Outcomes of endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in the treatment of paediatric hydrocephalus: Systematic review and meta-analysis.

PURPOSE: To evaluate the outcomes of endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in the treatment of paediatric hydrocephalus. METHODS: We searched PubMed, MEDLINE, and Cochrane Central Register of Controlled Trials databases for articles published from 2000 to May 2023 (last search date May 6, 2023). Keywords searched included "endoscopic third ventriculostomy", "ventriculoperitoneal shunting", "paediatric population", and "outcomes". Using random-effects models, we compared success rates and complications of ETV and VPS. The primary outcome was ETV vs.VPS success rates, and the secondary outcome was post-treatment complications. Included studies reported on treatment success and complication rates. RESULTS: Out of 126 articles, 8 RCTs and 1 prospective study were included. Six studies reported primary outcome data (806 patients identified: 464 in ETV group, 342 in VPS group). Combined success rates were 81.8% (n = 283/346) for ETV and 86.7% (n = 182/210) for VPS (median follow-up 41 months). There was no difference in success rates between ETV and VPS groups (risk ratio 0.84, 95% confidence interval 0.80-0.90, I2 = 0%, p = 0.93). Combined complication rates were 4.6% (n = 16/346) in the ETV group and 27.1% (n = 57/210) in the VPS group. ETV had a lower rate of postoperative complications (risk ratio 0.76, 95% confidence interval 0.42-1.38, I2 = 53%, p = 0.04). CONCLUSIONS: Both ETV and VPS are viable surgical options for the management of paediatric hydrocephalus with similar success rates when used as first-line treatment. However, our study concluded that VPS results in a higher complication rate. REGISTRATION: This systematic review and meta-analysis was formally registered in the PROSPERO International database under the registration number CRD42023452907 on the 29th of August 2023.

Enhanced recovery in cranial surgery (ERACraS) - A single-centre quality improvement study.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) is a well-established, protocol-driven, evidence-based approach to peri-operative care. ERAS protocols have been used to improve patient morbidity and mortality outcomes in various surgical specialties. More recently, it has been introduced to neurosurgery. Our aim was to establish an Enhanced Recovery After Cranial Surgery (ERACraS) protocol for patients as part of a quality improvement project (QIP) with the intention of reducing hospital length of stay (HLOS). METHODS: This QIP was carried out in the Department of Neurosciences (DCN), Edinburgh, over two four-month periods. A total of 40 patients over 18 years of age undergoing elective craniotomy surgery under a sole neurosurgeon were invited to take part in this QIP. Subsequently, data was retrospectively collected through our institution's online documentation system. RESULTS: 19 patients received conventional perioperative care (pre-ERACraS group) during December 2021-March 2022, and 21 received care according to the novel ERACraS (ERACraS group) during June-September 2022. Regarding supra-tentorial surgery, there was a reduction of 73% in HLOS in the ERACraS group. No change was observed in infra-tentorial surgery. Overall, the ERACraS protocol reduced HLOS by 50% in cranial surgery. CONCLUSION: The QIP data from ERACraS in our unit has shown that implementing ERAS protocols is feasible. A reduction in HLOS has implications for patient morbidity, mortality, and quality of care. We endeavour to collect long-term data by collaborating with neurosurgical units across the UK and Ireland to validate its feasibility and sustainability as part of a major QIP in neurosurgical practice. This can be potentially adopted by neurosurgical centres across the globe in a safe and sustained manner.

Early Preventive Strategies and CNS Meningioma - Is This Feasible? A Comprehensive Review of the Literature.

BACKGROUND: Meningiomas are one of the most common benign primary brain tumors; however, there is a paucity of literature on potential preventability. This comprehensive review aimed to explore the existing evidence for the potential risk factors that may contribute to meningioma development and to discuss early prevention strategies. METHODS: Literature search was conducted via MEDLINE, Embase, Web of Science, and Cochrane Database to retrieve existing literature on various environmental exposures and lifestyle behaviors that are potential risk factors for the development of meningiomas. RESULTS: Significant risk factors included exposure to ionizing radiation and certain environmental chemicals. Notably, this study also identified that cigarette smoking and obesity are associated with the development of meningiomas. To date, wireless phone usage, hormonal exposures, dietary factors, and traumatic brain injury remain inconclusive. Early prevention strategies should primarily be family-driven, community-based, and public health-endorsed strategies. Targeting unhealthy behaviors through healthcare organizations could execute a pivotal role in the maintenance of an optimum lifestyle, reducing the development of risk factors pertinent to meningiomas. CONCLUSIONS: To our knowledge, this is the first study that offers a perspective on prevention of meningiomas. A causal relationship of risk factors in developing meningiomas cannot be directly established with the current evidence. We are aware of the limitations of the hypothesis, but we believe that this study will raise more awareness and our findings could potentially be endorsed by organizations promoting health across the globe. Further prospective and retrospective studies will shed more light on this topic and help establish a definitive relationship.

Global Mentorship in Neurosurgery for Medical Students Study (the GloMNMS Study): a multinational multi-institutional cross-sectional audit.

OBJECTIVES: To assess the perception of global mentorship in neurosurgery among medical students across the world. Secondary aim included investigating the factors affecting the availability and benefits of providing global mentorship scheme in neurosurgery at a medical student level. SETTING: The Global Mentorship in Neurosurgery for Medical Students Study was a multinational cross-sectional audit that included medical students currently in the years 1-6 and intercalating programmes. They were invited to complete an online survey between 11 March and 1 May 2022. PARTICIPANTS: The survey was disseminated to 243 medical university ambassadors worldwide from 60 countries who distributed the survey within their respective medical student cohorts across the duration of the study. RESULTS: Overall, 2962 of 3017 (98.2%) responses from medical students from 60 countries worldwide were included; 1439 of 2962 (49%) and 1523 of 2962 (51%) were from years 1-3 and 4-6 medical students including intercalating degree programmes, respectively. 1712, 1502 and 1359 of responses gathered indicated that possible reasons for the lack of neurosurgical mentorship are lack of time and resources from trainees in neurosurgery, time within medical school's curriculum and awareness of societies in neurosurgery/neurology. 1276 and 1065 of medical students surveyed reported that it could also be due to lack of funding and overall inaccessibility within the area meaning there are few networking opportunities available. CONCLUSIONS: This pilot study indicates that there is a scope for improvement regarding the availability and accessibility of neurosurgical mentorship programmes worldwide at a medical student level. The evaluation suggested that medical students would most benefit from the neurosurgical mentorship in the future by means of increased numbers of mentors within their universities, accessibility to neurosurgical departments and the ability to choose mentorship globally via a unified digital platform.

Treatment of primitive myxoid mesenchymal tumour of infancy: a management paradigm focusing on surgical nuances.

Primitive myxoid mesenchymal tumour of infancy (PMMTI) is a rare mesenchymal tumour that typically appears in those under 6 months of age and preferentially affects the deep soft tissues of the trunk and paravertebral spinal regions. PMMTI has only recently been described, and there is scarce literature reporting cases regarding the management paradigm of the tumour. We report the case of an 11-week-old male who presented with bilaterally reduced movement and brisk reflexes in his lower limbs, and irritability. Despite numerous radiological investigations, including MRI, PMMTI was only diagnosed upon biopsy and histopathology. Although PMMTI is known to be relatively unresponsive to chemotherapy, we observed a notable decrease in tumour size after a series of chemotherapy sessions. After two-staged surgical resection of the tumour, the patient is currently stable and under close follow-up. In this article, we aim to report on the patient's clinical presentation, investigations, diagnosis, and treatment, while also discussing the findings from a review of the literature pertaining to future approaches in managing PMMTI. Overall, this case highlights the importance of considering PMMTI in the differential diagnosis of deep soft tissue tumours in young infants and the potential for a combination of chemotherapy and surgical resection to be effective in treating this rare tumour.

Fertility Preservation Techniques in Neuro-Oncology Patients: Protocol for a Systematic Review.

BACKGROUND: Advancements in cancer treatments have successfully improved central nervous system (CNS) cancer survivorship and overall quality of life. As a result, the awareness of the importance of fertility preservation techniques is increasing. Currently, a range of established techniques, such as oocyte cryopreservation and sperm cryopreservation, are available. However, oncologists may be hesitant to refer patients to a reproductive specialist. OBJECTIVE: The primary aim of the proposed systematic review is to assess the best evidence for fertility preservation techniques used in patients with CNS cancers. It also aims to evaluate outcomes related to their success and complications. METHODS: This protocol was produced in adherence with the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols). Electronic databases will be systematically searched to identify studies that meet our eligibility criteria. Studies will be included if they report at least one type of fertility preserving or sparing technique in male patients of any age and female patients aged <35 years. Animal studies, non-English studies, editorials, and guidelines will be excluded from the review. From the included studies, data will be extracted and synthesized by using a narrative approach and summarized in tables. The primary outcome will be the number of patients successfully undergoing a fertility preservation technique. The secondary outcomes will include the number of retrieved oocytes, the number of oocytes or embryos vitrified for cryopreservation, clinical pregnancy, and live birth. The quality of the included studies will be assessed by using the National Heart, Lung, and Blood Institute risk-of-bias tool for any type of study. RESULTS: The systematic review is expected to be completed by the end of 2023, and results will be published in a peer-reviewed journal and on PROSPERO. CONCLUSIONS: The proposed systematic review will summarize the fertility preservation techniques available for patients with CNS cancers. Given the improvement in cancer survivorship, it is becoming increasingly important to educate patients about fertility preservation techniques. There are likely to be several limitations to this systematic review. Current literature is likely to be of low quality due to insufficient numbers, and there may be difficulty in accessing data sets. However, it is our hope that the results from the systematic review provide an evidence base to help inform the referral of patients with CNS cancers for fertility preservation treatments. TRIAL REGISTRATION: PROSPERO CRD42022352810; https://tinyurl.com/69xd9add. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/44825.

h-Index, Journal Citation Indicator, and Other Impact Factors in Neurosurgical Publications: Is There a Cost Factor That Determines the Quality?

OBJECTIVE: There has been an increase in number of Neurosurgical publications, including open access (OA), in recent years. We aimed to compare journals' performance and the relationship to submission fees incurred in publication. METHODS: We identified 53 journals issuing neurosurgery-related work. Quantitative analysis from various search engines involved obtaining h-index, Journal Citation Indicator (JCI), and other metrics such as Immediacy Index and 5-year impact factor utilising Journal Citation Reports. OA fees and individual subscription fees were collected. Correlations were produced using Spearman rho (ρ) (P < 0.05). RESULTS: Median h-index for 53 journals was 54 (range: 0-292), with JCI median reported as 0.785 (range: 0-2.45). Median Immediacy Index was 0.797 (range: 0-4.076), and median for 5-year impact factor was 2.76 (range: 0-12.704). There was a very strong positive correlation between JCI and Immediacy Index, JCI and 5-year impact factor, and 5-year impact factor and Immediacy Index (ρ > 0.7, P < 0.05). It is unclear whether there was any correlation between the indices and the OA costs and subscription costs for personal usage (P > 0.05). CONCLUSIONS: Larger costs incurred for OA fees and subscription costs for personal use do not clearly reflect on the journals' performance, as quantified by using various indices. There appears to be a strong association with performance across the journals' metrics. It would be beneficial to include learning about bibliometric indices' impact for research publications in medical education training to maximize the quality of the scientific work produced and increase the visibility of the information produced. The potential full movement to exclusively OA journals would create a significant barrier for junior researchers, small institutions, and full time-trainee physicians with limited funding available. This study suggests the need for a robust measurement of journals' output and the quality of the work produced.

The role of surgery in relieving calcified shunt site-related pain in patients with functioning VP shunt.

PURPOSE: Shunt calcification is a known late sequela of ventriculoperitoneal (VP) shunt insertion and is associated with shunt malfunction. However, in some patients, while shunt functionality is preserved despite calcification of the catheters, they experience nociceptive symptoms. In this paper, the authors present their surgical experience in managing patients with a functional VP shunt and experiencing pain secondary to shunt calcification. METHODS: We analysed outcomes of patients presenting with pain at the level of a calcified shunt who underwent surgical untethering of the calcified catheter from the soft tissues. This procedure was commenced by the senior author in 2015. Patients were collected prospectively from the databases of two institutions. Evidence of shunt calcification was confirmed on neuroimaging. RESULTS: Seven patients, two male and five female, were included. The mean age at untethering was 13.5 years. The mean time interval between primary shunt surgery and symptom onset was 12 years (range 6-16 years). The commonest site of tethering was the neck (50%) followed by abdomen and chest (both 25%). Six patients underwent untethering of the catheter from soft tissues. One patient had removal of a redundant segment of calcified shunt left in situ during a previous revision. All patients experienced pain relief following shunt untethering. CONCLUSION: Untethering of calcified VP shunt catheters from soft tissue can be considered an effective treatment of shunt site pain and offered to patients presenting with a functional VP shunt.

A rare presentation of a bilateral intracranial parameningeal embryonal rhabdomyosarcoma mimicking vestibular schwannoma in a two-year-old child: a case report.

Intracranial parameningeal rhabdomyosarcomas are rare, aggressive, rapidly progressive paediatric malignancies that carry a poor prognosis. The authors report a case of a 2-year-old boy who initially presented with a left facial palsy, ataxia and, shortly after, bloody otorrhoea. MRI imaging was initially suggestive of a vestibular schwannoma. However, there was rapid progression of symptoms and further MRI imaging showed very rapid increase in tumour size with mass effect and development of a similar tumour on the contralateral side. A histological diagnosis of bilateral parameningeal embryonal rhabdomyosarcoma was made. Despite treatment, progression led to hydrocephalus and diffuse leptomeningeal disease, from which the patient did not survive. Few intracranial parameningeal rhabdomyosarcomas have previously been reported and these report similar presenting symptoms and rapid disease progression. However, this is the first reported case of a bilateral intracranial parameningeal embryonal rhabdomyosarcoma which, on initial presentation and imaging, appeared to mimic a vestibular schwannoma.

A 5-year outcome of propranolol for the treatment of paediatric intracranial cavernoma: case report and a review of the literature.

We describe a case of a young male patient with KRIT1-driven familial cavernous malformation syndrome who developed multiple brain cavernomas, intracranial bleeding, and persistent seizures. Due to the relentless growth of cavernous malformations and recurrent intracranial bleeds, it was decided to enrol the patient in the "Propranolol for Intracranial Cavernoma" (PICC) pilot trial at our institution. Over the 5-year treatment period with 20 to 40-mg oral propranolol three times daily (TDS), we noted the near-complete arrest of the growth of cavernous malformations with no further evidence of intracranial bleeding or any further seizures. The observed outcome is consistent with the extremely limited published literature on the topic; thus, this case provides important evidence that supports the use of propranolol as a prophylactic treatment for paediatric intracranial cavernomas. We strongly encourage and recommend future prospective randomised controlled trials to definitively assess and characterize the therapeutic utility of propranolol in this patient population.

Promoting padawans: a survey examining the state of mentorship in neurosurgical training in the United Kingdom.

BACKGROUND: Mentorship has long since been acknowledged as an integral part of Neurosurgical training. The authors sought to evaluate the state of mentorship in Neurosurgical training in the United Kingdom (UK). METHODS: A 28-point questionnaire was sent to all neurosurgical trainees in the UK and Ireland via the British Neurosurgical Trainee's Association (BNTA), comprising 180 trainees. RESULTS: There were 75 responses (180 trainees on the mailing list, 42% response rate). Despite all respondents reporting it to be at least somewhat important to have a mentor, 16% felt they had no mentors. The mean number of mentors was 2.91 with 72% of respondents having more than 1 mentor. In terms of the content of mentorship relationships, 63% were comfortable discussing career related topics with their mentor to a high or very high degree but only 29% felt comfortable discussing their general wellbeing. With regards to allocated educational supervisors, 43% thought this person to be a 'low' or 'very low' source of mentorship. The three most important traits of the ideal mentor as reported by respondents were: someone chosen by them (48%), working in the same hospital (44%) and having received formal mentorship training (36%). CONCLUSIONS: The current perception of mentorship in Neurosurgery from the surveyed trainees is mixed. A healthy majority of trainees benefit from mentorship of some kind, whilst a significant minority feel underserved. The surveyed trainees feel mentorship is slanted more towards clinical and professional aspects of development than it is towards personal ones. Suggestions for future insight would be an evaluation of senior registrar and consultant sentiments towards mentorship, whilst exploration into more flexible models for establishing mentoring relationships may help to address the heavy importance of trainee choice which is voiced by this survey's results.

Role of the glymphatic system in idiopathic intracranial hypertension.

This review discusses the potential significance of glymphatic system dysfunction in the pathophysiology of idiopathic intracranial hypertension (IIH). IIH is a clinical syndrome characterised by signs and symptoms which arise from raised intracranial pressure (ICP), in the absence of a clear primary cause of intracranial hypertension. The underlying pathophysiological mechanisms driving IIH remain unclear and raised cerebrospinal fluid (CSF) secretion, reduced fluid drainage, and elevated cerebral venous sinus pressure do not fully explain the condition's aetiology. There is a growing literature which implicates the glymphatic system, a mechanism by which fluid moves into the brain parenchyma via peri-arterial channels and out via perivenous spaces and brain lymphatics, in IIH pathogenesis. We propose that aquaporin-4 (AQP4) changes, neurogliovascular unit disruption, a pro-inflammatory CSF profile and impaired glymphatic outflow are the main mechanisms driving glymphatic dysfunction in IIH. However, it remains unclear which of these mechanisms are primary causes and which are secondary effects. Further studies using CSF tracers, electron microscopy, and immunohistochemistry are needed to better evaluate the cellular and molecular pathology associated with IIH at different timepoints in the disease course, which will help elucidate the mechanistic role of the glymphatic system in the condition's pathogenesis.

Smoking and degenerative spinal disease: A systematic review.

Smoking is a major cause of morbidity and mortality worldwide and is responsible for the death of more than 8 million people per year globally. Through a systematic literature review, we aim to review the harmful effects of tobacco smoking on degenerative spinal diseases (DSD). DSD is a debilitating disease and there is a need to identify if smoking can be an attributable contender for the occurrence of this disease, as it can open up avenues for therapeutic options. Sources such as PubMed and Embase were used to review literature, maintaining tobacco smoking and spinal diseases as inclusion factors, excluding any article that did not explore this relationship. Risk of bias was assessed using analysis of results, sample size and methods and limitations. Upon review of the literature, tobacco smoking was found to be a major risk factor for the occurrence of DSDs, particularly lumbar spinal diseases. Smokers also experienced a greater need for surgery and greater postoperative wound healing complications, increased pain perception, delay in recovery and decreased satisfaction after receiving surgery. These effects were noted along the entire spine. Many mechanisms of action have been identified in the literature that provide plausible pictures of how smoking leads to spinal degeneration, exploring possible primary targets which can open up opportunities to develop potential therapeutic agents. More studies on cervical and thoracic spinal degeneration would be beneficial in identifying the effect of nicotine on these spinal levels. Some limitations included insufficient sample size, inconclusive evidence and lack of sufficient repeat studies. However, there appears to be a sufficient amount of research on smoking directly contributing to lumbar spinal pathology.

The Future of Neurosurgical Training in the United Kingdom.

The National Health Service faces substantial challenges with staffing in the face of administrative turbulence just after a global pandemic resulting in significant economic losses. This staffing crisis extends to neurosurgical training with pervasive problems with the balance between trainees and consultants. In the face of Brexit, after the impact of the European Working Time Directive, these challenges provide an opportunity to explore possible solutions to improving training and staff retention. The recommended solutions include ensuring appropriate workforce planning and using novel (and already available) resources to revamp the structure of neurosurgery training and improving the attainment of surgical competence and staff retention. Creating a sustainable neurosurgery training program to adequately fill gaps in the National Health Service will require long-term solutions and the commitment of multiple stakeholders. The first step to achieving these goals would be to maximize the available opportunities to allow trainees maximize training time to become competent day-one consultants.

Treatment and outcomes of non-aneurysmal perimesencephalic subarachnoid haemorrhage: A 5 year retrospective study in a tertiary care centre.

PURPOSE: Perimesencephalic Subarachnoid Haemorrhage (PMSAH) is an uncommon type of SAH. Severity of PMSAH can be graded by the presence of blood in the Sylvian fissure. No study compares the outcomes from PMSAH with blood present or absent in the Sylvian fissure. Furthermore, the use of Nimodipine lacks evidence base in PMSAH. We investigated whether continuing Nimodipine to 21 days in PMSAH with or without blood in the Sylvian fissure made any significant difference to patient outcome. METHODS: Retrospective study of 93 cases admitted to tertiary centre from 2016 to 2020. We compared prevalence of cases with blood in Sylvian fissure, and analysed outcomes including complications and changes to patient modified rankin scale (MRS). We also audited use of Nimodipine in these cases and analysed whether Nimodipine made any significant difference in preventing complications. RESULTS: 91 % of PMSAH were grade 1, 24 cases (26 %) had blood in the Sylvian fissure. Sylvian fissure positive (Sylvian-positive) cases were statistically significantly more likely to have higher rates of complication compared to Sylvian fissure negative (Sylvian-negative) cases. Our centre stopped Nimodipine 56 % of the time in Sylvian-negative cases and 45 % of the time in Sylvian-positive cases. There was no statistically significant difference in outcomes when Nimodipine was continued to 21 days or ceased after negative angiogram; this result extended to both Sylvian-positive and Sylvian-negative subgroups when directly comparing Sylvian-positive cases with each other and Sylvian-negative cases likewise. DISCUSSION: Sylvian-positive cases have a significantly higher rate of complication, as well as an increase in MRS. This may be because of the inflammatory properties of haemoglobin in the subarachnoid space post-bleed. Furthermore, acknowledging the limitations of our retrospective data, we did not find a statistically significant difference in continuing Nimodipine to 21 days with relation to PMSAH outcomes in all subgroups.

The Management of Idiopathic and Refractory Syringomyelia.

Idiopathic syringomyelia (IS) and refractory syringomyelia (RS) are types of syringomyelia that often pose a management challenge and are associated with long-term clinical sequela. They are usually an epiphenomenon reflecting an underlying pathology where the treatment of the primary cause should be the aim for any surgical intervention. In the case of IS, the initial step is agreeing on the definition of the terms idiopathic and syringomyelia. After a rigorous exhaustive clinic-radiological workup, only IS patients with progressive neurology are treated, usually unblocking subarachnoid cerebrospinal fluid (CSF) pathway obstruction somewhere in the thoracic spinal canal and reserving shunting techniques to nonresponsive cases. Similar to IS, also RS is multifactorial, and its management varies based on the initial pathology, strongly supported by radiological and clinical features. We aim to address this topic focusing on the etiopathology, investigation paradigm, and surgical pathway, formulating algorithms of management with available evidence in literature. Surgical techniques are discussed in detail.