July 2013

These articles have been collected Dr Plat Razis, St. George’s Hospital, London, from the Journal of Neurosurgery. I can highly recommend this journal’s website because many of the articles are free to read in full. Editorial: Barrow Ruptured Aneurysm Trial Andrew Molyneux, F.R.C.R., Richard Kerr, F.R.C.S., and Jacqueline Birks, M.Sc. J Neurosurg July 2013 Volume 119 Issue 1 Pages 139-145 Response Robert F. Spetzler, M.D., Cameron G. McDougall, M.D., Felipe C. Albuquerque, M.D., Joseph M. Zabramski, M.D., Nancy K. Hills, Ph.D., Shahram Partovi, M.D., Peter Nakaji, M.D., and Robert C. Wallace, M.D. This editorial is extremely entertaining as there is history about how the ISAT trial findings were interpreted by the UK and US. From the UK side the argument against BRAT is that it does not fulfil the requirements of the Consolidated Standards of Reporting Trials (CONSORT). As a result the editorial concludes that the “paper is scientifically flawed”. The authors produce a response that hinges on clipping being the first choice of treatment rather than a RCT with equipoise. Although not strictly an “intention to treat” approach, they argue that it is more valid than ISAT because of the very much higher percentage of patients presenting being enrolled into the study. The divide across the pond is maintained. Enjoy it! The Barrow Ruptured Aneurysm Trial: 3-year results: Clinical article Robert F. Spetzler, M.D., Cameron G. McDougall, M.D., Felipe C. Albuquerque, M.D., Joseph M. Zabramski, M.D., Nancy K. Hills, Ph.D., Shahram Partovi, M.D., Peter Nakaji, M.D., and Robert C. Wallace, M.D. J Neurosurg July 2013 Volume 119 Issue 1 Pages 146-157 This is a follow up to 3 years of results that were presented at 1 year with some new sub-group analysis. It is difficult to imagine a similar trial being performed in the UK in which 38% of the patients in the coiling group would cross over to the clipping group. The main reason for their paper is that based on their figures, the degree of aneurysm obliteration, rate of aneurysm recurrence and rate of retreatment was significantly lower in the clipped rather than coiled patients. As there was no difference in the outcomes for anterior circulation aneurysms between the two groups at 3 years, this would strengthen the argument for clipping vs coiling. What is clear, is that posterior circulation aneurysms fared better with coiling although the 2 groups were not matched. I doubt practice in the UK will be influenced by these findings but the concern over long term results in coiled aneurysms remains.

Opening of the blood-brain barrier with an unfocused ultrasound device in rabbits: Laboratory investigation

Kevin Beccaria, M.D., Michael Canney, Ph.D., Lauriane Goldwirt, Pharm.D., Christine Fernandez, Pharm.D., Ph.D., Clovis Adam, M.D., Julie Piquet, M.S., Gwennhael Autret, Ph.D., Olivier Clément, Ph.D., Cyril Lafon, Ph.D., Jean-Yves Chapelon, Ph.D., and Alexandre Carpentier, M.D., Ph.D. Publish before Print article posted online 21 June 2013 These authors investigated the effect on the integrity of the BBB of a new extradurally implanted single-element planar unfocused ultrasound (US) transducer in rabbits. Its effect following 60-120 second bursts was assessed by looking for extravasation of Evans Blue Dye (EBD) with UV-visible spectrophotometry and Gadolinium (Gd) using MRI. Disruption of the BBB by US was significant for both EBD and Gd, with only minor histological changes. The BBB has thwarted many attempts at producing systemically administered drugs from acting on the brain especially in oncology. Perhaps this will lead to improvement in the management of gliomas by chemotherapy.

The impact of smoking on neurosurgical outcomes: A review

Darryl Lau, M.D., Mitchel S. Berger, M.D., Dhruv Khullar, B.A., and John Maa, M.D. Journal of Neurosurgery Posted online on 18 Jun 2013. Reviews of the effects of smoking and anaesthesia abound, but this is the first time I have come across one specifically looking at neurosurgery. Some of the discussion centres on how smoking affects disease incidence such as aneurysmal subarachnoid haemorrhage. Much more interesting are the attempts to look at how smoking affects neurosurgical procedures. Apart from the obvious ones of wound healing, ischaemia and bone quality in spinal surgery, I had never appreciated that craniotomy for tumour in smokers bleed more. Some of the discussion on mechanism of adverse effects was interesting and some figures are helpful for discussing anaesthesia with patients. A good general review.