Ruptured intracranial aneurysms: the outcome of surgical treatment in experienced hands in the period prior to the advent of endovascular coiling.

OBJECTIVES: To evaluate the results of treatment of patients with a ruptured intracranial aneurysm treated by a single experienced vascular neurosurgeon in the period prior to the introduction of endovascular coiling. METHODS: Over a mean (SD) period of 9 (2) years, between January 1990 and June 1999, 245 consecutive patients with ruptured intracranial aneurysms were treated. Patients' details were obtained from a database that had been constructed prospectively. The patients consisted of all those patients treated by the senior author (Mr Maurice-Williams) over this period-that is, every third day on call at his unit. During this period, all patients under the age of 75 years with a diagnosis of subarachnoid haemorrhage were admitted to the neurosurgical unit as soon as was practicable regardless of clinical grade. RESULTS: Of 245 patients, 190 (77.6%) underwent treatment by open surgery using standard microsurgical techniques. At 1 year, the mortality of the operated patients was 2.6%, while 89.5% of the patients had a Glasgow Outcome Score (GOS) of 4 and 5. The overall management outcome (all patients treated, including operated and non-operated cases) at 1 year was: 17.1 % dead while 74.3% had GOS 4 and 5. Of the 190 patients who underwent surgery, 38 (20%) required additional operations, totalling 72 operations in all. Of these, 32 were for hydrocephalus and 17 for the evacuation of intracranial haematomas/collections. Complications of surgery occurred in 56 patients (29.5%). CONCLUSION: Open surgery, despite good eventual results, is associated with a significant rate of re-operations and complications that would probably be largely avoided with endovascular treatment. Nevertheless, although endovascular coiling has these immediate advantages over surgery it is still not certain that the long term results will be superior to surgery which leads to permanent obliteration of the aneurysm. There may still be a need for open surgery in the future.

Topical antibiotics in neurosurgery: a re-evaluation of the Malis technique.

We report the effect on the neurosurgical wound infection rate of a modification of the 'Malis' technique of antibiotic prophylaxis. In this a combination of antibiotics is given in the form of both parenteral administration and wound irrigation. A series of 1173 clean neurosurgical operations was compared with a historical control of 303 operations. Both treatment and control groups were operated on by the same surgeon, using similar surgical techniques. The control group received parenteral pre- and postoperative antibiotics (flucloxacillin and ampicillin). The treatment group (where the parenteral antibiotics used was cephradine) also received wound irrigation with a solution of gentamicin and flucloxacilin. The infection rate was 0.42% in the treatment group (five patients), in the control group it was 3.96% (12 patients). The difference was highly significant (p = 0.00006). We believe that the use of wound irrigation with antibiotics should receive further study.

Extended anterior cervical decompression without fusion: a long-term follow-up study.

We report the long-term outcome in 80 patients who had undergone extended anterior cervical decompression without fusion for cervical nerve root or spinal cord compression. Follow-up ranged from 2 years 4 months to 13 years. Five patients had died from causes unrelated to the original pathology or the surgery. Of the remaining 75 patients, 66 (88%) were symptom free or clearly improved, eight (10%) were unchanged and one patient (1.5%) was worse. Sixty-eight patients (91%) were satisfied with the outcome of treatment. Nineteen patients (25%) had some degree of residual neck pain, but in none was this a major problem. Three patients had required subsequent surgery for cervical disc protrusions at levels adjacent to the first operation, while two patients had developed foraminal stenosis at the level of the surgery and had undergone foraminotomy. One patient had developed a symptomatic flexion deformity. Radiological assessment revealed bony fusion in 71%, some degree of flexion deformity in 13% and some degree of foraminal stenosis in 38%. Our results suggest that the initial good results of extended anterior cervical decompression without fusion are maintained long-term. Although a small number of patients eventually develop problems that might be avoided by an initial spacing procedure/formal fusion, these are no greater than the immediate problems associated with the harvesting and insertion of a bone graft.

Cervical foraminotomy: an effective treatment for cervical spondylotic radiculopathy.

Between 1983 and 1994, posterior cervical foraminotomy as described by Frykholm was performed on 89 patients with exclusively radicular symptoms caused by cervical osteophytes. The main presenting feature was arm pain. Objective neurological signs were present in 50% of the patients. At mean postoperative follow-up of 8.6 months, 95.5% of patients reported excellent or good results, while 4.5% were not improved. No patient was rendered worse following the procedure. There were no deaths and the complication rate was 2.2%. Further surgery for recurrent root symptoms was required by 6.7% of patients. Our findings are in keeping with the good results and low complication rate of this procedure as described in other studies. Informal inquiries suggest that this procedure is not widely used, at any rate in the United Kingdom, and we present this series in order to emphasize the efficacy and safety of this procedure.

Paired colloid cysts of the third and lateral ventricles.

We report the case of a man of aged 27 years who presented with obstructive hydrocephalus caused by a colloid cyst of the third ventricle. He was found to have an additional and larger colloid cyst lying adjacent to it, but within the lateral ventricle. The contents of the two cysts were of different consistency. We have been able to find only one previous report of more than one colloid cyst occurring in the same patient and none where one of the cysts lay within the lateral ventricle.

Delayed surgery for ruptured intracranial aneurysms: a reappraisal.

Delayed aneurysm surgery, once standard practice, is now followed by only a minority of neurosurgeons. We analysed the outcome of such a policy in 400 consecutive patients with ruptured aneurysms treated over a 14-year period. Despite an 'open door' admissions policy, admitting all patients immediately on referral, only 56% arrived within 24 h of the ictus (69% within 72 h). Surgery was generally delayed for 8-10 days in patients in Grades 1 and 2; for higher grade patients often for longer until their condition was stable. Two-hundred-and-eighty-seven patients (72%) underwent surgery, 93% on day 8 or later (78% on day 11 or later). Outcome was assessed at 1 year. For all patients 68% were in Glasgow Outcome Scale Grade 1, while 26% had died. Of the operated patients 88% were in GOS grade 1, while 5% had died (30-day surgical mortality was 3.5%). Fifty-one patients (12.8%) rebled, 30 in the first 10 days. Rebleeding was distributed evenly in time over the first 2 weeks. Eighty-four patients experienced non-haemorrhagic deterioration (NHD) all but 3 within 10 days. NHD peaked at days 4-9. Thirty-three patients died of rebleeding and 16 of NHD, but only 12 of the patients who died from rebleeding were fit for operation at anytime and might have been considered for early surgery. Two of these patients died so soon after admission that surgery could not have been performed leaving 10 patients who might have been saved by early surgery. We review the theoretical advantages of delayed as against early surgery and conclude that it is doubtful whether the timing of surgery has any significant effect on management outcome in line with the conclusions of the Cooperative Study.

Extended anterior cervical discectomy without fusion: a simple and sufficient operation for most cases of cervical degenerative disease.

Of 291 operations performed for cervical degenerative disease causing cord or root involvement over a 12-year period 187 have been treated by extended anterior discectomy without fusion, removing bone on either side of the posterior disc space so as to give a wide exposure of the anterior spinal and root dura. The technique has been used for 73% of the cases operated on in the last four years. Nine patients (4.8%) required an additional posterior decompression for coexisting spinal or root canal stenosis. By the first postoperative follow-up at 2-4 months 94.5% of patients showed clear neurological or functional improvement, 3% were worse and 1.5% had died (the deaths were in elderly patients with severe myelopathy and intercurrent disease). Minor treatable complications occurred in 3.2%. Only two patients (1%) complained of persistent postoperative neck pain. Patients were mobilized immediately after surgery without a collar and most left hospital within 1-4 days. A single level decompression was sufficient in 92% of patients and only one patient required more than two levels to be decompressed. In 79% of cases soft disc protrusions contributed to the compression while in 21% osteophytes alone caused the compression. We believe that this simple technique is a sufficient surgical treatment for the majority of cases of cervical degenerative disease. It does not require a fusion and avoids the specific problems and complications associated with Cloward type operations. We are engaged at present in a long-term follow up study of these patients, but to date no late problems have become apparent.

Two cases of Wegener's granulomatosis involving the pituitary.

We describe two patients with Wegener's granulomatosis involving the pituitary. The diagnosis of Wegener's granulomatosis was inferred from the histological appearance of biopsy tissue and the presence of anti-neutrophil cytoplasmic antibodies with cytoplasmic distribution in the first case, in which disease remained confined to the pituitary, causing anterior and posterior pituitary dysfunction. In the second case the diagnosis was made by the progressive involvement of other organ systems, compatible histology and the presence of anti-neutrophil cytoplasmic antibodies with cytoplasmic distribution. In neither patient did posterior pituitary dysfunction respond to immunosuppressive therapy, despite remission of other features of systemic vasculitis. Panhypopituitarism in association with isolated pituitary Wegener's granulomatosis has not previously been described.

Ossification of the posterior longitudinal ligament mimicking cord compression from a dorsal disc protrusion: a cautionary tale.

A patient with focal anterior compression of the dorsal cord at the level of the D6/7 disc was mistakenly diagnosed as a dorsal disc protrusion on the basis of CT myelography. The CT scanning had been confined to axial views at the level of the cord compression. A transthoracic exploration failed to reveal a disc protrusion and the correct diagnosis, ossification of the posterior longitudinal ligament, was only revealed by a subsequent sagittal CT scan. This case emphasizes the dangers of relying on limited axial imaging in diagnosing a spinal lesion.