Infective endocarditis as a complication of longstanding ventriculoatrial (VA) shunt: the importance of suspicion and early investigation in patients with VA shunt and pyrexia of unknown origin.

Ventriculoatrial (VA) shunts are a method of cerebrospinal fluid diversion, which nowadays are infrequently seen in medical practice. Infective endocarditis (IE) can occur as rare complications of VA shunts, through the introduction of a foreign body close to the tricuspid valve. We report a case of infective endocarditis, that is, in a patient with VA shunt for congenital hydrocephalus. We present the case to highlight the importance of early investigation for IE in patients with fever of unknown origin and shunt in situ, as rapid deterioration can occur and be fatal. We also discuss past experience reported in the literature on the role of cardiothoracic intervention. Prompt diagnosis and early cardiothoracic referral for surgery are crucial, there may only be a narrow window of opportunity for intervention before patients develop fulminant sepsis.

Survival after traumatic brain injury improves with deployment of neurosurgeons: a comparison of US and UK military treatment facilities during the Iraq and Afghanistan conflicts.

INTRODUCTION: Traumatic brain injury (TBI) is the most common cause of death on the modern battlefield. In recent conflicts in Iraq and Afghanistan, the US typically deployed neurosurgeons to medical treatment facilities (MTFs), while the UK did not. Our aim was to compare the incidence, TBI and treatment in US and UK-led military MTF to ascertain if differences in deployed trauma systems affected outcomes. METHODS: The US and UK Combat Trauma Registries were scrutinised for patients with HI at deployed MTFs between March 2003 and October 2011. Registry datasets were adapted to stratify TBI using the Mayo Classification System for Traumatic Brain Injury Severity. An adjusted multiple logistic regression model was performed using fatality as the binomial dependent variable and treatment in a US-MTF or UK-MTF, surgical decompression, US military casualty and surgery performed by a neurosurgeon as independent variables. RESULTS: 15 031 patients arrived alive at military MTF after TBI. Presence of a neurosurgeon was associated with increased odds of survival in casualties with moderate or severe TBI (p<0.0001, OR 2.71, 95% CI 2.34 to 4.73). High injury severity (Injury Severity Scores 25-75) was significantly associated with a lower survival (OR 4×104, 95% CI 1.61×104 to 110.6×104, p<0.001); however, having a neurosurgeon present still remained significantly positively associated with survival (OR 3.25, 95% CI 2.71 to 3.91, p<0.001). CONCLUSIONS: Presence of neurosurgeons increased the likelihood of survival after TBI. We therefore recommend that the UK should deploy neurosurgeons to forward military MTF whenever possible in line with their US counterparts.

Speech bubble: dysphasia secondary to spontaneous intraparenchymal pneumocephalus.

Spontaneous pneumocephalus is exceptionally rare, with few published cases in the literature. We describe a patient presenting with dysphasia, right facial weakness, headache and confusion who was subsequently found to have pneumocephalus due to an encephalocoele herniating into a tegmen tympani defect.

A preliminary study into injuries due to non-perforating ballistic impacts into soft body armour over the spine.

The UK Home Office test method for ballistic protective police body armours considers anterior torso impacts to be the worst-case scenario and tests rear armour panels to the same standards as front panels. The aim of this paper was to examine the injuries from spinal behind armour blunt trauma (BABT) impacts. This study used a cadaveric 65 kg, female pig barrel and 9 mm Luger ammunition (9 × 19 mm, FMJ Nammo Lapur Oy) into HG1/A + KR1 soft armour panels over the spine. Injuries were inspected and sections removed for x-radiography and micro-CT assessment. All shots over the spine resulted in deep soft tissue injuries from pencilling of the armour and the shirt worn under the armour. The wounds had embedded fabric debris which would require surgery to remove resulting in increased recovery time over injuries usually seen in anterior torso BABT impacts, which are typically haematoma and fractured ribs. The shot with the deepest soft tissue wound (41 mm) also resulted in a fractured spinous process. Shots were also fired at the posterior and anterior rib area of the pig barrel, for comparison to the spine. Similar wounds were seen on the shots to the posterior rib area while shallower, smaller wounds were seen on the anterior and one anterior rib shot resulted in a single, un-displaced rib fracture. The anatomical differences between pigs and humans would most likely mean that injury to a human from these impacts would be more serious.

Obstructive hydrocephalus secondary to odontoid pannus: case report and review of literature.

Odontoid pannus or periodontoid pseudotumour is associated with a variety of rheumatological conditions. We report a case of an 80-year old man who presented with acute hydrocephalus following an emergency operation to amputate his infected left big toe. Imaging revealed a large tissue mass causing severe compression at the cervico-medullary junction and obstruction of CSF flow. The acute hydrocephalus was presumed to be related to neck manoeuvring during general anaesthesia. Following an initial emergency CSF diversion through external ventricular drainage catheter insertion, the patient subsequently underwent ventriculo-peritoneal insertion and posterior spinal decompression and fixation. To our knowledge, there have been no reported cases of tophaceous gout of the odontoid pannus causing acute hydrocephalus.

Autologous cranioplasty following decompressive craniectomy in the trauma setting.

BACKGROUND: Decompressive craniectomy (DC) is an option for the treatment of increased intracranial pressure resulting from an acute neurological insult, including insults caused by trauma. When the brain swelling has receded, the skull is reconstructed with a wide choice of materials, each with its own advantages and disadvantages in terms of cost, cosmetic appearance, biocompatibility, implant strength and complication rate. Autologous cranioplasty (AC), where the patient's own bone flap is stored and reutilised, is common in many countries. No outcome studies have, however, been published on this technique for traumatic injuries. METHODS: A retrospective study was conducted including all AC operations performed following DC due to traumatic brain injury. All operations were performed in one institution during a 4-year time period. Results were analysed for complication rates. RESULTS: 44 cases were included. The mean time from craniotomy to cranioplasty was 86 (95% CI: 63-109) days. Complications severe enough to warrant readmission or further surgery were found in 13 cases (30%). No statistically significant predictor of complication from cranioplasty was detected. The complication rate was similar to published data on cranioplasty using artificial prosthetic materials. CONCLUSIONS: AC in the trauma setting is a valid treatment option with a complication rate that seems no worse than other alternatives.

Proposal for establishment of the UK Cranial Reconstruction Registry (UKCRR).

BACKGROUND: The increasing utilisation of decompressive craniectomy for traumatic brain injury and stroke has led to an increase in the number of cranioplasties undertaken. Cranioplasty is also undertaken following excision of tumours originating from or invading the skull vault, removal of bone flaps due to post-operative infection, and decompressive craniectomy for the management of rarer causes of brain oedema and/or refractory intracranial hypertension. The existing literature which mainly consists of single-centre, retrospective studies, shows a significant variation in practice patterns and a wide range of morbidity. There also exists a need to measure the outcome as perceived by the patients themselves with patient reported outcome measures (PROMs; functional outcome, quality of life, satisfaction with cosmesis). In the UK, the concept of long-term surveillance of neurosurgical implants is well established with the UK shunt registry. Based on this background, we propose to establish the UK Cranial Reconstruction Registry (UKCRR). AIM: The overarching aim of the UKCRR is to collect high-quality data about cranioplasties undertaken across the UK and Ireland in order to improve outcomes for patients. METHODS: Any patient undergoing reconstruction of the skull vault with autologous bone, titanium, or synthetic material in participating units will be eligible for inclusion. Data will be submitted directly by participating units to the Outcome Registry Intervention and Operation Network secure platform. A Steering Committee will be responsible for overseeing the strategic direction and running of the UKCRR. OUTCOME MEASURES: These will include re-operation due to a cranioplasty-related issue, surgical site infection, re-admission due to a cranioplasty-related issue, unplanned post-operative escalation of care, adverse events, length of stay in admitting unit, destination at discharge from admitting unit, mortality at discharge from admitting unit, neurological status and PROMs during routine follow-up. CONCLUSION: The UKCRR will be an important pillar in the ongoing efforts to optimise the outcomes of patients undergoing cranioplasty.

Spontaneous regression of a cystic hypoglossal schwannoma causing unilateral tongue atrophy.

A 60-year-old lady presented with intermittent headaches. Examination revealed striking marked unilateral tongue atrophy. Magnetic resonance imaging (MRI) revealed a cystic lesion in the hypoglossal canal and a provisional diagnosis of cystic hypoglossal schwannoma made. Annual surveillance scans showed stable appearances but surprisingly at 3 years they showed a significant reduction in the size of the lesion. Most patients with hypoglossal schwannomas present with ipsilateral hypoglossal nerve palsy; careful cranial nerve examination is vital in diagnosing such rare lesions. Little is known of their natural history, with most lesions undergoing surgery. This case highlights spontaneous regression following non-operative management.

A prospective study of the safety and efficacy of frameless, pinless electromagnetic image-guided biopsy of cerebral lesions.

BACKGROUND: In recent years, frameless navigation techniques have been reported to be safe and effective for biopsy of cerebral lesions. OBJECTIVE: To evaluate the safety and efficacy of a technique of frameless, pinless electromagnetic-guided biopsy for brain lesions with the Medtronic Stealth AxiEM. METHODS: Prospective data were collected on consecutive brain biopsies performed by a single surgeon (P.L.G.) with this technology between October 2007 and May 2010. One trajectory was made per lesion with multiple specimens taken for analysis. Outcome measures included measures of accuracy, histological yield, and complication rate. RESULTS: A total of 150 biopsies were performed in 149 patients (84 male and 65 female patients; age range, 19.8-83.8 years). The consultant performed 49 procedures, supervising a trainee in the others. In only 1 case (0.7%) was there nondiagnosis consequent of a registration error and inaccurate trajectory. In 4 other cases (2.7%), no specific diagnosis was established, but abnormal tissue was identified histologically, and postoperative imaging confirmed accurate targeting of these lesions. There were no instances of intracranial hemorrhage or significant morbidity and no deaths directly attributable to the procedure. Four patients (2.7%) died within 30 days of the procedure but not of complications of surgery. One patient suffered a transitory neurological deficit. CONCLUSION: Electromagnetic navigation is proven to be a simple, safe, and effective innovation for frameless and pinless biopsy of cerebral lesions. This technique is time efficient, and elimination of frame placement enhances patient comfort and facilitates the use of local anesthetic technique.

Giant prolactinoma causing cranio-cervical junction instability: a case report.

Prolactinomas are common secretory pituitary tumours, usually managed with dopamine agonists. There have previously been case reports of rarer giant prolactinomas causing invasion of surrounding structures. We describe a case report of an exceptionally aggressive giant prolactinoma that eroded the occipital condyles causing cranio-cervical joint instability mandating surgical fixation.

A review of casualties during the Iraqi insurgency 2006--a British field hospital experience.

BACKGROUND: Following the invasion of Iraq in April 2003, British and coalition forces have been conducting counter-insurgency operations in the country. As this conflict has evolved from asymmetric warfare, the mechanism and spectrum of injury sustained through hostile action (HA) was investigated. METHOD: Data was collected on all casualties of HA who presented to the British Military Field Hospital Shaibah (BMFHS) between January and October 2006. The mechanism of injury, anatomical distribution, ICD-9 diagnosis and initial discharge information was recorded for each patient in a trauma database. RESULTS: There were 104 HA casualties during the study period. 18 were killed in action (KIA, 21%). Of the remaining 86 surviving casualties, a further three died of their wounds (DOW, 3.5%). The mean number of diagnoses per survivor was 2.70, and the mean number of anatomical regions injured was 2.38. Wounds to the extremities accounted for 67.8% of all injuries, a percentage consistent with battlefield injuries sustained since World War II. Open wounds and fractures were the most common diagnosis (73.8%) amongst survivors of HA. Improvised explosive devices (IEDs) accounted for the most common cause of injury amongst casualties (54%). CONCLUSIONS: Injuries in conflict produce a pattern of injury that is not seen in routine UK surgical practice. In an era of increasing surgical sub-specialisation, the deployed surgeon needs to acquire and maintain a wide range of skills from a variety of surgical specialties. IEDs have become the modus operandi for terrorists. In the current global security situation, these tactics can be equally employed against civilian targets. Therefore, knowledge and training in the management of these injuries is relevant to both military and civilian surgeons.

Injuries from roadside improvised explosive devices.

BACKGROUND: After the invasion of Iraq in April 2003, coalition forces have remained in the country in a bid to maintain stability and support the local security forces. The improvised explosive device (IED) has been widely used by the insurgents and is the leading cause of death and injury among Coalition troops in the region. METHOD: From January 2006, data were prospectively collected on 100 consecutive casualties who were either injured or killed in hostile action. Mechanism of injury, new Injury Severity Score (NISS), The International Classification of Disease-9th edition diagnosis, anatomic pattern of wounding, and operative management were recorded in a trauma registry. The weapon incident reports were analyzed to ascertain the type of IED employed. RESULTS: Of the 100 casualties injured in hostile action, 53 casualties were injured by IEDs in 23 incidents (mean 2.3 casualties per incident). Twenty-one of 23 (91.3%) of the IEDs employed were explosive formed projectile (EFP) type. Twelve casualties (22.6%) were either killed or died of wounds. Median NISS score of survivors was 3 (range, 1-50). All fatalities sustained unsurvivable injuries with a NISS score of 75. Primary blast injuries were seen in only 2 (3.8%) and thermal injuries in 8 casualties (15.1%). Twenty (48.7%) of survivors underwent surgery by British surgeons in the field hospital. At 18 months follow, all but one of the United Kingdom Service personnel had returned to military employment. CONCLUSIONS: The injury profile seen with EFP-IEDs does not follow the traditional pattern of injuries seen with conventional high explosives. Primary blast injuries were uncommon despite all casualties being in close proximity to the explosion. When the EFP-IED is detonated, the EFP produced results in catastrophic injuries to casualties caught in its path, but causes relatively minor injuries to personnel sited adjacent to its trajectory. Improvements in vehicle protection may prevent the EFP from entering the passenger compartments and thereby reduce fatalities.