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Background Training of the neurosurgeon today differs greatly from that of the past, with several well-documented challenges contributing to reduced operative time for current cohorts. The Joint Committee on Surgical Training (JCST) in the UK and Ireland have stated that simulation-based education (SBE) is part of the solution to tackle this training crisis. Our objective was to develop a prioritised list of technical skills through consensus with key opinion leaders (KOLs). This approach aimed to enhance understanding of the essential procedures that should shape a technical skills framework for neurosurgical simulation-based learning curricula. Methods We utilised a modified Delphi process and Copenhagen Academy for Medical Education and Simulation (CAMES) Needs Assessment Formula (NAF) to reach consensus. A total of 71 procedures were included for initial analysis, which were extracted from all phases of the JCST curriculum and subsequent brainstorming with KOLs. A five person steering group oversaw the process, to ensure a robust methodological approach was followed at all stages. Results For each of the three Delphi rounds, there were 32, 30, and 31 KOL responses, respectively. A prioritised list of 47 procedural skills was generated through consensus. The top three ranking procedures were patient positioning, pinning positions and flap design, intracranial pressure (ICP) probe insertion and external ventricular drain (EVD) insertion. Emphasis was placed on acute cranial trauma, degenerative spine, neuro-oncology and CSF diversion procedures as the categorical themes of highest priority. Conclusions We describe a multi-jurisdiction general needs assessment for technical skills in neurosurgical simulation training. This study will inform the design of future simulation-based learning curriculum in this sphere of training.

A 75-year-old man with type 2 diabetes mellitus presented with complete loss of vision in his right eye and severe headaches for the past 24 hours. He had been treated for suspected giant cell arteritis (GCA) with high-dose corticosteroids which were being tapered to stop after an inconclusive right temporal artery biopsy and an erythrocyte sedimentation rate (ESR) value of 8. His current acute presentation, however, raised further concern for partially treated GCA and precipitated treatment with pulsed methylprednisolone. The patient, taking metformin, developed diabetic ketoacidosis and was transferred to the intensive care unit where a swollen, painful right eye with chemosis and complete ophthalmoplegia was subsequently revealed to be secondary to cavernous sinus thrombosis. Rhino-orbital skin necrosis with positive samples for the organism Rhizopus on eventual orbital exenteration revealed angioinvasive fungal infection, mucormycosis, to be the cause. We discuss here the lessons learnt, and how best to treat a susceptible cohort within our ageing western population.

Meningioangiomatosis is a rare histologically distinct abnormality that is occasionally associated with intracranial meningioma. The rhabdoid variant of meningioma is also uncommon and is classified as a World Health Organization Grade III tumour. We report a case of meningioangiomatosis in conjunction with a meningioma with prominent rhabdoid features, in an infant male who underwent complete surgical resection of the lesion. The patient has been followed up for 6 years with no disease recurrence. To our knowledge, this is the first report in the literature describing meningioangiomatosis combined with a meningioma with rhabdoid features.

Murat Gunel and colleagues report a genome-wide association study for intracranial aneurysm and identify risk variants near RBBP8 , CNNM and STARD13 . Saccular intracranial aneurysms are balloon-like dilations of the intracranial arterial wall; their hemorrhage commonly results in severe neurologic impairment and death. We report a second genome-wide association study with discovery and replication cohorts from Europe and Japan comprising 5,891 cases and 14,181 controls with ∼832,000 genotyped and imputed SNPs across discovery cohorts. We identified three new loci showing strong evidence for association with intracranial aneurysms in the combined dataset, including intervals near RBBP8 on 18q11.2 (odds ratio (OR) = 1.22, P = 1.1 × 10 −12 ), STARD13 - KL on 13q13.1 (OR = 1.20, P = 2.5 × 10 −9 ) and a gene-rich region on 10q24.32 (OR = 1.29, P = 1.2 × 10 −9 ). We also confirmed prior associations near SOX17 (8q11.23–q12.1; OR = 1.28, P = 1.3 × 10 −12 ) and CDKN2A - CDKN2B (9p21.3; OR = 1.31, P = 1.5 × 10 −22 ). It is noteworthy that several putative risk genes play a role in cell-cycle progression, potentially affecting the proliferation and senescence of progenitor-cell populations that are responsible for vascular formation and repair.

Spinal arachnoid cysts (SAC) are rare in isolation and the exact aetiology is still debated. Primary (congenital) cysts are caused by structural abnormalities in the arachnoid layer and largely affect the thoracic region. Secondary cysts are induced by a multitude of factors, infection, trauma or iatrogenic response, and can affect any level of the spinal cord. While subarachnoid haemorrhage (SAH) is a relatively common condition with significant repercussions, it is extremely uncommonly associated with SAC. When present, it may develop in the months and years after the original bleed, giving rise to new neurological symptoms. Prompt treatment is needed to halt or reverse the worsening of symptoms and questions are still being asked about how best to approach this condition. A 42-year-old man presented with chronic back pain, severe worsening ataxia and numbness below the umbilicus, 7 months after treatment for a World Federation of Neurosurgical Societies grade five (WFNS V) SAH. Imaging revealed a SAC extending from T12 to L4 and causing thecal compression. This was treated with a L3 laminectomy andmarsupialisation. An improvement in neurological function was observed at 6 months. Aetiology of the SAC and its association with SAH are discussed and a review of the relevant literature is provided.