An unusual presentation of colloid cyst--implications for lifestyle advice.

Colloid cysts are rare intracranial neoplasms which typically present with headaches. There is risk of neurological deterioration or death due to acute hydrocephalus. We report a case of colloid cyst presenting after a sudden acceleration/deceleration force from a theme park ride, highlighting the importance of lifestyle advice in these patients.

Never go to sleep on undrained pus: a retrospective review of surgery for intraparenchymal cerebral abscess.

Cerebral abscess is an emergency requiring urgent drainage via craniotomy or burrhole aspiration. We examine whether initial method of drainage affects outcome and important characteristics in patients with cerebral abscess. This is a retrospective analysis of 62 patients operated on in our unit with a loculated infected cerebral collection in the years 2003-2007 inclusive. Full statistical analysis was performed using data appropriate tests. Burrhole and craniotomy groups were evenly matched with no difference in any demographic factors. Surgical method made no difference to rate of re-operation (p = 0.276), antibiotic duration (p = 0.648), discharge GCS (p = 0.509), length of stay (p = 0.647) or GOS (p = 0.968). There was a trend to worsened outcome with delay to surgery (p = 0.132) with delayed patients requiring longer hospital stays (p < or = 0.005). Patients requiring a longer antibiotic duration had worse outcomes (p < or = 0.005). Surgical method did not have a significant effect on outcome, so burrhole aspiration with its advantages in terms of speed and scale of surgery should be strongly considered. Delay had an adverse affect, so operation should be as expeditious as possible whenever the differential diagnosis includes abscess, diagnosis of which may be aided by advanced magnetic resonance imaging techniques.

Atypical meningiomas: WHO moved the goalposts?

The histological grading of meningiomas underwent substantial revision and standardization in a WHO review of 2000. Prior to this the histological definition of atypical and malignant meningiomas was less tightly defined. We conducted a retrospective analysis of all meningiomas operated on between 1993 and 2003 in our unit (n=565), to assess whether the WHO changes had altered the proportion of tumours diagnosed as atypical. The percentage of tumours graded WHO II (atypical meningiomas) has increased significantly since these changes were adopted (18.3-23.1%, p=0.0408). We also examined the epidemiology of meningioma, finding that previous irradiation is associated with atypical meningiomas (p=0.038) and surgeons find that complete excision is also more difficult with atypical tumours (p=0.010), reporting poorer Simpson grades intraoperatively before the tumour grade is known. The increase in atypical lesions caused by the grading changes may lead to a corresponding increase in the numbers of patients referred for radiotherapy/radiosurgery, and we examine the evidence base for this strategy and whether our experience is replicated in other units.

Stereotactic brain biopsy: An audit of sampling reliability in a clinical case series.

Stereotactic brain biopsy is the current gold standard procedure to obtain a neuropathological diagnosis. An audit of 207 stereotactic cases, between January 1997 and December 2000 was carried out. The aim was to determine the optimum number of target sites required to make the final diagnosis and thereby set up recommendations for future practice. The overall diagnostic success rate was 89.3%. A significant positive correlation between the number of targets taken and the probability of achieving the final diagnosis was seen. In a subset of glioblastoma cases 96.1% of the tumours could have been confidently diagnosed on the basis of any two of the targets chosen, although often more targets were taken than this. The recommendations made by the audit were: (i) in cases where it is suspected the lesion does not require grading, one target site should be taken and further sites should only be taken if the first proves to be non diagnostic; (ii) in suspected glial series tumours, two targets should be routinely taken, with further sites taken only if these prove inconclusive on intraoperative smear.

The role of neuroendoscopy in the management of brain tumours.

Neuroendoscopy is increasingly used in the management of brain tumours and tumour related hydrocephalus and this study reviews the efficacy of neuroendoscopic interventions in this unit in patients with brain tumours. A series of 87 neuroendoscopic operations carried out in 77 patients with brain tumours over a 6-year period is reported. The age range of the patients was from 5 months to 70 years (median 13 years). In 56 cases (64%) presentation was with a newly-diagnosed tumour and hydrocephalus. The majority of the remaining patients had varying degrees of worsening hydrocephalus on the background of a previously diagnosed tumour. Neuroendoscopic third ventriculostomy (NTV) was successful in relieving hydrocephalus in the short term in 63/66 cases (95%) and in the longer term in 55/66 cases (83%). Neuroendoscopic tumour biopsies were successful in providing a tissue diagnosis in 17/28 cases (61%) and four extensive and three partial resections of tumour were carried out. There were two deaths within 30 days of the procedure with only one of these, secondary to intraventricular haemorrhage, directly related to neuroendoscopy. Few significant complications were noted otherwise. For selected intraventricular and paraventricular tumours neuroendoscopy offers the opportunity to combine relief of hydrocephalus with tumour biopsy and sampling of CSF in a single procedure.

The effectiveness of neuroendoscopic interventions in children with brain tumours.

OBJECT: The purpose of this study was to review the efficacy of neuroendoscopic interventions in children with brain tumours and tumour-related hydrocephalus. METHODS: In all, 61 consecutive neuroendoscopic operations carried out in 53 children with brain tumours over a 6-year period were reviewed. The patients ranged in age from 5 months to 18 years (median 9 years). Forty of 61 presentations were with a newly diagnosed tumour and hydrocephalus - the remainder predominantly had a known tumour and worsening hydrocephalus. CONCLUSIONS: Neuroendoscopic third ventriculostomy (NTV) successfully relieved hydrocephalus in the short term in 45 of 47 cases and in the longer term in 39 of 47 cases. Neuroendoscopic biopsy provided definitive tissue diagnosis in 10 of 16 cases and 5 tumours were resected. There was 1 postoperative death, which not directly related to the neuroendoscopy and few significant complications otherwise. Neuroendoscopic methods allow effective immediate and longer term control of hydrocephalus as well as the opportunity for CSF sampling and tumour biopsy in selected cases.

The management of brain tumours.

Current knowledge on the biology and clinical features of brain tumours is reviewed with particular reference to the most commonly occurring tumours - gliomas, meningiomas and metastases. Unfortunately, the enormous increase in understanding of the biology of these tumours over recent years has not, as yet, been paralleled by advances in treatment or improvements in clinical outcome. Developing adjuvant therapies, ranging from novel means of delivery of radiotherapy and new chemotherapy agents to gene therapy and anti-angiogenic agents, are currently being explored and offer some hope for improvement in our ability to treat these tumours over the next few decades.

Third ventricular cysts and membranes unsuspected on conventional CT and MRI.

Three cases are presented of symptomatic cysts or membranes within the third ventricle interfering with CSF flow and presenting as non-communicating triventricular hydrocephalus. None was visible on conventional CT or MRI, two being discovered at neuroendoscopy and one only with a specific MRI sequence designed to show CSF partitioning.

Can experimental models of rodent implantation glioma be improved? A study of pure and mixed glioma cell line tumours.

To evaluate the hypothesis that co-implantation of different rodent glioma cell lines might result in experimental brain tumours that more closely resemble human gliomas the neuropathology and immunocytochemical features of implantation gliomas derived from single cell lines (C6, A15A5, F98), two cell lines admixed 50:50 prior to implantation (C6 + F98 and C6 + A15A5) and three cell lines equally admixed (C6 + A15A5 + F98) was studied in the adult Wistar rat. Tumours grew consistently following implantation of the single and the two admixed cell lines, however tumour growth following triple mix implantation was considerably and consistently impaired. The tumours derived from admixed cell lines showed regional heterogeneity with areas characteristic of both the primary cell lines. Foci of lymphocytic infiltrates, tumoural necrosis, often with pseudopallisading, and peritumoural edema were consistent features of all tumours. Limited parenchymal and more extensive perivascular tumoural invasion was seen predominantly in tumours containing the C6 cell line. There were no significant differences in GFAP, vimentin and HSP70 staining between the mixed tumours, although the pure F98 and A15A5 tumours were, unlike the pure C6 gliomas, S-100 negative. Using PCNA expression as a measure of the tumour proliferation all except the tumours derived from the three cell lines mix, which had a staining index of 7-10%, had focal staining indices in viable tumour of between 40-80%. There was focal positive staining in both perilesional brain and in regions of all tumours for the macrophage markers ED-1 and ED-2. None of the three cell lines stained in vitro for either ED1 and ED2 but all were constitutively positive in vitro for OX-6, a proposed marker for antigen presenting cells. The macrophage and lymphocytic response suggest a vigorous but largely ineffective immunological response had been mounted against all tumours. The consistent failure of the triple mix tumours to grow is unexplained. This work has shown the feasibility of producing 'mixed' cell line experimental gliomas by combining two cell lines at the time of innoculation. However, the relative failure to produce (i) mixed tumours that have properties not inherent to either parent cell line and (ii) implantation glioma with three cell lines suggest there are limits to this approach. Admixture of cell lines at the time of implantation therefore does not make experimental glioma models that more closely resemble natural gliomas, and also has some particular disadvantages. This experimental approach is therefore not recommended for use in the study of tumour biology and in evaluating the effectiveness of novel therapies.

Avoidable deaths still occur after large bowel surgery. Scottish Audit of Surgical Mortality, Royal College of Surgeons of Edinburgh.

BACKGROUND: Postoperative death following large bowel surgery is relatively infrequent and no large study has analysed the cause of all deaths comprehensively and critically. METHODS: In-hospital deaths following large bowel surgery in South-East Scotland were reviewed by independent assessors. The audit was confidential but not anonymous. Independent assessors' reports were returned to consultants. RESULTS: The audit documented 187 deaths. The independent assessors noted an adverse event in 78 patients (42 per cent). Twenty-six deaths (14 per cent) occurred following an anastomotic leak. A further 43 deaths (23 per cent) occurred because surgery was delayed (17) or there was undue delay in making the initial diagnosis (12) or recognizing a developing complication (14). Consultants operated on only half the patients classed as American Society of Anesthesiologists grade IV or V, or undergoing a second or subsequent operation. CONCLUSION: Half the patients dying in this study had identifiable deficiencies in their management. There is a clear need for greater consultant input with critically ill patients.

Nail gun injury to the brain: an unusual case of suicide.

An unusual case of fatal suicidal craniocerebral penetrating injury due to a nail gun is described. The victim, a 52 year old joiner experienced in the use of nail drivers, shot himself just above the forehead in the midline, driving the nail through his hypothalamus and midbrain. Death was delayed by nearly 24 hours.