Burr-hole drainage with or without irrigation for chronic subdural haematoma (FINISH): a Finnish, nationwide, parallel-group, multicentre, randomised, controlled, non-inferiority trial.

BACKGROUND: Chronic subdural haematoma is a common surgically treated intracranial emergency. Burr-hole drainage surgery, to evacuate chronic subdural haematoma, involves three elements: creation of a burr hole for access, irrigation of the subdural space, and insertion of a subdural drain. Although the subdural drain has been established as beneficial, the therapeutic effect of subdural irrigation has not been addressed. METHODS: The FINISH trial was an investigator-initiated, pragmatic, multicentre, nationwide, randomised, controlled, parallel-group, non-inferiority trial in five neurosurgical units in Finland that enrolled adults aged 18 years or older with a chronic subdural haematoma requiring burr-hole drainage. Patients were randomly assigned (1:1) by computer-generated block randomisation with block sizes of four, six, or eight, stratified by site, to burr-hole drainage either with or without subdural irrigation. All patients and staff were masked to treatment assignment apart from the neurosurgeon and operating room staff. A burr hole was drilled at the site of maximum haematoma thickness in both groups, and the subdural space was either irrigated or not irrigated before inserting a subdural drain, which remained in place for 48 h. Reoperations, functional outcome, mortality, and adverse events were recorded for 6 months after surgery. The primary outcome was the reoperation rate within 6 months. The non-inferiority margin was set at 7·5%. Key secondary outcomes that were also required to conclude non-inferiority were the proportion of participants with unfavourable functional outcomes (ie, modified Rankin Scale score of 4-6, where 0 indicates no symptoms and 6 indicates death) and mortality rate at 6 months. The primary and key secondary analyses were done in both the intention-to-treat and per-protocol populations. The trial was registered with ClinicalTrials.gov (NCT04203550) and is completed. FINDINGS: From Jan 1, 2020, to Aug 17, 2022, we assessed 1644 patients for eligibility and 589 (36%) patients were randomly assigned to a treatment group and treated (294 assigned to drainage with irrigation and 295 assigned to drainage without irrigation; 165 [28%] women and 424 [72%] men). The 6-month follow-up period extended until Feb 14, 2023. In the intention-to-treat analysis, 54 (18·3%) of 295 participants required reoperation in the group assigned to receive no irrigation versus 37 (12·6%) of 294 in the group assigned to receive irrigation (difference of 6·0 percentage points, 95% CI 0·2-11·7; p=0·30; adjusted for study site). There were no significant between-group differences in the proportion of people with modified Rankin Scale score of 4-6 (37 [13·1%] of 283 in the no-irrigation group vs 36 [12·6%] of 285 in the irrigation group; p=0·89) or mortality rate (18 [6·1%] of 295 in the no-irrigation group vs 21 [7·1%] of 294 in the irrigation group; p=0·58). The findings of the primary intention-to-treat analysis were not materially altered in the per-protocol analysis. There were no significant between-group differences in the number of adverse events, and the most frequent severe adverse events were systemic infections (26 [8·8%] of 295 participants who did not receive irrigation vs 22 [7·5%] of 294 participants who received irrigation), intracranial haemorrhage (13 [4·4%] vs seven [2·4%]), and epileptic seizures (five [1·7%] vs nine [3·1%]). INTERPRETATION: We could not conclude non-inferiority of burr-hole drainage without irrigation. The reoperation rate was 6·0 percentage points higher after burr-hole drainage without subdural irrigation than with subdural irrigation. Considering that there were no differences in functional outcome or mortality between the groups, the trial favours the use of subdural irrigation. FUNDING: State Fund for University Level Health Research (Helsinki University Hospital), Finska Läkaresällskapet, Medicinska Understödsföreningen Liv och Hälsa, and Svenska Kulturfonden.

Temporal Changes in CSF Cell Parameters After SAH: Comparison of Ventricular and Spinal Drain Samples.

BACKGROUND: Forty percent of patients with aneurysmatic subarachnoid hemorrhage (aSAH) develop acute hydrocephalus requiring treatment with cerebrospinal fluid (CSF) drainage. CSF cell parameters are used in the diagnosis of nosocomial infections but also reflect sterile inflammation after aSAH. We aimed to study the temporal changes in CSF parameters and compare external ventricular drain (EVD)-derived and lumbar spinal drain-derived samples. METHODS: We retrospectively identified consecutive patients with aSAH treated at our neurointensive care unit between January 2014 and May 2019. We mapped the temporal changes in CSF leucocyte count, erythrocyte count, cell ratio, and cell index during the first 19 days after aSAH separately for EVD-derived and spinal drain-derived samples. We compared the sample sources using a linear mixed model, controlling for repeated sampling. RESULTS: We included 1360 CSF samples from 197 patients in the analyses. In EVD-derived samples, the CSF leucocyte count peaked at days 4-5 after aSAH, reaching a median of 225 × 106 (interquartile range [IQR] 64-618 × 106). The cell ratio and index peaked at 8-9 days (0.90% [IQR 0.35-1.98%] and 2.71 [IQR 1.25-6.73], respectively). In spinal drain-derived samples, the leucocyte count peaked at days 6-7, reaching a median of 238 × 106 (IQR 60-396 × 106). The cell ratio and index peaked at 14-15 days (4.12% [IQR 0.63-10.61%]) and 12-13 days after aSAH (8.84 [IQR 3.73-18.84]), respectively. Compared to EVD-derived samples, the leucocyte count was significantly higher in spinal drain-derived samples at days 6-17, and the cell ratio as well as the cell index was significantly higher in spinal drain-derived samples compared to EVD samples at days 10-15. CONCLUSIONS: CSF cell parameters undergo dynamic temporal changes after aSAH. CSF samples from different CSF compartments are not comparable.

Zero-heat-flux thermometry over the carotid artery in assessment of core temperature in craniotomy patients.

Zero-heat-flux core temperature measurements on the forehead (ZHF-forehead) show acceptable agreement with invasive core temperature measurements but are not always possible in general anesthesia. However, ZHF measurements over the carotid artery (ZHF-neck) have been shown reliable in cardiac surgery. We investigated these in non-cardiac surgery. In 99 craniotomy patients, we assessed agreement of ZHF-forehead and ZHF-neck (3M™ Bair Hugger™) with esophageal temperatures. We applied Bland-Altman analysis and calculated mean absolute differences (difference index) and proportion of differences within ± 0.5 °C (percentage index) during entire anesthesia and before and after esophageal temperature nadir. In Bland-Altman analysis [mean (limits of agreement)], agreement with esophageal temperature during entire anesthesia was 0.1 (-0.7 to +0.8) °C (ZHF-neck) and 0.0 (-0.8 to +0.8) °C (ZHF-forehead), and, after core temperature nadir, 0.1 (-0.5 to +0.7) °C and 0.1 (-0.6 to +0.8) °C, respectively. In difference index [median (interquartile range)], ZHF-neck and ZHF-forehead performed equally during entire anesthesia [ZHF-neck: 0.2 (0.1-0.3) °C vs ZHF-forehead: 0.2 (0.2-0.4) °C], and after core temperature nadir [0.2 (0.1-0.3) °C vs 0.2 (0.1-0.3) °C, respectively; all p > 0.017 after Bonferroni correction]. In percentage index [median (interquartile range)], both ZHF-neck [100 (92-100) %] and ZHF-forehead [100 (92-100) %] scored almost 100% after esophageal nadir. ZHF-neck measures core temperature as reliably as ZHF-forehead in non-cardiac surgery. ZHF-neck is an alternative to ZHF-forehead if the latter cannot be applied.

Early thrombocytopenia is associated with an increased risk of mortality in patients with traumatic brain injury treated in the intensive care unit: a Finnish Intensive Care Consortium study.

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 < 100 × 109/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.

Trends in mortality after intensive care of patients with traumatic brain injury in Finland from 2003 to 2019: a Finnish Intensive Care Consortium study.

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.

Incidence and Associated Factors of Anemia in Patients with Acute Moderate and Severe Traumatic Brain Injury.

BACKGROUND: Anemia might contribute to the development of secondary injury in patients with acute traumatic brain injury (TBI). Potential determinants of anemia are still poorly acknowledged, and reported incidence of declined hemoglobin concentration varies widely between different studies. The aim of this study was to investigate the incidence of severe anemia among patients with moderate to severe TBI and to evaluate patient- and trauma-related factors that might be associated with the development of anemia. METHODS: This retrospective cohort study involved all adult patients admitted to Tampere University Hospital's emergency department for moderate to severe TBI (August 2010 to July 2012). Detailed information on patient demographics and trauma characteristics were obtained, including data on posttraumatic care, data on neurosurgical procedures, and all measured in-hospital hemoglobin values. Severe anemia was defined as a hemoglobin level less than 100 g/L. Both univariate and multivariable analyses were performed, and hemoglobin trajectories were created. RESULTS: The study included 145 patients with moderate to severe TBI (male 83.4%, mean age 55.0 years). Severe anemia, with a hemoglobin level less than 100 g/L, was detected in 66 patients (45.5%) and developed during the first 48 h after the trauma. In the univariate analysis, anemia was more common among women (odds ratio [OR] 2.84; 95% confidence interval [CI] 1.13-7.15), patients with antithrombotic medication prior to trauma (OR 3.33; 95% CI 1.34-8.27), patients with cardiovascular comorbidities (OR 3.12; 95% CI 1.56-6.25), patients with diabetes (OR 4.56; 95% CI 1.69-12.32), patients with extracranial injuries (OR 3.14; 95% CI 1.69-12.32), and patients with midline shift on primary head computed tomography (OR 2.03; 95% CI 1.03-4.01). In the multivariable analysis, midline shift and extracranial traumas were associated with the development of severe anemia (OR 2.26 [95% CI 1.05-4.48] and OR 4.71 [95% CI 1.74-12.73], respectively). CONCLUSIONS: Severe anemia is common after acute moderate to severe TBI, developing during the first 48 h after the trauma. Possible anemia-associated factors include extracranial traumas and midline shift on initial head computed tomography.

Neurointensive care results and risk factors for unfavorable outcome in aneurysmatic SAH: a comparison of two age groups.

BACKGROUND: The mean age of actively treated subarachnoid hemorrhage (SAH) patients is increasing. We aimed to compare outcomes and prognostic factors between older and younger SAH patients. METHODS: A retrospective single-center analysis of aneurysmal SAH patients admitted to a neuro-ICU during 2014-2019. We defined older patients as ≥70 years and younger patients as <70 years. For every older patient, we identified three younger patients with the same World Federation of Neurological Surgeons (WFNS) grade. We only included patients receiving active aneurysm treatment. Favorable functional outcome, defined as a Glasgow Outcome Scale (GOS) of 4-5 at 12 months, was our primary outcome. We used logistic regression to compare prognostic factors between the groups. RESULTS: Ninety-five (85%) of 112 older patients and 317 (94%) of 336 younger patients received aneurysm treatment. Of the younger patients, 91% with a good-grade SAH (WFNS I-III) had a favorable outcome compared to 52% in the older good-grade SAH group. In poor-grade patients (WFNS IV-V), favorable outcome was seen in 51% of younger patients, compared to 24% of older patients. Acute hydrocephalus and intracerebral hemorrhage were associated with unfavorable outcome in the younger (OR 4.7, 95% CI 2.6-8.4, and OR 3.7, 95% CI 2.1-6.4), but not in the older patients (OR 1.8, 95% CI 0.8-4.2, and OR 1.3, 95% CI 0.5-3.1, respectively). CONCLUSIONS: In actively treated SAH patients, age was a major determinant of outcome. Factors reflecting increases in intracranial pressure associated with outcome only among younger patients.

Intensive care of traumatic brain injury and aneurysmal subarachnoid hemorrhage in Helsinki during the Covid-19 pandemic.

BACKGROUND: To ensure adequate intensive care unit (ICU) capacity for SARS-CoV-2 patients, elective neurosurgery and neurosurgical ICU capacity were reduced. Further, the Finnish government enforced strict restrictions to reduce the spread. Our objective was to assess changes in ICU admissions and prognosis of traumatic brain injury (TBI) and aneurysmal subarachnoid hemorrhage (SAH) during the Covid-19 pandemic. METHODS: Retrospective review of all consecutive patients with TBI and aneurysmal SAH admitted to the neurosurgical ICU in Helsinki from January to May of 2019 and the same months of 2020. The pre-pandemic time was defined as weeks 1-11, and the pandemic time was defined as weeks 12-22. The number of admissions and standardized mortality rates (SMRs) were compared to assess the effect of the Covid-19 pandemic on these. Standardized mortality rates were adjusted for case mix. RESULTS: Two hundred twenty-four patients were included (TBI n = 123, SAH n = 101). There were no notable differences in case mix between TBI and SAH patients admitted during the Covid-19 pandemic compared with before the pandemic. No notable difference in TBI or SAH ICU admissions during the pandemic was noted in comparison with early 2020 or 2019. SMRs were no higher during the pandemic than before. CONCLUSION: In the area of Helsinki, Finland, there were no changes in the number of ICU admissions or in prognosis of patients with TBI or SAH during the Covid-19 pandemic.

Early surgery for superficial supratentorial spontaneous intracerebral hemorrhage: a Finnish Intensive Care Consortium study.

BACKGROUND: The benefits of early surgery in cases of superficial supratentorial spontaneous intracerebral hemorrhage (ICH) are unclear. This study aimed to assess the association between early ICH surgery and outcome, as well as the cost-effectiveness of early ICH surgery. METHODS: We conducted a retrospective, register-based multicenter study that included all patients who had been treated for supratentorial spontaneous ICH in four tertiary intensive care units in Finland between 2003 and 2013. To be included, patients needed to have experienced supratentorial ICHs that were 10-100 cm3 and located within 10 mm of the cortex. We used a multivariable analysis, adjusting for the severity of the illness and the probability of surgical treatment, to assess the independent association between early ICH surgery (≤ 1 day), 12-month mortality rates, and the probability of survival without permanent disability. In addition, we assessed the cost-effectiveness of ICH surgery by examining the effective cost per 1-year survivor (ECPS) and per independent survivor (ECPIS). RESULTS: Of 254 patients, 27% were in the early surgery group. Overall 12-month mortality was 39%, while 29% survived without a permanent disability. According to our multivariable analysis, early ICH surgery was associated with lower 12-month mortality rates (odds ratio [OR] 0.22, 95% confidence intervals [CI] 0.10-0.51), but not with a higher probability of survival without permanent disability (OR 1.23, 95% CI 0.59-2.56). For the early surgical group, the ECPS and ECPIS were €111,409 and €334,227, respectively. For the non-surgical cohort, the ECPS and ECPIS were €76,074 and €141,471, respectively. CONCLUSIONS: Early surgery for superficial ICH is associated with a lower 12-month mortality risk but not with a higher probability of survival without a permanent disability. Further, costs were higher and cost-effectiveness was, thus, worse for the early surgical cohort.

Perioperative Treatment of Brain Arteriovenous Malformations Between 2006 and 2014: The Helsinki Protocol.

OBJECTIVE: We reviewed retrospectively the perioperative treatment of microsurgically resected brain arteriovenous malformations (bAVMs) at the neurosurgical department of Helsinki University Hospital between the years 2006 and 2014. We examined the performance of the treatment protocol and the incidence of delayed postoperative hemorrhage (DPH). METHODS: The Helsinki protocol for postoperative treatment of bAVMs was used for the whole patient cohort of 121. The patients who had subsequent DPH were reviewed in more detail. RESULTS: Five out of 121 (4.1%) patients had DPH. These patients had a higher Spetzler-Martin grade (SMG) (p = 0.043) and a more complex venous drainage pattern (p = 0.003) as compared to those who had no postoperative bleed. Patients with DPH had 43% larger intravenous fluid intake in the neurosurgical intensive care unit (p = 0.052); they were all male (p = 0.040) and had longer stay in the intensive care unit (p = 0.022). CONCLUSIONS: The Helsinki protocol for postoperative treatment of bAVMs was found to produce comparable results to a more complex treatment algorithm. DPH was associated with high SMG, complex venous drainage pattern, male gender and high intravenous fluid intake. Our findings support the use of SMG in defining patient's postoperative treatment as the DPHs in our study occurred in patients with grade 2-5.

Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage: Location, Distribution Patterns, Infarct Load, and Effect on Outcome.

BACKGROUND AND OBJECTIVES: Delayed cerebral ischemia (DCI) is one of the main contributing factors to poor clinical outcome after aneurysmal subarachnoid hemorrhage (SAH). Unsuccessful treatment can cause irreversible brain injury in the form of DCI-related infarction. We aimed to assess the association between the location, distribution, and size of DCI-related infarction in relation to clinical outcome. METHODS: Consecutive patients with SAH treated at 2 university hospitals between 2014 and 2019 (Helsinki, Finland) and between 2006 and 2020 (Aachen, Germany) were included. Size of DCI-related infarction was quantitatively measured as absolute volume (in milliliters). In a semiquantitative fashion, infarction in 14 regions of interest (ROIs) according to a modified Alberta Stroke Program Early CT Score (ASPECTS) was noted. The association of infarction in these ROIs along predefined regions of eloquent brain, with clinical outcome, was assessed. For this purpose, 1-year outcome was measured by the Glasgow Outcome Scale (GOS) and dichotomized into favorable (GOS 4-5) and unfavorable (GOS 1-3). RESULTS: Of 1,190 consecutive patients with SAH, 155 (13%) developed DCI-related infarction. One-year outcome data were available for 148 (96%) patients. A median overall infarct volume of 103 mL (interquartile range 31-237) was measured. DCI-related infarction was significantly associated with 1-year unfavorable outcome (odds ratio [OR] 4.89, 95% CI 3.36-7.34, p < 0.001). In patients with 1-year unfavorable outcome, vascular territories more frequently affected were left middle cerebral artery (affected in 49% of patients with unfavorable outcome vs in 30% of patients with favorable outcome; p = 0.029), as well as left (44% vs 18%; p = 0.003) and right (52% vs 14%; p < 0.001) anterior cerebral artery supply areas. According to the ASPECTS model, the right M3 (OR 8.52, 95% CI 1.41-51.34, p = 0.013) and right A2 (OR 7.84, 95% CI 1.97-31.15, p = 0.003) regions were independently associated with unfavorable outcome. DISCUSSION: DCI-related infarction was associated with a 5-fold increase in the odds of unfavorable outcome, after 1 year. Ischemic lesions in specific anatomical regions are more likely to contribute to unfavorable outcome. TRIAL REGISTRATION INFORMATION: Data collection in Aachen was registered in the German Clinical Trial Register (DRKS00030505); on January 3, 2023.

Aneurysmal Subarachnoid Hemorrhage in Hospitalized Patients on Anticoagulants-A Two Center Matched Case-Control Study.

Objective-Direct oral anticoagulants (DOAC) are replacing vitamin K antagonists (VKA) for the prevention of ischemic stroke and venous thromboembolism. We set out to assess the effect of prior treatment with DOAC and VKA in patients with aneurysmal subarachnoid hemorrhage (SAH). Methods-Consecutive SAH patients treated at two (Aachen, Germany and Helsinki, Finland) university hospitals were considered for inclusion. To assess the association between anticoagulant treatments on SAH severity measure by modified Fisher grading (mFisher) and outcome as measured by the Glasgow outcome scale (GOS, 6 months), DOAC- and VKA-treated patients were compared against age- and sex-matched SAH controls without anticoagulants. Results-During the inclusion timeframes, 964 SAH patients were treated in both centers. At the time point of aneurysm rupture, nine patients (0.93%) were on DOAC treatment, and 15 (1.6%) patients were on VKA. These were matched to 34 and 55 SAH age- and sex-matched controls, re-spectively. Overall, 55.6% of DOAC-treated patients suffered poor-grade (WFNS4-5) SAH compared to 38.2% among their respective controls (p = 0.35); 53.3% of patients on VKA suffered poor-grade SAH compared to 36.4% in their respective controls (p = 0.23). Neither treatment with DOAC (aOR 2.70, 95%CI 0.30 to 24.23; p = 0.38), nor VKA (aOR 2.78, 95%CI 0.63 to 12.23; p = 0.18) were inde-pendently associated with unfavorable outcome (GOS1-3) after 12 months. Conclusions-Iatrogenic coagulopathy caused by DOAC or VKA was not associated with more severe radiological or clinical subarachnoid hemorrhage or worse clinical outcome in hospitalized SAH patients.

Thromboelastometry during intraoperative transfusion of fresh frozen plasma in pediatric neurosurgery.

Normal blood coagulation is essential in pediatric neurosurgery because of the risk of abundant bleeding, and therefore it is important to avoid transfusion of fluids that might interfere negatively with the coagulation process. There is a lack of transfusion guidelines in massive bleeding with pediatric neurosurgical patients, and early use of blood compounds is partly controversial. We describe two pediatric patients for whom fresh frozen plasma (FFP) infusion was started at the early phase of brain tumor surgery to prevent intraoperative coagulopathy and hypovolemia. In addition to the traditional laboratory testing, modified thromboelastometry analyses were used to detect possible disturbances in coagulation. Early transfusion of FFP and red blood cells preserved the whole blood coagulation capacity. Even with continuous FFP infusion, fibrin clot firmness was near to critical value at the end of surgery despite increased preoperative values. By using FFP instead of large amounts of crystalloids and colloids when major blood loss is expected, blood coagulation is probably less likely to be impaired. Our results indicate, however, that the capacity of FFP to correct fibrinogen deficit is limited.

Correlation between arteriovenous malformation nidus size and intraparenchymal hematoma volume in the event of rupture.

•Our study did not support the hypothesis that small AVMs lead to larger hematoma volumes in the event of a rupture.•AVM size did not correlate with the clinical severity of the bleeding as measured with HH and WFNS scores.•Larger supratentorial hematomas were associated with a more severe clinical manifestation and a poorer outcome.•In the event of a rupture, the AVM size did not correlate with the 2-4-month GOS.•AVICH score showed a good correlation with the 2-4-month GOS score.

Incidence of surgery for chronic subdural hematoma in Finland during 1997-2014: a nationwide study.

OBJECTIVE: The number of surgeries performed for chronic subdural hematoma (CSDH) has increased. However, these changes have been poorly reported. The authors aimed to assess the national incidence of surgeries for CSDH in Finland during an 18-year time period from 1997 to 2014. They hypothesized that the incidence of CSDH surgeries has continued to increase, particularly among the elderly. METHODS: A nationwide register-based follow-up study was performed using the Finnish Care Register for Health Care. All adult patients undergoing primary CSDH surgeries during 1997-2014 were included. The study population was followed up from the time of CSDH surgery until death or the end of follow-up on December 31, 2017. The incidences of CSDH surgery per 100,000 person-years were calculated separately in each age group and sex. Age standardization was performed for those 20 years of age and older with weights from the 2013 European Standard Population. Negative binomial regression models were used to assess changes in incidence rate ratios (IRRs) during the study period. RESULTS: In total, 9280 patients were identified. The age-standardized incidence of CSDH surgery increased from 12.2 to 16.5 per 100,000 person-years during 1997-2014. The age- and sex-adjusted incidence of CSDH surgery increased by 30% (IRR 1.30, 95% CI 1.20-1.41). The age- and sex-adjusted incidence increased more in the older age groups, with an IRR of 1.24 for those aged 60-69 years, 1.32 for those 70-79 years, 1.46 for those 80-89 years, and 1.85 for those aged 90 years or older. The adjusted incidence did not increase for those aged 18-59 years. The sex difference (2:1 men/women) was consistent throughout the study period, with a higher incidence among men. One year after the primary surgery, 19% of the population had a resurgery, and the 1-year case fatality rate was 15%. The median age of patients increased from 73 to 76 years. CONCLUSIONS: During the past 2 decades, the age- and sex-adjusted incidence of CSDH surgery has increased in Finland, with major increases for those aged 60 years or older. This increase is likely to continue in parallel with the aging population and increased life expectancies.

Dynamic prediction of mortality after traumatic brain injury using a machine learning algorithm.

Intensive care for patients with traumatic brain injury (TBI) aims to optimize intracranial pressure (ICP) and cerebral perfusion pressure (CPP). The transformation of ICP and CPP time-series data into a dynamic prediction model could aid clinicians to make more data-driven treatment decisions. We retrained and externally validated a machine learning model to dynamically predict the risk of mortality in patients with TBI. Retraining was done in 686 patients with 62,000 h of data and validation was done in two international cohorts including 638 patients with 60,000 h of data. The area under the receiver operating characteristic curve increased with time to 0.79 and 0.73 and the precision recall curve increased with time to 0.57 and 0.64 in the Swedish and American validation cohorts, respectively. The rate of false positives decreased to ≤2.5%. The algorithm provides dynamic mortality predictions during intensive care that improved with increasing data and may have a role as a clinical decision support tool.

Comparison of hypertonic saline and mannitol on whole blood coagulation in vitro assessed by thromboelastometry.

BACKGROUND: Hypertonic saline (HS) is an alternative to mannitol for decreasing intracranial pressure in traumatic brain injury and before craniotomy. Both HS and mannitol may interfere with blood coagulation but their influence on coagulation has not been compared in controlled situations. Therefore, we evaluated different strengths of HS and 15% mannitol on blood coagulation in vitro. METHODS: Citrated fresh whole blood, withdrawn from 10 volunteers, was diluted with 0.9%, 2.5%, or 3.5% HS or 15% mannitol to make 10 vol.% and 20 vol.% hemodilution in vitro. The diluted blood and undiluted control samples were analyzed with thromboelastometry (ROTEM(®)) using two activators, tissue thromboplastin without (ExTEM(®)) or with cytochalasin (FibTEM(®)). RESULTS: In the FibTEM(®) analysis, maximum clot firmness (MCF) was stronger in the 2.5% HS group than in the mannitol group after both dilutions (P < 0.05). In the ExTEM(®) analysis, clot formation time (CFT) was more delayed in the mannitol group than in the 0.9%, 2.5%, or 3.5% HS groups in 20 vol.% hemodilution (P < 0.05). MCF was weaker in the mannitol group than in the other groups after 20 vol.% dilution (P < 0.05). MCF was also weaker in the 3.5% than in the 0.9% saline group after 20 vol.% dilution (P < 0.05). CONCLUSIONS: Blood coagulation is disturbed more by 15% mannitol than by equiosmolar 2.5% saline. This disturbance seems to be attributed to overall clot formation and strength but also to pure fibrin clot firmness. This saline solution might be more favorable than mannitol before craniotomy in patients with a high risk of bleeding.

One-Year Outcome After Aneurysmal Subarachnoid Hemorrhage in Elderly Patients.

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 at admission 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.

Transition of a Clinical Practice to Use of Subdural Drains after Burr Hole Evacuation of Chronic Subdural Hematoma: The Helsinki Experience.

BACKGROUND: A number of randomized controlled trials have shown the benefit of drain placement in the operative treatment of chronic subdural hematoma (CSDH); however, few reports have described real-life results after adoption of drain placement into clinical practice. We report the results following a change in practice at Helsinki University Hospital from no drain to subdural drain (SD) placement after burr hole craniostomy for CSDH. METHODS: We conducted a retrospective observational study of consecutive patients undergoing burr hole craniostomy for CSDH. We compared outcomes between a 6-month period when SD placement was arbitrary (July-December 2015) and a period when SD placement for 48 hours was routine (July-December 2017). Our primary outcome of interest was recurrence of CSDH necessitating reoperation within 6 months. Patient outcomes, infections, and other complications were assessed as well. RESULTS: A total of 161 patients were included, comprising 71 (44%) in the drain group and 90 (56%) in the non-drain group. There were no significant differences in age, comorbidities, history of trauma, or use of antithrombotic agents between the 2 groups (P > 0.05 for all). Recurrence within 6 months occurred in 18% of patients in the non-drain group, compared with 6% in the drain group (odds ratio, 0.28; 95% confidence interval, 0.09-0.87; P = 0.028). There were no differences in neurologic outcomes (P = 0.72), mortality (P = 0.55), infection rate (P = 0.96), or other complications (P = 0.20). CONCLUSIONS: The change in practice from no drain to use of an SD after burr hole craniostomy for CSDH effectively reduced the 6-month recurrence rate with no effect on patient outcomes, infections, or other complications.

Machine learning-based dynamic mortality prediction after traumatic brain injury.

Our aim was to create simple and largely scalable machine learning-based algorithms that could predict mortality in a real-time fashion during intensive care after traumatic brain injury. We performed an observational multicenter study including adult TBI patients that were monitored for intracranial pressure (ICP) for at least 24 h in three ICUs. We used machine learning-based logistic regression modeling to create two algorithms (based on ICP, mean arterial pressure [MAP], cerebral perfusion pressure [CPP] and Glasgow Coma Scale [GCS]) to predict 30-day mortality. We used a stratified cross-validation technique for internal validation. Of 472 included patients, 92 patients (19%) died within 30 days. Following cross-validation, the ICP-MAP-CPP algorithm's area under the receiver operating characteristic curve (AUC) increased from 0.67 (95% confidence interval [CI] 0.60-0.74) on day 1 to 0.81 (95% CI 0.75-0.87) on day 5. The ICP-MAP-CPP-GCS algorithm's AUC increased from 0.72 (95% CI 0.64-0.78) on day 1 to 0.84 (95% CI 0.78-0.90) on day 5. Algorithm misclassification was seen among patients undergoing decompressive craniectomy. In conclusion, we present a new concept of dynamic prognostication for patients with TBI treated in the ICU. Our simple algorithms, based on only three and four main variables, discriminated between survivors and non-survivors with accuracies up to 81% and 84%. These open-sourced simple algorithms can likely be further developed, also in low and middle-income countries.