P. D. Lees

Use of antibiotics in penetrating craniocerebral injuries

Summary The Working Party was instituted to investigate the rationale of prophylactic and therapeutic antibiotic use in penetrating craniocerebral injuries (PCCI), and to make recommendations for current practice. A systematic review of papers on civilian and military PCCI over the past 25 and 50 years, respectively, was done via electronic databases and secondary sources, and data were evaluated. Guidelines on the removal of indriven bone or metal fragments only if further neural damage can be avoided were supported. However, no publications were identified where the data on infection or its treatment and prevention were complete or satisfactorily derived, and no controlled trials have been published. All studies were retrospective or anecdotal. Working Party recommendations are based on the data available and the professional experience and knowledge of the members. Broad-spectrum antibiotic prophylaxis is recommended for both military and civilian PCCI, including those due to sports or recreational injuries.

The management of neurosurgical patients with postoperative bacterial or aseptic meningitis or external ventricular drain-associated

This article is dedicated to the management of neurosurgical patients who develop postoperative meningitis or external ventricular drain (EVD)-related ventriculitis. Postoperative meningitis is either bacterial or aseptic, the latter occurring more commonly. However, owing to difficulties associated with distinguishing between the two processes, all patients with the clinical and laboratory features of postoperative meningitis should receive empirical antibiotic therapy; if a cultured sample of CSF is sterile after incubation for 3 days, the antibiotics can be discontinued. Patients with confirmed bacterial meningitis should be treated with one of the organism-specific regimens provided. Also provided are recommendations for the management of patients with EVD-related ventriculitis and a strategy for preventing shunt infections in patients with EVDs who undergo implantation of CSF shunts.This article is dedicated to the management of neurosurgical patients who develop postoperative meningitis or external ventricular drain (EVD)-related ventriculitis. Postoperative meningitis is either bacterial or aseptic, the latter occurring more commonly. However, owing to difficulties associated with distinguishing between the two processes, all patients with the clinical and laboratory features of postoperative meningitis should receive empirical antibiotic therapy; if a cultured sample of CSF is sterile after incubation for 3 days, the antibiotics can be discontinued. Patients with confirmed bacterial meningitis should be treated with one of the organism-specific regimens provided. Also provided are recommendations for the management of patients with EVD-related ventriculitis and a strategy for preventing shunt infections in patients with EVDs who undergo implantation of CSF shunts.

The rational use of antibiotics in the treatment of brain abscess

The Working Party was instituted to investigate the rationale of therapeutic antibiotic usage in patients with brain abscess and to make recommendations for current practice. A systematic review of English language publications on brain abscess over the last 25 years was carried out using electronic databases and secondary sources, and data were evaluated. Few publications were identified where the microbiological procedures were adequately described and many authors continue to report sterile pus in a proportion of cases. The vast majority of reports were retrospective neurosurgical assessments in which details of laboratory procedures and antibiotic regimens were missing. There are no published reports of controlled clinical trials or comparative therapeutic studies. The recommendations made by the Working Party are based on relevant published information and the expertise of Working Party members. Recommendations vary according to the location of the abscess which reflects the likely source of the infection and therefore the bacterial types most likely to be present in aspirated pus. Bacteria with multiple resistance to antimicrobial agents do not feature significantly in cases of brain abscess.The Working Party was instituted to investigate the rationale of therapeutic antibiotic usage in patients with brain abscess and to make recommendations for current practice. A systematic review of English language publications on brain abscess over the last 25 years was carried out using electronic databases and secondary sources, and data were evaluated. Few publications were identified where the microbiological procedures were adequately described and many authors continue to report sterile pus in a proportion of cases.The vast majority of reports were retrospective neurosurgical assessments in which details of laboratory procedures and antibiotic regimens were missing.There are no published reports of controlled clinical trials or comparative therapeutic studies.The recommendations made by the Working Party are based on relevant published information and the expertise of Working Party members. Recommendations vary according to the location of the abscess which reflects the likely source of the infection and therefore the bacterial types most likely to be present in aspirated pus. Bacteria with multiple resistance to antimicrobial agents do not feature significantly in cases of brain abscess.

The orbitozygomatic infratemporal fossa approach: a quantitative anatomical study.

SummaryUsing detailed cadaveric dissections this study has demonstrated and quantified the increase in exposure and additional access gained by using the Orbitozygomatic infratemporal fossa approach for neurosurgical access.The surgical window of exposure can be increased by up to 300% when this technique is utilised to facilitate access via either a subtemporal (to access the P2 segment of the posterior cerebral artery) or transsylvian (to access the basilar bifurcation) approach. In addition the distance between the surgeon and the operative field can be decreased by approximately 2–3 cm.The orbitozygomatic infratemporal fossa approach is a relatively simple technique which can readily increase neurosurgical exposure of the skull base. It also provides simultaneous access to the infratemporal fossa, pterygopalatine fossa and the orbit.

Absence of mutations in the growth hormone (GH)-releasing hormone receptor gene in GH-secreting pituitary adenomas.

GH‐releasing hormone (GHRH) is a potent stimulator of somatotroph cell proliferation and GH secretion. GHRH acts via binding to a G‐protein coupled receptor (GPCR) (GHRH‐R), that activates adenylyl cyclase (AC) and increases growth and function of somatotroph cells. Indeed, a subset (30–40%) of somatotrophic adenomas contain somatic mutations of the GNAS1 gene that encodes the alpha subunit of the G‐protein (Gsα) that stimulates AC. As activating mutations of other GPCRs cause development of endocrine tumours, we hypothesized that somatic activating mutations of the GHRH‐R might provide the molecular basis for somatotroph cell proliferation in a subset of human GH‐secreting pituitary adenomas.

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 transzygomatic approach: A long-term clinical review

SummaryThe transzygomatic approach has been utilised to improve access to the skull base, infratemporal fossa and orbit for a number of years. It provides a low anterolateral approach to the skull base, along the floor of the middle fossa. It allows both a transsylvian and subtemporal approach with a reduction in brain retraction and better exposure of adjacent neurovasculature structures. A long term review of 53 patients is presented highlighting outcome at two years post surgery and morbidity of the approach. It is concluded that the technique is versatile and can be used to improve exposure of a variety of anatomical locations. There is minimal long term morbidity attributable to the surgery of access and the majority of patients have had good outcomes.

Distinguishing between Chemical and Bacterial Meningitis in Patients Who Have Undergone Neurosurgery

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A nationwide study to investigate current opinion amongst maxillo-facial and neurological surgeons with regard to access surgery for neurosurgical procedures

Over the past two decades there has been much interest in the use of craniofacial disassembly techniques to improve difficult access to some neurosurgical lesions, However, it is not known to what extent these techniques have been adopted throughout the UK. The aim of this study was to establish how many maxillofacial surgeons and neurosurgeons are currently involved in this type of collaborative surgery and to determine current opinion regarding the use of these procedures. A self-completion questionnaire was sent to all consultant maxillofacial surgeons and neurosurgeons within the UK. The results of the questionnaire suggest that there is a high level of interest in this type of collaborative surgery within the UK. It has demonstrated some interesting differences of emphasis regarding possible advantages and disadvantages of these procedures, and the areas to which access can be particularly improved. In addition, the future of this type of collaborative surgery and some of the difficulties involved in its organization were highlighted.