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Publication History View all

  • BMJ (online) 02/2013; 346:f1000.
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    ABSTRACT: The authors report a case of an isolated schwannoma of left hypoglossal nerve in a 9-year-old girl. To the authors' knowledge, this is the first case report of hypoglossal nerve schwannoma in the pediatric population in the absence of neurofibromatosis Type 2. The patient presented with a 2-month history of morning nausea and vomiting with occasional daytime headaches. Magnetic resonance imaging and subsequent CT scanning revealed a dumbbell tumor with a belly in the lower third of the posterior fossa and head underneath the left jugular foramen. Its neck protruded through an expanded hypoglossal canal. Although the lesion bore radiological characteristics of a hypoglossal schwannoma, the absence of hypoglossal palsy and the apparent lack of such tumors in the pediatric population the preoperative diagnosis was not certain. The tumor was approached via a midline suboccipital craniotomy, and gross-total resection was achieved. Pathological examination confirmed the diagnosis of schwannoma. Blood and tumor tests for mutations in the NF2 gene were negative. Postoperative mild hypoglossal palsy recovered by the 3-month follow-up, and an MRI study obtained at 1 year did not show recurrence.
    Journal of Neurosurgery Pediatrics 06/2012; 10(2):130-3.
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    ABSTRACT: Local anesthesia is widely used, in isolation or in conjunction with general anesthesia. The authors describe 2 adolescent patients presenting with absent brainstem reflexes and delayed awakening following elective foramen magnum decompression for Chiari Type I malformation. In both cases, neurological deficits were closely associated with the administration of a levobupivacaine field block following wound closure. In the absence of any structural or biochemical abnormalities, and with spontaneous recovery approximating the anesthetic half-life, the authors' observations are consistent with transient brainstem paralysis caused by perioperative local anesthetic infiltration.
    Journal of Neurosurgery Pediatrics 06/2012; 10(1):60-1.
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    European Journal of Intensive Care Medicine 04/2012; 38(6):925-7.
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    ABSTRACT: Numerous statistical methods have been utilised to generate predictive models that identify clinical and biochemical parameters of prognostic value following traumatic brain injury. While these methods provide an accurate statistical description between these variables and outcome, they are difficult to interpret intuitively. Hierarchical log linear analysis can be utilised to present the complex interactions between these variables and outcome visually. We compiled a database of 327 traumatic brain injury patients, their admission blood parameters, clinical admission parameters, and 6-month Glasgow Outcome Score. Seven variables (age, injury severity, Glasgow Coma Score, glucose, albumin, haemoglobin, white cell count) that correlated with outcome in a univariate analysis and two further variables, included on the basis of biological plausibility, (abnormal clotting and magnesium) were used to derive and present a hierarchical log linear model. Seventeen (out of an original forty-five possible) inter-relationships between the chosen variables were identified as remaining in the hierarchical log linear model. This data is presented pictorially in a hierarchy demonstrating the directness of the statistical association between each of the variables and dichotomised outcome. Four variables within the hierarchical log linear model (age, raised serum glucose, low haemoglobin, Glasgow Coma Score) had a direct independent statistical relationship with outcome. The remaining five variables only had a statistical relationship with outcome via at least one other variable. Hierarchical log linear analysis allows the presentation of multivariate, categorical data sets in a pictorial and more easily interpretable fashion.
    Acta Neurochirurgica 06/2010; 152(6):953-7.
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    ABSTRACT: A considerable body of evidence supporting the use of external drainage after evacuation of primary chronic subdural hematoma (CSDH) exists in the literature. However, no systematic study of the value of postoperative drainage in the treatment of recurrent CSDH has been published. The aim of the study was to investigate external drains and subdural-to-peritoneal conduit in the treatment of recurrent CSDH. A retrospective review of cases of CSDH treated in our institution between October 2002 and October 2006 was conducted. During the study period, 408 patients had burr hole evacuation. Sixty-four patients (15.9%) had treatment for recurrence. One patient had craniotomy, and the remaining 63 had another burr hole evacuation: 36 without placement of a drain (BHO), 14 with external drainage (SED), and 13 with placement of subdural-peritoneal catheter (SPC). Fifteen patients (24%) developed a secondary recurrence requiring a third drainage procedure. Postoperative drainage (SED or SPC) was associated with a significantly lower secondary recurrence rate when compared to BHO: 3/27 (11%) versus 12/36 (33%) (χ(2), P=.040). There was no significant difference in recurrence rates between SED and SPC. Postoperative complications included acute subdural hematoma (2), subdural empyema (2), brain edema (2), pneumonia (3), and in-hospital death (2). None of the complications was associated with the use of a specific technique. The results indicate that, as in the treatment of primary CSDHs, the use of drain (SED or SPC) with burr hole evacuation is safe and is associated with lower recurrence rate. Further investigation is needed to clarify the indications of currently available surgical techniques in the treatment of recurrent CSDH.
    World Neurosurgery 06/2010; 73(6):747-50.
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    ABSTRACT: Survivors of head injury are often left with varying degrees of disability and complex and varied needs, necessitating prolonged periods of rehabilitation and continuing care. Advances have been made in the acute management of these patients, but continuing management in terms of rehabilitation remains deficient with lack of specialist resources and a fragmented service. For head-injured patients, lack of access to appropriate ongoing rehabilitation may have profound effects on outcome and social re-integration. There are also considerable economic implications for planning and provision of services. The aims of this paper are to describe, review and evaluate the role of a Neurotrauma clinic within the Head Injury Service at Addenbrooke's Hospital, Cambridge. The multidisciplinary Neurotrauma clinic commenced in June 2003 following an extensive collaborative research programme to assess current regional head injury service provision and address deficiencies and management issues. Patients of all ages with ongoing problems following varying severity of head injury are followed up at 2 months + post-injury for as long as appropriate. Patients complete an SF-36 and GOSE questionnaire at each clinic appointment and this self-reported data is complemented by neuropsychological assessments, and demographic data entered on a database. The clinic acts as a 'gateway' to access appropriate ongoing rehabilitation and a source of information and support. The routine collection of outcome data enables tracking of individual patient progress and outcome and provides an information resource for further research. The findings highlight deficiencies in rehabilitation both in general service provision and specific patient need. Evidence in support of demand, need and effectiveness of rehabilitation for head injury is particularly relevant within the limited resources of the NHS. Early indications show that a specialist clinic can assist in providing continuity of patient care, in improving coordination of services, and act as a resource for further research on epidemiology, outcome and impact of rehabilitation.
    British Journal of Neurosurgery 10/2009; 23(5):530-7.
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    ABSTRACT: Chronic subdural haematoma causes serious morbidity and mortality. It recurs after surgical evacuation in 5-30% of patients. Drains might reduce recurrence but are not used routinely. Our aim was to investigate the effect of drains on recurrence rates and clinical outcomes. We did a randomised controlled trial at one UK centre between November, 2004, and November, 2007. 269 patients aged 18 years and older with a chronic subdural haematoma for burr-hole drainage were assessed for eligibility. 108 were randomly assigned by block randomisation to receive a drain inserted into the subdural space and 107 to no drain after evacuation. The primary endpoint was recurrence needing redrainage. The trial was stopped early because of a significant benefit in reduction of recurrence. Analyses were done on an intention-to-treat basis. This study is registered with the International Standard Randomised Controlled Trial Register (ISRCTN 97314294). Recurrence occurred in ten of 108 (9.3%) people with a drain, and 26 of 107 (24%) without (p=0.003; 95% CI 0.14-0.70). At 6 months mortality was nine of 105 (8.6%) and 19 of 105 (18.1%), respectively (p=0.042; 95% CI 0.1-0.99). Medical and surgical complications were much the same between the study groups. Use of a drain after burr-hole drainage of chronic subdural haematoma is safe and associated with reduced recurrence and mortality at 6 months. Academy of Medical Sciences, Health Foundation, and NIHR Biomedical Research Centre (Neurosciences Theme).
    The Lancet 09/2009; 374(9695):1067-73.
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    ABSTRACT: Carotid artery disease underlies a significant proportion of ischaemic strokes. Whilst secondary prevention by drug treatment is the first step in managing patients with known carotid stenoses, evidence from a number of large randomised controlled trials have clearly demonstrated a benefit for surgical treatment in symptomatic patients with moderate-to-severe stenosis. In asymptomatic patients with severe stenosis a benefit is conferred by surgery in selected patients. Carotid endarterectomy has formed the mainstay of surgical treatment. Endovascular angioplasty (with/without stenting) for carotid stenoses has been proposed as a viable or even superior alternative to carotid endarterectomy. The results from four large randomised controlled trials comparing the two modalities, considered together suggest a marginally better outcome for carotid endarterectomy compared with angioplasty in terms of perioperative mortality and stroke, though the results of further studies are awaited. For carotid surgery, a multi-centre randomised controlled trial evaluating the use of local anaesthesia versus general anaesthesia demonstrated no significant difference in outcome. Refinements in surgical technique such as patch angioplasty and intraluminal shunting provide equivocal benefit, with wide variation in their usage and in the results of studies evaluating them. More robust evidence supporting or refuting a benefit for these techniques is required.
    British Journal of Neurosurgery 09/2009; 23(4):387-92.
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    ABSTRACT: Delayed ischemic deficits (DIDs), a major source of disability following aneurysmal subarachnoid hemorrhage (aSAH), are usually associated with severe cerebral vasospasm and impaired autoregulation. Systemic erythropoietin (EPO) therapy has been demonstrated to have neuroprotective properties acting via EPO receptors on cerebrovascular endothelia and ischemic neurons. In this trial, the authors explored the potential neuroprotective effects of acute EPO therapy following aSAH. Within 72 hours of aSAH, 80 patients (age range 24-82 years) were randomized to receive intravenous EPO (30,000 U) or placebo every 48 hours for a total of 90,000 U. Primary end points were the incidence, duration, and severity of vasospasm and impaired autoregulation on transcranial Doppler ultrasonography. Secondary end points were incidence of DIDs and outcome at discharge and at 6 months. Randomization characteristics were balanced except for age, with the EPO group being older (mean age 59.6 vs 53.3 years, p=0.034). No differences were demonstrated in the incidence of vasospasm and adverse events; however, patients receiving EPO had a decreased incidence of severe vasospasm from 27.5 to 7.5% (p=0.037), reduced DIDs with new cerebral infarcts from 40.0 to 7.5% (p=0.001), a shortened duration of impaired autoregulation (ipsilateral side, p<0.001), and more favorable outcome at discharge (favorable Glasgow Outcome Scale score, p=0.039). Among the 71 survivors, the EPO group had fewer deficits measured with National Institutes of Health Stroke Scale (median Score 2 vs 6, p=0.008). This preliminary study showed that EPO seemed to reduce delayed cerebral ischemia following aSAH via decreasing severity of vasospasm and shortening impaired autoregulation.
    Journal of Neurosurgery 04/2009; 111(1):171-80.
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