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Cerebral cavernous malformations (CCM) may undergo a period of clinical and/or radiographical surveillance that precedes or follows definitive treatment. There are no international guidelines on the optimal surveillance strategy. This study describes the surveillance strategies at our centre and explore the related clinical outcomes. We performed a retrospective study of adult patients with CCMs referred to a neurovascular service over an 8-year period, to determine the frequency and type of surveillance, intervention, and explore the associated outcomes. We report our findings adhering to STROBE guidelines. 133 patients (Male:Female 73:60; men age 42 years; range 12–82) were included. CCMs were identified in patients first presenting with symptomatic intracerebral haemorrhage (42.11%); headache, focal neurological deficit, or seizure without haemorrhage (41.35%); or, as an incidental finding (16.54%). The most common CCM location was supratentorial (59.40%), followed by brain stem (21.80%), cerebellum (10.53%) and basal ganglia (6.02%). Of the 133 patients, 77 patients (57.89%) were managed conservatively, 49 patients (36.84%) were managed by surgical resection alone, and seven patients (5.26%) were managed with stereotactic radiosurgery (SRS). Patients follow-up had a mean duration of 65.94 months, and varied widely (SD = 52.59; range 0–265), for a total of 730.83 person-years of follow up. During surveillance, 16 patients suffered an ICH equating to a bleeding rate of 2.19 per 100 patient years. CCMs that increased in size had a higher bleeding rate (p = 8.58 ×10−4). There were 8 (6.02%) cases where routine clinic review or MRI resulted in a change in management. Our single centre retrospective study supports existing literature relating to presentation and sequalae of CCM, with an increase in CCM size being associated with higher rates of detected bleeding. There remains heterogeneity, even within a single centre, on the frequency and modality of surveillance. Further, there are no international guidelines or high-quality data that recommends the optimal duration and frequency of surveillance, and its effect on clinical outcomes. This is a future research direction. •There is no formal guidance on appropriate surveillance strategies for CCMs.•This study is the first to describe and quantify surveillance strategies for CCMs and their impact on patient outcomes.•We find no significant impact of surveillance frequency on outcomes; surveillance imaging did not change management.•This may stimulate prospective studies and the formulation of formal surveillance guidance for CCMs.•We present a preliminary alternative model for surveillance of patients with CCMs.

This article reviews the literature pertinent to epigenetic changes, and in particular, DNA methylation following traumatic brain injury (TBI). TBI is a heterogeneous disease that is a major cause of death and long-term disability. The links between TBI and epigenetics, the process by which environmental factors alter gene expression without changing the underlying DNA sequence, is an expanding area of research that may have profound consequences for understanding the disease, and for clinical care. There are various epigenetic changes that may occur as a direct result of TBI, including DNA methylation, histone modification, and changes in the levels of non-coding RNA. This review focuses on DNA methylation, its potential to alter the degree of injury, and the extent of recovery, including development of post-traumatic neurodegeneration, response to therapies, and the hereditable consequences of injury. The functional consequences of non-coding RNA and histone modifications are well described in the literature; however, the mechanism by which these three mechanisms interact are often overlooked. Here, we briefly describe the interaction of DNA methylation with the two other key epigenetic changes, and highlight key work being performed to understand the functional relevance of those mechanisms. The field of epigenetics is rapidly advancing as a result of the advent of less invasive and more versatile methods for measuring epigenetic proteins and their functional impact on cells; however, the evidence specific to TBI is limited. This review identifies several important outstanding questions that remain from the work already conducted, and highlights directions for the future.

ObjectiveThis study aims to develop a comprehensive process map for patients with brain tumours to identify opportunities for quality improvement and automated data collection. Through optimising workflows, the overall goal is to improve patient recruitment to clinical trials.DesignA two-stage mixed methods design, combining qualitative development of a process map with quantitative validation using electronic health records (EHR). Following this, a cross-sectional survey was conducted to assess how patients learn about clinical trials.SettingA single neurosurgery centre in the United Kingdom.ParticipantsThe process map was developed through stakeholder interviews with neuro-oncology multidisciplinary team members and patients (n=13). Clinical encounters were validated with EHR data from 50 patients. A cross-sectional survey presented the validated process map to 25 postoperative patients to identify the resources they used to learn about ongoing clinical trials.InterventionsPostoperative questionnaires were given to patients after brain tumour surgery, either on the ward or in follow-up clinic.Primary and secondary outcome measuresThe primary outcome was the percentage of the study cohort that was present at encounters on the process map. Key timepoints were defined if >80% of patients were present. They represent high-yield opportunities to offer information on clinical trial recruitment. The secondary outcome was the resources used by patients to learn about ongoing clinical trials.ResultsQuantitative validation of patient pathways identified 345 encounters involving 19 discrete events, including clinics, telephone follow-ups and treatments. The flow of encounters reflected the process map with 90.7% accuracy, with key timepoints identified at imaging and biopsy/surgical procedures. A cross-sectional survey conducted during outpatient neuro-oncology clinics identified that patients predominantly used self-directed internet searches (n=17, 68%) and verbal information from their neurosurgeon (n=16, 64%) to learn about clinical trials.ConclusionsThis study demonstrates the effectiveness of process mapping in identifying key timepoints for automated data collection and opportunities for quality improvement for clinical trial recruitment. Integrating online and in-clinic education strategies could enhance patient awareness and participation in clinical trials.

IntroductionUnruptured intracranial aneurysms (UIA) are common in the adult population, but only a relatively small proportion will rupture. It is therefore essential to have accurate estimates of rupture risk to target treatment towards those who stand to benefit and avoid exposing patients to the risks of unnecessary treatment. The best available UIA natural history data are the PHASES study. However, this has never been validated and given the known heterogeneity in the populations, methods and biases of the constituent studies, there is a need to do so. There are also many potential predictors not considered in PHASES that require evaluation, and the estimated rupture risk is largely based on short-term follow-up (mostly 1 year). The aims of this study are to: (1) test the accuracy of PHASES in a UK population, (2) evaluate additional predictors of rupture and (3) assess long-term UIA rupture rates.Methods and analysisThe Risk of Aneurysm Rupture study is a longitudinal multicentre study that will identify patients with known UIA seen in neurosurgery units. Patients will have baseline demographics and aneurysm characteristics collected by their neurosurgery unit and then a single aggregated national cohort will be linked to databases of hospital admissions and deaths to identify all patients who may have subsequently suffered a subarachnoid haemorrhage. All matched admissions and deaths will be checked against medical records to confirm the diagnosis of aneurysmal subarachnoid haemorrhage. The target sample size is 20 000 patients. The primary outcome will be aneurysm rupture resulting in hospital admission or death. Cox regression models will be built to test each of the study’s aims.Ethics and disseminationEthical approval has been given by South Central Hampshire A Research Ethics Committee (21SC0064) and Confidentiality Advisory Group support (21CAG0033) provided under Section 251 of the NHS Act 2006. The results will be disseminated in peer-reviewed journals.Trial registration numberISRCTN17658526.

ObjectivesBuild the theoretical and evidence-base for a digital platform (map-OR) which delivers intraoperative language tests during awake craniotomy and facilitates collaborative sharing of brain mapping data.DesignMixed methodology study including two scoping reviews, international survey, synthesis of development guiding principles and a risk assessment using failure modes and effects analysis.SettingThe two scoping reviews examined the literature published in the English language. International survey was completed by members of awake craniotomy teams from 14 countries.Main outcome measuresScoping review 1: number of technologies described for language mapping during awake craniotomy. Scoping review 2: barriers and facilitators to adopting novel technology in surgery. International survey: degree of language mapping technology penetration into clinical practice.ResultsA total of 12 research articles describing 6 technologies were included. The technologies required a range of hardware components including portable devices, virtual reality headsets and large integrated multiscreen stacks. The facilitators and barriers of technology adoption in surgery were extracted from 11 studies and mapped onto the 4 Unified Theory of Acceptance and Use of Technology constructs. A total of 37 awake craniotomy teams from 14 countries completed the survey. Of the responses, 20 (54.1%) delivered their language tests digitally, 10 (27.0%) delivered tests using cards and 7 (18.9%) used a combination of both. The most commonly used devices were tablet computers (67.7%; n=21) and the most common software used was Microsoft PowerPoint (60.6%; n=20). Four key risks for the proposed digital platform were identified, the highest risk being a software and internet connectivity failure during surgery.ConclusionsThis work represents a rigorous and structured approach to the development of a digital platform for standardized intraoperative language testing during awake craniotomy and for collaborative sharing of brain mapping data.Trial registration numberScoping review protocol registrations in OSF registries (scoping review 1: osf.io/su9xm; scoping review 2: osf.io/x4wsc).

BackgroundMidline shift in trauma relates to the severity of head injury. Large craniectomies are thought to help resolve brain shift but can be associated with higher rates of morbidity. This study explores the relationship between craniectomy size and subtemporal decompression for acute subdural haematomas with the resolution of brain compression and outcomes. No systematic study correlating these measures has been reported.MethodA retrospective study of all adult cases of acute subdural haematomas that presented to a Major Trauma Centre and underwent a primary decompressive craniectomy between June 2008 and August 2013. Data collection included patient demographics and presentation, imaging findings and outcomes. All imaging metrics were measured by two independent trained assessors. Compression was measured as midline shift, brainstem shift and cisternal effacement.ResultsThirty-six patients with mean age of 36.1 ± 12.5 (range 16–62) were included, with a median follow-up of 23.5 months (range 2.2–109.6). The median craniectomy size was 88.7 cm2 and the median subtemporal decompression was 15.0 mm. There was significant post-operative resolution of shift as measured by midline shift, brainstem shift and cisternal effacement score (all p < .00001). There was no mortality, and the majority of patients made a good recovery with 82.8% having a Modified Rankin Score of 2 or less. There was no association between craniectomy size or subtemporal decompression and any markers of brain shift or outcome (all R2 < 0.05).ConclusionsThis study suggests that there is no clear relationship between craniectomy size or extent of subtemporal decompression and resolution of brain shift or outcome. Further studies are needed to assess the relative efficacy of large craniectomies and the role of subtemporal decompression.

Are you about to start the Foundation Programme?Do you know what to expect and how to thrive?The Hands-on Guide for Junior Doctors , Fourth Edition, is the ultimate, practical guide for junior doctors and medical students.

Background Awake craniotomy allows continuous assessment of a patient’s clinical and neurological status during open brain surgery. This facilitates early detection of interference with eloquent cortex, and hence can allow a surgeon to maximize resection margins without compromising neurological function. Methods Awake craniotomy requires an effective scalp blockade, intraoperative assessment, and a carefully co-ordinated theatre team. A variety of clinical and electrophysiological techniques can be used to assess cortical function. Conclusions Effective scalp blockade and awake craniotomy provides the opportunity to intraoperatively assess cortical function in the awake patient, thus providing an important neurosurgical option for lesions near eloquent cortex.

There has been an explosion in the development of microscopic and miniaturized technology over the past decade and we have long awaited their arrival and integration into clinical practice. We have now reached the stage where promises are beginning to be delivered. This article reviews their place in modern medicine and looks toward the future. Miniature camera robots (microrobots) provide a mobile viewing platform, enhancing a surgeon s view. Nanorobots have arisen from the fictional world of the 'Fantastic Voyage and are finally approaching clinical application. As the targeting and drive forces are further developed, these vehicles could be realistically used for delivery of agents for diagnosis and therapies. These new robots have the potential to further evolve the robotic armamentarium for surgeons.