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Background: Enhanced Recovery After Surgery (ERAS) is a well-established, protocol-driven, evidence-based approach to peri-operative care. ERAS protocols have been used to improve patient morbidity and mortality outcomes in various surgical specialties. More recently, it has been introduced to neurosurgery. Our aim was to establish an Enhanced Recovery After Cranial Surgery (ERACraS) protocol for patients as part of a quality improvement project (QIP) with the intention of reducing hospital length of stay (HLOS)., Methods: This QIP was carried out in the Department of Neurosciences (DCN), Edinburgh, over two four-month periods. A total of 40 patients over 18 years of age undergoing elective craniotomy surgery under a sole neurosurgeon were invited to take part in this QIP. Subsequently, data was retrospectively collected through our institution's online documentation system., Results: 19 patients received conventional perioperative care (pre-ERACraS group) during December 2021-March 2022, and 21 received care according to the novel ERACraS (ERACraS group) during June-September 2022. Regarding supra-tentorial surgery, there was a reduction of 73% in HLOS in the ERACraS group. No change was observed in infra-tentorial surgery. Overall, the ERACraS protocol reduced HLOS by 50% in cranial surgery., Conclusion: The QIP data from ERACraS in our unit has shown that implementing ERAS protocols is feasible. A reduction in HLOS has implications for patient morbidity, mortality, and quality of care. We endeavour to collect long-term data by collaborating with neurosurgical units across the UK and Ireland to validate its feasibility and sustainability as part of a major QIP in neurosurgical practice. This can be potentially adopted by neurosurgical centres across the globe in a safe and sustained manner., (Copyright © 2023. Published by Elsevier B.V.)

Background: Meningiomas are one of the most common benign primary brain tumors; however, there is a paucity of literature on potential preventability. This comprehensive review aimed to explore the existing evidence for the potential risk factors that may contribute to meningioma development and to discuss early prevention strategies., Methods: Literature search was conducted via MEDLINE, Embase, Web of Science, and Cochrane Database to retrieve existing literature on various environmental exposures and lifestyle behaviors that are potential risk factors for the development of meningiomas., Results: Significant risk factors included exposure to ionizing radiation and certain environmental chemicals. Notably, this study also identified that cigarette smoking and obesity are associated with the development of meningiomas. To date, wireless phone usage, hormonal exposures, dietary factors, and traumatic brain injury remain inconclusive. Early prevention strategies should primarily be family-driven, community-based, and public health-endorsed strategies. Targeting unhealthy behaviors through healthcare organizations could execute a pivotal role in the maintenance of an optimum lifestyle, reducing the development of risk factors pertinent to meningiomas., Conclusions: To our knowledge, this is the first study that offers a perspective on prevention of meningiomas. A causal relationship of risk factors in developing meningiomas cannot be directly established with the current evidence. We are aware of the limitations of the hypothesis, but we believe that this study will raise more awareness and our findings could potentially be endorsed by organizations promoting health across the globe. Further prospective and retrospective studies will shed more light on this topic and help establish a definitive relationship., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: There has been an increase in number of Neurosurgical publications, including open access (OA), in recent years. We aimed to compare journals' performance and the relationship to submission fees incurred in publication., Methods: We identified 53 journals issuing neurosurgery-related work. Quantitative analysis from various search engines involved obtaining h-index, Journal Citation Indicator (JCI), and other metrics such as Immediacy Index and 5-year impact factor utilising Journal Citation Reports. OA fees and individual subscription fees were collected. Correlations were produced using Spearman rho (ρ) (P < 0.05)., Results: Median h-index for 53 journals was 54 (range: 0-292), with JCI median reported as 0.785 (range: 0-2.45). Median Immediacy Index was 0.797 (range: 0-4.076), and median for 5-year impact factor was 2.76 (range: 0-12.704). There was a very strong positive correlation between JCI and Immediacy Index, JCI and 5-year impact factor, and 5-year impact factor and Immediacy Index (ρ > 0.7, P < 0.05). It is unclear whether there was any correlation between the indices and the OA costs and subscription costs for personal usage (P > 0.05)., Conclusions: Larger costs incurred for OA fees and subscription costs for personal use do not clearly reflect on the journals' performance, as quantified by using various indices. There appears to be a strong association with performance across the journals' metrics. It would be beneficial to include learning about bibliometric indices' impact for research publications in medical education training to maximize the quality of the scientific work produced and increase the visibility of the information produced. The potential full movement to exclusively OA journals would create a significant barrier for junior researchers, small institutions, and full time-trainee physicians with limited funding available. This study suggests the need for a robust measurement of journals' output and the quality of the work produced., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

The National Health Service faces substantial challenges with staffing in the face of administrative turbulence just after a global pandemic resulting in significant economic losses. This staffing crisis extends to neurosurgical training with pervasive problems with the balance between trainees and consultants. In the face of Brexit, after the impact of the European Working Time Directive, these challenges provide an opportunity to explore possible solutions to improving training and staff retention. The recommended solutions include ensuring appropriate workforce planning and using novel (and already available) resources to revamp the structure of neurosurgery training and improving the attainment of surgical competence and staff retention. Creating a sustainable neurosurgery training program to adequately fill gaps in the National Health Service will require long-term solutions and the commitment of multiple stakeholders. The first step to achieving these goals would be to maximize the available opportunities to allow trainees maximize training time to become competent day-one consultants., (Copyright © 2022 Elsevier Inc. All rights reserved.)

This review discusses the potential significance of glymphatic system dysfunction in the pathophysiology of idiopathic intracranial hypertension (IIH). IIH is a clinical syndrome characterised by signs and symptoms which arise from raised intracranial pressure (ICP), in the absence of a clear primary cause of intracranial hypertension. The underlying pathophysiological mechanisms driving IIH remain unclear and raised cerebrospinal fluid (CSF) secretion, reduced fluid drainage, and elevated cerebral venous sinus pressure do not fully explain the condition's aetiology. There is a growing literature which implicates the glymphatic system, a mechanism by which fluid moves into the brain parenchyma via peri-arterial channels and out via perivenous spaces and brain lymphatics, in IIH pathogenesis. We propose that aquaporin-4 (AQP4) changes, neurogliovascular unit disruption, a pro-inflammatory CSF profile and impaired glymphatic outflow are the main mechanisms driving glymphatic dysfunction in IIH. However, it remains unclear which of these mechanisms are primary causes and which are secondary effects. Further studies using CSF tracers, electron microscopy, and immunohistochemistry are needed to better evaluate the cellular and molecular pathology associated with IIH at different timepoints in the disease course, which will help elucidate the mechanistic role of the glymphatic system in the condition's pathogenesis., (Copyright © 2022. Published by Elsevier B.V.)

Purpose: Perimesencephalic Subarachnoid Haemorrhage (PMSAH) is an uncommon type of SAH. Severity of PMSAH can be graded by the presence of blood in the Sylvian fissure. No study compares the outcomes from PMSAH with blood present or absent in the Sylvian fissure. Furthermore, the use of Nimodipine lacks evidence base in PMSAH. We investigated whether continuing Nimodipine to 21 days in PMSAH with or without blood in the Sylvian fissure made any significant difference to patient outcome., Methods: Retrospective study of 93 cases admitted to tertiary centre from 2016 to 2020. We compared prevalence of cases with blood in Sylvian fissure, and analysed outcomes including complications and changes to patient modified rankin scale (MRS). We also audited use of Nimodipine in these cases and analysed whether Nimodipine made any significant difference in preventing complications., Results: 91 % of PMSAH were grade 1, 24 cases (26 %) had blood in the Sylvian fissure. Sylvian fissure positive (Sylvian-positive) cases were statistically significantly more likely to have higher rates of complication compared to Sylvian fissure negative (Sylvian-negative) cases. Our centre stopped Nimodipine 56 % of the time in Sylvian-negative cases and 45 % of the time in Sylvian-positive cases. There was no statistically significant difference in outcomes when Nimodipine was continued to 21 days or ceased after negative angiogram; this result extended to both Sylvian-positive and Sylvian-negative subgroups when directly comparing Sylvian-positive cases with each other and Sylvian-negative cases likewise., Discussion: Sylvian-positive cases have a significantly higher rate of complication, as well as an increase in MRS. This may be because of the inflammatory properties of haemoglobin in the subarachnoid space post-bleed. Furthermore, acknowledging the limitations of our retrospective data, we did not find a statistically significant difference in continuing Nimodipine to 21 days with relation to PMSAH outcomes in all subgroups., Competing Interests: Conflicts of interest The authors have no relevant financial or non-financial interests to disclose., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objective: With the recent paradigm shift in neurosurgical publications, open access (OA) publishing is burgeoning along with traditional publishing methods. We aimed to explore costs of publication across 53 journals., Methods: We identified 53 journals publishing neurosurgical work. Journal type, submission and open access charges, color print fees, impact indicators, publisher, and subscription prices were obtained from journal and publisher websites. Costs were unified in U.S. dollars. Mean prices per journal were used to equilibrate membership and subscription discounts. Correlations were performed using Spearman ρ (P < 0.05)., Results: Of 53 journals, 12 were OA only, 40 were hybrid, and 1 was traditional. Submission costs were provided by 22 and 43 journals, respectively, by the end of phase 1 and 2 (prices always for phase 2: 26 free of charge, 4 <$500, and 1 <$1000). Median OA charge was $3286 (49 journals; range, $0-$7827). Of 53 journals, 36 did not list print fees for color figures (29 in phase 2). Median fee estimate per figure was $422 (range, $25-$1060). Median personal subscription for 1 year was $344 (range, $60-$1158; 48 journals). Median institutional subscription for 1 year was $2082 (range, $38-$5510; 34 journals). There was a mild positive correlation between Journal Impact Factor and OA fees (ρ = 0.287, P = 0.046)., Conclusions: The lack of easily accessible information about neurosurgical publications, such as submission costs or OA charges, creates an unnecessary hurdle and should be remedied. Publishing in neurosurgery should be a positive learning experience, and cost should not be a limiting factor., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The management of IIH during pregnancy is a topic of clinical importance and it may pose a management challenge as most cases of IIH occur in women of childbearing age. Although there is a consensus that pregnant women with IIH should be treated similarly to non-pregnant patients, there are uncertainties regarding optimal management. This review aims to analyse current evidence and literature to help guide management of IIH during pregnancy. It is recommended that pregnant women with IIH are treated in health care settings that have access to multi-specialty input to optimise treatment. The management depends on disease severity with a treatment paradigm that encompasses conservative, medical and surgical management., (Copyright © 2022. Published by Elsevier B.V.)

Objective: There has been an increasing number of reported errors in neurosurgical publications. Subsequent published correction details in the form of errata and corrigenda has not been analyzed previously. Our study aims to review the published errata and corrigenda in neurosurgical literature, and we discuss the characteristics and future implications of postpublication errors., Methods: PubMed and Embase databases were screened using a designed search strategy for errata and corrigenda in neurosurgical articles published between 1990 and March 2021. Data including journal impact factor, number of authors and citations, country of origin, study design, level of evidence, category, severity, and timing of correction of errors were extracted for summary and analysis., Results: A total of 768 included articles contributed to 918 error corrections. In 563 (73.31%) articles, the correction was acknowledged in the original record. Median journal impact factor was 3.114 (interquartile range [IQR], 2.139). Median correction time was 3 months (IQR, 5 months), with no statistically significant difference in timing of correction across different error severities (Kruskal-Wallis test, P = 0.058). A total of 398 (51.82%) studies showed level 3 evidence. Errors with minimal severity most commonly occurred in the author list 197(82.43%), with typographic error being the predominant cause. Errors with high severity most commonly occurred in the Results section. Eight errors (0.87%) prompted modification of study conclusions., Conclusions: Observations of postpublication corrections across a wide range of studies prompted more awareness of errors in the neurosurgical literature regardless of impact factors and level of evidence. More standardization in the recognition and acknowledgment of errors, with active engagements from authors, readers, editors, and publishers, is recommended., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The best surgical treatment for adult Chiari malformation type 1 remains widely debated., Objective: This study aimed to assess the efficacy of posterior fossa decompression and duraplasty with arachnoid preservation compared with arachnoid dissection for the treatment of adult Chiari malformation type 1., Methods: Two reviewers (M.O.-G. and M.A.) performed a PubMed, MEDLINE, and Embase literature search using the following terms: ("Chiari" OR "Chiari 1") AND ("duraplasty" OR "arachnoid preservation" OR "arachnoid spar∗" OR "posterior fossa surgery" OR "posterior fossa decompression" OR "foramen magnum decompression"). Studies assessing the efficacy of posterior fossa decompression with duraplasty for the treatment of patients aged >18 years with Chiari malformation type 1 were included. Case reports with <10 patients, editorials, and non-English studies were excluded., Results: Of 195 studies identified, 24 were included for meta-analysis. In the 1006 participants, there was no difference in postoperative clinical or radiologic improvement between the 2 techniques. Patients who underwent posterior fossa decompression with duraplasty and arachnoid dissection had a greater prevalence of total complications (0.20, 95% confidence interval [CI], 0.13-0.29 vs. 0.09, 95% CI, 0.05-0.14; Q = 6.47; P = 0.01) and cerebrospinal fluid-related complications (0.15, 95% CI, 0.10-0.22 vs. 0.05, 95% CI, 0.02-0.12; Q = 4.88; P = 0.03) compared with arachnoid preservation. Furthermore, the prevalence of reoperation in the arachnoid dissection group was 25 times greater than in the arachnoid preservation group (0.08, 95% CI, 0.06-0.10 vs. 0.003, 95% CI, 0.00-0.02; Q = 10.73; P > 0.001)., Conclusions: Posterior fossa decompression and duraplasty with arachnoid preservation is a beneficial technique to treat Chiari malformation type 1 and reduces the risk of complications, particularly cerebrospinal fluid-related complications and the rate of reoperation., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: This study is aimed to compare and evaluate any differences in clinical and radiological outcomes of different operative techniques of cranio-cervical decompression (CCD) performed in adults with symptomatic Chiari malformation type I (CM-1) within a single tertiary neurosurgical center., Methods: A retrospective review using the Hospital theatre management system (ORSOS) and records of patients who underwent CCD for CM-1 between January 2011 and October 2019 was performed. Patients were divided in three cohorts according to the operative technique used: an extradural osteo-ligamentous decompression (BD), BD followed by dural opening either without duraplasty (DOWD) or plus duroplasty (DOPD). The primary clinical outcome was measured by utilizing the Chicago Chiari Outcome Scale (CCOS). Syrinx outcome was measured on post-op MRI. Statistical analysis was performed using IBM SPSS 24 with α = 0.05., Results: 67 adults underwent 69 CCD: 10 BD, 29 DOWD and 30 DOPD. Median follow-up was 47.3 months (Interquartile Range (IQR) 26.3-73.7). Patients who underwent DOPD had a shorter median hospital stay (p-value 0.001), fewer unplanned readmissions (p-value 0.015), a higher median CCOS (p-value 0.001) and a lower post-operative complications rate (p-value 0.001) compared to patients who underwent DOWD. BD revealed a 40 % failure rate and was ineffective in cases with syringomyelia., Conclusion: Better clinical outcomes, lower complication risk, and short duration of hospital stay were associated with patients who underwent dural opening with augmentative watertight duraplasty. Bony decompression alone despite being a very safe technique, does not appear to be reliable and effective in controlling and relieving the clinical symptoms and the syringomyelia of adult patients with CM-1., (Crown Copyright © 2020. Published by Elsevier B.V. All rights reserved.)

Vascular Ehlers-Danlos (vEDS) is a rare form of the Ehlers-Danlos Syndrome (EDS) where arterial fragility results from mutations in the gene that encodes type III collagen. The disease can lead to major neurological complications including carotico-cavernous fistulae (CCF), aneurysms of the Circle of Willis and endovascular procedures have an increased risk profile due to the delicate vasculature. Management of intracranial disease in vEDS requires an intricate understanding of the syndrome but is still associated with significant complications that lead to morbidity and mortality. As well as providing an approach to the management of neurovascular complications in vEDS, the relevant literature regarding nosology, aetiology and genetics of the condition is summarised here. Particular emphasis is placed on the two most common intracranial complications, namely carotico-cavernous fistulas and and cerebral aneurysms. Pros and cons of surgical and endovascular interventions are discussed and a technical discussion is concentrated on the surgical aspects of management., Competing Interests: Declaration of Competing Interest None., (Crown Copyright © 2020. Published by Elsevier B.V. All rights reserved.)

Background: We describe three cases of extradural haematomas (EDHs) and their management, focusing on operative and non-operative treatment. We also review the available literature from the past three decades as well as the guidelines for the management of EDH. An algorithm is formulated based on different factors, including the clinical course of the patients and their CT findings., Methods: The first patient presented to us after sustaining a fall with a GCS of 15/15 and a large parieto-occipital EDH with a volume of 90 cm3. He was treated non-operatively. Follow-up CT showed good resolution of the haematoma. The second patient presented with a GCS of 7/15, a posterior fossa EDH with a volume of 30 cm3, and obstructive hydrocephalus. Emergency ventriculostomy was performed, which was converted to a VP shunt. The third case was a patient presenting with a large hemispheric EDH, which was 130 cm3 in volume. The GCS at presentation was 14/15 but dropped to 6/15, following which he underwent craniotomy and evacuation of the EDH., Results: The Glasgow Outcome Scale (GOS) at three months was five for the first two cases and three for the third case with a dense right hemiplegia., Conclusion: EDH, both supratentorial and in the posterior fossa, can be managed non-operatively. A large volume EDH (>30 cm3) can be managed non-operatively provided the GCS at presentation and follow up remains the same with symptomatic improvement. Prompt treatment of a large volume EDH may still result in a poor outcome., (Crown Copyright © 2013. Published by Elsevier B.V. All rights reserved.)

Objective: To describe three cases of delayed development of intracranial hypertension (IH) after surgical treatment of intracranial arachnoid cyst, including the pathogenesis of IH and a review of the literature., Methods: A retrospective and prospective analysis of three male patients (two 18 years old and one 45 years old) was performed. All patients underwent surgical intervention for symptomatic intracranial arachnoid cyst in the form of fenestration of the cyst and a cystoperitoneal shunt., Results: All three patients presented at a later stage with new-onset headaches after the initial management of arachnoid cyst. Magnetic resonance imaging and magnetic resonance venography ruled out any intracranial vascular pathology. Lumbar puncture and intracranial pressure monitoring showed increased intracranial pressure suggestive of idiopathic IH. To manage IH, intracranial pressure monitoring, cystoperitoneal shunt, ventriculoperitoneal shunt, and lumboperitoneal shunt were performed., Conclusions: The pathogenesis of delayed development of IH in this clinical setting is not clearly elucidated. When intracranial arachnoid cysts are treated, the possibility of future development of IH should be borne in mind. Delayed presentation with headaches in patients after treatment of intracranial arachnoid cysts should raise the possibility of IH., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The authors report a rare case of an aneurysm arising at fenestrated anterior cerebral artery. The embryogenesis of this anatomical variation is discussed along with the review of relevant literature. Management of such lesions depends upon the location and morphology of the aneurysms and intracranial vascular anatomy. The authors discuss various management options and highlight possible technical difficulties that can be encountered in the surgical management of this rare sub-group of aneurysms.

We report two cases of broncho-pleural fistula resulting from trans-diaphragmatic migration of the distal catheter of a ventriculo-peritoneal shunt. Relevant literature on thoracic complications of a ventriculo-peritoneal shunt is reviewed. The clinical presentation, diagnosis and management of V-P shunt-related broncho-pleural fistulae are discussed.

Objective: To analyse outcome of surgical management of aneurysms unsuitable for endovascular intervention in a tertiary referral neurosurgical unit over a 5-year post-ISAT period. To compare secondary parameters such as operating time, number of clips required, and training over last 5 years with similar number of patients in the pre-ISAT period., Methods: Consecutive 54 patients harbouring 62 uncoilable aneurysms admitted from May 2002 to April 2007 in a tertiary neurosurgical unit. Outcome analysed at 3 months using Glasgow Outcome Score and Modified Rankin Scale based on standard questionnaires. Comparison with outcome of surgical arm of ISAT study performed., Results: At 3 months 28 (90%) of Grades I-II and 9 (39%) of Grades III-V patients harbouring uncoilable aneurysms had good clinical outcome (MRS 0-2) comparing favourably with the surgical arm of the ISAT study at 2 months. (relative risk=0.28, 95% CI 0.08-0.45; P=0.01) Surgical time, number of clips required for aneurysmal obliteration had however increased significantly compared to pre-ISAT period. The training potential was severely restricted with uncoilable aneurysms., Conclusions: Ruptured cerebral aneurysms deemed unsuitable for endovascular intervention are also difficult cases to treat surgically. However, with neurovascular sub-specialisation, it is possible to achieve favourable surgical outcome in a higher percentage of cases than reported in the ISAT study and the National Study of Subarachnoid Haemorrhage. These cases, due to their technical complexities, unfortunately offer limited training potential for pre-certification Neurosurgical trainees.

The authors describe a rare case of internal carotid artery (ICA) trifurcation aneurysm and its surgical management. Carotid trifurcation is a unique anatomical variant where three arterial branches arise from the carotid termination than the usual two. Aneurysm arising from the trifurcation, due to its rarity, is difficult to treat. The anatomy, embryological basis and significance of such an anomaly during surgical management are discussed.