Results of surgery for aneurysmal subarachnoid haemorrhage in northern Norway: a retrospective study with special focus on timing of surgery in a rural area.

OBJECTIVES: This study reports data on time consumption before aneurysm surgery and the results of treatment in northern Norway. MATERIAL AND METHODS: A total of 279 cases were identified and included in our analysis of time span from bleeding to arrival at our department. Fifty-one patients were treated conservatively, either because of bad clinical condition or because angiography revealed no aneurysm. The remaining 228 patients were operated and included in our analysis of outcome after early aneurysm surgery. RESULTS: Among all 279 patients with aneurysmal subarachnoid haemorrhage (SAH), median time from ictus to arrival at the university hospital was 1 (0-30) day. Forty-one per cent arrived at the day of bleeding and 86% within the first 3 days after bleeding. Among the 228 patients who underwent surgical aneurysm repair, median time from bleeding to operation was 2 (0-33) days. Early aneurysm surgery (< 72 h) was performed in 146 patients (64%). Fifty patients (22%) underwent intermediate surgery (days 4-10) and 32 patients (14%) were operated later (day 11 or later). A significant association was found between Hunt and Hess (HH) grade and Glasgow Outcome Scale (GOS) score (P < 0.001). CONCLUSIONS: Most patients suffering aneurysmal SAH in northern Norway undergo early aneurysm surgery and the outcome is comparable with that obtained in other Scandinavian centres. Initial Hunt and Hess grade is a major determinant for outcome in aneurysmal subarachnoid haemorrhage.

[Thyroid-associated ophthalmopathy]. / Dystyreot oftalmopati.

Thyroid-associated ophthalmopathy is a local autoimmune reaction in the orbit. Typical signs are retraction of the eyelid, periorbital oedema, proptosis and impaired eye motility. Exposure keratopathy or compression of the optic nerve may be a complication. Patients with severe proptosis or progressive loss of vision need an efficient and safe treatment modality. Immunosuppression may be the first choice, followed by surgical decompression of the orbit. We describe a combined external and endoscopic approach with resection of the lateral, inferior and medial orbital walls. In this way, the increased intraorbital pressure is relieved. Retraction of the upper eyelid is corrected by transconjunctival approach and the release of muscles from the tarsus.

[Early surgery of subarachnoid hemorrhage from cerebral aneurysms. A material from health care region 5]. / Tidlig operasjon ved subaraknoidalblødning fra cerebrale aneurismer. Et materiale fra helseregion 5.

During the period 1986 to 1993, 94 patients were admitted consecutively to the neurosurgical department of Tromsø university hospital following subarachnoid haemorrhage. Nine-three patients were operated on. Five patients were in extremely poor condition and three were operated on as emergency cases after computerized tomography without previous angiography. They are included in the total management outcome and also in the outcomes after early surgery. Of all the patients, 63.8% returned to their previous activities, 12.8% experienced moderate invalidity, and 9.6% had serious invalidities. The total management mortality was 13.8%. Fifty-four patients were operated on within three days, and 64.8% of these returned to their previous activities. Of these 14.8% ended up with moderate invalidity; mortality was 11.1%. Of eight patients above 70 years of age, five underwent early surgery. In six of these older patients the final outcome was good, one became disabled and one died. We consider early surgery to be by far the most important factor for achieving optimal results from surgery.

Management of minor head injury: the value of early computed tomography and serum protein S-100 measurements.

Computed tomography (CT) scan was performed within 6 h in 91 patients with minor head injury (MHI). Eight patients (9%) demonstrated intracranial lesions on CT scan (6 brain contusions, 1 brain edema and 1 extradural hematoma). No patient required craniotomy. In patients with normal CT scan, no complications to the head injury were observed. Patients with intracranial lesions were hospitalized significantly longer (mean 9.4 days) than patients without (mean 1.6 days). In a subgroup of 50 patients with normal CT scan, serum S-100 protein was measured on admission. Elevated S-100 levels were seen in 10 of 50 patients (0.5-2.4 mug/L, mean 1.1). These patients were hospitalized significantly longer (mean 3.4 days) compared to patients with normal CT scan and normal S-100 levels (mean 1.1 days). MHI patients with GCS 14-15 without neurological deficits can safely be discharged when CT scan is normal. Serum protein S-100 measurements appear to provide information about diffuse brain injury after MHI.

[Ten years of neurosurgery at the University Hospital in Tromsø. Need for further development]. / Ti års neurokirurgi ved Regionsykehuset i Tromsø. Behov for videre utbygging.

The Department of Neurosurgery at the University Hospital of Tromsø was established in January 1986 to provide neurosurgical treatment for the population of northern Norway. During the first ten years, 3,225 patients were operated on, including 1,157 craniotomies and 1,335 spinal procedures. The annual number of operations increased from 201 to 442, and the number of hospitalized patients from 265 to 908. The number of patients treated per employee increased by 250%, while the mean duration of hospital stay decreased by 43% to 4.5 days. The growth in activity is expected to continue. This is because of improved diagnostics of nervous system disease, a growing number of elderly patients and new treatment options. The falling number of spinal surgical procedures in local hospitals is also a contributing factor. Neurosurgery is highly cost-effective. It is impossible to make further cost savings without a decline in quality. The department must be expanded to cater for more operations by increasing both the number of beds and employees.

[Minor head injuries in sport. Occurrence, management, sequelae and prevention]. / Lette hodeskader i idretten. Forekomst, håndtering, senfølger og forebygging.

Approximately 10% of all head injuries are caused during sport and about 10% of all sport-related injuries are head injuries. Most of these are minor head injuries. Many sports involve risk of repeated head injury. The classic punch-drunk syndrome in boxers reflects severe chronic traumatic encephalopathy. Recent research shows that repeated head injury can entail encephalopathy also in other types of athletes. They may experience symptoms such as headache, dizziness, irritability, memory deficit and concentration deficit. Neuropsychological testing reveals such cognitive deficits as impaired memory and attention, and reduced speed of information processing. Persistent sequelae can be prevented by correct management in the acute stage, appropriate follow-up, and prevention of repeated head injuries.

Recovery of sensory function after surgical decompression in carpal tunnel syndrome.

The function of thick and thin sensory nerve fibers after surgical decompression in carpal tunnel syndrome were evaluated using quantitative sensory testing (QST). The thin nerve fibers were studied using tests for thermal thresholds, and the thick myelinated fibers by vibrametry. The tests were performed before surgery and at 6 weeks, 4 and 10 months after surgery. The improvement of function in thin nerve fibers came within 6 weeks (P = 0.001). The improvement of function in thick myelinated fibers continued to improve until 4 months after the operation (P = 0.0001). This difference in the time course of the recovery indicates that the thick myelinated nerve fibers were more affected than the thin nerve fibers. The function of both type sensory nerve fibers did also improve in the fifth finger (P = 0.05). The function in thin nerve fibers worsened somewhat between 6 weeks and 4 months after surgery, possibly due to postoperative scar tissue.

[Minor head injuries. May early CT-scanning replace in-hospital observation?]. / Lette hodeskader. Kan tidling CT-undersøkelse erstatte observasjon i sykehus?

A one-year prospective study was undertaken to judge whether in-hospital observation after minor head injury could be partly replaced by early computerized tomography (CT), and if such a practice would save hospital resources. All 146 patients had a Glasgow Coma Score (GCS) > or = 14 and no neurological deficits. 128 had suffered loss of consciousness. CT of 97 (67%) patients revealed intracranial lesions in eight (contusions six, oedema one and epidural haematoma in one). Mean duration of hospitalization was 9.4 days in patients with intracranial lesions and 1.6 days in patients without such lesions. We observed no complications to the head injury in patients with normal CT. There is no need for hospitalization after minor head injury in patients with GCS > or = 14 with no neurological deficits and normal CT. We advocated wide use of early CT in cases of minor head injury, to allow early detection of intracranial haematomas, diagnoses of brain contusions and avoidance of unnecessary hospitalization.

Large peripheral cystic schwannomas. Two case reports and a review.

Two patients presented with benign cystic schwannomas, which originated from the brachial plexus and the sciatic nerve, respectively. The tumours were single, egg-shaped growths that were excised completely without damage to the nerve. Histopathological examination confirmed the diagnosis of encapsulated, cystic, benign schwannomas. Preoperative magnetic resonance imaging provided useful information and is recommended in the evaluation of peripheral nerve tumours.

Modified Robinson-Smith procedure for the treatment of cervical radiculopathy.

In the present study, a modified Robinson-Smith procedure was used surgery for cervical radiculopathy in 52 patients. Thirty-one one-level and 21 two-level operations were performed. All patients were followed up between 1 and 3 years (mean 23 months) after surgery with a clinical evaluation by an independent investigator including a radiological examination. In 26 patients the postoperative result was classified as excellent, in 23 the result was good, in 2 satisfactory, while one patient was unchanged compared to the preoperative examination. No patient developed worsening of symptoms after surgery. Of 18 patients with duration of symptoms of more than 4 years, 16 demonstrated markedly improvement. No permanent postoperative complications were seen. A modified Robinson-Smith procedure appears to be safe and reliable and can be recommended in surgery for cervical radiculopathy.

Hypothalamic hamartoma causing precocious puberty treated by surgery: case report.

A 6-year-old girl was treated for precocious puberty secondary to a hypothalamic hamartoma by resection of the tumor. When she was six months old, her parents noticed incipient pubic hair and menses accompanied by breast development. Computed tomography was judged as normal. The girl was treated with monthly gonadotropin-releasing hormone analogue injections until 6 years of age, when magnetic resonance imaging (MRI) demonstrated a pedunculated isodense mass below the tuber cinereum. The hamartoma was totally removed using microsurgery. The symptoms and signs of precocious puberty disappeared after surgery. Follow-up MRI 1 year later showed no remaining tumor.

Symptomatic, expansive middle cranial fossa arachnoid cyst treated by a cysto-peritoneal shunt. Case report and evaluation of treatment options.

We report a symptomatic space-occupying arachnoid cyst in a 16-year-old boy. During the last two years, he was frequently absent from school because of headaches. Due to symptoms of nausea, fever and headache the patient was primarily referred to a surgical unit, where appendectomy was performed, revealing a normal appendix. Postoperatively, the patient complained of severe headache. Computed tomography (CT) of the head demonstrated a large left-sided middle cranial fossa arachnoid cyst. The patient was operated with insertion of a cysto-peritoneal shunt. A total regress of the clinical symptoms was seen at follow-up examination 3 months after shunting.

Duration of symptoms as a predictor of outcome after lumbar disc surgery.

Retrospectively 93 consecutive patients operated on for lumbar disc herniation were studied in order to evaluate the prognostic value of symptoms (lumbar pain and sciatica) and sick-leave. Surgical results were evaluated 1-3 years postoperatively by a questionaire. The duration of the present attack of sciatica and sick-leave prior to surgery was significantly longer in the group with unsatisfactory outcome compared to the group with satisfactory outcome. Patients with duration of the present attack of sciatica of less than 6 months had a significantly better result concerning outcome compared to patients with duration of 6-12 months and more than 12 months. Patients who returned to the same type of work had a preoperatively statistically significant shorter duration of present sick-leave, compared to the patients who had changed the type of work and the patients who did not return to work. The patients with duration of their present sick-leave of less than 6 months had a significantly higher percentage of returning to the same type of work compared to patients with duration of their present sick-leave of 6-12 months and more than 12 months. We conclude that the duration of sciatica and sick-leave before the operation has value as predictive factors concerning the over-all result after surgery for lumbar disc herniation.

Alterations in T-helper and T-suppressor lymphocyte populations after multiple injuries.

Fifteen patients with multiple injuries and an Injury Severity Score (ISS) ranging from 2 to 57 (median 25) were studied for variations in lymphocyte populations on the day of injury and the three following days. Nine of the patients had an ISS above 16. In all patients the total number of lymphocytes fell during the first 24 hours after the injury (P less than 0.01), mainly due to a reduction in the number of circulating T-lymphocytes from a median of 1.8 to 0.6 x 10(9) cells/l (P less than 0.01). No reduction in the T-helper/T-suppressor cell ratio could be demonstrated for the group as a whole, but in the 9 patients with an Injury Severity Score (ISS) of more than 16 a significant reduction in ratio from median 1.5 to 0.8 was found. Due to clinical observations patients with an ISS of more than 16 are considered severely injured and at risk of developing complications such as infection and septicaemia. The fall in T-helper/T-suppressor ratio indicates impaired immunity in these patients.

Complement activation following multiple injuries.

Complement activation was evaluated by assay of plasma C3dg and the terminal complement complex (TCC) in 19 patients with multiple injuries. In the nine patients with thoracic involvement, statistically significant increase of plasma TCC was found at first sampling (average 90 min post-trauma), and of C3dg after 24 hours. Such increase was not found in the ten patients without thoracic involvement. Heightened granulocyte elastase activity was found in bronchial lavage fluid 90 min after the trauma in three patients with thoracic injury. Pulmonary insufficiency (pO2/FiO2 less than 16 kPa on intermittent positive-pressure ventilation) arose in four patients. All four had raised plasma levels of TCC or C3dg on arrival at the hospital. Six patients with complement activation did not show pulmonary insufficiency. Although the series was relatively small, the results indicate that thoracic injury is particularly associated with complement activation, and that complement activation alone does not suffice to produce post-traumatic pulmonary insufficiency.

Extradural haematoma. Report of 132 cases.

In a consecutive unselected series of 132 cases of acute extradural haematoma among 9,600 patients who sustained a head injury and were admitted without delay to a regional neurosurgical department during the years 1964 to 1975 the overall mortality was 23 per cent. Associated intradural lesions, the relative infrequency of the lucid interval, sustained loss of consciousness from the time of admission, lack of the classical pupillary changes, and the rapid rise in intracranial pressure in some patients are factors of importance for the prognosis. It should be possible to improve the results and lower the mortality if due consideration is taken of these factors.

Intracranial arteriovenous malformations: conservative or surgical treatment?

Of 89 patients with arteriovenous malformations of the brain, 47 were conservatively treated, nine of these died (19%), four with the first bleed, five of recurrent bleeding. Of 42 surgically treated patients, five died, a mortality of 12%. Four of these deaths occurred with patients in a deteriorating clinical condition caused by large intracerebral haematomas. The fifth death occurred with a recurrent bleeding where a ligation of feeding artery was the only treatment. There were no deaths in those patients in good clinical condition who underwent an excision of the malformation. Total excision of arteriovenous malformations should be performed whenever possible.