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Salehi-Reyhani SA, Zilani G, Lammie A, Hayhurst C. Malignant vestibular schwannoma with intracerebral metastasis. Br J Neurosurg 2023; 37:1354-1357. [PMID: 33686895 DOI: 10.1080/02688697.2021.1884650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 01/29/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Malignant change in vestibular schwannoma is rare and intracranial metastatic deposits have not been reported. CLINICAL PRESENTATION We report the case of a 64 year old woman with a benign vestibular schwannoma who underwent translabyrinthine excision in 1996 and Gamma Knife® radiosurgery (Elekta AB, Stockholm, Sweden) (GKRS) in 2006. She presents 10 years after GKRS with progressive neurological deterioration. Histopathologic analysis confirms a malignant peripheral nerve sheath tumour, WHO grade IV with subsequent metastatic spread to the left thalamus confirmed on biopsy. CONCLUSION We report a rare case of a vestibular schwannoma metastasizing with histological confirmation. It also reminds us of malignant conversion of a benign vestibular schwannoma following GKRS and subsequent aggressive behaviour, with poor prognosis.
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Affiliation(s)
- Sayedeh Ameneh Salehi-Reyhani
- Department of Neurosurgery, University Hospital of Wales, Cardiff, United Kingdom of Great Britain and Northern Ireland
| | - Gulam Zilani
- Department of Neurosurgery, University Hospital of Wales, Cardiff, United Kingdom of Great Britain and Northern Ireland
| | - Alistair Lammie
- Department of Histopathology, University Hospital Wales, Cardiff, United Kingdom of Great Britain and Northern Ireland
| | - Caroline Hayhurst
- Department of Neurosurgery, University Hospital of Wales, Cardiff, United Kingdom of Great Britain and Northern Ireland
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2
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James Z, Makwana M, Hayhurst C. De Novo Skull Base Atypical Meningioma: Incidence and Outcome. J Neurol Surg B Skull Base 2023; 84:113-118. [PMID: 36895814 PMCID: PMC9991523 DOI: 10.1055/a-1757-3212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 01/30/2022] [Indexed: 10/19/2022] Open
Abstract
Objective Atypical meningiomas are uncommon in skull base practice and present a management challenge. We aimed to review all de novo atypical skull base meningioma cases within a single unit to analyze presentation and outcome. Methods A retrospective review of all patients undergoing surgery for intracranial meningioma identified consecutive cases of de novo atypical skull base meningioma. Electronic case records were analyzed for patient demographics, tumor location and size, extent of resection, and outcome. Tumor grading is based on the 2016 WHO criteria. Results Eighteen patients with de novo atypical skull base meningiomas were identified. The most common tumor location was the sphenoid wing in 10 patients (56%). Gross total resection (GTR) was achieved in 13 patients (72%) and subtotal resection (STR) in 5 patients (28%). There was no tumor recurrence recorded in patients who had undergone GTR. Patients with tumors >6 cm were more likely to undergo a STR as opposed to a GTR ( p < 0.01). Patients who had undergone a STR were more likely to have postoperative tumor progression and be referred for radiotherapy ( p = 0.02 and <0.01, respectively). On multiple regression analysis, tumor size is the only significant factor correlating with overall survival ( p = 0.048). Conclusion The incidence of de novo atypical skull base meningioma is higher in our series than currently published data. Tumor size was a significant indicator for patient outcome and extent of resection. Those undergoing a STR were more likely to have tumor recurrence. Multicenter studies of skull base meningiomas with associated molecular genetics are needed to guide management.
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Affiliation(s)
- Z James
- Department of Neurosurgery, University Hospital of Wales, Cardiff, United Kingdom
| | - M Makwana
- Department of Neurosurgery, University Hospital of Wales, Cardiff, United Kingdom
| | - C Hayhurst
- Department of Neurosurgery, University Hospital of Wales, Cardiff, United Kingdom
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3
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Pak HYV, Hayhurst C, Taylor P. 414 Are Lumbar Drains Necessary in Endoscopic Transellar Surgery with an Intraoperative High Flow Leak? a Systematic Review. Br J Surg 2022. [DOI: 10.1093/bjs/znac269.273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Aim
Perioperative lumbar drains have been used to facilitate healing of the dura and prevent postoperative cerebrospinal fluid (CSF) leaks. However, the use of perioperative lumbar drains is controversial and has primarily been left to the surgeon's preferences. Through the use of meta-analysis, we aim to find out whether lumbar drains effectively reduce the risk of postoperative CSF leak in the context of a high flow intraoperative leak.
Method
A systematic review was conducted using PRISMA guidelines. Databases used in literature searching include PubMed, Ovid (including Embase and Medline), Scopus and Cochrane Library. Articles published in 2006 or later were searched. The random-effects model was used in statistical analysis.
Results
A total of 2623 articles were identified. After screening and full-text reviews, 21 studies were included. From the quantitative data analysis, lumbar drains did not significantly lower the rates of postoperative CSF leaks. In addition, lumbar drains were associated with complications as well as a lengthier hospital stay.
Conclusions
Modern and rigorous repair techniques after endoscopic transsellar surgery are sufficient, and the use of lumbar drains is not necessary.
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Affiliation(s)
- HYV Pak
- Cardiff University , Cardiff , United Kingdom
| | - C Hayhurst
- University Hospital Wales , Cardiff , United Kingdom
| | - P Taylor
- Cardiff University , Cardiff , United Kingdom
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4
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Ved R, Mo M, Hayhurst C. Olfactory Outcomes after Resection of Tuberculum Sella and Planum Sphenoidale Meningiomas via a Transcranial Approach. Skull Base Surg 2022; 83:296-304. [DOI: 10.1055/s-0040-1722671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/01/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Objectives Controversy exists surrounding the optimal approaches to tuberculum sella meningioma (TSM) and planum meningioma (PM). Olfaction is infrequently considered within this context but is nonetheless an important quality of life measure. The evolution of olfactory outcomes following contemporary transcranial surgery remains unclear. This study reviews olfactory outcomes after supraorbital craniotomy for TSM or PM and defines temporal trends in its recovery.
Study Design A prospective study of a patients who underwent a minimally invasive supraorbital craniotomy for TSM or PM was conducted at a single neurosurgical center.
Participants & Main Outcome Measures All patients were questioned about olfaction at presentation 3 months postoperatively, 12 months postoperatively, and annually thereafter (median follow-up = 37 months). The olfactory status of patients was categorized as normosmia, anosmia, hyposmia, parosmia, (altered perception of odours), or phantosmia, (olfactory hallucinations).
Results Twenty-two patients were included in the study analysis, (range = 27–76). Precisely, 3 months after surgery, seven patients had normal olfaction (32%). Six patients were anosmic, (27%) four hyposmic, (18%), three parosmic, (14%), and two were phantosmic (9%). At 1-year follow-up, almost half of patients (10; 48%) were normosmic, while two patients (9.5%) were anosmic. There were no further improvements in olfaction between 1 year and long-term follow-up.
Conclusion Subfrontal transcranial approaches for TSM or PM appear to be associated with changes in olfaction that can improve with time; these improvements occur within the first year after surgery. Impacts upon olfaction should be considered when selecting a surgical approach and patients counseled appropriately.
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Affiliation(s)
- Ronak Ved
- Department of Neurosurgery, University Hospital of Wales, Heath Park, Cardiff, United Kingdom of Great Britain and Northern Ireland
- School of Medicine, Cardiff University, Heath Park, Cardiff, United Kingdom of Great Britain and Northern Ireland
| | - Matthew Mo
- Department of Neurosurgery, University Hospital of Wales, Heath Park, Cardiff, United Kingdom of Great Britain and Northern Ireland
- School of Medicine, Cardiff University, Heath Park, Cardiff, United Kingdom of Great Britain and Northern Ireland
| | - Caroline Hayhurst
- Department of Neurosurgery, University Hospital of Wales, Heath Park, Cardiff, United Kingdom of Great Britain and Northern Ireland
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5
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Chia C, Merola J, Taylor P, Hayhurst C. 245 Changing Demographics of Head Injury During the COVID-19 Pandemic. Br J Surg 2022. [DOI: 10.1093/bjs/znac039.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Introduction
Studies have shown that men are more likely to sustain head injuries (HI) due to a higher likelihood of participation in high-risk behaviours. However, the COVID-19 lockdown caused substantial alterations to the daily routines of the Welsh population. We aimed to describe the demographical changes of HI patients caused by this large-scale restriction of public social activity.
Method
A retrospective review of our neurosurgical referral database was performed between 1/1/19 to 31/12/20 to extract patient demographics and referral outcomes (admission/advice only) of adult head injury patients. Referrals during lockdown in Wales (26/3/20 – 1/6/20 and 31/10/20 and 2/12/20) were compared with non-lockdown periods in 2019 and 2020.
Results
There was no significant difference in HI referral volume in 2019 (n = 1228) vs 2020 (n = 1179) (OR: 0.71; 95% CI: 0.53 – 0.96, p = 0.02). Women were less likely to be admitted in 2019 (OR: 0.60, 95%CI: 0.39 – 0.91, p = 0.02) and 2020 (OR: 0.52, 95%CI: 0.31–0.88, p = 0.01). We observed evidence of interaction by age and sex in lockdown vs non-lockdown (p = 0.02). Most strikingly, there was higher odds of admission in women aged 40–70 years during lockdown (OR: 10.4, 95%CI: 1.13 – 95.8, p = 0.04).
Conclusions
We observed significant demographical shifts in HI during lockdown periods, with striking increases in admission rates of men under 40 years and women aged 40–70. The cause of these substantial changes need clarification and have important public health implications. Given likely reduced road traffic accidents during lockdown, other factors such as alcohol or assault need considering.
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Affiliation(s)
- C.W.L. Chia
- School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - J. Merola
- Department of Neurosurgery, University Hospital of Wales, Cardiff, United Kingdom
| | - P. Taylor
- Division of Infection and Immunity, University Hospital of Wales, Cardiff, United Kingdom
| | - C. Hayhurst
- Department of Neurosurgery, University Hospital of Wales, Cardiff, United Kingdom
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Bandyopadhyay S, Khan DZ, Marcus HJ, Schroeder BE, Patel V, O'Donnell A, Ahmed S, Alalade AF, Ali AM, Allison C, Al-Barazi S, Al-Mahfoudh R, Amarouche M, Bahl A, Bennett D, Bhalla R, Bhatt P, Boukas A, Cabrilo I, Chadwick A, Chowdhury YA, Choi D, Cudlip SA, Donnelly N, Dorward NL, Dow G, Fountain DM, Grieve J, Giamouriadis A, Gilkes C, Gnanalingham K, Halliday J, Hanna B, Hayhurst C, Hempenstall J, Henderson D, Hossain-Ibrahim K, Hirst T, Hughes M, Javadpour M, Jenkins A, Kamel M, Mannion RJ, Kolias AG, Khan MH, Khan MS, Lacy P, Mahmood S, Maratos E, Martin A, Mathad N, McAleavey P, Mendoza N, Millward CP, Mirza S, Muquit S, Murray D, Naik PP, Nair R, Nicholson C, Paluzzi A, Pathmanaban O, Paraskevopoulos D, Pollock J, Phillips N, Piper RJ, Ram B, Robertson I, Roman E, Ross P, Santarius T, Sayal P, Shapey J, Sharma R, Shaw S, Shoakazemi A, Shumon S, Sinha S, Solomou G, Soon WC, Stapleton S, Statham P, Stew B, Thomas N, Tsermoulas G, Tysome JR, Varma A, Weir P, Williams A, Youssef M, Veljanoski D. CSF Rhinorrhea After Endonasal Intervention to the Skull Base (CRANIAL) - Part 2: Impact of COVID-19. World Neurosurg 2021; 149:e1090-e1097. [PMID: 33444833 PMCID: PMC7965443 DOI: 10.1016/j.wneu.2020.12.169] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 12/02/2022]
Abstract
BACKGROUND During the coronavirus disease 2019 (COVID-19) pandemic, concerns have been raised regarding the increased risk of perioperative mortality for patients with COVID-19, and the transmission risk to healthcare workers, especially during endonasal neurosurgical operations. The Pituitary Society has produced recommendations to guide management during this era. We sought to assess contemporary neurosurgical practice and the effects of COVID-19. METHODS A multicenter prospective observational cohort study was conducted at 12 tertiary neurosurgical units (United Kingdom and Ireland). Data were collected from March 23 to July 31, 2020, inclusive. The data points collected included patient demographics, preoperative COVID-19 test results, operative modifications, and 30-day COVID-19 infection rates. RESULTS A total of 124 patients were included. Of the 124 patients, 116 (94%) had undergone COVID-19 testing preoperatively (transsphenoidal approach, 97 of 105 [92%]; expanded endoscopic endonasal approach, 19 of 19 [100%]). One patient (1 of 116 [0.9%]) had tested positive for COVID-19 preoperatively, requiring a delay in surgery until the infection had been confirmed as resolved. Other than transient diabetes insipidus, no other complications were reported for this patient. All operating room staff had worn at least level 2 personal protective equipment. Adaptations to surgical techniques included minimizing drilling, draping modifications, and the use of a nasal iodine wash. At 30 days postoperatively, no evidence of COVID-19 infection (symptoms or positive formal testing results) were found in our cohort and no mortality had occurred. CONCLUSIONS Preoperative screening protocols and operative modifications have facilitated endonasal neurosurgery during the COVID-19 pandemic, with the Pituitary Society guidelines followed for most of these operations. We found no evidence of COVID-19 infection in our cohort and no mortality, supporting the use of risk mitigation strategies to continue endonasal neurosurgery in subsequent pandemic waves.
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7
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Ahmad S, Surya A, Hayhurst C, Davies S. Pituitary infundibular epidermoid cyst: a rare cause of hypopituitarism. BMJ Case Rep 2021; 14:14/3/e241065. [PMID: 33762289 PMCID: PMC7993165 DOI: 10.1136/bcr-2020-241065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 53-year-old man presented with 6 months history of weight loss associated with nausea, fatigue, dizziness and headache. On arrival he was in adrenal crisis. Biochemistry revealed anterior hypopituitarism with low cortisol, thyroxine, testosterone and a slightly raised prolactin. He was commenced on steroids, thyroxine and testosterone. MRI pituitary gland was reported to have a 9.4 mm microadenoma. Cabergoline was started for a possible microprolactinoma. Follow-up MRI showed increase in the size of complex cystic lesion causing chiasmal compression raising a possibility of craniopharyngioma. Visual fields assessment was normal. In view of the rapid enlargement, to protect vision and obtain a tissue diagnosis he underwent endoscopic trans-sphenoidal surgery. A cystic lesion was noted intraoperatively originating from pituitary stalk with intrasellar and suprasellar extension. It was filled with white caseous material and fluid. Histology revealed epidermoid cyst. His headache resolved postoperatively.
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Affiliation(s)
- Sajjad Ahmad
- Department of Diabetes and Endocrinology, University Hospital of Wales, Cardiff, Cardiff, UK
| | - Ashutosh Surya
- Department of Diabetes and Endocrinology, University Hospital of Wales, Cardiff, Cardiff, UK
| | - Caroline Hayhurst
- Division of Neurosurgery, University Hospital of Wales, Cardiff, Cardiff, UK
| | - Stephen Davies
- Department of Endocrinology, University of Wales College of Medicine, Cardiff, UK
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8
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Abstract
Background Melanoma brain metastases (MBMs) have historically poor overall survival (OS). Recently introduced systemic anticancer therapies (SACTs), namely targeted therapies such as BRAF inhibitors and immunotherapy, to control advanced disease have shown improved survival. Today, increasingly aggressive strategies are sought for MBM. We review outcomes in MBM after surgery or stereotactic radiosurgery (SRS) and the survival impact in advanced systemic disease when combined with novel anticancer therapies. Methods A retrospective cohort study of patients referred to a regional neuro-oncology multidisciplinary team (MDT) meeting with MBM. Demographic data, extent of systemic disease, and data on surgical and oncological management were collected, plus the use of SACT. The primary outcomes were median OS, 12- and 24-month survival, and progression-free survival. Results Between 2010 and 2018, 142 patients with MBM were referred. Following the introduction of SACT, the rate of referrals to MDT more than doubled from 11.6 to 25.7 patients per year. Focal brain metastasis was treated surgically in 23 (16.2%) patients and by SRS in 29 (20.4%). Fifty-six (39.4%) patients underwent palliative whole-brain radiotherapy and 34 (23.9%) did not receive treatment. Median OS was 11 months for the surgical cohort, 9 months for the SRS cohort, and increased when treatment with or without SACT was considered to 23 and 12 months, respectively. Conclusion In the setting of SACTs, survival in MBM is significantly improved after surgery or SRS even in patients with advanced and uncontrolled systemic disease at the time of presentation, supporting an aggressive approach to MBM management.
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Affiliation(s)
- Joseph P Merola
- Department of Neurosciences, University Hospital of Wales, Cardiff, UK
| | | | | | | | - Caroline Hayhurst
- Department of Neurosciences, University Hospital of Wales, Cardiff, UK
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9
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Ahmad S, Best T, Lansdown A, Hayhurst C, Smeeton F, Davies S, Rees A. Spinal epidural lipomatosis: a rare association of Cushing's disease. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200111. [PMID: 33434165 PMCID: PMC7576635 DOI: 10.1530/edm-20-0111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 09/29/2020] [Indexed: 11/08/2022] Open
Abstract
SUMMARY Excess cortisol is associated with hypertrophy and redistribution of adipose tissue leading to central obesity which is classically seen in Cushing's syndrome. Abnormal accumulation of fatty tissue in the spinal canal is most commonly associated with chronic steroid therapy and rarely reported with endogenous Cushing's syndrome. Herein, we describe a case of spinal epidural lipomatosis (SEL) associated with Cushing's disease. A 17-year-old man was referred with lower limb weakness, weight gain, multiple stretch marks, back pain and loss of height. He had clinical and biochemical features of Cushing's syndrome. MRI and Inferior Petrosal Sinus Sampling (IPSS) confirmed a pituitary adenoma as the source. On day 1 post trans-sphenoidal adenectomy he developed spastic paraparesis with a sensory deficit to the level of T5. MRI spine showed increased fat deposition in the spinal canal from T2 to T9 consistent with a diagnosis of SEL. He was managed conservatively and made a good recovery following restoration of eucortisolism and a period of rehabilitation. LEARNING POINTS SEL is a serious complication of glucocorticoid excess and should be considered in any patient presenting with new lower limb neurological symptoms associated with hypercortisolism. It is important to distinguish symptomatic SEL from cortisol-induced proximal myopathy by good history and clinical examination. MRI of the spine is the gold standard investigation for making a diagnosis of SEL. Restoration of eucortisolism can lead to resolution of fat accumulation and good neurological outcome.
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Affiliation(s)
- Sajjad Ahmad
- GIM/Diabetes & Endocrinology, University Hospital of Wales, Cardiff, UK
| | | | - Andrew Lansdown
- GIM/Diabetes & Endocrinology, University Hospital of Wales, Cardiff, UK
| | | | - Fiona Smeeton
- GIM/Diabetes & Endocrinology, Neville Hall Hospital, Abergavenny, UK
| | - Steve Davies
- GIM/Diabetes & Endocrinology, University Hospital of Wales, Cardiff, UK
| | - Aled Rees
- GIM/Diabetes & Endocrinology, University Hospital of Wales, Cardiff, UK
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10
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Pak HYV, Lansdown A, Taylor P, Rees DA, Davies JS, Hayhurst C. Acromegaly and the information gap: patient perceptions of the journey from primary to tertiary care. Endocr Connect 2020; 9:971-977. [PMID: 33048063 PMCID: PMC7576652 DOI: 10.1530/ec-20-0335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/10/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Acromegaly is a rare condition and there is often a long path to diagnosis for many patients. We sought to explore patient's perceptions and understanding of acromegaly, to examine the quality of communication and find gaps in the information provided at diagnosis. DESIGN A prospective study using qualitative research methodology and grounded theory. A semi-structured interview was conducted with 18 patients treated for acromegaly in a single tertiary centre and verbatim transcripts were thematically analysed for overarching themes. RESULTS Eighteen patients with acromegaly were interviewed. The mean age of participants was 52 (range 30-72). Four overarching themes emerged; (1) Patients rely on online resources to understand acromegaly in the time between diagnosis and tertiary care clinic; (2) There is not enough support available for patients; (3) Patients have a basic understanding of acromegaly and associated conditions, but the long-term impact is underestimated; and (4) Patients initially felt intimidated by the multidisciplinary team panel, but overall found it useful. CONCLUSION Acromegalic patients have a strong need for information at the point of initial diagnosis, in particular online resources and interaction with other experienced patients. Wider dissemination of patient educational resources into primary and secondary care settings may improve overall patient satisfaction, treatment adherence and subsequent health care provider-patient relationships.
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Affiliation(s)
- Hei Yi Vivian Pak
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
- Cardiff University School of Medicine, Cardiff, UK
| | - Andrew Lansdown
- Centre for Diabetes and Endocrinology, University Hospital of Wales, Cardiff, UK
| | - Peter Taylor
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
- Centre for Diabetes and Endocrinology, University Hospital of Wales, Cardiff, UK
| | - Dafydd Aled Rees
- Centre for Diabetes and Endocrinology, University Hospital of Wales, Cardiff, UK
- Neuroscience and Mental Health Research Institute, Cardiff University, Cardiff, UK
| | - John Stephen Davies
- Centre for Diabetes and Endocrinology, University Hospital of Wales, Cardiff, UK
| | - Caroline Hayhurst
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
- Cardiff University School of Medicine, Cardiff, UK
- Correspondence should be addressed to C Hayhurst:
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11
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Khan DZ, Bandyopadhyay S, Patel V, Schroeder BE, Cabrilo I, Choi D, Cudlip SA, Donnelly N, Dorward NL, Fountain DM, Grieve J, Halliday J, Kolias AG, Mannion RJ, O'Donnell A, Phillips N, Piper RJ, Ramachandran B, Santarius T, Sayal P, Sharma R, Solomou G, Tysome JR, Marcus HJ, Alalade AF, Ahmed S, Al-Barazi S, Al-Mahfoudh R, Bahl A, Bennett D, Bhalla R, Bhatt P, Dow G, Giamouriadis A, Gilkes C, Gnanalingham K, Hanna B, Hayhurst C, Hempenstall J, Hossain-Ibrahim K, Hughes M, Javadpour M, Jenkins A, Kamel M, Habibullah Khan M, Lacy P, Maratos E, Martin A, Mathad N, Mendoza N, Mirza S, Muquit S, Nair R, Nicholson C, Paluzzi A, Paraskevopoulos D, Pathmanaban O, Pollock J, Ram B, Robertson I, Ross P, Shaw S, Shoakazemi A, Sinha S, Stapleton S, Statham P, Stew B, Thomas N, Tsermoulas G, Weir P, Williams A. CSF rhinorrhoea after endonasal intervention to the anterior skull base (CRANIAL): proposal for a prospective multicentre observational cohort study. Br J Neurosurg 2020; 35:408-417. [PMID: 32909855 DOI: 10.1080/02688697.2020.1795622] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The endonasal transsphenoidal approach (TSA) has emerged as the preferred approach in order to treat pituitary adenoma and related sellar pathologies. The recently adopted expanded endonasal approach (EEA) has improved access to the ventral skull base whilst retaining the principles of minimally invasive surgery. Despite the advantages these approaches offer, cerebrospinal fluid (CSF) rhinorrhoea remains a common complication. There is currently a lack of comparative evidence to guide the best choice of skull base reconstruction, resulting in considerable heterogeneity of current practice. This study aims to determine: (1) the scope of the methods of skull base repair; and (2) the corresponding rates of postoperative CSF rhinorrhoea in contemporary neurosurgical practice in the UK and Ireland. METHODS We will adopt a multicentre, prospective, observational cohort design. All neurosurgical units in the UK and Ireland performing the relevant surgeries (TSA and EEA) will be eligible to participate. Eligible cases will be prospectively recruited over 6 months with 6 months of postoperative follow-up. Data points collected will include: demographics, tumour characteristics, operative data), and postoperative outcomes. Primary outcomes include skull base repair technique and CSF rhinorrhoea (biochemically confirmed and/or requiring intervention) rates. Pooled data will be analysed using descriptive statistics. All skull base repair methods used and CSF leak rates for TSA and EEA will be compared against rates listed in the literature. ETHICS AND DISSEMINATION Formal institutional ethical board review was not required owing to the nature of the study - this was confirmed with the Health Research Authority, UK. CONCLUSIONS The need for this multicentre, prospective, observational study is highlighted by the relative paucity of literature and the resultant lack of consensus on the topic. It is hoped that the results will give insight into contemporary practice in the UK and Ireland and will inform future studies.
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Affiliation(s)
- Danyal Z Khan
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospitals Trust, Cambridge, UK
| | | | - Vikesh Patel
- Department of Neurosurgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Ivan Cabrilo
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - David Choi
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Simon A Cudlip
- Department of Neurosurgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Neil Donnelly
- Department of ENT Surgery, University of Cambridge and Cambridge University Hospitals, Cambridge, UK
| | - Neil L Dorward
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Daniel M Fountain
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK
| | - Joan Grieve
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Jane Halliday
- Department of Neurosurgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospitals Trust, Cambridge, UK
| | - Richard J Mannion
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospitals Trust, Cambridge, UK
| | - Alice O'Donnell
- Birmingham Medical School, University of Birmingham, Birmingham, UK
| | - Nick Phillips
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Clinical lead for Cranial Neurosurgery, Getting it Right First Time, UK
| | - Rory J Piper
- Department of Neurosurgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Bhavna Ramachandran
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospitals Trust, Cambridge, UK
| | - Thomas Santarius
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospitals Trust, Cambridge, UK
| | - Parag Sayal
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Rishi Sharma
- Department of ENT Surgery, University of Cambridge and Cambridge University Hospitals, Cambridge, UK
| | | | - James R Tysome
- Department of ENT Surgery, University of Cambridge and Cambridge University Hospitals, Cambridge, UK
| | - Hani J Marcus
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
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Ahmad S, Smeeton F, Hayhurst C, Lansdown A. Pituitary metastasis of prostate cancer presenting as a unilateral third nerve palsy. BMJ Case Rep 2020; 13:13/6/e234550. [PMID: 32532912 DOI: 10.1136/bcr-2020-234550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 60-year-old man presented with right third nerve palsy and headaches. Neuroimaging showed a pituitary lesion. There was evidence of rapid enlargement on interval scans, invasion of the cavernous sinus and displacement of the pituitary stalk. He subsequently developed anterior hypopituitarism. CT thorax, abdomen and pelvis did not show any evidence of malignancy. This was thought to be an aggressive pituitary macroadenoma but histology post-trans-sphenoidal surgery surprisingly showed metastasis from an undiagnosed prostate primary. His prostate specific antigen was raised and MRI pelvis confirmed locally advanced prostate cancer.
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Affiliation(s)
- Sajjad Ahmad
- Diabetes and Endocrinology, University Hospital of Wales, Cardiff, Wales, UK
| | - Fiona Smeeton
- Department of Diabetes and Endocrinology, Nevill Hall Hospital, Abergavenny, Monmouthshire, UK
| | | | - Andrew Lansdown
- Diabetes and Endocrinology, University Hospital of Wales, Cardiff, Wales, UK
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13
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Hayhurst C, Taylor PN, Lansdown AJ, Palaniappan N, Rees DA, Davies JS. Current perspectives on recurrent pituitary adenoma: The role and timing of surgery vs adjuvant treatment. Clin Endocrinol (Oxf) 2020; 92:89-97. [PMID: 31715012 DOI: 10.1111/cen.14127] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 11/02/2019] [Accepted: 11/10/2019] [Indexed: 12/15/2022]
Abstract
The clinical course of pituitary adenoma can be highly variable. Aggressive pituitary tumours may require multimodal therapy with multiple operations. Even standard pituitary adenomas exhibit relatively high long-term recurrence rates and delayed intervention is often required. The indications for revision surgery in the endoscopic era are expanding for both functioning and nonfunctioning tumours, including access to the cavernous sinus and intracranial compartments. Although revision surgery can be challenging, it has been demonstrated to be both safe and effective. The question of the use of early radiotherapy in pituitary adenoma remains controversial. Our increasing understanding of pituitary tumour biology facilitates individualized treatment and surveillance protocols, with early intervention in high-risk adenoma subtypes. In this review, we discuss the treatment options for recurring pituitary tumours and focus on the role of revision surgery.
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Affiliation(s)
- Caroline Hayhurst
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Peter N Taylor
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
- Centre for Diabetes and Endocrinology, University Hospital of Wales, Cardiff, UK
| | - Andrew J Lansdown
- Centre for Diabetes and Endocrinology, University Hospital of Wales, Cardiff, UK
| | | | - Dafydd Aled Rees
- Neuroscience and Mental Health Research Institute, Cardiff University, Cardiff, UK
| | - John Stephen Davies
- Centre for Diabetes and Endocrinology, University Hospital of Wales, Cardiff, UK
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Ved R, Taylor P, Stewart P, Foulkes J, Fields‐Jewell W, Davies S, Hayhurst C. Vitamin D deficiency is endemic in neurosurgical patients and is associated with a longer length of inpatient stay. Endocrinol Diabetes Metab 2020; 3:e00097. [PMID: 31922024 PMCID: PMC6947696 DOI: 10.1002/edm2.97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/30/2019] [Accepted: 10/02/2019] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Vitamin D deficiency is common in spinal surgery and critical care. Hypovitaminosis D may impact on outcomes in cranial neurosurgical care and play roles in underlying disease processes. METHODS A prospective observational cohort study was performed. All emergency cranial neurosurgical ward admissions from 1st January to 10th May 2017 were screened for inclusion (n = 406). Patients already receiving vitamin D supplementation, spinal patients and elective admissions were excluded. Admission vitamin D levels were checked for all remaining patients (n = 95). Patients with vitamin D <30 nmol/L were defined as "deficient" and those 30-50 nmol/L as "inadequate." All patients with levels <50 nmol/L were replaced, as per local guidelines. Descriptive analyses of the cohorts were undertaken, with multivariate regression used to assess the effect of vitamin D on length of stay, inpatient morbidity and mortality. RESULTS The median age of participants was 61 years (n = 95; 57% male, 43% female). The median vitamin D level was 23 nmol/L (deficient). 84% (n = 80) of patients had low vitamin D levels, with 61% (n = 58) classed as deficient (<30 nmol/L). Vitamin D deficiency rates were similar in those aged below 65 years (86%; n = 38/44) and those above 65 years (82%; n = 42/51). Deficient vitamin D level was associated with longer hospital stay (P = .03), and this relationship persisted after adjusting for potential confounders such as age, sex and preadmission Charlson co-morbidity index. No statistically significant association was seen with vitamin D status and inpatient morbidity or mortality. CONCLUSIONS Vitamin D deficiency is common in cranial neurosurgical patients, even in predefined low-risk groups (age <65). Lower vitamin D level was associated with longer length of stay. This study supports the need for: (a) further investigation into the roles of vitamin D in neurosurgical pathologies and management and (b) an appropriately powered, randomised investigation into the impact of vitamin D status upon neurosurgical diagnoses and complications.
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Affiliation(s)
- Ronak Ved
- University Hospital of WalesCardiffUK
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15
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Abstract
A 69-year-old woman presented with an 8-month history of diplopia and examination findings consistent with a right third-nerve palsy. Head MRI identified the presence of a 5.8 mm, nodular, isointense lesion in the suprasellar cistern, which demonstrated enhancement with gadolinium contrast. The lesion did not show any evidence of growth over a 3-month follow-up period. These MRI findings, alongside the clinical features, suggest oculomotor nerve schwannoma. Oculomotor schwannomas are a rare cause of third-nerve palsy. The presenting features and management options for oculomotor schwannomas are discussed to provide a framework for the diagnosis and management of these patients.
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Affiliation(s)
- Emily Bentley
- Department of Neurosurgery, Cardiff and Vale University Health Board, Cardiff, UK
| | - Ronak Ved
- Department of Neurosurgery, Cardiff and Vale University Health Board, Cardiff, UK
| | - Caroline Hayhurst
- Department of Neurosurgery, Cardiff and Vale University Health Board, Cardiff, UK
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16
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Abstract
Introduction: A retrospective study over a three-year period at University Hospital of Wales (UHW) of the incidence of atypical cranial grade II meningioma both pre and post 2016 revision of The World Health Organisation (WHO) classification of tumours of the central nervous system.Subjects: All available histology from January 2015 to December 2017 of patients with cranial meningiomas.Method: Institutional online reporting system Welsh Clinical Portal to identify patients and view histology reports.Results: Overall 164 patient histology results were analysed (median age 59, age range 23-82, 74% females). There were 55 patients in 2015: 69.1% grade I, 29.1% grade II and 1.8% grade III. There were 109 patients in 2016/17; 68.8% grade I, 29.4% grade II, 1.8% grade III.Discussion: There is significant variability in the reported incidence of grade II meningioma, likely due to variation in local interpretation of diagnostic criteria. Neuropathologists at our institution have reported brain invasion as grade II prior to 2016. This was due to compelling published evidence that brain invasive meningiomas have recurrence and mortality rates similar to that of grade II meningioma as defined using other criteria. The new 2016 WHO criteria now recognise this specifically. As other institutions adapt to the amended 2016 guidelines we anticipate that there will be a greater consensus in line with our incidence rates of grade II meningioma.
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Affiliation(s)
- Lindsey S Bulleid
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Zoe James
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Alistair Lammie
- Department of Pathology, University Hospital of Wales, Cardiff, UK
| | - Caroline Hayhurst
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Paul A Leach
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
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Affiliation(s)
- Zoe James
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Paul A Leach
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Caroline Hayhurst
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
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18
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Makwana M, Taylor PN, Stew BT, Shone G, Hayhurst C. Smoking and Obesity are Risk Factors for Thirty-Day Readmissions Following Skull Base Surgery. J Neurol Surg B Skull Base 2019; 81:206-212. [PMID: 32206541 DOI: 10.1055/s-0039-1684034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 02/25/2019] [Indexed: 10/27/2022] Open
Abstract
Background Thirty-day readmission has become a significant health care metric reflecting the quality of care and on the cost of service delivery. There is little data on the impact of complications following skull base surgery (SBS) on emergency readmission. Identifying modifiable risk factors for readmission may improve care and reduce cost. Design The study was designed as a single-center retrospective cohort study. Methods Records for a consecutive series of 165 patients who underwent open or endoscopic SBS by a single surgeon reviewed. Patients with pituitary adenoma were excluded. The diagnosis, procedure, complications, length of stay (LOS), body mass index (BMI), and smoking status were recorded. Readmission to the neurosurgical department or regional hospitals was either noted prospectively or the patient contacted. Cause and length of readmission was documented. Results Of the 165 cases, 14 (8.5%) were readmitted within 30 days. Causes for readmission included cerebrospinal fluid (CSF) leak in 5/14 or 35.7% (overall rate for readmission for this complication in the series is 3.1%), infection in 4/14 (28.6%), hyponatraemia in 2/14 (14.3%), vascular: sinus thrombosis in 1/14 (7.1%), seizures in 1/14 (7.1%), and epistaxis in 1/14 (7.1%). Initial and readmission LOS was 6 and 14 days, respectively. BMI was higher in those readmitted within 30 days (33.2 kg/m 2 ) versus no readmission (27.1 kg/m 2 ). In addition, of those readmitted within 30 days, 35.7% were smokers compared with 20.8% in those not readmitted. Conclusion In this series, smoking and raised BMI may be indicators for within 30-day readmission and complications in this population, raising the question of risk factor modification prior to elective intervention.
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Affiliation(s)
- Milan Makwana
- Department of Neurosurgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Peter N Taylor
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Benjamin T Stew
- Department of Otolaryngology, Head and Neck Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Geoffrey Shone
- Department of Otolaryngology, Head and Neck Surgery, University Hospital of Wales, Cardiff, United Kingdom
| | - Caroline Hayhurst
- Department of Neurosurgery, University Hospital of Wales, Cardiff, United Kingdom
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James Z, Leach P, Hayhurst C. P47 30 day readmission is not an accurate measure of morbidity in cranial meningioma surgery. J Neurol Neurosurg Psychiatry 2019. [DOI: 10.1136/jnnp-2019-abn.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objectives30 day readmission rate is a widely adopted marker of quality and performance of acute care, but validity is not well demonstrated. We analysed readmission data following cranial meningioma surgery to assess risk factors for readmission.DesignRetrospective cohort study.SubjectsAll adult patients who underwent cranial meningioma resection from January 2015 to December 2017 in a single institution.MethodsUsing Welsh Clinical Portal electronic data to identify readmission within and beyond 30 days to both the index hospital and regional hospitals. Causes of readmission were recorded.Results160 patients were included (76% female, median age 58). 28 cases were emergency admissions, median length of initial admission 7 days. 26% had seizures at presentation. Total readmission rate was 13.5% (median age 54.5, pre-operative seizure rate 40.1%, median length of readmission 9 days). 13 (59%) patients presented within 30 days and 9 (41%)>30 days. Readmission causes were seizure, neurological deficit, thromboembolic, infection, CSF, bleeding and social. Causes after 30 days were the same except social or neurological deficit.ConclusionsReadmission rates are not associated with age, admission route or initial length of stay. Those who have had seizures are more likely to be readmitted. 41% of readmissions presented outside of the 30 day post-operative time. 30 day readmission rates may not be the most suitable method to demonstrate neurosurgical unit performance in meningioma surgery.
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Stewart PJ, Martin J, Thomas J, Hayhurst C. P55 The neurosurgical physician: a new role in the UK. J Neurol Neurosurg Psychiatry 2019. [DOI: 10.1136/jnnp-2019-abn.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
ObjectivesWith reduction in numbers of junior doctors and strict deanery requirements for training opportunities, the provision of ward cover and continuity has consistently fallen. Various methods of addressing this have been implemented in the UK, including increased nurse practitioners and physician associates. We introduced a new position of GP with a specialist neuroscience interest in line with the North American model of hospitalist and review the impact on patients and trainees.DesignQualitative descriptive study.Subjects14 core and speciality trainees.MethodsRetrospective review of the impact of a permanent neurosurgical physician on ward care and provision of training with a qualitative study of trainee experience. Saturation was reached at 14 interviews.ResultsA neurosurgical physician role was instituted in 2013, enabling a formal training rota to fulfil deanery requirements for core training and provide continuity of care at senior medical level, reducing medical ward consults to zero, improved communication with relatives and reduced the need for ST ward rounds. Qualitative assessment revealed a senior medical presence aided trainees own knowledge, resulted in better rapport and communication with patients and improved patient care through knowledge of best medical practice guidelines.ConclusionsThe addition of the neurosurgical physician role has positively impacted on the quality of patient care and junior doctor training. Senior medical care is provided with continuity, in contrast to other models.
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Roberts M, Hayhurst C, Shires J, Northmore T. TM1-2 Diffuse low grade glioma after the 2016 WHO update, seizure characteristics, imaging correlates and outcomes. J Neurol Neurosurg Psychiatry 2019. [DOI: 10.1136/jnnp-2019-abn.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
ObjectivesSeizures are a common presenting symptom in patients with low grade glioma (LGG). Exact mechanisms of epileptogenesis are unknown and the influence of radiological and histological characteristics are not well studied, particularly after the 2016 WHO reclassification of gliomas. We aimed to define predictors of seizure development and outcome in patients with LGG.DesignRetrospective single institution case series.Subjects63 patients who underwent resection of supratentorial LGG in a single institution, 45 presented with seizures.MethodsRetrospective analysis of patient records to assess seizure outcome and other demographics including radiological variables, tumour characteristics, type of surgery and histology based on the 2016 WHO update.ResultsAfter surgery, 33 patients (73%) who presented with seizures were Engel class I at median follow up of 43 months. Complete and near total resection were associated with improved Engel class compared to subtotal resection. Awake craniotomy gave improved seizure outcomes compared to under general anaesthesia (84% vs 65%). Molecular genetics did not predict seizure outcome. Updated histology did not predict seizures at diagnosis, only tumour heterogeneousity on initial MRI (p=0.043). Tumour volume at presentation impacted EOR but not seizure outcome.ConclusionsSeizure outcome is directly related to EOR. Tumour histology based on molecular genetics did not predict seizure development or outcome. Use of awake craniotomy results in greater EOR and improved Engel class.
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Galloway L, Hayhurst C. P44 Is restoration of pituitary function a realistic goal in endoscopic pituitary surgery? J Neurol Neurosurg Psychiatry 2019. [DOI: 10.1136/jnnp-2019-abn.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
ObjectivesThe ability to restore pituitary function after endoscopic transsphenoidal surgery (ETSS) in pituitary tumours causing hypopituitarism remains unclear. This study analyses patients that required steroid replacement therapy prior to ETSS, and reviews endocrine function postoperatively.MethodsA prospectively held pituitary database was retrospectively analysed from May 2011 – July 2017 at a tertiary university hospital. Patients requiring steroids for hypopituitarism pre-operatively were included. Patient demographic data, tumour characteristics, and tumour hormonal profile were recorded.ResultsFrom a database of 156 patients, 28 (18%) were hypoadrenal pre-operatively and were included in the study. All patients underwent ETSS by a single neurosurgeon. The median age of patients was 56 years (range 17–81), whilst median follow-up was 48 months (range 6–78). 20 male patients and 8 female patients were included. All patients were established on steroid therapy preoperatively with either hydrocortisone (26 patients) or prednisolone (2 patients). 5 (18%) patients were able to stop steroid replacement postoperatively. The median time to cessation of steroid therapy was 4 months (range 2–16 months).ConclusionsRestoration of pituitary function following ETSS surgery was only successful in a small number of patients despite meticulous gland preservation. Our results suggest that restoration of function in all patients undergoing ETSS is an unrealistic goal and patients should be counselled accordingly.
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Roberts M, Northmore T, Shires J, Taylor P, Hayhurst C. Diffuse low grade glioma after the 2016 WHO update, seizure characteristics, imaging correlates and outcomes. Clin Neurol Neurosurg 2018; 175:9-15. [DOI: 10.1016/j.clineuro.2018.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 09/13/2018] [Accepted: 10/01/2018] [Indexed: 10/28/2022]
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Bhatt H, Zilani G, Hayhurst C. Orbitocerebral mucormycosis and intracranial haemorrhage: a role for caution with steroids in suspected giant cell arteritis. BMJ Case Rep 2018; 2018:bcr-2017-224086. [PMID: 30012677 DOI: 10.1136/bcr-2017-224086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 75-year-old man with type 2 diabetes mellitus presented with complete loss of vision in his right eye and severe headaches for the past 24 hours. He had been treated for suspected giant cell arteritis (GCA) with high-dose corticosteroids which were being tapered to stop after an inconclusive right temporal artery biopsy and an erythrocyte sedimentation rate (ESR) value of 8. His current acute presentation, however, raised further concern for partially treated GCA and precipitated treatment with pulsed methylprednisolone. The patient, taking metformin, developed diabetic ketoacidosis and was transferred to the intensive care unit where a swollen, painful right eye with chemosis and complete ophthalmoplegia was subsequently revealed to be secondary to cavernous sinus thrombosis. Rhino-orbital skin necrosis with positive samples for the organism Rhizopus on eventual orbital exenteration revealed angioinvasive fungal infection, mucormycosis, to be the cause. We discuss here the lessons learnt, and how best to treat a susceptible cohort within our ageing western population.
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Affiliation(s)
- Harsh Bhatt
- Cardiff University, Cardiff, UK.,Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Gulam Zilani
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Caroline Hayhurst
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
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Abstract
BACKGROUND Xanthogranulomas are inflammatory masses most commonly found at peripheral sites such as the skin. Sellar and parasellar xanthogranulomas are rare and present a diagnostic challenge as they are difficult to differentiate from other sellar lesions such as craniopharyngiomas and Rathke's cleft cysts pre-operatively. Their radiological imaging features are yet to be clearly defined, and clinical outcomes after surgery are also uncertain. This study reviews clinical presentation, radiological appearances, and clinical outcomes in a cohort of patients with pituitary xanthogranulomas. METHODS A prospectively maintained pituitary surgery database was screened for histologically confirmed pituitary xanthogranulomas between May 2011-December 2016. Retrospective case note assessments were then performed by three independent reviewers. Patient demographics, clinical presentations, imaging, and clinical outcomes were analysed. RESULTS During the study period 295 endoscopic endonasal pituitary surgeries were performed. Six patients had confirmed pituitary xanthogranulomas (2%). Patients most commonly presented with visual field deficits and/or endocrine dysfunction. Common imaging features included: a cystic consistency, hyperintensity on T1-weighted MR images, and contrast enhancement either peripherally (n = 3) or homogenously (n = 3). The most common pre-operative endocrine deficits were hyperprolactinaemia and hypoadrenalism (at least one of which was identified in 4/6 patients; 66%). Thirty-three percent (2/6) of patients presented with diabetes insipidus. The most common post-operative endocrinological deficits were adrenocortical dysfunction (66%) and gonadotropin deficiency (66%). Visual assessments normalised in all six patients post-operatively. Gross total resection was achieved in all patients, and at median follow up of 33.5 months there were no cases of tumour recurrence. CONCLUSIONS The prevalence of pituitary xanthogranulomas in our series is higher than that suggested in the literature. Surgery restored normal vision to all cases, however four patients (67%) required long-term hormonal replacement post-operatively. Imaging features such peripheral rim enhancement, a suprasellar tumour epicentre, and the absence of both calcification or cavernous sinus invasion were identified as potential indicators that together should alert clinicians to the possibility of pituitary xanthogranuloma when assessing patients with cystic sellar and parasellar tumours.
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Affiliation(s)
- R Ved
- B4 Office, Department of Neurosurgery, University Hospital of Wales, Cardiff, CF 14 4XW, UK.
| | - N Logier
- B4 Office, Department of Neurosurgery, University Hospital of Wales, Cardiff, CF 14 4XW, UK
| | - P Leach
- B4 Office, Department of Neurosurgery, University Hospital of Wales, Cardiff, CF 14 4XW, UK
| | - J S Davies
- Department of Endocrinology, University Hospital of Wales, Cardiff, CF 14 4XW, UK
| | - C Hayhurst
- B4 Office, Department of Neurosurgery, University Hospital of Wales, Cardiff, CF 14 4XW, UK
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Galloway L, Palaniappan N, Shone G, Hayhurst C. Trigeminal neuropathy in vestibular schwannoma: a treatment algorithm to avoid long-term morbidity. Acta Neurochir (Wien) 2018; 160:681-688. [PMID: 29344779 DOI: 10.1007/s00701-017-3452-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 12/22/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Trigeminal neuropathy (TGN) can occur as a presenting feature of vestibular schwannoma (VS) or as an adverse effect of radiosurgery. This study was designed to evaluate a treatment algorithm for presenting symptoms of TGN in patients with VS, and a new radiosurgery dosimetric tolerance to avoid TGN after treatment. Outcome was measured after microsurgery (MS), stereotactic radiosurgery (SRS), hypofractionated stereotactic radiotherapy (HSRT), and fractionated radiotherapy (FRT). METHODS A prospectively held VS database was retrospectively analysed from 2011 to 2016 at a tertiary university hospital. All patients who underwent MS from 2011 and all patients who underwent radiotherapy (SRS, HSRT, FRT) from 2015 were studied. Patients on surveillance and neurofibromatosis type 2 patients were not included. Patient demographic data, tumour characteristics, presenting symptoms, and post-treatment outcomes were analysed. RESULTS Eighty-eight patients were included in the study (43 microsurgery, 45 radiotherapy). Twenty-seven (31%) patients presented with TGN symptoms. The median age of patients included was 56.5 (range 6-72 years), with a median follow-up for MS and SRS of 38 and 20 months, respectively (range 10-80 months). All 27 patients with TGN were offered MS as per protocol. Three patients declined, or were not fit for surgery, and received FRT. Complete resolution of TGN symptoms was achieved in all 24 patients who underwent MS and 33% (1/3) of patients with FRT. Eleven patients experienced transient post-operative complications (pseudomeningocele (6), meningitis (3), venous sinus thrombosis, cerebellar haemorrhagic contusion, and posterior fossa haematoma). Of the 45 patients in the radiotherapy cohort, 36 were suitable for SRS, of which 30 patients who met the dose-volume constraints for trigeminal nerve underwent single-fraction SRS and 6 patients who did not meet the constraints received HSRT. Nine patients (20%) received FRT including three patients with pre-treatment TGN. None of the patients developed new TGN symptoms following SRS or HSRT. CONCLUSIONS Our algorithm to select the optimal treatment modality appears to achieve comparable or better long-term outcome. Microsurgical resection in our cohort resulted in complete resolution of symptoms in all patients. None of our SRS- or HSRT-treated patients developed TGN during the follow-up period. The adherence to strict trigeminal nerve dose-volume constraints for SRS remains critical to minimise TGN post treatment. Fractionated radiotherapy is an alternative for patients who refuse surgery or those who are unfit for surgery.
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Affiliation(s)
- Luke Galloway
- Cardiff Skull Base Centre, University Hospital of Wales, Cardiff, Wales, UK.
- Department of Neurosurgery, University Hospital of Wales, Cardiff, Wales, CF14 4XW, UK.
| | - Nachi Palaniappan
- Cardiff Skull Base Centre, University Hospital of Wales, Cardiff, Wales, UK
| | - Geoffrey Shone
- Cardiff Skull Base Centre, University Hospital of Wales, Cardiff, Wales, UK
| | - Caroline Hayhurst
- Cardiff Skull Base Centre, University Hospital of Wales, Cardiff, Wales, UK
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Asad S, Shone G, Morris D, Hayhurst C, Johnston A. PO004 Painless and progressive think compressive. J Neurol Neurosurg Psychiatry 2017. [DOI: 10.1136/jnnp-2017-abn.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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28
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Taylor P, Dehbozorgi S, Tabasum A, Scholz A, Bhatt H, Stewart P, Kumar P, Draman MS, Watt A, Rees A, Hayhurst C, Davies S. Cerebral salt wasting following traumatic brain injury. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM160142. [PMID: 28458890 PMCID: PMC5404462 DOI: 10.1530/edm-16-0142] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 03/02/2017] [Indexed: 11/29/2022] Open
Abstract
Summary Hyponatraemia is the most commonly encountered electrolyte disturbance in neurological high dependency and intensive care units. Cerebral salt wasting (CSW) is the most elusive and challenging of the causes of hyponatraemia, and it is vital to distinguish it from the more familiar syndrome of inappropriate antidiuretic hormone (SIADH). Managing CSW requires correction of the intravascular volume depletion and hyponatraemia, as well as mitigation of on-going substantial sodium losses. Herein we describe a challenging case of CSW requiring large doses of hypertonic saline and the subsequent substantial benefit with the addition of fludrocortisone. Learning points:
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Affiliation(s)
- Peter Taylor
- Department of Diabetes and Endocrinology, University Hospital of Wales, Heath Park, CardiffUK.,Thyroid Research Group, Division of Infection and Immunity, School of Medicine, Cardiff University, Heath Park, CardiffUK
| | - Sasan Dehbozorgi
- Department of Neurosurgery, University Hospital of Wales, Heath Park, CardiffUK
| | - Arshiya Tabasum
- Department of Diabetes and Endocrinology, University Hospital of Wales, Heath Park, CardiffUK
| | - Anna Scholz
- Department of Diabetes and Endocrinology, University Hospital of Wales, Heath Park, CardiffUK
| | - Harsh Bhatt
- Department of Neurosurgery, University Hospital of Wales, Heath Park, CardiffUK
| | - Philippa Stewart
- Department of Neurosurgery, University Hospital of Wales, Heath Park, CardiffUK
| | - Pranav Kumar
- Department of Diabetes and Endocrinology, University Hospital of Wales, Heath Park, CardiffUK
| | - Mohd S Draman
- Department of Diabetes and Endocrinology, University Hospital of Wales, Heath Park, CardiffUK.,Thyroid Research Group, Division of Infection and Immunity, School of Medicine, Cardiff University, Heath Park, CardiffUK
| | - Alastair Watt
- Department of Diabetes and Endocrinology, North Devon District Hospital, BarnstapleUK
| | - Aled Rees
- Department of Diabetes and Endocrinology, University Hospital of Wales, Heath Park, CardiffUK.,Institute of Neuroscience and Mental Health Research Institute, School of Medicine, Cardiff University, CardiffUK
| | - Caroline Hayhurst
- Department of Neurosurgery, University Hospital of Wales, Heath Park, CardiffUK
| | - Stephen Davies
- Department of Diabetes and Endocrinology, University Hospital of Wales, Heath Park, CardiffUK
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Hayhurst C, Sughrue ME, Gore PA, Bonney PA, Burks JD, Teo C. Results with Expanded Endonasal Resection of Skull Base Meningiomas Technical Nuances and Approach Selection Based on an Early Experience. Turk Neurosurg 2017; 26:662-70. [PMID: 27337239 DOI: 10.5137/1019-5149.jtn.16105-15.3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AIM Reconstruction technique advances have created renewed enthusiasm for the expanded endonasal approach (EEA). However, as with any new technique, early experiences inevitably lead to more selective use of these techniques. We reviewed our experience of the expanded endonasal endoscopic approach for skull base meningiomas and place it in context of the literature. MATERIAL AND METHODS We performed retrospective review of all endonasal cases performed at our center for histologically proven meningioma. Tumor locations in 26 patients included the olfactory groove (n=9), tuberculum sellae (n=7), optic nerve sheath (n=1), planum sphenoidale (n=2), clival (n=1) petroclival (n=3), cavernous sinus (n=2) and extensive pan-basal meningioma (n=1). RESULTS The median follow-up was 38.6 months. Excluding 3 patients with tumors found incidentally, pre-operative symptoms improved in 14 of 23 (61%), were the same in 8 of 23 (35%) and worsened in one of 23 patients (4%) at time of last follow-up. Of all 26 patients, 16 (62%) had complete macroscopic resection of their tumor, 5 (19%) underwent at least 90% resection, and 5 (19%) underwent subtotal resection. There were two neurological complications and one cerebrospinal fluid leak. CONCLUSION This study presents outcomes of patients treated with endonasal endoscopic meningioma surgery. We believe that very low rates of morbidity can be achieved in carefully selected patients, thus avoiding brain manipulation.
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Affiliation(s)
- Caroline Hayhurst
- University Hospital of Wales, Department of Neurosurgery, Cardiff, United Kingdom
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Abstract
Supratentorial diffuse intrinsic low-grade gliomas represent a distinct but heterogenous group of tumours, with the propensity to grow and to differentiate into malignant tumours. They have been historically viewed in the 'benign' spectrum of intrinsic brain tumours, so a watch-and-wait policy was often adopted. With recent advances in our understanding of the natural history of these tumours, combined with advances in surgical technique, an aggressive approach is now recommended. Increasing quality evidence of the impact of tumour resection and multicentre trials of adjuvant radiotherapy and chemotherapy have led to a new algorithm for low-grade glioma management. This review aims to outline the emerging evidence that has shifted neuro-oncology practice.
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Affiliation(s)
- Caroline Hayhurst
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
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Affiliation(s)
| | - Caroline Hayhurst
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
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32
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Peel S, Bhatia S, Eggbeer D, Morris DS, Hayhurst C. Evolution of design considerations in complex craniofacial reconstruction using patient-specific implants. Proc Inst Mech Eng H 2016; 231:509-524. [DOI: 10.1177/0954411916681346] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Previously published evidence has established major clinical benefits from using computer-aided design, computer-aided manufacturing, and additive manufacturing to produce patient-specific devices. These include cutting guides, drilling guides, positioning guides, and implants. However, custom devices produced using these methods are still not in routine use, particularly by the UK National Health Service. Oft-cited reasons for this slow uptake include the following: a higher up-front cost than conventionally fabricated devices, material-choice uncertainty, and a lack of long-term follow-up due to their relatively recent introduction. This article identifies a further gap in current knowledge – that of design rules, or key specification considerations for complex computer-aided design/computer-aided manufacturing/additive manufacturing devices. This research begins to address the gap by combining a detailed review of the literature with first-hand experience of interdisciplinary collaboration on five craniofacial patient case studies. In each patient case, bony lesions in the orbito-temporal region were segmented, excised, and reconstructed in the virtual environment. Three cases translated these digital plans into theatre via polymer surgical guides. Four cases utilised additive manufacturing to fabricate titanium implants. One implant was machined from polyether ether ketone. From the literature, articles with relevant abstracts were analysed to extract design considerations. In all, 19 frequently recurring design considerations were extracted from previous publications. Nine new design considerations were extracted from the case studies – on the basis of subjective clinical evaluation. These were synthesised to produce a design considerations framework to assist clinicians with prescribing and design engineers with modelling. Promising avenues for further research are proposed.
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Affiliation(s)
- Sean Peel
- PDR – International Centre for Design & Research, Cardiff Metropolitan University, Cardiff, UK
| | - Satyajeet Bhatia
- University Hospital of Wales, Cardiff & Vale University Health Board, Cardiff, UK
| | - Dominic Eggbeer
- PDR – International Centre for Design & Research, Cardiff Metropolitan University, Cardiff, UK
| | - Daniel S Morris
- University Hospital of Wales, Cardiff & Vale University Health Board, Cardiff, UK
| | - Caroline Hayhurst
- University Hospital of Wales, Cardiff & Vale University Health Board, Cardiff, UK
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Othman H, Evans S, Morris D, Bhatia S, Hayhurst C. 3D Printed Models for Surgical Planning and Reconstructive Implant Design in Sphenoorbital Tumor Surgery. Skull Base Surg 2016. [DOI: 10.1055/s-0036-1592451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Stewart K, Al-Rikabi A, Bhatia S, Morris D, Hayhurst C. Periorbital Dermoid: A Retrospective Review. Skull Base Surg 2016. [DOI: 10.1055/s-0036-1592450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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35
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Fishpool SJC, Amato-Watkins A, Hayhurst C. Free middle turbinate mucosal graft reconstruction after primary endoscopic endonasal pituitary surgery. Eur Arch Otorhinolaryngol 2016; 274:837-844. [DOI: 10.1007/s00405-016-4287-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 08/26/2016] [Indexed: 10/21/2022]
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36
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Stovell MG, Zakaria R, Ellenbogen JR, Gallagher MJ, Jenkinson MD, Hayhurst C, Mallucci CL. Long-term follow-up of endoscopic third ventriculostomy performed in the pediatric population. J Neurosurg Pediatr 2016; 17:734-8. [PMID: 26870897 DOI: 10.3171/2015.11.peds15212] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Endoscopic third ventriculostomy (ETV) is an effective treatment for obstructive hydrocephalus and avoids the risk for foreign-body infection associated with ventriculoperitoneal (VP) shunts. The short-term failure rate of ETV strongly depends on the indications for its use but is generally thought to be lower in the long term than that of VP shunts. However, few studies are available with long-term follow-up data of ETV for hydrocephalus in children. The authors reviewed the long-term success of ETV at their institution to investigate the rate of any late failures of this procedure. METHODS Between April 1998 and June 2006, 113 children (including neonates and children up to 16 years old) had primary or secondary ETV for different causes of hydrocephalus. The patients' medical records and the authors' electronic operation database were reviewed for evidence of additional surgery (i.e., repeat ETV or VP shunt insertion). These records were checked at both the pediatric and adult neurosurgical hospitals for those patients who had their care transferred to adult services. RESULTS The median length of follow-up was 8.25 years (range 1 month to 16 years). Long-term follow-up data for 96 patients were available, 47 (49%) of whom had additional ETV or VP shunt insertion for ETV failure. Twenty patients (21%) had a second procedure within 1 month, 17 patients (18%) between 1 and 12 months, 7 patients (7%) between 1 and 5 years, and 3 patients (3%) between 5 and 8 years. CONCLUSIONS In the authors' series, ETV had an initial early failure rate for the treatment of pediatric hydrocephalus as reported previously, and this rate significantly depended on patient age and hydrocephalus etiology. Once stabilized and effective, ETV appeared to be durable but not guaranteed, and some late decline in effectiveness was observed, with some ETV failures occurring many years later. Thus, successful ETV in children cannot be guaranteed for life, and some form of follow-up is recommended long term into adulthood.
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Affiliation(s)
| | - Rasheed Zakaria
- Department of Neurosurgery, The Walton Centre for Neurology and Neurosurgery, Liverpool; and
| | - Jonathan R Ellenbogen
- Department of Neurosurgery, Royal Liverpool Children's Hospital;,Department of Neurosurgery, The Walton Centre for Neurology and Neurosurgery, Liverpool; and
| | - Mathew J Gallagher
- Department of Neurosurgery, The Walton Centre for Neurology and Neurosurgery, Liverpool; and
| | - Michael D Jenkinson
- Department of Neurosurgery, The Walton Centre for Neurology and Neurosurgery, Liverpool; and
| | - Caroline Hayhurst
- Department of Neurosurgery, University Hospital Wales, Heath Park, Cardiff, United Kingdom
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Amato-Watkins AC, Lammie A, Hayhurst C, Leach P. Pineal parenchymal tumours of intermediate differentiation - An evidence-based review of a new pathological entity. Br J Neurosurg 2015; 30:11-5. [PMID: 26571134 DOI: 10.3109/02688697.2015.1096912] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Pineal region lesions are uncommon, and pineal parenchymal tumours (PPT) account for 20-30% of tumours in this area of which pineocytomas (PCs) and pineoblastomas (PBs) are more prevalent. In 2007, the World Health Organisation (WHO) reclassified PPT from two subgroups (PC and PB) into four, including pineal parenchymal tumours of intermediate differentiation (PPTID). PPTID have been further divided into low- and high-grade lesions (WHO II and III), but due to their rarity have proven difficult lesions to diagnose and a paucity of literature means their optimal treatment options are a challenge to define. This article is a review of the literature of PPTID highlighting diagnostic criteria, a discussion on the role of surgery and radiotherapy, including treatment paradigms and reported outcomes for these problematic neoplasms.
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Affiliation(s)
| | - Alistair Lammie
- b Department of Neuropathology , University Hospital of Wales , Cardiff , UK.,c Department of Pathology , University Hospital of Wales , Cardiff , UK
| | - Caroline Hayhurst
- a Department of Neurosurgery , University Hospital of Wales , Cardiff , UK
| | - Paul Leach
- a Department of Neurosurgery , University Hospital of Wales , Cardiff , UK
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Glasbey J, Hayhurst C. Primary resection of malignant intracranial neoplasms conveys a functional benefit in a select patient cohort. Int J Surg 2015. [DOI: 10.1016/j.ijsu.2015.07.344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Bondugulapati LNR, Campbell C, Chowdhury SR, Goetz P, Davies JS, Rees DA, Hayhurst C. Use of day 1 early morning cortisol to predict the need for glucocorticoid replacement after pituitary surgery. Br J Neurosurg 2015; 30:76-9. [PMID: 26313503 DOI: 10.3109/02688697.2015.1071325] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Assessment of adrenal reserve in patients who have undergone pituitary surgery is crucial. However, there is no clear consensus with regards to the type and timing of the test that should be used in the immediate post-operative period. Recently, there has been increased interest in measuring post-operative cortisol levels. We present our data utilising day 1 post-operative early morning cortisol as a tool to assess adrenal reserve in steroid-naive patients. METHODS A retrospective analysis of endoscopic pituitary surgery undertaken over a 2-year period. 82 patients underwent 84 surgeries in total. Patients who were already on glucocorticoids pre-operatively and patients with Cushing's disease, pituitary apoplexy and those without follow-up data were excluded, leaving a study group of 44 patients with 45 operations. A 9am day 1 post-operative cortisol value of > 400 nmol/L was taken as an indicator of adequate adrenal reserve. All the patients were reassessed at 6 weeks with a standard short synacthen test (SST) using 250 micrograms of intravenous synacthen. RESULTS 22 out of 45 patients had a cortisol value of > 400 nmol/L on day 1 post-operatively and were discharged without glucocorticoid supplementation. Of these, only 2 patients subsequently failed the SST when reassessed at 6-8 weeks. The remaining 23 patients had a cortisol value of < 400 nmol/L on day 1 post-operatively and were discharged on hydrocortisone 10 mg twice daily. At 6-8 weeks, nine continued to show suboptimal stimulated cortisol levels whereas the remaining fourteen patients showed adequate adrenal reserve. The 9 am cortisol value had high specificity (81.8%) and positive predictive value (90.9%) for integrity of the HPA axis. Sensitivity was 58.8% and negative predictive value was 39.1%. CONCLUSION A day 1 post-operative early morning cortisol is a useful tool to predict adrenal reserve post-pituitary surgery, enabling clinicians to avoid unnecessary blanket glucocorticoid replacement.
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Affiliation(s)
| | - Christopher Campbell
- b Institute of Molecular and Experimental Medicine, Cardiff University , Cardiff , UK
| | | | - Pablo Goetz
- c Department of Neurosurgery , University Hospital of Wales , Cardiff , UK
| | - J Stephen Davies
- a Department of Endocrinology , University Hospital of Wales , Cardiff , UK
| | - D Aled Rees
- a Department of Endocrinology , University Hospital of Wales , Cardiff , UK.,b Institute of Molecular and Experimental Medicine, Cardiff University , Cardiff , UK
| | - Caroline Hayhurst
- c Department of Neurosurgery , University Hospital of Wales , Cardiff , UK
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40
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Zilani G, Yee C, Goetz P, Hayhurst C. Visual Outcomes for Giant Pituitary Adenomas. Skull Base Surg 2015. [DOI: 10.1055/s-0035-1546566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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41
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Evans S, Lane C, Bhatia S, Martin J, Morris D, Hayhurst C. Premoulded Custom Implants for Spheno-Orbital Reconstruction: A Novel Multidisciplinary Approach. Skull Base Surg 2015. [DOI: 10.1055/s-0035-1546609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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42
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Larjani S, Monsalves E, Pebdani H, Krischek B, Gentili F, Cusimano M, Laperriere N, Hayhurst C, Zadeh G. Identifying predictors of early growth response and adverse radiation effects of vestibular schwannomas to radiosurgery. PLoS One 2014; 9:e110823. [PMID: 25337892 PMCID: PMC4206429 DOI: 10.1371/journal.pone.0110823] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 09/23/2014] [Indexed: 01/09/2023] Open
Abstract
PURPOSE To determine whether pre-treatment growth rate of vestibular schwannomas (VS) predict response to radiosurgery. METHODS A retrospective review of a prospectively maintained database of all VS patients treated with 12Gy prescription dose between September 2005 and June 2011 at our institution using the Leksell Model 4C Gamma Knife Unit was conducted. Patients who had a minimum of 12-months clinical and radiological assessment before and after radiosurgery were included in this study. Tumor growth rates were calculated using specific growth rate (SGR). Tumor volumes were measured on FIESTA-MRI scans using ITK-SNAP v2.2. RESULTS Following radiosurgery, twenty-seven (42.9%) patients showed a significant decrease in volume after one year, twenty-nine (46.0%) stabilized, and seven (11.1%) continued to grow. There was no correlation between VS pre-treatment SGRs with post-treatment SGRs (p = 0.34), and incidence of adverse radiation effects (ARE). The reduction in tumors' SGRs after radiosurgery was proportional to pre-treatment SGRs, although this correlation was not statistically significant (p = 0.19). Analysis of risk factors revealed a positive correlation between post-treatment SGRs and incidence of non-auditory complications, most of which were attributed to ARE (p = 0.047). CONCLUSION Pre-treatment growth rate of VS does not predict tumor response to radiosurgery or incidence of ARE. VS with higher SGRs post-radiosurgery are more likely to experience ARE.
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Affiliation(s)
- Soroush Larjani
- Department of Neurosurgery, University Health Network, Toronto, Canada
- * E-mail: (SL); (GZ)
| | - Eric Monsalves
- Department of Neurosurgery, University Health Network, Toronto, Canada
| | - Houman Pebdani
- Department of Neurosurgery, University Health Network, Toronto, Canada
| | - Boris Krischek
- Department of Neurosurgery, University Health Network, Toronto, Canada
| | - Fred Gentili
- Department of Neurosurgery, University Health Network, Toronto, Canada
| | - Michael Cusimano
- Department of Neurosurgery, St. Michael's Hospital, Toronto, Canada
| | | | - Caroline Hayhurst
- Department of Neurosurgery, The Walton Centre, Liverpool, United Kingdom
| | - Gelareh Zadeh
- Department of Neurosurgery, University Health Network, Toronto, Canada
- * E-mail: (SL); (GZ)
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Fishpool S, Amato-Watkins A, Hayhurst C. Free Middle Turbinate Mucosal Graft Reconstruction after Endonasal Pituitary Surgery: Minimizing CSF Leak and Sinonasal Morbidity without Pedicled Flaps. Skull Base Surg 2014. [DOI: 10.1055/s-0034-1384063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Mete O, Hayhurst C, Alahmadi H, Monsalves E, Gucer H, Gentili F, Ezzat S, Asa SL, Zadeh G. The role of mediators of cell invasiveness, motility, and migration in the pathogenesis of silent corticotroph adenomas. Endocr Pathol 2013; 24:191-8. [PMID: 24091601 DOI: 10.1007/s12022-013-9270-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Silent corticotroph adenomas (SCAs) represent a distinct subset of clinically non-functioning pituitary adenomas. There are two variants of SCA; type I are densely granulated basophilic tumors and type II are sparsely granulated and chromophobic tumors. SCAs are known to be aggressive than the more common non-functioning gonadotroph adenomas (NFGAs). Cell-matrix interactions play an important role in the pathogenesis of pituitary adenomas. In this study, we compared 19 SCAs and 50 NFGAs with known fibroblast growth factor receptor-4 (FGFR4) status using semi-quantitative immunohistochemistry to localize β1-integrin, osteopontin, and matrix metalloproteinase-1 (MMP-1) as cytoplasmic, membranous, or mixed cytoplasmic-membranous staining to achieve scores of 1-4. Staining for β1-integrin was significantly higher in SCAs (100 %, score 3.3) than in NFGAs (96 %; score 2.6) (p = 0.0482); there was no statistical difference within subgroups of SCA (type II score 3.4; type I score 2.8) (p = 0.2663). Osteopontin immunoreactivity was also higher in SCAs (100 %, score 3.7) than in NFGAs (42 %, score 0.8) (p = 0.0001); there was no statistical difference within subgroups of SCA (type II score 3.6; type I score 3.9) (p = 0.2787). In contrast, MMP-1 immunoreactivity was lower in SCAs (89 %; score 2.5) than in NFGAs (98 %; score 3.6) (p = 0.0005); there was no statistical difference within subgroups of SCA (type II score 2.7; type I score 2.0) (p = 0.30704). The MMP-1 results correlated with FGFR4 expression (NFGA 96 %, type II SCA 71 %, type I SCA 40 %). Our data indicate that the biological aggressivity of SCAs compared with NFGA may be due to high osteopontin expression; in contrast, high MMP-1 is characteristic of NFGAs that also express more FGFR4. Further investigations are warranted to clarify the underlying regulatory mechanisms of these markers. The high osteopontin or FGFR4/MMP-1 expression levels in SCAs and NFGAs, respectively, indicate the potential for therapeutic strategies targeting osteopontin or FGFR4/MMP-1 for inoperable tumors of these types.
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Affiliation(s)
- Ozgur Mete
- Department of Pathology, University Health Network, 200 Elizabeth Street, 11th floor, Toronto, ON, M5G 2C4, Canada,
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Hayhurst C, Williams D, Yousaf J, Richardson D, Pizer B, Mallucci C. Skull base surgery for tumors in children: long-term clinical and functional outcome. J Neurosurg Pediatr 2013; 11:496-503. [PMID: 23432483 DOI: 10.3171/2013.1.peds12120] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Skull base tumors in children are rare but require complex approaches with potential morbidity to the developing craniofacial skeleton, in addition to tumor-related morbidity. Reports of long-term clinical and functional outcome following skull base approaches in children are scarce. The authors report long-term outcome in children with tumors undergoing multidisciplinary skull base surgery. METHODS A retrospective analysis was undertaken of children undergoing surgery at a single institution between 1998 and 2008 for benign and malignant lesions of the anterior, middle, or posterior cranial base. Patients with craniopharyngioma, pituitary tumors, and optic glioma were excluded. Histology, surgical morbidity, length of hospital stay, progression-free survival, and adjuvant therapy were recorded. Functional and cognitive outcome was assessed prospectively using the Late Effects Severity Score (LESS). RESULTS Twenty-three children ranging in age from 13 months to 15 years underwent skull base approaches for resection of tumors during the study period. The median follow-up duration was 60 months. Tumor types included meningioma, schwannoma, rhabdomyosarcoma, neuroblastoma, angiofibroma, and chordoma. Complete resection was achieved in 12 patients (52%). Thirteen patients (57%) had benign histology. The median hospital stay was 7 days. There were 3 deaths, 1 perioperative and 2 from tumor progression. Two patients had CSF leakage (9%) and 2 developed meningitis. Two children (9%) had residual neurological deficit at last follow-up evaluation. Thirteen (59%) of 22 surviving patients received adjuvant therapy. The majority of the patients remain in mainstream education and 19 of the 20 surviving children have an LESS of 3 or lower. CONCLUSIONS Children tolerate complex skull base procedures well, with minimal surgical-related morbidity as well as good long-term tumor control rates and functional outcomes from maximal safe resection combined with adjuvant treatment when required.
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Affiliation(s)
- Caroline Hayhurst
- Department of Neurosurgery, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom.
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Larjani S, Pebdani H, Monsalves E, Hayhurst C, Krischek B, Gentili F, Cusimano M, Laperriere N, Zadeh G. Does Natural History of Vestibular Schwannomas Govern Treatment Response and Complications to Radiosurgery? Skull Base Surg 2013. [DOI: 10.1055/s-0033-1336255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Alexandru D, Satyadev R, So W, Lee SH, Lee YS, Hong YK, Kang CS, Rodgers SD, Marascalchi BJ, Strom RG, Riina H, Samadani U, Frempong-Boadu A, Babu R, Sen C, Zagzag D, Anderson MD, Abel TW, Moots PL, Odia Y, Orr BA, Eberhart CG, Rodriguez F, Sweis RT, Lavingia J, Connelly J, Cochran E, van den Bent M, Hartmann C, Preusser M, Strobel T, Dubbink HJ, Kros JM, von Deimling A, Boisselier B, Sanson M, Halling KC, Diefes KL, Aldape K, Giannini C, Rodriguez FJ, Ligon AH, Horkayne-Szakaly I, Rushing EJ, Ligon KL, Vena N, Garcia DI, Douglas Cameron J, Eberhart CG, Raghunathan A, Wani K, Armstrong TS, Vera-Bolanos E, Fouladi M, Gajjar A, Goldman S, Lehman NL, Metellus P, Mikkelsen T, Necesito-Reyes MJT, Omuro A, Packer RJ, Partap S, Pollack IF, Prados MD, Ian Robbins H, Soffietti R, Wu J, Gilbert MR, Aldape KD, Prosniak M, Harshyne LA, Andrews DW, Craig Hooper D, Kagawa N, Hosen N, Kijima N, Hirayama R, Chiba Y, Yamamoto F, Kinoshita M, Hashimoto N, Fujimoto Y, Yoshimine T, Hu J, Nuno M, Patil C, Rudnick J, Phuphanich S, Bannykh S, Chu R, Yu J, Black K, Choi J, Kim D, Shim KW, Kim SH, Kanno H, Nishihara H, Tanaka S, Nishihara H, Yanagi T, Kanno H, Tanaka S, Buczkowicz P, Khuong-Quang DA, Rakopoulos P, Bouffet E, Morrison A, Bartels U, Pfister SM, Jabado N, Hawkins C, Weinberg BD, Newell KL, Kumar P, Wang F, Venneti S, Madden M, Coyne T, Phillips J, Gorovets D, Huse J, Kofler J, Lu C, Tihan T, Sullivan L, Santi M, Judkins A, Thompson C, Perry A, Iorgulescu JB, Laufer I, Hameed M, Lis E, Boland P, Komotar R, Bilsky M, Amato-Watkins AC, Neal J, Rees AD, Davies JS, Hayhurst C, Lu-Emerson C, Snuderl M, Davidson C, Kirkpatrick ND, Huang Y, Duda DG, Ancukiewicz M, Stemmer-Rachamimov A, Batchelor TT, Jain RK, Ellezam B, Theeler BJ, Sadighi ZS, Mehta V, Tran MDT, Adesina AM, Puduvalli VK, Bruner JM. CLIN-PATHOLOGY. Neuro Oncol 2012. [DOI: 10.1093/neuonc/nos233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Alahmadi H, Lee D, Wilson JR, Hayhurst C, Mete O, Gentili F, Asa SL, Zadeh G. Clinical features of silent corticotroph adenomas. Acta Neurochir (Wien) 2012; 154:1493-8. [PMID: 22619024 DOI: 10.1007/s00701-012-1378-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Accepted: 05/01/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Silent corticotrph adenomas represent a distinct pathological subtype of non-functioning pituitary adenomas that are traditionally believed to carry a more aggressive biological behavior and higher potential for recurrence. METHODS We conducted a retrospective review of all silent corticotroph adenomas treated and followed at our institution over the last 10 years. We reviewed clinical, radiological and pathological features. The series was compared to a matched cohort of ACTH-negative, non-functioning adenomas to compare clinical, radiological and pathological features. Our results were compared to the literature. RESULTS Twenty patients met our inclusion criteria. Fifty-six percent of the patients were females. Mean age was 51 years (range 24-78 years). Visual dysfunction was the most common clinical presentation (38 %). Thirteen percent of the cases presented with acromegaly secondary to double adenoma (silent corticotroph adenoma and growth hormone adenoma) and 13 % presented with pituitary tumor apoplexy. All the tumors were macroadenomas. Frank cavernous sinus invasion occurred in 31 % of the cases. The patients who presented with acromegaly did not achieve remission postoperatively. In the remaining patients, recurrence occurred in 14 % of the cases over a mean follow-up period of 41 months. Compared to non-functioning adenomas, silent corticotroph adenomas were more likely to bleed (p value 0.014) and have double adenoma (p value 0.047). There was no difference in recurrence rates between silent corticotroph adenomas and non-functioning adenomas (p value 0.647). CONCLUSION These results suggest that silent corticotroph adenomas have some unique features compared to non-functioning adenomas. Within the limits of our follow-up duration and sample size and our review of the literature, we would recommend that the traditional view to manage all silent corticotroph adenomas with adjuvant radiation should be reconsidered. We suggest adopting an initially more conservative follow-up surveillance and delay of upfront radiation until there is clear evidence of tumor recurrence.
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Affiliation(s)
- Hussein Alahmadi
- Division of Neurosurgery, University Health Network, University of Toronto, Toronto, Canada.
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Al-Jumaily M, Jones B, Hayhurst C, Jenkinson MD, Murphy P, Buxton N, Mallucci C. Long term neuropsychological outcome and management of ‘decompensated’ longstanding overt ventriculomegaly in adults. Br J Neurosurg 2012; 26:717-21. [DOI: 10.3109/02688697.2012.673647] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
BACKGROUND The management of complex hydrocephalus is challenging. There is no consensus of the best treatment for isolated fourth ventricles, arachnoid cysts, and multiloculated hydrocephalus, although the avoidance of multiple shunts is desirable. We reviewed our experience with the use of endoscopic techniques to simplify complex multicompartmental hydrocephalus to determine its efficacy and safety. METHODS We performed a retrospective study of 114 consecutive adults and children undergoing endoscopic management of hydrocephalus by a single surgeon. The type of hydrocephalus and endoscopic procedure performed were recorded. The management algorithm for simplification of complex hydrocephalus is reviewed. All patients were followed up in the office or by telephone. RESULTS A total of 143 endoscopic procedures were performed on 114 patients with a mean age of 4.4 years (4 weeks to 32 years). The endoscopic procedures performed included cyst fenestration, septum pellucidotomy, endoscopic third ventriculostomy, aqueductal plasty with and without stent, and removal of cystercicotic cysts. Twenty-two (19.3%) patients had planned staged endoscopic procedures. Mean follow up was 65 months (range 33-122 months). Eighty-two (72%) patients were reduced to 1 shunt, shunt independence was achieved in 32 (28%) patients, and only 8 (11%) patients required shunt revision in the follow-up period. CONCLUSIONS Endoscopic simplification of complex hydrocephalus enables dependence on only a single shunt in the majority of patients, and a significant proportion achieve shunt independence. Endoscopic management should be considered before the placement of a second shunt, and some cases require staged endoscopic procedures to adequately communicate multicompartmental hydrocephalus.
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Affiliation(s)
- Charles Teo
- Centre for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Randwick, New South Wales, Australia.
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