Harry Bulstrode

Atypical presentation of delayed communicating hydrocephalus after supratentorial glioma resection with opening of the ventricles

Abstract We report four cases of communicating hydrocephalus, requiring shunt placement, in the subset of patients whose ventricles were breached at the time of glioma resection (a total 97 cases over 3 years). The hydrocephalus in these cases presented without ventricular dilatation on computed tomography (CT) scanning, and in 3 cases without headache. Failure to progress, visual deterioration or cerebrospinal fluid (CSF) leak in the post-operative patient after tumour resection with ventricular opening should alert clinicians to the possibility of hydrocephalus, despite the absence of headache or ventriculomegaly, and lumbar puncture should be performed without delay.

Temporising an extradural haematoma by intraosseous needle craniostomy in the District General Hospital by non-neurosurgical doctors – A case report:

We report the case of a 69-year-old man admitted to the emergency department of a UK district general hospital with an extradural haematoma following closed head injury. He deteriorated rapidly before transfer to the regional neurosurgical centre and was treated with decompression of the extradural haematoma through an EZ-IO™ intraosseous needle in our department, with telephone guidance from the neurosurgeon. We believe this to be the first reported use of this technique in a district general hospital.

Reply from authors to letter on Temporising an extradural haematoma by intraosseous needle craniostomy in the District General Hospital by non-neurosurgical doctors - a case report

We are grateful to Dr Wiles for his comments and are pleased that this report has provoked interest and discussion of new strategies in the emergency management of a group of patients in extremis. Our primary principle at all stages has been to have our patient’s interests as the paramount consideration – we have only attempted a technique where the individual circumstances meant that it seemed to be the most appropriate option at the time. After making this intervention, we felt it could be of interest to the wider medical community to learn of our experience, so that other clinicians could be aware of this potential treatment option under certain circumstances. To be clear, this technique has not been used as part of a clinical trial, and we do not advocate it as standard practice. This is an off-label application of an approved device, where the relevant NICE guidance advises ‘balancing the risks and benefits to the patient’ and advises consideration of ethical and legal implications. We were satisfied that the balance of risks and benefits was reasonable in the cases presented and would welcome a broader discussion of ethical and legal implications involved. Perhaps, it is worth noting that the majority of emergency neurosurgery is performed without the benefit of Class 1 evidence, reflecting the difficulty of designing and implementing effective clinical trials in this area. We entirely agree that any future trial of this technique would need to be conducted in the context of standard ethical approvals. Finally, we are grateful to Dr Wiles for highlighting the CT report which was indeed incorrect. The initial CT report at the referring hospital diagnosed an extradural haematoma, but further analysis of the images shows they are more in keeping with acute subdural haematoma. The authors regret that this was not made clear in the original manuscript.

Decision tree classification system for brain cancer detection using spectrographic samples

Hyperspectral imaging is an active research field for remote sensing applications. These images provide a lot of information about the characteristics of the materials due to the high spectral resolution. This work is focused in the use of this kind of information to detect tumour tissue, particularly brain cancer tissue. In recent years, the study of this kind of tumour has been a challenging task due to the nature of these tissues. The neurosurgeon usually finds several problems to detect tumour tissues by the naked eye. In order to address this problem, this work makes use of high spectral resolution samples in the range from 400 nm to 6000 nm, provided by an Agilent Resolutions Pro V.5 spectrometer that has been diagnosed by histopathology. This instrument can sample a single pixel with a very high spectral resolution. The high spectral resolution allows a reliable separation between the different tissues in brain tumour. The proposed approach is based on a hierarchical decision tree. This approach is composed by several systems of Support Vector Machine classifiers. The 225 used samples come from 25 adults (males and females) and have been taken at different surgical procedures at the University Hospital of Southampton. The main goal is to discriminate between tumour tissue and normal tissue. Specifically, it assigns priority to the group of classes known a priori to the classification showed accordingly to the level of detail. The experimental results indicate that the use of the proposed new decision tree approach could be a solution to effectively discriminate between tumour and normal tissue and additionally provide information about the specific tissue for these classes. For our data set, a sensitivity of 100% and a specificity of 99.27% have been obtained when healthy and tumour samples are discriminated. These results clearly indicate that the use of high dimensionality spectral data is a promising and effective technique to indicate if a brain sample is or not affected by cancer with a high reliability.

Pilocytic astrocytoma originating at the cavernous sinus

We report a case of histologically proven pilocytic astrocytoma arising within the cavernous sinus, confirmed radiographically and at operation. We discuss the implications in the context of previous reports of ectopic glioma origin. In particular, the possiblity of glioma development within glial cell islands in the peripheral segment of cranial nerves is explored.

Induced Hypothermia in Trauma

Induced hypothermia has established indications in cardiac arrest in adults and in hypoxic-ischaemic encephalopathy in infants. Despite substantial research effort its application in the setting of trauma remains controversial. In head and spinal trauma mild cooling may help to limit secondary injury. In penetrating trauma, profound cooling at the time of cardiac arrest may offer an extended window to control haemorrhage before irreversible ischaemic brain damage occurs. Both of these potential indications are the subject of clinical trials. This review seeks to set in context these studies and previous work in this field.