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“Syndrome of the trephined” or “sinking skin flap syndrome” is an unusual syndrome in which neurological deterioration occurs following removal of a large skull bone flap. The neurological status of the patient can occasionally be strongly related to posture. A 77-year-old male patient with an acute subdural hematoma was treated using a hemicraniectomy and evacuation of the hematoma. On the 9th postoperative day there was deterioration in sensorium associated with a sunken scalp flap and worsening midline shift on CT. A significant improvement in sensorium and a filling up of the scalp flap occurred after maintaining the patient's head in a dependent position. The patient subsequently made an excellent recovery following replacement of the bone flap. The pathophysiology of “syndrome of the trephined” or “sinking skin flap syndrome” is reviewed.

Continuous transcranial Doppler ultrasonography of the middle cerebral artery (TCD-MCA) has been proposed as a method of identifying the lower cerebral autoregulatory threshold. This study investigated the relationship between continuous TCD-MCA and cerebral blood flow (CBF) in sheep. Arterial blood pressure, intracranial pressure, CBF and left TCD-MCA were measured in 12 anaesthetized and ventilated merino sheep. Cerebral perfusion pressure (CPP) was reduced by haemorrhagic hypotension. Measurements were recorded continuously and breakpoint thresholds calculated by an analysis of variance. The TCD-MCA systolic velocity breakpoint (50 +/- 1.5 mmHg) did not significantly differ from the lower limit of autoregulation, identified by the CBF breakpoint (50 +/- 1.8 mmHg). The TCD-MCA diastolic velocity breakpoint occurred at a significantly higher level of CPP (64 +/- 2 mmHg) (P0.01). The relationship between TCD-MCA flow velocity and CBF thresholds has been described. Early divergence of flow velocity may represent a compensatory mechanism to maintain CBF.

Preventable secondary injury remains disturbingly common and can only be reduced by highly organized and integrated services, and careful and continuous monitoring. Continuous non- or relatively non-invasive bedside monitoring of factors closely related to brain metabolism and function is becoming a practical reality. To the extent that the complex changes initiated by traumatic brain injury are ‘processes’ rather than ‘events’ it may become possible for components of injury to be halted or reversed. Pharmacological therapy given early after injury may be able to reduce the harmful events initiated by the injury. Head injury management is multidisciplinary. Improvements in head injury outcome have come about through better organisation of services — efficient retrieval, early investigation and removal of clots, and management in experienced intensive care units. Australian neurosurgeons have played a leading role in defining standards of care, in organizing services and in raising public health issues related to head injury. With the increasing and necessary involvement of other specialists and the greater dependence on technically demanding intensive monitoring and medical management, it is important that neurosurgeons remain at the forefront of the care of patients with head injury and not simply be reduced to managing the surgical complications on request.86

A false aneurysm of the pericallosal artery formed following resection of a colloid cyst. The aneurysm presumably resulted from arterial damage during surgery and its enlargement may have been facilitated by the surgical defect in the corpus callosum. A spherical hyperdense lesion on postoperative CT may indicate a false aneurysm.

Background: Due to the geographical remoteness of Darwin, which has no resident neurosurgeon, emergency transfer of patients for neurosurgery is usually impractical. In Darwin emergency neurosurgery must be undertaken by general surgeons. Methods: Data from the operating theatre, Emergency Department and Intensive Care Unit were prospectively recorded on all patients who underwent an emergency neurosurgical procedure between January 1992 and June 2004. Outcomes were assessed by retrospective case note review. Results: Three hundred and five neurosurgical procedures were performed upon 258 patients (average 26.5 procedures per year), including 130 craniotomies, 88 burr holes, 3 posterior fossa craniotomies, 2 decompressive frontal lobectomies, 4 decompressive craniectomies, 25 elevations of fracture and 33 ventricular drains only. Assault/domestic incident (31%) was a more common aetiology than motor vehicle accidents (29%). Outcome was best for extradural haematoma (82% good/moderate) and chronic subdural haematoma (84% good/moderate). In contrast, 44% with acute subdural haematoma and 77% with intracerebral haematoma died. Irrespective of type of bleed, Glasgow Coma Scale (GCS) score at presentation was a reliable predictor of outcome following surgery (61% correlation): 60% with GCS less than 9 died whereas 79% with GCS over 11 had a good recovery. Acute Physiology And Chronic Health Evaluation, version 2 and Simplified Acute Physiology Score, version 2 scores were also independent predictors of outcome. Time from presentation to operation for extradural haematoma and acute subdural haematoma was prolonged (more than 4 h) in 48% and was associated with worse outcome (P = 0.0001). Neither extremes of age nor the particular surgeon performing the operation affected outcome. Conclusions: General surgeons undertake a substantial number of procedures across a broad spectrum of emergency neurosurgery in Darwin. Outcomes following surgery appear acceptable.

The authors report a 23-year-old man who was diagnosed with a brain stem malignant glioma following his first episode of generalised seizure. This was subsequently complicated by three separate documented episodes of intracranial haemorrhage. The literature is reviewed and the pathophysiological mechanisms of tumoural haemorrhage are discussed. It is speculated that significant intratumoural arteriovenous shunting may lead to recurrent haemorrhages.

In the 25 years since the 'Talk and Die' paper there have been substantial advances in the management of patients with severe closed head injury. This paper discusses developments in understanding of primary and secondary injury. Current management focuses on preventing secondary brain injury. That this has been successful is illustrated by a fall in mortality in recent decades. Evidence based guidelines have set standards of management but they do not take into account variations between individuals, between regions of the brain and variations with time from injury. Various monitoring techniques such as transcranial doppler, jugular venous oxygen saturation and ICP waveform analysis attempt to set individual therapeutic endpoints and to target therapy appropriately. Primary injury is no longer seen as a single irreversible event occurring at the time of impact, but rather as a process initiated by the impact and evolving over subsequent hours and days. Experimental studies have identified agents which reduce the evolution of brain injury and improve outcome. An experimental model of brain injury developed by the Adelaide He ad Injury Group identifies diffuse axonal injury as a target for therapeutic manipulation. Magnesium has been shown in other studies to improve outcome after diffuse brain injury. This has now been linked with upregulation of beta amyloid precursor prote in. Although this and several other experimental therapies have shown great promise, they have not so far produced benefit in large clinical studies. Avoiding secondary insults will remain the goal of management for the foreseeable future. Halting the evolution of the primary injury remains a highly sought after goal. Although elusive so far, it is likely to be the next major advance in clinical care.

Amyloid precursor protein (APP), a membrane spanning glycoprotein which plays an important role in neuronal growth and synaptic plasticity, is increased after traumatic brain injury (TBI) and has been used as a sensitive marker of neuronal damage in an adult sheep head impact model. We hypothesised that APP expression would similarly be increased in lambs, suggesting that in the immature injured brain APP is also upregulated as an acute phase response to trauma. Ten anaesthetised and ventilated 4-5 week old Merino lambs sustained a left temporal head impact from a humane stunner. At 2 h after impact, there was widespread and intense neuronal cell body APP immunoreactivity which was more widely distributed than axonal APP. APP messenger RNA (mRNA) expression was also markedly increased with a distribution similar to that of APP antigen. These results demonstrate that APP antigen and mRNA are sensitive early indicators of TBI in paediatric cases.

The 1975 paper ‘patients with head injury who talk and die’ depended on the insight of Bryan Jennett who coined the phrase and saw the significance of this group of patients and the excellent neuropathological studies of a large series of fatal head injuries conducted by Hume Adams and David Graham – a type of study almost impossible to replicate. That paper highlighted the distinction between primary head injury, in this group minor, and secondary head injury which was fatal. The important implication of that paper was that the primary head injury itself was potentially survivable. An analysis of ‘talk and die’ patients might therefore be an important audit of a trauma system. Goldschlager et al. in a retrospective review over 10 years, identified 15 patients who died after being admitted with mild head injury to a major trauma centre. This is an incidence of 1.5% per year or >6% of all mild head injuries. The selection of patients is based on coronial reporting but the analysis is based on CT scans rather than neuropathology. The patients were mostly elderly and the majority died as the result of acute subdural haematomas or contusions with swelling.

Two cases of perforated duodenal diverticula are presented. Each of these followed the ingestion of an aerated soft drink. The importance of a sudden rise in intraluminal pressure as a cause of perforation is discussed. The diverticulum was excised completely in both cases.

The importance of the empty sella syndrome has increased with recent interest in pituitary micro-adenomas, trans-sphenoidal hypophysectomy and computerised tomography. Four cases of the empty sella syndrome which illustrate the clinical and radiological features are reported, and the literature is reviewed. Headache, visual symptoms and endocrine disturbances are commonly found in association with the empty sella syndrome, and the coexistence of pituitary micro-adenomas is well recognised. Symmetrical ballooning of the sella turcica without changes in configuration is the typical finding with plain radiography, but occasionally more extensive destructive changes in the region of the pituitary fossa may occur. Provided that the correct angulation, collimation and level of cut are chosen, computerised tomography now may be used to make a definitive diagnosis, making air encephalography unnecessary.

Shunt function testing by radionuclide injection and shunt pressure measurement was performed in 312 cases. In our experience the test has a sensitivity of 92% and accuracy of 89%. The diagnostic value of the components of the test are discussed. The test is a safe and integral part of the assessment of shunt function. The significance of shunt malfunction must of course be determined by clinical evaluation, measures of ventricular size by CAT scanning or ultrasound, and by continuous ICP recording. However the shunt function test combined with shunt pressure measurement is a safe and essential investigation of symptomatic shunt malfunction.

Kernohan grade III and IV astrocytomas are usually fetal and in the past have had a case survival rate of only about 10% two years from diagnosis. Data on 285 cases registered at the Royal Adelaide Hospital in 1977-1986 showed a median survival of approximately six months. The survival rate was 25% at one year and 15% at two years. Survival reduced markedly with increase in age at diagnosis from a two-year rate of 53% for patients under 40 years of age to 5% for patients aged 70 years or more. This may have been due in part to the more frequent treatment of younger patients by decompression and radiotherapy. Apart from age and treatment mode, factors related to extended survival included a longer duration of symptoms before diagnosis and location of the tumour in the frontal lobes. Notwithstanding prospects for an increase in short-term survival from the use of radiotherapy as an adjunct to surgery, long-term outcomes for these neoplasms are still very poor.