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).

Volume reduction with surgery for ICH: when is it effective? Analysis of the CT scans from the STICH II trial.

BACKGROUND: The surgical trial of lobar intracerebral haemorrhage (STICH II) was a randomised controlled trial evaluating early surgical removal of a clot. This paper investigates volume change in both arms of the trial with respect to Extended Glasgow Outcome Scale (GOSE) groups. METHODS: Patients randomised into STICH II had an initial diagnostic CT and a second CT 5 days after randomisation. Each scan was anonymously assessed by at least two central readers. An analysis of agreement between the two readers was conducted using kappa tests and intraclass correlation. The change in volume in both the early surgery (ES) and the initial conservative treatment (ICT) arms were analysed with respect to the six-month GOSE outcome. RESULTS: Of the 597 patients randomised in the trial there were 582 pre-randomisation scans and 566 5-day scans available for analysis of agreement. There was good agreement between the assessors for the radiological inclusion criteria including volume (ICC = 0.87) and this was better than the agreement between the assessor and local investigator (ICC = 0.73). There were 526 patients with two scans available for analysis of change in volume measurement. The median percentage change in volume for the ES group was a reduction of 92.4% (IQR 75.6%, 99.0%) while for the ICT group, in which some cases crossed over to delayed surgery, it was only 5.7% (IQR 16.4% increase, 29.5% reduction). ES patients with almost complete removal (99-100%) had the best outcome with only 30% dead or lower severely disabled. For the ICT group outcome was related to the final volume: the smaller the final volume the better the outcome. CONCLUSIONS: This analysis provides evidence for central assessments of scans in exploratory analyses and further information regarding the potential advantage of early and more complete clot removal on outcome in ICH and should inform the planning of future trials.Clinical trials registration: ISRCTN22153967.

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.

Refractory cerebrospinal fluid leak following posterior fossa surgery secondary to superior vena cava obstruction: a case report.

We report a case of refractory post-operative cerebrospinal fluid leak from a posterior fossa operative site secondary to superior vena cava construction. The patient developed the leak after a posterior fossa craniotomy and resection of a cerebellar lung metastasis. The leak persisted despite conservative measures and lumbar drain insertion. Suspicion of superior vena cava obstruction was raised following clinical examination. She was managed with stenting of the superior vena cava, with cessation of leak.

Lumbar disc disease: the effect of inversion on clinical symptoms and a comparison of the rate of surgery after inversion therapy with the rate of surgery in neurosurgery controls.

[Purpose] We have previously shown inversion therapy to be effective in a small prospective randomised controlled trial of patients with lumbar disc protrusions. Our purpose now was to measure symptoms and to compare the surgery rate following inversion for 85 participants with the surgery rate in 3 control groups. [Participants and Methods] Each of the 85 inverted participants acted as their own control for the "symptomatic" part of the study. In the "Need for surgery" part of the study, one control group was made up of similar patients with leg pain and sciatica who were referred to the same clinic in the same year. Two additional control groups were examined: the original control group from the pilot trial and the lumbar disc surgery waiting list patients. [Results] Inversion therapy relieved symptoms: there were improvements in the Visual Analogue Score, Roland Morris and Oswestry Disease indices and Health Utility Score compared with their pre-treatment status. Also, the 2 year surgery rate in the inversion participants in the registry (21%) was significantly lower than in the matched control group (39% at two years and 43% at four years). It was also lower than the surgery rate in the other 2 control groups. [Conclusion] Inversion therapy relieved symptoms and avoided surgery.

Neurosurgery activity levels in the United Kingdom and republic of Ireland during the first wave of the covid-19 pandemic - a retrospective cross-sectional cohort study.

The impact of Covid-19 on surgical patients worldwide has been substantial. In the United Kingdom (UK) and the Republic of Ireland (RoI), the first wave of the pandemic occurred in March 2020. The aims of this study were to: (1) evaluate the volume of neurosurgical operative activity levels, Covid-19 infection rate and mortality rate in April 2020 with a retrospective cross-sectional cohort study conducted across 16 UK and RoI neurosurgical centres, and (2) compare patient outcomes in a single institution in April-June 2020 with a comparative cohort in 2019. Across the UK and RoI, 818 patients were included. There were 594 emergency and 224 elective operations. The incidence rate of Covid-19 infection was 2.6% (21/818). The overall mortality rate in patients with a Covid-19 infection was 28.6% (6/21). In the single centre cohort analysis, an overall reduction in neurosurgical operative activity by 65% was observed between 2020 (n = 304) and 2019 (n = 868). The current and future impact on UK neurosurgical operative activity has implications for service delivery and neurosurgical training.

Deep Learning for Understanding Satellite Imagery: An Experimental Survey.

Translating satellite imagery into maps requires intensive effort and time, especially leading to inaccurate maps of the affected regions during disaster and conflict. The combination of availability of recent datasets and advances in computer vision made through deep learning paved the way toward automated satellite image translation. To facilitate research in this direction, we introduce the Satellite Imagery Competition using a modified SpaceNet dataset. Participants had to come up with different segmentation models to detect positions of buildings on satellite images. In this work, we present five approaches based on improvements of U-Net and Mask R-Convolutional Neuronal Networks models, coupled with unique training adaptations using boosting algorithms, morphological filter, Conditional Random Fields and custom losses. The good results-as high as A P = 0.937 and A R = 0.959 -from these models demonstrate the feasibility of Deep Learning in automated satellite image annotation.

Spinal paraganglioma presenting as normal pressure hydrocephalus: a rare occurrence.

Objective: We report a 63 years old female who presented with confusion, urinary retention and gait disturbances.Method: CT head shows communicating hydrocephalus. Spinal MRI demonstrated an L5- S1 intradural lesion.Result: Histopathology proved it to be paraganglioma. Postoperative CT head showed reduction in size of ventricles. Association between spinal tumors and hydrocephalus is known but occurs infrequently.Conclusion: The presence of an intraspinal tumor must be kept in mind as a possible cause of the hydrocephalus.

Case Report of a Novel Technique for Repair of the Vertebral Artery During Cranial Surgery.

Surgery of complex cranial base lesions carries a high risk of damage to main vessels, often resulting in life-changing or even life-threatening injuries. We describe a rapid, effective, and noninvasive application of a collagen-based hemostatic patch to repair the vertebral artery during cranial surgery. A 61-year-old male patient underwent retrosigmoid craniotomy to remove a foramen magnum meningioma that encased the vertebral artery. A linear incision was made behind the ear and standard retrosigmoid craniotomy was performed with preservation of the transverse and sigmoid sinuses. The dura was opened in a Y-shaped fashion and the cerebellum was retracted with cerebrospinal fluid being released. Removing the exposed tumor from the artery resulted in a small arterial bleed. Two pieces of an N-hydroxysuccinimide-functionalized polyethylene glycol-coated collagen patch (Hemopatch®, Baxter Healthcare Ltd.) were applied sequentially and were pressed to the bleed site for 2 min each. Hemostasis of the vertebral artery was achieved at the patient's regular blood pressure. There was no postoperative bleeding, dissection or pseudoaneurysm. The patient recovered gradually with several cranial nerve deficits. There was no brain stem stroke. Twelve months on, the patient has made an excellent recovery from surgery, is independently mobile and has minimal cranial nerve deficits. Application of the collagen-based hemostatic patch proved to be an efficient, safe, and noninvasive technique that achieved rapid hemostasis, confirming its effectiveness in complicated surgery, where risk of hemorrhage can be critical for the surgery outcome.Funding: There was no funding for this case report. Baxter Healthcare Ltd. provided funding for preparation of this manuscript and the journal's Rapid Service Fee.