Although increasingly used, the precise role of radiotherapy in the management of meningiomas is still disputed. The objective of this study, therefore, was to appraise the evidence for adjuvant radiotherapy in benign and atypical intracranial meningiomas, and to compare and contrast it with the current opinion and practice of neurosurgeons in the United Kingdom and the Republic of Ireland. The use of radiotherapy as a primary treatment strategy or its use in the treatment of recurrence was not considered. We performed a systematic review of the evidence for adjuvant radiotherapy in benign and atypical intracranial meningiomas, surveyed current opinion amongst neurosurgeons involved in such cases and ascertained local practice using data from the regional cancer registry. Overall, 10 cohorts were identified that fulfilled our eligibility criteria. Four studies showed significantly improved local control in patients receiving adjuvant radiotherapy for incompletely resected grade I meningiomas. Our survey demonstrated that the vast majority (98%) of neurosurgeons would not recommend adjuvant radiotherapy in grade I meningioma. In grade II meningioma, most (80%) would not advocate adjuvant radiotherapy if completely excised, but the majority (59%) would recommend radiotherapy in cases of subtotal resection. Significant variation in opinion between centres exists, however, particularly in cases of completely resected atypical meningiomas (p = 0.02). Data from the Eastern Cancer Registration and Information Centre appears to be in line with these findings: less than 10% of patients with grade I meningiomas, but almost 30% of patients with grade II meningiomas received adjuvant radiotherapy in the Eastern region. In conclusion, our study has highlighted significant variation in opinion and practice, reflecting a lack of class 1 evidence to support the use of adjuvant radiotherapy in the treatment of meningiomas. Efforts are underway to address this with a randomized multicentre trial comparing a policy of watchful waiting versus adjuvant irradiation.

We aim to describe the outcomes after chronic subdural hematoma drainage (CSDH) management in a large cohort of patients on antithrombotic drugs, either antiplatelets or anticoagulants, at presentation and to inform clinical decision making on the timing of surgery and recommencement of these drugs. We used data from a previous UK-based multi-center, prospective cohort study. Outcomes included recurrence within 60 days, functional outcome at discharge, and thromboembolic event during hospital stay. We performed Cox regression on recurrence and multiple logistic regression on functional outcome. There were 817 patients included in the analysis, of which 353 (43.2%) were on an antithrombotic drug at presentation. We observed a gradual reduction in risk of recurrence for patients during the 6 weeks post-CSDH surgery. Neither antiplatelet nor anticoagulant drug use influenced risk of CSDH recurrence (hazard ratio, 0.93; 95% confidence interval [CI], 0.58-1.48; p = 0.76) or persistent/worse functional impairment (odds ratio, 1.08; 95% CI, 0.76-1.55; p = 0.66). Delaying surgery after cessation of antiplatelet drug did not affect risk of bleed recurrence. There were 15 in-hospital thromboembolic events recorded. Events were more common in the group pre-treated with antithrombotic drugs (3.3%) compared to the non-antithrombotic group (0.9%). Patients on an antithrombotic drug pre-operatively were at higher risk of thromboembolic events with no excess risk of bleed recurrence or worse functional outcome after CSDH drainage. The data did not support delaying surgery in patients on antithrombotic therapy. In the absence of a randomized controlled trial, early surgery and early antithrombotic recommencement should be considered in those at high risk of thromboembolic events.

ObjectivesStereotactic brain biopsy is among the most common neurosurgical procedures. Planning a safe surgical trajectory requires careful attention to a number of features including:traversing the skull perpendicularly;avoiding critical neurovascular structures; andminimising trajectory length.The aim of this study was to develop a platform, SurgiNav, for automated trajectory planning in stereotactic brain biopsy.MethodsA prospectively maintained database was searched between February and August 2017 to identify all adult patients that underwent stereotactic brain biopsy in whom post-operative imaging was available. In each case, the standard pre-operative T1-weighted gadolinium-enhanced MRI was used to generate models of the cortex and vasculature. A surgical trajectory was then generated using automated computer-assisted planning (CAP) and metrics compared to the trajectory of the implemented manual plan (MP) using the paired T-test.Results15 consecutive patients were identified; who had a diagnostic biopsy and there were no immediate complications. Feasible trajectories were generated using CAP in 12 patients, and in these the mean trajectory length using CAP was comparable to MP (31.7 mm vs. 37.1 mm; p=0.3), and mean angle was similarly perpendicular from orthogonal (9.3° vs. 15.3° p=0.1), but the risk-metric was significantly lower (0.16 vs. 0.48; p=0.03).ConclusionsComputer-assisted planning for stereotactic brain biopsy appears feasible in most cases and may be safer in selected cases.

PurposeGlioblastoma prognosis is poor. Treatment options are limited at progression. Surgery may benefit, but no quality guidelines exist to inform patient selection. We sought to describe variations in surgical management at progression, highlight where further evidence is needed, and build towards a consensus strategy. MethodsCurrent practice in selection of patients with progressive GBM for second surgery was surveyed online amongst specialists in the UK and Europe. We complemented this with an assessment of practice in a retrospective cohort study from six United Kingdom neurosurgical units. We used descriptive statistics to analyse the data. Results234 questionnaire responses were received. Maintaining or improving patient quality of life was key to decision making, with variation as to whether patient age, performance status or intended extent of resection was relevant. MGMT methylation status was not important. Half considered no minimum time after first surgery. 288 patients were reported in the cohort analysis. Median time to second surgery from first surgery 390 days. Median overall survival 815 days, with no association between time to second surgery and time to death (p=0.874). ConclusionThis is the most wide-ranging examination of contemporaneous practice in management of GBM progression. Without evidence-based guidelines, the variation is unsurprising. We propose consensus guidelines for consideration, to reduce heterogeneity in decision making, support data collection and analysis of factors influencing outcomes, and to inform clinical trials to establish whether second surgery improves patient outcomes, or simply selects to patients already performing well.

ObjectivesVestibular dysfunction following traumatic brain injury (TBI) is a major cause of morbidity and unemployment and has impact on the patient’s ability to rehabilitate. Chronically, up to a quarter of TBI cases have cryptogenic dizziness and imbalance, possibly due to chronic brain adaptation that masks the diagnosis. Establishing the spectrum of vestibular diagnoses in acute TBI – when they may be more obvious – may aid diagnosis in chronic TBI cases.DesignProspective audit of referrals to specialist neuro-otology team.SubjectsConsecutive Major Trauma Ward TBI in-patients admitted between June 2014 and May 2015.MethodsAll cases were screened by the therapists for vestibular symptoms and/or signs and referred for specialist neuro-otology review.ResultsOf 111 patients screened, 96 had features of vestibular dysfunction. Of 96 cases, SYMPTOMS (i.e. subjective report) included: – imbalance (58.3%) – headache (50%) -dizziness (40%) Of 96 cases, SIGNS (i.e. examination) included: – gait ataxia (75.5%) – broken smooth pursuit (61.2%) – positive Hallpike (51%) – positive head impulse test (18%). The data indicate that BPPV affects 49% and headache with migraine-like features affect 40.8%. Acute peripheral unilateral vestibular loss affects 18% TBI cases.ConclusionsVestibular dysfunction in TBI is common, typically involving peripheral and central structures, often in the same case, and requires specialist neuro-otological management.