Cerebrospinal Fluid Diversion for Refractory Intracranial Hypertension in Traumatic Brain Injury: A Single Center Experience.

BACKGROUND: Diversion of cerebrospinal fluid (CSF) is a common neurosurgical procedure for control of intracranial pressure (ICP) in the acute phase after traumatic brain injury (TBI), where medical management is insufficient. CSF can be drained via an external ventricular drain (EVD) or, in selected patients, via a lumbar (external lumbar drain [ELD]) drainage catheter. Considerable variability exists in neurosurgical practice on their use. METHODS: A retrospective service evaluation was completed for patients receiving CSF diversion for ICP control after TBI, from April 2015 to August 2021. Patients were included whom fulfilled local criteria deeming them suitable for either ELD/EVD. Data were extracted from patient notes, including ICP values pre/postdrain insertion and safety data including infection or clinically/radiologically diagnosed tonsillar herniation. RESULTS: Forty-one patients were retrospectively identified (ELD = 30 and EVD = 11). All patients had parenchymal ICP monitoring. Both modalities affected statistically significant decreases in ICP, with relative reductions at 1, 6, and 24 hour pre/postdrainage (at 24-hour ELD P < 0.0001, EVD P < 0.01). Similar rates of ICP control failure, blockage and leak occurred in both groups. A greater proportion of patients with EVD were treated for CSF infection than with ELD. One event of clinical tonsillar herniation is reported, which may have been in part attributable to ELD overdrainage, but which did not result in adverse outcome. CONCLUSIONS: The data presented demonstrate that EVD and ELD can be successful in ICP control after TBI, with ELD limited to carefully selected patients with strict drainage protocols. The findings support prospective study to formally determine the relative risk-benefit profiles of CSF drainage modalities in TBI.

External Lumbar Drainage for Refractory Intracranial Hypertension in Traumatic Brain Injury: A Systematic Review.

Considerable variation exists in the clinical practice of cerebrospinal fluid diversion for medically refractory intracranial hypertension in patients with acute traumatic brain injury (TBI), which is achievable via lumbar or ventricular drainage. This systematic review sought to compile the available evidence for the efficacy and safety of the use of lumbar drains for intracranial pressure (ICP) control. A systematic review of the literature was performed with the search and data extraction performed by two reviewers independently in duplicate. Nine independent studies were identified, enrolling 230 patients, 159 with TBI. Efficacy for ICP control was observed across all studies, with immediate and sustained effect, reducing medical therapy requirements. Lumbar drainage with medical therapy appears effective when used alone and as an adjunct to ventricular drainage. Safety reporting varied in quality. Clinical or radiological incidents of cerebral herniation (with an unclear relationship to lumbar drainage) were observed in 14/230 patients resulting in one incident of morbidity without adverse patient outcome. The available data is generally poor in quality and volume, but supportive of the efficacy of lumbar drainage for ICP control. Few reports of adverse outcomes are suggestive of, but are insufficient to confirm, the safety of use in the appropriate patient and clinical setting. Further large prospective observational studies are required to generate sufficient support of an acceptable safety profile.

Spinal Tumour en Bloc Surgery: A Series of Abandoned Surgical Cases.

Select spinal tumors can be treated with en bloc spondylectomy (EBS) but the surgical complexity and relatively low frequency of eligible tumors render EBS an uncommon procedure. The expanded surgical access encompasses acceptance of relatively high morbidity as a trade-off against improved oncological results and survival. EBS durations can be long with dynamic changes affecting the risk-benefit ratio as the surgery proceeds.  We present a series of cases where we have elected to "abandon" EBS due to adverse findings or rising intraoperative risk along with our lessons learned.  A search of our surgical database for all "en bloc" spinal tumor procedures over a three-year period was performed and 27 operations were identified. Of these, four were abandoned. Two of the four surgeries were halted owing to adverse anatomical findings. One involved significant tumor growth from the interval imaging bringing into question disease control and the other displayed tumor adherence to the lung requiring significant dissection. The further two cases incurred significant blood loss and associated physiological complications of end-organ dysfunction.  Pre-operative embolization (POE), anesthetic monitoring, controlled hypotension, volume replacement, and transfusion optimize our chance of achieving the surgical plan. However, cardiovascular instability must be managed promptly and early warning signs of end-organ injury (lactate, renal output) should not be overlooked. In some situations abandoning the procedure may be in the best interests of the patient.

Cerebrospinal Fluid Diversion for Refractory Intracranial Hypertension: A United Kingdom and Ireland Survey on Practice Variation.

Introduction Diversion of cerebrospinal fluid (CSF) in a traumatic brain injury (TBI) is an established means for achieving control of intracranial pressure (ICP), aimed at improving intracranial homeostasis. The literature and anecdotal reports suggest a variation in practice between neurosurgical centres internationally, with current guidelines advocating ventricular drainage over lumbar drainage. We sought to establish the current neurosurgical practice in the United Kingdom regarding the methods of ICP control in TBI. Methods A 20-point survey was distributed electronically to British and Irish neurosurgeons after ratification by the Society of British Neurological Surgeons. Questions were directed at the clinician's opinion and experience of lumbar drain usage in patients with TBI: frequency, rationale, and experience of complications. Questions on lumbar drain usage in neurovascular patients were asked for practice comparison. Results Thirty-six responses from 21 neurosurgical centres were returned. Twenty-three per cent (23%) of responders reported using lumbar drains for refractory ICP in TBI patients: six units use lumbar drains and 15 do not. Three units showed partial usage, with mixed "yes/no" responses between consultants. Concerns of tonsillar herniation and familiarity with EVD were commonly given reasons against the usage of lumbar drains. Fifty-six per cent (56%) reported use in neurovascular patients. Conclusion This contemporary practice survey demonstrates mixed practice across the UK and within some centres. Responses and survey feedback demonstrate that the use of lumbar drains in TBI is a polarising topic. The variety of practice between and within neurosurgical units supports consideration of the prospective study of CSF diversion methods for control of refractory ICP in patients with TBI.

A rare case of inferior vena cava occlusion secondary to abdominal pseudocyst associated with ventriculoperitoneal shunt-case report and review of literature.

BACKGROUND AND IMPORTANCE: Abdominal pseudocyst (APC) is an uncommon but well-recognised complication of ventriculo-peritoneal (VP) shunt. Diagnosis is based on clinical features of shunt malfunction, including headaches, vomiting and drowsiness, and abdominal swelling. APCs can grow to large sizes resulting in compression of abdominal viscera; however, inferior vena cava (IVC) compression is extremely rare, and only one other case associated with VP shunt had been reported. CLINICAL PRESENTATION: We report a case of a 12-year-old girl with a background of open myelomeningocoele repair, kyphoscoliosis and right-sided VP shunt in situ who presented with bilateral lower limb swelling and abdominal distension. She exhibited no features of raised intracranial pressure but had bilateral pitting oedema up to the groin. Abdominal ultrasound and CT scan showed a massive septated pseudocyst (20 × 18 × 8 cm) compressing the IVC. The APC was drained, and the shunt was externalised, with conversion to a ventriculo-atrial (VA) shunt 1 week later after cultures of the cystic fluid, cerebrospinal fluid and shunt tube came back sterile. The patient remained well with no recurrence of the abdominal fluid and no VA shunt complication at 36-month follow-up. CONCLUSION: This patient had specific risk factors for development of a massive APC and the subsequent IVC compression, including prior surgeries, spinal deformity, abnormal abdominal anatomy and poor abdominal muscle tone and sensation. Early recognition of this complication and prompt alleviation of the mass effect of IVC compression can prevent long-term neurological and vascular sequalae.

Factors Influencing Surgical Outcomes for Intradural Spinal Tumours: A Single-Centre Retrospective Cohort Study.

Introduction Intradural spinal tumours are relatively uncommon tumours of the central nervous system. In this study, we sought to assess our current practice and determine the factors which affect the surgical outcomes of intradural spinal tumour resection. Methods All consecutive patients who underwent surgical resection of intradural spinal tumours from December 2011 to November 2018 were retrospectively reviewed. The Modified McCormick Scale (MMS) was used to grade patients' neurological status both pre-operatively and at the latest follow-up. The associations between changes in MMS and variables such as patient demographics, tumour location, number and experience of consultants involved in the procedure, use of intraoperative neuro-monitoring, bony spinal exposure and dural closure methods were assessed. A multivariable binary logistic regression model was performed to identify independent predictors of improvements in MMS. All analyses were performed using IBM SPSS 22 (IBM Corp. Armonk, NY), with p<0.05 deemed to be indicative of statistical significance throughout. Results A total of 145 patients met the inclusion criteria, with a median age of 56.5 years; of whom 119 had extramedullary tumours and 26 had intramedullary tumours. Methods of dural closure were variable, and there was an increasing trend over time towards using the laminoplasty approach for bony exposure. Neither the experience of consultants (p=0.991) nor the number of consultants involved (p=0.084) was found to be significantly associated with the change in MMS, with the strongest predictor being the baseline MMS (p<0.001). Patients who had adjuvant therapy were also significantly more likely to have a poorer neurological outcome (p=0.001). Conclusion A good neurological baseline is a significant positive predictor of an improved functional outcome. The number and seniority of consultant surgeons involved in intradural spinal tumour resections did not significantly alter the postoperative outcomes of patients in our single-unit retrospective study.

The Neurology and Neurosurgery Interest Group (NANSIG)-ten years of cultivating interest in clinical neurosciences.

Collaboration and successful teamworking are important components of clinical practise, and these skills should be cultivated early in medical school. The breadth of current medical school curricula means that students often have limited exposure to clinical neurosciences. Since its inception in 2009, the Neurology and Neurosurgery Interest Group (NANSIG) has become a national (UK and Republic of Ireland) example of student and junior doctor synergistic collaboration to deliver educational materials, research, conferences, seminars and workshops, as well as advocating for diversity in this field. Recently, it has expanded to incorporate an international audience and cater for a larger group of young medical professionals. The organisation has overcome numerous challenges and is constantly innovating new approaches to harness the necessary knowledge, skills and network to succeed in a career in neurosciences, neurology and neurosurgery. This article summarises the initiatives undertaken by the group over its first 10 years of existence and its organisational structure, as well as its future plans.

CovidNeuroOnc: A UK multicenter, prospective cohort study of the impact of the COVID-19 pandemic on the neuro-oncology service.

BACKGROUND: The COVID-19 pandemic has profoundly affected cancer services. Our objective was to determine the effect of the COVID-19 pandemic on decision making and the resulting outcomes for patients with newly diagnosed or recurrent intracranial tumors. METHODS: We performed a multicenter prospective study of all adult patients discussed in weekly neuro-oncology and skull base multidisciplinary team meetings who had a newly diagnosed or recurrent intracranial (excluding pituitary) tumor between 01 April and 31 May 2020. All patients had at least 30-day follow-up data. Descriptive statistical reporting was used. RESULTS: There were 1357 referrals for newly diagnosed or recurrent intracranial tumors across 15 neuro-oncology centers. Of centers with all intracranial tumors, a change in initial management was reported in 8.6% of cases (n = 104/1210). Decisions to change the management plan reduced over time from a peak of 19% referrals at the start of the study to 0% by the end of the study period. Changes in management were reported in 16% (n = 75/466) of cases previously recommended for surgery and 28% of cases previously recommended for chemotherapy (n = 20/72). The reported SARS-CoV-2 infection rate was similar in surgical and non-surgical patients (2.6% vs. 2.4%, P > .9). CONCLUSIONS: Disruption to neuro-oncology services in the UK caused by the COVID-19 pandemic was most marked in the first month, affecting all diagnoses. Patients considered for chemotherapy were most affected. In those recommended surgical treatment this was successfully completed. Longer-term outcome data will evaluate oncological treatments received by these patients and overall survival.