Decompressive hemicraniectomy following malignant middle cerebral artery infarctions: a mixed methods exploration of carer experience and level of burden.

PURPOSE: This study explores the experiences and sense of burden of family carers of survivors of malignant middle cerebral artery infarctions who had undergone decompressive hemicraniectomy. To date, there have been no studies examining carer outcomes among this unique population. This study, taken alongside an already published study of survivor outcomes, provides a more holistic picture with regard to sequelae within the sample. METHOD: Six family carers completed the Sense of Competence Questionnaire and the Hospital Anxiety and Depression Scale. These results were compared with existing normative data. Carers also consented to a semi-structured interview. Interview data were examined using thematic content analysis. Consistent with the mixed methods design, quantitative and qualitative findings were integrated for further analysis. RESULTS: While carers experienced many losses, their overall sense of burden was not outside 'Average' limits, nor did they experience clinically significant symptoms of depression. All carers identified methods of coping with the demands of caregiving. These included intrapersonal, interpersonal and practical strategies. All carers apart from one were able to identify areas of post-traumatic growth. CONCLUSION: Carers will benefit from information, support and care. In addition, problem solving skills are essential in managing the myriad difficulties that arise in the aftermath of stroke.

Long-term neuropsychological and psychosocial outcomes of decompressive hemicraniectomy following malignant middle cerebral artery infarctions.

PURPOSE: This study examines long-term neuropsychological and psychosocial outcomes of survivors of malignant middle cerebral artery infarction treated via decompressive hemicraniectomy. METHOD: A case series design facilitated a detailed analysis of the outcomes among five participants. Neuropsychological domains assessed included premorbid and current IQ, sustained, selective and divided attention, visual and auditory memory, executive functioning and visuo-spatial ability. Psychosocial domains assessed included self-rated depression, anxiety and quality of life. Participants and their main carer were asked about their retrospective view of surgery. RESULTS: All participants showed neuropsychological impairments in multiple cognitive domains, with preserved ability in others. Effects of laterality of brain function were evident in some domains. Clinically significant depression was evident in two participants. Overall quality of life was within average limits in three of four assessed participants. Four participants retrospectively considered surgery as having been a favourable course of action. CONCLUSION: While neuropsychological impairments are highly likely post-surgery, preserved abilities and social support may serve a protective function against depression and an unacceptably poor quality of life. Results do not support the suggestion that decompressive hemicraniectomy following malignant middle cerebral artery infarction necessarily leads to unacceptable neuropsychological or psychosocial outcomes. [ IMPLICATIONS FOR REHABILITATION: • Malignant middle cerebral artery infarction is a life threatening condition.• The neurosurgical procedure, "decompressive hemicraniectomy" has been shown to be life-saving among patients with this condition.• There is little known about the long-term neuropsychological and psychosocial outcomes following decompressive hemicraniectomy for malignant middle cerebral artery infarction.• This study concludes that neuropsychological impairments are highly probable post-surgery. However, preserved abilities and social support may serve a protective function against depression and an unacceptably poor quality of life.]

Episodic cauda equina compression from an intradural lumbar herniated disc: a case of 'floppy disc'.

Intradural disc herniation (IDDH) is a rare complication of intervertebral disc disease and comprises 0.26-0.30% of all herniated discs, with 92% of them located in the lumbar region (1). We present a case of IDDH that presented with intermittent symptoms and signs of cauda equina compression. We were unable to find in the literature, any previously described cases of intermittent cauda equina compression from a herniated intradural disc fragment leading to a "floppy disc syndrome".

The impact of antithrombotic therapy on neurosurgical emergency referral load.

The authors sought to determine the impact of antithrombotic therapy on emergency referrals at one neurosurgical centre. All emergency telephone referrals over a 90 day period were carefully documented with particular attention paid to current antithrombotic medications and their indication. Details regarding age, gender, diagnosis, radiological findings and treatment were also recorded. 713 emergency referrals were documented in the data collection period. 174 (24.4%) patients presented with intracranial or spinal haemorrhage and 75 (43.1%) of these were on antithrombotic therapy, ranging in age from 46-94 years (mean 71.1 years) with 29 (31.8%) on warfarin, 43 (47.2%) on aspirin and 15 (16.4%) on clopidogrel alone or in combination with another antithrombotic agent. 17 (22.6%) had no documented indication for antithrombotic therapy (all of these were on aspirin therapy) and 9 (31%) of those on warfarin had an INR in excess of 3.5 on presentation. Almost one quarter of those on antithrombotic therapy who presented with a haemorrhagic complication had no obvious indication for such therapy. One third of those on warfarin were over anticoagulated.

Image-guided transarticular atlanto-axial screw fixation.

BACKGROUND: The aim of this paper was to outline the use of frameless stereotaxy for the safe insertion of C1/C2 transarticular screws in the clinical setting of patients with atlanto-axial instability. METHODS: A retrospective review was conducted of cases involving the use of image guidance for the accurate placement of transarticular C1/C2 screws. The outcome measures considered were neural injury, vascular injury, death, and screw placement on postoperative imaging. RESULTS: We evaluated 60 patients for image-guided C1/2 transarticular screw fixation. There was a total of 109 screws inserted. There were no intraoperative complications. CONCLUSIONS: Frameless stereotaxy can be applied safely in a clinical setting for transarticular screw fixation. Image guidance can facilitate preoperative planning and help determine an optimal trajectory that avoids the vertebral artery.

Use of topically applied rt-PA in the evacuation of extensive acute spinal subdural haematoma.

Spontaneous spinal subdural haematoma is a rare cause of spinal cord compression, usually confined to a few vertebral levels. When the haematoma extends over several spinal segments, surgical decompression is a major undertaking. Recombinant tissue plasminogen activator (rt-PA) has previously been used in a number of surgical procedures, but not in the setting of acute spinal subdural haematoma. A minimally invasive technique of decompression, using topical rt-PA, is presented in two patients with extensive spinal intradural haematoma. Two patients receiving long-term anticoagulation therapy presented with acute-onset back pain progressing to paraparesis. Magnetic resonance imaging of the spine demonstrated spinal subdural haematomas extending over 15 vertebral levels in one patient and 12 in the other. An angiography catheter was introduced into the subdural space through a limited laminectomy. Thrombolysis and evacuation of haematoma was then achieved by intermittent irrigation of the subdural space with rt-PA, followed by saline lavage. Postoperative imaging demonstrated satisfactory decompression in both patients. There was significant improvement of neurological function in one patient. Topical application of rt-PA for spinal subdural haematoma allows evacuation of the haematoma through a limited surgical exposure. Decompression of the subdural space by this minimally invasive technique may be advantageous over extensive surgery by minimising surgical exposure, reducing postoperative pain and risk of neuronal injury. This technique may be useful in patients presenting with compression extending over several vertebral levels or poor surgical candidates.

Neurosurgery for the elderly: facts and figures.

A retrospective audit of all patients admitted to a national neurosurgical unit, aged 65 years or over, was reviewed. Details of clinical presentation, investigations, management and functional outcome were recorded. Our findings confirm that elderly patients constitute a major proportion of the neurosurgical workload and this has major medical and socio-economic implications.

Cheilectomy for hallux rigidus.

Cheilectomy is the excision of an irregular osseous rim that interferes with joint motion. Twenty cases of hallux rigidus/limitus treated by cheilectomy have been reviewed 18 months after surgery. A satisfactory outcome was achieved in all but 2 cases, which were failures. Range of joint motion, in particular dorsi flexion, improved in all but 6 cases. Cheilectomy is a simple and effective alternative to arthrodesis in the treatment of hallux rigidus.