G. Neil-Dwyer

Cognitive Outcome and Quality of Life One Year after Subarachnoid Haemorrhage

In this prospective study, 100 patients with subarachnoid haemorrhage (SAH) were assessed at discharge, 3 months, and 1 year using modern methods of neuropsychology to examine cognitive status and semistructured interviews to assess changes in personality and quality of life. A control group of 50 patients suffering myocardial infarction were also assessed at discharge and 1 year. Results of cognitive testing in the SAH group were unremarkable and compared well with the control group. Similarly, there was no evidence of a consequent reduction in the quality of life in the majority of the SAH patients. These results lead us to conclude that where the medical and surgical course of SAH is uncomplicated, patients recover with no permanent or significant reduction in their intellectual ability of life status. Possible reasons for the difference between these results and those of other studies are discussed.

Zygomaticotemporal Approach to the Basis Cranii and Basilar Artery

When using the zygomaticotemporal approach, one removes the whole of the zygomatic bone with its attachment to the masseter muscle, allowing a lower and more anterior approach to the interpeduncular cistern along the inferomedial surface of the temporal lobe. Minimal brain retraction is required to give an excellent view of the bifurcation of the basilar artery and of the suprasellar region.

The suboccipital transcondylar approach to the clivus and cranio-cervical junction for ventrally placed pathology at and above the foramen magnum

SummaryThe dorsolateral suboccipital transcondylar approach for pathology anterolateral or ventral to the neuraxis around the lower clivus and brainstem was used in 10 patients with a variety of different pathological problems. Key features of the approach include exposure and mobilisation of the vertebral artery and resection of the postero-medial portion of the atlanto-occipital joint. Despite the excellent access achieved additional exposure may be required in some patients with strictly anterior pathology or a lesion above the mid-clivus.

An Alternative Surgical Approach to Aneurysms of the Posterior Cerebral Artery

The value of a skull base approach (the transzygomatic approach) is assessed in the treatment of patients with posterior cerebral artery aneurysms. The operative approach is outlined, and the advantages and disadvantages of the procedure are discussed.

Recovery after subarachnoid haemorrhage.

OBJECTIVE--To determine the implications of subarachnoid haemorrhage for quality of life and aftercare. DESIGN--Prospective follow up study of patients surviving subarachnoid haemorrhage over one year (at discharge, three months, and one year) by examination of cognitive functions (a test battery) and changes in everyday life (semistructured interview). SETTING--Regional neurosurgical unit at a tertiary referral centre. PATIENTS--100 Patients with subarachnoid haemorrhage; 17 were lost during the study because of ineligibility (further surgery, previous head injury, relevant psychiatric history, and cultural differences), loss of contact, and non-compliance; a further 13 patients who developed a neurological deficit were considered separately. MAIN OUTCOME MEASURE--Performance on cognitive test battery and reported changes in quality of life. RESULTS--At discharge patients with and without neurological deficit scored below established norms with most tests, but by three months the difference had resolved in patients without deficit. Reduced quality of life attributable to subarachnoid haemorrhage at one year mainly included less energy (seven patients), adverse emotional changes (five), early retirement, affected social life, and domestic tension (three each). None reported reduced capacity for work. CONCLUSIONS--Patients surviving subarachnoid haemorrhage without neurological symptoms have a good prognosis and should be encouraged to return to a normal lifestyle within about three months.

Craniofacial Access in Children

Summary We have used craniofacial access in 20 children (age range 3/12–14 years) for complex skull base/intracranial pathology over the past 5 years. The majority of the patients had a tumour – 7 of the skull base, 5 extensive suprasellar lesions and 3 acoustic neuromas; 4 had an aneurysm or AVM and in 1 there was a congenital problem.This extended application of established adult techniques in a paediatric practice emphasises the fundamental point that the quintessence of good surgical practice is the construction of an operation for the individual patients pathology. We therefore used transzygomatic, orbital, transoral, transmandibular, petrous, transcondylar, translabyrinthine and transbasal access techniques. Good function and cosmesis with minimal complications were achieved. We have not observed complications with craniofacial growth and the majority of patients were able to return to normal school. The range of approaches used emphasise the importance of a multidisciplinary team with both paediatric and neurosurgical expertise, especially with complex vascular and skull base pathology, in dealing with these difficult problems. The case for specialist referral merits some discussion within the representative bodies of paediatric neurosurgeons.

A review of the management of 15 cases of aneurysms of the posterior cerebral artery

The presenting features of 15 cases of posterior cerebral artery aneurysm are discussed. The use of the axial radiographic view in determining the anatomy of these aneurysms is highlighted. Ten out of 15 patients underwent surgery. In three patients the aneurysm was approached by the transzygomatic route, in six via the subtemporal route and in one using the pterional approach. There was no operative mortality. Nine out of 10 patients made good long-term recoveries following surgery, one patient remains moderately disabled. Three out of five patients in the non-surgical group made a good recovery. The advantages and disadvantages of the various operative approaches are discussed with particular reference to ease of access, brain retraction and adequate exposure of the aneurysm. It was possible to clip the aneurysm and spare the parent vessel in all three cases using the transzygomatic approach, but this was possible in only one of the remaining cases.

The Extended Transbasal Approach: A Quantitative Anatomical and Histological Study

Summary Since its introduction in 1972 the transbasal approach to the anterior fossa and sphenoethmoidal region has undergone a number of modifications. The extended transbasal approach with preservation of olfaction not only improves exposure of the anterior fossa, but also provides access to the clivus as far inferiorly as the foramen magnum. An anatomical study has been undertaken to photographically demonstrate and quantify the varying degrees of exposure that this technique provides. The pituitary stalk was used as an intracranial target. The amount of exposure was compared using a standard subfrontal approach, a transbasal approach and an extended transbasal with preservation of olfaction. In addition, a histological study was carried out to investigate the level to which identifiable olfactory nerves extended into the nasal mucosa. The anatomical study demonstrates the area of the “external window of exposure” can be doubled using a transbasal approach and more than quadrupled using the extended transbasal approach, when gaining access to the pituitary stalk. In addition, the study highlights the exposure of other anatomical areas, such as the medial orbit, the cavernous sinus, the clivus and the vertebrobasilar complex. The histological study establishes that the olfactory nerves extend only 10mms below the cribriform plate.

The zygomatico-temporal approach to the skull base: A critical review of 11 patients

The zygomatico-temporal approach to the base of the skull is a relatively new but established surgical technique. The approach involves the removal of the zygomatic bone to provide access to the skull base, middle cranial fossa, parasellar region and interpeduncular cistern with minimal brain retraction. An excellent view of the bifurcation of the basilar artery and suprasellar region is provided. The outcome of 11 patients undergoing this procedure is reported with particular reference to the post-operative morbidity and the cosmetic result.

The extended transbasal approach: clinical applications and complications.

Summary Objectives. To describe in detail key technical aspects of the extended transbasal approach which involves en-bloc mobilisation of the supraorbital rim, the orbital roof and the nasoethmoidal complex. In some patients osteotomies were performed around the cribriform plate with a view to maintaining olfaction. To review 18 patients with deep seated lesions located in the central skull base region (including 6 recurrences) to highlight patient selection, presentation, surgical morbidity and outcome. Methods. Prospective data recording and clinical chart review. Results. Outcome was assessed at a minimum of 1 year after operation using the Glasgow Outcome Score. Thirteen patients had made a good recovery, 1 was moderately disabled, 2 were severely disabled (both had been severely disabled before operation), and 2 died. By contrast, quality of life assessment indicated that only 7 of the surviving 14 adults had returned to normal levels of activity and perceived health; although 6 of the other 7 patients had resumed their former occupations, their follow up assessments showed a reduced quality of life. Of the 13 patients who had an olfaction preservation procedure, 6 showed appreciation of smell on formal testing. Conclusions. In patients with progressive and extensive deep seated lesions this technique provides wide exposure in a shallow surgical field. Complication rates although acceptable were significantly higher in patients with intradural lesions. In some selected patients it was possible to preserve olfaction. Specific surgical outcome assessments pointed to satisfactory results, but failed to reflect the degree of patient disability. There is a need for outcome measures that take into account the patients expectations and which address his quality of life in order to validate the benefits of these procedures.