547 Postoperative Outcomes Are Significantly Worse Among Patients Undergoing Repair of Ruptured Versus Unruptured Iliac Artery Aneurysms – a 10-Year Longitudinal Cohort Study

Aim

The European Society for Vascular Surgery defines iliac artery aneurysms (IAA) as beyond 1.5 times its normal diameter. Common iliac arteries (CIA) beyond 1.8cm in men and 1.5cm in women are considered aneurysmal. This study aimed to assess outcomes following IAA rupture as their natural history is poorly understood and treatment recommendations based on low-level evidence.

Method

Patients with IAAs at a single vascular centre between 1st January 2010 and 31st August 2021 were identified from a prospectively collected departmental database and Caldicott-approved data collection performed. The primary outcomes included aneurysm rupture, rupture diameter, post-operative complications, 30-day, 1-year and 5-year mortality rates. Statistical analysis with SPSS® was performed using chi-squared tests.

Results

Of 203 patients included, 90.6% were men and median(IQR) age at detection was 77 (71–83). Co-morbidities included hypertension (54.2%), hyperlipidaemia (42.9%) and ischaemic heart disease (35.5%). IAA were in the CIA (85.2%), IIA (21.7%) and EIA (2.0%), mostly asymptomatic (78.8%). Overall IAA rupture rate was 7.9% with CIA (81.2%) and EIA (18.8%). Mean (SD) diameters at rupture were 4.6 (2.4)cm for CIA and 4.6 (3.0)cm for IIA. Post-operative major adverse cardiovascular events (MACE) more frequently occurred following repair of ruptured compared to unruptured IAA (33.3% vs 3.5%, p=.011). Mortality at 30-days, 1-year and 5-years postoperatively were higher following repair of ruptured vs unruptured aneurysms (88.9%, 88.9%, 100% vs 1.2%, 10.6%, 36.1% respectively).

Conclusions

Early detection and elective treatment of IAA aneurysms before they approach 4.6cm may reduce rupture risk, morbidity and mortality associated with emergency repair following rupture.

548 A 10-Year Longitudinal Cohort Study Assessing Growth Rates and Surveillance Intervals for Common Iliac Artery Aneurysms

Aim

The European Society for Vascular Surgery defines common iliac artery (CIA) aneurysms as greater than 1.8cm in men and 1.5cm in women. Their reported growth rate is 1–4mm/year depending on their diameter. This study aimed to assess the natural history and surveillance intervals for CIA aneurysms as intervention threshold is based on low-quality evidence.

Method

Patients diagnosed with an IAA at a single vascular centre between 1st January 2010 and 31st August 2021 were identified from a prospectively collected departmental database and Caldicott-approved data collection performed. The primary outcomes included diameter-based mean aneurysm growth rates and median surveillance intervals. Statistical analysis with SPSS® was performed using chi-squared tests.

Results

Of the 203 patients included, 90.6% were men and median (IQR) age at detection was 77 (71–83). IAA were located in the CIA (85.2%), IIA (21.7%) and EIA (2.0%) with the majority being asymptomatic (78.8%). CT was most frequently used as the imaging modality for IAA surveillance (66.3%), followed by ultrasound scan (29.8%) and MRA (3.9%). Growth rate for CIA aneurysms measuring 1.0–1.9cm were -2.1mm/year, 2.0–2.9cm were 0.8mm/year, 3.0–3.9cm were 3.5mm/year, 4.0–4.9cm were 9.4mm/year, 5.0–5.9cm were 2.9mm/year and >6.0cm were 13.8mm/year. Median surveillance intervals for CIA aneurysms at 1.0–1.9cm were 12-monthly, 2.0–2.9cm were 11-monthly, 3.0–3.9cm were 5-monthly, 4.0–4.9cm were 5-monthly, 5.0–5.9cm were 5.5-monthly and >6.0cm were 14.5-monthly. Mean(SD) CIA diameter at rupture was 4.6 (2.4)cm.

Conclusions

CIA aneurysms demonstrate faster growth rates as they enlarge and may require more frequent clinical assessments, surveillance, and consideration for repair prior to rupture.

Nitroglycerin cardioplegia effect on coronary artery targets in bypass grafting

BACKGROUND

Coronary artery targets are essential for referral acceptance to achieve complete coronary revascularization.

PATIENTS AND METHODS

A prospective double-blind study was carried out to determine whether the addition of nitroglycerin to cold blood hyperkalemic cardioplegia would optimize the size and number of coronary artery targets during conventional coronary bypass grafting.

RESULTS

A total of 60 adult elective coronary artery bypass grafting cases were enrolled; 30 in group N (nitroglycerin added to cardioplegia) and 30 in group C (controls). The number of bypassed vessels ranged from 2 to 5 with a mean of 3.63. In a comparison between groups N and C, the average number of grafts per patient (3.67 ± 0.77 vs. 3.67 ± 0.92); the average performed/predicted ratio for coronary artery bypass grafting targets (0.96 ± 0.18 vs. 1.02 ± 0.31); and the average intraoperatively measured luminal diameter of the bypassed coronary artery targets (1.55 ± 0.23 vs. 1.51 ± 0.23) showed no significant difference between the two groups, except that the luminal diameter of the obtuse marginal II artery was larger in group C compared to group N ( P = 0.037).

CONCLUSIONS

The addition of nitroglycerin to cardioplegia did not show any benefit, either quantitatively or qualitatively, for optimizing coronary artery bypass grafting targets.

Spinal aspergillosis in nonimmunocompromised host mimicking Pott's paraplegia

The aim of this report is to highlight the less-known aspergillus spondylitis (AS) that may completely mimic Pott's paraplegia, leading to occasional but expensive diagnostic error, as the chemotherapeutic management of the two is different. A case of a patient with the diagnosis of Pott's paraplegia who turned out to have aspergillus spondylitis is described. Issues and difficulties regarding the differentiation between these two forms of spine infection and their therapeutic implications are discussed. We conclude that differential diagnosis of spinal tuberculosis (TB) should include aspergillus spondylitis, as cure of spinal aspergillosis, especially in early stages, is possible with surgery and/or antifungal agents, and morbidity and mortality are high in neglected cases.

Atypical forms of spinal tuberculosis: case report and review of the literature

OBJECTIVE

The object of this report is to highlight some of the less known atypical features of spinal tuberculosis (TB) in the hope of facilitating early diagnosis. Pure neural arch and sacral TB is rare and the co-existence of these two as widely separated skip lesions in the same patient is even rarer.

CLINICAL PRESENTATION

An unusual case of tuberculous process affecting the sacrum as well as the neural arches of upper cervical vertebrae is presented. Neither the clinical features nor the imaging techniques, including radiography, bone scintigraphy, computed tomography, and magnetic resonance imaging, were helpful in establishing the diagnosis. The destructive lesion of the sacrum with a rectally palpable presacral mass was thought to be a chordoma or chondrosarcoma until the patient developed upper cervical cord compression with an extradural myelographic block. Development of this second destructive lesion involving the posterior spinal elements (the neural arch) led to a diagnosis of malignant spinal metastasis. The true diagnosis was only revealed by the histology of the solid tumor-like extradural mass in the upper cervical region and demonstration of acid-fast bacilli (AFB) in the lesion. Anti-TB chemotherapy resulted in complete resolution of sacral and cervical lesions as well as the neurologic deficits.

CONCLUSION

Differential diagnosis of the obscure spinal lesion should include tuberculosis, specifically the atypical forms; especially because complete cure is possible with early treatment and neurologic morbidity is high in neglected cases.

Intramedullary ossified cavernous angioma of the spinal cord: case report

A case of a heavily ossified cavernous angioma of the spinal cord along with its histological features and surgical implications is reported. The unusually dense calcification and even bone formation along with the unique eggshell-like cyst formation posed problems in diagnosis and surgical excision. This calcified vascular lesion was treated by subtotal excision.

Orbito-cranial injury caused by penetrating metallic foreign bodies: report of two cases

Two cases of orbito-cranial injury caused by foreign bodies (FBs) penetrating the lateral wall and roof of the orbit are described. In the first patient, a long rusted nail acted as a missile and was only detected by X-rays and CT scan. The nail penetrated the orbit, the eyeball, the lateral orbital wall, and the temporal lobe of the brain. Lodged partly in the orbit and partly in the brain, this nail caused leakage of cerebrospinal fluid (CSF) through eye and led to orbital cellulitis and localized meningitis. The foreign body (FB) was removed through an extradural pterional approach with rapid resolution of orbital cellulitis and meningitis. In the second patient, large metallic FB, having penetrated the orbital roof was lodged intracranially above the chiasma. This was removed via frontal craniotomy. Mechanism of such injuries and appropriate surgical approaches are described as well.

Childhood brain abscess in Saudi Arabia

The characteristics of childhood brain abscess in Saudi Arabia are outlined in this review of 17 consecutive cases treated at King Khalid University Hospital (KKUH) between 1985 and 1994. The data on 20 consecutive adults with brain abscess treated at KKUH during the same period were also analysed. Compared with series from the West, the children were unusual because of the relatively low incidence of cardiogenic and anaerobic abscesses and the relatively high incidence of post-traumatic, infratentorial and staphylococcal abscesses and sterile cultures. Compared with cases of brain abscess in adults, the children showed a much lower incidence of idiopathic abscess, a higher incidence of infratentorial abscess and a much better outcome. Factors accounting for the zero mortality rate in these children are discussed.

Neural arch tuberculosis: radiological features and their correlation with surgical findings

Radiological features of 17 cases of neural arch tuberculosis (NAT), treated surgically by the authors, are reviewed and correlated with the operative and histopathological findings. The diagnostic accuracy of different imaging modalities in the evaluation of this rare, atypical form of spinal tuberculosis was found to be very low. Thus, the initial diagnosis was in error in 15 out of 17 of our cases. Recognition of the radiological diagnostic features of NAT is important, not only because they may mimic primary or metastatic spinal neoplasms, but also because of the surgical implications. Computed tomography (CT) and magnetic resonance imaging (MRI) features correlated most closely with the surgical findings, whereas plain spinal radiographs and myelograms were found to be non-specific and non-diagnostic.

Intestinal obstruction caused by extraperitoneal cerebrospinal fluid collection

External compression caused by a massive extraperitoneal cerebrospinal fluid collection lead to intestinal obstruction in a 3-year-old child who had previously had a ventriculoperitoneal shunt for treatment of hydrocephalus. Radiological findings and ways of preventing this situation are discussed. A useful diagnostic radiological sign, the "coiling sign', indicating shunt misplacement at the peritoneal level, is also described.

Cranial and intracranial aspergillosis of sino-nasal origin. Report of nine cases

This paper is an attempt at defining the most efficacious surgical and antifungal therapy for invasive cranial and intracranial aspergillosis, and is based on experience with nine non-immunocompromised patients treated and followed-up by the authors between 1983 and 1994; as well as on the summary of previously reported cases and advances in therapy of this condition. Depending on the degree of aspergillar involvement of the cranial base and intracranial structures, a classification, with implications for treatment and prognosis, is also proposed. Two patients had extracranial skull base erosion; whereas relentlessly progressive granulomas, mimicking malignancy, invaded the skull base and intracranial contents in seven cases. Of these seven patients with cranial and intracranial invasion, two died of acute intracranial haemorrhage due to fungal invasion of cerebral blood vessels. In two patients, complete surgical eradication of the disease proved impossible due to cavernous sinus involvement, while residual aspergillomas are still present in orbit and paranasal sinuses (PNS) in a further two patients in spite of multiple surgical procedures and prolonged antifungal chemotherapy (AFC). What appears to be a cure has been effected in one patient only. Multiple therapeutic strategies were used. Biopsy plus systemic AFC was ineffective, surgical drainage and debridement plus systemic AFC resulted in long-term survivals but no cure. Radical surgery in conjunction with systemic and local (intracavitary) AFC should be considered to improve an otherwise poor prognosis.

Modified coronal computerized tomographic cuts for transsphenoidal surgery. Technical note

Computerized tomographic (CT) cuts passing through the anterior nasal spine and the most prominent part of the sellar floor (spino-sellar or SS cuts) were found to be useful in minimizing the chances of anatomical disorientation during the transsphenoidal microsurgical approach as well as in preoperative planning and selection of the length and choice of the instruments to be used. Routine preoperative SS cuts of CT scan are advised.

Isolated posterior fossa hypertension and brainstem compression caused by entrapped Dandy-Walker cyst: a case report

Lateral ventricular shunting alone is often considered to be adequate treatment for hydrocephalus caused by Dandy-Walker syndrome. A patient is presented in whom progressive spastic tetraparesis and signs of severe brainstem compression developed due to an entrapped posterior fossa cysts, in spite of an adequately functioning lateral ventricular shunt. Addition of a cystoperitoneal shunt resulted in rapid resolution of symptoms and deficits. This case illustrates that potentially fatal brainstem compression and dangerous posterior fossa hypertension may develop if the posterior fossa cyst does not communicate with the lateral ventricles, where the shunt is placed.

Survival in malignant astrocytoma at King Khalid University Hospital

Malignant astrocytoma (Kernohan grade III and IV) still has one of the worst outcomes of all malignant tumors. To determine factors affecting the survival of patients with malignant astrocytoma in Saudi Arabia, a retrospective study of 76 cases that were treated at King Khalid University Hospital over one decade was carried out. Kaplan-Meier survival diagrams were constructed for each prognostic factor. Twenty-eight percent of cases survived two years. A significantly better survival rate was found in females, patients </=50 years and patients who had re-operation for a recurrence. A better survival rate which did not reach significance was found in patients with grade III tumors, patients with a Karnofsky score of >/=70 at presentation, patients who had craniotomy and excision and patients who had radiotherapy. It is suggested that to improve the outcome of patients with malignant astrocytoma, aggressive surgical excision with radiotherapy (and possibly chemotherapy) is required.

Spinal intradural extramedullary enterogenous cysts. Report of two cases and review of literature

Two patients with intradural extramedullary cysts of the spinal canal are described. Both presented with slowly progressive myelo-radiculopathy caused by mucin-producing epithelial-lined cysts in cervical and upper thoracic region. Histologically, both lesions were considered to be neurenteric cysts with an endodermal origin. Radiographic diagnosis was made by a combination of myelography, computed tomographic scan with myelography (CTM), and magnetic resonance imaging (MRI). Complete surgical resection was curative in both cases. Clinical presentation, histological characteristics, imaging findings and surgical management of this rare lesion are highlighted.

Bronchoalveolar lavage: results of sequential, selective techniques in viable murines

The purpose of this study was to develop an optimal technique for performing sequential bronchoalveolar lavage (BAL) in a murine animal model. Two general anesthetic regimens and four operative techniques of BAL were tested. Anesthesia by intraperitoneal injection of ketamine hydrochloride (100 mg/kg body wt) resulted in death for four of ten subjects, whereas inhalation of diethyl ether led to death for one of ten subjects. BAL using a balloon catheter under bronchoscopic guidance was comparable with postmortal lavage, tolerated better, and resulted in superior cell retrieval with respect to cell differential (macrophages: 95 +/- 2.3; lymphocytes: 3 +/- 1.2; polymorphonuclear lymphocytes [PNL]: 1.2 +/- 1.4) compared with two other techniques using a bent metal tube/polyethylene tubing combination (macrophages: 19.3 +/- 27.4; lymphocytes: 3.8 +/- 4.3; PNL: 35.5 +/- 35.5) and a bronchoscope/polyethylene tubing combination (macrophages: 11.1 +/- 25.5; lymphocytes: 0.7 +/- 1.0; PNL: 55.8 +/- 41.0). The BAL fluid contained significantly more alveolar macrophages and fewer PNL and epithelial cells (p = 0.0001, p = 0.0025, p = 0.02, respectively). We conclude that the technique using a balloon catheter under bronchoscopic guidance during inhalation of diethyl ether is the procedure of choice and results in a representative sample of BAL.

Growing skull fractures: classification and management

Seven patients with growing skull fractures treated between 1983 and 1993 are described. These growing fractures constituted 1.6% of all the cases of skull fractures seen during the period (a total of 449 cases). Based on aetiopathogenesis, computed tomography (CT) appearances, operative findings and management strategies required, three main types of growing skull fractures were recognized. In type I (n = 3) a leptomeningeal cyst, in type II (n = 3) damaged and gliotic brain, and in type III (n = 2) a porencephalic cyst extended through the skull defect into the subgaleal space. A combination of type I and type III co-existed in one patient. Initial head injury and neurological deficit were judged to be mild to moderate in all the seven cases. Continued growth of skull fractures correlated closely to the increasing neurological deficit in five cases. In two patients natural arrest of fracture growth at 5 and 7 months after trauma was accompanied by arrest in progress of neurological deficit. Available surgical options are discussed and general guidelines for the management are given.

Clinical characteristics of traumatic extradural hematoma: a comparison between children and adults

In this study of 43 children who had surgery for traumatic extradural hematoma (EDH) at Frenchay Hospital, England, between 1975 and 1987, the authors attempt to outline the various clinical characteristics of EDH which are different in children (age range 1-15 years) and adults (age range 16-84 years). The results confirm that children with traumatic EDH are less likely to have injury be caused by an RTA, are less likely to remain unconscious from the time of injury to the time of the operation, and are less likely to require immediate surgery (less than 6 hours after injury). In addition, the CT scan is less likely to show in associated intradural injury, and the outcome is significantly better.

Cervical lymph nodes metastases from a pituitary carcinoma

The authors report a case of a pituitary carcinoma which was locally invasive and which metastasized to cervical lymph nodes more than 9 years after the initial presentation. Cells from the tumour and metastasis immunostained with antibodies to prolactin and growth hormone, even though there was no clinical or biochemical evidence that the tumour was secreting prolactin or growth hormone. In addition, ultrastructural studies showed a monomorphic tumour with secretory granules much smaller than those normally associated with prolactin and growth hormone secretion. The clinical and pathological features suggest that the tumour is probably an acidophil stem cell adenoma, which although known to be aggressive in its clinical behaviour has not been previously reported to metastasize.

Results of day-case surgery for lumbar disc prolapse

Microdiscectomy for lumbar disc prolapse on a day-patient basis was introduced by our department in 1985 and first reported in 1987, but has not been generally adopted in the United Kingdom. We now report our experience of the first 100 patients with lumbar disc prolapse treated by day-case microdiscectomy. Post-operative assessment was in the out-patient clinic and by subsequent postal questionnaire (average follow-up 37 months, range 3-64 months). Complications were few and are described. Only three patients developed a recurrent disc prolapse. Patient feedback was favourable and the majority (85%) said that, if necessary, they would be prepared to have the operation again on a day-case basis. For selected patients, lumbar microdiscectomy is a suitable procedure for day-case surgery.

Multiple brain abscesses at King Khalid University Hospital

The authors reviewed six cases of multiple brain abscesses that were treated at King Khalid University Hospital (KKUH) over an eight year period. This represented 22% of the total brain abscesses treated during the same period. The series is unusual in that the infective pathogens were fungi (Fonsecaea pedrosoi) in two patients (33%) and an aerobic actinomycete (Nocardia asteroides) in one patient (16%). Two patients treated elsewhere with antibiotics empirically for one month died at three and 28 days following admission. The poor outcome was probably related t the delay in obtaining a microbiological diagnosis and commencing the appropriate antimicrobial therapy. The importance of early identification of the pathogen in patients with multiple brain abscesses is stressed.

Neurosurgical management of intraventricular haemorrhage in preterm infants

A review of intraventricular haemorrhage (IVH) diagnosed in 103 preterm infants from 1983 to 1993 describes the presenting features and management of this condition. In this 10-year period, 37 infants with IVH developed post-haemorrhagic hydrocephalus (PHH), defined as ventriculomegaly, raised intracranial pressure and increasing head circumference. PHH was treated by external ventricular drainage and/or ventriculo-peritoneal shunting; but other drainage procedures like lumbar punctures and subcutaneous ventricular reservoir were used occasionally. Relative indications, merits and demerits of these various surgical options is discussed and results summarized. High incidence of neuro-developmental handicap and its correlation with the grade of haemorrhage and PHH is emphasized. External ventricular drainage (EVD) was found to be an effective and safe therapy for rapidly progressive PHH and increased intracranial pressure. Ultimate outcome depended mainly on the grade of haemorrhage, severity of PHH and promptness of its neurosurgical management.

The outcome of surgery of aneurysmal subarachnoid haemorrhage

Aneurysmal subarachnoid haemorrhage is a challenging pathology which remains a cause of considerable mortality and morbidity. To demonstrate to general practitioners the results of surgery for this condition a retrospective study of 160 consecutive cases who had undergone aneurysmal surgery was carried out. On admission 57% of cases had a good Hunt and Hess grade (grades I and II) and 43% a poor grade (grades III, IV and V). Twelve per cent of cases had a pre-existing hypertension and 73% of cases were treated with nimodipine. Angiography was performed from 0 to 73 days (median 3 days) after the bleed. Early surgery (within the first three days after the bleed) was performed in 41% of cases. Twenty-two per cent of cases rebled before surgery from 1 to 69 days after initial presentation (median seven days). Delayed cerebral ischaemia was diagnosed in 38% of cases, but only 15% of cases had evidence of low density on the CT scan. The outcome was determined at six months using the 'Glasgow outcome scale'. Fifty-five per cent of cases made a good recovery (back to normality), 15% a fair recovery (moderately disabled but independent), 15% a poor recovery (severely disabled and dependent), and 15% died. The significant poor prognostic factors were: a poor pre-operative Hunt and Hess grade, the presence of an intracerebral haematoma or angiographic spasm, evidence of rebleeding and early surgery without treatment with nimodipine. Other factors which did not reach a statistical significance include: age, presence of subarachnoid and intraventricular blood on CT, timing of surgery, history of long-standing hypertension, intraoperative rupture, and the development of hydrocephalus or delayed ischaemia.

Spinal tumors: Experience at King Khalid University Hospital

This paper summarizes data on 30 consecutive spinal tumors treated at King Khalid University Hospital (KKUH) between 1984-1991. The male:female ratio was 2.75:1. Thirty percent of cases were less than 20 years of age while 71% were more than 60 years of age. The brain to spinal cord tumor ratio in our unit was 12.3:1. The ratio of Schwannoma to meningioma was 1.6:1. Metastatic carcinoma accounted for a mere 13% of cases and only 35% of tumors were located in the thoracic spine. Intramedullary tumors accounted for 17% of cases. An overall 63% of cases improved postoperatively while 37% remained unchanged.

Cerebellopontine angle epithelial cyst. A case report

A case of epithelial cyst in the cerebellopontine angle is reported. The cyst wall showed glandular epithelium with areas of non-keratinized stratified epithelium and flattened cuboidal cells. The glandular areas stained positively with antibodies to cytokeratin. In addition, the cyst wall contained areas of arachnoid tissue. This, and the unusual position of the cyst, suggest that the epithelial elements in the cyst wall may be metaplastic in origin. Similar previously described cysts were considered to be endodermal in origin.

The influence of concomitant intradural pathology on the presentation and outcome of patients with acute traumatic extradural haematoma

The pre-operative and early postoperative CT scans of 120 patients who had surgery for acute extradural haematoma were reviewed, 88 cases (73%) had an extradural haematoma alone (Group 1) while 32 cases (27%) had an additional intradural abnormality (Group 2). The abnormalities were a subdural haematoma in eight, a haemorrhagic contusion in 16 and hemisphere swelling in eight. The two groups were compared with regard to the findings that an additional intradural abnormality is likely to be associated with an older age, an injury following a road traffic accident, a GCS less than 7 at operation, additional extracranial injuries and a poorer outcome. The increase in the percentage of patients who were unconscious from the onset and the decrease in those who were always conscious with a concomitant intradural damage was without statistical significance.

Unique complications of cerebrospinal fluid shunts in children--a report of two cases

The authors report on two cases with unusual CSF shunt complications. The first case had a peritoneal catheter which migrated down a patent processus vaginalis into a hydrocoele. The second case had an atrial catheter which perforated the atrial wall and came to lie in the pericardium causing an effusion. Clinicians should be aware of the frequent and occasionally bizarre complications of CSF shunting.

MRI in the diagnosis of spinal extradural angiolipoma

We report the case of a 68-year-old woman with a 1-year history of progressive spastic paraparesis, due to an extradural angiolipoma of the mid-thoracic spine. The MRI appearance of the angiolipoma is reported here for the first time. This appearance is characteristic, allows preoperative diagnosis and assists planning of the surgical approach.

Metastasis of a renal carcinoma to a cerebellar haemangioblastoma in a case of von Hippel-Lindau disease

A patient with Von Hippel-Lindau disease had a long-standing cerebellar cyst which recurred for the fifth time. At operation there was evidence of a renal carcinoma metastasis in the wall of the cyst which was probably a haemangioblastoma.

The treatment of trigeminal neuralgia by microvascular decompression and partial sensory rhizotomy

A retrospective study was carried out on 60 cases that had microvascular decompression or partial rhizotomy for trigeminal neuralgia. There were 25 males and 35 females with a mean age of 59.5 years. The mean duration of symptoms prior to surgery was 6.9 years. Thirty seven cases (61.6%) has previous ablative surgical procedure for the trigeminal neuralgia. In 42 cases (70%), there was evidence of arterial compression of the trigeminal root, venous compression in five cases (8.3%), and compression by a small meningioma in two cases (3.3%). There was no evidence of any compression in 11 cases (18.3%). There was no mortality. Minor morbidity was transient in 11.7%, and permanent in 3.3% of cases. The trigeminal neuralgia recurred within the first year after surgery in 8.3% of cases. 88.3% of the cases were pain-free or had minimal pain which did not require treatment. 11.7% continued to have pain which was controlled on drug therapy. There was a mean follow-up of 23 months. This form of surgical treatment has become the first line treatment in cases of trigeminal neuralgia which failed to respond to medical treatment.

Justification for evacuating acute subdural haematomas in patients above the age of 75 years

The author has reviewed the outcome of 27 patients aged 75 years and over who had an operation for acute traumatic subdural haematoma at Frenchay Hospital, Bristol, over a 10-year period. There were 15 men and 12 women with a mean age of 79.2 years. The outcome at 6 months was determined using the Glasgow Outcome Score. Of the patients, 15 per cent made a good recovery, 15 per cent a poor recovery and 70 per cent died. The influence of age, sex, mechanism of injury, preoperative Glasgow Coma Score (GCS), pupillary reactivity to light, skull and limb fractures, clinical course, CT scan appearance and timing of operation were analysed in relation to the outcome. The results showed that a preoperative GCS of 4 or less and unilateral pupillary dilatation and non-reactivity to light were not compatible with good survival in the very elderly patient with acute subdural haematoma. Under these circumstances, operation is not justified. The prognosis was worse in patients who were unconscious immediately after injury and with a CT scan showing a subdural haematoma and a haemorrhagic contusion which required urgent early intervention. The prognostic indicators present may prove useful in the selection of patients for active surgical intervention.

Outcome following surgical evacuation of traumatic intracranial haematomas in the elderly

In order to determine the factors influencing outcome following craniotomy for trauma in patients over the age of 65 and to establish criteria for surgical intervention, the authors carried out a retrospective analysis of the hospital and general practice records of all head injury patients over the age of 65 who underwent a craniotomy for evacuation of a post-traumatic haematoma within 7 days of injury at Frenchay Hospital during a 10-year period (1980-89). Outcome was measured using the Glasgow Outcome Scale and patients were allotted to a good outcome group (good recovery or moderate disability but independent) or a poor outcome group (severe disability, vegetative state of death). There were 35 men and 31 women with a mean age of 72.5 years (range 65-85 years). The mortality rate was 61% and 9% of patients survived in a severely disabled or vegetative state. All 20 (30%) patients with a good outcome had a Glasgow Coma Score (GCS) of 5 or more immediately before surgery. All 18 (27%) patients with a GCS of 4 or less and all 22 (33%) patients with unilateral or bilateral pupillary dilatation had a poor outcome. Outcome was significantly worse in the older patients (75-85 years) compared with the younger patients (65-74 years) and in those patients requiring craniotomy within 24 hours of injury, but the mechanism of injury (fall or road traffic accident), the presence or absence of skull fractures and limb fractures and the pre-operative CT scan appearances did not influence outcome. This study confirms the high probability of poor outcome following surgical evacuation of traumatic intracranial haematomas for elderly head-injured patients with pupillary dilatation or extensor motor responses. Craniotomy under these circumstances is not justified.

Ventriculitis and hydrocephalus caused by Candida albicans successfully treated by antimycotic therapy and cerebrospinal fluid shunting

A unique case of Candida albicans ventriculitis and hydrocephalus in the absence of any evidence of systemic candidiasis or immunosuppression is reported. Initial treatment with CSF shunting and intravenous antimycotic therapy appeared to have eradicated the infection. Recurrence occurred 5 months after discharge and this was treated by intravenous and intrathecal antimycotic therapy in addition to removal of the shunt system, external ventricular drainage and then replacement of the shunt. A concomitant pyogenic brain abscess responded to burrhole aspiration and antibiotics. The role of mannan antigen monitoring is discussed.

C-reactive protein monitoring in the management of intracranial abscess

C-reactive protein (CRP) content was measured serially in 12 patients with intracranial abscess. All patients had undergone surgery and were treated with antimicrobial therapy. The CRP content ultimately returned to normal in 11 patients and this correlated with good recovery in all. Death in one patient with a high CRP level was due to pulmonary embolism. In one case, the CRP level remained elevated because of an inadequately treated chronic ear infectionl; a second peak correlated with reinfection. In two patients, a persistently high CRP level postoperatively coincided with a re-formation of the abscess. One patient had an unexplained normal CRP level two days after his abscess was excised. A transient rise in the CRP value during an uneventful decrease to normal was due to deep venous thrombosis in one case. CRP levels in patients with intracranial abscess is useful for monitoring the effectiveness of treament but must be used in combination with the clinical response and computed tomographic scans. These can provide guidelines for terminating antimicrobial therapy.

The value of autopsies in neurosurgery

Many previous studies have reported the value of autopsy in assessing clinical diagnostic accuracy. None of them however, assessed the value of autopsies in a specific clinical speciality. The authors reviewed the findings of 123 consecutive neurosurgical autopsies with reference to the premortem clinical diagnoses. The study showed that 7% of cases had a wrong clinical diagnosis and in 9% of cases the clinical diagnosis was incomplete. Only in 5% of all cases knowledge of the autopsy findings would have led to a change in management and outcome. The autopsies also confirmed that 11% of cases died following a surgical complication and in 3% of cases the primary cause of death was non-neurosurgical. The latter was a previously unrecognised finding in 8% of autopsies. The autopsy will remain a valuable means of clinical audit and the increasing financial pressures to reduce the number of autopsies should be resisted.

Recurrent subarachnoid haemorrhage from an angiographically occult large distal pica aneurysm

The author reports an unusual case with recurrent episodes of subarachnoid haemorrhage. Complete angiographic examination was negative on three occasions. An unexpected distal posterior inferior cerebellar artery aneurysm was found at autopsy. The case illustrates the occasional failure of angiography in the detection of aneurysms and the need to have a high index of suspicion of an aneurysm in cases with recurrent subarachnoid haemorrhage with negative angiography. The role of magnetic resonance imaging is discussed.

The treatment of spondylotic cervical myelopathy by multiple subtotal vertebrectomy and fusion

The authors report their experience in the treatment of cervical spondylotic myelopathy by multiple subtotal vertebrectomy and fusion. There were 27 cases with a mean age of 66.9 years. The clinical assessment was carried out using both the Nurick and the Japanese Orthopaedic Association (JOA) grading pre- and post-operatively at 6 months. The post-operative radiological assessment was done at 3 and 6 months. Two cases died from unrelated medical problems. There were three cases of graft dislodgement. Clinical improvement was detected in 80% of cases using the Nurick grading and in 88% of cases using the JOA scoring. No cases deteriorated neurologically after operation. Bony fusion was achieved in 96% of the surviving cases by 6 months. Multiple subtotal vertebrectomy and fusion is therefore an effective method for the treatment of cervical spondylotic myelopathy.