Hyponatremia is common in neurosurgical patients and is associated with significant morbidity and mortality. Despite significant research efforts to date, we still lack a complete understanding of the pathophysiological mechanisms underlying hyponatremia in this patient setting. The purpose of this narrative review is to provide an overview of our understanding of hyponatremia in neurosurgical patients, the management principles, and the challenges that arise for the physician managing such patients. Challenges to managing these patients include: the fact that the syndrome of inappropriate antidiuretic hormone (SIADH) and cerebral salt wasting (CSW) may actually represent parts of the same clinical spectrum; the difficulty in distinguishing between CSW, SIADH, and the hypovolemic hyponatremia resulting from a normal pressure natriuresis caused by the administration of large fluid volumes; and that hyponatremia can result from therapeutic agents used in these patients. Treatment of the hyponatremia depends on factors such as the underlying neurosurgical pathology, whether the hyponatremia is acute or chronic, and the fluid status of the patient. Hypertonic saline is a common treatment option. Other treatment options include vasopressin 2 receptor antagonists and steroids, but large prospective trials are required to suitably assess their efficacy and safety in the neurosurgical setting. Of all the challenges that hyponatremia in neurosurgical patients present, perhaps the most pressing is the need for a better understanding of the underlying pathophysiological mechanisms. Only once we begin to better understand this can more efficacious treatments be directed against hyponatremia in this important population.
It is unusual for paediatric central nervous system (CNS) tumours to be disseminated at presentation, and literature on the clinical features, management and outcomes of this specific group is scarce. Surgical management decisions can be challenging, particularly in the presence of hydrocephalus. We present our experience in managing paediatric CNS tumours disseminated and nondisseminated at presentation over fourteen years. Retrospective review of prospectively-collected data on children presenting to our tertiary centre between 2003 and 2016 inclusive. We identified 53 patients with CNS tumour dissemination at presentation (M:F=34:19, median age=3.8 years, range=7 days-15.6 years) and 308 without dissemination (M:F=161:147, median age=5.8 years, range=1 day-16.9 years). Five tumour groups were studied: medulloblastoma (disseminated n=29/nondisseminated n=74), other primitive neuroectodermal tumour (n=8/n=17), atypical teratoid rhabdoid tumour (n=8/n=22), pilocytic astrocytoma (n=6/n=138), and ependymoma (n=2/n=57). Median follow-up in survivors was not significantly different between those with (64.0 months, range=5.2–152.0 months) and those without disease dissemination at presentation (74.5 months, range=4.7–170.1 months; P>0.05). Dissemination status at presentation significantly impacted survival, risk of recurrence, rates of complete resection of the operated lesion, chance of proceeding to palliative care as an early management strategy, surgical complication rate, and risk of requiring CSF diversion (all Ps<0.05). Differences between the five tumour groups were evident. No factors to predict the need for permanent CSF diversion following temporary external ventricular drainage were identified on multivariate analysis, and there was no clear superiority of either ventriculoperitoneal shunt or endoscopic third ventriculostomy as a permanent CSF diversion procedure. Tumour type and dissemination status at initial presentation significantly affect outcomes across a range of measures. The management of hydrocephalus in patients with CNS tumours is challenging, and further prospective studies are required to identify the optimal CSF diversion strategy or strategies in this population.
Intracerebral haemorrhage is a devastating condition lacking effective therapies, with an uncertain role for surgery in many. Early research described an ischaemic penumbra around the haematoma, representing an area of potential therapeutic intervention. This article discusses the evidence for and against the existence of an ischaemic penumbra in ICH, with particular reference to recent imaging studies.
Background Improved treatment and survival of patients with skull base tumors has made the assessment of quality-of-life (QoL) in this population increasingly important. This article provides a comprehensive systematic review pertaining to QoL assessment in adults undergoing anterior skull base surgery. Methods We performed a literature search using the electronic databases of Ovid Medline and Embase. Additional articles were identified through a search using the phrase anterior skull base. Further articles were sought through hand-searching relevant journals and reference lists of identified articles. Results Our search strategy identified 29 articles for inclusion in our systematic review, with considerable variation between studies in population characteristics, methodological design and quality, follow-up length, and outcome assessment. The most commonly used QoL tools were the Karnofsky Performance Status and the Anterior Skull Base Questionnaire. QoL following anterior skull base surgery appears to improve beyond preoperative levels in the months after surgery. For patients undergoing endoscopic skull base surgery, the gain in QoL appears to be greater and may manifest earlier, with no clear long-term deleterious effect on sinonasal outcomes compared with open surgery. Conclusions QoL after anterior skull base surgery in adults appears to improve within several months of surgery, but earlier and to a larger extent if the endoscopic approach is used. Given the relative paucity and heterogeneity of anterior skull base tumors, large-scale prospective multicentre studies utilizing valid and reliable multidimensional QoL tools are required. This may result in improved patient care, by understanding patients' needs better and facilitating the provision of reliable outcome data for clinical trials.
The past decade has seen significant changes to the face of neurosurgical training in the United Kingdom, driven in part by an increasing focus on patient safety and the introduction of Modernising Medical Careers and the European Working Time Directive (EWTD). Recent reforms to neurosurgical training over the past few years have resulted in creation of an 8-year 'run-through' training programme. In this programme, early years (ST1 and ST2) trainees often lack dedicated time for elective theatre lists and outpatient clinics. Further, any time spent in theatre and clinics is often with different teams. Here we describe a training model for early years trainees at the National Hospital for Neurology and Neurosurgery, who are given the responsibilities traditionally associated with a more senior trainee including dedicated weekly theatre and clinic time under the supervision of a single consultant, in addition to out of hours experience. The advantages and considerations for implementing this model are discussed, including the benefit of guidance under a single consultant in the early stages of training, along with key educational concepts necessary for understanding its utility. We feel that this is an effective model for junior neurosurgical training in the EWTD era, expediting the trainee's development of key technical and non-technical skills, with potentially significant rewards for patient, trainee and trainer. National implementation of this model should be considered.
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