Kenneth W. Lindsay

Effect of fludrocortisone acetate in patients with subarachnoid hemorrhage.

In this study with randomized controls, we administered fludrocortisone acetate to 46 of 91 patients with subarachnoid hemorrhage in an attempt to prevent excessive natriuresis and plasma volume depletion. Fludrocortisone significantly reduced the frequency of a negative sodium balance during the first 6 days (from 63% to 38%, p = 0.041). A negative sodium balance was significantly correlated with decreased plasma volume during both the first 6 days (p = 0.014) and during the entire 12-day study period (p = 0.004). Although fludrocortisone treatment tended to diminish the decrease in plasma volume, the difference was not significant (p = 0.188). More patients in the control group developed cerebral ischemia (31% vs. 22%) and, consequently, more control patients were treated with plasma volume expanders (24% vs. 15%), which may have masked the effects of fludrocortisone on plasma volume. Fludrocortisone therefore reduces natriuresis and remains of possible therapeutic benefit in the prevention of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage.

Amount of blood on computed tomography as an independent predictor after aneurysm rupture.

Background and Purpose After admission to the hospital of patients with aneurysmal subarachnoid hemorrhage, we assessed the predictive value of the extent of the hemorrhage on computed tomography in addition to that of clinical grading scales for poor outcome, infarction, and rebleeding. Methods We studied 471 consecutive patients with aneurysmal subarachnoid hemorrhage and used logistic regression with step-wise forward selection of variables. Results On admission, poor outcome was predicted by a low Glasgow Coma Scale score (odds ratio, 0.8; 95% confidence interval, 0.7-0.9); treatment with fluid restriction (2.5; 1.6-4.0); age over 52 (2.6; 1.7-3.9); loss of consciousness at ictus (1.7; 1.1-2.6); or a large amount of subarachnoid blood (2.0; 1.3-3.1). Delayed infarction was predicted by a large amount of subarachnoid blood (1.8; 1.2-2.6) or treatment with tranexamic acid (1.6; 1.1-2.4). Rebleeding was predicted by treatment with tranexamic acid (0.4; 0.3-0.7; protective effect); age over 52 (1.9; 1.2-3.0); loss of consciousness at ictus (1.7; 1.1-2.7); or admission to a neurosurgery service (0.6; 0.3-0.9; protective effect). Comparison of the observed and predicted outcome events showed that inclusion of the amount of subarachnoid blood into a predictive model added little to the prediction of poor outcome in general, but much to the prediction of delayed cerebral ischemia. Conclusions The total amount of subarachnoid blood on the initial computed tomogram has independent predictive power for the occurrence of delayed cerebral ischemia.

Definition of initial grading, specific events, and overall outcome in patients with aneurysmal subarachnoid hemorrhage. A survey.

Background and Purpose Scientific communication in medicine can be effective only if reports are based on unequivocal criteria for clinical conditions or specific diagnoses. Methods We reviewed all articles about subarachnoid hemorrhage published in nine neurosurgical or neurological journals from 1985 through 1992 and assessed the presence and the precision of definitions used for reporting the initial grade, the specific complications of rebleeding, delayed cerebral ischemia, and hydrocephalus, and the overall outcome. We identified 184 articles reporting direct observations in at least 10 patients on one or more of these conditions. Results Of 161 articles reporting the initial condition, only 19% used an unequivocal grading system (World Federation of Neurological Surgeons Scale or Glasgow Coma Scale); this proportion did not increase after 1988, when the World Federation of Neurological Surgeons Scale was introduced. The specific outcome events of rebleeding, ischemia, and hydrocephalus (283 instances) were sufficiently defined in only 31% of instances, incompletely in 22%, and not at all in 47%. The proportions were similar when the results were analyzed according to the type of complication, the year of publication, or per study. The four exclusively neurosurgical journals featured suitable definitions for any of the three outcome events in 20% of 209 instances, whereas the five mainly neurological journals published fewer articles about subarachnoid hemorrhage (74 instances of outcome events) but more often with precise criteria (65%). Overall outcome was adequately reported in 63% of all articles, with an increase over the years (54% in 1985 through 1988, 71% in 1989 through 1992). Conclusions Reports about subarachnoid hemorrhage require closer scrutiny before publication to ascertain whether the conclusions about specific outcome events are based on unequivocal criteria.

Treatment of acute hydrocephalus after subarachnoid hemorrhage with serial lumbar puncture.

Computed tomography demonstrated acute hydrocephalus less than or equal to 72 hours after subarachnoid hemorrhage in 24 (23%) of 104 patients. Of these 24 patients, six (25%) had no impairment of consciousness. In nine (11%) of the remaining 80 patients, acute hydrocephalus developed within 1 week after subarachnoid hemorrhage. With the exception of three patients, all 104 patients received antifibrinolytic treatment. Delayed clinical deterioration from acute hydrocephalus occurred in seven (29%) of the 24 patients with acute hydrocephalus on admission and in six (8%) of the remaining 80 patients. Serial lumbar puncture was performed in 17 patients. Twelve (71%) of the 17 patients treated with serial lumbar puncture, including 10 (77%) of the 13 patients with delayed deterioration from acute hydrocephalus after admission, achieved improvement in the level of consciousness. Four of these 17 patients (4% of all 104 patients) required an internal shunt. No patient deteriorated from coning following serial lumbar puncture. The rebleeding rate within 12 days after subarachnoid hemorrhage in hydrocephalic patients with serial lumbar puncture was not higher than the rate in those without hydrocephalus (two [12%] of 17 versus nine [13%] of 71). Neither meningitis nor ventriculitis was observed. We conclude that if neither a hematoma with a mass effect nor an obstructive element exists, cerebrospinal fluid drainage with serial lumbar puncture is a good alternative to ventricular drainage in patients with acute hydrocephalus after subarachnoid hemorrhage.

Standards of training in endovascular neurointerventional therapy: As approved by the ESNR, EBNR, UEMS Section of Neurosurgery and EANS (February 2007). Enclosed the standards of practice as endorsed by the WFITN

1 Department of Neurosurgery, Paracelsus Medical University, Salzburg, Austria 2 Hôpital de Bicetre – Université Paris-Sud, Paris, France 3 Department of Neuroradiology, Radcliff Hospital, Oxford University, Oxford, UK 4 Department of Neurosurgery, Southern General Hospital, Glasgow, UK 5 Neurosurgical Department, Centre Hospitalier, Luxembourg, Luxembourg 6 Department of Neurosurgery, University Medical School, Lublin, Poland

Treatment of chronic subdural haematomas – A retrospective comparison of minicraniectomy versus burrhole drainage

Primary chronic subdural haematomas remains one of the commonest conditions managed by neurosurgeons. Despite this there is a relative lack of evidence regarding best management and certain treatments such as minicraniectomy, have rarely been assessed in the literature. A retrospective case note review comparing minicraniectomy and burrhole drainage of primary chronic subdural haematoma was therefore performed. We sought to determine the proportion of patients requiring repeat drainage or dandy cannula aspiration following initial surgery and to assess outcome at outpatient follow-up. The mean age of patients undergoing minicraniectomy was 73, compared to 63 in the burrhole group (p < 0.001). 130 patients underwent burrhole drainage, 23 of whom (18%) developed a symptomatic recurrence. 21 (16%) of these patients required repeat drainage. Of the 116 patients who underwent a craniectomy 23 (20%) patients suffered a symptomatic recurrence. 15 (13%) patients required the minicraniectomy to be reopened for further washout (p = 0.48). (8%) patients who underwent burrhole drainage died compared to 20 (17%) patients following craniectomy (95%CI 2 to 18%; p = 0.03). However, controlling for age using logistic logression, showed no significant difference between the two treatment groups in recurrence (p = 0.28) or death (p = 0.06). Craniectomy may be considered as a treatment option particularly in the elderly population and in patients with multiple loculated collections.

Perimesencephalic nonaneurysmal subarachnoid hemorrhage caused by jugular venous occlusion: case report.

OBJECTIVE The cause of perimesencephalic nonaneurysmal subarachnoid hemorrhage remains unknown. We describe a patient in whom jugular venous occlusion preceded the occurrence of perimesencephalic nonaneurysmal subarachnoid hemorrhage. This finding supports the theory that the source of the hemorrhage is venous in origin. CLINICAL PRESENTATION A 25-year-old man presented with sudden onset of headache after his head was held in a headlock during a playful fight 48 hours before the ictus. His computed tomographic (CT) scan on admission demonstrated a perimesencephalic pattern of subarachnoid hemorrhage. CT angiography excluded the presence of an underlying aneurysm or vascular malformation but showed bilateral jugular venous obstruction with hematoma surrounding the right internal jugular vein. Magnetic resonance imaging and a 4-vessel cerebral angiogram confirmed the CT angiographic findings. INTERVENTION The patient was observed as an inpatient and had no complication of his hemorrhage. Follow-up at 5 months with CT angiography showed resolution of his neck hematoma and reopening of his internal jugular veins. CONCLUSION The presence of acute jugular venous occlusion as a cause of perimesencephalic nonaneurysmal subarachnoid hemorrhage supports a venous origin of hemorrhage.

Spine surgery training and competence of European Neurosurgical Trainees

BackgroundLittle is known about the nature of spine surgery training received by European neurosurgical trainees during their residency and the level of competence they acquire in dealing with spinal disorders.MethodsA three-part questionnaire entailing 32 questions was devised and distributed to the neurosurgical trainees attending the EANS (European Association of Neurosurgical Societies) training courses of 2004.ResultsOf 126 questionnaires, 32% were returned. The majority of trainees responding to the questionnaire were in their final (6th) year of training or had completed their training (60.3% of total). Spinal surgery training in European residency programs has clear strengths in the traditional areas of microsurgical decompression for spinal stenosis and disc herniation (77-90% competence in senior trainees). Deficits are revealed in the management of spinal trauma (34-48% competence in senior trainees) and spinal conditions requiring the use of implants and anterior approaches, with the exception of anterior cervical stabilisation.ConclusionsEuropean neurosurgical trainees possess incomplete competence in dealing with spinal disorders. EANS trainees advocate the development of a postresidency spine subspecialty training program.

Outcome of aneurysmal subarachnoid hemorrhage in patients 66 years of age and older

The outcome at three months after aneurysmal SAH in a group of older patients and a group of younger patients is compared. The patients were admitted within 72 hours of their SAH. Of 61 patients 66 years of age and older, comprising 13% of the whole patient group, 52% died, 12% remained dependent and 36% became independent. In the younger group, 55% had an independent outcome (p less than 0.01). In contrast to what we expected in the older patient group, not extracranial, but intracranial events (re-bleeds, infarcts, hydrocephalus) were by far the most frequent cause of deterioration.

Neurosurgical training in the United kingdom and ireland: assessing progress and attainment.

OBJECTIVE To review neurosurgical training in the United Kingdom and Ireland in the past decade and the methods used to monitor training and assess trainee competence. METHODS A database was compiled with data from 1990 to 2000 on behalf of the Specialist Advisory Committee in Neurosurgery from trainee logbook operative totals submitted on achieving accreditation or receiving the Certificate of Completion of Surgical Training. RESULTS During the 11-year period, 109 trainees achieved accreditation or Certificate of Completion of Surgical Training. The median duration of training, including research, was 6.1 years. The total training duration per year did not change overall, although results suggested an increasing trend in the duration of clinical training (excluding research) from 4.8 to 5.6 years since 1997. The median age at accreditation or at receipt of Certificate of Completion of Surgical Training was 35 years 7 months. At completion of training, the Specialist Advisory Committee used operative totals in addition to reports from trainers to analyze the trainees’ competence. Despite changes to the training system and a reduction in hours of work, the quality of training, as reflected by median operative totals, did not change during the decade. The database also permitted assessment of operative experience gained within each training program. CONCLUSION The duration of training and training standards in terms of operative experience have remained constant during the past decade. Operative totals provide an objective method of assessing trainee progress and attainment and enable a comparison of experience offered by different training programs. An alternative method of assessing trainee operative competence that can be used in conjunction with median operative totals is proposed.