Neil Kitchen

Psychosocial outcomes at three and nine months after good neurological recovery from aneurysmal subarachnoid haemorrhage: predictors and prognosis

Objectives: To investigate (1) the prevalence of various aspects of cognitive and psychosocial dysfunction, including post-traumatic stress symptoms, over nine months after subarachnoid haemorrhage (SAH); (2) whether SAH is preceded by increased life stress; (3) to what extent adverse outcomes may be predicted from preillness life stress, early neurological impairment, age, and sex; and (4) relations between emotional and functional outcomes. Methods: 52 patients with good neurological recovery after surgery for SAH were each matched for age, sex, and occupation with a healthy control participant. SAH patients were assessed three and nine months postdischarge on measures of cognitive functioning, mood, and social functioning. Objective stressors and subjective life change during the preceding year were rated retrospectively. Controls completed measures of mood and social functioning once only. Results: Compared with controls, SAH patients showed increased mood disturbance, subtle cognitive impairment, and abnormally low independence and participation on measures of social functioning. 60% showed clinically significant post-traumatic stress symptomatology (intrusive thoughts or avoidance of reminders) at three months and 30% at nine months. Independence in activities of daily living was greatly reduced in half to a third of the sample at both three and nine months. Productive employment was below the 10th percentile of the control group for 75% of patients at three months and for 56% at nine months; this outcome could not be predicted from selected demographic, premorbid, or clinical variables but dependence on others for organisational activities was predicted by impaired prose recall. Mood at nine months was strongly predicted by prior mental health problems, poor physical health, dysphasia, and impaired prose recall at three months. There was no evidence of an abnormally high level of stressful life events in the year before SAH, although patients rated their subjective level of stress in this period slightly more highly than did the control participants. Conclusions: These findings highlight the need for structured support and treatment after surgery for SAH to reduce persisting mood disturbance and increase independence and participation.

Psychosocial outcomes at 18 months after good neurological recovery from aneurysmal subarachnoid haemorrhage

Objectives: To evaluate functioning, 18 months after surgery, of 49 patients with good neurological recovery following aneurysmal subarachnoid haemorrhage (SAH), and to determine the extent of any improvements in disturbances of mood, cognitive functioning, and levels of activity and participation previously observed at 9 month follow up. Methods: SAH patients, matched for age, gender, and occupation with healthy control participants, completely quantitative measures of mood (HADS, FIES, BDI) and activity/participation (BICRO-39 scales), and a brief cognitive assessment battery (verbal fluency, digit span, prose recall). Controls completed the HADS and the BICRO-39. Results: Patients showed some recovery of cognitive functioning, though impairments of prose recall persisted. Anxiety and depression symptoms were higher in patients than in controls, but fewer than 20% scored in the clinical range on any questionnaires except for RIES-Intrusive thoughts (22%); only three showed signs of full blown post-traumatic stress disorder. Almost half showed elevated dependence on others for domestic activities and organisation and abnormally low levels of employment. Very little variance in outcome was predicted by demographic variables, neurological or cognitive impairment, prior life stress, or mood. However, levels of social activity and self-organisation were related to persisting fatigue. Conclusions: The observed decline in intrusive thoughts and avoidance over time is consistent with that seen after life threatening illness or trauma. The persistent reductions in independence and levels of employment may in some cases reflect considered lifestyle adjustments rather than adverse and unwanted changes but in others indicate a need for focused rehabilitation.

Hemangiopericytoma: long-term outcome revisited. Clinical article.

OBJECT Hemangiopericytomas are rare tumors that behave aggressively with a high rate of local recurrence and distant metastases. With the aim of determining the outcome and response to various treatment modalities, a series of 39 patients who underwent microsurgical resection for primary meningeal hemangiopericytoma over a 24-year period is presented. METHODS Patients with hemangiopericytoma were identified from histopathology records and their medical records were analyzed retrospectively by 2 independent reviewers to collect data on surgical treatment, adjuvant therapy, postoperative course, local or distant recurrence, and follow-up. RESULTS Of the 39 patients, 19 were male and 20 were female. Mean patient age was 44.1 years. Thirty-four tumors were intracranial and 5 were spinal. The mean follow-up period was 123 months. Twenty-eight patients developed local recurrence. The recurrence rate at 1, 5, and 15 years was 3.5%, 46%, and 92%, respectively. Extraneural metastasis occurred in 8 patients (26%) at an average of 123 months after initial surgery. Recurrences and metastases were treated by surgical excision, external beam radiation therapy (EBRT), chemotherapy, and/or stereotactic radiosurgery. Adjuvant EBRT following initial surgery was found to extend the disease-free interval from 154 months to 254 months, although it did not prevent the development of metastasis. In those patients with EBRT and complete resection, the mean recurrence-free interval was found to be 126.3 months longer (p = 0.04) and overall survival 126 months longer than without EBRT. Furthermore, adjusting for resection, patients undergoing EBRT had 0.33 times increased risk of recurrence compared with those who did not (p = 0.03). A majority of patients remained able to live independently despite revision surgery for recurrence. CONCLUSIONS The mean follow-up of this patient series represents the longest follow-up duration published to date and demonstrates extended survival in a significant number of patients with hemangiopericytoma. Gross-total resection followed by adjuvant EBRT provides patients with the highest probability of an increased recurrence-free interval and overall survival. Prolonged survival justifies long-term follow-up and aggressive treatment of initial, recurrent, and metastatic disease.

Conservative Versus Surgical Management of Idiopathic Normal Pressure Hydrocephalus: A Prospective Double-Blind Randomized Controlled Trial: Study Protocol

There is no level I evidence to indicate whether placement of a shunt is effective in the management of idiopathic normal pressure hydrocephalus (INPH), because no trial has as yet compared the placement of a shunt versus no shunt in a randomized controlled manner. We started recruiting patients into a prospective double-blind randomized controlled study aiming to provide class I evidence supporting or refuting the role of surgical management in INPH. Inclusion criterion was the diagnosis of probable INPH plus objective improvement of walking speed following 72 h of extended lumbar drainage. Patients with concomitant Alzheimers disease or vascular dementia were excluded. All patients included in the trial were to have a shunt placed with proGAV(®) adjustable valve. Patients were randomly assigned into two groups: group A was to have the shunt immediately adjusted to function, and group B was to have the shunt valve adjusted to the highest setting for 3 months then adjusted to function. Assessment of gait, cognitive function, and urinary symptoms were done before shunt insertion and at 3 months. Primary end point was to be an improvement in gait. Secondary end points were improvement in mental function or urinary function and incidence of complications. Final results are expected mid 2011.

Generalised Wasserstein Dice Score for Imbalanced Multi-class Segmentation Using Holistic Convolutional Networks.

The Dice score is widely used for binary segmentation due to its robustness to class imbalance. Soft generalisations of the Dice score allow it to be used as a loss function for training convolutional neural networks (CNN). Although CNNs trained using mean-class Dice score achieve state-of-the-art results on multi-class segmentation, this loss function does neither take advantage of inter-class relationships nor multi-scale information. We argue that an improved loss function should balance misclassifications to favour predictions that are semantically meaningful. This paper investigates these issues in the context of multi-class brain tumour segmentation. Our contribution is threefold. 1) We propose a semantically-informed generalisation of the Dice score for multi-class segmentation based on the Wasserstein distance on the probabilistic label space. 2) We propose a holistic CNN that embeds spatial information at multiple scales with deep supervision. 3) We show that the joint use of holistic CNNs and generalised Wasserstein Dice scores achieves segmentations that are more semantically meaningful for brain tumour segmentation.

Neurosurgery for Affective Disorders at Atkinson Morley’s Hospital 1948–1994

Neurosurgical practice in the treatment of affective disorders has changed dramatically over the last 40 years. This paper traces the changes which have occurred in one institution, namely Atkinson Morleys Hospital, Wimbledon, London, UK from 1948 to the present day. Freehand operations designed by McKissock and performed on large numbers of patients disappeared as better non-surgical treatments became available and long term complications and treatment failures became dearer. In the 1970s stereotactic limbic leucotomy, a much more focal and accurate operation, was devised and became popular. The present day practice utilises precisely the same techniques as the original stereotactic limbic leucotomy but is employed on small numbers of patients. The procedure continues to have a role for those few patients with severe psychiatric illness, particularly obsessive compulsive disorder, which has proved refractory to other therapeutic modalities.

Scalable Multimodal Convolutional Networks for Brain Tumour Segmentation

Brain tumour segmentation plays a key role in computer-assisted surgery. Deep neural networks have increased the accuracy of automatic segmentation significantly, however these models tend to generalise poorly to different imaging modalities than those for which they have been designed, thereby limiting their applications. For example, a network architecture initially designed for brain parcellation of monomodal T1 MRI can not be easily translated into an efficient tumour segmentation network that jointly utilises T1, T1c, Flair and T2 MRI. To tackle this, we propose a novel scalable multimodal deep learning architecture using new nested structures that explicitly leverage deep features within or across modalities. This aims at making the early layers of the architecture structured and sparse so that the final architecture becomes scalable to the number of modalities. We evaluate the scalable architecture for brain tumour segmentation and give evidence of its regularisation effect compared to the conventional concatenation approach.

Spontaneous intracranial hypotension, hygromata and haematomata

We describe our management of complex spontaneous intracranial hypotension associated with bilateral subdural hygromata. The accompanying images illustrate evolutionary changes over a 6-month period, including late subdural haemorrhage into resolving hygromata. This case demonstrates that conservative management has a place in the management of some patients. A 65-year-old man presented to us with a severe fronto-occipital throbbing headache. A few days earlier he had noticed a “twinge” in the back of his neck and saw a chiropractor. His headaches were postural, relieved by lying flat and …

Secondary normal pressure hydrocephalus in a patient with isolated frontal dilatation—an insight into pathophysiology?

Current theories of the pathophysiology of normal pressure hydrocephalus suggest the classical symptoms are a consequence of disruption of normal frontal function. We present the case of a 70-year-old patient with an isolated, frontal dilatation of his lateral ventricles in the presence of a complete triad as supportive of these theories.

Top ten research priorities for brain and spine cavernous malformations

Cavernous malformations, also known as cavernomas, aff ect people at any age and occur throughout the CNS. In the brain, they can cause haemorrhagic stroke and epileptic seizures, and in the spinal cord, they can bleed and cause myelopathy. Despite the availability of microsurgical excision and stereotactic radiosurgery for cavernoma treatment and known genetic causes of most familial forms of cavernoma, uncertainties remain about cause, diagnosis, prognosis, treatment, and care. Therefore, to prioritise these uncertainties about brain and spine cavernomas for researchers and funding agencies, we undertook a James Lind Alliance priority setting partnership. This partnership included a multidisciplinary steering group of patients, carers, health-care professionals, representatives of patient support organisations, an information specialist, a James Lind Alliance adviser, and an administrator according to a protocol developed in August, 2014, and approved in January, 2015. The methods are described in full online . Between January and March 2015, we gathered uncertainties using a web-based survey that was distributed by professional and support organisations in the UK via email, post, and social media to patients, carers, and health-care professionals. We received 2268 uncertainties from 299 respondents (63% patients, 18% health-care professionals, and 19% others), and identifi ed a further 34 uncertainties from searches of the scientifi c literature. An information specialist subsequently de-duplicated these submissions, rejected submissions that were out of the scope of the priority setting partnership, rejected uncertainties if there was evidence in published systematic reviews that they had been answered, and added uncertainties identifi ed by these systematic reviews, resulting in a long list of 79 unique uncertainties. The steering group worked in pairs to further shorten the list to 54 uncertainties, which we circulated to 246 survey respondents who chose priorities from the long list of uncertainties. 136 (55%) respondents participated in the web-based prioritisation exercise, in which we used the rank order technique to generate a short list of 31 uncertainties. At a fi nal in-person workshop including 29 participants (41% patients, 31% healthcare professionals, and 28% others) and facilitated by three James Lind Alliance advisers, we achieved consensus on a fi nal list of 27 uncertainties (listed in the UK Database of Uncertainties about the Eff ects of Treatments [DUETs]), of which the top ten are immediate priorities for future research (panel). The top ten uncertainties refl ect the concerns of patients, carers, and health-care professionals in the UK: fi ve concerned prognosis, three concerned treatment or care, and two concerned cause. The James Lind Alliance process assures the internal validity and reliability of these priorities, but their generalisability to other populations is unknown. The 27 uncertainties identifi ed by this priority setting partnership, and in particular the top ten, can now inform the projects that the research community pursue and that funding bodies support in the UK and perhaps other parts of the world.