunctive the risk of recurrence is 1.4-8.9% compared to 10-20% in surgical series. EMMA has minimal morbidity and it is feasible under local anaesthesia or slight sedation in the majority of cases. Conclusion: There is cumulative low-quality evidence in the literature that EMMA may be able to modify the natural course of the disease. It appears effective in controlling progression of CSDHs in patients having it as a primary standing alone treatment and it reduces the risk of recurrence and the need for surgical intervention in refractory postsurgical cases or as a postsurgical adjunctive treatment with minimal morbidity (recommendation: C).

Middle meningeal artery embolisation for chronic subdural haematomas: the first prospective UK study.

Background/Objectives: MMA embolisation has emerged in recent years as a safe endovascular treatment for chronic subdural haematoma. We report the first UK series of endovascular treatment of chronic subdural haematomas.Design: Prospective case series.Subjects: All adult patients referred with midline shift ≤10 mm and GCS ≥13 were considered. Patients had to be mobile with a standard origin of Middle Meningeal and Ophthalmic arteries. Patients with GCS < 13 or profound weakness (MRC grade ≤ 3) were treated with burr hole drainage and placement of subdural drains.Methods: Patients were recruited over a 14-month period from 25 October 2020 to 25 December 21 through our electronic referral system. Patients' demographics, pre-morbid modified Rankin Score (mRS), symptoms; anticoagulation and co-morbidities were prospectively collected. Suitability for endovascular treatment was discussed with the interventional neuroradiologist and neurosurgeon. SQUID-12 embolic material was used for all MMA embolisations, which was performed under general anaesthetic. Baseline CT/MRI characteristics were collected. Further imaging was obtained at 7, 21, 90 and 180 days. Clinical assessment and mRS was completed at three months.Results: Fifteen patients underwent endovascular embolisation of MMA in the study period. Of these 13 were male, median age was 79 years. Median length of stay was four days. Follow-up CT at three months has demonstrated significant reduction in both midline shift (p = 0.002) and maximum thickness of haematoma (p = 0.001). Nine patients had reached the three months' follow-up period. All of them had complete or near-complete resolution of the CSDH. One patient required surgical rescue at two months post procedure due to progression of CSDH. We report one mortality due to COVID-19.Conclusions: For select patients, MMA embolisation is a safe alternative treatment option for chronic subdural haematoma. As we gain more experience, the procedure could be performed under local anaesthetic.

Use of an Online Referral Service for Acute Neurosurgical Referrals: An Institutional Experience.

OBJECTIVE: We sought to review the current scope of emergency neurosurgical referrals and examine the long-term use of a web-based referral system. METHODS: This was a single-center retrospective observational study. Referral information was collected retrospectively over a 1-year period after the implementation of a web-based referral system (June 2019-June 2020). Information such as demographics, clinical information, referrer details, and neurosurgical response times and outcomes were collected. Statistical analyses were performed using R Version 6.3.1. RESULTS: Our unit received 5949 referrals with a median age of 63 years old (range: 0-107 years) (male = 50.3%). We observed an average of 16.3 referrals per day (range: 4-32), with Fridays having the highest average and the weekend days receiving statistically fewer referrals (P < 0.001). More than a third (35.9%) of referrals occurred within hours (8:00-17:00 Monday-Friday), with A + E making up approximately 50% of referrals. Common reasons for referral were traumatic brain injury, intracranial tumors, and degenerative spine. The median time from referral to first response was 32 minutes, occurring within an hour in 72.9% of cases. The median time to definite response was 83 minutes, occurring within 2 hours in 58.2% of cases. Factors found to impact the response time were referral emergency and time of day. Our acceptance rate over this period was 18.5%. CONCLUSIONS: With an increasing number of referrals, it is feasible to provide traceable advice in a timely manner through an electronic web-based referral system transferable to any specialty. Insights could be used to direct resources and workforce planning according to emergency referral patterns.

Neurosurgical Referral Patterns During the Coronavirus Disease 2019 Pandemic: A United Kingdom Experience.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a severe respiratory viral illness that has spread rapidly across the world. However, the United Kingdom has been particularly affected. Evidence has suggested that stroke, cardiac, and spinal presentations decreased during the pandemic as the public avoided seeking care. The effect on neurosurgical presentations and referrals during COVID-19 is unclear. Our aim, therefore, was to describe the referral patterns to a high-volume neurosurgical department in the United Kingdom during the COVID-19 pandemic. METHODS: Electronic referrals were identified from the referrals database from January 1, 2020 to May 31, 2020, inclusive, with January used as the baseline. The demographic data and referral diagnoses were captured on Excel (Microsoft, Redmond, Washington, USA). Statistical analyses were performed using SPSS, version 22 (IBM Corp., Armonk, New York, USA). Differences between referral volumes were evaluated using χ2 goodness-of-fit tests. RESULTS: A total of 2293 electronic referrals had been received during the study period. The median age was 63 years. Overall, the referrals had decreased significantly in volume during the study period [χ2(4) = 60.95; P < 0.001]. We have described the patterns in the daily referrals as the pandemic progressed. The reduction in the volume of referrals for degenerative spine cases and traumatic brain injuries was statistically significant (P < 0.001). CONCLUSIONS: The referrals for degenerative spine and traumatic brain injuries decreased significantly during the pandemic, which can be explained by the lower vehicular traffic and patient avoidance of healthcare services, respectively. The risk of neurological deterioration and increased morbidity and mortality, as a consequence, is of concern, and neurosurgeons worldwide should consider the optimal strategies to mitigate these risks as the pandemic eases.

Structural connectivity centrality changes mark the path toward Alzheimer's disease.

INTRODUCTION: The pathophysiological process of Alzheimer's disease is thought to begin years before clinical decline, with evidence suggesting prion-like spreading processes of neurofibrillary tangles and amyloid plaques. METHODS: Using diffusion magnetic resonance imaging data from the Alzheimer's Disease Neuroimaging Initiative database, we first identified relevant features for dementia diagnosis. We then created dynamic models with the Nathan Kline Institute-Rockland Sample database to estimate the earliest detectable stage associated with dementia in the simulated disease progression. RESULTS: A classifier based on centrality measures provides informative predictions. Strength and closeness centralities are the most discriminative features, which are associated with the medial temporal lobe and subcortical regions, together with posterior and occipital brain regions. Our model simulations suggest that changes associated with dementia begin to manifest structurally at early stages. DISCUSSION: Our analyses suggest that diffusion magnetic resonance imaging-based centrality measures can offer a tool for early disease detection before clinical dementia onset.

Outcome after craniotomy for recurrent cranial metastases.

OBJECTIVE: To investigate the outcomes of patients with recurrent/progressive cranial metastases who underwent re-do craniotomy and to assess the utility of surgery as a treatment option. METHODS: A retrospective study was conducted assessing survival after re-do craniotomy for recurrent or progressive cranial metastases. 29 patients were identified between January 2006 and December 2013. Data was gathered from a prospective pathology database, patients' notes and electronic records. The diagnosis of cranial metastasis was obtained through pathological analysis at the time of tumour resection. Results were analysed with Cox regression tests and converted into a Kaplan-Meier curve. RESULTS: Median patient age was 57 years old (range 24-74 years) at diagnosis of brain metastases. Two patients had serious complications after re-do surgery. Five patients had >2 craniotomies for recurrent disease. Median survival after the first craniotomy was 18 months (range 4.1-50.9 months). Median survival after re-do craniotomy was 7.6 months (range 0.2-31.3 months). 90% of patients survived at least 3 months after re-do surgery, 65.5% survived at least 6 months. CONCLUSION: This study suggests that re-do surgery is a viable treatment option for patients with recurrent cranial metastases.