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A previously independent 82-year-old woman presented with 5 months of worsening confusion, mobility and cognitive decline, with deficits in orientation, language and executive function. A cerebral dural arteriovenous fistula was identified and successfully embolised, after which her cognitive ability and independence dramatically improved. Although rare, a dural arteriovenous fistula may mimic a rapidly progressive dementia, but its early recognition and treatment can completely reverse the dementia.

ObjectiveWe describe the chronological trends in cerebral revascularization surgery through a single-surgeon experience; and we review whether in the context of giant and fusiform cerebral aneurysms, flow-diverting stents have impacted on the use of cerebral revascularization surgery.MethodsWe review our single institution prospectively collected database of cerebral revascularization procedures between 2006 and 2018. Comparing this to our database of flow-diverting endovascular stent procedures, we compare the treatment of fusiform and giant aneurysms. We describe patient demographics, procedural incidence, complications, and outcomes.ResultsBetween 2006 and 2018, 50 cerebral revascularization procedures were performed. The incidence of cerebral revascularization surgery is declining. In the context of giant/fusiform aneurysm treatment, the decline in cerebral revascularization is accompanied by a rise in the use of flow-diverting endovascular stents. Thirty cerebral revascularizations were performed for moyamoya disease and 11 for giant/fusiform aneurysm. Four (14%) direct bypass grafts occluded without neurological sequela. Other morbidity included hydrocephalus (2%), transient ischemic attacks (2%), and ischemic stroke (2%). There was one procedure-related mortality (2%). Flow-diverting stents were inserted for seven fusiform and seven giant aneurysms. Comparing the treatment of giant/fusiform aneurysms, there was no significant difference in morbidity and mortality between cerebral revascularization and flow-diverting endovascular stents.ConclusionWe conclude that with the decline in the incidence of cerebral revascularization surgery, there is a need for centralization of services to allow high standards and outcomes to be maintained.

INTRODUCTION Out of programme (OOP) experience from training increases the skill pool of the neurosurgical workforce and drives innovation in the specialty. OOP approval criteria are well defined but transition back to clinical work can be challenging with a paucity of data published on trainee perspectives. Our study aimed to investigate factors influencing transition from OOP back to clinical work among neurosurgical trainees in the UK. METHODS An online survey was sent to all members of the Society of British Neurological Surgeons. Questions pertained to details of OOP and factors influencing transition back to clinical work. RESULTS Among the 73 respondents, 7 were currently on OOP and 27 had completed OOP in the past. Research was the most common reason for OOP (28/34, 82%) and this was generally motivated by the aspiration of an academic neurosurgery career (17/34, 50%). Although the majority (27/34, 79%) continued clinical work during OOP, 37% of this group (10/27) reported a reduction in their surgical skills. Fewer than half (15/34, 44%) had a return to work plan, of which only half (8/34, 24%) were formal plans. The majority of respondents who had completed OOP in the past (22/27, 81%) felt that they were able to apply the skills gained during OOP to their clinical work on return. CONCLUSIONS Skills learnt during OOP are relevant and transferable to the clinical environment but mainly limited to research with OOP for management and education underrepresented. Deterioration of surgical skills is a concern. However, recognition of this problem has prompted new methods and schemes to address challenges faced on return to work.

Background The Ottawa subarachnoid haemorrhage (SAH) rule and the Emerald SAH rule are clinical decision tools to aid in the decision for computed tomography (CT) of the head in patients attending an emergency department (ED) with acute non-traumatic headache. The objective of this study was to analyse the performance of these rules in a contemporary UK cohort. Methods We performed a retrospective external validation study. Patients undergoing CT of the head for the evaluation and treatment of non-traumatic headaches over a 6-month period in the ED at two tertiary centres were assessed. Each patient’s Ottawa rule and Emerald rule were calculated and compared with their final diagnosis. Results The cohort consisted of 366 patients and there were 16 cases of SAH (based on CT findings or the presence of xanthochromia in cerebrospinal fluid). The Ottawa rule identified 288 patients requiring CT of the head. The sensitivity of the Ottawa rule was 100% (95% confidence interval (CI) 71–100%) and the specificity was 22% (95% CI 18–27%). The Emerald rule identified 267 patients who required CT, and achieved a sensitivity of 81% (95% CI 54–96%) and a specificity of 27% (95% CI 23–32%). Conclusions The Ottawa SAH rule correctly identified all patients with SAH in this contemporary cohort. The Emerald rule did not perform as well in this cohort and is unsuitable for clinical use. The Ottawa rule is a useful tool to aid in the decision for CT of the head in patients presenting with acute non-traumatic headache to the ED.

Brain arteriovenous malformations management remains controversial despite the numerous, available treatment options. Randomized controlled trials (RCTs) theoretically provide the strongest evidence for the assessment of any therapeutic intervention. However, poorly designed RCTs may be associated with biases, inaccuracies, and misleading conclusions. The purpose of our study is to assess reporting transparency and methodological quality of the existing RCTs.A search was performed in the PubMed, Scopus, Embase, clinicaltrials.gov, and Cochrane databases. The search was limited to English literature. We included all published RCTs reporting on the management of unruptured brain arteriovenous malformations. The eligible studies were evaluated by 5 blinded raters with the CONsolidated Standards of Reporting Trials 2010 statement and the risk-of-bias 2 tool. The inter-rater agreement was assessed with the Fleiss' Kappa.A randomized trial of unruptured brain arteriovenous malformations (ARUBA) and treatment of brain arteriovenous malformations (TOBAS) trials were evaluated. ARUBA achieved high CONsolidated standards of reporting trials compliance, while TOBAS showed a moderate one. In ARUBA the introduction, discussion, and other information sections reached the highest compliance rate (80%-86%). The lowest rates were recorded in the results and the methods (62% and 73%, respectively). The inter-rater agreement was moderate to substantial (54.1% to 78.4%). All the examined studies demonstrated a high risk of bias, mainly related to ill-defined intended interventions, missing outcome data, and selection of the reported results.Our study confirmed the high risk of bias mainly attributed to several protocol violations, deviations, minimal external validity and selection, attrition, and allocation biases of the ARUBA trial. Analysis of the TOBAS trial revealed a moderate overall reporting clarity and a high risk of bias.

Introduction and objectivesThe novel severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has had drastic effects on global healthcare with the UK amongst the countries most severely impacted. The aim of this study was to examine how COVID-19 challenged the neurosurgical delivery of care in a busy tertiary unit serving a socio-economically diverse population.MethodsA prospective single-centre cohort study including all patients referred to the acute neurosurgical service or the subspecialty multidisciplinary teams (MDT) as well as all emergency and elective admissions during COVID-19 (18th March 2020–15th May 2020) compared to pre-COVID-19 (18th of January 2020–17th March 2020). Data on demographics, diagnosis, operation, and treatment recommendation/outcome were collected and analysed.ResultsOverall, there was a reduction in neurosurgical emergency referrals by 33.6% and operations by 55.6% during the course of COVID-19. There was a significant increase in the proportion of emergency operations performed during COVID-19 (75.2% of total,n=155) when compared to pre-COVID-19 (n= 198, 43.7% of total,p< 0.00001). In contrast to other published series, the 30-day perioperative mortality remained low (2.0%) with the majority of post-operative COVID-19-infected patients (n= 13) having underlying medical co-morbidities and/or suffering from post-operative complications.ConclusionThe capacity to safely treat patients requiring urgent or emergency neurosurgical care was maintained at all times. Strategies adopted to enable this included proactively approaching the referrers to maintain lines of communications, incorporating modern technology to run clinics and MDTs, restructuring patient pathways/facilities, and initiating the delivery of NHS care within private sector hospitals. Through this multi-modal approach we were able to minimize service disruptions, the complications, and mortality.

Background Superior medullary velum cerebral cavernous malformations pose a challenge in terms of appropriate microsurgical approach. Safe access to this deep location as well as preservation of surrounding anatomical structures, in particular the superior cerebellar peduncle just lateral to the superior medullary velum and the dentate nuclei, is paramount to achieve a good functional outcome. Methods Cadaveric dissections provide useful knowledge of the normal anatomy while tractography allows a better understanding of the individual anatomy in the presence of a lesion. The medial-tonsillar telovelar approach provides a feasible corridor for accessing superior velum cerebral cavernous malformations without compromising the fibres contained in the superior cerebellar peduncle. The major cerebellar efferents—cerebello-rubral, cerebello-thalamic and cerebello-vestibular tracts—and afferents, anterior spinocerebellar, tectocerebellar and trigeminocerebellar tracts, within the superior cerebellar peduncle are preserved, and the dentate nuclei are not affected. Results and conclusion A retraction-free exposure through this natural posterior fossa corridor allows the patient with the anatomical and functional subtract to make a good functional recovery by minimizing the risk of a superior cerebellar syndrome, ataxia, tremor and dysmetria; decomposition of movement in the ipsilateral extremities, nystagmus and hypotonia; or akinetic mutism, reduced or absent speech with onset within the first post-operative week.

OBJECTIVEMost intracranial aneurysms are now treated by endovascular rather than by microsurgical procedures. There is evidence to demonstrate superior outcomes for patients with aneurysmal subarachnoid hemorrhage (aSAH) treated by endovascular techniques. However, some cases continue to require microsurgery. The authors have examined the relationship between the number of aneurysms treated by microsurgery and outcome for patients undergoing treatment for aSAH at neurosurgical centers in England.METHODSThe Neurosurgical National Audit Programme (NNAP) database was used to identify aSAH cases and to provide associated 30-day mortality rates for each of the 24 neurosurgical centers in England. Data were compared for association by regression analysis using the Pearson product-moment correlation coefficient and any associations were tested for statistical significance using the one-way ANOVA test. The NNAP data were validated utilizing a second, independent registry: the British Neurovascular Group’s (BNVG) National Subarachnoid Haemorrhage Database.RESULTSIncreasing numbers of microsurgical cases in a center are associated with lower 30-day mortality rates for all patients treated for aSAH, irrespective of treatment modality (Pearson r = 0.42, p = 0.04), and for patients treated for aSAH by endovascular procedures (Pearson r = 0.42, p = 0.04). The correlations are stronger if all (elective and acute) microsurgical cases are compared with outcome. The BNVG data validated the NNAP data set for patients with aSAH.CONCLUSIONSThere is a statistically significant association between local microsurgical activity and center outcomes for patients with aSAH, even for patients treated endovascularly. The authors postulate that the number of microsurgical cases performed may be a surrogate indicator of closer neurosurgical involvement in the overall management of neurovascular patients and of optimal case selection.

Vagus Nerve Stimulation (VNS) is an established treatment for intractable epilepsy, depression, anxiety disorders and certain medically refractory headache conditions. VNS can either be surgically ...

Objectives: Within the pan London Major Trauma System many patients with minor or non-life threatening traumatic brain injury (TBI) remain at their local hospital and are not transferred to a major...

Background: The novel severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has had a drastic effect on global healthcare with the UK amongst the countries most severely impacted. The aim of this study was to examine how COVID-19 challenged the neurosurgical delivery of care in a busy tertiary unit serving a socio-economically diverse population. We also describe the strategies we adopted to meet these challenges. Methods: A prospective single centre cohort study including all patients referred to the acute neurosurgical service or the subspecialty multi-disciplinary teams (MDT) as well as all emergency and elective admissions during COVID-19 (18th March 2020-15th May 2020) compared to pre-COVID-19 (18th of January 2020-17th March 2020). Data on demographics, diagnosis, operation, and treatment recommendation/outcome were collected and analysed. Findings: Overall, there was a reduction in neurosurgical emergency referrals by 33·6% and operations by 55·6% during the course of COVID-19. There was a significant increase in the proportion of emergency operations performed during COVID-19 (75·2% of total, n=155) when compared to pre-COVID-19 (n=198, 43·7% of total, p

BackgroundFlow-diverting stents have demonstrated great promise for the treatment of cerebral aneurysms; however, clinical experience with the devices remains very preliminary. We present two cases of spontaneous delayed complications—one fatal aneurysm rupture and one symptomatic increase in aneurysm volume—following the treatment of intradural aneurysms with the Pipeline Embolization Device (PED).Presentation/interventionTwo patients with unruptured, intradural aneurysms of the carotid artery underwent uneventful treatment with the PED (eV3, Irvine, California, USA). One patient, with a giant aneurysm of the carotid terminus, experienced worsening headache 5 days after the procedure and ultimately collapsed and became unresponsive. CT of the head demonstrated acute subarachnoid and intraventricular hemorrhage. The patient died the following day. A second patient with a large left posterior communicating artery aneurysm presented with progressive memory loss 3 months after PED reconstruction of the carotid artery. Although serial CT angiograms showed progressive thrombosis of the aneurysm to near-complete occlusion, MR of the brain demonstrated marked interval growth of the collective aneurysm–intra-aneurysmal thrombus mass with extensive edema throughout the adjacent left temporal lobe.ConclusionsFlow-diverting devices have demonstrated tremendous promise for the treatment of complex, unruptured cerebral aneurysms. However, experience with this novel approach to aneurysm treatment is preliminary and the consequences of its application within the cerebrovasculature remain incompletely defined. Mural destabilization resulting in delayed, spontaneous, aneurysm growth and/or rupture may occur in the days to weeks following the application of flow-diverting devices to treat previously unruptured intracranial aneurysms. A better understanding of the incidence and etiology of these complications is essential for this technology to be optimally applied.

Objective Arteriovenous malformations (AVMs) were believed to be congenital. However, an increasing number of de novo AVM cases have questioned this doctrine. Methods A consensus meeting of international experts attempted to establish a consensus on the nature of these relatively rare but challenging vascular lesions. In addition, an extensive search of the subject was performed using the PubMed medical database. Results All participants agreed that genetic factors may play a role in the pathogenesis of AVMs. All but 1 participant believed that an underlying genetic predisposition may be detected later on in a patient's life, whereas genetic variations may contribute to sporadic AVM formation. The presence of genetic variations alone may not be enough for an AVM formation. A second hit is probably required. This consensus opinion is also supported by our literature search. Conclusions We discuss the literature on the genetics of AVMs and compare it with the consensus meeting outcomes. The congenital or noncongenital character of intracranial AVMs has an impact on the understanding their biological behavior, as well as their efficient short-term and long-term management.

F47, RH, receptionist, lives with family, hx obesity, presents with 3m hx back pain and after a minor fall lower limb weakness and numbness, o/e hypoaesthesia below T12, normal sphincteric function, spastic weakness MRC grade 4/5 of both lower limbs with increased reflexes and clonus

M71, RH, retired civil servant, non smoker, only medical background of HTN, presents with sudden severe h/a, n/v, ataxia and left sided incoordination with subsequent confusion and drowsiness, blood pressure 230/120

F28, RH, smoker, social etoh intake, no significant pmh, presents with 2m hx gradually worsening mid thoracic pain worse at night, unsteadiness, LL weakness and ascending loss of sensation, 24 h prior to admission developed insensate urinary retention requiring bladder catheterisation, o/e spastic LL weakness MRC 4/5, increased tone and bilateral LL clonus, sensory level at T4 will all modalities affected (pin prick, pain, temperature, proprioception) and no bladder sensation, normal UL and cranial examination

M47, RH, lives on his own, works in a restaurant, background of HTN, non compliant with medication, presents with sudden severe h/a, drowsiness, confusion and left sided hemiplegia, o/e GCS E3 V4 M6, left sided hemiplegia, gaze deviation to the right, PERLA 3+, BP 170/110

F60, RH, previously healthy and still very active, non smoker, IT school teacher, lives with her husband, 4w ago presented with right sided facial and limb weakness and focal seizure activity after 2D of behavioural change and mild cognitive decline. Currently no c/o h/a, intact neurologically except mild cognitive impairment and subtle Right UMN facial weakness, no speech impairment or pronator drift

M30, RH, healthy, motorbike racing driver, sustained thoracic spine injury whilst racing expressed with back pain and no neurological compromise

M29, RH, plasterer, intoxicated with EtoH and crashed into a tree at 40 mph. At scene GCS E2 V2 M5, I+V+S, upon admission left pupil dilated to 5 mm

F54, RH, lives with parents, carer of father, smoker, pmh of hypothyroidism on levothyroxine, presents with acute painful right sided ptosis, o/e, GCS E4 V5 M6, no limb deficit, complete R III nerve palsy with fixed and dilated pupil

F22, RH, previously healthy, sustained polytrauma after jump from three storey building in an attempt to escape from assault, upon admission intact level of consciousness, c/o lumbosacral pain and Right L5/S1 dermatomal distribution loss of pin prick sensation and weakness of EHL/ADF 3/5

F78, RH, retired homecare assistant, independent with PMH of HTN presents with 5w hx neck pain and rapidly worsening mobility and dexterity, o/e bilaterally positive Hoffman’s, mild spastic weakness of all four limbs MRC grade 4/5, bilaterally positive Babinski, diffusely reduced pin prick sensation of upper limbs

M61, RH, lorry driver, lives with wife, ex smoker (stopped 5 years ago), no other significant PMH, presents with 1 year hx gradually worsening h/a, behavioural changes and vacant episodes (absent seizures) on a background of a 3 year anosmia, o/e mild cognitive impairment and short term memory deficit, anosmia, normal vision and fundoscopy

F35, RH, previously healthy, non smoker, on contraceptive pill, presents 3w ago with sudden severe h/a associated with n/v and subsequent 1w ago visual impairment. Referred to NS and blue lighted to the unit. Currently GCS E4 V5 M6, no FND, visual findings as above with peripheral VF restriction and reduced visual acuity

F56, RH, heavy smoker, TIIDM on metformin, undergoes uneventful Right occipital craniotomy for breast Ca metastasis expressed with h/a and left sided hemianopia, 7 years earlier Right breast Ca 2010: mastectomy + node clearance + chemoradiotherapy (XRT for 6w then 18m herceptin), presents 6w post op with pus discharge from cranial wound, worsening h/a and low grade pyrexia, WBC 9.75, CRP 8.9, Na 132

M15 previously healthy was hit by a car travelling at 30 mph while crossing the road. He had a cardiac arrest at the scene, with bystander CPR for 4 min. He required chest compressions by LAS with return of systemic circulation after 9 min, not requiring adrenaline. He I+V at scene and had bilateral thoracostomies performed by HEMS who transferred him to A+E. He received hypertonic saline en-route in view of concerns regarding raised intracranial pressures. Pupils had reacted for a short while after but then became persistently fixed and dilated. On arrival to ED, pupils were fixed, dilated 7 cm and non-reactive. Further boluses of hypertonic saline were given to no effect.

F18, RH, healthy, assaulted with a hammer blow on the head, presented with LOC for 30 secs, o/e intact neurologically, c/o h/a, left parietal laceration

M38, RH, with background of Depression, hypertension, ETOH excess, fell from a flight of stairs whilst intoxicated and developed neck pain with numbness and flaccid weakness of his limbs, o/e sensory level at C6, LL power 0/5, elbow flexion /extension 3/5 and O/5 distal UL power, retained bladder catheter sensation

M67, RH, lives on his own, with known spinal and pelvic metastatic prostate Ca received in the past XRT and hormonal therapy presented with fall from stairs 3D ago causing significant neck pain and right shoulder soft tissue injury, o/e neurologically intact except mild limitation of right shoulder ROM due to localised injury

M79, RH, only PMH of HTN and high cholesterol, active and independent, lives with wife, presents with 2w hx worsening back pain, malaise, loss of appetite and weight, night sweats and low grade pyrexia, o/e mid thoracic myelopathy expressed with spastic weakness of LL MRC grading 4/5 and T6 sensory level

F73, retired pharmacist, pmh of lymphoedema and bilateral hip replacements, presents with 4m of gradually worsening mobility and sphincteric dysfunction. Last month more rapid deterioration and last week double incontinence and unsteadiness o/e lower thoracic severe myelopathy with loss of proprioception, weakness 4/5, double incontinence, can feel catheter tug

M61, RH, lives with friend, ex smoker, no etoh, background of Hypopharynx SCC—T4A N2C M0, resected 1 year ago followed by adjuvant chemoradiotherapy, presents with 1m hx h/a, ataxia, left sided dysmetria and visual impairment secondary to papilloedema and deteriorates rapidly to GCS E2 V tracheostomy M4

F72 with background of breast Ca, mastectomy and adjuvant chemoradiotherapy 15 years ago, presents with 2m hx upper thoracic back pain worse at night and 3w hx progressive lower limb weakness and numbness, o/e sensory level at T4 with hypoaesthesia, bilateral spastic LL weakness MRC grade 4/5 with increased reflexes, bilateral clonus and reduced proprioception, no sphincteric disturbance

M83, RH, previously healthy and independent, lives with wife, non smoker, no etoh, underwent elective lumbar laminectomy for lumbar canal stenosis expressed with neurogenic claudication, complicated by intraoperative dural tear and csf leak which was primarily repaired, re presented with persistent lumbar wound csf leak followed by pyrexia, confusion and double incontinence, rapidly deteriorated to GCS E2 V1 M3 and systemic sepsis