Introduction
Management of patients with intracranial metastases from an unknown primary tumor (CUP) varies compared to those with metastases of known primary tumor origin (CKP). The National ...Institute for Health and Care Excellence (NICE) recognizes the current lack of research to support the management of CUP patients with brain metastases. The primary aim was to compare survival outcomes of CKP and CUP patients undergoing early resection of intracranial metastases to understand the efficacy of surgery for patients with CUP.
Methods
A retrospective study was performed, wherein patients were identified using a pathology database. Data was collected from patient notes and trust information services. Surgically managed patients during a 10-year period aged over 18 years, with a histological diagnosis of intracranial metastasis, were included.
Results
298 patients were identified, including 243 (82.0%) CKP patients and 55 (18.0%) CUP patients. Median survival for CKP patients was 9 months (95%CI 7.475–10.525); and 6 months for CUP patients (95%CI 4.263–7.737,
p
= 0.113). Cox regression analyses suggest absence of other metastases (
p
= 0.016), age (
p
= 0.005), and performance status (
p
= 0.001) were positive prognostic factors for improved survival in cases of CUP. The eventual determination of the primary malignancy did not affect overall survival for CUP patients.
Conclusions
There was no significant difference in overall survival between the two groups. Surgical management of patients with CUP brain metastases is an appropriate treatment option. Current diagnostic pathways specifying a thorough search for the primary tumor pre-operatively may not improve patient outcomes.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
BackgroundAlthough idiopathic aqueductal stenosis is a congenital disorder, some patients present in adulthood. Many theories have tried to account for the late-onset presentation; however, the ...aetiology remains uncertain. This study aimed to investigate the clinical presentation, management, and outcomes of patients with late-onset idiopathic aqueductal stenosis (LIAS) managed at our centre.MethodologyA retrospective study of patients with a diagnosis of LIAS managed at our centre between 1996 and 2018 was undertaken. Data on clinical presentation, imaging, management, and outcomes were retrieved from patient records and radiology reports.ResultsA total of 20 patients were diagnosed with LIAS during the study period. Endoscopic third ventriculostomy (ETV) was the initial modality of treatment for nine patients, ventriculoperitoneal shunt (VPS) for four patients, and conservative management in seven patients, in four of them intracranial pressure (ICP) was found to be normal following a period of ICP monitoring. The median follow-up period was three years (1 month to 24 years). One patient was lost to follow-up. One ETV failed in the first six months necessitating VPS insertion. Two cases that were initially managed conservatively required a VPS three and nine years following the initial presentation. Of the patients undergoing VPS insertion, all subsequently required valve adjustment or surgical revision.ConclusionsThe majority of patients with LIAS undergoing ETV were managed successfully, whereas VPS insertion was associated with a high rate of revision surgery in this cohort. ETV should be considered as the treatment of choice to avoid the long-term complications of shunting for patients with LIAS.
ObjectiveTo establish a consensus on the structure and process of healthcare services for patients with concussion in England to facilitate better healthcare quality and patient outcome.DesignThis ...consensus study followed the modified Delphi methodology with five phases: participant identification, item development, two rounds of voting and a meeting to finalise the consensus statements. The predefined threshold for agreement was set at ≥70%.SettingSpecialist outpatient services.ParticipantsMembers of the UK Head Injury Network were invited to participate. The network consists of clinical specialists in head injury practising in emergency medicine, neurology, neuropsychology, neurosurgery, paediatric medicine, rehabilitation medicine and sports and exercise medicine in England.Primary outcome measureA consensus statement on the structure and process of specialist outpatient care for patients with concussion in England.Results55 items were voted on in the first round. 29 items were removed following the first voting round and 3 items were removed following the second voting round. Items were modified where appropriate. A final 18 statements reached consensus covering 3 main topics in specialist healthcare services for concussion; care pathway to structured follow-up, prognosis and measures of recovery, and provision of outpatient clinics.ConclusionsThis work presents statements on how the healthcare services for patients with concussion in England could be redesigned to meet their health needs. Future work will seek to implement these into the clinical pathway.
IntroductionSurgery remains the mainstay for treatment of primary glioblastoma, followed by radiotherapy and chemotherapy. Current standard of care during surgery involves the intraoperative use of ...image-guidance and 5-aminolevulinic acid (5-ALA). There are multiple other surgical adjuncts available to the neuro-oncology surgeon. However, access to, and usage of these varies widely in UK practice, with limited evidence of their use. The aim of this trial is to investigate whether the addition of diffusion tensor imaging (DTI) and intraoperative ultrasound (iUS) to the standard of care surgery (intraoperative neuronavigation and 5-ALA) impacts on deterioration free survival (DFS).Methods and analysisThis is a two-stage, randomised control trial (RCT) consisting of an initial non-randomised cohort study based on the principles of the IDEAL (Idea, Development, Exploration, Assessment and Long-term follow-up) stage-IIb format, followed by a statistically powered randomised trial comparing the addition of DTI and iUS to the standard of care surgery. A total of 357 patients will be recruited for the RCT. The primary outcome is DFS, defined as the time to either 10-point deterioration in health-related quality of life scores from baseline, without subsequent reversal, progressive disease or death.Ethics and disseminationThe trial was registered in the Integrated Research Application System (Ref: 264482) and approved by a UK research and ethics committee (Ref: 20/LO/0840). Results will be published in a peer-reviewed journal. Further dissemination to participants, patient groups and the wider medical community will use a range of approaches to maximise impact.Trial registration numberISRCTN38834571.
BACKGROUNDCancellation of elective operations during the COVID-19 pandemic has led to a significant increase in the number of patients waiting for treatment. In neurosurgery, treatment for spinal ...diseases, in particular, has been disproportionately delayed. We aim to describe the waiting list burden at our institution and forecast the time and theatre capacity required to return to pre-pandemic levels. METHODSA retrospective evaluation of the waiting list records (both cranial and spinal), from January 2015-October 2022, inclusive, was conducted at a high-volume neurosciences centre. The average monthly decrease in the waiting list was calculated for the months since the waiting list was noted to fall consistently during or after the pandemic, as applicable. Five different scenarios were modelled to identify the time required to reduce the waiting list to the pre-pandemic level of December 2019. Data collection and analyses were performed on Excel (Microsoft). RESULTSAt the pre-pandemic threshold (December 2019), 782 patients were on the waiting list. Between January 2015-January 2020, inclusive, an average of 673 patients were on the waiting list but this has doubled over the subsequent months to a peak of 1388 patients in December 2021. Between December 2021-October 2022, on average, the waiting list reduced by 18 per month. At the current rate of change, the waiting list would fall to the pre-pandemic level by October 2024, an interval of 24 months. A seven-day service would require 18 months to clear the backlog. Doubling or tripling the current rate of change would require 12 months and 8 months, respectively. CONCLUSIONSPre-existing, pandemic-related, and new NHS-wide challenges continue to have negative influences on reducing the backlog. Proposals for surgical hubs to tackle this carry the risks of removing staff from hospitals which cannot avoid emergency/urgent operating thereby further reducing those institutions' capacity to undertake elective work.
Objective: To investigate the outcomes of patients with recurrent/progressive cranial metastases who underwent re-do craniotomy and to assess the utility of surgery as a treatment option.
Methods: A ...retrospective study was conducted assessing survival after re-do craniotomy for recurrent or progressive cranial metastases. 29 patients were identified between January 2006 and December 2013. Data was gathered from a prospective pathology database, patients' notes and electronic records. The diagnosis of cranial metastasis was obtained through pathological analysis at the time of tumour resection. Results were analysed with Cox regression tests and converted into a Kaplan-Meier curve.
Results: Median patient age was 57 years old (range 24-74 years) at diagnosis of brain metastases. Two patients had serious complications after re-do surgery. Five patients had >2 craniotomies for recurrent disease. Median survival after the first craniotomy was 18 months (range 4.1-50.9 months). Median survival after re-do craniotomy was 7.6 months (range 0.2-31.3 months). 90% of patients survived at least 3 months after re-do surgery, 65.5% survived at least 6 months.
Conclusion: This study suggests that re-do surgery is a viable treatment option for patients with recurrent cranial metastases.
The National Neurosurgical Audit Programme (NNAP) publishes mortality outcomes of consultants and neurosurgical units across the United Kingdom. It is unclear how useful outcomes data is for patients ...and whether it influences their decision-making process. Our aim was to identify patients' perceptions and understanding of the NNAP data and its influences.
This single-centre study was conducted in the outpatient neurosurgery clinics at a regional neurosurgical centre. All adult (age ≥ 18) neurosurgical patients, with capacity, were invited to take part. Native and non-native English speakers were eligible. Statistical analyses were performed on SPSS v28 (IBM). Ethical approval was obtained.
A total of 84 responses were received (54.7% females). Over half (51.0%) of respondents felt that they understood a consultant's mortality outcomes. Educational level determines respondents' understanding (χ
(8) = 16.870;
= .031). Most respondents were unaware of the NNAP (89.0%). Only a third of respondents (35.1%) understood the funnel plot used to illustrate mortality.
Most patients were unaware of the NNAP and most did not understand the data on the website. Understanding of mortality data seemed to be related to respondents' educational level which would be important to keep in mind when planning how to depict mortality data.
The novel coronarvirus disease (COVID-19) has had a major impact on provision of spinal neurosurgery across the world, especially in the UK, with a significant fall in operating and patient volumes, ...and elective clinical activities. It is unclear whether the pandemic has affected the volume of urgent spinal procedures in the UK, especially surgical decompressions for cauda equina syndrome (CES).
Therefore, we conducted a retrospective analysis of theatre records and electronic operation notes at our institution to identify all procedures performed for CES before (December 2019 to February 2020) and during (March 2020 to May 2020) the COVID-19 pandemic. Statistical analyses were performed on SPSS v22 (IBM).
Forty-four patients underwent surgical decompressions during the study period. Over half (54.5%) were female and the median age was 45 years (range = 22-78 years). Three in four procedures were performed at L4-5 and L5-S1 levels (79.5%). There was no statistically significant difference in the number of decompressions performed each month χ
(5)=1.818;
= 0.874. On the other hand, the number of referrals for suspected or confirmed CES fell by 81.8% between December 2019 and April 2020.
Our results did not show any statistically significant decline in the volume of surgical decompressions performed for CES despite the considerable fall in electronic referrals for CES and degenerative spinal conditions. This suggests that patients with critical neurological symptoms continued to present and were treated appropriately despite the restrictions imposed on spinal surgeons during the pandemic.
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DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Coronavirus disease 2019 (COVID-19) is a severe respiratory viral illness that has spread rapidly across the world. However, the United Kingdom has been particularly affected. Evidence has suggested ...that stroke, cardiac, and spinal presentations decreased during the pandemic as the public avoided seeking care. The effect on neurosurgical presentations and referrals during COVID-19 is unclear. Our aim, therefore, was to describe the referral patterns to a high-volume neurosurgical department in the United Kingdom during the COVID-19 pandemic.
Electronic referrals were identified from the referrals database from January 1, 2020 to May 31, 2020, inclusive, with January used as the baseline. The demographic data and referral diagnoses were captured on Excel (Microsoft, Redmond, Washington, USA). Statistical analyses were performed using SPSS, version 22 (IBM Corp., Armonk, New York, USA). Differences between referral volumes were evaluated using χ2 goodness-of-fit tests.
A total of 2293 electronic referrals had been received during the study period. The median age was 63 years. Overall, the referrals had decreased significantly in volume during the study period χ2(4) = 60.95; P < 0.001. We have described the patterns in the daily referrals as the pandemic progressed. The reduction in the volume of referrals for degenerative spine cases and traumatic brain injuries was statistically significant (P < 0.001).
The referrals for degenerative spine and traumatic brain injuries decreased significantly during the pandemic, which can be explained by the lower vehicular traffic and patient avoidance of healthcare services, respectively. The risk of neurological deterioration and increased morbidity and mortality, as a consequence, is of concern, and neurosurgeons worldwide should consider the optimal strategies to mitigate these risks as the pandemic eases.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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