Surgery for chronic subdural haematoma: is there an evidence base?
Explore the source record for details and available documents.
Chronic Disease↗
Biomedical subjects
L T Dunn
Publications and source records attributed to L T Dunn.
Clinical experience in the use of the Spiegelberg automated compliance device in the assessment of patients with hydrocephalus.
Deciding upon shunting in patients with hydrocephalus with possibly related symptomatology, is difficult. The Spiegelberg automated device allows continuous measurements of intracranial compliance. We aimed to evaluate the added information that this new technology can provide, in addition to standard continuous ICP monitoring. Thirty-three patients with hydrocephalus were continuously monitored for ICP and compliance. Patients with abnormal ICP or compliance profiles were selected for shunting. Thirteen patients underwent ventriculo-peritoneal shunting on this basis, with 12 obtaining benefit and one dying as a complication of shunt-related sepsis. The 13 patients undergoing shunting had abnormalities in either intracranial pressure or compliance or both. Only 1 patient had normal ICP, but abnormal compliance and so the true complementary role of continuous compliance measurements cannot be determined. It is proposed that further recruitment be on a larger multi-centre basis. Determination of benefit is required, particularly as a possible time lag of abnormal ICP abnormal compliance over appearing during monitoring can be demonstrated.
Adolescent↗
Facial nerve repair and regeneration: an overview of basic principles for neurosurgeons.
The facial nerve may be damaged by trauma, surgical manipulation, inflammation or neoplastic disease. Current techniques for repair and regeneration of the damaged nerve produce suboptimal results. This review outlines the current knowledge of experimental facial nerve regeneration in vitro and in vivo to provide an insight for neurosurgeons in clinical practice.
Animals↗
The influence of apolipoprotein E genotype on outcome after spontaneous subarachnoid hemorrhage: a preliminary study.
OBJECTIVE: Possession of an apolipoprotein E (APOE)epsilon4 allele has been shown to be associated with a poor outcome after closed head injury and spontaneous intracerebral hemorrhage but not after ischemic stroke. This study assessed the influence of the APOE genotype on outcome in patients admitted to a neurosurgical unit with spontaneous subarachnoid hemorrhage. METHODS: A total of 100 patients with spontaneous subarachnoid hemorrhage were studied. Four patients were excluded because the diagnosis of subarachnoid hemorrhage was not confirmed. The incidence of rehemorrhage and delayed ischemia and the outcome at 6 months were determined using the Glasgow Outcome Scale. APOE genotypes were determined by polymerase chain reaction and restriction enzyme digestion. RESULTS: Allele frequencies in this patient group were 0.04 for epsilon2, 0.86 for epsilon3, and 0.1 for epsilon4. Of 96 patients, 72 had an aneurysmal hemorrhage and 1 had a hemorrhage from an arteriovenous malformation. In 14 patients, the results of angiography were negative, and in 9, no angiogram was performed. Of the 96 patients, 20 had one or more epsilon4 allele. Outcome at 6 months was no worse in patients with one or more epsilon4 allele than in those with no epsilon4 allele (odds ratio, 0.98; 95% confidence interval, 0.35-2.74). None of the 12 patients who experienced delayed ischemic deterioration had an epsilon4 allele. Of the 20 patients with an epsilon4 allele, 3 had a rehemorrhage, as compared with 6 of 76 patients without an epsilon4 allele. CONCLUSION: There was underrepresentation of the epsilon4 allele in this group when compared with previously studied cases of subarachnoid hemorrhage with a fatal outcome and with the general population. This suggests that patients with the epsilon4 allele who have a subarachnoid hemorrhage are less likely to be admitted to a neurosurgical unit. This study does not support an association between possession of an epsilon4 allele and poor outcome in patients admitted to a neurosurgical unit with spontaneous subarachnoid hemorrhage, although the wide confidence interval does not preclude a clinically relevant association between APOE genotype and outcome. The findings indicate that an association between genotype and the development of delayed ischemic complications after subarachnoid hemorrhage may be possible.
Adult↗
Head injury in the severely injured: long-term follow-up in 157 patients.
Ninety-two patients with head injury in the context of multiple injury were followed up 5 years after injury. Severe disability in this group of patients was nearly always due to brain/spinal cord injury, rather than musculoskeletal injury. A substantial number of patients with mild or moderate head injuries had significant persisting disability 5 years after injury.
Adult↗
Identification of a human olfactory ensheathing cell that can effect transplant-mediated remyelination of demyelinated CNS axons.
The olfactory ensheathing cell (OEC) has attracted much interest recently because of its potential for transplantation-based therapy of CNS disease. Rat OECs are able to remyelinate demyelinated axons and support regeneration of damaged axons. Although OECs can be grown readily from the rat, a macrosmatic species, it has been uncertain whether it would be similarly straightforward to obtain these cells from the human, a microsmatic species with a relatively poorly developed olfactory system. In this study, we have identified a human OEC which shares many properties with its rat counterpart, including expression of the low-affinity nerve growth factor receptor (L-NGFr) and similar growth factor requirements. Purified populations of human OECs obtained by selection with L-NGFr antibodies have extremely high viability in tissue culture, and are capable of remyelinating persistently demyelinated CNS axons following transplantation into experimentally induced demyelinating lesions in the rat spinal cord. Thus, the human OEC represents an important new cell for the development of transplant therapy of CNS diseases.
Animals↗
NMDA receptor blockade fails to alter axonal injury in focal cerebral ischemia.
The ability of the NMDA receptor antagonist, MK-801, to protect myelinated axons after focal cerebral ischemia has been examined. Amyloid precursor protein (APP) immunocytochemistry was used to assess the anatomic extent of axonal injury, and conventional histopathology was used to assess the volume of ischemic damage to neuronal perikarya. The middle cerebral artery was permanently occluded in 16 cats. The cats were treated with either vehicle or MK-801 as a 0.5-mg/kg bolus at 15 minutes before middle cerebral artery occlusion, followed by an infusion of 0.14 mg/kg per hour. After 6 hours, the animals were killed and the brains processed for histology and immunocytochemistry. The volume of neuronal necrosis was determined from 16 preselected coronal levels of the brain. The circumscribed zones of APP accumulation in axons were mapped onto images at the same 16 coronal levels, and quantitative analysis was performed using a transparent counting grid, randomly placed over each image. The histologic appearance and anatomic location of axons with increased APP immunoreactivity was similar in animals treated with vehicle and MK-801. MK-801 failed to reduce the hemispheric APP score significantly. In vehicle-treated animals, there was a significant association between the volume of neuronal necrosis and the amount of APP immunoreactivity. MK-801 significantly reduced the slope of the association between the volume of neuronal necrosis and the amount of APP immunoreactivity compared with that observed in vehicle-treated animals. As a result, the ratio of hemispheric APP score and volume of neuronal necrosis was significantly increased with MK-801 treatment. The inability of NMDA receptor antagonists to protect axons may limit their functional efficacy in improving functional outcome after stroke.
Amyloid beta-Protein Precursor↗
A standardised neurosurgical referral letter for the inter-hospital transfer of head injured patients.
OBJECTIVES: (1) To evaluate the use of a standardised neurosurgical referral letter in terms of compliance, completeness and clinical relevance. (2) To compare the clinical information provided on the standardised neurosurgical letter with that provided by referring hospitals that used alternative documentation. DESIGN: A six month prospective audit was conducted in south west Scotland. Consultant neurosurgeons were asked to weight key clinical variables on the neurosurgical referral letter (NRL). Postal surveys of 114 referring accident and emergency (A&E) staff and 18 neurosurgical receiving staff were undertaken to determine the clinical relevance of the NRL. Case notes were examined for the presence and level of completeness of the NRL. In the absence of the NRL, a form was completed retrospectively using data from the referring hospital's letter. This enabled comparison of the NRL with routine hospital letters in terms of the availability of key clinical information. RESULTS: 139 adult patients were identified as suitable for inclusion: 99 patients were transferred from 11 hospitals with access to the NRL. The compliance rate for use of the NRLwas 82%. Forty patients were transferred from nine hospitals that did not have access to the NRL. The completion rate of key variables on the NRL was higher than when an ordinary letter was sent: 87% compared with 38%. The NRL was considered useful by 67 of 71 (94%) A&E questionnaire respondents and by 14 of 15 neurosurgeons who responded. CONCLUSIONS: The widespread acceptance of the NRL and its ability to provide essential clinical information in a concise format not available in routine hospital letters indicates that national, standardised documentation can be implemented if users are involved in both its design and implementation.
Adult↗
Secondary insults during the interhospital transfer of head-injured patients: an audit of transfers in the Mersey Region.
To assess the incidence of secondary insults and unidentified extracranial injuries a prospective audit of 50 head-injury transfers to a regional neurosurgical unit using a standardized assessment proforma was undertaken. There was wide variability in the quality of transfers. Six per cent of the group were hypoxic on arrival and 15 per cent were hypotensive. In the patients with multiple injuries, 29 per cent had inadequately diagnosed or managed injuries when they arrived. A comparison of this cohort of patients with previous studies is presented. As a result of the audit a set of transfer and referral guidelines have been drawn up and, following distribution of the guidelines to our referring hospitals, a further cohort of patients will be audited.
Adolescent↗
Brain stem dermoid cyst.
Explore the source record for details and available documents.
Brain Neoplasms↗
Iatrogenic spinal infection following epidural anaesthesia: case report.
Explore the source record for details and available documents.
Abscess↗
Hemispherectomy for intractable seizures: a further modification and early experience.
Hemispherectomy is well recognized as an effective treatment for some types of intractable epilepsy, but the procedure is also known to be associated with significant late complications. A number of modifications to the original operation have been developed to try and minimize such late complications. These are reviewed and a further modification is described using a Zenoderm graft to isolate the hemispherectomy cavity from the remaining CSF pathways. We present our early experience with this new modification in seven patients with intractable epilepsy.
Adolescent↗
Demonstration of neurovascular compression in trigeminal neuralgia with magnetic resonance imaging. Comparison with surgical findings in 52 consecutive operative cases.
Until recently, the inability to demonstrate neurovascular compression of the trigeminal nerve preoperatively resulted in surgery being offered only in cases of severe trigeminal neuralgia (TGN), frequently after a prolonged trial of medical treatment and following less invasive procedures, despite the fact that posterior fossa microvascular decompression gives long-term pain relief in 80% to 90% of cases. To assess whether vascular compression of the nerve could be demonstrated preoperatively, high definition magnetic resonance tomographic angiography (MRTA) was performed in 50 consecutive patients, five of whom had bilateral TGN, prior to posterior fossa surgery. The imaging results were compared with the operative findings in all patients, including two patients who underwent bilateral exploration. Vascular compression of the trigeminal nerve was identified in 42 of 45 patients with unilateral symptoms and on both sides in four patients with bilateral TGN. In the last patient with bilateral TGN, neurovascular compression was identified on one side, and on the other side the compressing superior cerebellar artery was separated from the nerve by a sponge placed during previous surgery. There was full agreement regarding the presence or absence of neurovascular compression demonstrated by MRTA in 50 of 52 explorations, but MRTA misclassified four vessels compressing the trigeminal nerve as arteries rather than veins. In two cases, there was disagreement between the surgical and MRTA findings. In the first of these cases, surgery revealed distortion of the nerve at the pons by a vein that MRTA had predicted to lie 6 mm remote from this point. In the second patient, venous compression was missed; however, this patient was investigated early in the series and did not have gadolinium-enhanced imaging. In nine cases, MRTA correctly identified neurovascular compression of the trigeminal nerve by two arteries. Moreover, MRTA successfully guided surgical reexploration in one patient in whom a compressing vessel was missed during earlier surgery and also prompted exploration of the posterior fossa in two patients with multiple sclerosis and one patient with Charcot-Marie-Tooth syndrome, in whom neurovascular compression was identified preoperatively. It is concluded that MRTA is an extremely sensitive and specific method for demonstrating vascular compression in TGN. As a result, open surgical procedures can be recommended with confidence, and microvascular decompression is now the treatment of choice for TGN at the authors' unit. They propose MRTA as the definitive investigation in such patients in whom surgery is contemplated.
Aged↗
Brain stem dermoid cyst.
Explore the source record for details and available documents.
Brain Neoplasms↗
An immunotoxicity assessment of food flavouring ingredients.
A rapid screening protocol incorporating key elements of the US National Toxicology Program's immunotoxicity tier testing strategy was used to evaluate the effects of 35 commonly used food flavouring ingredients on humoral and cell-mediated immune responses. The test compounds were administered intragastrically on a daily basis for 5 days at three dose levels to female CD-1 or B6C3F1 mice, 6-8 wk old. A host resistance assay (Listeria monocytogenes bacterial challenge) was conducted to assess cell-mediated immunity. Humoral immunity was measured by the antibody plaque-forming cell (PFC) response to sheep erythrocytes. Body weights, lymphoid organ weights and spleen cellularity were also measured. Cyclophosphamide (80 mg/kg) served as an immunosuppressive positive control agent. The results indicated that the majority of the flavouring ingredients tested did not modulate the cell-mediated or humoral immune response. However, at very high dose levels, two of the materials tested, peppermint oil and citral dimethyl acetal, did increase mortality rate and reduce survival time in the host resistance assay. Neither of these materials significantly altered the PFC response. This rapid, economical screening battery for potential immunotoxicants proved to be a useful means of evaluating a large number of structurally diverse compounds and mixtures to prioritize them for more definitive testing.
Animals↗
Anticonvulsant and antibiotic prophylaxis in head injury.
The evidence for and against the prophylactic use of anticonvulsants and antibiotics in head injury is reviewed. There is a lack of blinded placebo-controlled trials in this area. On balance there is no compelling evidence to support the use of either anticonvulsant or antibiotic prophylaxis in head injury, with the possible exception of antibiotic prophylaxis in compound depressed skull fractures and penetrating brain injuries.
Animals↗
Double dissociations of the effects of amygdala and insular cortex lesions on conditioned taste aversion, passive avoidance, and neophobia in the rat using the excitotoxin ibotenic acid.
The results in this article show that although electrolytic amygdala lesions disrupt learning of a conditioned taste aversion (CTA), ibotenic acid-induced, axon-sparing lesions of the amygdala do not. However, ibotenic acid lesions of the insular cortex do disrupt learning of a CTA. Electrolytic, but not ibotenic acid lesions of the amygdala, interrupt axons running between the insular (gustatory) cortex and the brain stem/hypothalamus. It is the destruction of these projections which appear to underly CTA deficits after amygdala lesions. Other results revealed that ibotenic acid lesions of the insular cortex attenuated the reaction to the novel taste of saccharin in a familiar environment but failed to affect the ingestion of a novel food in a novel environment or passive avoidance learning. Conversely, ibotenic acid lesions of the amygdala did not affect the reaction to novel saccharin in a familiar environment but did impair both the reaction to novel food in a novel environment and passive avoidance learning. We conclude that the insular cortex is involved in reactions to the novelty and associative salience exclusively of taste stimuli, whereas the amygdala is probably more concerned with the reaction to more general aspects of novelty in the environment and in fear-motivated behavior.
Amygdala↗
The effects of lesions to noradrenergic projections from the locus coeruleus and lateral tegmental cell groups on conditioned taste aversion in the rat.
Lesions of the coeruleo-cortical noradrenergic projections caused marked cortical noradrenaline depletions but were not associated with deficits in the acquisition or extinction of a conditioned taste aversion (CTA). Lesions of lateral tegmental noradrenergic projections resulted in marked hypothalamic noradrenaline depletions, enhanced neophobia to the novel taste of saccharin, unimpaired acquisition but prolonged extinction of the CTA. However, when animals with lateral tegmental noradrenergic lesions received extensive preconditioning exposure to saccharin, acquisition of the CTA was attenuated and extinction was more rapid than in controls. Alterations in CTA learning and extinction following lesions of the lateral tegmental noradrenergic system appear to reflect alterations in the way that animals with lesions react toward the hedonic aspects of taste-related stimuli rather than alterations in associational or attentional mechanisms.
Animals↗