Objectives The objective of this study was to investigate the utility of the days alive and out of hospital (DAOH) metric within a cohort of patients undergoing burr-hole drainage of a chronic subdural haematoma (CSDH). We evaluate the validity of the DAOH metric in a national CSDH cohort and examine how the DAOH metric compares to its constituent outcomes (mortality and hospital bed days) at an organisational level.Methods Retrospective cohort study using Hospital Episode Statistics data linked to the national death registry to identify patients who underwent burr-hole drainage of CSDH in English National Health Service neurosurgical units between 1 April 2013 and 31 March 2020. Construct validity was assessed by measuring the patterns of DAOH across categories of known perioperative risk factors. Variation between units in the risk-adjusted values for DAOH, postoperative mortality and days in hospital was explored using funnel plots. Linear regression and logistic regression were used to derive the risk-adjusted rates.Results Overall, 16 450 patients who underwent at least one burr-hole drainage of CSDH were identified during the time period. The median 30-day DAOH was 16 (IQR, 0–24); the median for the 90-day DAOH was 74 (42–84), and was better at measuring the complete stay associated with the index admission. Worse 90-day DAOH values were associated with older age, increasing comorbidities and greater frailty. Risk-adjusted 90-day DAOH values for neurosurgical units varied more markedly than for its constituent outcomes.Conclusions The 90-day DAOH looks to be a valid outcome metric for patients undergoing burr-hole drainage for CSDH that is feasible to derive using national hospital data. Future work should explore how to estimate a minimally important clinical difference for DAOH and evaluate its utility as an outcome measure.

BACKGROUND AND OBJECTIVES:Chiari 1 malformation (CM1) is a common MRI finding and a frequent reason for neurosurgical consultation. Although many studies have investigated surgical outcomes for patients with CM1, outcomes for those treated without surgery have been less frequently reported. The UK Chiari 1 Study reports the quality of life of adults and children with CM1 treated without surgery, 12 months after the first neurosurgical clinic visit. METHODS:The UK Chiari 1 Study was a prospective, multicenter cohort study of adults (≥16 years) and children (<16 years) with CM1. This was an observational study that did not alter the course of clinical care. Symptoms and quality-of-life data (using Short-Form 36 in adults and the Pediatric Quality of Life Inventory™ in children) were collected at baseline and 12 months after the first clinical review for all participants. RESULTS:One hundred ninety-two patients with CM1 (146 females; 148 adults) were studied at baseline, and 113 patients with CM1 treated without surgery were studied at a 12-month follow-up. Baseline quality-of-life scores in the study cohort were significantly lower in every domain compared with normative control data, in both adults and children. There were no decreases in quality-of-life subscores after 12 months in this cohort of adults and children with CM1 treated without surgery. Social functioning ( t = -40, P < .001) and bodily pain (t = -2.9; P = .03) Short-Form 36 scores showed improvements at 12 months in adult patients treated without surgery. CONCLUSION:This study demonstrates the stability of quality-of-life domains in adults and children with CM1 after 12 months who have been managed without surgery. Further studies are required to understand the determinants of poor quality of life in patients with CM1 and to investigate interventions for improving quality of life. There is a further need for robust comparison of surgical and nonsurgical management for patients with CM1.

Objectives To evaluate the outcomes of patients undergoing external ventricular drain (EVD) insertion in England, focusing on the timing of EVD relative to index neurosurgical procedures, and to assess the implications for benchmarking and performance monitoring between neurosurgical centres. Methods We conducted a retrospective cohort study using Hospital Episode Statistics. Adult patients (≥16 years) undergoing EVD insertion between April 2013 and March 2020. Outcomes included 90-day mortality, length of stay (LOS), and emergency readmission within 30 days. Multivariable logistic regression was used for mortality and readmission, with adjustment for age, admission method, comorbidity (RCS Charlson index), and neurosurgical clinical category. A quantile regression model was performed with LOS as the outcome. Results The cohort comprised 10,239 patients. Crude 90-day mortality was 26.7 % overall, highest in the EVD-only group (43.2 %) and lowest when EVD was performed with an index procedure (19.7 %). Mortality rose with age, comorbidity, emergency admission, and was highest in Oncology, Vascular, and General & Trauma categories. The final risk-adjustment model showed good discrimination (AUC 0.71) and reduced apparent inter-unit variation in mortality. Conclusions Our findings demonstrate that treating all EVD insertions as a single cohort obscures clinically meaningful differences in patient trajectories and leads to misleading comparisons of outcomes. Although the absence of detailed severity markers in administrative data means that conclusions about quality of care must be interpreted cautiously, this study illustrates how carefully constructed, clinically meaningful cohorts can transform the interpretation of common neurosurgical procedures.

This study identified the proportion of spontaneous subarachnoid haemorrhage (SAH) patients diagnosed by Lumbar Puncture (LP). Furthermore reporting the incidence of aneurysmal SAH if a CT scan performed within 6 h was reported as negative, and finally investigated if there has been a change in practice since the new NICE guidance for the diagnosis of SAH was published in November 2022. A pragmatic multicentre audit was conducted in the UK and Ireland capturing referrals to 25 Neurosurgical centres between 1st November 2020-31st October 2023. Case referral identification was done in each unit using local medical records and referral databases based on local protocols. 10,187 cases of spontaneous SAH were diagnosed within the study period: 9,357 were diagnosed by CT and 717 by LP. 7% of all confirmed SAH cases underwent lumbar punctures to return a diagnosis of spontaneous SAH when a CT head scan was non-diagnostic. This yielded 213 (3%) diagnoses of aneurysmal SAH. 55 cases(1%) of aneurysmal SAH initially had negative CT head scans within 6 h of ictus and a positive LP. We did not identify any evidence of a change in practice following the introduction of the NICE guidance in November 2022. This study shows that LP continues to be an important diagnostic test that will confirm a diagnosis of aneurysmal SAH in a small, but significant number of patients with thunderclap headache. We provide new data that may impact the current NICE guidelines on the diagnosis of SAH.

OBJECTIVES:The aim of this study is to help better understand whether length of stay (LOS) for patients admitted with spontaneous subarachnoid haemorrhage (SAH) is an appropriate quality indicator of care for comparison of NHS Neurosurgical department performance. METHODS:We utilised Hospital Episode Statistics (HES) at a unit level to demonstrate the number of spells between 2019 and 2023 for patients presenting with spontaneous SAH as well as those that had an endovascular or microsurgical procedure to secure the aneurysm. We captured data concerning average LOS and average readmission within 30 day rates for each centre throughout the period. RESULTS:We demonstrated a weak relationship between shorter LOS and increased readmission rates; however, when a single outlier institutions data were removed, this relationship disappeared. The mean LOS was 25.7 days with a mean readmission rate of 4.9% for treated spontaneous SAH patients. If each centre reduced LOS to that of the shortest, there is the potential for 10,000 bed days saved per year. CONCLUSIONS:LOS for aneurysmal SAH patients has some promise as a quality indicator of care. We support a national quality improvement project going forwards to better understand the reasons for variation in LOS and to help eliminate unnecessary variability.

ObjectivesThe COVID-19 pandemic required a change in resource priority from Neurosurgical care in order to treat medically unwell patients suffering from the complications of COVID-19 infections. We demonstrate the impact of COVID-19 on total bed days in 24 Neurosurgical centres in England offering adult Neurosurgery as well as the total spells (single inpatient episodes) for operative Neurosurgical patients between 2020 and 2022 when compared with 2019.MethodsWe used Capse Healthcare Knowledge System software iCompare in order to show the change in total spells for patients undergoing a primary or secondary Neurosurgical procedure as defined using the National Neurosurgical Audit Programme (NNAP) OPCS-4 coding framework between 2019 and 2022.ResultsThe overall mortality rate of COVID-19 patients was 12.3% and the percentage of total bed days taken up by COVID-19 patients in hospitals at large was on average 7.7%. The total number of spells for all procedures over the 24 centres in 2022 was 39,019 compared with 45,742 in 2019. There was a cumulative deficit of 24,904 spells. The loss of spells was not equally distributed across regions and hospital Trusts. The average number of referral to treatment pathways completed within 18 weeks has declined from 76% to 57% over the study period and the referral to treatment clearance time has risen from 17 to 24 weeks.ConclusionsThe mean elective cranial output in 2022 compared with 2019 is at 88% with spinal output lagging at 69%. If the rate of change year on year were to remain at current levels then we would reach pre-pandemic levels of output by 2026.

Cerebral cavernous malformations within the intracranial portion of the trigeminal nerve are rare. We discuss the first reported case presenting in a child, who was successfully treated with microsurgical resection, and review the published literature. This rare diagnosis should be considered in the differential diagnosis of mass lesions arising in the region of the trigeminal root entry zone. Surgical resection is recommended to prevent neurological deterioration and can produce a significant improvement in symptoms.

Cerebral cavernous malformations within the intracranial portion of the trigeminal nerve are rare. We discuss the first reported case presenting in a child, who was successfully treated with microsurgical resection, and review the published literature. This rare diagnosis should be considered in the differential diagnosis of mass lesions arising in the region of the trigeminal root entry zone. Surgical resection is recommended to prevent neurological deterioration and can produce a significant improvement in symptoms.