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Background Lumbar disc herniation is often managed conservatively; nevertheless, surgical intervention can be required. Majority of patients experience a drastic relief of symptoms after surgery, but previous studies have reported that their health-related quality of life remains inferior compared to the general population for several years. There may be a major cumulative loss of health-related quality of life for young patients as they have long expected life ahead of them. Methods A total of 526 eligible adult patients under the age of 40 underwent surgery for lumbar disc herniation from 1990 to 2005. Patients’ baseline characteristics were acquired by chart review to confirm eligibility to the study. Follow-up quality of life data was acquired by sending patients EQ-5D questionnaire at median 18 years after index surgery, and those 316 patients responding to the questionnaire (60%) were included in the study. Propensity score matching was utilized to match every study patient with two general population sample participants from a large Finnish population health study. Primary objective was to compare the quality of life to that of the control population. Secondary objective was to explore which patient characteristics lead to inferior outcome. Results The mean EQ-index for the patient cohort was 0.86, while it was 0.84 for the age and gender–matched general population sample (difference 0.02, 95% CI − 0.0004 to 0.049). Within the patient cohort, an increasing number of lifetime lumbar surgeries was associated with progressively deteriorating EQ-index scores (p = 0.049) and longer duration of symptoms prior to the surgery correlated with lower score (p = 0.013). Conclusion Patients who underwent surgery for lumbar disc herniation nearly two decades ago reported quality of life comparable to the age and gender–matched general population. However, patients who had undergone numerous lumbar surgeries had significantly worse outcome. Therefore, possible ways to prevent cumulation of lumbar surgeries could improve long-term health-related quality of life.

Background Admission computed tomography (CT) scoring systems can be used to objectively quantify the severity of traumatic brain injury (TBI) and aid in outcome prediction. We aimed to externally validate the NeuroImaging Radiological Interpretation System (NIRIS) and the Helsinki CT score. In addition, we compared the prognostic performance of the NIRIS and the Helsinki CT score to the Marshall CT classification and to a clinical model. Methods We conducted a retrospective multicenter observational study using the Finnish Intensive Care Consortium database. We included adult TBI patients admitted in four university hospital ICUs during 2003–2013. We analyzed the CT scans using the NIRIS and the Helsinki CT score and compared the results to 6-month mortality as the primary outcome. In addition, we created a clinical model (age, Glasgow Coma Scale score, Simplified Acute Physiology Score II, presence of severe comorbidity) and combined clinical and CT models to see the added predictive impact of radiological data to conventional clinical information. We measured model performance using area under curve (AUC), Nagelkerke’s R2 statistics, and the integrated discrimination improvement (IDI). Results A total of 3031 patients were included in the analysis. The 6-month mortality was 710 patients (23.4%). Of the CT models, the Helsinki CT displayed best discrimination (AUC 0.73 vs. 0.70 for NIRIS) and explanatory variation (Nagelkerke’s R2 0.20 vs. 0.15). The clinical model displayed an AUC of 0.86 (95% CI 0.84–0.87). All CT models increased the AUC of the clinical model by + 0.01 to 0.87 (95% CI 0.85–0.88) and the IDI by 0.01–0.03. Conclusion In patients with TBI treated in the ICU, the Helsinki CT score outperformed the NIRIS for 6-month mortality prediction. In isolation, CT models offered only moderate accuracy for outcome prediction and clinical variables outweighing the CT-based predictors in terms of predictive performance.

Injury : international journal of the care of the injured 53(8), 2774-2782 (2022). doi:10.1016/j.injury.2022.05.009, Published by Elsevier Science, Amsterdam [u.a.]

Background Coagulopathy after traumatic brain injury (TBI) is associated with poor prognosis. Purpose To assess the prevalence and association with outcomes of early thrombocytopenia in patients with TBI treated in the intensive care unit (ICU). Methods This is a retrospective multicenter study of adult TBI patients admitted to ICUs during 2003–2019. Thrombocytopenia was defined as a platelet count 9/L during the first day. The association between thrombocytopenia and hospital and 12-month mortality was tested using multivariable logistic regression, adjusting for markers of injury severity. Results Of 4419 patients, 530 (12%) had early thrombocytopenia. In patients with thrombocytopenia, hospital and 12-month mortality were 26% and 48%, respectively; in patients with a platelet count > 100 × 109/L, they were 9% and 22%, respectively. After adjusting for injury severity, a higher platelet count was associated with decreased odds of hospital mortality (OR 0.998 per unit, 95% CI 0.996–0.999) and 12-month mortality (OR 0.998 per unit, 95% CI 0.997–0.999) in patients with moderate-to-severe TBI. Compared to patients with a normal platelet count, patients with thrombocytopenia not receiving platelet transfusion had an increased risk of 12-month mortality (OR 2.2, 95% CI 1.6–3.0), whereas patients with thrombocytopenia receiving platelet transfusion did not (OR 1.0, 95% CI 0.6–1.7). Conclusion Early thrombocytopenia occurs in approximately one-tenth of patients with TBI treated in the ICU, and it is an independent risk factor for mortality in patients with moderate-to-severe TBI. Further research is necessary to determine whether this is modifiable by platelet transfusion.

Background Return to work (RTW) might be delayed in patients with complicated mild traumatic brain injury (MTBI), i.e., MTBI patients with associated traumatic intracranial lesions. However, the effect of different types of lesions on RTW has not studied before. We investigated whether traumatic intracranial lesions detected by CT and MRI are associated with return to work and post-concussion symptoms in patients with MTBI. Methods We prospectively followed up 113 adult patients with MTBI that underwent a brain MRI within 3–17 days after injury. Return to work was assessed with one-day accuracy up to one year after injury. Rivermead Post-Concussion Symptoms Questionnaire (RPQ) and Glasgow Outcome Scale Extended (GOS-E) were conducted one month after injury. A Kaplan–Meier log-rank analysis was performed to analyze the differences in RTW. Results Full RTW-% one year after injury was 98%. There were 38 patients with complicated MTBI, who had delayed median RTW compared to uncomplicated MTBI group (17 vs. 6 days), and more post-concussion symptoms (median RPQ 12.0 vs. 6.5). Further, RTW was more delayed in patients with multiple types of traumatic intracranial lesions visible in MRI (31 days, n = 19) and when lesions were detected in the primary CT (31 days, n = 24). There were no significant differences in GOS-E. Conclusions The imaging results that were most clearly associated with delayed RTW were positive primary CT and multiple types of lesions in MRI. RTW-% of patients with MTBI was excellent and a single intracranial lesion does not seem to be a predictive factor of disability to work.

Isocitrate dehydrogenase (IDH) mutation status is an important factor for surgical decision-making: patients with IDH-mutated tumors are more likely to have a good long-term prognosis, and thus favor aggressive resection with more survival benefit to gain. Patients with IDH wild-type tumors have generally poorer prognosis and, therefore, conservative resection to avoid neurological deficit is favored. Current histopathological analysis with frozen sections is unable to identify IDH mutation status intraoperatively, and more advanced methods are therefore needed. We examined a novel method suitable for intraoperative IDH mutation identification that is based on the differential mobility spectrometry (DMS) analysis of the tumor. We prospectively obtained tumor samples from 22 patients, including 11 IDH-mutated and 11 IDH wild-type tumors. The tumors were cut in 88 smaller specimens that were analyzed with DMS. With a linear discriminant analysis (LDA) algorithm, the DMS was able to classify tumor samples with 86% classification accuracy, 86% sensitivity, and 85% specificity. Our results show that DMS is able to differentiate IDH-mutated and IDH wild-type tumors with good accuracy in a setting suitable for intraoperative use, which makes it a promising novel solution for neurosurgical practice. publishedVersion

Background: Spontaneous intracerebral hemorrhage (ICH) entails significant mortality and morbidity. Severely ill ICH patients are treated in intensive care units (ICUs), but data on 1-year healthcare costs and patient care cost-effectiveness are lacking. Methods: Retrospective multi-center study of 959 adult patients treated for spontaneous ICH from 2003 to 2013. The primary outcomes were 12-month mortality or permanent disability, defined as being granted a permanent disability allowance or pension by the Social Insurance Institution by 2016. Total healthcare costs were hospital, rehabilitation, and social security costs within 12 months. A multivariable linear regression of log transformed cost data, adjusting for case mix, was used to assess independent factors associated with costs. Results: Twelve-month mortality was 45% and 51% of the survivors were disabled at the end of follow-up. The mean 12-month total cost was €49,754, of which rehabilitation, tertiary hospital and social security costs accounted for 45%, 39%, and 16%, respectively. The highest effective cost per independent survivor (ECPIS) was noted among patients aged >70 years with brainstem ICHs, low Glasgow Coma Scale (GCS) scores, larger hematoma volumes, intraventricular hemorrhages, and ICH scores of 3. In multivariable analysis, age, GCS score, and severity of illness were associated independently with 1-year healthcare costs. Conclusions: Costs associated with ICHs vary between patient groups, and the ECPIS appears highest among patients older than 70 years and those with brainstem ICHs and higher ICH scores. One-third of financial resources were used for patients with favorable outcomes. Further detailed cost-analysis studies for patients with an ICH are required.

Background To examine published data and assess evidence relating to safety and efficacy of surgical management of symptomatic pineal cysts without hydrocephalus (nhSPC), we performed a systematic review of the literature and meta-analysis. Methods Following the PRISMA guidelines, we searched Pubmed and SCOPUS for all reports with the query ‘Pineal Cyst’ AND ‘Surgery’ as of March 2021, without constraints on study design, publication year or status (PROSPERO_CRD:42,021,242,517). Assessment of 1537 hits identified 26 reports that met inclusion and exclusion criteria. Results All 26 input studies were either case reports or single-centre retrospective cohorts. The majority of outcome data were derived from routine physician-recorded notes. A total of 294 patients with surgically managed nhSPC were identified. Demographics: Mean age was 29 (range: 4–63) with 77% females. Mean cyst size was 15 mm (5–35). Supracerebellar-infratentorial approach was adopted in 90% of cases, occipital-transtentorial in 9%, and was not reported in 1%. Most patients were managed by cyst resection (96%), and the remainder by fenestration. Mean post-operative follow-up was 35 months (0–228). Presentation: Headache was the commonest symptom (87%), followed by visual (54%), nausea/vomit (34%) and vertigo/dizziness (31%). Other symptoms included focal neurology (25%), sleep disturbance (17%), cognitive impairment (16%), loss of consciousness (11%), gait disturbance (11%), fatigue (10%), ‘psychiatric’ (2%) and seizures (1%). Mean number of symptoms reported at presentation was 3 (0–9). Outcomes: Improvement rate was 93% (to minimise reporting bias only consecutive cases from cohort studies were considered, N = 280) and was independent of presentation. Predictors of better outcomes were large cyst size (OR = 5.76; 95% CI: 1.74–19.02) and resection over fenestration (OR = 12.64; 3.07–52.01). Age predicted worse outcomes (OR = 0.95; 0.91–0.99). Overall complication rate was 17% and this was independent of any patient characteristics. Complications with long-term consequences occurred in 10 cases (3.6%): visual disturbance (3), chronic incisional pain (2), sensory disturbance (1), fatigue (1), cervicalgia (1), cerebellar stroke (1) and mortality due to myocardial infarction (1). Conclusions Although the results support the role of surgery in the management of nhSPCs, they have to be interpreted with a great deal of caution as the current evidence is limited, consisting only of case reports and retrospective surgical series. Inherent to such studies are inhomogeneity and incompleteness of data, selection bias and bias related to assessment of outcome carried out by the treating surgeon in the majority of cases. Prospective studies with patient-reported and objective outcome assessment are needed to provide higher level of evidence.

Background Spontaneous angiogram-negative subarachnoid hemorrhage (SAH) is considered a benign illness with little of the aneurysmal SAH-related complications. We describe the clinical course, SAH-related complications, and outcome of patients with angiogram-negative SAH. Methods We retrospectively reviewed all adult patients admitted to a neurosurgical intensive care unit during 2004–2018 due to spontaneous angiogram-negative SAH. Our primary outcome was a dichotomized Glasgow Outcome Scale (GOS) at 3 months. We assessed factors that associated with outcome using multivariable logistic regression analysis. Results Of the 108 patients included, 84% had a favorable outcome (GOS 4–5), and mortality was 5% within 1 year. The median age was 58 years, 51% were female, and 93% had a low-grade SAH (World Federation of Neurosurgical Societies grading I–III). The median number of angiograms performed per patient was two. Thirty percent of patients showed radiological signs of acute hydrocephalus, 28% were acutely treated with an external ventricular drain, 13% received active vasospasm treatment and 17% received a permanent shunt. In the multivariable logistic regression model, only acute hydrocephalus associated with unfavorable outcome (odds ratio = 4.05, 95% confidence interval = 1.05–15.73). Two patients had a new bleeding episode. Conclusion SAH-related complications such as hydrocephalus and vasospasm are common after angiogram-negative SAH. Still, most patients had a favorable outcome. Only acute hydrocephalus was associated with unfavorable outcome. The high rate of SAH-related complications highlights the need for neurosurgical care in these patients.

Background Entrustable professional activities (EPAs) represent an assessment framework with an increased focus on competency-based assessment. Originally developed and adopted for undergraduate medical education, concerns over resident ability to practice effectively after graduation have led to its implementation in residency training but yet not in vascular neurosurgery. Subjective assessment of resident or fellow performance can be problematic, and thus, we aim to define core EPAs for neurosurgical vascular training. Methods We used a nominal group technique in a multistep interaction between a team of experienced neurovascular specialists and a medical educator to identify relevant EPAs. Panel members provided feedback on the EPAs until they reached consent. Results The process produced seven core procedural EPAs for vascular residency and fellowship training, non-complex aneurysm surgery, complex aneurysm surgery, bypass surgery, arteriovenous malformation resection, spinal dural fistula surgery, perioperative management, and clinical decision-making. Conclusion These seven EPAs for vascular neurosurgical training may support and guide the neurosurgical society in the development and implementation of EPAs as an evaluation tool and incorporate entrustment decisions in their training programs.

BackgroundSerotonergic antidepressants may predispose to bleeding, but little is known of the risk for traumatic intracranial bleeding.MethodsThis was a prospective case-control study of 218 patients with mild traumatic brain injuries (TBI) who were treated at a Finnish tertiary trauma hospital. Injury-related information and clinical findings were prospectively collected in the emergency department. Detailed pre-injury health history was collected from electronic medical records. Information on the use of serotonergic antidepressants was attained from the Finnish national prescription registry. All head CT scans were reviewed by a neuroradiologist based on the Common Data Elements. Cases were patients with traumatic intracranial hemorrhage on head CT. Controls were patients from the same cohort, but without traumatic intracranial lesions on CT. The proportion with traumatic intracranial bleeding for patients on serotonergic antidepressant medication was compared to the proportion for patients not on serotonergic medication.ResultsThe study cohort consisted of 24 cases with traumatic intracranial bleeding and 194 injured controls. The median age of the sample was 70 years (interquartile range = 50–83). One fifth (21.6%) of all the patients were taking a serotonergic antidepressant. Of the patients on an antidepressant, 10.6% (5/47) had an acute hemorrhagic lesion compared to 11.1% (19/171) of those who were not on an antidepressant (p = 0.927). In the regression analysis, traumatic intracranial hemorrhage was not associated with antidepressant use.ConclusionSerotonergic antidepressant use was not associated with an increased risk of traumatic intracranial hemorrhage after a mild TBI. The patients in this relatively small cohort were mostly middle-aged and older adults. These factors limit the generalizability of the results in younger patients with mild TBI.

Background and ObjectivesWhile somatic mutations have been well-studied in cancer, their roles in other complex traits are much less understood. Our goal is to identify somatic variants that may contribute to the formation of saccular cerebral aneurysms.MethodsWe performed whole-exome sequencing on aneurysm tissues and paired peripheral blood. RNA sequencing and the CRISPR/Cas9 system were then used to perform functional validation of our results.ResultsSomatic variants involved in supervillin (SVIL) or its regulation were found in 17% of aneurysm tissues. In the presence of a mutation in theSVILgene, the expression level of SVIL was downregulated in the aneurysm tissue compared with normal control vessels. Downstream signaling pathways that were induced by knockdown ofSVILvia the CRISPR/Cas9 system in vascular smooth muscle cells (vSMCs) were determined by evaluating changes in gene expression and protein kinase phosphorylation. We found thatSVILregulated the phenotypic modulation of vSMCs to the synthetic phenotype via Krüppel-like factor 4 and platelet-derived growth factor and affected cell migration of vSMCs via the RhoA/ROCK pathway.DiscussionWe propose that somatic variants form a novel mechanism for the development of cerebral aneurysms. Specifically, somatic variants inSVILresult in the phenotypic modulation of vSMCs, which increases the susceptibility to aneurysm formation. This finding suggests a new avenue for the therapeutic intervention and prevention of cerebral aneurysms.

Purpose Intensive care patients have increased risk of death and their care is expensive. We investigated whether risk-adjusted mortality and resources used to achieve survivors change over time and if their variation is associated with variables related to intensive care unit (ICU) organization and structure. Methods Data of 207,131 patients treated in 2008–2017 in 21 ICUs in Finland, Estonia and Switzerland were extracted from a benchmarking database. Resource use was measured using ICU length of stay, daily Therapeutic Intervention Scoring System Scores (TISS) and purchasing power parity-adjusted direct costs (2015–2017; 17 ICUs). The ratio of observed to severity-adjusted expected resource use (standardized resource use ratio; SRUR) was calculated. The number of expected survivors and the ratio of observed to expected mortality (standardized mortality ratio; SMR) was based on a mortality prediction model covering 2015–2017. Fourteen a priori variables reflecting structure and organization were used as explanatory variables for SRURs in multivariable models. Results SMR decreased over time, whereas SRUR remained unchanged, except for decreased TISS-based SRUR. Direct costs of one ICU day, TISS score and ICU admission varied between ICUs 2.5–5-fold. Differences between individual ICUs in both SRUR and SMR were up to > 3-fold, and their evolution was highly variable, without clear association between SRUR and SMR. High patient turnover was consistently associated with low SRUR but not with SMR. Conclusion The wide and independent variation in both SMR and SRUR suggests that they should be used together to compare the performance of different ICUs or an individual ICU over time. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06546-4.

Background A subset of good‐grade patients with aneurysmal subarachnoid hemorrhage (aSAH) develop delayed cerebral ischemia (DCI) that may cause permanent disabilities after aSAH. However, little is known about the risk factors of DCI among this specific patient group. Methods and Results We obtained a multinational cohort of good‐grade (Glasgow Coma Scale 13–15 on admission) patients with aSAH by pooling patient data from 4 clinical trials and 2 prospective cohort studies. We collected baseline data on lifestyle‐related factors and the clinical characteristics of aSAHs. By calculating fully adjusted risk estimates for DCI and DCI‐related poor outcome, we identified the most high‐risk patient groups. The pooled study cohort included 1918 good‐grade patients with aSAH (median age, 51 years; 64% women), of whom 21% and 7% experienced DCI and DCI‐related poor outcome, respectively. Among men, patients with obesity and (body mass index ≥30 kg/m 2 ) thick aSAH experienced most commonly DCI (33%) and DCI‐related poor outcome (20%), whereas none of the normotensive or young (aged 2 ) had DCI‐related poor outcome. In women, the highest prevalence of DCI (28%) and DCI‐related poor outcome (13%) was found in patients with preadmission hypertension and thick aSAH. Conversely, the lowest rates (11% and 2%, respectively) were observed in normotensive women with a thin aSAH. Conclusions Increasing age, thick aSAH, obesity, and preadmission hypertension are risk factors for DCI in good‐grade patients with aSAH. These findings may help clinicians to consider which good‐grade patients with aSAH should be monitored carefully in the intensive care unit.

Background and aimPrediction models for patients with traumatic brain injury (TBI) require generalizability and should apply to different settings. We aimed to validate the IMPACT and Helsinki prognostic models in patients with TBI who underwent cranial surgery in a Chinese center.MethodsThis validation study included 607 surgical patients with moderate to severe TBI (Glasgow Coma Scale [GCS] score ≤12) who were consecutively admitted to the Neurotrauma Center of People's Liberation Army (PLANC), China, between 2009 and 2021. The IMPACT models (core, extended and lab) and the Helsinki CT clinical model were used to estimate 6-month mortality and unfavorable outcomes. To assess performance, we studied discrimination and calibration.ResultsIn the PLANC database, the observed 6-month mortality rate was 28%, and the 6-month unfavorable outcome was 52%. Significant differences in case mix existed between the PLANC cohort and the development populations for the IMPACT and, to a lesser extent, for the Helsinki models. Discrimination of the IMPACT and Helsinki models was excellent, with most AUC values ≥0.80. The highest values were found for the IMPACT lab model (AUC 0.87) and the Helsinki CT clinical model (AUC 0.86) for the prediction of unfavorable outcomes. Overestimation was found for all models, but the degree of miscalibration was lower in the Helsinki CT clinical model.ConclusionIn our population of surgical TBI patients, the IMPACT and Helsinki CT clinical models demonstrated good performance, with excellent discrimination but suboptimal calibration. The good discrimination confirms the validity of the predictors, but the poorer calibration suggests a need to recalibrate the models to specific settings.

Background: Intravenous thrombolysis seems safe in acute ischemic stroke patients with saccular, unruptured intracranial aneurysms (UIAs), but little is known about the differences in cardiovascular risk factors and outcomes between intravenous thrombolysis-treated stroke patients with and without UIAs. We hypothesized that UIA patients would have a higher burden of cardiovascular risk factors and, therefore, a higher risk of an unfavorable outcome. Methods: In this prospective cohort study conducted in Helsinki University Hospital, we identified intravenous thrombolysis-treated patients with concurrent saccular UIAs admitted to a comprehensive stroke center between 2005 and 2019 using 2 overlapping methods. For each UIA patient, a control patient was identified and matched (1:1) for age, sex, admission year, and stroke severity. The primary outcome was an unfavorable outcome at 3 months, defined as a modified Rankin Scale (mRS) score 3 to 6. The secondary outcomes were an excellent outcome (mRS score 0–1) at 3 months and mRS difference in shift analysis. Results: In total, 118 UIA patients and 118 matched control patients were identified. The UIA patients were more often current smokers, and their admission systolic blood pressure was higher. The rate of hemorrhagic complications did not differ between the groups. UIAs were not associated with an unfavorable outcome in the conditional logistic regression analysis (odds ratio, 1.41 [95% CI, 0.79–2.54]; P =0.25). However, the UIA patients were less likely to have excellent outcomes (odds ratio for non-excellent outcome, 2.09 [95% CI, 1.13–3.85]; P =0.02). In shift analysis, UIAs were associated with higher mRS (odds ratio, 1.61 [95% CI, 1.03–2.49]; P =0.04). Conclusions: The intravenous thrombolysis-treated stroke patients with UIAs were more often current smokers and had higher systolic blood pressure than the matched patients without UIAs. They were as likely to have unfavorable outcomes at 3 months but seemed less likely to achieve excellent outcomes and were more likely to have higher mRS in shift analysis.

Scientific reports 12, 16571 (2022). doi:10.1038/s41598-022-20170-2, Published by Macmillan Publishers Limited, part of Springer Nature, [London]

Saccular intracranial aneurysm (sIA) rupture leads to subarachnoid haemorrhage and is preceded by chronic inflammation and atherosclerotic changes of the sIA wall. Increased lymphangiogenesis has been detected in atherosclerotic extracranial arteries and in abdominal aortic aneurysms, but the presence of lymphatic vessels in sIAs has remained unexplored. Here we studied the presence of lymphatic vessels in 36 intraoperatively resected sIAs (16 unruptured and 20 ruptured), using immunohistochemical and immunofluorescence stainings for lymphatic endothelial cell (LEC) markers. Of these LEC-markers, both extracellular and intracellular LYVE-1-, podoplanin-, VEGFR-3-, and Prox1-positive stainings were detected in 83%, 94%, 100%, and 72% of the 36 sIA walls, respectively. Lymphatic vessels were identified as ring-shaped structures positive for one or more of the LEC markers. Of the sIAs, 78% contained lymphatic vessels positive for at least one LEC marker. The presence of LECs and lymphatic vessels were associated with the number of CD68+ and CD163+ cells in the sIA walls, and with the expression of inflammation indicators such as serum amyloid A, myeloperoxidase, and cyclo-oxygenase 2, with the presence of a thrombus, and with the sIA wall rupture. Large areas of VEGFR-3 and α-smooth muscle actin (αSMA) double-positive cells were detected in medial parts of the sIA walls. Also, a few podoplanin and αSMA double-positive cells were discovered. In addition, LYVE-1 and CD68 double-positive cells were detected in the sIA walls and in the thrombus revealing that certain CD68+ macrophages are capable of expressing LEC markers. This study demonstrates for the first time the presence of lymphatic vessels in human sIA walls. Further studies are needed to understand the role of lymphatic vessels in the pathogenesis of sIA.

BACKGROUND: Different treatment options have been proposed for obstructive hydrocephalus associated with pineal lesions. We discuss the obstructive hydrocephalus management associated with pineal region tumors and cysts in Helsinki Neurosurgery. METHODS: In this article, hydrocephalus treatment by tumor-cyst removal (n = 40), shunt surgery (n = 25), and endoscopic ventriculostomies (n = 3) is evaluated in 68 patients with obstructive hydrocephalus among 136 patients with pineal region tumor and cyst. Multivariate statistical analysis was followed by univariate and multivariate regression models of last functional status, last tumor-free imaging, and disease-specific mortality of the study population. RESULTS: Preoperative hydrocephalus was linked to higher World Health Organization tumor grades, poor functional status, higher mortality, and incomplete resection of pineal region cysts and tumors. Preoperative hydrocephalus remained a predictor of poor last functional status after multivariate regression. Pineal lesion removal with the posterior third ventricle opening as primary hydrocephalus treatment resulted in better last functional status, fewer postoperative shunts, fewer hydrocephalus related procedures, and fewer postoperative infections than in the shunt-treatment group. Multivariate regression analysis linked higher World Health Organization tumor & nbsp;grade, poor immediate functional status, postoperative complications, and incomplete surgical resection as independent predictors of disease mortality in patients with hydrocephalus. Same variables (except immediate modified Rankin Scale score) and higher number of shunt surgeries became independent predictors of poor last functional status at multivariate analysis. Incomplete resection was the only independent predictor of tumor-free magnetic resonance imaging at the last evaluation. CONCLUSIONS: Direct removal of pineal lesions with the opening of the posterior third ventricle could represent effective and reliable management of the associated obstructive hydrocephalus. Further research is required to generalize our inferences.

Background We wanted to understand how patients with different modified Rankin Scale (mRS) grades differ regarding their health-related quality of life (HRQoL) and how this affects the interpretation and dichotomization of the grade. Methods In 2016, all adult patients in our brain arteriovenous malformation (AVM) database (n = 432) were asked to fill in mailed letters including a questionnaire about self-sufficiency and lifestyle and the 15D HRQoL questionnaire. The follow-up mRS was defined in 2016 using the electronic patient registry and the questionnaire data. The 15D profiles of each mRS grade were compared to those of the general population and to each other, using ANCOVA with age and sex standardization. Results Patients in mRS 0 (mean 15D score = 0.954 ± 0.060) had significantly better HRQoL than the general population (mean = 0.927 ± 0.028), p p Conclusions Using 15D, we were able to find significant differences in the HRQoL between mRS 0 and mRS 1 AVM patients, against the recent findings on stroke patients using EQ-5D in their analyses. Although the dichotomization cut point is commonly set between mRS 1 and 2, patients in these grades had a similar HRQoL and a decreased ability to continue their premorbid lifestyle, in contrast to patients in mRS 0.

OBJECTIVE: Previous reports suggest that more experienced surgeons have better postoperative outcomes in neurosurgery. We studied whether this association is found in a fragile cohort of >= 80-year-old intracranial meningioma (IM) patients. METHODS: We identified 83 very old IM patients who were operated on by 12 different surgeons between 2010 and 2018. Besides general patient-and tumor-related characteristics, we collected information about the surgeons' case volume and length of surgical career (LSC). We classified neurosurgeons into 3 different categories: 1) low-volume (8 surgeons; 1-4 operations per surgeon); 2) moderate-volume (3 surgeons; 8e12 operations per surgeon); and 3) high-volume (1 reference surgeon; 37 operations). We calculated odds ratios (ORs) with 95% confidence intervals for 1-year mortality and 3-month independency (capability to live at home) by surgeon volume categories and per 5-year increase of LSC. RESULTS: We found no significant differences in any preoperative characteristics between the surgeon volume categories. IM patients operated on by low-volume surgeons had the lowest risk of first-year mortality (OR, 0.15 [0.01-2.05]) and the highest likelihood of living at home 3 months after surgery (OR, 12.61 [1.21-131.03]). Increasing LSC was associated with 1-year mortality (OR, 1.34 [1.03-1.73]) and with lower likelihood to live at home 3 months after surgery (OR, 0.83 [0.69-1.00]), but these associations were slightly nonsignificant after adjusting for IM patients' age, sex, and preoperative independency. CONCLUSIONS: In a high-volume academic hospital, less experienced neurosurgeons seem to achieve similar results as the more experienced neurosurgeons, even when operating on selected highly fragile meningioma patients.

Background The role of coagulopathy in patients with traumatic brain injury has remained elusive. In the present study, we aim to assess the prevalence of coagulopathy in patients with traumatic intracranial hemorrhage, their clinical features, and the effect of coagulopathy on treatment and mortality. Methods An observational, retrospective single-center cohort of consecutive patients with traumatic intracranial hemorrhage treated at Helsinki University Hospital between 01 January and 31 December 2010. We compared clinical and radiological parameters in patients with and without coagulopathy defined as drug- or disease-induced, i.e., antiplatelet or anticoagulant medication at a therapeutic dose, thrombocytopenia (platelet count < 100 E9/L), international normalized ratio > 1.2, or thromboplastin time < 60%. Primary outcome was 30-day all-cause mortality. Logistic regression analysis allowed to assess for factors associated with coagulopathy and mortality. Results Of our 505 patients (median age 61 years, 65.5% male), 206 (40.8%) had coagulopathy. Compared to non-coagulopathy patients, coagulopathy patients had larger hemorrhage volumes (mean 140.0 mL vs. 98.4 mL, p < 0.001) and higher 30-day mortality (18.9% vs. 9.7%, p = 0.003). In multivariable analysis, older age, lower admission Glasgow Coma Scale score, larger hemorrhage volume, and conservative treatment were independently associated with mortality. Surgical treatment was associated with lower mortality in both patients with and without coagulopathy. Conclusions Coagulopathy was more frequent in patients with traumatic intracranial hemorrhage presenting larger hemorrhage volumes compared to non-coagulopathy patients but was not independently associated with higher 30-day mortality. Hematoma evacuation, in turn, was associated with lower mortality irrespective of coagulopathy.

Aim: The purpose of this study is to document the annual incidence and incidence trends of pediatric traumatic brain injury (pTBI) in Finland over the course of 21 years. Methods: We conducted a retrospective nationwide register-based cohort study and used the Finnish Care Register and Population information statistics from 1998 to 2018. The patient group includes all patients aged

Purpose The purpose of the study was to evaluate the long-term outcome after surgery for lumbar disc herniation in a young adult population. Methods A total of 526 consecutive patients between 18 and 40 years of age who underwent surgery for lumbar disc between 1990 and 2005 were included in the study. The primary outcomes were the need for new lumbar spine surgery during the follow-up and secondary outcomes were short-term subjective outcome, the Oswestry Disability Index (ODI) score, and the ability to carry out employment at the end of the long-term follow-up. Results A total of 96% of the patients had a reduction in their symptoms at the clinical follow-up (median of 50 days post-surgery). Twenty-one patients (4.0%) had a reoperation within 28 days. Excluding these early reoperations, 136 patients (26%) had additional lumbar spine surgery and 18 patients (3.4%) underwent lumbar fusion during the follow-up of median 18 years. The annual risk for new surgery was 1.4%. In total, 316 patients (60%) returned the ODI questionnaire, and their mean score was 8.1. Patients with a higher number of additional lumbar spine surgeries (p Conclusion Patients showed excellent short-term recovery from their symptoms. In the long term, the mean ODI score for the patients was comparable to the normative population. However, a notable proportion of the patients required additional lumbar surgery during the follow-up period, and a higher number of lumbar surgeries was associated with poor ODI scores.

Background In recent years, smaller-sized (diameter Methods The use of localization markers in advance can help to acquire preoperative CT images of the patients to create and calculate a three-dimensional (3D) virtual graph using a computer. With the 3D graph, spatial distance of the tumor from the markers is calculated and the tumor location projected on the scalp by the Triangle Pythagorean theorem. This enables precise localization of intracranial microlesions preoperatively. Results The location of the tumor was consistent with that of the pre-operative virtual image, and the craniotomy was exact. The patient was discharged 3 days later without any neurological deficits. Conclusions This method is simple and reliable, inexpensive, and accurate in the location of small-sized lesions, which can partially compensate for the lack of neuro-navigation and is suitable for widespread application in hospitals in developing countries.

Background: Our aim was to assess the occurrence and risk factors for psychotropic medication use after pediatric traumatic brain injury treated in the intensive care unit. Methods: We combined data from the Finnish Intensive Care Consortium database, data on reimbursed medications from the Social Insurance Institute, and individual electronic health care data. We analyzed data on children aged five to 17 years treated for traumatic brain injury in intensive care units of four university hospitals in Finland during 2003 to 2013 and being alive six months after injury with no history of psychotropic medication use before traumatic brain injury. Results: We identified 248 patients of whom 46 (19%) were prescribed a new psychotropic medication after traumatic brain injury. In multivariable logistic regression, a higher age associated with a higher probability for use of any psychotropic medication. Subgroup analyses showed that higher age associated with an increased risk of antidepressant and antipsychotic use but with a decreased risk of stimulant use. Apart from age, we found no other clinical, radiological, or treatment-related factors that significantly associated with subsequent use of psychotropics. Psychotropic medication was most common (45%) in children aged 12 to 17 years and had moderate disability at six-month follow-up. Conclusions: One fifth of children treated in the intensive care unit for traumatic brain injury were prescribed a new psychotropic medication during a median follow-up of three years and five months. Psychotropic medication was most common among teenagers with moderate post-traumatic disability. The need and use of psychotropics postinjury seem multifactorial and not related to any traumatic brain injury type. (C) 2020 Elsevier Inc. All rights reserved.

BACKGROUND: The number of elderly patients with aneurysmal subarachnoid hemorrhage (aSAH) admitted to intensive care units (ICUs) has increased. We aimed to analyze the characteristics and outcomes of such patients in a tertiary university hospital during a 5-year period. METHODS: A retrospective single-center analysis was performed of patients with aSAH >= 70 years old admitted to a tertiary neuro-ICU during January 2014-May 2019 based on medical records and computed tomography scans. The primary outcome was functional outcome at 12 months. We used multivariable logistic regression to assess factors associated with unfavorable outcome (Glasgow Outcome Scale score 1-3 and institutionalized). RESULTS: Of 117 included patients, 49% had a favorable outcome at 12 months, and mortality was 41%. In multivariable analysis, poor-grade aSAH and intraventricular hemorrhage were predictors of poor outcome (odds ratio, 4.7, 95% confidence interval, 1.7-12.5 and odds ratio, 2.8, 95% confidence interval, 1.1-7.2, respectively). None of the patients with a Glasgow Coma Scale (GCS) motor score of 1-3 three days after admission was alive at 12 months. In contrast, 65% of those with a GCS motor score 6 had favorable outcome. CONCLUSIONS: Half of elderly patients with aSAH admitted to a neuro-ICU were able to live at home after 12 months. Mortality was significant, but the number of severely disabled patients was low. Clinical status atadmission was the strongest predictor of outcome, whereas intraventricular hemorrhage increased the risk of poor outcome as well. GCS motor score 3 days after admission seemed to predict mortality and outcome.

OBJECTIVE: The midline supracerebellar infratentorial (SCIT) approach and its paramedian development are commonly used for dealing with pineal lesions. Comparative clinical studies are lacking, however. We aim to establish the better performance of the paramedian SCIT approach in terms of clinical safety in surgically treated pineal cysts and pineal region tumors. Procedural functionality and effectiveness have been also analyzed. METHODS: A comparative analysis of clinical, radiologic, pathologic, and surgical features, and outcome was performed between 55 midline and 57 paramedian SCIT approaches that were exclusively performed in 112 patients (57 pineal cysts and 55 tumors of the pineal region) operated in sitting position by a single surgeon. Information was retrieved from hospital records and microsurgical videos. RESULTS: The paramedian SCIT approach linked with fewer postoperative complications (odds ratio [OR]: 0.40) and fewer approach-related complications (OR: 0.28) than the midline SCIT approach. The SCIT paramedian approach was achieved in a shorter time, by a smaller bone flap, and with fewer complex procedural steps than the midline approach. The SCIT paramedian approach did not require the opening of the falx cerebelli, midline cerebellar retraction, section of the midline cerebellar draining veins, nor wide opening of the dura. Gross total resection, size of the lesion, microsurgical time for removal, histopathological diagnosis and postoperative outcome were statistically similar in both groups. CONCLUSIONS: The SCIT approach represents a safer and more functional approach for the removal of cysts and tumors of the pineal region than the classic midline approach, while maintaining the same effectiveness.

Publisher Copyright: © 2022 Purpose: The resource use of cardiac surgery and neurosurgery patients likely differ from other ICU patients. We evaluated the relevance of these patient groups on overall ICU resource use. Methods: Secondary analysis of 69,862 patients in 17 ICUs in Finland, Estonia, and Switzerland in 2015–2017. Direct costs of care were allocated to patients using daily Therapeutic Intervention Scoring System (TISS) scores and ICU length of stay (LOS). The ratios of observed to severity-adjusted expected resource use (standardized resource use ratios; SRURs), direct costs and outcomes were assessed before and after excluding cardiac surgery or cardiac and neurosurgery. Results: Cardiac surgery and neurosurgery, performed only in university hospitals, represented 22% of all ICU admissions and 15–19% of direct costs. Cardiac surgery and neurosurgery were excluded with no consistent effect on SRURs in the whole cohort, regardless of cost separation method. Excluding cardiac surgery or cardiac surgery plus neurosurgery had highly variable effects on SRURs of individual university ICUs, whereas the non-university ICU SRURs decreased. Conclusions: Cardiac and neurosurgery have major effects on the cost structure of multidisciplinary ICUs. Extending SRUR analysis to patient subpopulations facilitates comparison of resource use between ICUs and may help to optimize resource allocation.

Background We investigated preoperative physical activity (PA) and sedentary behaviour (SB) in patients scheduled for elective cardiac procedures and compared them with population-based sample of Finnish adults. Methods Cardiac patients (n = 139) undergoing cardiac operations carried a triaxial accelerometer for seven days during the month before the procedure. Patients were categorised into four groups according to the procedure: percutaneous coronary intervention or coronary angiography (PCI-CA), coronary artery bypass grafting (CABG), aortic valve replacement (AVR) and mitral valve surgery (MVS). The raw accelerometer data was analyzed with dedicated algorithms to determine metabolic equivalents (METs, 3.5 mL/kg/min of oxygen consumption) of PA. The intensity of PA was divided into two categories: light (LPA, 1.5–2.9 METs) and moderate-to-vigorous (MVPA, ≥ 3.0 METs), while SB represented intensity Results Cardiac patients had fewer daily steps than the FinFit population (p = 0.01), and less SB accumulating from p = 0.002) but more from 20 to 60 min bouts (p = 0.002). Particularly, CABG group had less daily MVPA (p = 0.002) and MVPA accumulating from > 10 min bouts (p Conclusions We found large differences in PA and SB between the patient groups and the FitFit population, CABG group having the worst activity profile. Also, the variation within the patient groups was wide, which should be considered to individualise the rehabilitation programs postoperatively. Trial registration clinicaltrials.gov (NCT03470246). Registered 19 March 2018, https://clinicaltrials.gov/ct2/show/NCT03470246.

Objective: Spinal meningiomas are neurosurgical rarities that manifest with progressive para- or tetraparesis. The effect of timing of surgery on the recovery after the loss of walking ability is poorly known. We studied the effect of timing of surgery on restoring walking ability in surgically-treated spinal meningioma patients.Methods: Using electronic health records, we retrospectively identified ≥18-year-old patients operated on during 2010-2020. The patients were followed until 30th September 2020, death or emigration.Results: We identified 108 patients (81% women) with operated spinal meningiomas. The mean age of the patients was 64 years (range 18-94). A gross-total resection was achieved in 101 (94%), and 21 (19%) patients suffered from perioperative complications. Of the 108 patients operated on, 49 (45%) could not walk without assistance prior to surgery. At the time of first postoperative visit (mean 3.1 months, range 1.3-13.1), 14 (58%) out of 24 patients operated on within 29 days and eight (40%) out of 20 patients operated on later than 29 days since the loss of walking ability without assistance, were able to walk without assistance. Also, three out of five paraplegic patients who underwent surgery later than 29 days after they lost the walking ability, were able to at least walk with assistance at first postoperative visit.Conclusion: Early surgical treatment following the loss of walking ability restores walking ability in a substantial number of patients. However, even late surgery may restore walking ability.

Background Several studies have suggested no change in the outcome of patients with traumatic brain injury (TBI) treated in intensive care units (ICUs). This is mainly due to the shift in TBI epidemiology toward older and sicker patients. In Finland, the share of the population aged 65 years and over has increased the most in Europe during the last decade. We aimed to assess changes in 12-month and hospital mortality of patients with TBI treated in the ICU in Finland. Methods We used a national benchmarking ICU database (Finnish Intensive Care Consortium) to study adult patients who had been treated for TBI in four tertiary ICUs in Finland during 2003–2019. We divided admission years into quartiles and used multivariable logistic regression analysis, adjusted for case-mix, to assess the association between admission year and mortality. Results A total of 4535 patients were included. Between 2003–2007 and 2016–2019, the patient median age increased from 54 to 62 years, the share of patients having significant comorbidity increased from 8 to 11%, and patients being dependent on help in activities of daily living increased from 7 to 15%. Unadjusted hospital and 12-month mortality decreased from 18 and 31% to 10% and 23%, respectively. After adjusting for case-mix, a reduction in odds of 12-month and hospital mortality was seen in patients with severe TBI, intracranial pressure monitored patients, and mechanically ventilated patients. Despite a reduction in hospital mortality, 12-month mortality remained unchanged in patients aged ≥ 70 years. Conclusion A change in the demographics of ICU-treated patients with TBI care is evident. The outcome of younger patients with severe TBI appears to improve, whereas long-term mortality of elderly patients with less severe TBI has not improved. This has ramifications for further efforts to improve TBI care, especially among the elderly.

One-fourth of people with aneurysmal subarachnoid hemorrhage (SAH) die from the bleed suddenly in emergency rooms or before reaching hospital [1]. Unless medicolegal or medical autopsies are systematically performed to all sudden deaths, these SAH deaths are almost invariably classified as sudden cardiac deaths. The first observable symptom of sudden SAH death is loss of consciousness (LOC), which is also a common presenting symptom of non-fatal SAH. The pathophysiology of LOC at the time of aneurysm rupture is controversial. However, similar to sudden SAH deaths, the etiology of LOC in non-fatal SAHs is often considered to be cardiogenic. This presumption may, however, stem from the lack of evidence suggesting other etiologies. This report illustrates that a transient intracranial circulatory arrest associates with LOC and can occur without cardiac arrest. Furthermore, the case shows that patients experiencing a transient intracranial circulatory arrest can recover relatively well, despite the poor clinical status at the time of bleed. Clinical Presentation Reporting follows the CARE guideline [2]. According to the Finnish legislation, the patient consent is not required to use de-identified patient information for scientific purposes. Presenting Symptoms A 50- to 60-year-old ex-smoker with hypertension and asthma lost consciousness while playing sports. Bystanders performed cardiopulmonary resuscitation, and the patient regained consciousness in a couple of minutes.

Objective To assess the prognostic profile, clinical outcome, treatment-associated morbidity, and treatment burden of elderly patients with glioblastoma (GBM) undergoing microsurgical tumor resection as part of contemporary treatment algorithms. Methods We retrospectively identified patients with GBM ≥65 years of age who were treated by resection at 2 neuro-oncology centers. Survival was assessed by Kaplan-Meier analyses; log-rank tests identified prognostic factors. Results The study population included 160 patients (mean age, 73.1 ± 5.1 years), and the median contrast-enhancing tumor volume was 31.0 cm3. Biomarker analyses revealed O(6)-methylguanine-DNA methyltransferase–promoter methylation in 62.7% and wild-type isocitrate dehydrogenase in 97.5% of tumors. The median extent of resection (EOR) was 92.3%, surgical complications were noted in 10.0% of patients, and the median postoperative hospitalization period was 8 days. Most patients (60.0%) received adjuvant radio-/chemotherapy. The overall treatment-associated morbidity was 30.6%. The median progression-free and overall survival were 5.4 months (95% confidence interval [CI], 4.6–6.4 months) and 10.0 months (95% CI, 7.9–11.7 months). The strongest predictors for favorable outcome were patient age ≤73.0 years (P = 0.0083), preoperative Karnofsky Performance Status Scale score ≥80% (P = 0.0179), postoperative modified Rankin Scale score ≤1 (P Conclusions Clinical outcome for elderly patients with GBM remains limited. Nonetheless, the observed treatment-associated morbidity and treatment burden were moderate in the patients, and patient age and performance status remained the strongest predictors for survival. The risks and benefits of tumor resection in the age of biomarker-adjusted treatment concepts require further prospective evaluation.

BACKGROUND: Mirror distal anterior cerebral artery aneurysms (DACAAs) are a rare finding in patients with subarachnoid hemorrhage, with only a few cases reported. CASE DESCRIPTION: A 40-year-old man was admitted for sudden-onset headache, nausea and vomiting, and transient right arm hypoesthesia. Computed tomography scan showed a subarachnoid hemorrhage with intracerebral hemorrhage within the interhemispheric fissure, but computed tomography angiography failed to identify any aneurysms. Subsequent digital subtraction angiography with three-dimensional reconstructions revealed 1.5-mm-diameter mirror DACAAs on the A3 segments. However, the definite rupture site remained unidentifiable. After interdisciplinary consultation, endovascular treatment was favored, and complete occlusion of both DACAAs was achieved by coiling without stent placement. During coiling of the right DACAA, a thrombus in the right callosomarginal artery formed, and treatment with abciximab (ReoPro) was initiated to dissolve the thrombus. After treatment, the patient presented with right leg paresis; however, computed tomography did not show any ischemia, intracerebral hemorrhage increase, or vasospasm. Over the following days, the leg paresis improved, and the patient achieved increased mobilization. He was transferred for further rehabilitation 16 days after hemorrhage. The leg paresis had recovered to a grade 3/5. CONCLUSIONS: Rapid identification of the rupture site in patients with subarachnoid hemorrhage and multiple aneurysms is crucial for initiating optimal treatment. In patients with mirror aneurysms in close proximity to each other, this is not easily accomplished, complicating treatment decisions. Although clipping has been the standard for DACAA occlusion, coiling should be taken into consideration as a viable alternative.

Aim Studies suggest that hyperoxemia increases short-term mortality after cardiopulmonary resuscitation (CPR), but the effect of hyperoxemia on long-term outcomes is unclear. We determined the prevalence of early hyperoxemia after CPR and its association with long-term neurological outcome and mortality. Methods We analysed data from adult cardiac arrest patients treated after CPR in tertiary ICUs during 2005–2013. We retrieved data from the resuscitation and the first arterial blood sample collected after return of spontaneous circulation (ROSC) (severe hyperoxemia defined as PaO2 > 40 kPa and moderate as PaO2 16–40 kPa). We inspected two outcomes, neurological performance at one year after resuscitation according to the Cerebral Performance Category and one-year mortality. We used logistic regression to test associations between hyperoxemia and the outcome and interaction analyses to test the effect of hyperoxemia exposure on the outcomes in smaller subgroups. Results Of 1110 patients 11% had severe hyperoxemia, prevalence was 10% for out-of-hospital arrests, 13% for in-hospital arrests and 9% for in-ICU arrests. In total 585(53%) patients had an unfavourable neurological outcome. Compared to normoxemia, severe (Odds ratio [OR] 0.81, 95% confidence interval [CI] 0.50–1.30) and moderate hyperoxemia (OR 0.94 95%CI 0.69–1.27) did not associate with neurological outcome. Additionally, hyperoxemia had no association with mortality. In subgroup analyses there were no significant associations between severe hyperoxemia and outcomes regardless of cardiac arrest location, initial rhythm or time-to-ROSC. Conclusion We found no association between early post-arrest hyperoxemia and unfavourable outcome. Subgroup analysis found no differential effect depending on arrest location, initial rhythm or time-to-ROSC.

Aneurysmal subarachnoid hemorrhage (aSAH) is a highly complex disease. Majority of aSAH survivors confront post-SAH complications including cerebral vasospasm (CVS) and delayed cerebral ischemia (DCI) that mainly influence the clinical outcome. Tissue damage during early brain injury may lead to release of damage associated molecular pattern molecules (DAMPs) that may initiate and sustain inflammation during the course of aSAH through activation of pattern recognition receptors. Mitochondrial DNA (mtDNA) due to unmethylated CpG motifs acts as a DAMP via binding to toll-like receptor-9. The aim of this study was to investigate the cell free circulating mtDNA in the systemic circulation of aSAH patients and its association with post-SAH complications and clinical outcome. The DNA was extracted from the serum of 80 aSAH patients at days 1, 3, 5, 7, 9, 11, 13 and from 18 healthy controls. Three representative mitochondrial gene fragments including Cytochrome B (CytB), D-Loop and Cytochrome c oxidase subunit-1 (COX-1) were quantified using a Taqman-probes based qPCR. Levels of mtDNA were quantified from standard curves generated using mtDNA extracted from HepG2 cell mitochondria. Clinical outcome of the patients was assessed by Glasgow outcome scale (GOS) and modified Rankin scale (mRS). Clinical data and post-SAH complications were recorded from patient's record file. Serum D-Loop and COX-1 were significantly elevated early after aSAH and remained high over first 2 weeks. CytB levels were however, initially unchanged but elevated later at day 7 as compared to healthy controls. Cumulative levels measured over two weeks showed significant correlations with post-SAH complications including a negative correlation of D-Loop with pneumonia infection, hydrocephalus and occurrence of epilepsy, a positive correlation of Cyt B with occurrence of CVS and a negative correlation of COX-1 with occurrence of systemic infections and seizures. Cumulative D-Loop values negatively correlated with clinical outcome. Our data suggest that mtDNA may directly or indirectly influence post-SAH complications and clinical outcome.

Neurosurgeons are vulnerable to additional noise in their natural operating environment. Noise exposure is associated with reduced cognitive function, inability to concentrate, and nervousness. Mediation music provides an opportunity to create a calmer environment which may reduce stress during surgery. A pilot study was performed to find a suitable task, meditation music of surgeon’s choice, and operation noise and to reach a certain level of training. For the main experiment, two neurosurgeons with different microsurgical experience used real operation noise and meditation music with delta waves as mediating music. Each surgeon performed 10 training bypasses (five with noise and five with music) with 16 stitches in each bypass. The total time to complete 16 stitches, a number of unachieved movements (N.U.Ms), length of thread consumed, and distribution of the stitches were quantified from the recorded videos and compared in both groups. A N.U.Ms were significantly reduced from 109 ± 38 with operation room (OR) noise to 38 ± 13 (p

Background Treatment of gunshot wounds of the brain (GSWB) remains controversial and there is high variation in reported survival rates (from 90%) depending on the etiology and country. We retrospectively analyzed the outcome of a series of consecutive GSWB patients admitted alive to a level 1 trauma center in a safe high-income welfare country with a low rate of homicidal gun violence. Methods Patients admitted due to a GSWB to the HUS Helsinki University Hospital during 2000–2012 were identified from hospital discharge registry and log books of the emergency room and ICU. CT scans and medical records of these patients were reviewed. Univariate analysis and backward logistic regression were performed, and their results compared with that of a systematic literature review of factors related to the outcome of GSWB patients. Results Sixty-four patients admitted alive after GSWB were identified. Eighty percent had self-inflicted GSWB, 81% were contact shots, and 70% were caused by handguns. In-hospital mortality was 72%. Factors associated with mortality in our series were low GCS (≤ 8) at admission, transventricular bullet trajectory, and associated damage to deep brain structures, as reported before in the literature. Of the 64 patients admitted alive, 42% (27/64) were admitted to ICU, 34% (22/64) underwent surgery, and in 25% (16/64), craniotomy and hematoma evacuation was performed. Mortality in the surgically treated group was 32% but near 100% without surgery and ICU treatment. Median GOS in the surgically treated patients was 3 (range 1–5). Conclusions GSWB caused by contact shot from handguns has a high mortality rate, but can be survived with reasonable outcome if limited to lobar injury without significant damage to deep brain structures or brain stem. In such GSWB patients, initial aggressive resuscitation, ICU admission, and surgery seem indicated. Electronic supplementary material The online version of this article (10.1007/s00701-019-03952-y) contains supplementary material, which is available to authorized users.

OBJECTIVES: Cochleovestibular nerve compression syndrome due to intra-meatal anterior inferior cerebellar artery (AICA) that causes tinnitus is an extremely rare condition with special therapeutic challenges and implications. Here we present the first surgically treated pediatric case of tinnitus showing microvascular conflict of the cochleovestibular nerve and intrameatal AICA loop. METHODS: A pediatric case of tinnitus is described, and a surgical technique is elaborated with video material. A PubMed literature search was performed to identify surgically treated pediatric cases of intrameatal compression of the eighth nerve with an AICA loop. RESULTS: Tinnitus was completely resolved and hearing was intact immediately after surgical decompression. The patient was free from further symptoms after a short follow-up of 12 weeks. Microsurgical decompression including opening of the internal auditory canal and transposition of the AICA was an effective treatment option in this case. CONCLUSION: Decompression of the cochleovestibular nerve including opening of the internal auditory canal and transposition of the AICA appears to be an effective treatment option for cases with radiologically confirmed intrameatal vascular compression of the eighth nerve causing unilateral pulsatile tinnitus.

Background and purpose For prevention of cerebrovascular diseases at younger age, it is important to understand the risk factors occurring early in life. We investigated the relationship between mothers’ general health during pregnancy and the offspring’s risk of cerebrovascular disease in age of 15 to 52 years. Methods Within the population-based prospective Northern Finland Birth Cohort 1966, 11,926 persons were followed from antenatal period to 52 years of age. Information on their mother’s ill health conditions, i.e., hospitalizations, chronic diseases, medications, vitamin or iron supplement, fever, anemia, mood, and smoking was collected from 24th gestational week onwards. Ischemic and hemorrhagic cerebrovascular diseases of the offspring were identified from national registers in Finland. Cox proportional hazard models were used to estimate the association of mother’s health conditions with incidence of cerebrovascular disease in the offspring, with adjustments for potential confounders. Results During 565,585 person-years of follow-up, 449 (2.8%) of the offspring had a cerebrovascular disease. Hospitalization during pregnancy was associated with an increased risk of cerebrovascular disease in the offspring (hazard ratio (HR) = 1.49; 95% confidence interval (CI) 1.06–2.08) after adjustment for confounders, as was having more than three ill health conditions (HR = 1.89; CI 1.14–3.11). Not using vitamin or iron supplement was associated with increased risk for cerebrovascular disease in the offspring (HR = 1.39; CI 1.01–1.89). Conclusions The results suggest that the risk of cerebrovascular disease may start as early as during the antenatal period, and the health characteristics of mothers during pregnancy may play a role in cerebrovascular disease risk of the offspring.

Scandinavian journal of trauma, resuscitation and emergency medicine 29(1), 113 (2021). doi:10.1186/s13049-021-00930-1, Published by BioMed Central, London

Background Trauma-induced coagulopathy in patients with traumatic brain injury (TBI) is associated with high rates of complications, unfavourable outcomes and mortality. The mechanism of the development of TBI-associated coagulopathy is poorly understood. Methods This analysis, embedded in the prospective, multi-centred, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study, aimed to characterise the coagulopathy of TBI. Emphasis was placed on the acute phase following TBI, primary on subgroups of patients with abnormal coagulation profile within 4 h of admission, and the impact of pre-injury anticoagulant and/or antiplatelet therapy. In order to minimise confounding factors, patients with isolated TBI (iTBI) (n = 598) were selected for this analysis. Results Haemostatic disorders were observed in approximately 20% of iTBI patients. In a subgroup analysis, patients with pre-injury anticoagulant and/or antiplatelet therapy had a twice exacerbated coagulation profile as likely as those without premedication. This was in turn associated with increased rates of mortality and unfavourable outcome post-injury. A multivariate analysis of iTBI patients without pre-injury anticoagulant therapy identified several independent risk factors for coagulopathy which were present at hospital admission. Glasgow Coma Scale (GCS) less than or equal to 8, base excess (BE) less than or equal to − 6, hypothermia and hypotension increased risk significantly. Conclusion Consideration of these factors enables early prediction and risk stratification of acute coagulopathy after TBI, thus guiding clinical management.

Background: The prevalence of unruptured intracranial aneurysms (UIAs) is around 2 to 3% in the general population. We hypothesized that the prevalence of small UIAs is higher among 50 to 60-year-old female smokers, since the incidence of aneurysmal subarachnoid hemorrhage (aSAH) is exceptionally high in 60 to 70-year-old female smokers. Methods: Ethics approval for this pilot study of 50 women was obtained from the hospital ethics committee. In order to minimize recruitment bias, preliminary invitation letters were sent to 50 to 60-year-old women who were known to be active smokers. Those interested in participating were further informed about the study rationale and protocol. Following written consent, participants filled a detailed questionnaire and underwent computed tomography angiography (CTA) analysis. All abnormalities were recorded. Results: Of the 158 preliminary invitation letters, 70 potential participants initially replied. Of these, 50 returned questionnaires and written consents, 43 of which underwent CTA analysis. Most (39; 91%) were postmenopausal, and 9 (21%) were hypertensive. Two reported a family history (≥ 1 first-degree members) of intracranial aneurysms. UIAs (maximum sizes of 2, 2, 3, 3 and 7 mm) were found in five (12%) female smokers. One woman was operated on, and the remaining four were treated with non-invasive preventive actions (smoking cessation and follow-ups). Conclusion: Small UIAs, which may be best suited for non-invasive preventive actions, may be relatively common in 50 to 60-year-old female smokers. Whether this kind of targeted screening leads to improved health in female smokers requires further investigation.

BackgroundPsychiatric sequelae after traumatic brain injury (TBI) are common and may impede recovery. We aimed to assess the occurrence and risk factors of post-injury psychotropic medication use in intensive care unit (ICU)-treated patients with TBI and its association with late mortality.MethodsWe conducted a retrospective multi-centre observational study using the Finnish Intensive Care Consortium database. We included adult TBI patients admitted in four university hospital ICUs during 2003–2013 that were alive at 1 year after injury. Patients were followed-up until end of 2016. We obtained data regarding psychotropic medication use through the national drug reimbursement database. We used multivariable logistic regression models to assess the association between TBI severity, treatment-related variables and the odds of psychotropic medication use and its association with late all-cause mortality (more than 1 year after TBI).ResultsOf 3061 patients, 2305 (75%) were alive at 1 year. Of these, 400 (17%) became new psychotropic medication users. The most common medication types were antidepressants (61%), antipsychotics (35%) and anxiolytics (26%). A higher Glasgow Coma Scale (GCS) score was associated with lower odds (OR 0.93, 95% CI 0.90–0.96) and a diffuse injury with midline shift was associated with higher odds (OR 3.4, 95% CI 1.3–9.0) of new psychotropic medication use. After adjusting for injury severity, new psychotropic medication use was associated with increased odds of late mortality (OR 1.19, 95% CI 1.19–2.17, median follow-up time 6.4 years).ConclusionsPsychotropic medication use is common in TBI survivors. Higher TBI severity is associated with increased odds of psychotropic medication use. New use of psychotropic medications after TBI was associated with increased odds of late mortality. Our results highlight the need for early identification of potential psychiatric sequelae and psychiatric evaluation in TBI survivors.

Background Cardiac arrest (CA) is a leading cause of death worldwide. As population ages, the need for research focusing on CA in elderly increases. This study investigated treatment intensity, 12-month neurological outcome, mortality and healthcare-associated costs for patients aged over 75 years treated for CA in an intensive care unit (ICU) of a tertiary hospital. Methods This single-centre retrospective study included adult CA patients treated in a Finnish tertiary hospital’s ICU between 2005 and 2013. We stratified the study population into two age groups: $$\ge$$ ≥ 75 years. We compared interventions defined by the median daily therapeutic scoring system (TISS-76) between the age groups to find differences in treatment intensity. We calculated cost-effectiveness by dividing the total one-year healthcare-associated costs of all patients by the number of survivors with a favourable neurological outcome. Favourable outcome was defined as a cerebral performance category (CPC) of 1–2 at 12 months after cardiac arrest. Logistic regression analysis was used to identify independent associations between age group, mortality and neurological outcome. Results This study included a total of 1,285 patients, of which 212 (16 %) were $$\ge$$ ≥ 75 years of age. Treatment intensity was lower for the elderly compared to the younger group, with median TISS scores of 116 and 147, respectively (p p p p Conclusions The elderly ICU-treated CA patients in this study had worse neurological outcomes, higher mortality and lower cost-effectiveness than younger patients. Elderly received less intense treatment. Further efforts are needed to recognize the tools for assessing which elderly patients benefit from a more aggressive treatment approach in order to improve the cost-effectiveness of post-CA management.

Background Pain is a frequent and inevitable factor affecting the quality of life among older people. Several studies have highlighted the ineffectiveness of treating chronic pain among the aged population, and little is known about the prevalence of analgesics administration among community-dwelling older adults. The objective was to examine older adults’ prescription analgesic purchases in relation to SF-36 pain in a population-based setting. Methods One thousand four hundred twenty community-dwelling citizens aged 62–86 years self-reported SF-36 bodily pain (pain intensity and pain-related interference) scores for the previous 4 weeks. The Social Insurance Institution of Finland register data on analgesic purchases for 6 months prior to and 6 months after the questionnaire data collection were considered. Special interest was focused on factors related to opioid purchases. Results Of all participants, 84% had purchased prescription analgesics during 1 year. NSAIDs were most frequently purchased (77%), while 41% had purchased paracetamol, 32% opioids, 17% gabapentinoids, and 7% tricyclic antidepressants. Age made no marked difference in purchasing prevalence. The number of morbidities was independently associated with analgesic purchases in all subjects and metabolic syndrome also with opioid purchases in subjects who had not reported any pain. Discussion Substantial NSAID and opioid purchases emerged. The importance of proper pain assessment and individual deliberation in terms of analgesic contraindications and pain quality, as well as non-pharmacological pain management, need to be highlighted in order to optimize older adults’ pain management.

Population aging is likely increasing the number of surgically treated very old (>= 80-year-old) intracranial meningioma (IM) patients. Since there is little data on mortality in this patient group, we studied whether survival of surgically treated very old IM patients differs from survival of a matched general population. We retrospectively identified 83 consecutive very old IM patients (median age 83 years; 69% women) operated between 2010 and 2018. During the first postoperative year, operated IM patients suffered 2.5 times higher mortality as compared to age- and sex-matched general population but no annual survival difference occurred thereafter. Regarding cumulative estimates, no excess mortality was detected after the second postoperative year. Of the patient who were and who were not able to live at home preoperatively, 78% and 42% lived at home within 3 months, respectively. Preoperative loss of capability to live at home associated with a less frequent return to home [odds ratio (95% confidence interval) 0.21 (0.06-0.67)]. Operated very old IM patients had short-term excess mortality but similar cumulative survival as the matched general population. Moreover, most patients returned home soon after surgery.

Aneurysmal subarachnoid hemorrhage (SAH) is associated with high morbidity and mortality. Devastating post-SAH complications, such as cerebral vasospasm (CVS), delayed cerebral ischemia or seizures to mention a few, are mainly responsible for the poor clinical outcome. Inflammation plays an indispensable role during early brain injury (EBI) and delayed brain injury (DBI) phases over which these complications arise. T helper cells are the major cytokine secreting cells of adaptive immunity that can polarize to multiple functionally unique sub-populations. Here, we investigate different CD4+ T cell subsets during EBI and DBI phases after SAH, and their dynamics during post-SAH complications. Peripheral venous blood from 15 SAH patients during EBI and DBI phases, was analyzed by multicolour flowcytometry. Different subsets of CD3+ CD4+ T cells were characterized by differential cell surface expression of CXCR3 and CCR6 into Th1, Th2, Th17, whereas Tregs were defined by CD25hiCD127lo. The analysis of activation states was done by the expression of stable activation markers CD38 and HLA-DR. Interestingly, compared to healthy controls, Tregs were significantly increased during both EBI and DBI phases. Different activation states of Tregs showed differential significant increase during EBI and DBI phases compared to controls. HLA-DR− CD38+ Tregs were significantly increased during DBI phase compared to EBI phase in SAH patients developing CVS, seizures and infections. However, HLA-DR− CD38− Tregs were significantly reduced during EBI phase in patients with cerebral ischemia (CI) compared to those without CI. HLA-DR− CD38− Th2 cells were significantly increased during EBI phase compared to controls. A significant reduction in Th17/Tregs and HLA-DR− CD38+ Th17/Tregs ratios was observed during both EBI and DBI phases compared to controls. While HLA-DR− CD38− Th17/Tregs and HLA-DR− CD38− Th1/Th2 ratios were impaired only during EBI phase compared to controls. In conclusion, CD4+ T cell subsets display dynamic and unique activation patterns after SAH and during the course of the manifestation of post-SAH complications, which may be helpful for the development of precision neurovascular care. However, to claim this, confirmatory studies with larger patient cohorts, ideally from different ethnic backgrounds, are required. Moreover, our descriptive study may be the grounds for subsequent lab endeavors to explore the underlying mechanisms of our observations.