This technique of image-guided biopsy has high diagnostic yield with acceptably low morbidity and may be performed as a day case. Intraoperative neuropathological examination would not have increased the diagnostic yield further in this study, and its routine use may not be necessary. In the authors' department pounds sterling 70,350 (UK)/$114,522 (US) would have been saved by not using intraoperative neuropathology in this series. Therefore, intraoperative neuropathology should no longer be routinely recommended.
Day-case biopsy and craniotomy for brain tumours have been reported as safe and feasible options for selected patients. The incidence and timing of complications after such procedures has also been characterized in recent publications. However, more widespread adoption of day-case cranial neurosurgery has not taken place. We report the first UK series of day-case surgery for intra-axial tumours, consisting of 30 image-guided biopsies and 11 craniotomies, taking place over 1 year from October 2006. Patients were studied prospectively and 27/30 biopsy and 9/11 craniotomy patients were discharged 6 h postoperatively. One biopsy case was admitted due to increased headache postoperatively, but with a normal CT and one craniotomy case had transient worsening of lower limb paresis requiring overnight admission. The three other overnight admissions were for patient preference. One biopsy patient was readmitted 30 h postoperatively with a seizure and discharged the following day. No patients suffered an adverse outcome. The results are presented together with the Toronto series of 284 cases over 11 years, also with no patients suffering an adverse outcome because of planned early discharge. These results suggest that day-case surgery for brain tumours is a safe and feasible option for patients in the UK.
This preliminary study suggests that 30 minutes of moderate intensity exercise in ALL patients receiving maintenance therapy provides a similar neutrophil response to that of healthy age and sex-matched controls.
Awake craniotomy is increasingly used to facilitate safe maximal resection of brain tumours. Very little published data is available to determine patient experiences and satisfaction. This knowledge may lead to improvement in technique and enhance future patient care. In 2006, we began to use conscious sedation ('full awake technique') for craniotomies for tumour resection. A questionnaire designed with reference to Royal College of Surgeons (RCS) guidelines was sent out to 60 consecutive patients. Four areas of care were explored. These included the out-patient consultation with the neurosurgeon, anaesthetic consultation, operation and the post-operative period. Fourty-five responses were received. Ninety-three percent of the patients in our study felt involved sufficiently in the decision for awake surgery and felt they were given enough information when seen in the surgical consultation. However, only 64% of patients received written information in advance of their surgical date. Ninety-one percent of patients were confident that they would be looked after during surgery following their anaesthetic consultation. Eighty-seven percent of patients felt at ease during surgery. Twenty-four percent experienced some discomfort during surgery, some of which was related to positioning of the patient rather than surgical technique. Fifty-six percent of our patients reported no post-operative pain. Eighty-four percent of patients were happy with timing of their discharge. Eighty percent felt well supported post-discharge. This study demonstrates high levels of patient satisfaction and provides surgeons with useful data for consenting patients. We identified no difference in levels of patient satisfaction comparing day-case patients with those admitted. We identified areas for improvement including provision of written information, enhancing post-discharge support and allowing more time for anaesthetic discussion before surgery.
Alterations in the hypothalamo-pituitary-adrenal (HPA) axis following traumatic brain injury have not been documented in detail. We used fluid percussion injury (FPI) to evaluate the early changes in components of the HPA axis following experimental traumatic brain injury. Wistar rats were sacrificed at 2 or 4 h following sham or FPI surgery. In situ hybridization histochemistry was used to determine the expression of mRNAs of corticotrophin releasing hormone (CRH) and arginine vasopressin (AVP) in the hypothalamus and pro-opiomelanocortin (POMC) in the pituitary. A group of animals undergoing no surgery were used as control. Repeated blood sampling from an indwelling catheter demonstrated that plasma corticosterone (CORT) levels peaked 30 min following surgery in sham and FPI animals but there was no significant difference in CORT concentration between these groups at any time. Pituitary POMC expression was increased following sham and FPI surgery (compared with control non-operated animals) but with no significant difference between the two groups undergoing surgery. Hypothalamic CRH mRNA expression was significantly higher in animals undergoing FPI compared with sham surgery. Hypothalamic AVP mRNA expression was not significantly increased when compared with control nonoperated animals. These data indicate that the anaesthesia and/or surgery associated with FPI or sham surgery induces a generalised activation of the HPA axis. The selective increase in CRH mRNA in animals undergoing FPI may be due to specific effects of traumatic brain injury rather than a general stress response and may suggest an additional neurotransmitter role for CRH following head injury. The absence of an AVP response suggests that the effects of FPI may be mediated through the CRH-alone-containing subpopulation of neurons.
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