Brain Conditions - DRAFT

Overview

The information on this page has been produced in partnership with James Pendle, Olivier Sluijters and Adam Williams at NBT.

The following page gives advice on management of neurosurgical conditions affecting the brain which are not covered elsewhere.

Please also consider the following pages:

• Brain & CNS - USC (2WW)
• Subdural Haematoma DRAFT
• Arachnoid cysts DRAFT
• Carotid Artery Stenosis

Radiology queries - if you require further clarification on radiology reports then please contact the trust concerned. See the Radiology Advice & Queries page.

Brain Abscess

If the patient has a brain abscess seen on imaging, they should then be seen and assessed in the nearest Emergency Department as this may require emergency surgery / treatment.

Cavernous / Ateriovenous Malformations

Cavernous / Ateriovenous Malformations can be treated by a number of different specialties including interventional radiology or oncology for stereotactic radiosurgery.

For the most safe and rapid assessment of the patient please refer directly to the Neurovascular MDT.

If your patient is unwell, has a new neurological deficit or presents with severe headaches, they may have had a bleed associated with this malformation and should be urgently assessed in their closest Emergency Department, who will liaise with the on-call team as required.

Colloid Cysts

Colloid Cysts are benign lesions often found in or near the foramen of Monroe, between the lateral and third ventricles. If they are large enough, they can cause sudden obstructive hydrocephalus which can be life-threatening.

If the patient is presenting with headaches, vomiting or confusion, please send them to the nearest Emergency Department immediately as this is a life-threatening condition.

If there is hydrocephalus reported on imaging, please refer urgently to the on-call team via Refer a Patient. See the Neurosurgical Referrals - General DRAFT page for details on how to to this.

If seen incidentally on imaging in the absence of acute symptoms or reported hydrocephalus, please refer to the Neuro-Oncology MDT. 

Intracranial Aneurysms

Bleeding intracranial Aneurysm

If you have any concern that a patient has an aneurysmal bleed, or if the patient presents with a progressive cranial nerve palsy, please arrange for the patient to be urgently seen and assessed in the nearest Emergency Department, to investigate for a spontaneous subarachnoid haemorrhage.

Incidental Intracranial Aneurysm

Incidental aneurysms in the absence of concerning symptoms can be managed electively, with input from neurosurgery and interventional radiology as required. They are common and their management needs to be determined on a case-by-case basis.

If your patient has an incidental finding of an intracranial aneurysm, please refer via the Neurovascular MDT.

Meningioma

Asymptomatic Meningioma

If a patient has an incidental finding of a meningioma and is well and asymptomatic, please refer as follows:

• Skull base meningiomas  - refer to the Skullbase MDT.
• Convexity meningiomas (a brain tumour that grows on the surface of the brain) - refer to the Neuro-Oncology MDT. 

Symptomatic Meningioma

If a patient with recent imaging suggestive of a new extrinsic brain tumour acutely presents with new confusion, vomiting, or progressive neurological deficit, please refer urgently to the nearest Emergency Department for assessment.  

Intracranial Hypotension

Intracranial hypotension is often a consequence of an undiagnosed CSF leak and presents with headaches, dizziness and nausea that is worse in the upright position. If the patient reports an active fluid leak from their nose or ear (i.e. after trauma or recent neurosurgery), please refer them to the on-call services via referapatient. See the Neurosurgical Referrals - General DRAFT page for advice on how to do this.

In the absence of a noted CSF leak or recent neurosurgical intervention, these patients should be referred to neurology services.

Idiopathic Intracranial Hypertension

Idiopathic intracranial hypertension (IIH) often presents with intractable headaches and can lead to progressive visual loss. If you suspect your patient has IIH, please consider requesting  Neurology Advice and Guidance or refer to neurology via eRS. If surgical management is required they can then refer patients to the neurosurgical team.

If a patient with IIH, has a shunt, and you are concerned this is not functioning properly, please refer urgently to the on-call service via referapatient or alternatively you may also wish to discuss with the hydrocephalus team via the advice line (see Shunt section below).

Signs and symptoms of shunt dysfunction include nausea, vomiting and a worsening of visual function. If possible, please specify whether your patient has papilloedema when referring.

Pineal Cysts

Pineal cysts are often incidental findings that do not require surgical intervention, but rarely they can represent pineal tumours. There are radiological features that help determine whether a cyst needs further follow-up / investigation.

If your patient has a pineal cyst, please refer to the Neuro-Oncology MDT.

Pituitary Lesions

Pituitary lesions often present benign adenomas that are either secreting or non-secreting. Their size, type and associated symptoms determine the modality of treatment.

If a patient with recent imaging evidence of a pituitary lesion presents acutely with progressive visual field defect, evidence of haemorrhage on imaging or focal cranial nerve palsies, please refer urgently to the on-call via Referapatient, as these patients may require surgical decompression.

If there is evidence of a new and incidental pituitary lesion, without acutely worsening neurological symptoms, please refer to the local endocrinology service. They will discuss the case with our services via the pituitary MDT if appropriate. Please also see the Hyperprolactinaemia (endocrinology) page.

For questions regarding known pituitary tumours where the patient is already known to endocrinology, please refer via the Pituitary MDT - use the link for the Skullbase MDT and then select the pituitary MDT in the referral form.

Shunts

Acute neurosurgical shunt blockage

If you are clinically concerned that your patient has an acute neurosurgical shunt blockage, please refer as follows:

• If you normally refer patients to NBT then refer directly to the on-call team via Referapatient.
• If you normally refer patients to UHBW or other acute trust then your patient should be sent to your local Emergency Department.

Normal Pressure Hydrocephalus shunt blockage

If your patient has Normal Pressure Hydrocephalus, shunt blockage does not present with typical symptoms (vomiting, headaches and confusion), and can be managed via the helpline below. 

There is a hydrocephalus advice line in working hours that is covered by the neurosurgery advanced nurse practitioners: 0117 414 6613.

New Hydrocephalus without a shunt

If the patient has evidence of new hydrocephalus without a shunt in situ, please refer to the on-call via Refer-a-Patient, unless the report specifies that the patient has Normal Pressure Hydrocephalus – in which case see the Normal Pressure Hydrocephalus section below.

Skull Base Tumours

Symptomatic Patients with Skull Base tumour

If a patient with recent imaging evidence of a skull base tumour acutely presents with severe headaches, progressive neurological decline or a rapidly progressive cranial nerve palsy (over the course of days), please refer urgently to our on-call via Referapatient.

Asymptomatic Patients with Skull Base tumour

Most skullbase tumours are benign, and don’t fit the criteria for a USC/2WW referral.

Please refer via the  Skullbase MDT.

Subdural Hygromas

Subdural hygromas describe expanded subdural CSF spaces and are incidental findings in the elderly population. They do not require neurosurgical intervention or follow-up. 

Normal Pressure Hydrocephalus

Normal Pressure Hydrocephalus (NPH) is a chronic neurodegenerative condition that does not require admission or emergency treatment. Typical symptoms include cognitive decline, gait and balance disturbance and urinary incontinence (Hakim’s triad).

Please also see the Normal Pressure Hydrocephalus (Remedy BNSSG ICB) page for further advice on assessment and referral.

Appropriate patients should be referred via eRS to the Adult Hydrocephalus Triage/RAS service. Referrals will be triaged and appropriate patients assessed in clinic, at which point further work-up and consideration for surgical intervention is considered. 

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.