Acta Neurochirurgica 46, 173--180 (1979)

9 by Springer-Verlag 1979

Abstracts of Papers Presented at the 94th Meeting of the Society of British Neurological Surgeons, London, 14--15 September 1978 Collected by

P. R. R. Clarke

Crockard, H. A., Gordon, D. S. (Belfast): Treatment of Giant Aneurysms by Intra-Aneurysmal Cuprous Wiring. Giant intracranial aneurysms pose a rare but difficult surgical problem; Mullan of Chicago described their obliteration by inserting fine copper alloy wires to produce intra-aneurysmal thrombosis. We have used the technique in nine cases; five internal carotid, one middle cerebral, and one anterior communicating aneurysm, and two carotico-cavernous fistulas. Seven presented as space-occupying lesions, and two had subarachnoid haemorrhages. One of the latter died due to post-operative spasm and another from a perforated duodenal ulcer, but all the others improved following the procedure, and their proptosis and cranial nerve palsies resolved. None has bled from a treated aneurysm, and post-operative angiography has shown a marked reduction in aneurysmal lumen. In one patient we have successfully removed the bulk of the clot. Details of the technique were described.

Gibson, R. M. (Leeds): Spontaneous Rhinorrhoea. Post-traumatic rhinorrhoea is well-known to neurosurgeons, although the indications for, and the timing of operative repair may be subject to individual preference or experience. The spontaneous or non-traumatic variety of rhinorrhoea is much less common, and in the first instance may present to the physician or otolaryngologist as a "rhinitis" or a "running nose". Little has been written on the subject of spontaneous rhinorrhoea with the exception of excellent contributions by O'Connell (1964) and Ommaya (1968). The classification proposed at that time by Ommaya has the advantage of simplicity but it is not entirely satisfactory. The present paper reviews the salient clinical features of spontaneous rhinorrhoea in a personal series of 10 cases and several others referred by colleagues, and annotates the high pressure variety, the tendency to copious flow, and the much lower incidence of meningitis in these cases than in the traumatic group. Recent methods of investigation are examined. The spontaneous variety always requires operative closure. The proposition is made that some of the low pressure spontaneous leaks are in fact delayed-onset traumatic cases, and a numerically small but important variety following long-standing chronic rhinitis with atrophy of the olfactory

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P . R . R . Clarke:

bulb and filaments is described. Because of the rarity of the condition case numbers are small and these are propositions to be further considered rather than conclusions. Nonetheless, it is important to recognise these cases and to cIose the fistulas.

Galbraith, S., Teasdale, G., Jennett, B. (Glasgow): The Results of Conservative _Management of Acute Traumatic Intradural Haematoma. Since the introduction of computer tomography it has become apparent that haematomas can be present in patients who are not clinically deteriorating. Because the natural history of these haematomas was not known we have studied 17 patients to determine how often operation was required and whether this could be predicted. Only 6 (350/0) patients eventually required operation, and of those managed conservatively 9 made a good recovery, 1 remained severeIy disabled, and I died. Patients who were not in coma and had no midline shift did not require operation; other than this, age, midline shift, intracranial pressure, and level of responsiveness were unhelpful in predicting the need for surgery. The implications of these findings were discussed.

Mendelow, A. D., Karmi, M., Paul, K., Fuller, G. A., Gillingham, F. J. (Edinburgh): The Importance of Immediate Surgery in Patients With Extradural Haematoma. All patients with extradural haematomas treated in the Edinburgh area over two separate decades (1951-1960 and 1968-1977) were analysed to assess tile effect of delay on morbidity and mortality. A totaI of 145 cases were treated surgically, and of these 50 were associated with subdural haematoma or brain contusion or both. Only extradurai haematomas of greater than 1.5 cm in thickness were included in the present study (83). Five posterior fossa haematomas were encountered. In seven patients time intervals were inadequately documented, and they were therefore excluded. The results of the study are summarized in the table below :

Number of cases Mean delay from deterioration in consciousness to start of operation Good recovery Mortality





8.0 40.7% 33.3%

1.4 (hours) 67.9% 8.9%

Detailed analysis of the delay from deterioration in level of consciousness to definitive operation showed that a delay of more than 2 hours resulted in increased morbidity and mortality in both groups. The policy of immediate admission of all head injuries for at least 24 hours to the head and spinal injuries unit of the Department of Surgical Neurology was not instituted until after 1960. The improved results in the 1968-1977 period suggest that this policy is advantageous because of the earlier surgical intervention that was possible.

Abstracts of Papers Presented at the 94th Meeting


Ramamurthi, B. (Madras): Nonvolitional Biofeedback in the Control of Some Higher Nervous Functions. Feedback techniques to enhance or retard certain physiological functions like pulse rate and blood pressure have been well known for many years. This paper presented the adoption of the technique of non-volitional biofeedback in the control of some higher nervous functions. The EEG waves from the subjects scalp are analysed and separated by a wave analyser into delta, theta, alpha, and beta frequencies. Selected frequencies are fed back to the subject as light stimuli through a system where the frequency and the amplitude of the EEG wave modulates the frequency and the intensity of the light stimuli. Such biofeedback techniques lead to definite changes in the EEG pattern, as well as the psychological state of the subject. Generally, delta waves produce discomfort, alphas induce tranquilUity, and betas cause drowsiness. The technique has been tried on patients with intractable epilepsy, chronic depression, and anxiety neuroses, with beneficial results. The paper also indicates the progress of experiments where wave forms from the EEGs of Yogis and meditators are fed back to healthy subjects and patients with depression and anxiety neurosis.

Hardy, G. (London): The Relationships Between the Superior Cerebellar Artery and the Trigeminal Nerve. Arterial compression and distortion of the trigeminal nerve at the pons has been observed in patients with trigeminal neuralgia i ~. This observation has formed the basis for its treatment by the operation of posterior fossa neurovascular decompression 8. However, little information has been published on the normal neurovascular relationships in the area. In this study, the relationship between the superior cerebellar artery and the trigeminal nerve was investigated in 66 cadaveric hemispheres. In 38 some relationship between the trigeminal nerve and adjacent vessels was found. In 34 the vessel involved was the superior cerebellar artery, and in 4 the vessel involved was the anterior inferior cerebellar artery. Not all produced distortions of the nerve, but this was not uncommon, and in 10 cases contact occurred at the dorsal root entry zone. The implications of these findings were discussed. 1. Dandy, W. E., Amer. J. Surg. 24 (1934), 447--455. 2. Jannetta, P. J., J. Neurosurg. 26 (1967), 159--I62. 3. Jannetta, P. J., Prog. Neurol. Surg. 7 (1976), 180--200.

Perrin, R. G., Livingston, K. E. (Toronto): The Neurosurgical Management of Spinal Metastases Causing Cord or Cauda Equina Compression. Spinal metastases causing cord compression occur i n about 5 o of patients with systemic cancer. They inevitably produce devastating morbidity, and it is widely held that surgical treatment is ineffective. In our experience such a gloomy verdict is not justified. We have treated 100 patients with spinal metastases causing cord or cauda compression between 1968 and 1978.


P . R . R . Clarke:

Thirty-nine men and 61 women ranged in age from 21 to 80 years. Thirty per cent (all women) had breast cancer. The most common primary in men was prostatic carcinoma. Pain was the earliest and most prominent symptom, followed by weakness. Preoperatively, 97 patients demonstrated motor impairment--50 were completely bedridden, and 21 were totally paraplegic. Sensory abnormalities were defined in 90 patients, Five presented with Brown-Sequard syndrome. Bladder dysfunction was recorded in 40 patients. Spinal compression occurred in the thoracic region in 76 patients. Surgical treatment involved urgent and extensive laminectomy decompression. Concomitant spinal stabilization was performed in ten cases, involving posterior rib graft fusion (7) and Harrington rod instrumentation (3). In January 1978 29 of these patients were living. The average post-operative survival was 2.3 years. Seventy-one patients had died, with an average survival of 8.8 months. Surgical decompression produced ineffective pain relief in 70%. Fifty-eight patients were ambulatory post-operatively--40 were walking and continent of urine 6 months following surgery (including 5 patients who presented as totally paraplegic). A positive approach and aggressive management in this problem can achieve results superior to those generally reflected in the literature. Kothandaram,

P., S h e t t y , K . R. ( S a l f o r d ) :

Delayed Extradural

Haematoma--Review of 10 Cases. While the majority of extradural haematomas are acute, and the clinical presentation is fairly typical, we described 10 cases of delayed extra-dural haematomas wherein the symptoms of cerebral compression were late in onset, from four to five days to as late as three weeks after trauma. They were all fully conscious, except for one patient who remained unconscious from the time of the accident. The only complaint in the majority was of bouts of severe head ache and infrequent vomiting. Only five of the ten cases had blurring of optic disc margins with congested veins. In the remaining five the optic discs were normal. Eight of the ten cases had radiological evidence of fracture of the skull. In two cases there was no evidence of fractured skull either in the X-rays or at the time of operation. Two patients had bilateral extradural clots. Carotid angiography was performed in 8 of the 10 cases. In two cases the extradural clot was detected at the time of elevating a simple depressed fracture of the skull. S h a n n o n , N . ( L o n d o n ) : Is Unilateral Excision of Protruded Lumbar Intervertebral Discs Adequate Surgical Treatment? A retrospective study including computer analysis has been made of 323 protruded lumbar intervertebral discs at the L 4/5, L 5/S 1 levels only. Twenty had central protrusions operated on bilaterally, and over a mean eight year follow-up period there have been no recurrences requiring re-operation, whereas 15 of 301 unilaterally operated cases recurred over the same interval. Further analysis showed the L4/5 recurrences (1I) to be statistically greater than the L5/S 1 recurrences (4).

Abstracts of Papers Presented at the 94th Meeting


The paper also discussed correlates between the weight of disc excised and the likelihood of recurrence and long term (more than four years) morbidity classified into three grades, viz grade I--asymptomatic with no signs; grade II a - symptomatic with no signs; grade II b--symptomatic with signs. The terms recurrence, nonrecurrence and new protrusions were defined. Five of the 301 cases developed new protrusions within six years of the first operation, and the rationale for two level explorations was discussed. M a c F a r l a n e , M . , S y m o n , L. ( L o n d o n ) : Lyophilized Dura: Experimental Implantation and Extended Clinical NeurosurgicaI Use. Lyophilized human cadaver dura has been implanted intracranially in baboons, and the accompanying histological changes have been documented. Over a ten year period lyophilized dnra has been used in over 100 patients in clinical neurosurgical practice. The indications and efficacy of lyo-dura in the reconstitution of dural defects were described. Pickard,




Vasoactive Agents and Cerebral

Ischaemia. The evidence remains controversial for the old concept that the effects of focal cerebral ischaemia are exacerbated by leakage of vasoactive agents from ischaemic neurones. It is uncertain whether the effects of such agents are the result of vasoconstriction of cerebral vessels or of disturbance of synaptic activity, of cerebral metabolism, or of the blood-brain barrier. Experiments on the effects of prostaglandins, both exogenous and endogenous, on the cerebral circulation in primates have demonstrated some of the relative quantitative contributions that such agents might make to the consequences of cerebral ischaemia. J e f f e r s o n , A . ( S h e f f i e l d ) : The Management and Treatment of the Intracranial Arteriovenous Malformation: A Survey After 22 Years. This paper reports the management and the results of treatment in a series of 73 consecutive patients admitted during the last 22 years on account of an intracrania] arteriovenous malformation. It was hoped to draw the attention-particularly of our medical colleagues--to the scope and safety of surgery with particular reference to the various technical advances of the past few years. Forty-two patients were operated on with only two deaths (one of these was due to an error of judgement in tackling a lesion graded as inoperable 13 years previously). From this series there is no definite evidence that conventional radiation therapy reduced the size of the treated lesions. Nevertheless, to date, the only one of these twelve patients to have succumbed from the effect of an arteriovenous malformation was the one with the massive lesion who died postoperatively and who has already been mentioned. In contrast, 4 of the 16 patients treated conservatively have died as a result of their malformations. One patient developed fits following surgery and another (who presented with epilepsy) may have developed an increased liability to epilepsy following the operation. Operation induced a significant long-term neurological deficit in no more than 15~ of the 40 postoperative survivors. However, the possible snags of surgery have to be viewed against the actual deficits which are repeatedly 12

Acta Neurochirurgica, Vol. 46, Fasc. 1--2


P . R . R . Clarke:

encountered when an arteriovenous malformation bleeds and gives rise to an intracranial haematoma which is frequently massive and near fatal. The longterm follow up in this series has allowed serial observations on some patients who had initially been rejected as surgical candidates but were re-admitted to hospital later with a serious deficit from a further haemorrhage. The fact that arteriovenous malformations may be excised with relative impunity from areas that are commonly regarded as neurologically very sensitive is illustrated. It is not suggested that all arteriovenous malformations could or should be excised but the author believes that all arteriovenous malformations should be referred for a surgical opinion. J e f f r e y s , R. V. ( L i v e r p o o l ) :

The Surgical Treatment of Cervical

Spondylotic Myelopathy. There is still debate on the indications for surgery and the type of operation in patients with cervical spondylotic myelopathy (CSM). In a personal prospective series of patients with CSM 50 patients have been treated by Cloward's operation, and 13 by decompressive cervical laminectomy. The indications for surgery and the type of operation were decided upon at the beginning and adhered to throughout the series. Of the 50 patients treated by Cloward's operation 44 have returned to employment, 3 have been much improved, and 3 remained unchanged. The patients treated by laminectomy were suffering from multiple anterior protrusion, congenital canal stenosis, or indentations from ligamentum flavum. Eleven of these have benefited to varying extents, and the other 2 have remained unchanged. P u n t , J. ( L o n d o n ) :

Spinal Compression from Neuroblastorna--

Review of 21 Cases. Neuroblastomas comprise 8~ of all childhood malignant tumonrs. Presentation with spinal compression is unusual. Paradoxically, the commonest spinal turnout in paediatric neurosurgical practice is neuroblastoma. The records of 21 children in whom the presentation of neuroblastoma was with spinal compression were reviewed: 15 were direct extensions of paraspinal tumours, and 6 were wholly intraspinal. Striking differences from the majority of neuroblastomas were the large proportion of children under one year of age (11/21), the virtual absence of disseminated disease at presentation (2/21), and the high survival rate (13/21). Morbidity was, however, high, 6/13 survivors having a permanent neurological deficit. This related to the very young age of many of the surviving children, four of whom had had deficit from birth. P r i c e , D . J., M a s o n , J., D u g d a l e , R. E. (Leeds): An Attempt at More Effective Control of Status Epilepticus by Using a Computer. Repeated or prolonged generalized epilepsy unfortunately continues to be a cause of unnecessary secondary brain damage. The initial urgent management by elective ventilation to correct both the hypoxia and hypercarbia is essential, but it is then necessary to establish a satisfactory brain level of anticonvulsant before attempting to wean the patient off the ventilator.

Abstracts of Papers Presented at the 94th Meeting


High dose of an anticonvulsant with minimal sedative side effects is required and the dosage of the drug given intravenously can best be controlled by a simple computer based servo-system. We describe how a minicomputer detects the frequency of seizure activity from bi-parietal electrodes, and then adjusts the rate of infusion of Sodium Valproate to attain optimum control. Neil-Dwyer,

G., B a r t l e t t , J. R. ( W o o l w i c h ) :

The Role of the

Head Scanner in the Care of the In)ured. The records of 377 head-injured patients admitted to the South East Thames Regional Neurosurgical Unit in the two years following the introduction of the EMI Scanner were examined. Each patient was assessed on the reason for transfer, the necessity for transfer, the safety of transfer, and whether immediate access to a scanner would have altered management. The results show that the majority of patients were referred because of a possible intracranial haematoma, 30o/0 of the patients required operation, in 6% transfer was unnecessary, and 10~ arrived with inadequate resuscitation. It is suggested that with a wider deployment of head-dedicated scanners to some accident centres the majority of head-injured patients currently being transferred to special units for assessment would be reduced substantially with improvement of patient care. T e a s d a l e , G., H a y , I. D., M c C r u d e n , D., Beastall, G. H . , G r o s s a r t , K . W . ( G l a s g o w ) : Cushing's Precept Fulfilled? The management of functioning pituitary tumours is currently controversial. We have reviewed the results of 58 transphenoidal operations for acromegaly. Half were performed using a stereotaxic cryosurgical technique, and half by microsurgical dissection. The features of the patients in the two groups were similar. After cryosurgery only 21~ of patients had normal levels of growth hormone ( < 10 mu/L). Microsurgery gave better results, growth hormone levels becoming normal in 65~ and this method was especially effective in patients with small tumours (sella area < 1.6 cme), of whom 930/o achieved normal growth hormone levels. The "cure" of growth hormone-producing adenomas by early transphenoidal microsurgery represents the achievement of a goal first stated by Harvey Cushing in 1927. G a r f i e l d , J. ( S o u t h a m p t o n ) : Status of European Organisation for Research on Treatment of Cancer (E.O.R.T.C.)--Brain Tumour Group Glioma Trials. The first study (26,741), with 111 patients randomized between January 1973 and November 1975, showed that after resection of supratentorial malignant glioma and radiotherapy (5,500 to 6,000 rads) CCNU without steroids did not prolong free interval; objective remission (3 to 14 months) occurred in 30o/0, and CCNU after relapse prolonged median survival from 22.5 to 62 weeks. Study 26,742 showed that CCNU in patients requiring postoperative steroids prolonged median survival from 21.5 to 31 weeks. 12"


P . R . R . Clarke: Abstracts of Papers Presented at the 94th Meeting

The current randomized study (26,751) of 127 patients in phase I, to assess the effect of CCNU and VM 26, is showing an increase in median free interval from 30 to 46 weeks. The discrepancy between these results and other more favourable reports, and the implications for current management of patients, including the use of steroids and radiotherapy, were discussed.

Merory, J., Du Boulay, G. H., Marshall, J., Ross Russell, R. W., Symon, L., Thomas, D. J., Zilkha, E. (London): Cerebral Blood Flow Following Aneurysmal Surgery After Subarachnoid Haemorrhage. The study of cerebral blood flow in patients who have undergone aneurysmal surgery following subarachnoid haemorrhage has been undertaken to determine why some patients in good clinical condition with uneventful surgery develop late complications. Fifty patients had 385 studies of cerebral blood flow by the intravenous l~aXe clearance method. The time course of cerebral blood flow following surgery has been defined. Normally there is a first postoperative day peak followed by a fall with a further more sustained rise on the fourth and fifth postoperative days. Patients lading the first day peak are more liable to develop complications. Details of these cases were presented in the report, together with suggestions as to how they may be avoided. Author's address: Dr. P. R. R. Clarke, Middlesbrough General Hospital, Ayresome Green Lane, Middlesbrough, Cleveland TS5 5AZ, England.

Abstracts of papers presented at the 94th Meeting of the Society of British Neurological Surgeons, London, 14--15 September 1978.

ACTA NEUROCHIRURGICA Acta Neurochirurgica 46, 173--180 (1979) 9 by Springer-Verlag 1979 Abstracts of Papers Presented at the 94th Meeting of the So...
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