Just another case of bacterial meningitis or is it?

Non-traumatic cerebrospinal fluid (CSF) rhinorrhoea is a rare condition. We describe a case of a 62-year-old woman with pneumococcal bacterial meningitis who later was found to have CSF rhinorrhoea secondary to an eroding skull base tumour, which was proven to be pituitary macroadenoma on biopsy. She recovered well from meningitis without any neurological sequelae and underwent trans-sphenoidal surgery for tumour removal as well as dural repair.

Presentation, management and outcomes in acute pituitary apoplexy: a large single-centre experience from the United Kingdom.

OBJECTIVE: To study the presentation, management and outcomes and to apply retrospectively the Pituitary Apoplexy Score (PAS) (United Kingdom (UK) guidelines for management of apoplexy) to a large, single-centre series of patients with acute pituitary apoplexy. DESIGN: Retrospective analysis of casenotes at a single neurosurgical centre in Liverpool, UK. RESULTS: Fifty-five patients [mean age, 52·4 years; median duration of follow-up, 7 years] were identified; 45 of 55 (81%) had nonfunctioning adenomas, four acromegaly and six prolactinomas. Commonest presenting features were acute headache (87%), diplopia (47·2%) and visual field (VF) defects (36%). The most frequent ocular palsy involved the 3rd nerve (81%), followed by 6th nerve (34·6%) and multiple palsies (19%). Twenty-three patients were treated conservatively, and the rest had surgery either within 7 days of presentation or delayed elective surgery. Indications for surgery were deteriorating visual acuity and persistent field defects. Patients presenting with VF defects (n = 20) were more likely to undergo surgery (75%) than to be managed expectantly (25%). There was no difference in the rates of complete/near-complete resolution of VF deficits and cranial nerve palsies between those treated conservatively and those who underwent surgery. Endocrine outcomes were also similar. We were able to calculate the PAS for 46 patients: for the group treated with early surgery mean, PAS was 3·8 and for those managed conservatively or with delayed surgery was 1·8. CONCLUSIONS: Patients without VF deficits or whose visual deficits are stable or improving can be managed expectantly without negative impact on outcomes. Clinical severity based on a PAS ≥ 4 appeared to influence management towards emergency surgical intervention.

Brain biopsy in benign neurological disease.

Brain biopsy is well established in clinical practice when there is suspicion of CNS malignancy. However, there is little consensus regarding the indications for brain biopsy in non-malignant neurological disease. This is due in no small part to limitations in the available literature pertaining to diagnostic brain biopsies. The published evidence largely comprises small, retrospective, single-centre analyses performed over long time periods, including non-homogeneous patient groups with considerable variation in reported outcomes. Here we present pragmatic guidance for those clinicians considering diagnostic brain biopsy in a patient with non-neoplastic neurological disease and highlight practice points with the aim of maximising the probability of gaining clinically useful information from the procedure.

Inner calvarial erosion from traumatic subdural haematoma in infancy.

CASE REPORT: This is a report of a case of a subdural haematoma in infancy of possible non-accidental aetiology with raised pericerebral pressure, which we postulate has eroded the inner table of the cranial bones and resulted in leakage of marrow precursor cells into the extradural space. RESULT: Subdural tapping via the fontanelle has created a channel allowing subsequent ingress of nucleated red cell precursors into the subdural space. This addition to the subdural collection has prolonged its course necessitating subduro-peritoneal shunting.

Clinical databases and data protection: are they compatible?

In the current climate of clinical governance and audit, and in the setting of an active academic unit, an effective clinical database is an invaluable tool. In this article, we will present our neurovascular database, discuss the issues related to setting up the ideal clinical database, discuss the problems related to accurate data input and review the legal requirements of data protection. The success of a clinical database is reflected by the completeness of the data, the accessibility of the information and how useful it has proven to be. After 4 years of experimentation we currently use a database designed on Microsoft Access. The form is a single page. Junior medical staff input the information as medical staff have been found to be the most reliable personnel for data input in terms of accuracy. However, time is generally in short supply amongst this group. For our purposes, the ideal database is one that is simple, that can be used to flag up cases, rather than provide all of the information and ensures a complete dataset. The arrival of the UK 1998 Data Protection Act has put many clinical databases and registries in jeopardy, and introduced further bureaucracy to research. We discuss the Act and its interpretation by the General Medical Council, Medical Research Council, British Medical Association, Department of Health and our own trust with respect to databases and research.

Pressure compensation in shunt-dependent hydrocephalus with CSF shunt malfunction.

This study is a retrospective analysis of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) data from 56 children with active hydrocephalus and cerebrospinal fluid (CSF) shunt malfunction. The pressures were measured from a separately sited CSF access device placed in the frontal horn of the lateral ventricle. Of the patients, 79% had an elevated ICP (mean 20+/-12 mmHg). A subgroup of patients demonstrated ten different forms of CSF-filled swelling. This group had significantly lower ICP recordings (P=0.000075) with a mean ICP of 8.5 mmHg compared with the remainder (22.9 mmHg). This pressure 'compensation' was because of additional nonphysiological accommodation of CSF volume. Overall the CPP was normal in 35% of cases despite normal ICP occurring in only 11% of cases. The CPPs were not significantly different in those with and without compensation. Measurement of ICP may not always be a reliable indicator of shunt malfunction in shunt-dependent children who present with compensatory CSF-filled spaces.

A classification of CSF shunt malfunction.

A classification of dysfunctional shunts is proposed and clarification of the terminology discussed. This is based on experience of successive shunt malfunctions over a 3-year period with the aid of ventricular pressure measurements, imaging and clinical semiology. The classification system is both anatomical and functional.