A survey of selected key areas of management of South African neurosurgical patients.

BACKGROUND: Previous surveys of neurosurgical patient management, including a South African (SA) survey conducted in 2001, confirmed the existence of significant dissimilarities in management on national and international levels. This survey aimed to determine current SA neurosurgical patient management and to compare this with international trends. METHOD: Questionnaires in multiple choice question (MCQ) and free text entry format covering key areas of neurosurgical practice were emailed to SA neurosurgeons following ethics approval. All responses were captured anonymously. RESULTS: The response rate was 53%. Demographically only 5.7% respondents were younger than 40 years, 59.3% obtained a local college fellowship, 14.8% an international fellowship, 40.7% a MMed and 16.6% obtained more than one postgraduate qualification. Public sector specialists predominantly practised intracranial surgery (69%) while private specialists practised mainly spinal surgery (58%). Years in specialist practice were negatively associated with endoscopic surgery (p = 0.014) and decompressive craniectomies (p = 0.008) but not with other more recently introduced techniques including pedicle screws, neuro-navigation and cell-saver techniques. Age per se had no influence on practice. In subarachnoid haemorrhage (SAH) disease, 88% routinely administered nimodipine, 8% restricting its use to managing vasospasm. Endovascular coiling, more recently introduced for intracranial aneurysm management, was preferred to surgical clipping (54%); 69% preferred total intravenous to inhalational anaesthesia with propofol primarily replacing thiopentone for brain protection. 27% still utilised the sitting position. Only one incident of a postoperative visual defect was recorded with prone positioning. CONCLUSION: With the exception of endoscopic and decompressive craniectomy surgery, overall management in key areas surveyed was in line with international trends.

Operative sepsis in neurosurgery: a method of classifying surgical cases.

Neurosurgical operations have traditionally been classified along the lines of general surgical procedures. A prospective study, during an 18-month period, was undertaken in 2249 patients undergoing neurosurgical procedures to establish and evaluate a method of classifying surgical cases by the use of specific neurosurgical criteria. Patients were placed in one of five categories according to the level and type of contamination at the time of surgery. Infection included all abnormal wounds and was documented as deep when infection occurred beneath the galea (subgaleal pus, osteitis, abscess/empyema, ventriculomeningitis) and as superficial if only the scalp (including wound erythema) was involved. A statistically significant difference in the sepsis rate was found in the different categories (P < 0.0001). Of the 342 "dirty cases," 9.1% of patients developed further wound sepsis. Concomitant cerebrospinal fluid fistulae (44%), second operations (11.8%), and patients with penetrating injuries (9.2%) were the major factors implicated in sepsis in the "contaminated" category (9.7%). In the "clean contaminated" category, a sepsis rate of 6.8% was found. Prolonged surgery (longer than 4 hours) was also implicated in higher infection rates (13.4%). This study strongly supports the separation of patients who have foreign materials implanted (sepsis rate = 6.0%) from "clean" patients, essentially cases categorized as having no known risk factors that may affect sepsis, in whom a sepsis rate of 0.8% was found (P < 0.001). Importantly, surgery for the repair of so-called "clean" neural tube defects in neonates requires separate consideration. An infection rate of 14.8% existed in this subgroup. A uniform system of reporting wound abnormalities is also proposed.

The use of transcranial Doppler ultrasonography as a method of assessing intracranial pressure in hydrocephalic children.

Previous studies in children have shown a strong correlation between raised intracranial pressure (RICP) and the Gosling pulsatility index (PI) as determined by transcranial Doppler ultrasonography (TCD). This diagnostic modality can, therefore, be used as a non-invasive method for the indirect evaluation of shunt function in children with hydrocephalus. Transcranial Doppler waveform analyses were done in 15 children with hydrocephalus, before and after insertion of a ventriculo-peritoneal shunt. All had clinical evidence of raised intracranial pressure (ICP) prior to surgery. CT had demonstrated dilated ventricles and, in some, additional features of RICP. Fifteen children without clinical and CT evidence of hydrocephalus were examined in an identical manner to act as a control group. The results clearly demonstrated that TCD may be a useful, non-invasive means of assessing the need for a cerebrospinal fluid (CSF) diversionary procedure and also for follow-up and monitoring.

Penetrating stab wounds to the brain: the timing of angiography in patients presenting with the weapon already removed.

Angiography is always necessary in patients with penetrating stab wounds to the head, to exclude unexpected vascular lesions. The most important, since they are seldom clinically evident, are traumatic aneurysms and arteriovenous fistulae. It has previously been proposed that carotid angiography should be delayed until the start of the second week, to allow for better visualization of these complications. However, traumatic aneurysms can rupture at any time after the injury, and the mortality resulting from a second hemorrhage is unacceptably high. A prospective study was undertaken in which 330 patients with penetrating stab wounds to the head underwent angiography as soon as possible after admission. In 250 of these patients (76%), the weapon had already been removed by the assailant, and there was radiological evidence of penetration of the dura. Of these 250, 130 patients underwent angiography within 7 days of the injury. Another 51 patients, who presented late, underwent angiography more than 7 days after the injury. The timing of angiography did not affect the identification of traumatic aneurysms, the incidence of which was 12% in both groups. Of the patients with cranial stabs and who required urgent evacuation of intracerebral hematomas, 10% had traumatic aneurysms that could be dealt with simultaneously. No patient in this series suffered a secondary hemorrhage. We conclude that it is neither necessary nor safe to delay angiography. In some patients, either because of vasospasm or "cut-off" of a vessel, a second angiogram may be necessary to further elucidate a vascular abnormality that might not have been evident originally.

Prevention of death from head injury in Natal.

A detailed review of 100 consecutive head injury deaths in the Natal area was undertaken after forensic autopsies had been performed; neurohistological examination was carried out in 69 cases. It was found that one-third of deaths could have been prevented by medical treatment. Hypoxic and ischaemic brain damage was judged to be a contributing cause of death in 88% of all victims. Factors isolated as major causes of preventable death included: failure to prevent hypoxic brain damage by timeous endotracheal intubation and rapid resuscitation; major delays in referral from feeder hospitals; and failure to detect intracerebral haematomas and contusions which subsequently caused raised intracranial pressure. Recommendations for improving this situation are discussed, with particular reference to the situation in Natal.

Moyamoya disease as a cause of subarachnoid haemorrhage. A case report.

A woman with a subarachnoid haemorrhage secondary to an aneurysm associated with moyamoya disease is reported. Moyamoya disease is a rare but well-described disease of the intracranial carotid artery, characterised by an unusual vascular network at the base of the brain.