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OBJECTIVE Despite growing published evidence of the merits of endoscopic third ventriculostomy (ETV) instead of shunt revision at the time of shunt malfunction (secondary ETV), concerns about its efficacy and complications remain and ETV is still not used widely in this context. This study aimed to carry out a comprehensive meta-analysis and reports on the success and safety of secondary ETV in the pediatric age group. METHODS In accordance with the PRISMA guidelines, systematic searches of Medline, Embase, and Cochrane Central were undertaken from database inception to September 7, 2022. ETV success was defined as the lack of need for a shunt and was the primary outcome measure. Secondary outcome measures were the rates of complications and mortality. A random-effects model was used. Summary-level meta-regression was performed to identify predictors for success in accordance with the ETV Success Score (ETVSS). RESULTS Sixteen studies reporting on 584 patients who underwent secondary ETV for shunt malfunction were included in the meta-analysis. The overall pooled mean (95% CI) age was 6.1 (3–9) years, and 57.0% of patients were male. The pooled prevalence rates of the hydrocephalus etiologies were as follows: aqueduct stenosis (39.3%); myelomeningocele (27.6%); postinfectious (17.1%); posthemorrhagic (13.0%); neoplasm (13.0%); and malformation (11.3%). The overall pooled success rates of ETV for shunt malfunction at 3 months, 6 months, and 12 months were 65.69% (95% CI 52%–77%, prediction interval 47%–81%, I2 = 0, p = 0.775); 63.25% (95% CI 54%–72%, prediction interval 38%–83%, I2 = 65, p < 0.001); and 53.37% (95% CI 24%–81%, prediction interval 1%–99%, I2 = 47, p = 0.154). The overall pooled prevalence of intraoperative bleeding was 4.96% (95% CI 0%–64%, prediction interval 0%–99%, I2 = 85, p < 0.001). The overall rates of complications were low, with new neurological deficit (transient or permanent) having the highest rate at 1.61% (95% CI 0.68%–3.72%, prediction interval 0.67%–3.78%, I2 = 0, p > 0.999). On meta-regression, age (p = 0.138), proportion of patients with postinfectious hydrocephalus (p = 0.8736), and number of shunt revisions (p = 0.1775) were not statistically significant predictors of secondary ETV success at 6 months. CONCLUSIONS This meta-analysis demonstrates that secondary ETV after shunt malfunction in pediatric patients is a feasible option with acceptable success rates and low complication rates. Clinical trial registration no.: CRD42022359573 (PROSPERO)

Neuro-endoscopic lavage (NEL) has shown promise as an emerging procedure for intraventricular haemorrhage (IVH) and post-haemorrhagic ventricular dilatation (PHVD). However, there is considerable variation with regard to the indications, objectives, and surgical technique in NEL. There is currently no randomised trial evidence that supports the use of NEL in the context of PHVD. This study aims to form a consensus on technical variations in the indications and procedural steps of NEL. A mixed-methods modified Delphi consensus process was conducted between consultant paediatric neurosurgeons across the UK. Stages involved literature review, survey, focused online consultation, and iterative revisions until > 80% consensus was achieved. Twelve consultant paediatric neurosurgeons from 10 centres participated. A standardised protocol including indications, a 3-phase operative workflow (pre-ventricular, intraventricular, post-ventricular), and post-operative care was agreed upon by 100% of participants. Case- and surgeon-specific variation was considered and included through delineation of mandatory, optional, and not recommended steps. Expert consensus on a standardised protocol for NEL was achieved, delineating the surgical workflow into three phases such as pre-ventricular, intraventricular, and post-ventricular, each consisting of mandatory, optional, and not recommended steps. The work provides a platform for future trials, training, and implementation of NEL.

Epilepsy surgery is an established safe and effective treatment for selected candidates with drug-resistant epilepsy. In this opinion piece, we outline the clinical and experimental evidence for selectively considering epilepsy surgery prior to drug resistance. Our rationale for expedited surgery is based on the observations that (i) a high proportion of patients with lesional epilepsies (e.g. focal cortical dysplasia, epilepsy-associated tumours) will progress to drug resistance; (ii) surgical treatment of these lesions, especially in non-eloquent areas of brain, is safe; and (iii) earlier surgery may be associated with better seizure outcomes. Potential benefits beyond seizure reduction or elimination include less exposure to antiseizure medications, which may lead to improved developmental trajectories in children and optimize long-term neurocognitive outcomes and quality of life. Further, there exists emerging experimental evidence that brain network dysfunction exists at the onset of epilepsy, where continuing dysfunctional activity could exacerbate network perturbations. This in turn could lead to expanded seizure foci and contribution to the comorbidities associated with epilepsy. Taken together, we rationalize that epilepsy surgery, in carefully selected cases, may be considered prior to drug resistance. Last, we outline the path forward, including the challenges associated with developing the evidence base and implementing this paradigm into clinical care.

The UK neurosurgical community has a track record of delivering high-quality, practice-changing clinical research studies, facilitated by a robust clinical research infrastructure and close collaborations between neurosurgical centers. More recently, these large-scale studies have been conceived, developed, and delivered by neurosurgical trainees, working under the umbrella of the British Neurosurgical Trainee Research Collaborative (BNTRC). In this paper, we outline the current landscape of large-scale neurosurgical studies in the UK, focusing on the role of trainees in facilitating this research. Importantly, we focus on our experience of trainee-led studies, including the development of the network, current challenges, and future directions. We believe that a similar model can be applied in different settings and countries, which will drive up the quality of neurosurgical research, ultimately benefiting future neurosurgical patients.

Background: Subdural empyema is a neurosurgical emergency requiring prompt diagnosis and treatment. There is a debate between the benefits and risks of starting early antibiotics prior to surgical drainage as this is purported to reduce the rate of microbiological diagnosis. Here, we describe our experience of treating this potentially life-threatening condition, advocating for the early commencement of antibiotics and importance of source control in its treatment. Methods: Retrospective review of a prospectively collected electronic departmental database included all patients who were admitted to our unit with a diagnosis of subdural empyema over an 11-year period (2008–2018). Basic demographic data were collected. Further data pertaining to mode of presentation, surgical approach, causative organism, post-operative antibiotic regime, anti-seizure medications, length of hospital stay, further surgery, and neurological outcomes were extracted. Results: Thirty-six children underwent 44 operations for subdural empyema at our institution during the study period. Median age was 11.0 (range 0.2–15.8); 47.2% (17/36) were female. Over time, there was decreasing use of burr holes and increasing use of craniectomy as the index surgery. Using a combination of extended culture and polymerase chain reaction, a microbiological diagnosis was achieved in all 36 cases; the commonest causative microorganism was of the Streptococcus anginosus group of bacteria. Seven patients underwent repeat surgery, and 4 patients underwent a concurrent ENT procedure. No risk factors were significant in predicting the likelihood of re-operation (location of subdural empyema, age, index surgery type, inflammatory markers, concurrent ENT procedure, and microorganism) although it was notable that none of the patients undergoing a concurrent ENT procedure underwent repeat surgery (p = 0.29). Median length of stay was 12 days (range 3–74), and there were no inpatient or procedure-related mortalities. Clinical outcomes were good with 94.4% (34/36) categorized as modified Rankin Scale 0–3 at discharge and there were 2 cranioplasty-related complications. Conclusions: We observed an evolution of practice from limited surgical approaches towards more extensive index surgery over the study period. Given that a microorganism was isolated in all cases using a comprehensive approach, initiation of antibiotic therapy should not be delayed on presentation. Concurrent ENT surgery may be an important factor in providing aggressive source control thereby reducing the need for repeat surgery.

Summary The incidence of external ventricular drain (EVD) infections remains high. Chlorhexidine dressings have demonstrated efficacy in reducing infections associated with indwelling catheters at other body sites, although evidence for their use with EVDs is limited. The aim of this systematic review and meta-analysis was to evaluate the efficacy of chlorhexidine dressings in reducing EVD-associated cerebrospinal fluid infection (EVDAI). MEDLINE, EMBASE and the Cochrane library were queried for articles from inception. The primary outcome was the incidence of EVDAI. Secondary outcomes included device safety, microbiological outcomes and shunt-dependency. From 896 unique records, five studies were included of which four presented suitable data for quantitative analysis including three case series and one underpowered randomized controlled trial. There was a high risk of bias in all studies. A total of 880 patients were included with a mean age of 57.7 years (95% confidence interval (CI) 57.4–58.0 years). In primary outcome analysis, the chlorhexidine dressing group had a significantly lower incidence of EVDAI (1.7% vs 7.9%, risk difference (RD) = 0.07, 95% CI 0.00–0.13, P=0.04). In conclusion, chlorhexidine dressings may reduce the incidence of EVDAI but require future study in randomized trials to definitively determine efficacy.

OBJECTIVE In children with drug-resistant epilepsy (DRE), resective, ablative, and disconnective surgery may not be feasible or may fail. Neuromodulation in the form of deep brain stimulation (DBS) and responsive neurostimulation (RNS) may be viable treatment options, however evidence for their efficacies in children is currently limited. This systematic review aimed to summarize the literature on DBS and RNS for the treatment of DRE in the pediatric population. Specifically, the authors focused on currently available data for reported indications, neuromodulation targets, clinical efficacy, and safety outcomes. METHODS PRISMA guidelines were followed throughout this systematic review (PROSPERO no. CRD42020180669). Electronic databases, including PubMed, Embase, Cochrane Library, OpenGrey, and CINAHL Plus, were searched from their inception to February 19, 2021. Inclusion criteria were 1) studies with at least 1 pediatric patient (age < 19 years) who underwent DBS and/or RNS for DRE; and 2) retrospective, prospective, randomized, or nonrandomized controlled studies, case series, and case reports. Exclusion criteria were 1) letters, commentaries, conference abstracts, and reviews; and 2) studies without full text available. Risk of bias of the included studies was assessed using the Cochrane ROBINS-I (Risk of Bias in Non-randomised Studies - of Interventions) tool. RESULTS A total of 35 studies were selected that identified 72 and 46 patients who underwent DBS and RNS, respectively (age range 4–18 years). Various epilepsy etiologies and seizure types were described in both cohorts. Overall, 75% of patients had seizure reduction > 50% after DBS (among whom 6 were seizure free) at a median (range) follow-up of 14 (1–100) months. In an exploratory univariate analysis of factors associated with favorable response, the follow-up duration was shorter in those patients with a favorable response (18 vs 33 months, p < 0.05). In the RNS cohort, 73.2% of patients had seizure reduction > 50% after RNS at a median (range) follow-up of 22 (5–39) months. On closer inspection, 83.3% of patients who had > 50% reduction in seizures actually had > 75% reduction, with 4 patients being seizure free. CONCLUSIONS Overall, both DBS and RNS showed favorable response rates, indicating that both techniques should be considered for pediatric patients with DRE. However, serious risks of overall bias were found in all included studies. Many research needs in this area would be addressed by conducting high-quality clinical trials and establishing an international registry of patients who have undergone pediatric neuromodulation, thereby ensuring robust prospective collection of predictive variables and outcomes.

Peer reviewed: True, Chronic subdural haematoma is the medical name for bleeding that occurs between the skull and the brain. It usually happens to older people, like grandparents. If it causes serious symptoms, brain surgeons will operate. However, even after surgery, chronic subdural haematomas can come back, and further operations may be needed. We tested whether a medication called dexamethasone could prevent chronic subdural haematomas from coming back by performing a study of 750 people, in which half received the medication and half did not. The results showed that dexamethasone was good at stopping brain bleeds from coming back, but it had other effects that caused patients to have a more difficult recovery than did those who did not take it. These results are really important to stop doctors from giving this medication—it shows that, at the moment, surgery alone is the best treatment.

PurposeThis retrospective cohort study aimed to investigate the surgical and neurodevelopmental outcomes (NDO) of infant hydrocephalus. We also sought to determine whether these outcomes are disproportionately poorer in post-haemorrhagic hydrocephalus (PHH) compared to other causes of infant hydrocephalus.MethodsA review of all infants with hydrocephalus who had ventriculoperitoneal (VP) shunts inserted at Great Ormond Street Hospital (GOSH) from 2008 to 2018 was performed. Demographic, surgical, neurodevelopmental, and other clinical data extracted from electronic patient notes were analysed by aetiology. Shunt survival, NDO, cerebral palsy (CP), epilepsy, speech delay, education, behavioural disorders, endocrine dysfunction, and mortality were evaluated.ResultsA total of 323 infants with median gestational age of 37.0 (23.29–42.14) weeks and birthweight of 2640 g (525–4684 g) were evaluated. PHH was the most common aetiology (31.9%) and was associated with significantly higher 5-year shunt revision rates, revisions beyond a year, and median number of revisions than congenital or “other” hydrocephalus (allp p = 0.01) and mortality rates (p = 0.04).ConclusionsInfants with PHH have poorer surgical and NDO compared to all other aetiologies, except genetic hydrocephalus. Research into measures of reducing neurodisability following PHH is urgently required. Long-term follow-up is essential to optimise support and outcomes.

Advances in medical care have led to more premature babies surviving the neonatal period. In these babies, germinal matrix haemorrhage (GMH), intraventricular haemorrhage (IVH) and posthaemorrhagic ventricular dilatation (PHVD) are the most important determinants of long-term cognitive and developmental outcomes. In this review, we discuss current neurosurgical management of IVH and PHVD, including the importance of early diagnosis of PHVD, thresholds for intervention, options for early management through the use of temporising measures and subsequent definitive CSF diversion. We also discuss treatment options for the evolving paradigm to manage intraventricular blood and its breakdown products. We review the evidence for techniques such as drainage, irrigation, fibrinolytic therapy (DRIFT) and neuroendoscopic lavage in the context of optimising cognitive, neurodevelopmental and quality of life outcomes in these premature infants.

Neuroimaging represents an important step in the evaluation of pediatric epilepsy. The crucial role of brain imaging in the diagnosis, follow-up and presurgical assessment of patients with epilepsy is noted and has to be familiar to all neuroradiologists and trainees approaching pediatric brain imaging. Morphological qualitative imaging shows the majority of cerebral lesions/alterations underlying focal epilepsy and can highlight some features which are useful in the differential diagnosis of the different types of epilepsy. Recent advances in MRI acquisitions including diffusion-weighted imaging (DWI), post-acquisition image processing techniques, and quantification of imaging data are increasing the accuracy of lesion detection during the last decades. Functional MRI (fMRI) can be really useful and helps to identify cortical eloquent areas that are essential for language, motor function, and memory, and diffusion tensor imaging (DTI) can reveal white matter tracts that are vital for these functions, thus reducing the risk of epilepsy surgery causing new morbidities. Also positron emission tomography (PET), single photon emission computed tomography (SPECT), simultaneous electroencephalogram (EEG) and fMRI, and electrical and magnetic source imaging can be used to assess the exact localization of epileptic foci and help in the design of intracranial EEG recording strategies. The main role of these “hybrid” techniques is to obtain quantitative and qualitative informations, a necessary step to evaluate and demonstrate the complex relationship between abnormal structural and functional data and to manage a “patient-tailored” surgical approach in epileptic patients.

Objective Despite a high burden of neurosurgical disease that is often assessed, investigated, and managed by generalists, to our knowledge, there is no specific medical school curriculum in neurosurgery. This scoping review was carried out to map available evidence pertaining to the provision of neurosurgery education in the medical school curriculum across the world. Methods This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews. Inclusion criteria were full-text articles reported from 1999 onward, which reported on neurosurgery education in the medical curriculum. Results Ten studies were included. Six were from the United Kingdom, 2 from the United States, and 1 each from Canada and Ireland. Seven studies reported perceptions of medical students and 5 reported perceptions of clinicians. Three main themes were identified. Neurosurgery was perceived as an important part of the general medical student curriculum by students and neurosurgeons but less so by medical school deans. Exposure to neurosurgery teaching was varied but, when received, deemed useful and students were keen to receive more. Interest in a neurosurgical career among surveyed medical students was high. Conclusions The limited evidence has shown variability of perceptions about the importance of neurosurgery among stakeholders and medical students' exposure to neurosurgery teaching. Our findings highlight the need to systematically assess specialty-specific teaching and determine adequacy. Stakeholders should include neurosurgeons, medical educators, general practitioners, and the variety of specialists who play a crucial role in the management of patients with neurosurgical conditions.

Entrance to neurosurgical training is highly competitive. Without proper advice, information and opportunities, talented individuals may be dissuaded from applying. The Neurology and Neurosurgery Interest Group (NANSIG) organises a Careers Day in Neurosurgery every year. Our objective was to assess the overall utility of a neurosurgery careers day and the perceived factors that attract and detract from the specialty, from attendees of the ninth annual neurosurgery careers day.Eighteen-item pre-conference and 19-item post-conference questionnaires were disseminated electronically to conference attendees. Questions aimed to capture: (i) baseline demographics; (ii) previous experience and exposure in neurosurgery; (iii) interest in neurosurgery; (iv) understanding training and a career in neurosurgery; (v) perceived factors of attraction and dissuasion of neurosurgery; and (vi) perceived value, quality and educational purpose of the conference.In total, 77 delegates attended the careers day. Most did not have a formal neurosurgical rotation during medical school (24.7%,Formal undergraduate exposure to neurosurgery is limited. Neurosurgery careers days increase awareness and understanding of the application process and improve interest in a selected cohort. The factors attracting applicants to neurosurgery remain practical links to neuroanatomy, opportunities in neurosurgery for innovation and research, and direct impact on patients.

Neurosurgery is one of the most competitive specialties in the UK. In 2019, securing an ST1 post in neurosurgery corresponds to competition ration of 6.54 whereas a CST1 post 2.93. Further, at ST3 level, neurosurgery is the most competitive. In addition, the number of neurosurgical training posts are likely to be reduced in the coming years. A number of very specific shortlisting criteria, aiming to filter and select the best candidates for interview exist. In the context of the high competition ratios and the specific shortlisting criteria, developing an interest in the neurosciences early on will allow individuals more time to meet the necessary standards for neurosurgery. Here, we aim to outline the shortlisting criteria and offer advice on how to achieve maximum scores, increasing the likelihood to be shortlisted for an interview., Highlights • Neurosurgery is one of the most competitive specialities in the UK. • At ST3 level neurosurgery is the most competitive surgical speciality in the UK. • Leadership and management skills are desirable skills in the NHS.

Objective This retrospective, cross‐sectional study evaluated the feasibility and potential benefits of incorporating deep‐learning on structural magnetic resonance imaging (MRI) into planning stereoelectroencephalography (sEEG) implantation in pediatric patients with diagnostically complex drug‐resistant epilepsy. This study aimed to assess the degree of colocalization between automated lesion detection and the seizure onset zone (SOZ) as assessed by sEEG. Methods A neural network classifier was applied to cortical features from MRI data from three cohorts. (1) The network was trained and cross‐validated using 34 patients with visible focal cortical dysplasias (FCDs). (2) Specificity was assessed in 20 pediatric healthy controls. (3) Feasibility of incorporation into sEEG implantation plans was evaluated in 34 sEEG patients. Coordinates of sEEG contacts were coregistered with classifier‐predicted lesions. sEEG contacts in seizure onset and irritative tissue were identified by clinical neurophysiologists. A distance of

One outstanding challenge for machine learning in diagnostic biomedical imaging is algorithm interpretability. A key application is the identification of subtle epileptogenic focal cortical dysplasias (FCDs) from structural MRI. FCDs are difficult to visualize on structural MRI but are often amenable to surgical resection. We aimed to develop an open-source, interpretable, surface-based machine-learning algorithm to automatically identify FCDs on heterogeneous structural MRI data from epilepsy surgery centres worldwide. The Multi-centre Epilepsy Lesion Detection (MELD) Project collated and harmonized a retrospective MRI cohort of 1015 participants, 618 patients with focal FCD-related epilepsy and 397 controls, from 22 epilepsy centres worldwide. We created a neural network for FCD detection based on 33 surface-based features. The network was trained and cross-validated on 50% of the total cohort and tested on the remaining 50% as well as on 2 independent test sites. Multidimensional feature analysis and integrated gradient saliencies were used to interrogate network performance. Our pipeline outputs individual patient reports, which identify the location of predicted lesions, alongside their imaging features and relative saliency to the classifier. On a restricted ‘gold-standard’ subcohort of seizure-free patients with FCD type IIB who had T1 and fluid-attenuated inversion recovery MRI data, the MELD FCD surface-based algorithm had a sensitivity of 85%. Across the entire withheld test cohort the sensitivity was 59% and specificity was 54%. After including a border zone around lesions, to account for uncertainty around the borders of manually delineated lesion masks, the sensitivity was 67%. This multicentre, multinational study with open access protocols and code has developed a robust and interpretable machine-learning algorithm for automated detection of focal cortical dysplasias, giving physicians greater confidence in the identification of subtle MRI lesions in individuals with epilepsy.

Funder: National Institute for Health Research (NIHR) GOSH BRC, OBJECTIVE: Drug-resistant focal epilepsy is often caused by focal cortical dysplasias (FCDs). The distribution of these lesions across the cerebral cortex and the impact of lesion location on clinical presentation and surgical outcome are largely unknown. We created a neuroimaging cohort of patients with individually mapped FCDs to determine factors associated with lesion location and predictors of postsurgical outcome. METHODS: The MELD (Multi-centre Epilepsy Lesion Detection) project collated a retrospective cohort of 580 patients with epilepsy attributed to FCD from 20 epilepsy centers worldwide. Magnetic resonance imaging-based maps of individual FCDs with accompanying demographic, clinical, and surgical information were collected. We mapped the distribution of FCDs, examined for associations between clinical factors and lesion location, and developed a predictive model of postsurgical seizure freedom. RESULTS: FCDs were nonuniformly distributed, concentrating in the superior frontal sulcus, frontal pole, and temporal pole. Epilepsy onset was typically before the age of 10 years. Earlier epilepsy onset was associated with lesions in primary sensory areas, whereas later epilepsy onset was associated with lesions in association cortices. Lesions in temporal and occipital lobes tended to be larger than frontal lobe lesions. Seizure freedom rates varied with FCD location, from around 30% in visual, motor, and premotor areas to 75% in superior temporal and frontal gyri. The predictive model of postsurgical seizure freedom had a positive predictive value of 70% and negative predictive value of 61%. SIGNIFICANCE: FCD location is an important determinant of its size, the age at epilepsy onset, and the likelihood of seizure freedom postsurgery. Our atlas of lesion locations can be used to guide the radiological search for subtle lesions in individual patients. Our atlas of regional seizure freedom rates and associated predictive model can be used to estimate individual likelihoods of postsurgical seizure freedom. Data-driven atlases and predictive models are essential for evidence-based, precision medicine and risk counseling in epilepsy.

BackgroundIn recent years an increasing number of patients with cerebral metastasis (CM) have been referred to the neuro-oncology multidisciplinary team (NMDT). Our aim was to obtain a national picture of CM referrals to assess referral volume and quality and factors affecting NMDT decision making.MethodsA prospective multicenter cohort study including all adult patients referred to NMDT with 1 or more CM was conducted. Data were collected in neurosurgical units from November 2017 to February 2018. Demographics, primary disease, KPS, imaging, and treatment recommendation were entered into an online database.ResultsA total of 1048 patients were analyzed from 24 neurosurgical units. Median age was 65 years (range, 21-93 years) with a median number of 3 referrals (range, 1-17 referrals) per NMDT. The most common primary malignancies were lung (36.5%, n = 383), breast (18.4%, n = 193), and melanoma (12.0%, n = 126). A total of 51.6% (n = 541) of the referrals were for a solitary metastasis and resulted in specialist intervention being offered in 67.5% (n = 365) of cases. A total of 38.2% (n = 186) of patients being referred with multiple CMs were offered specialist treatment. NMDT decision making was associated with number of CMs, age, KPS, primary disease status, and extent of extracranial disease (univariate logistic regression, P < .001) as well as sentinel location and tumor histology (P < .05). A delay in reaching an NMDT decision was identified in 18.6% (n = 195) of cases.ConclusionsThis study demonstrates a changing landscape of metastasis management in the United Kingdom and Ireland, including a trend away from adjuvant whole-brain radiotherapy and specialist intervention being offered to a significant proportion of patients with multiple CMs. Poor quality or incomplete referrals cause delay in NMDT decision making.

IntroductionOne outstanding challenge for machine learning in diagnostic biomedical imaging is algorithm interpretability. A key application is the identification of subtle epileptogenic focal cortical dysplasias (FCDs) from structural MRI. FCDs are difficult to visualise on structural MRI but are often amenable to surgical resection. We aimed to develop an open-source, interpretable, surface-based machine-learning algorithm to automatically identify FCDs on heterogeneous structural MRI data from epilepsy surgery centres worldwide.MethodsThe Multi-centre Epilepsy Lesion Detection (MELD) Project collated and harmonised a retrospective MRI cohort of 1015 participants, 618 patients with focal FCD-related epilepsy and 397 controls, from 22 epilepsy centres worldwide. We created a neural network for FCD detection based on 33 surface-based features. The network was trained and cross-validated on 50% of the total cohort and tested on the remaining 50% as well as on 2 independent test sites. Multidimensional feature analysis and integrated gradient saliencies were used to interrogate network performance.ResultsOur pipeline outputs individual patient reports, which identify the location of predicted lesions, alongside their imaging features and relative saliency to the classifier. Overall, after including a border-zone around lesions, the developed MELD FCD surface-based algorithm had a sensitivity of 67% and a specificity of 54% on the withheld test cohort, and a sensitivity of 85% on a restricted subcohort of seizure free patients with FCD type IIB who had T1 and FLAIR MRI data.ConclusionsThis multicentre, multinational study with open access protocols and code has developed a robust and interpretable machine-learning algorithm for automated detection of focal cortical dysplasias, giving physicians greater confidence in the identification of subtle MRI lesions.HighlightsThis large, multi-centre, multi-scanner neuroimaging cohort captures the heterogeneity of histopathological subtypes and imaging features of patients with FCD.We developed a robust and interpretable surface-based algorithm which detects FCDs with a sensitivity of 67% and a specificity of 54%.The algorithm generates individual patient reports that “open the AI black-box” highlighting predicted lesion locations, alongside the imaging features and their relative saliency to the classifier.

Focal cortical dysplasia (FCD) is a malformation of cortical development and is associated with drug-resistant epilepsy. Standard indication for epilepsy surgery is drug resistance (as defined by the ILAE). Given the high incidence of drug resistance in these children, this delay may not be warranted. The aim of the study was to determine the proportion of patients with a presumed FCD who develop drug resistance, and evaluate post-operative outcomes.This study incorporated a survey within a regional paediatric epilepsy network and a retrospective database review of a paediatric epilepsy centre serving the network to identify children with epilepsy and a presumed FCD on MRI.The survey revealed that 86% of the patients with epilepsy and presumed FCD on MRI within the network were referred to our centre. Of 139 paediatric patients included in the study, 131 (94.2%) had drug-resistant epilepsy. One hundred and ten (83.9%) patients were referred to epilepsy surgery, of whom 97 underwent surgery. Of 92 with one-year postoperative follow-up, 59.8% had an Engel Class 1 (seizure-free) outcome. Concordance of location between MRI and ictal EEG was strongly associated with Engel Class 1 outcome (p0.001), as was older age at seizure onset (p=0.03). Time from diagnosis to surgery, number of medications, type of surgery and histology were not associated with improved outcome.Our data suggest that most children presenting with seizures and a radiological diagnosis of FCD will develop drug-resistant epilepsy and are candidates for epilepsy surgery. The main outcome predictors are the correlation between MRI and ictal EEG localization and age at onset. This suggests that patients with FCD and epilepsy may be considered for surgery before traditional criteria of drug resistance are met. This change in practice has the potential to improve quality of life and cognitive function, and reduce burden on epilepsy services.

ObjectiveTo compare cognitive testing scores in neurosurgeons and aerospace engineers to help settle the age old argument of which phrase—“It’s not brain surgery” or “It’s not rocket science”—is most deserved.DesignInternational prospective comparative study.SettingUnited Kingdom, Europe, the United States, and Canada.Participants748 people (600 aerospace engineers and 148 neurosurgeons). After data cleaning, 401 complete datasets were included in the final analysis (329 aerospace engineers and 72 neurosurgeons).Main outcome measuresValidated online test (Cognitron’s Great British Intelligence Test) measuring distinct aspects of cognition, spanning planning and reasoning, working memory, attention, and emotion processing abilities.ResultsThe neurosurgeons showed significantly higher scores than the aerospace engineers in semantic problem solving (difference 0.33, 95% confidence interval 0.13 to 0.52). Aerospace engineers showed significantly higher scores in mental manipulation and attention (−0.29, −0.48 to −0.09). No difference was found between groups in domain scores for memory (−0.18, −0.40 to 0.03), spatial problem solving (−0.19, −0.39 to 0.01), problem solving speed (0.03, −0.20 to 0.25), and memory recall speed (0.12, −0.10 to 0.35). When each group’s scores for the six domains were compared with those in the general population, only two differences were significant: the neurosurgeons’ problem solving speed was quicker (mean z score 0.24, 95% confidence interval 0.07 to 0.41) and their memory recall speed was slower (−0.19, −0.34 to −0.04).ConclusionsIn situations that do not require rapid problem solving, it might be more correct to use the phrase “It’s not brain surgery.” It is possible that both neurosurgeons and aerospace engineers are unnecessarily placed on a pedestal and that “It’s a walk in the park” or another phrase unrelated to careers might be more appropriate. Other specialties might deserve to be on that pedestal, and future work should aim to determine the most deserving profession.

BACKGROUNDCore Outcome Sets (COSs) are necessary to standardize reporting in research studies. This is urgently required in the field of chronic subdural hematoma (CSDH), one of the most common disease entities managed in neurosurgery and the topic of several recent trials. To complement the development of a COS, a standardized definition and baseline Data Elements (DEs) to be collected in CSDH patients, would further improve study quality and comparability in this heterogeneous population.OBJECTIVETo, first, define a standardized COS for reporting in all future CSDH studies; and, second, to identify a unified CSDH Definition and set of DEs for reporting in future CSDH studies.METHODSThe overall study design includes a Delphi survey process among 150 respondents from 2 main stakeholder groups: healthcare professionals or researchers (HCPRs) and Patients or carers. HCPR, patients and carers will all be invited to complete the survey on the COS, only the HCPR survey will include questions on definition and DE.EXPECTED OUTCOMESIt is expected that the COS, definition, and DE will be developed through this Delphi survey and that these can be applied in future CSDH studies. This is necessary to help align future research studies on CSDH and to understand the effects of different treatments on patient function and recovery.DISCUSSIONThis Delphi survey should result in consensus on a COS and a standardized CSDH Definition and DEs to be used in future CSDH studies.

We aimed to determine whether the proportion of putative seizure onset zone (SOZ) contacts resected associates with seizure outcome in a cohort of children undergoing stereoelectroencephalography (SEEG)-guided resective epilepsy surgery.Patients who underwent SEEG-guided resective surgery over a six-year period were included. The proportion of SOZ contacts resected was determined by co-registration of pre- and post-operative imaging. Outcome was classified as seizure free (SF, Engel class I) or not seizure-free (NSF, Engel class II-IV) at last clinical follow-up.Twenty-nine patients underwent resection of whom 22 had sufficient imaging data for analysis (median age at surgery of 10 years, range 5-18). Fifteen (68.2%) were SF at median follow-up of 19.5 months (range 12-46). On univariate analysis, histopathology, was the only significant factor associated with SF (p 0.05). The percentage of defined SOZ contacts resected ranged from 25-100% and was not associated with SF (p = 0.89). In a binary logistic regression model, it was highly likely that histology was the only independent predictor of outcome.The percentage of SOZ contacts resected was not associated with SF in children undergoing SEEG-guided resective epilepsy surgery.Factors such as spatial organisation of the epileptogenic zone, neurophysiological biomarkers and the prospective identification of pathological tissue may therefore play an important role.

PurposeChildren undergoing stereoelectroencephalography (SEEG)-guided epilepsy surgery represent a complex cohort. We aimed to determine whether the proportion of putative seizure onset zone (SOZ) contacts resected associates with seizure outcome in a cohort of children undergoing SEEG-guided resective epilepsy surgery.MethodsPatients who underwent SEEG-guided resective surgery over a six-year period were included. The proportion of SOZ contacts resected was determined by co-registration of pre- and post-operative imaging. Seizure outcomes were classified as seizure free (SF, Engel class I) or not seizure-free (NSF, Engel class II-IV) at last clinical follow-up.ResultsOf 94 patients undergoing SEEG, 29 underwent subsequent focal resection of whom 22 had sufficient imaging data to be included in the primary analysis (median age at surgery of 10 years, range 5-18). Fifteen (68.2%) were SF and 7 (31.8%) NSF at median follow-up of 19.5 months (range 12-46). On univariate analysis, histopathology, was the only significant factor associated with SF (pConclusionHistopathology is a significant predictor of surgical outcomes in children undergoing SEEG-guided resective epilepsy surgery. The percentage of SOZ contacts resected was not associated with SF. Factors such as spatial organisation of the epileptogenic zone, neurophysiological biomarkers and the prospective identification of pathological tissue may therefore play an important role.

Network control theory provides a framework by which neurophysiological dynamics of the brain can be modelled as a function of the structural connectome constructed from diffusion MRI. Average controllability describes the ability of a region to drive the brain to easy-to-reach neurophysiological states whilst modal controllability describes the ability of a region to drive the brain to difficult-to-reach states. In this study, we identify increases in mean average and modal controllability in children with drug-resistant epilepsy compared to healthy controls. Using simulations, we purport that these changes may be a result of increased thalamocortical connectivity. At the node level, we demonstrate decreased modal controllability in the thalamus and posterior cingulate regions. In those undergoing resective surgery, we also demonstrate increased modal controllability of the resected parcels, a finding specific to patients who were rendered seizure free following surgery. Changes in controllability are a manifestation of brain network dysfunction in epilepsy and may be a useful construct to understand the pathophysiology of this archetypical network disease. Understanding the mechanisms underlying these controllability changes may also facilitate the design of network-focussed interventions that seek to normalise network structure and function.

Epilepsy and epilepsy surgery lend themselves well to the application of machine learning (ML) and artificial intelligence (AI) technologies. This is evidenced by the plethora of tools developed for applications such as seizure detection and analysis of imaging and electrophysiological data. However, few of these tools have been directly used to guide patient management. In recent years, the Idea, Development, Exploration, Assessment, Long-Term Follow-Up (IDEAL) collaboration has formalised stages for the evaluation of surgical innovation and medical devices, and, in many ways, this pragmatic framework is also applicable to ML/AI technology, balancing innovation and safety.In this protocol paper, we outline the preclinical (IDEAL stage 0) evaluation and the protocol for a prospective (IDEAL stage 1/2a) study to evaluate the utility of an ML lesion detection algorithm designed to detect focal cortical dysplasia from structural MRI, as an adjunct in the planning of stereoelectroencephalography trajectories in children undergoing intracranial evaluation for drug-resistant epilepsy.

Network control theory provides a framework by which neurophysiological dynamics of the brain can be modelled as a function of the structural connectome constructed from diffusion MRI. Average controllability describes the ability of a region to drive the brain to easy-to-reach neurophysiological states whilst modal controllability describes the ability of a region to drive the brain to difficult-to-reach states.In this study, we identify increases in mean average and modal controllability in children with drug-resistant epilepsy compared to healthy controls. Using simulations, we purport that these changes may be a result of increased thalamocortical connectivity. At the node level, we demonstrate decreased modal controllability in the thalamus and posterior cingulate regions. In those undergoing resective surgery, we also demonstrate increased modal controllability of the resected parcels, a finding specific to patients who were rendered seizure free following surgery.Changes in controllability are a manifestation of brain network dysfunction in epilepsy and may be a useful construct to understand the pathophysiology of this archetypical network disease. Understanding the mechanisms underlying these controllability changes may also facilitate the design of network-focussed interventions that seek to normalise network structure and function.

Purpose Lumbosacral lipoma (LSL) is a severe occult spinal dysraphism, frequently associated with neurological, urological and orthopaedic complications. Whole spine imaging is typically performed to identify concomitant, but spatially separate, congenital anomalies. Our hypothesis: the incidence of additional, clinically significant abnormalities of the neuraxis is low; thus, imaging should be optimised at the lumbosacral region. We aim to assess the prevalence and relevance of LSL-associated lesions. Method A single-centre, retrospective, radiological review using a prospectively maintained operative database. Inclusion criteria: children ( Results One hundred twelve patients (40:72, M:F) aged 0.5 years (0.2–2.7) (median ± IQR) with LSL had whole spine MRI between 2001 and 2017. Classification of LSL: transitional 48 (43%); dorsal 30 (27%); caudal 28 (25%) and chaotic 6 (5%). Additional anomalies included syringohydromyelia 44 (39%), subcutaneous tract 19 (17%), abnormal vertebral segmentation 18 (16%), dermoid cyst 1 and 1 Chiari I deformity. There were no Chiari II malformations. No child required surgery for an associated lesion. Binary logistic regression revealed no factors associated with predicting secondary lesions. Conclusions In congenital LSL, additional anomalies of the neuraxis are typically loco-regional rather than pan-CNS and additional lesions are rarely clinically significant. The loco-regional distribution of anomalies suggests that only lumbosacral spinal imaging is required in the initial evaluation of LSL. Such a policy would lessen the anaesthetic/sedation time for children and reduce imaging cost per patient. MRI protocols could be refined to optimise imaging quality at the region of interest.

Background In patients with spontaneous subarachnoid haemorrhage (SAH), a vascular cause for the bleed is not always found on initial investigations. This study aimed to systematically evaluate the delayed investigation strategies and clinical outcomes in these cases, often described as “non-aneurysmal” SAH (naSAH). Methods A systematic review was performed in concordance with the PRISMA checklist. Pooled proportions of primary outcome measures were estimated using a random-effects model. Results Fifty-eight studies were included (4473 patients). The cohort was split into perimesencephalic naSAH (PnaSAH) (49.9%), non-PnaSAH (44.7%) and radiologically negative SAH identified on lumbar puncture (5.4%). The commonest initial vascular imaging modality was digital subtraction angiography. A vascular abnormality was identified during delayed investigation in 3.9% [95% CI 1.9–6.6]. There was no uniform strategy for the timing or modality of delayed investigations. The pooled proportion of a favourable modified Rankin scale outcome (0–2) at 3–6 months following diagnosis was 92.0% [95% CI 86.0–96.5]. Complications included re-bleeding (3.1% [95% CI 1.5–5.2]), hydrocephalus (16.0% [95% CI 11.2–21.4]), vasospasm (9.6% [95% CI 6.5–13.3]) and seizure (3.5% [95% CI 1.7–5.8]). Stratified by bleeding pattern, we demonstrate a higher rate of delayed diagnoses (13.6% [95% CI 7.4–21.3]), lower proportion of favourable functional outcome (87.2% [95% CI 80.1–92.9]) and higher risk of complications for non-PnaSAH patients. Conclusion This study highlights the heterogeneity in delayed investigations and outcomes for patients with naSAH, which may be influenced by the initial pattern of bleeding. Further multi-centre prospective studies are required to clarify optimal tailored management strategies for this heterogeneous group of patients. Electronic supplementary material The online version of this article (10.1007/s00701-019-04025-w) contains supplementary material, which is available to authorized users.

OBJECTIVE Drug-resistant epilepsy (DRE) during the first few months of life is challenging and necessitates aggressive treatment, including surgery. Because the most common causes of DRE in infancy are related to extensive developmental anomalies, surgery often entails extensive tissue resections or disconnection. The literature on "ultra-early" epilepsy surgery is sparse, with limited data concerning efficacy controlling the seizures, and safety. The current study's goal is to review the safety and efficacy of ultra-early epilepsy surgery performed before the age of 3 months. METHODS To achieve a large sample size and external validity, a multinational, multicenter retrospective study was performed, focusing on epilepsy surgery for infants younger than 3 months of age. Collected data included epilepsy characteristics, surgical details, epilepsy outcome, and complications. RESULTS Sixty-four patients underwent 69 surgeries before the age of 3 months. The most common pathologies were cortical dysplasia (28), hemimegalencephaly (17), and tubers (5). The most common procedures were hemispheric surgeries (48 procedures). Two cases were intentionally staged, and one was unexpectedly aborted. Nearly all patients received blood products. There were no perioperative deaths and no major unexpected permanent morbidities. Twenty-five percent of patients undergoing hemispheric surgeries developed hydrocephalus. Excellent epilepsy outcome (International League Against Epilepsy [ILAE] grade I) was achieved in 66% of cases over a median follow-up of 41 months (19-104 interquartile range [IQR]). The number of antiseizure medications was significantly reduced (median 2 drugs, 1-3 IQR, p

Background Core Outcome Sets (COS) are a consensus-based agreed minimum set of outcomes that should be measured and reported in all studies within a research field. Common Data Elements (CDEs) are the minimum data points that should be collected regarding the characteristics of population, condition and intervention. The use of COS and CDEs minimises research wastage by increasing the cross-comparison and meta-analysis of study findings. Objective The primary objective was to collate and describe the current process of developing core outcome sets and common data elements in published research pertaining to clinical neurosciences. The secondary objective was to identify the clinical neuroscience subspecialties that have developed COS and CDEs, the countries of origin of authors, and the process through which COS and CDEs were developed. Design A search between 2000-2020 of the top 40 Impact Factor neurosurgical and neurological journals was conducted. A scoping review was performed in accordance with the PRISMA-ScR Checklist. Results Our search returned 169 papers, of which 35 were eligible for inclusion in the present study. The USA published the majority of papers (20/35). The papers mostly related to neurosurgery (30/35), with the most common neurosurgical sub-specialty being traumatic brain injury (14/35) and subarachnoid haemorrhage (10/35). There is an increasing publication trend over time, with 12 papers published in 2019. COS and CDE development is an international collaborative process, with authors from a number of different countries. Five papers were systematic reviews conducting with the intention of COS/CDE development. 27 papers reported CDE development and 2 papers reported COS development (aphasia and non-specific low back pain). The COS development papers utilised international consensus meetings and adhered to international development statements. Conclusions COS and CDEs are an essential research tool to reduce research wastage and ultimately improve patient outcomes through homogenous outcome reporting, aligned with patient-derived outcomes. COS and CDEs are increasingly being developed within clinical neurosciences.

ImportanceStereoelectroencephalography (SEEG) is more frequently being used in the pre-surgical evaluation of children with focal epilepsy. Many factors affect the rate of identification of a definable seizure onset zone (SOZ) and subsequent seizure freedom following SEEG-guided epilepsy surgery, which have not been systematically examined in multi-centre studies.ObjectivesDetermine the rates and factors that predict (a) whether or not a definable putative SOZ was identified on SEEG and (b) subsequent seizure freedom following surgical intervention.DesignRetrospective cohort studySettingMulticentre study involving 6 of 7 UK Children’s Epilepsy Surgery Service centres that perform paediatric SEEG in the UK.ParticipantsAll children undergoing SEEG from 2014 - March 2019 were included. Demographic, non-invasive evaluation, SEEG and operative factors were collected retrospectively from patient records.Main OutcomesThe two main outcome measures were (a) whether or not a definable putative SOZ was identified on SEEG (binary yes/no outcome) and (b) subsequent seizure freedom following surgical intervention (Engel classification)FindingsOne hundred and thirty-five patients underwent 139 SEEG explorations using a total of 1767 electrodes. A definable SOZ was identified in 117 patients (85.7%); odds of successfully finding a SOZ were 6.4x greater for non-motor seizures compared to motor seizures (p=0.02) and 3.6x more if ≥ 4 seizures were recorded during SEEG (p=0.03). Of 100 patients undergoing surgical treatment, 47 (47.0%) had an Engel class I outcome at a median follow-up of 1.3 years; the only factor associated with outcome was indication for SEEG (p=0.03). SEEG was safe with one (0.7%) haematoma requiring surgical evacuation and no long-term neurological deficits as a result of the procedure.Conclusions and RelevanceThis large nationally representative cohort illustrates that, in these patients who may not have otherwise been offered resective surgery, SEEG-guided surgery can still achieve high rates of seizure freedom. Seizure semiology and the number of seizures recorded during SEEG are important factors in the identification of a definable SOZ and the indication for SEEG is an important factor in post-operative outcomes.