A 10 year old boy is brought to hospital by his parents after falling off his skateboard and hitting his head.
A.) List 3 evidence based clinical decision rules that can be used to decide whether to perform a CT scan on this child?
B.) How sensitive and specific are these clinical decision rules over all?
- High Se e.g. PECARN 96.8% > 2 y.o.; 100% < 2 y.o.; NEXUS II 98.6%
- low Sp e.g. NEXUS II 15.1%
C.) List 8 historical factors according to the clinical decision rules that would make you more likely to order a CT scan on this child?
- NEXUS II
- Persistent vomiting
- Abnormal behaviour
- Witnessed LOC > 5 mins
- Amnesia > 5 mins
- 3 or more episodes of vomiting
- Traumatic seizure
- Suspicion of NAI
- MVA > 40 kph
- Fall > 3 m
- High-velocity projectile
- Loss of conscious ness > 5 s
- Severe mechanisms (MVA with ejection, rollover, death of passenger, pedestrian or bicyclist with no helmet struck by motorised vehicle, fall > 2 m (age > 2) or 1m (age < 2), head struck on high-impact object)
- Abnormal behaviour if < 2 y.o.
- Severe headache > 2 y.o.
D.) List 6 features of physical examination according to the clinical decision rules that would make you more likely to order a CT scan on this child?
- NEXUS II
- Significant skull fracture
- Altered LOC
- Neurological deficit
- Scalp haematoma
- Abnormal behaviours
- GCS < 15 if < 1 y.o.
- GSC < 14 if > 1 y.o.
- Depressed or basilar skull fracture
- Penetrating injury
- Tense fontanelle
- Focal neurological deficit
- Bruising, swelling, laceration > 5 cm if < 1yo
- Scalp haematoma except frontal
- Skull fracture
- Abnormal behaviour
- Signs of basilar skull fracture if > 2 y.o.
E.) What advice will you give on discharge in regards to coming back to the emergency department?
Go back to your doctor or hospital immediately if your child has:
- Unusual or confused behavior.
- Severe or persistent headache which is not relieved by paracetamol (irritability in a baby).
- Frequent vomiting.
- Bleeding or discharge from the ear or nose.
- A fit or convulsion, or spasm of the face or arms or legs.
- Difficulty in waking up.
- Difficulty in staying awake.
- If you are worried for any reason.
F.) What is your discharge advice regarding concussion symptoms?
- The suspected diagnosis of concussion can include one or more of the following concussion complaints:
- there was loss of consciousness or
- inability to remember the event (amnesia)
- symptoms of headache or feeling like in a fog
- being irritable
- slowed reaction times
- sleep disturbances or drowsiness
- see doctor if these occur
G.) What advice would you give regarding returning to sport if the child does show evidence of concussion?
- Need rest from physical activity and those that require concentration e.g. video games, school work
- Graded return to activity
- Each step takes at least 24 hours (a minimum of seven days total).
- Your child should only move to the next step if they have no concussion complaints.
- If concussion complaints occur, go back to the previous step.
- If your child cannot advance to the next step without concussion complaints, you should see your doctor before returning to play.
(4 marks; detail not needed)
Author: J Haire
Ref: Tintinalli p. 888-92 + RCH guidelines
A 19 year old woman is brought to the emergency department by her concerned parents with a two day history of irritability and headache. She has a history of developmental delay and a ventriculoperitoneal shunt for congenital hydrocephalus.
Her Glasgow Coma Score is 15. Her vital signs are normal.
A.) List 4 causes of shunt malfunction
- Mechanical failure e.g. Fracture, disconnection, migration, misplacement
- Slit ventricle syndrome or overdrainage
- Abdominal complications e.g. pseudocyst formation
B.) Describe how you would examine the valve chamber for obstruction.
- Gently compress chamber and observe for refill
- Difficulty compressing chamber – distal obstruction
- Slow refill (> 3s after compression) – proximal obstruction
C.) How sensitive is this examination for shunt obstruction?
- Not very sensitive
- 40% obstructed shunts compress and refill normally
D.) What imaging should be ordered for and ventriculoperitoneal shunt and what for?
- Shunt series
- AP & lateral skull
- AP chest and abdomen
- For mechanical failure
- CT brain
- For raised ICP/low pressure
E.) How sensitive are these tests?
- Poor sensitivity
- Still need neurosurgical opinion
F.) Which populations are at the most risk for shunt infection?
- Very young
- Very old
- Recently placed shunts
G.) When do shunt infections occur most commonly?
- After initial placement
- 70% in first 2 months
- 80% in first 6 months
H.) How do patients with infected shunts present?
- Symptoms of:
- Abdominal pain
I.) What is the definitive investigation needed to diagnose shunt infection and how is it performed?
- Shunt tap
- Shaved and sterilise skin over reservoir
- 23G butterfly attached to a manometer
- Measure opening pressure
- Should be 12 +/- 2 cmH2O
- > 20 cm H2O – distal obstruction
- < normal – proximal obstruction
- Removed CXF and send for analysis
Author: J Haire
Ref: Tintinalli P 1180-83
A 55 year old man has just undergone endotracheal intubation for severe asthma. Immediately post intubation, his systolic blood pressure falls to 80 mmHg.
A.) What are the likely causes of this patient’s hypotension?
- Dynamic hyperinflation (gas-trapping) leading to raised intra-thoracic pressure and decreased venous return
- hypovolaemia secondary to dehydration
- induction drugs causing myocardial depression and vasodilatation
- tension pneumothorax secondary to barotrauma
- hypoxia secondary to barotrauma, mucous plugging, ETT migration/misplacement, disconnection from ventilator
B.) What actions would you take to address this situation?
- Disconnect the patient from the ventilator and move to BMV
- Long expiration time and can compress chest to exclude gas-trapping
- Check tube in right place
- Fluid bolus
- Push-dose pressor e.g. metaraminol
- Check for pneumothorax clinically and decompress emergently
C.) Describe your ventilation strategy in asthmatic patients.
- Long expiration times to avoid gas-trapping & barotrauma and permissive hypercarbia
- Will need heavy sedation (uncomfortable)
- High flow rate to reduce inspiratory time 80-100- l/min
- TV 8 ml/kg
- Low RR i.e. 10 bpm
- High I:E ratio i.e. 1:5
- PEEP 0 mmHg
- Initial settings
- Aim is for adequate oxygenation but tolerate high CO2 as long as pH > 7.25
Author: J Haire
Ref: Tintinalli p. 520; Roberts and Hedges 5th Ed 144 & experience
A 23 year old man is brought in to the emergency department by ambulance with an isolated stab wound to his left anterior chest. He is alert, sweaty and taking shallow breaths. The weapon is not in situ upon his arrival in the emergency department.
His examination findings are:
HR 105 /min
BP 95/60 mmHg supine
RR 30 /min
O2 Saturation 93 % on room air
A.) What are the main issues in this patient?
- Penetrating life-threatening trauma
- Haemorrhagic shock
B.) What are the potential injuries causing this?
- Tension pneumothorax
- Cardiac tamponade secondary to puncture heart or great vessels
- Haemothorax secondary to laceration of intra-thoracic vessels
C.) What are the essential investigations in this patient?
D.) What are the indications for emergency department thoracotomy?
- Penetrating injury
- Patients have signs of life in field or ED but then deteriorate
E.) Briefly describe how you would perform an left anterolateral thoracotomy
- Incision in left 4th or 5th intercostal space (space below nipple in man and in infra-mammary fold in woman)
- Incision from sternum to the posterior axillary line along that intercostal space through skin, s/c fat, superficial muscle
- Cut remaining muscles with scissors along top of rib
- Spread ribs
- Apply retractor handle down
F.) List 3 options for control of haemorrhage cardiac wounds?
- Finger occlusion
- Horizontal mattress sutures
- Foley catheter
- Occlude the SVC and IVC
Author: J Haire
Ref: Tintinalli p. 1761; Roberts and Hedges 5thEd P. 319-20
A 45 year old man presents to your emergency department with vertigo and ataxia.
A.) What are the main abnormalities in this CT?
- Multiple areas of low attenuation in the cerebellum
B.) What is your differential diagnosis?
- Ischaemic CVA
C.) What further investigations would help to establish the diagnosis?
- Contrast CT
- CVA look for source
- Mets look for source
- CT head/chest/abdo
- Biopsy lesion
Author: J Haire
A head CT scan of an 83 year old woman has been performed, who has presented with a 3 day history of increasing confusion and unsteady gait following a fall. Her GCS is 12 (M5, V3, E4).
A.) Describe the abnormalities seen in this CT.
- Large right frontotemperoparietal subdural haematoma
- Heterogeneous – acute on chronic
- Significant mass effect with movement of midline at least 2 cm
- Effacement of superior horns of lateral ventricles
- Effacement of sulci
- Blood in posterior horn on right and tracking along falx cerebri
B.) What is the diagnosis?
- Massive acute on chronic subdural with significant mass effect
C.) What is the prognosis?
D.) What factors would you take into account in deciding whether operative therapy was appropriate?
- Previous wishes of patient if articulated
- Pre-morbid function
- Neurosurgical opinion re prognosis/futility
E.) Who would you consult in making this decision?
Author: J Haire
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As defined by the World Association of Medical Editors:
Plagiarism is the use of others' published and unpublished ideas or words (or other intellectual property) without attribution or permission, and presenting them as new and original rather than derived from an existing source. The intent and effect of plagiarism to mislead the reader as to the contributions of the plagiarizer. This applies whether the ideas or words are taken from abstracts, research grant applications, Institutional Review Board applications, or unpublished or published manuscripts in any publication format (print or electronic).
Plagiarism is scientific misconduct and will be addressed as such. When plagiarism is detected at any time before publication, the NEUROSURGERY® Publications Editorial Office will alert the author, asking her or him to rewrite or quote exactly and to cite the original source. If the plagiarism is extensive (i.e., >25% of the original submission), the editors will take appropriate action to notify both readers and the author’s employers of the infraction.
NEUROSURGERY® Publications is a member of CrossCheck by CrossRef and . is a plagiarism screening service that verifies the originality of content submitted before publication. checks submissions against millions of published research papers, and billions of web content. Authors, and freelancers can also use to screen their work before submission by visiting http://www.ithenticate.com.
NEUROSURGERY® Publications actively checks accepted manuscripts for self-plagiarism prior to publication. Self-plagiarism is not a tolerated practice. Manuscripts containing high-levels of self-plagiarism (>25% of the original in question) will be reviewed by the Editor-in-Chief for originality. Authors found to have self-plagiarized will be asked to rewrite those portions of their accepted manuscripts and or to quote exactly and cite the original source.
Neuroscience Peer Review Consortium
NEUROSURGERY® Publications is a member of the Neuroscience Peer Review Consortium. The Consortium is an alliance of neuroscience journals that have agreed to accept manuscript reviews from each other. If you submit a revision of your manuscript to another Consortium journal, we can forward the reviews of your manuscript to that journal, should you decide this might be helpful. You can find a list of Consortium journals and details about forwarding reviews at http://nprc.incf.org.
All manuscripts intended for submission to Neurosurgery must be submitted online http://www.editorialmanager.com/neu.
Please click the Register button at http://www.editorialmanager.com/neu. Upon successful registration, you will be sent an email providing your username and password. Save this information for future reference. Please note: Authors need only register as a new user under either Neurosurgery or OperativeNeurosurgery. Registration on one site automatically registers the user on the other site.
Note: If you have received an email from us with an assigned username and password, or if you are a repeat user, do not register again. Just log in. Once you have an assigned username and password, you do not have to re-register.
Authors who have a registered ORCID can now to Editorial Manager using those credentials. To find out more about ORCID, please visit http://orcid.org.
Please click the Login button from the menu at the top of the page and login to the system as an author. Submit your manuscript according to the author instructions. You will be able to track the progress of your manuscript through the system.
If you experience any problems, please contact the Editorial Office via phone (+1)404.712.5930 or email: firstname.lastname@example.org.
Necessary Files for Submission
- Cover Letter
- Title Page
- Manuscript (including abstract, main text, references and figure/video legends)
- Figure(s) (when appropriate)
- Table(s) (when appropriate)
The above items should be prepared as separate files. Each file must contain a file extension.
Note: In accordance with the Journal’s blinded review process, author/institutional information should be omitted or blinded from the following submission files: Manuscript, Figure(s), Table(s), Supplemental Digital Content, and Response to Reviewers.
Format and Style
- Text should be 1.5-spaced.
- Font style should be Times New Roman or similar serif typeface.
- Body text size should be 12 pt.
- Page size should be US Letter with margins.
- Do not include author names in headers or footers.
- To assist reviewers, please include page numbers and line numbering in the manuscript file.
- Accepted file formats for text files: DOC and DOCX
The cover letter should include a brief explanation of the submission and its perceived value. Cover letters may be addressed Nelson M. Oyesiku, MD, , , Editor-in-Chief, NEUROSURGERY® Publications.
The title page should be created as a separate document and must include the following:
- Full title of the paper—short, clear, and specific. Please use 1-2 article keywords in the title. Abbreviations and declarative statements should not be used in article titles.
- All authors’ full names, each followed by his/her highest academic degree(s) (e.g., BS, BMed, MBBS, MD, ). US fellowship designations (e.g., FACP, FAAN, ) and honorary designations should be omitted. Non-US designations (e.g., FRCP, FRCPC) may be listed.
- Departmental and institutional affiliations for each author, including the city, state or province, and country (use superscript numbers to identify each author with his/her corresponding affiliation).
- Details of previous presentation(s). Details should include the name of the annual meeting, sponsoring society (if applicable), date, location, and type (i.e., poster, plenary, etc.).
- Disclosure of funding received for this work from any of the following organizations: National Institutes of Health (NIH); Wellcome Trust; Howard Hughes Medical Institute (HHMI); and other foundation(s) requiring open access.
- The source of financial support and industry affiliations of all those involved must be stated. List all grants pertinent to the paper. In addition, authors must state whether they have any personal or institutional financial interest in drugs, materials, or devices described in their submissions.
- Concise acknowledgment of contributors not listed as authors is welcome. Do not include Acknowledgements within the manuscript document.
- Corresponding Author contact information including the name, address, and email address of the author responsible for correspondence, form(s) competition, and galley proof review. Clearly indicate if changes of address are anticipated, and include forwarding addresses. It is the Corresponding Author's responsibility to notify the Editorial Office of changes of address. Only the Corresponding Author should communicate with the Editorial Office for matters regarding each manuscript.
For article types requiring a structured abstract (not including Case Reports and Study Protocols), the abstract should be no more than 250 words, summarizing the problem being considered, how the study was performed, the salient results, and the principal conclusions under the following headings:
- Background: Address the background and rationale for the study.
- Objective: State the precise objective or study question addressed.
- Methods: Define the basic design, procedures, and/or setting in which the study was conducted.
- Results: Present significant data and observations gathered.
- Conclusion: Interpret findings and give principal conclusions.
Abstracts for Research-Human-Study Protocols should be no more than 250 words and should summarize all the key elements of the protocol under the following headings: Background; Objective; Methods; Expected Outcomes; Discussion.
Review (qualitative), Legacy-Institutions and People, Special Article, and Surgical Video article types require an unstructured abstract of no more than 250 words.
Abstracts for Case Reports contain the following headings:
- Background and Importance: State the significance of the issue and importance of the case(s).
- Clinical Presentation: Define the case(s) presented, pertinent attendant issues, and observations.
- Conclusion: State outcome of (s) and recommend treatment pathways.
On the same page, provide a running title (short title) of 50 characters or less and list, in alphabetical order, keywords (maximum of 7) for coding and indexing. Consult the Index Medicus for appropriate keywords.
Introduction: Brief description of the background that led to the study (current results and conclusions should not be included).
Methods: Details relevant to the conduct of the study. Wherever possible give numbers of subjects studied (not percentages alone). Statistical methods should be clearly explained at the end of this section.
Results: Work should be reported in SI units. Undue repetition in text and tables should be avoided. Comment on validity and significance of results is appropriate but broader discussion of their implication is restricted to the next section. Subheadings that aid clarity of presentation within this and the previous section are encouraged.
Discussion: The nature and findings of the study are placed in of other relevant published data. Caveats to the study should be discussed. Avoid undue extrapolation from the study topic. If lengthy, please separate into sections with subheadings to enhance readability.
Conclusion: Should restate the purpose of the study and primary empirical questions that were asked, and should restate the most significant findings. The conclusions should aid the reader in understanding the significance of the study in contributing to the base of knowledge about the subject.
Research articles that adhere to a reporting guideline (e.g., STROBE, CONSORT, PRISMA) should include subheadings, particularly in the Results and Discussion, that address specific items listed in the associated checklist.
Background and Importance: State the significance/uniqueness of the case in relation to the existing literature. Why is it being reported?
Clinical Presentation: Describe the clinical features of the case(s), and the pertinent observations (imaging, pathology operative findings as appropriate). When applicable, use subheadings for clarity. Brevity is essential.
Discussion: Discuss the relevant literature in the context of the current case. The discussion need not be exhaustive, and it should focus specifically on how the case differs from existing literature and what lessons can be gleaned from dissemination of its findings
Conclusion: State outcome of case(s) and recommendations/lessons.
Non–Native Speakers of English
Authors who are not native speakers of English who submit manuscripts to international journals often receive negative comments from referees or editors about the English–language usage in their manuscripts, and these problems can contribute to a decision to reject a paper. To help reduce the possibility of such problems, we strongly encourage such authors to take at least one of the following steps:
- Have your manuscript reviewed for clarity by a colleague whose native language is
- Use a service such as one of those listed below.
In an effort to better assist our authors in securing translation/editing services, NEUROSURGERY® Publications has partnered with American Journal Experts (AJE) to provide these services at a discount. AJE has helped thousands of researchers around the world to present their research in polished English suitable for publication in scientific and medical journals. To take advantage of this partnership, visit secure.aje.com/p/neuro15 for a discount off of all AJE services. Note: If this is your first purchase through AJE, the link should automatically append the promo code to your account. If you already have an account with AJE, please enter “NEURO15" as a promo code at the payment step of the submission process to receive the discount.
*Please note: this is a one-time discount. The use of such a service is at the author's own expense and risk and does not guarantee that the article will be accepted. NEUROSURGERY® Publications accepts no responsibility for the interaction between the author and the service provider or for the quality of the work performed.
For manuscripts that report statistics, the Editor requires that the authors provide evidence of statistical consultation (or at least expertise); a biostatistician may review such manuscripts during the review process.
In the Methods section:
- Identify the statistical tests used to analyze the data.
- Indicate the prospectively determined P value that was taken to indicate a significant difference.
- Cite textbook and published article references to support your choices of tests.
- Identify any statistics software used.
In the Results section:
- Note that following the AMA Manual of Style: A Guide for Authors and Editors, 10th Edition. New York: Oxford University Press; 2007, page 889, the Journal does not use a zero to the left of the decimal point, because “…statistically it is not possible to prove or disprove the null hypothesis completely when only a sample of the population is tested (P cannot equal 0 or 1, except by rounding).”
- Report actual P values rather than thresholds: not just whether the P value was above or below the significant-difference threshold. Example: write “P = .18”, not “P > .05” or “P = NS.”
- P should be expressed to 2 digits for P ≥ .01, because expressing P to more than 3 digits does not add useful information. If P < .001, it should be expressed as P < .001, rather than P < .0001 or P = .00001 for example.
- If P > .99, P = .999 for example, it should be expressed as P > .99.
Abbreviations, and Symbols
These should conform to those found in the AMA Manual of Style: A Guide for Authors and Editors, 10th Edition. The use of standard international units is encouraged. Note: The use of nonstandard abbreviations is strongly discouraged. In accepted manuscripts, use of such abbreviations may cause a delay in the copyediting process.
Neurosurgery ARTICLE TYPES
These represent a substantial body of laboratory or clinical work. Additional data may be presented as supplementary information, which will be published online should the article be accepted. A structured abstract of no more than 250 words is required. Maximum length: 3,000 words of text (not including abstract, references, figures, tables, and online-only material). For observational epidemiological studies and diagnostic accuracy studies, see Research Reporting Guidelines for further requirements.
Study Protocols describe proposed or ongoing and provide a detailed account of the hypothesis, rationale, and methodology of the planned study. The journal will consider Study Protocols of proposed or ongoing trials (provided they have not completed patient recruitment at the time of submission). Study Protocols will usually be published without further peer review if the study has received institutional IRB and ethics approval, and peer-review and grant funding from a major extramural funding body. We are unable to consider Study Protocols without ethics or IRB approval or major extramural funding at the time of submission. All clinical trials must be registered at an appropriate online public registry, and registration information should be included with the submission.
Examples of major funding agencies including, but not limited to:
- Academy of Finland (Finland)
- BIOTEC (Thailand)
- California Institute for Regenerative Medicine (US)
- Canadian Institutes of Health Research (Canada)
- Centre National de la Recherche (France)
- Consejo Superior de Investigaciones Cientifcas (Spain)
- Consiglio Nazionale Ricerche (Italy)
- Danmarks Grundforskningsfond (Denmark)
- Deutsche Forschungsgemeinschaft (Germany)
- FAPESP (Brazil)
- Fondazione Telethon (Italy)
- Fonds Forderung der Forschung (Austria)
- Fonds Wetenschappelijk Onderzoek (Belgium)
- Health Research Board (Ireland)
- Howard Hughes Medical Institute (US)
- Indian Council of Medical Research (India)
- INSERM (France)
- International Human Frontier Science Program Organization (International)
- Israel Science Foundation (Israel)
- Max Planck Society (Germany)
- Medical Research Council (UK)
- National Health Service (UK)
- National Institutes of Health (US)
- National Science Foundation (US)
- Natural Environment Research Council (UK)
- Nederlandse Organisatie Wetenschappelijk Onderzoek (Netherlands)
- Rockefeller Foundation (US)
- South African Medical Research Council (South Africa)
- Swedish Foundation for Strategic Research (Sweden)
- Swedish Research Council (Sweden)
- Swiss National Science Foundation (Switzerland)
- Wellcome Trust (UK)
Study Protocols accepted for publication will be citable and accessible online and in print. Investigators must consent in principle to submit all or a substantial portion of the primary manuscript to Neurosurgery at the conclusion of the study, which the Journal will send for peer-review. The Journal will provisionally commit to rapidly publish the main clinical findings of the study absent major deviations from protocol, poor reporting or over