Malcolm D. M. Shaw

Arteriovenous malformations of the brain: natural history in unoperated patients.

Two-hundred and seventeen patients from a total population of 343 patients with arteriovenous malformations, were managed without surgery. Follow up was for a mean of 10.4 years. Using life survival analyses, there was a 42% risk of haemorrhage, 29% risk of death, 18% risk of epilepsy and a 27% risk of having a neurological handicap by 20 years after diagnosis in unoperated patients.

Do prophylactic anticonvulsant drugs alter the pattern of seizures after craniotomy

A total of 276 patients with a high risk of developing postoperative seizures were randomised to treatment with carbamazepine or phenytoin for six or 24 months, or to no treatment. No significant differences were found (though the confidence limits were fairly wide) between the regimes in respect of the incidence of seizures or death. In a substantial proportion of the patients postoperative epilepsy remained a continuing disability. A high incidence of drug-related side effects was found in the treatment groups. Prophylactic anticonvulsants cannot therefore be recommended routinely following supratentorial craniotomy.

Serum anticonvulsant concentrations and the risk of drug induced skin eruptions.

In two prospective studies of anticonvulsant therapy there was a high incidence of drug-induced skin reactions to phenytoin (7%) and carbamazepine (16.6%). High initial serum concentrations of these drugs appeared to be a factor influencing the occurrence of such skin reactions.

Smoking and subarachnoid haemorrhage: A case control study

Retrospective and epidemiological studies have suggested that smoking increases the risk of developing aneurysmal subarachnoid haemorrhage (SAH). During 1990, 217 patients presenting to the Mersey Regional Neurosurgical unit with spontaneous SAH were prospectively studied. Smoking habits of patients with SAH were compared with age, sex and occupation matched controls. The relative risk of spontaneous aneurysmal SAH for smokers was twice that of non-smokers (p < 0.001). Management outcome at 6 months following aneurysmal SAH was similar for smokers and non-smokers (p = 0.43) but smokers had more postoperative pulmonary complications requiring ventilation. Significance was tested with chi-square tests.

The effectiveness of prophylactic anticonvulsants following neurosurgery

SummaryOne hundred and two patients who underwent supratentorial procedures for neurosurgical conditions, which are known to carry a high incidence of postoperative seizures, have been given prophylactic anticonvulsant medication. This preliminary analysis has failed to demonstrate any dramatic effect on the postoperative incidence of seizures in the first six months as the result of this policy. There has been a high incidence of serious side effects, but compliance has not been a major problem. This long-term study is continuing, though with a modified protocol.

Recurrent Aneurysmal Subarachnoid Haemorrhage: Incidence, timing and effects. A re-appraisal in a surgical series

A series of 510 patients with proven aneurysmal subarachnoid haemorrhage (SAH) is reported. The incidence of recurrent haemorrhage during the period awaiting surgery was 13.7%. There was no significant difference in incidence between good and poor grade patients. Following rebleeding there was an immediate mortality of 34% in good grade patients and 52% in poor grade patients. In the long term only 44.4% of good grade and 8% of poor grade patients made a good recovery following a second bleed as compared to 70.6% and 52.8% respectively for those who did not rehaemorrhage.

Post-ictal Blood Pressure in Aneurysmal Subarachnoid Haemorrhage

A prospective study in which the effect of the post-ictal systemic blood pressure levels on the outcome following surgically treated aneurysmal subarachnoid haemorrhage (SAH) in 325 patients is reported. No differentiation was made between pre-existing essential and prolonged reactive hypertension. A significant association was found between the trend for rising diastolic blood pressure levels and the tendency towards a poor outcome. There was a similar trend for rising systolic blood pressure levels which did not reach statistical significance. Patients with definite hypertension (blood pressure of 160/95 mmHg or greater) were 1.6 times as likely to have a poor outcome than were those with lower blood pressures.

Idiopathic spinal extradural lipomas: Three cases and review of the literature

Three cases of extradural spinal lipomas in adults are described in which there was no association with steroids. In all three cases the tumors were situated in the lumbar region and the patients were muscular, nonobese males. Two of the three cases had long histories contrary to those previously reported. Preceding transient neurological symptoms were noted in two of the three cases. The etiology of this phenomenon is discussed. It is possible that these lipomas, which are not associated with steroids, may represent a different spectrum of disease.

The Natural History of Subarachnoid Haemorrhage with Negative Angiography: A prospective study and 3-year follow-up

One hundred and forty-eight patients with negative cerebral angiography after subarachnoid haemorrhage are reported. Good grade, normotension and normal CT are associated with a favourable outcome. In 89 patients with negative four-vessel angiography the overall annual risks of rebleeding and fatal rebleeding were 1.5% and 0.4% respectively. In 52 patients undergoing appropriate limited angiography corresponding risks were 2.5% and 1.9%. No fatal rebleeds occurred after 6 months. Initial CT scanning in 104 patients was abnormal in 34. Of these, 14 had SAH alone, in whom no episodes of rebleeding occurred, although SAH on CT was associated with an increased chance of a poor outcome. Twenty had other abnormalities, three of whom rebled, two (both with ICH on CT) being fatal. The annual risks of rebleeding and fatal rebleeding in patients with these CT abnormalities were 5.0% and 3.33% respectively. Fifty-two patients were hypertensive, of whom six rebled, four fatally. Two of the 89 normotensive patients rebled, neither fatally.

How many beds do we really need—for example, in neurosurgery?

I committed two errors. Firstly, I did not consider the possibility of a second lesion seriously enough when I found the ulcer. Secondly, in retrospect, during colonoscopy when I thought I was in the caecum I was in fact in the proximal transverse colon, which commonly hangs down to the pelvis. This mistake was due to lack of experience (I had just started colonoscopy) compounded by not having x-ray screening facilities.