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Background: The aim of this study was to identify prognostic factors associated with resection of intracranial metastases. Methods: A retrospective case series including patients who underwent resection of cranial metastases from March 2014 to April 2021 at a single center. This identified 112 patients who underwent 124 resections. The median age was 65 years old (24-84) and the most frequent primary cancers were nonsmall cell lung cancer (56%), breast adenocarcinoma (13%), melanoma (6%), and colorectal adenocarcinoma (6%). Postoperative MRI with contrast was performed within 48 hours in 56% of patients and radiation treatment was administered in 41%. GraphPad Prism 9.2.0 was used for the survival analysis. Results: At the time of data collection, 23% were still alive with a median follow-up of 1070 days (68-2484). The 30- and 90-day, and 1- and 5-year overall survival rates were 93%, 83%, 35%, and 17%, respectively. The most common causes of death within 90 days were as follows: unknown (32%), systemic or intracranial disease progression (26%), and pneumonia (21%). Age and extent of neurosurgical resection were associated with overall survival (P < 0.05). Patients aged >70 had a median survival of 5.4 months compared with 9.7, 11.4, and 11.4 for patients <50, 50-59, and 60-69, respectively. Gross-total resection achieved an overall survival of 11.8 months whereas sub-total, debulking, and unclear extent of resection led to a median survival of 5.7, 7.0, and 9.0 months, respectively. Conclusion: Age and extent of resection are potential predictors of long-term survival.
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BACKGROUND: Posterior fossa surgery in the supine position remains a relatively underutilised approach, compared to the routinely performed prone, park-bench or sitting positions. This surgical approach may confer additional advantages over other modalities commonly restricted by patient co-morbidity and anaesthetic concerns. The purpose of this article is to highlight this approach as a potential viable, safe and alternative approach. METHODS: We retrospectively collected data of all supine infra-tentorial/posterior fossa surgery by one surgeon between 2015 and the present via our electronic patient record system. Demographic data alongside duration of surgery, ASA grading, location of lesions, length of stay, presence of post-operative infections, presence of post-operative CSF leak/pseudomeningocele and post-operative mortality were assessed. RESULTS: A total of 64 procedures on 58 patients were identified. Of the procedures, 60 were performed for neoplasms (93.8%). Mean overall surgical time was 176 min. Median ASA grade for tumour surgery was 3. Median length of stay was 3 days. Of the non-emergency tumour cases (n = 53), 43 (81.1%) lesions were located in the cerebellar hemisphere, the remainder were in the vermis and tentorium. There were 6 documented post-operative infections (9.4%). The rates of CSF-related complications were: CSF Leak 1.6% (1/64) and Pseudomeningocele 1.6% (1/64). 30-day mortality was 1.6% (1/64). CONCLUSION: This study suggests that supine positioning is a safe alternative to be considered when operating upon posterior fossa lesions. Further studies are warranted to assess efficacy of this approach, but it can be considered for wider use in the UK and further afield.
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Neurocirugia , Fosa Craneal Posterior/cirugía , Estudios de Factibilidad , Humanos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/patología , Estudios Retrospectivos , Posición Supina , Reino UnidoRESUMEN
There has been a growing anxiety in carrying out awake craniotomy surgeries during the SARS-CoV-2 pandemic, not only due to airway management but also close proximity to the team in theatre. We set out to safely perform the first documented awake craniotomy in the UK since the beginning of lockdown. We performed a thorough workup of the patient with minimal hospital visits, using remote communication wherever possible. We modified our existing awake craniotomy protocol/technique guided by local/national policies. An asleep-awake-asleep craniotomy for tumour resection was performed successfully without compromising patient and staff safety with excellent post-operative outcome. With appropriate pre- and peri-operative modifications to established protocols, awake craniotomies with functional mapping can be safely carried out. By incorporating novel aspects to our technique, we believe that this service can safely resume in carefully selected patients.
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Neoplasias Encefálicas/cirugía , COVID-19/epidemiología , Craneotomía/métodos , Glioma/cirugía , Adulto , Estudios de Factibilidad , Femenino , Humanos , Masculino , Pandemias , SARS-CoV-2/aislamiento & purificación , VigiliaRESUMEN
We describe the case of a 52 year old male presenting with subacute headache. Cranial imaging suggested haemorrhage into a parietal, partially intraventricular, space occupying lesion. The radiology was interpreted to be most consistent with a glioblastoma. The lesion was near totally resected. The histopathology was a WHO grade 1 schwannoma.
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Neoplasias Encefálicas/patología , Neurilemoma/patología , Neoplasias Encefálicas/cirugía , Hemorragia Cerebral/patología , Hemorragia Cerebral/cirugía , Diagnóstico Diferencial , Glioblastoma/patología , Cefalea/etiología , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Neurilemoma/cirugía , Tomografía Computarizada por Rayos XRESUMEN
INTRODUCTION: Cauda equina syndrome (CES) is a condition with significant implications and medico-legal profile. The literature still lacks large primary studies to provide strong evidence for a robust management pathway. Statements from Neurosurgical and Spinal societies support early diagnosis and imaging but this has not resulted in any noticeable shift in referral pattern. We strongly feel the need for a nationally agreed, evidence-based referral pathway in practice. We present our large series and in-depth analysis of the referral pathway to provide strong evidence for more robust referrals and management. METHODS: We reviewed 250 referrals of suspected CES (sCES) to the regional neurosurgical unit, evaluating the importance of clinical findings and the imaging pathway. RESULTS: After clinico-radiological evaluation only 32 (13%) had confirmed CES requiring urgent surgery. There was no significant difference in terms of clinical presentation between these true cases of CES (tCES) and false cases (fCES). Imaging was therefore the key rate-limiting step. MRI was the most common investigation used. 73 patients presented without imaging out of hours (OOH). In this group, investigation was delayed to the next day in 60/73 (82%) patients while only 13 (18%) patients underwent OOH MRI. Only 2 (3%) were able to have this at their local hospital. CONCLUSIONS: As with previous studies we conclude that signs/symptoms are insufficient to identify tCES. Taking into consideration the improved outcome with early diagnosis, the importance of early scanning in diagnosing tCES, and the poor availability of OOH MRI scanning outside of neurosurgical units, we recommend a national policy of 24/7 MRI availability for cases of sCES at all hospitals with MRI scanners. This would remove the 87% of patients not requiring urgent surgery from an unnecessary and distracting referral process.
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Implementación de Plan de Salud/organización & administración , Polirradiculopatía/diagnóstico , Derivación y Consulta/organización & administración , Adulto , Anciano , Anciano de 80 o más Años , Descompresión Quirúrgica , Medicina Basada en la Evidencia , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Evaluación de Procesos y Resultados en Atención de Salud , Polirradiculopatía/terapia , Estudios Retrospectivos , Estadística como Asunto , Reino Unido , Adulto JovenRESUMEN
INTRODUCTION: Pituitary surgery has seen a recent shift from a microscopic to an endoscopic trans-sphenoidal approach. We present our early experience with endoscopic surgery and compare the outcome with our recent microscopic experience. METHODS: From January 2008 until present time, 80 consecutive patients underwent trans-sphenoidal pituitary surgery in our institution. Until September 2009, all patients had a microscopic trans-septal approach. After this time, the patients underwent endoscopic trans-sphenoidal surgery. All patients underwent pre- and post-operative MRI and full endocrinological evaluation. Data was collected prospectively including tumour volume, endocrine function, visual function, length of stay and complications. RESULTS: There were 40 patients in each group. In the microscopic group, there were 26 non-functioning tumours and 14 functioning tumours. In the endoscopic group, there were 24 non-functioning and 16 functioning tumours. There were significantly better results in terms of tumour resection (p = 0.002) and remission (p = 0.018) in the endoscopic group. In this group there was also a lower incidence of CSF leaks and a shorter length of stay for secreting tumours (p = 0.005). 1 patient in the endoscopic group died at day 43 post-operatively, having initially presented in a poor clinical state with pituitary apoplexy. CONCLUSION: Microscopic trans-sphenoidal surgery remains the benchmark for future surgical techniques. Our early results suggest that endoscopic trans-sphenoidal surgery provides favourable results in both tumour resection and control of secreting tumours in comparison with microscopic surgery. Further longer-term evaluation is required to ensure the outcome of endoscopic surgery.
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Adenoma/cirugía , Microcirugia/métodos , Neuroendoscopía/métodos , Neoplasias Hipofisarias/cirugía , Adenoma/patología , Adulto , Anciano , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Neoplasia Residual/patología , Neoplasias Hipofisarias/patología , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Hueso Esfenoides/cirugía , Carga Tumoral , Adulto JovenRESUMEN
OBJECT: The role of radiosurgery in the treatment of cavernous malformations (CMs) remains controversial. It is frequently recommended only for inoperable lesions that have bled at least twice. Rehemorrhage can carry a substantial risk of morbidity, however. The authors reviewed their practice of treating deep-seated inoperable CMs to assess the complication rate of radiosurgery, the impact that radiosurgery might have on rebleeding, and whether a more active, earlier intervention is justified in managing this condition. METHODS: The authors performed a retrospective analysis of 113 patients with 79 brainstem and 39 thalamic/basal ganglia CMs treated with Gamma Knife surgery. Lesions were stratified into 2 groups: those that might be lower risk with no more than 1 symptomatic bleed before radiosurgical treatment and those deemed high risk with multiple symptomatic hemorrhages before treatment. RESULTS: Forty-one CMs had multiple symptomatic hemorrhages before radiosurgery with a first-ever bleed rate of 2.9% per lesion per year, a rebleed rate of 30.5% per lesion per year, and a median time of 1.5 years between the first and second bleeds. In this group the rebleed rate decreased to 15% for the first 2 years after radiosurgery and declined further to 2.4% thereafter. Pretreatment multiple bleeds led to persistent deficits in 72% of the patients. Seventy-seven CMs had no more than 1 symptomatic bleed before radiosurgery, making for a lifetime bleed rate of 2.2% per lesion per year. The short period between the presenting bleed and treatment (median 1 year) makes the natural history in this group uncertain. The rate of hemorrhage in the first 2 years after treatment was 5.1%, and 1.3% thereafter. Pretreatment hemorrhages resulted in permanent deficits in 43% of the patients in this group, a rate significantly lower than in the multiple-bleeds group (p < 0.001). Posttreatment hemorrhages led to persistent deficits in only 7.3% of the patients. Permanent adverse radiation effects were rare (7.3%) and minor in both groups. CONCLUSIONS: Stereotactic radiosurgery is a safe management strategy for CMs in eloquent sites with the marked advantage of reducing rebleed risks in patients with repeated pretreatment hemorrhages. The benefit in treating CMs with a single bleed is less clear. Note, however, that repeated hemorrhage carries a significant risk of increased morbidity far in excess of any radiosurgery-related morbidity, and the authors assert that this finding justifies the early active management of deep-seated CMs.
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Neoplasias Encefálicas/cirugía , Hemangioma Cavernoso del Sistema Nervioso Central/cirugía , Malformaciones Arteriovenosas Intracraneales/cirugía , Procedimientos Neuroquirúrgicos , Radiocirugia , Adolescente , Adulto , Anciano , Enfermedades de los Ganglios Basales/cirugía , Neoplasias Encefálicas/mortalidad , Neoplasias del Tronco Encefálico/cirugía , Niño , Preescolar , Estudios de Seguimiento , Hemangioma Cavernoso del Sistema Nervioso Central/mortalidad , Humanos , Lactante , Malformaciones Arteriovenosas Intracraneales/mortalidad , Hemorragias Intracraneales/epidemiología , Masculino , Persona de Mediana Edad , Procedimientos Neuroquirúrgicos/mortalidad , Selección de Paciente , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Radiocirugia/mortalidad , Medición de Riesgo , Enfermedades Talámicas/cirugía , Adulto JovenRESUMEN
A number of reports have suggested that academic medicine within the UK may be in decline. This article assesses the number and outcome of abstracts presented at consecutive British Society of Gastroenterology (BSG) meetings. All abstracts presented at the BSG between 1994 and 2002 were assessed (n=4,096). Full publication rates of abstracts were then compared between meetings. Other abstract characteristics were also analysed. There was a significant downward trend demonstrated for the percentage of abstracts going onto full publication (p=0.02). In 1994, 57.6% of abstracts were subsequently fully published but by 2002 this number had fallen to 30.7%. The results show that the number of abstracts at the BSG which are then fully published has fallen with a significant trend. This observation could be taken as an indicator that there is a decline in research activity within the UK gastroenterology community.