How is vasospasm screening using transcranial Doppler associated with delayed cerebral ischemia and outcomes in aneurysmal subarachnoid hemorrhage?

BACKGROUND: Delayed cerebral ischemia (DCI) is an independent predictor of an unfavorable outcome after aneurysmal subarachnoid hemorrhage (aSAH). Many centers, but not all, use transcranial Doppler (TCD) to screen for vasospasm to help predict DCI. We used the United Kingdom and Ireland Subarachnoid Haemorrhage (UKISAH) Registry to see if outcomes were better in centers that used TCD to identify vasospasm compared to those that did not. METHODS: TCD screening practices were ascertained by national survey in 13 participating centers of the UKISAH. The routine use of TCD was reported by 5 "screening" centers, leaving 7 "non-screening" centers. Using a cross-sectional cohort study design, prospectively collected data from the UKISAH Registry was used to compare DCI diagnosis and favorable outcome (Glasgow Outcome Score 4 or 5) at discharge based on reported screening practice. RESULTS: A cohort of 2028 aSAH patients treated ≤ 3 days of hemorrhage was analyzed. DCI was diagnosed in 239/1065 (22.4%) and 220/963 (22.8%) of patients in non-screening and screening centers respectively while 847/1065 (79.5%) and 648/963 (67.2%) achieved a favorable outcome. Odds ratios adjusted for age, injury severity, comorbidities, need for cerebrospinal fluid diversion, and re-bleed returned neutral odds of diagnosing DCI of 0.90 (95% CI 0.72-1.12; p value = 0.347) in screening units compared to those of non-screening units but significantly decreased odds of achieving a favorable outcome 0.56 (95% CI 0.42-0.82; p value < 0.001). CONCLUSIONS: Centers that screened for vasospasm using TCD had poorer in-hospital outcomes and similar rates of DCI diagnosis compared to centers that did not.

Autobiographical memory loss following a right prefrontal lobe tumour resection: a case report and review of the literature.

INTRODUCTION: The right prefrontal lobe has not traditionally been considered eloquent brain. Resection of tumours within this region does not typically lead to permanent functional impairment. In this report, we highlight the case of a patient who developed autobiographical memory loss following an uncomplicated resection of a right prefrontal tumour. CASE MATERIAL: A previously fit and well 15-year old presented with a persistent right-sided headache. An MRI demonstrated an expanded right mid-frontal gyrus with changes consistent with a low-grade tumour. The patient underwent a right-sided craniotomy and resection of the lesion which was confirmed as a WHO grade II diffuse astrocytoma. Postoperatively, the patient reported profound retrograde amnesia for a range of memory components, in particular autobiographical memory and semantic memory. Postoperative imaging showed a good resection margin with no evidence of underlying brain injury. Over an 18-month period, the patient showed no improvement in autobiographical memory; however, significant relearning of semantic knowledge took place and her academic performance was found to be in line with expectations for her age. CONCLUSION: In this report, we discuss a case and review the literature on the role of the right prefrontal cortex in memory and caution on the perception of right prefrontal non-eloquence.

Magnetic resonance diffusion metrics indexing high focal cellularity and sharp transition at the tumour boundary predict poor outcome in glioblastoma multiforme.

AIM: To investigate the prognostic power of intra-tumoural and gradient magnetic resonance imaging (MRI) diffusion metrics in patients with glioblastoma multiforme (GBM). MATERIALS AND METHODS: Forty-six consecutive patients with histologically confirmed GBM who had undergone preoperative diffusion tensor imaging at 3 T were included. Mean diffusivity (MD) and MD gradient maps were computed. Regions of interest were analysed to determine the minimum MD within the enhancing tumour (minMD). MD gradients were calculated along the enhancing tumour boundary and subjected to histogram analysis. Overall survival (OS) and time to progression (TTP) were derived and survival analysis was undertaken. RESULTS: There were 31 deaths and 37 patients progressed during the study period. Multivariate survival analysis, controlling for treatment and gender, showed that minMD values<6.1×10(-4) mm(2)/s predicted shorter OS (hazard ratio [HR]=2.82, 1.25-6.34; p=0.012) and TTP (HR=5.43, 1.96-15.05; p=0.001). Higher MD gradient values of the tumour boundary predicted shorter survival: MD gradient values >4.7×10(-5) mm(2)/s (10(th) centile) had a significantly shorter OS with a HR of 0.43 (0.19-0.96; p=0.04). Similarly, a value above 1.4×10(-4) mm(2)/s (75(th) centile) was a significant predictor for shorter OS (HR=0.39, 0.17-0.89; p=0.03). CONCLUSIONS: Lower minMD and higher MD gradient values for the 10(th) and 75(th) percentile of the tumour boundary demonstrated prognostic value in preoperative GBM. This suggests that MRI diffusion metrics indicative of higher focal cellularity and steeper transition from high cellular tumour edge to low cellular oedema define more aggressive glioblastoma subtypes with a poorer prognosis.

Nitroglycerin cardioplegia effect on coronary artery targets in bypass grafting.

BACKGROUND: Coronary artery targets are essential for referral acceptance to achieve complete coronary revascularization. PATIENTS AND METHODS: A prospective double-blind study was carried out to determine whether the addition of nitroglycerin to cold blood hyperkalemic cardioplegia would optimize the size and number of coronary artery targets during conventional coronary bypass grafting. RESULTS: A total of 60 adult elective coronary artery bypass grafting cases were enrolled; 30 in group N (nitroglycerin added to cardioplegia) and 30 in group C (controls). The number of bypassed vessels ranged from 2 to 5 with a mean of 3.63. In a comparison between groups N and C, the average number of grafts per patient (3.67 ± 0.77 vs. 3.67 ± 0.92); the average performed/predicted ratio for coronary artery bypass grafting targets (0.96 ± 0.18 vs. 1.02 ± 0.31); and the average intraoperatively measured luminal diameter of the bypassed coronary artery targets (1.55 ± 0.23 vs. 1.51 ± 0.23) showed no significant difference between the two groups, except that the luminal diameter of the obtuse marginal II artery was larger in group C compared to group N ( P = 0.037). CONCLUSIONS: The addition of nitroglycerin to cardioplegia did not show any benefit, either quantitatively or qualitatively, for optimizing coronary artery bypass grafting targets.

Spontaneous intracerebral haemorrhage: a clinical review.

This article provides a clinical overview of spontaneous intracerebral haemorrhage, focusing on clinical aspects of the aetiology, diagnosis and management (both in the emergency department and in a critical care environment) of this important and devastating condition.

Traumatic brain injury in children.

This article provides a clinical overview of traumatic brain injury in children. It concentrates on the current management guidelines from initial assessment in the accident and emergency department through to specialist critical care.

Anaesthetists' and surgeons' attitudes towards informed consent in the UK: an observational study.

BACKGROUND: The attitudes of patients' to consent have changed over the years, but there has been little systematic study of the attitudes of anaesthetists and surgeons in this process. We aimed to describe observations made on the attitudes of medical professionals working in the UK to issues surrounding informed consent. METHOD: A questionnaire made up of 35 statements addressing the process of consent for anaesthesia and surgery was distributed to randomly selected anaesthetists and surgeons in Queen's Medical Centre (Nottingham), Royal Sussex County Hospital (Brighton) and Eastbourne District General Hospital (Eastbourne) during 2007. Participants were asked to what extent they agreed with statements regarding consent. RESULTS: Of 234 questionnaires distributed, 63% were returned. Of the respondents 79% agreed that the main purpose of the consent process is to respect patient autonomy. While 55% of the examined cohort agreed that the consent process maybe inappropriate as patients do not usually remember all the information given to them. Furthermore, 84% of the participants agreed that what the procedure aims to achieve should be explained to the patient during the consent process. While of the participants, over 70% agreed that major risks of incidence greater than 1/100 should be disclosed to the patient as part of the consent process. CONCLUSIONS: The majority of respondents appear to hold attitudes in standing with current guidelines on informed consent however there was still a significant minority who held more paternalistic views to the consent process bringing into question the need for further training in the area.

Operating theatre related syncope in medical students: a cross sectional study.

BACKGROUND: Observing surgical procedures is a beneficial educational experience for medical students during their surgical placements. Anecdotal evidence suggests that operating theatre related syncope may have detrimental effects on students' views of this. Our study examines the frequency and causes of such syncope, together with effects on career intentions, and practical steps to avoid its occurrence. METHODS: All penultimate and final year students at a large UK medical school were surveyed using the University IT system supplemented by personal approach. A 20-item anonymous questionnaire was distributed and results were analysed using the Statistical Package for Social Sciences, version 15.0 (Chicago, Illinois, USA). RESULTS: Of the 630 clinical students surveyed, 77 responded with details of at least one near or actual operating theatre syncope (12%). A statistically significant gender difference existed for syncopal/near-syncopal episodes (male 12%; female 88%), p < 0.05. Twenty-two percent of those affected were graduate entry medical course students with the remaining 78% undergraduate. Mean age was 23-years (range 20 - 45). Of the 77 reactors, 44 (57%) reported an intention to pursue a surgical career. Of this group, 7 (9%) reported being discouraged by syncopal episodes in the operating theatre. The most prevalent contributory factors were reported as hot temperature (n = 61, 79%), prolonged standing (n = 56, 73%), wearing a surgical mask (n = 36, 47%) and the smell of diathermy (n = 18, 23%). The most frequently reported measures that students found helpful in reducing the occurrence of syncopal episodes were eating and drinking prior to attending theatre (n = 47, 61%), and moving their legs whilst standing (n = 14, 18%). CONCLUSION: Our study shows that operating theatre related syncope among medical students is common, and we establish useful risk factors and practical steps that have been used to prevent its occurrence. Our study also highlights the detrimental effect of this on the career intentions of medical students interested in surgery. Based on these findings, we recommend that dedicated time should be set aside in surgical teaching to address this issue prior to students attending the operating theatre.

New type of left ventricular rupture during redo mitral valve replacement. A case report.

We report the case of a 41 years old woman who presented with massive bleeding after redo mitral valve replacement. A Left ventricular rupture, different from the three known types of wall rupture was hardly identified and controlled with extreme difficulty. The patient died eight days postoperatively due to disseminated intravascular coagulopathy. Retrospective analysis of the Echocardiographic examination was highly suggestive of abnormal position of the previously implanted mitral valve bioprosthesis with left ventricular outflow tract obstruction and weakness of the posterior wall of the left ventricular outflow tract.

Spinal aspergillosis in nonimmunocompromised host mimicking Pott's paraplegia.

The aim of this report is to highlight the less-known aspergillus spondylitis (AS) that may completely mimic Pott's paraplegia, leading to occasional but expensive diagnostic error, as the chemotherapeutic management of the two is different. A case of a patient with the diagnosis of Pott's paraplegia who turned out to have aspergillus spondylitis is described. Issues and difficulties regarding the differentiation between these two forms of spine infection and their therapeutic implications are discussed. We conclude that differential diagnosis of spinal tuberculosis (TB) should include aspergillus spondylitis, as cure of spinal aspergillosis, especially in early stages, is possible with surgery and/or antifungal agents, and morbidity and mortality are high in neglected cases.

Atypical forms of spinal tuberculosis: case report and review of the literature.

OBJECTIVE: The object of this report is to highlight some of the less known atypical features of spinal tuberculosis (TB) in the hope of facilitating early diagnosis. Pure neural arch and sacral TB is rare and the co-existence of these two as widely separated skip lesions in the same patient is even rarer. CLINICAL PRESENTATION: An unusual case of tuberculous process affecting the sacrum as well as the neural arches of upper cervical vertebrae is presented. Neither the clinical features nor the imaging techniques, including radiography, bone scintigraphy, computed tomography, and magnetic resonance imaging, were helpful in establishing the diagnosis. The destructive lesion of the sacrum with a rectally palpable presacral mass was thought to be a chordoma or chondrosarcoma until the patient developed upper cervical cord compression with an extradural myelographic block. Development of this second destructive lesion involving the posterior spinal elements (the neural arch) led to a diagnosis of malignant spinal metastasis. The true diagnosis was only revealed by the histology of the solid tumor-like extradural mass in the upper cervical region and demonstration of acid-fast bacilli (AFB) in the lesion. Anti-TB chemotherapy resulted in complete resolution of sacral and cervical lesions as well as the neurologic deficits. CONCLUSION: Differential diagnosis of the obscure spinal lesion should include tuberculosis, specifically the atypical forms; especially because complete cure is possible with early treatment and neurologic morbidity is high in neglected cases.

Factors affecting the outcome of foetal hydrocephaly.

In this study, the authors attempt to provide an account of the factors that affect the outcome of hydrocephaly in 26 foetuses. The hydrocephalus was related to a myelomeningocele in 35% of patients. Sixty-two percent of foetuses showed intra-uterine progression of their hydrocephalus and 50% were shunted postnatally. At a mean follow up of 2 years, the outcome was considered "fair" in 54% of patients. Our findings demonstrate that in foetal hydrocephaly a more favourable outcome is expected in patients with hydrocephalus which does not progress in utero, in whom the labour is not induced before 36 weeks of gestation, who are delivered vaginally weighing more than 2.5 kg and have a head circumference below the 95th centile and a CT cortical mantle thickness of 2 cm and more and who are treated by CSF shunting. The diagnosis of the foetal hydrocephaly at or before 28 weeks of gestation and the presence of a myelomeningocele did not affect the outcome significantly. Neurosurgeons are reminded to keep an open mind for infants with foetal hydrocephaly and to offer active treatment to patients with a potentially favourable outcome.

Primary midline cranial vault lymphoma simulating a parasagittal meningioma: the role of angiography in preoperative diagnosis.

Primary non-Hodgkin's lymphoma (NHL) of the skull with extra- and intracranial extension without systemic or skeletal manifestation in a non-immunocompromised patient is extremely rare. Up to date, only nine such cases have been reported in the literature and in none was the lesion located in the midline. The authors report a unique case of a primary NHL involving the midline of the cranium. The lesion presented as a slowly growing scalp swelling mimicking a parasagittal meningioma. The angiographic findings of mild vascularity in the periphery of the tumor and downward displacement of a patent superior sagittal sinus indicated that the lesion was unlikely to be a meningioma. Neurosurgeons must maintain a broad differential diagnosis in any patient with a scalp mass eroding through the skull and associated neurological symptoms or signs. An intraoperative frozen section is recommended since the identification of a lymphoma is likely to influence the neurosurgeon's decision about the extent of the surgical excision.

Low rate of shunt revision in tumoural obstructive hydrocephalus.

The authors calculated the shunt revision rate for 77 consecutive patients with tumoural obstructive hydrocephalus. At a mean follow up of 23.7 months, the annual revision rate was 0.06 which is significantly lower than the annual revision rate of 0.39 for other hydrocephalic patients treated during the same period. Shunted patients who had total excision of their lesions had a significantly lower revision rate than patients who had a partial excision or a biopsy. It is therefore, suggested that cases with tumoural obstructive hydrocephalus may represent a subset of hydrocephalic patients who are associated with a relatively low risk of shunt complications. The observation has to be addressed when the role of endoscopic third ventriculostomy in these patients is being considered.

Intraventricular and leptomeningeal dissemination of a pilocytic cerebellar astrocytoma in a child with a ventriculoperitoneal shunt: case report.

Dissemination of a pilocytic cerebellar astrocytoma is a very rare occurrence. So far only eight cases have been reported in the literature and in only one of these cases had the tumour spread into the ventricles. We report a case of a child who presented with communicating hydrocephalus and a small cerebellar lesion. The patient was initially treated by a ventriculoperitoneal (VP) shunt and the lesion was followed-up. Two years later, intraventricular and leptomeningeal dissemination of the tumour which proved to be a pilocytic astrocytoma was documented. The role of the VP shunt in diverting metastasizing tumour cells into the ventricles is discussed.

Intramedullary ossified cavernous angioma of the spinal cord: case report.

A case of a heavily ossified cavernous angioma of the spinal cord along with its histological features and surgical implications is reported. The unusually dense calcification and even bone formation along with the unique eggshell-like cyst formation posed problems in diagnosis and surgical excision. This calcified vascular lesion was treated by subtotal excision.