Risk factor synergism in aneurysmal subarachnoid hemorrhage: a cross-sectional study.

BACKGROUND: Spontaneous subarachnoid hemorrhage (SAH) accounts for 5-10% of strokes but a disproportionately large amount of stroke-related morbidity. Several risk factors have been described, including smoking, hypertension, increasing age, and female sex. METHODS: This cross-sectional study examined all patients with aSAH within a nationally representative catchment from 01/01/2017 to 31/12/2020. Patients with aneurysmal SAH were identified from multiple sources, including a prospective database and death records. The population was estimated from projections from a door-to-door census and risk factors from stratified random sampled surveys conducted on a yearly basis. Poisson regression models were used to estimate the incidence and incidence rate ratios (IRRs) for risk factors with 95% confidence intervals (95% CIs). RESULTS: We identified 875 cases of aSAH in 11,666,807 patient-years of follow-up, which corresponded to a crude incidence of 7.5 per 100,000 patient-years (95% CI 7-8) and a standardized incidence of 6.1/100,000 (95% CI 5.6-6.5). Smoking was the strongest individual risk factor, with a standardized incidence of 24/100,000 (95% CI 20-27) in smokers compared with 2.6/100,000 (2.1-3.2) in non-smokers (age-adjusted IRR 9.2, 95% CI 6.3-13.6). Hypertension (age-adjusted IRR 3.1, 95% CI 2.2-4.3) and female sex (age-adjusted IRR 1.8, 95% CI 1.4-2.3) were also associated with increased incidence. The highest incidence was observed in hypertensive smokers (standardized incidence 63/100,000, 95% CI 41-84), who had a lifetime risk of aSAH of 6.7% (95% CI 5.4-8.1) after age 35. Compared with participants who were non-smokers without hypertension, the age-adjusted IRR in hypertensive smokers was 27.9 (95% CI 15.9-48.8). CONCLUSION: Smoking is the most prominent individual risk factor for aSAH. Smoking and hypertension appear to interact to increase the risk of aSAH synergistically.

When does too little pressure become too much? A case of spontaneous intracranial hypotension presenting with acute loss of consciousness.

Background: We present a unique case of spontaneous intracranial hypotension (SIH) presenting with acute collapse and loss of consciousness. Case Description: The affected patient suffered an abrupt decline in level of consciousness several weeks after initial diagnosis. The patient was urgently transferred to a specialist neurosurgical unit. Imaging showed bilateral subdural fluid collections with significant associated local mass effect. The treating team faced a clinical conundrum with a lack of clarity as to whether this sudden deterioration was secondary to the local pressure effect on brainstem traction from reduced intracranial pressure. A decision was made to proceed with urgent burr-hole decompression of the bilateral subdural fluid collections. Conclusion: After a protracted, complex postoperative course, the patient recovered to full functional independence. To the author's knowledge, this is the first case in literature describing successful surgical management of SIH, with bilateral burr-hole evacuation to relieve the paradoxical mass effect of bilateral subdural fluid collections.

Pituitary hyperplasia resulting in visual deficit.

Background: Pituitary hyperplasia is an infrequent cause of visual disturbance and few such cases have been reported in the literature. Case Description: We describe the case of a 16-year-old female who presented with a short history of progressive headache and visual blurring. Examination revealed markedly constricted visual fields. Imaging revealed an enlarged pituitary gland. Hormonal panel was normal. Following endoscopic endonasal transsphenoidal biopsy and decompression of the optic apparatus, an immediate improvement in vision was noted. Final histopathological examination revealed pituitary hyperplasia. Conclusion: In patients with pituitary hyperplasia, visual deficit, and no identifiable reversible causes, surgical decompression can be considered to preserve vision.

Prognostic factors influencing survival following re-resection for isocitrate dehydrogenase (IDH) -wildtype glioblastoma multiforme - Data from a national neuro-oncology registry.

The role of surgical resection in recurrent Glioblastoma Multiforme (GBM) remains unclear. We aimed to investigate survival outcomes and associated prognostic factors in patients undergoing surgical re-resection for recurrent IDH-wildtype GBM in a national neuro-oncology center. We evaluated all patients who underwent re-resection for recurrent GBM following adjuvant treatment between 2015 and 2018. 32 patients were eligible for inclusion. 19 (59%) were male,median age at re-resection was 53. Median time from initial surgery to re-resection was 13.5 months. Median overall survival (OS) was 28.6 months from initial surgery and 9.5 months from re-resection. MGMT methylation was significantly associated with improved OS from initial surgery, 40 months versus 19.1 months, (p = 0.004), and from re-resection, 9.47 months versus 6.93 months, (p = 0.028). A late re-resection was associated with improved OS compared to an early re-resection, 44.1 months versus 15.7 months, (p = 0.002). There was a trend for improved outcomes in younger patients, median OS from initial surgery 44.1 months for <53 years compared to 21.7 months for patients ≥53, (p = 0.099). Higher Karnofsky Performance Status (KPS) at re-resection was associated with improved median OS, 9.5 months versus 4.1 months for KPS ≥70 and <70 respectively, (p = 0.013). Furthermore, there was a trend for improved OS with greater extent of re-resection, however this did not reach statistical significance, possibly due to small sample size. Re-resection for recurrent GBM was associated with improved OS in those with good performance status and could be considered in carefully selected cases.

Angiocentric glioma: Drop Metastases to the Spinal Cord.

BACKGROUND: Angiocentric glioma (AG) is an epileptogenic low grade (World Health Organization grade I) glial tumor with astrocytic and ependymal differentiation, most commonly affecting the pediatric and adolescent population. Despite its infiltrating histological growth kinetics, it is widely accepted that AG has a low potential for aggressive behavior. CASE DESCRIPTION: We present the case of a 42-year-old man who represents the first documented case of not only extracranial manifestation of AG, but also spinal metastatic dissemination. Our patient initially presented with a generalized tonic clonic seizure; following a biopsy, he was diagnosed with a low-grade supratentorial astrocytoma and subsequently received fractionated radiotherapy. He presented 10 months later with worsening dorsal column symptoms and was found to have a contrast-enhancing intradural extramedullary lesion that was surgically resected and histologically confirmed as an AG. CONCLUSION: Further research is required to examine the microenvironment and potential for malignant change in this tumor.

Intra-operative imaging for spinal level localisation in lumbar surgery.

Study Design: Retrospective review of the practice of 3 surgeons in a single centre during a 1-year period. Objective: We aimed to investigate our adherence to the Society of British Neurological Surgeons (SBNS) guidelines regarding intra-operative imaging during lumbar surgery and to determine if this has any impact on length of surgery or complications rates, in particular rates of wrong-level surgery. Background: The SBNS recommends three x-rays for intra-operative spinal localisation - one prior to incision, the second after exposure of the laminae and before the commencement of decompression, and the third at the end of the operation to confirm the adequacy of decompression. At our centre, surgeon A performs x-rays 1 and 3 routinely, and x-ray 2 in cases where the anatomy is uncertain, surgeon B performs x-ray 2 only, and the practice of surgeon C varies depending on the complexity of cases. Method: We reviewed the surgical logbooks of 3 consultant neurosurgeons in our centre for the 1-year period between October 2015 and October 2016. Our study included 301 patients who had undergone lumbar decompression or lumbar discectomy during this period. Results: There were no cases of wrong-level surgery. The incorrect spinal level was initially exposed in 13 cases (4.3%). 10 of these had x-ray 2 only, 1 had x-ray 1, 1 had x-rays 1 and 2, and 1 had all 3 x-rays. Surgeon B performed 8 of these cases, four were performed by surgeon C, and 1 by surgeon A. The median duration of surgery was 80 minutes for lumbar decompression and 67.5 minutes for lumbar discectomy. The median duration of surgery in patients in whom the wrong level was initially exposed was 85 minutes for lumbar decompression and 80 minutes for lumbar discectomy. Conclusion: Performance of the 3 recommended x-rays may increase the identification of wrong-level exposures before the commencement of decompression and may reduce the length of surgery.