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We present a case of extradural hematoma resulting from a relatively minor closed injury over the vertex where a plasma cell tumour had invaded the superior sagittal sinus. The patient underwent an emergency craniotomy and evacuation of the hematoma. Hemostasis and prevention of recollection of the hematoma were hampered by the erosion of the sagittal sinus making its direct repair impossible. This was achieved by hitching up the dura lateral to the sinus to become its lateral wall reinforced by hemostatic agents. The patient made a full recovery. Malignant tumours invading the dural venous sinuses and eroding the skull can cause life-threatening intracranial bleeding after relatively minor trauma.

Background: We describe a novel progressive neurological syndrome complicating traumatic spinal cord injury (TSCI). Based on clinical and radiological features, we propose the term 'Chronic Relapsing Ascending Myelopathy' (CRAM). We distinguish between the previously described sub-acute progressive ascending myelopathy (SPAM) and post-traumatic syringomyelia (PTS), which may lie on a spectrum with CRAM., Case Report: A 60-year-old man sustained a T4 ASIA-A complete TSCI. Four months post-injury, he developed a rapidly progressive ascending sensory level to C4. Clinical and radiological evaluation revealed ascending myelopathy with progressive T2 hyper-intense cord signal change. He underwent cord detethering and expansion duroplasty. Following an initial dramatic resolution of symptoms, the patient sustained two relapses, each 1-month post-discharge characterised by recurrence of disabling ascending sensory changes, each correlating with the radiological recurrence of cord signal change. Symptoms and radiological signal change permanently resolved with more extensive detethering and expansion duroplasty. There is radiological and clinical resolution at 1-year follow-up., Conclusion: Acute neurological deterioration post-TSCI may be due to SPAM or may occur after years due to PTS. We propose CRAM as a previously unrecognised phenomenon. The radiological characteristics overlap with SPAM. However, CRAM presents later and, clinically, behaves like PTS, but without cord cystic change. Cord detethering with expansion duroplasty are an effective treatment.

We describe the unique case of a 51-year-old lady who developed a contralateral lumbosacral plexopathy two days after a lumbar microdiscectomy. This is the first report to date of this complication occurring following this procedure. We review the literature regarding lumbosacral plexopathy and discuss the evidence base behind investigating and managing this condition and the potential pathophysiological mechanisms which underlie its development. We draw comparisons with the more widely recognised post-operative brachial neuritis, characterised by delayed onset brachial plexopathy developing after cervical decompression, and propose an immune-mediated inflammatory mechanism linking the two conditions.

MR scans from 65 patients with traumatic spinal cord injury were analysed; on admission 95% had evidence of cord compression - in 26% due to the dura, and in the remaining 74% due to extradural factors. Compression due to dural factors resolved with a half-life of 8.7 days. These findings suggest that bony decompression alone may not relieve spinal cord compression in the quarter of patients in whom dural factors are significant.

Introduction: Uncertainty remains as to the role of decompressive craniectomy (DC) for primary evacuation of acute subdural haematomas (ASDH). In 2011, a collaborative group was formed in the UK with the aim of answering the following question: "What is the clinical- and cost-effectiveness of decompressive craniectomy, in comparison with craniotomy for adult patients undergoing primary evacuation of an ASDH?" The proposed RESCUE-ASDH trial (Randomised Evaluation of Surgery with Craniectomy for patients Undergoing Evacuation of Acute Subdural Haematoma) is a multicentre, pragmatic, parallel group randomised trial of DC versus craniotomy for adult head-injured patients with an ASDH. In this study, we used an online questionnaire to assess the current practice patterns in the management of ASDH in the UK and the Republic of Ireland, and to gauge neurosurgical opinion regarding the proposed RESCUE-ASDH trial., Materials and Methods: A questionnaire survey of full members of the Society of British Neurological Surgeons and members of the British Neurosurgical Trainees Association was undertaken between the beginning of May and the end of July 2012., Results: The online questionnaire was answered by 95 neurosurgeons representing 31 of the 32 neurosurgical units managing adult head-injured patients in the UK and the Republic of Ireland. Forty-five percent of the respondents use primary DC in at least 25% of patients with ASDH. In addition, of the 22 neurosurgical units with at least two Consultant respondents, only three units (14%) showed intradepartmental agreement regarding the proportion of their patients receiving a primary DC for ASDH., Conclusion: The survey results demonstrate that there is significant uncertainty as to the optimal surgical technique for primary evacuation of ASDH. The fact that the majority of the respondents are willing to become collaborators in the planned RESCUE-ASDH trial highlights the relevance of this important subject to the neurosurgical community in the UK and Ireland.

Background: Acute disc prolapse in young adults has been studied extensively. However, little is known about acute disc prolapse in the elderly., Objective: We aimed to define the features of acute disc prolapse in the elderly., Design, Setting and Patients: Elderly (≥ 65 years) patients who had lumbar or thoracic discectomy for acute (< 3 months) disc prolapse in our unit between July 2004 and March 2010 were identified. For comparison, we used a 'young' (25-45 years) patient cohort with acute thoracic or lumbar disc prolapse. Data collected included age, symptom onset, preoperative signs and spinal level., Results: During the study period, 390 patients had discectomy, of which 59.7% were 'young' and 7.4% 'elderly'. The young and elderly patients had significantly different distributions of prolapsed disc levels. In the young, 97% of all disc protrusions were at L4/5 or L5/S1, but < 50% were at these levels in the elderly. In the elderly, about 10% of disc protrusions were thoracic., Conclusions: Acute disc prolapse is rare in the elderly and primarily affects the upper lumbar and lower thoracic spine.

Background and Purpose: Spontaneous aneurysmal subarachnoid haemorrhage (SAH) is managed as a neurosurgical priority with guidelines and published literature emphasising the identification and the treatment of the ruptured aneurysm within 48 h of ictus. We audited the timing of management of good grade (WFNS 1 & 2) SAH in a neurosurgical unit in Greater London. We also reviewed the available services for treating SAH within Greater London., Materials and Methods: Retrospective audit of patients admitted with SAH to St. George's Hospital between 31 May 2007 and 31 May 2009 was performed. Prospective telephone and public record review of the catchment area and neurovascular provisions of the seven London neurosurgical units were assessed., Results: There were 141 WFNS grade 1 and 2 SAH patients admitted. Only a quarter were treated within 48 h of ictus. Patients destined for endovascular treatment waited significantly longer periods until treatment when compared with that of clipping group patients. The day of the week on which diagnostic angiography occurred was critical in determining treatment delays, probably due to the lack of routine provision of clipping at weekends and next day coiling services. We estimated that 440 good grade SAH are admitted per annum in Greater London. There are 20 neurovascular surgeons and 16 interventional neuroradiologists across seven neurosurgical units that routinely treat SAH., Conclusions: We have identified significant delays in treating three quarters of good grade SAH patients in London. This appears to be due to a lack of next day treatment availability. A collaborative strategy between the seven London neurosurgical units could reduce treatment delays.

Introduction: MRI scanning has historically been considered difficult to interpret in the early period following lumbar spine surgery, and hence of limited value. We investigate the hypothesis that MRI scanning within 6 weeks of lumbar spine surgery cannot accurately diagnose neural compression in symptomatic patients, and define the utility of postoperative MRI in this context., Methods: A series of 32 consecutive patients had early postoperative MRI following lumbar discectomy or laminectomy for continued, worsening or new symptoms of neural compression. The neuroradiologists' reports were evaluated for the reported presence of neural compression and confidence level (low, medium, high). These MRI findings were then compared to the patients' subsequent course and findings of any surgery performed., Results: Twenty of 29 scans (69%) were confidently predictive of the correct treatment pathway (reoperation with positive finding or conservative treatment with a good outcome) whereas 3/3 (100%) patients who had conservative management despite the MRI confidently suggesting compression had poor outcome. The MRI is highly likely to influence management: 11/14 (79%) patients with scans suggesting neural compression had revision surgery and 18/18 (100%) patients with no neural compression on MRI were managed conservatively., Conclusions: Our data suggest that early MRI scanning after lumbar laminectomy or discectomy accurately detects neural compression at the surgery site in patients with continued or worsening symptoms.

The introduction of the shift system in response to the European Working Time Directive has had an enormous impact on the running of neurosurgical units in the UK. This study seeks to establish what provisions are currently in place for out of hours cover and what has been the effect of the introduction of shifts in three main areas: patient safety, training and 'work/life balance'. The on-call registrar at each UK neurosurgical unit was contacted by telephone. Data regarding current emergency provision were sought. Registrars who had worked both on-calls and the shift system during their career as a neurosurgical registrar were asked to make a comparison. Data were collected from all 33 UK units. Twenty-two still use a traditional 24-h on-call system. Twenty-one on-call rotas were classed as non-resident although 12/21 of those officially on non-resident rotas were in fact resident whilst on call. Twenty-two registrars had worked both systems as a neurosurgical registrar. Twenty-one (95.45%) felt that traditional on-calls gave better clinical exposure. Twenty-one (95.45%) felt that on-calls allowed the provision of better patient care. Nineteen (86.36%) felt that on-calls were safer. Thirteen (59.09%) reported that they were more tired when doing shift work than on-calls. Fourteen (63.63%) found that the on-call system gives more useful spare time and more time to deal with family commitments. Current neurosurgery registrars feel the shift system is less safe, harmful to training and worse in terms of work/life balance. More than one-third of units are claiming to have non-resident on-call systems in order to appear compliant with EWTD when registrars are in fact resident.

Glioblastoma is the most common primary brain tumour. The aim of this study was to determine trends in survival over a 12-year period. Survival data were collected retrospectively for 625 patients who had surgery for histologically-confirmed glioblastoma between 1993 and 2004 in a single centre. Data including age, sex, preoperative Karnofsky performance score, tumour site, date of surgery, and type of surgical and adjuvant treatment were collected. Overall median survival was 189 days; there was no significant change in survival over 12 years. Multivariate analysis identified the following independent positive prognostic factors: age <60 years (p < 0.0005), Karnofsky score > or = 70 (p < 0.0001), tumour debulking, rather than biopsy (p < 0.001), right-sided lesion (p < 0.05), unilateral tumour (p < 0.05) and radiotherapy (p < 0.0001). Despite neurosurgical advances, the survival of patients with glioblastoma has not changed for more than a decade. Although, overall, glioblastoma has a short survival, our data show that individual patient survival is heterogeneous.

Currently, brain tumours are diagnosed by surgical biopsy and light microscopic examination of tissue, with immunohistochemistry in difficult cases. We review research in the field of brain tumour diagnosis and discuss several new approaches. In future, tumour type, optimal treatment, and prognosis could be obtained by studying the gene (genomics), protein (proteomics) or metabolite (metabolomics) content of tumour cells. These techniques generate complex data, analysed using techniques such as pattern recognition software to identify biomarker signatures of different tumours. Compared with individual biomarkers, biomarker signatures appear to increase diagnostic accuracy and may produce an improved brain tumour classification system.

A common property of brain tumours is their ability to cause oedema in the surrounding brain. Oedema forms as a result of a leaky blood-tumour barrier and persists when the brain fails to clear the excess fluid. It is a significant source of morbidity and mortality. The principal anatomical component of the blood-brain barrier is the endothelial tight junction which opens in glioma microvessels. Multiple tight junction proteins have recently been identified, such as occludin, claudin, ZO-1, ZO-2 and ZO-3. We propose a model to explain tight junction opening in gliomas based on vascular endothelial growth factor secretion and loss of tight junction inducing factor production by tumour cells. The level of expression of the water channel aquaporin-4 in peritumoural astrocytes may determine the rate of oedema fluid clearance. The identification of the molecular mechanisms of brain tumour oedema may allow the design of novel anti-oedema medications.

In this review we explore gene therapy as a possible treatment for conditions causing cerebral ischaemia and briefly consider other neurological pathologies such as brain tumours. DNA transfer may be achieved using retrovirus, herpes simplex virus, adenovirus, and adeno-associated virus vectors or liposomes. After cerebral ischaemia, these vectors are used to upregulate genes that increase survival and inhibit those that promote death in the injured cells. In contrast, in brain tumours gene therapy aims to kill the target cells. Examples from studies using cell culture, animal models and patients are presented. We conclude that manipulation of gene expression has potential for the treatment of cerebral ischaemia and brain tumours, although, at present, there are formidable technical obstacles to be overcome before clinical applications become a reality.

Ischaemia is the final common pathway of brain cell death following a variety of insults. We consider the effect of cerebral ischaemia on gene expression, concentrating on immediate early genes, those encoding heat shock proteins, growth factors, cytokines, adhesion molecules, nitric oxide synthase and proteins involved in programmed cell death. We conclude that the changes in gene expression resulting from ischaemia are important determinants of neuronal and glial survival. In the future it may become possible to manipulate gene expression to limit the extent of damage arising from cerebral ischaemia.

Patients with factitious symptoms occasionally present as neurosurgical emergencies. We have had six admissions over an 8-year period. They all presented at night, half of them during a weekend. Although an organic cause had to be excluded, they were all discharged within 24 h of admission without surgical intervention.

We report two cases of craniofacial fibrous dysplasia which presented with acute visual loss. The first patient had a sphenoid sinus mucocele compressing the optic chiasm. In the second patient the optic canal was narrowed by dysplastic bone. In both cases optic nerve decompression restored vision to normal.