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Angelos G. Kolias, Peter J. Hutchinson, Dion G. Morton, Jane M. Blazeby and Peter McCulloch

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Federico Nicolosi, Zefferino Rossini, Ismail Zaed, Angelos G. Kolias, Maurizio Fornari and Franco Servadei

OBJECTIVE

Neurosurgical training is usually based on traditional sources of education, such as papers, books, direct surgical experience, and cadaveric hands-on courses. In low-middle income countries, standard education programs are often unavailable, mainly owing to the lack of human and economic resources. Introducing digital platforms in these settings could be an alternative solution for bridging the gap between Western and poor countries in neurosurgical knowledge.

METHODS

The authors identified from the Internet the main digital platforms that could easily be adopted in low-middle income countries. They selected free/low-cost mobile content with high educational impact.

RESULTS

The platforms that were identified as fulfilling the characteristics described above are WFNS Young Neurosurgeons Forum Stream, Brainbook, NeuroMind, UpSurgeOn, The Neurosurgical Atlas, Touch surgery, The 100 UCLA Subjects in Neurosurgery, Neurosurgery Survival Guide, EANS (European Association of Neurosurgical Societies) Academy, Neurosurgical.TV, 3D Neuroanatomy, The Rhoton Collection, and Hinari. These platforms consist of webinars, 3D interactive neuroanatomy and neurosurgery content, videos, and e-learning programs supported by neurosurgical associations or journals.

CONCLUSIONS

Digital education is an emerging tool for contributing to the spread of information in the neurosurgical community. The continuous improvement in the quality of content will rapidly increase the scientific validity of digital programs. In conclusion, the fast and easy access to digital resources could contribute to promote neurosurgical education in countries with limited facilities.

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Georgios V. Varsos, Angelos G. Kolias, Peter Smielewski, Ken M. Brady, Vassilis G. Varsos, Peter J. Hutchinson, John D. Pickard and Marek Czosnyka

OBJECT

Cerebral blood flow is associated with cerebral perfusion pressure (CPP), which is clinically monitored through arterial blood pressure (ABP) and invasive measurements of intracranial pressure (ICP). Based on critical closing pressure (CrCP), the authors introduce a novel method for a noninvasive estimator of CPP (eCPP).

METHODS

Data from 280 head-injured patients with ABP, ICP, and transcranial Doppler ultrasonography measurements were retrospectively examined. CrCP was calculated with a noninvasive version of the cerebrovascular impedance method. The eCPP was refined with a predictive regression model of CrCP-based estimation of ICP from known ICP using data from 232 patients, and validated with data from the remaining 48 patients.

RESULTS

Cohort analysis showed eCPP to be correlated with measured CPP (R = 0.851, p < 0.001), with a mean ± SD difference of 4.02 ± 6.01 mm Hg, and 83.3% of the cases with an estimation error below 10 mm Hg. eCPP accurately predicted low CPP (< 70 mm Hg) with an area under the curve of 0.913 (95% CI 0.883–0.944). When each recording session of a patient was assessed individually, eCPP could predict CPP with a 95% CI of the SD for estimating CPP between multiple recording sessions of 1.89–5.01 mm Hg.

CONCLUSIONS

Overall, CrCP-based eCPP was strongly correlated with invasive CPP, with sensitivity and specificity for detection of low CPP that show promise for clinical use.

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Aswin Chari, Angelos G. Kolias, Thomas Santarius, Simon Bond and Peter J. Hutchinson

Object

The incidence of chronic subdural hematoma (CSDH) is expected to increase substantially over the next 25 years. Continuing refinement of techniques for surgical evacuation is essential for optimizing patient outcomes. A novel technique involving a hollow screw, which is threaded through a twist-drill hole in the cranium and then connected to a closed drainage system, has been increasing in popularity. The aim of this systematic review is to collate and analyze the published experience with this novel technique and to evaluate its efficacy in comparison with the other surgical treatment methods.

Methods

This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and has been registered with the PROSPERO International Prospective Register of Systematic Reviews (registration number CRD42013003544). MEDLINE, Web of Knowledge, EMBASE, and the Cochrane Database of Systematic Reviews were searched for published series involving more than 10 patients treated with these new techniques.

Results

Nine eligible studies were found (6 case series and 3 case-control studies) comprising 796 patients treated with these new techniques. Pooled analysis showed a “success rate” of 77.6% (95% CI 74.6%–80.4%), recurrence rate of 22.4%, and in-hospital mortality of 1.4%.

Conclusions

This systematic review adds further evidence to the pool of data assessing the safety and efficacy of the use of this novel, minimally invasive technique for the treatment for CSDH. Overall, twist-drill craniostomy with hollow screws appears to be safe and effective. Class I evidence is necessary to optimize the surgical management of patients with CSDH.

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Georgios V. Varsos, Melissa C. Werndle, Zofia H. Czosnyka, Peter Smielewski, Angelos G. Kolias, Isaac Phang, Samira Saadoun, B. Anthony Bell, Argyro Zoumprouli, Marios C. Papadopoulos and Marek Czosnyka

OBJECT

In contrast to intracranial pressure (ICP) in traumatic brain injury (TBI), intraspinal pressure (ISP) after traumatic spinal cord injury (TSCI) has not received the same attention in terms of waveform analysis. Based on a recently introduced technique for continuous monitoring of ISP, here the morphological characteristics of ISP are observationally described. It was hypothesized that the waveform analysis method used to assess ICP could be similarly applied to ISP.

METHODS

Data included continuous recordings of ISP and arterial blood pressure (ABP) in 18 patients with severe TSCI.

RESULTS

The morphology of the ISP pulse waveform resembled the ICP waveform shape and was composed of 3 peaks representing percussion, tidal, and dicrotic waves. Spectral analysis demonstrated the presence of slow, respiratory, and pulse waves at different frequencies. The pulse amplitude of ISP was proportional to the mean ISP, suggesting a similar exponential pressure-volume relationship as in the intracerebral space. The interaction between the slow waves of ISP and ABP is capable of characterizing the spinal autoregulatory capacity.

CONCLUSIONS

This preliminary observational study confirms morphological and spectral similarities between ISP in TSCI and ICP. Therefore, the known methods used for ICP waveform analysis could be transferred to ISP analysis and, upon verification, potentially used for monitoring TSCI patients.

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Paul M. Brennan, Angelos G. Kolias, Alexis J. Joannides, Jonathan Shapey, Hani J. Marcus, Barbara A. Gregson, Patrick J. Grover, Peter J. Hutchinson and Ian C. Coulter

OBJECTIVE

Symptomatic chronic subdural hematoma (CSDH) will become an increasingly common presentation in neurosurgical practice as the population ages, but quality evidence is still lacking to guide the optimal management for these patients. The British Neurosurgical Trainee Research Collaborative (BNTRC) was established by neurosurgical trainees in 2012 to improve research by combining the efforts of trainees in each of the United Kingdom (UK) and Ireland's neurosurgical units (NSUs). The authors present the first study by the BNTRC that describes current management and outcomes for patients with CSDH throughout the UK and Ireland. This provides a resource both for current clinical practice and future clinical research on CSDH.

METHODS

Data on management and outcomes for patients with CSDH referred to UK and Ireland NSUs were collected prospectively over an 8-month period and audited against criteria predefined from the literature: NSU mortality < 5%, NSU morbidity < 10%, symptomatic recurrence within 60 days requiring repeat surgery < 20%, and unfavorable functional status (modified Rankin Scale score of 4–6) at NSU discharge < 30%.

RESULTS

Data from 1205 patients in 26 NSUs were collected. Bur-hole craniostomy was the most common procedure (89%), and symptomatic recurrence requiring repeat surgery within 60 days was observed in 9% of patients. Criteria on mortality (2%), rate of recurrence (9%), and unfavorable functional outcome (22%) were met, but morbidity was greater than expected (14%). Multivariate analysis demonstrated that failure to insert a drain intraoperatively independently predicted recurrence and unfavorable functional outcome (p = 0.011 and p = 0.048, respectively). Increasing patient age (p < 0.00001), postoperative bed rest (p = 0.019), and use of a single bur hole (p = 0.020) independently predicted unfavorable functional outcomes, but prescription of high-flow oxygen or preoperative use of antiplatelet medications did not.

CONCLUSIONS

This is the largest prospective CSDH study and helps establish national standards. It has confirmed in a real-world setting the effectiveness of placing a subdural drain. This study identified a number of modifiable prognostic factors but questions the necessity of some common aspects of CSDH management, such as enforced postoperative bed rest. Future studies should seek to establish how practitioners can optimize perioperative care of patients with CSDH to reduce morbidity as well as minimize CSDH recurrence. The BNTRC is unique worldwide, conducting multicenter trainee-led research and audits. This study demonstrates that collaborative research networks are powerful tools to interrogate clinical research questions.

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Adriaan R. E. Potgieser, J. Marc C. van Dijk and Jan D. M. Metzemaekers

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Angelos G. Kolias, Peter J. Hutchinson, David K. Menon, Geoffrey T. Manley, Clare N. Gallagher and Franco Servadei