Cerebrospinal fluid (CSF) shunting and ventriculocisternostomy (ETV) in 400 pediatric patients. Shifts in understanding, diagnostics, case-mix, and surgical management during half a century.

OBJECTIVE: To characterize shifts from the 1960s to the first decade in the 21st century as to diagnostics, case-mix, and surgical management of pediatric patients undergoing permanent CSF diversion procedures. METHODS: One hundred and thirty-four patients below 15 years of age were the first time treated with CSF shunt or ETV for hydrocephalus or idiopathic intracranial hypertension (IIH) in 2009-2013. This represents our current practice. Our previously reported cohorts of shunted children 1967-1970 (n = 128) and 1985-1988 (n = 138) served as backgrounds for comparison. RESULTS: In the 1960s, ventriculography and head circumference measurements were the main diagnostic tools; ventriculoatrial shunt was the preferred procedure (94 %), neural tube defect (NTD) was the leading etiology (33 %), and overall 2-year survival rate was 76 % (non-tumor survival 84 %). In the 1980s, computerized tomography (CT) was the preferred diagnostic imaging tool; ventriculoperitoneal shunt (VPS) had become standard (91 %), the proportion of NTD children declined to 17 %, and the 2-year survival rate was 91 % (non-tumor survival 95 %). Hydrocephalus caused by intracranial hemorrhage had, on the other hand, increased from 7 to 19 %. In the years 2009-2013, when MRI and endoscopic third ventriculocisternostomy (ETV) were matured technologies, 73 % underwent VPS, and 23 % ETV as their initial surgical procedure. The most prevalent etiology was CNS tumor (31 %). The proportion of NTD patients was yet again halved to 8 %, while intracranial hemorrhage was also reduced to 12 %. In this last period, six children were treated with VPS for Idiopathic Intracranial Hypertension (IIH) due to unsatisfactory response to medical treatment. They all had headache, papilledema, and visual disturbances and responded favorably to treatment. The 2 years of survival was 92 % (non-tumor survival 99 %). In contrast to the previous periods, there was no early shunt related mortality (2 years). Aqueductal stenosis was a small but distinctive group in all cohorts with 5, 6 and 3 % respectively. CONCLUSIONS: The case-mix in pediatric patients treated with permanent CSF diversion has changed over the last half-century. With the higher proportion of children with CNS tumor patients and inclusion of the IIH children, the median age at initial surgery has shifted substantially from 3.2 to 14 months. Between the 1960s and the current cohort, 2 years of all-cause mortality fell from 24 to 8 %. Prolonged asymptomatic periods, extending 15 years, were relatively common. Nevertheless, 18 patients experienced shunt failure more than 15 years after last revision, and first-time shunt failure has been observed 29 years after initial treatment. This underscores the importance of life-long follow-up.

Predictors of early in-hospital death after decompressive craniectomy in swollen middle cerebral artery infarction.

BACKGROUND: Swollen middle cerebral artery infarction is a life-threatening disease and decompressive craniectomy is improving survival significantly. Despite decompressive surgery, however, many patients are not discharged from the hospital alive. We therefore wanted to search for predictors of early in-hospital death after craniectomy in swollen middle cerebral artery infarction. METHODS: All patients operated with decompressive craniectomy due to swollen middle cerebral artery infarction at the Department of Neurosurgery, Oslo University Hospital Rikshospitalet, Oslo, Norway, between May 1998 and October 2010, were included. Binary logistic regression analyses were performed and candidate variables were age, sex, time from stroke onset to decompressive craniectomy, NIHSS on admission, infarction territory, pineal gland displacement, reduction of pineal gland displacement after surgery, and craniectomy size. RESULTS: Fourteen out of 45 patients (31%) died during the primary hospitalization (range, 3-44 days). In the multivariate logistic regression model, middle cerebral artery infarction with additional anterior and/or posterior cerebral artery territory involvement was found as the only significant predictor of early in-hospital death (OR, 12.7; 95% CI, 0.01-0.77; p = 0.029). CONCLUSIONS: The present study identified additional territory infarction as a significant predictor of early in-hospital death. The relatively small sample size precludes firm conclusions.

Long-term outcome and quality of life after craniectomy in speech-dominant swollen middle cerebral artery infarction.

BACKGROUND: Decompressive craniectomy in malignant middle cerebral artery infarction (MMCAI) reduces mortality. Whether speech-dominant side infarction results in less favorable outcome is unclear. This study compared functional outcome, quality of life, and mental health among patients with speech-dominant and non-dominant side infarction. METHODS: All patients undergoing decompressive craniectomy for MMCAI were included. Demographics, side of infarction, and speech-dominant hemisphere were recorded. Outcome at follow-up was assessed by global functioning (modified Rankin Scale score), neurological impairment (National Institutes of Health Stroke Scale score), dependency (Barthel Index), anxiety and depression (Hospital Anxiety and Depression scale), and quality of life (Short Form-36). RESULTS: Twenty-nine out of 45 patients (mean age ± SD, 48.1 ± 11.6 years; 58 % male) were alive at follow-up, and 26 were eligible for analysis [follow-up, median (interquartile range): 66 months (32-93)]. The speech-dominant hemisphere was affected in 13 patients. Outcome for patients with speech-dominant and non-dominant side MMCAI was similar regarding neurological impairment (National Institutes of Health Stroke Scale score, mean ± SD: 10.3 ± 7.0 vs. 8.9 ± 2.7, respectively; p = 0.51), global functioning [modified Rankin Scale score, median (IQR): 3.0 [2-4] vs. 4.0 [3-4]; p = 0.34], dependence (Barthel Index, mean ± SD: 16.2 ± 5.0 vs. 13.1 ± 4.8; p = 0.12), and anxiety and depression (Hospital Anxiety and Depression scale, mean ± SD: anxiety, 5.0 ± 4.5 vs. 7.3 ± 5.8; p = 0.30; depression, 5.0 ± 5.2 vs. 5.9 ± 3.9; p = 0.62). The mean quality of life scores (Short Form-36) were not significantly different between the groups. CONCLUSIONS: There was no statistical or clinical difference in functional outcome and quality of life in patients with speech-dominant compared to non-dominant side infarction. The side affected should not influence suitability for decompressive craniectomy.

Volume and densities of chronic subdural haematoma obtained from CT imaging as predictors of postoperative recurrence: a prospective study of 107 operated patients.

BACKGROUND: Chronic subdural haematoma (CSDH) is a common entity in neurosurgery with a considerable postoperative recurrence rate. Computerised tomography (CT) scanning remains the most important diagnostic test for this disorder. The aim of this study was to characterise the relationship between the recurrence of CSDH after treatment with burr-hole irrigation and closed-system drainage technique and CT scan features of these lesions to assess whether CT findings can be used to predict recurrence. METHODS: We investigated preoperative and postoperative CT scan features and recurrence rate of 107 consecutive adult surgical cases of CSDH and assessed any relationship with univariate and multivariate regression analyses. RESULTS: Seventeen patients (15.9 %) experienced recurrence of CSDH. The preoperative haematoma volume, the isodense, hyperdense, laminar and separated CT densities and the residual total haematoma cavity volume on the 1st postoperative day after removal of the drainage were identified as radiological predictors of recurrence. If the preoperative haematoma volume was under 115 ml and the residual total haematoma cavity volume postoperatively was under 80 ml, the probability of no recurrence was very high (94.4 % and 97.4 % respectively). CONCLUSIONS: These findings from CT imaging may help to identify patients at risk for postoperative recurrence.

Local and systemic pro-inflammatory and anti-inflammatory cytokine patterns in patients with chronic subdural hematoma: a prospective study.

OBJECTIVE AND DESIGN: Innate immune pro- and anti-inflammatory responses in patients with chronic subdural hematoma (CSDH) were investigated by measuring and comparing the systemic and subdural fluid levels of cytokines. MATERIALS AND METHOD: Cytokine values were analyzed in samples obtained during surgery of 56 adult patients who were operated on for unilateral CSDHs using a Multiplex antibody bead kit. RESULTS: There were significantly higher levels of the pro-inflammatory IL-2R (p = 0.004), IL-5 (p < 0.001), IL-6 (p < 0.001), and IL-7 (p < 0.001), and anti-inflammatory mediators IL-10 (p < 0.001) and IL-13 (p = 0.002) in CSDH fluid compared with systemic levels. The pro-inflammatory TNF-alpha (p < 0.001), IL-1beta (p < 0.001), IL-2 (p = 0.007) and IL-4 (p < 0.001) were significantly lower in hematoma fluid compared with systemic levels. The ratios between pro- versus anti-inflammatory cytokines were statistically significant higher in CSDH (7.8) compared with systemic levels (1.3). CONCLUSIONS: The innate immune responses occur both locally at the site of CSDH, as well as systematically in patients with CSDH. The local hyper-inflammatory and low anti-inflammatory responses exist simultaneously. The findings suggest poorly coordinated innate immune responses at the site of CSDH that may lead to propagating of local inflammatory process and basically contribute to formation and progression of CSDH.

Chemokines as markers of local inflammation and angiogenesis in patients with chronic subdural hematoma: a prospective study.

OBJECTIVE: The goal of this study was to investigate the chemokines CCL2, CXCL8, CXCL9 and CXCL10 as markers of the inflammatory responses in chronic subdural hematoma (CSDH). METHODS: Samples of peripheral venous blood and CSDH fluid (obtained during surgery) in 76 adult patients were prospectively analyzed. Chemokine values were assessed by a Multiplex antibody bead kit. RESULTS: We found significantly higher levels of chemokines CCL2, CXCL8, CXCL9 and CXCL10 in hematoma fluid compared with serum. CONCLUSIONS: Chemokines are elevated in the hematoma cavity of patients with CSDH. It is likely that these signaling modulators play an important role in promoting local inflammation. Furthermore, biological activity of CCL2 and CXCL8 may promote neovascularization within the outer CSDH membrane, and a compensatory angiostatic activity of CXCL9 and CXCL10 may contribute to repairing this disorder. This phenomenon was restricted to the hematoma site, and the systemic chemokine levels might not reflect local immune responses.

Cognitive functioning and health related quality of life after rupture of an aneurysm on the anterior communicating artery versus middle cerebral artery.

The neuropsychological outcome and Health Related Quality of Life (HRQOL) after SAH have been largely believed to be unrelated to the location of the ruptured aneurysm. This notion needs verification due to the contemporary availability of more sensitive neuropsychological test batteries and more recent clinical observations of deviant behaviour after SAH. To this end, we compared patients with ruptured aneurysms on respectively the anterior communicating artery (ACoA) (n = 24) or middle cerebral artery (MCA) (n = 22). All patients underwent an extensive neuropsychological examination, clinical interview and answered questionnaires 12 months after SAH. We found mild to moderate discrepancies from population norm in test scores on a number of areas of cognitive functioning in both patient groups, with a consistent, but statistically non-significant trend towards better functioning in MCA patients despite of the fact that patients with ruptured MCA aneurysms were initially in a poorer clinical condition and more often had intracranial haematomas. We observed slight reductions in executive functions, on the first conditions on the Delis-Kaplan Executive Functioning System (D-KEFS) tests, and some measures of memory functions in the ACoA patients. ACoA patients seemed to have problems with initiation of problem solving behaviour. None of the patient groups scored for apathy and depression. Some measures of HRQOL were equally reduced as compared to the population norm in both groups. ACoA patients remained longer on sick-leave compared to MCA patients.

[Hemicraniectomy in acute brain infarction]. / Hemikraniektomi ved akutt hjerneinfarkt.

BACKGROUND: Massive hemispheric brain infarctions are associated with high mortality, due to cerebral oedema, increased intracranial pressure, distortion of the brain stem and herniation. Decompressive craniectomy involves opening of the dura mater to give more space for the brain. This review describes hemicraniectomy and discusses its usefulness, especially in massive cerebral infarctions. MATERIAL AND METHODS: Literature up to January 2007 was retrieved from Medline with the terms "hemicraniectomy" and "decompressive craniotomy" in combination with "stroke" and "cerebral infarction". 39 studies were found of patients operated with decompressive craniotomy for cerebral infarction in the period 1990-2006. RESULTS AND INTERPRETATION: Hemicraniectomy for massive supratentorial brain infarction has been insufficiently documented. Hemicraniectomy performed within 48 hours of stroke onset has recently been compared to medical management alone in three randomized studies. A pooled analysis of patients (93 patients aged < 60 years) with massive infarction in the arteria cerebral media territory, indicated a significantly lower one-year mortality and a significantly larger proportion with a one-year outcome of mRS <3 after hemicraniectomy than after medical management alone. The following key questions still need to be answered: surgical timing, the relevance of hemispheric dominance, the extension of infarcted brain, and whether the reduced mortality justifies the morbidity among survivors (particularly in older age groups). Even though increased survival has now been documented, the decision to perform hemicraniectomy in patients with massive brain infarction must still be made on an individual basis.

[Subarachnoid haemorrhage--diagnosis and management]. / Subaraknoidalblødning--diagnostikk og behandling.

INTRODUCTION: Subarachnoid haemorrhage (SAH) causes 3% of all strokes and is caused by a ruptured cerebral aneurysm in four of five cases. This review article presents an update of knowledge on symptoms, diagnosis and management of SAH. MATERIAL AND METHODS: This article is based on selected literature and the authors' clinical experience. RESULTS AND INTERPRETATION: The mortality of SAH is approximately 50% and one out of three survivors have permanent disabling neurological symptoms. Patients with suspected or diagnosed SAH need urgent examination and treatment. A large randomised multicentre study (International Subarachnoid Aneurysm Trial) suggests that endovascular repair with coiling may be less traumatic than microsurgery. Not all patients are suitable for endovascular treatment, despite new tools like balloon- and stent-assisted coiling. Centres that treat patients with SAH should have both methods available at all hours. The management of these patients involves advanced neuro-intensive care, and co-operation between neurosurgeons, neuroradiologists and neuroanestesiologists.

[Life following acute subarachnoid haemorrhage]. / Livet etter akutt hjernehinneblødning.

BACKGROUND: We studied the outcome after aneurysmal subarachnoid haemorrhage from a patient perspective. We compared outcomes of microsurgical and endovascular aneurysm repair and assessed the impact of gender and age on quality of life. MATERIAL AND METHODS: 60 patients undergoing repair of a ruptured intracranial aneurysm from January to July 2001 were included consecutively (35 women). Endovascular repair was performed on 39 and microsurgery on 21. The mean age was 55 years. Quality of life was assessed 3 and 12 months after the bleed using WHOQOL-BREF and Rankin score questionnaires, and through interviews (n = 9). RESULTS AND INTERPRETATION: A total of 40 of 58 patients returned both questionnaires; two died. Twelve months after the bleed, 26 of 44 patients reported a "good" or "very good" subjective quality of life, 3 out of 44 reported a "poor", and 15 of out 44 a "neither good nor poor" subjective quality of life. Males reported a significantly better quality of life (p=0.008). Women reported feeling more depressed and also significantly more symptoms of asthenia, less energy and working capacity. We found no significant differences pertaining to age. Despite moderate disabilities, the respondents generally scored high on quality of life after subarachnoid haemorrhage. The gender differences clearly deserving further investigations.

Pediatric hydrocephalus: 40-year outcomes in 128 hydrocephalic patients treated with shunts during childhood. Assessment of surgical outcome, work participation, and health-related quality of life.

OBJECT: Treatment for hydrocephalus has not advanced appreciably since the advent of CSF shunts more than 50 years ago. The outcome for pediatric patients with hydrocephalus has been the object for several studies; however, much uncertainty remains regarding the very long term outcome for these patients. Shunting became the standard treatment for hydrocephalus in Norway during the 1960s, and the first cohorts from this era have now reached middle age. Therefore, the objective of this study was to review surgical outcome, mortality, social outcome, and health-related quality of life in middle-aged patients treated for hydrocephalus during childhood. METHODS: Data were collected in all patients, age 14 years or less, who required a CSF shunt during the years 1967-1970. Descriptive statistics were assessed regarding patient characteristics, surgical features, social functioning, and work participation. The time and cause of death, if applicable, were also determined. Kaplan-Meier survival estimates were used to determine the overall survival of patients. Information regarding self-perceived health and functional status was assessed using the 36-Item Short Form Health Survey (SF-36) and the Barthel Index score. RESULTS: A total of 128 patients were included in the study, with no patient lost to follow-up. Of the 128 patients in the study, 61 (47.6%) patients died during the 42-45 years of observation. The patients who died belonged to the tumor group (22 patients) and the myelomeningocele group (13 patients). The mortality rate was lowered to 39% if the patients with tumors were excluded. The overall mortality rates at 1, 2, 10, 20, and 40 years from time of initial shunt insertion were 16%, 24%, 31%, 40%, and 48% respectively. The incidence of shunt-related mortality was 8%. The majority of children graduated from a normal school (67%) or from a school specializing in education for physically handicapped children (20%). Self-perceived health was significantly poorer in 6 out of 8 domains assessed by SF-36 as compared with the background population. Functional status among the survivors varied greatly during the follow-up period, but the majority of patients were self-dependent. A total of 56% of the patients were socially independent, and 42% of the patients were employed. CONCLUSIONS: Approximately half of the patients are still alive. During the 42-45 year follow-up period, the mortality rate was 48%. Two deaths were due to acute shunt failure, and at least 8% of the deaths were shunt related (probable or late onset). The morbidity in middle-aged individuals treated for pediatric hydrocephalus is considerable. The late mortality rate was low, but not negligible. Twelve patients died during the last 2 decades, 1 of whom died because of acute shunt failure. Although the shunt revision rate was decreasing during the study period, many patients required shunt surgery during adulthood. Forty-one revisions in 21 patients were performed during the last decade. Thus, there is an obvious need for life-long follow-up in these patients.

Twenty-year outcome in young adults with childhood hydrocephalus: assessment of surgical outcome, work participation, and health-related quality of life.

OBJECT: Shunting of CSF is one of the most commonly performed operations in the pediatric neurosurgeon's repertoire. The 1st decade after initial shunt insertion has been addressed in several previous reports. The goals of the authors' study, therefore, were to determine 20-year outcomes in young adults with childhood hydrocephalus and to assess their health-related quality of life (HRQOL). METHODS: Patients younger than 15 years of age, in whom a first-time shunt insertion was performed for hydrocephalus in the calendar years 1985-1988, were included in a retrospective study on surgical morbidity, mortality rates, academic achievement, and/or work participation. Information concerning perceived health and functional status was assessed using the 36-Item Short Form Health Survey (SF-36) and Barthel Index, which were completed by patients still alive by September 1, 2009. RESULTS: Overall, 138 patients participated, no patient being lost to follow-up. For the 20-year period, the overall mortality rate was 21.7%. The mortality rate was not significantly higher in the 1st decade after initial shunt insertion than in the 2nd decade (p = 0.10). Ten percent of the patients surviving still live with their primary shunt in place, whereas 81% required at least one revision, and among these individual the mean number of revisions was 4.2 (median 3, range 0-26). There was a significantly higher revision rate during the 1st decade after initial shunt insertion compared with the 2nd decade (p = 0.027). The majority of patients live lives comparable with those of their peers. At follow-up, 56% were employed in open-market jobs or were still students, 23% had sheltered employment, and 21% were unemployed. The HRQOL was slightly lower in the hydrocephalic cohort than in the normative population. A significant difference was found in 2 of 8 SF-36 domains-Physical Functioning and General Health. CONCLUSIONS: During the 20-year follow-up period, 81% of the patients required at least one revision of the CSF shunt. The mortality rate was high: 24 patients died in the 1st decade and 6 died in the 2nd decade after implantation of the initial shunt. In total, 4 deaths (2.9%) were due to shunt failure. Shunt placement to treat childhood hydrocephalus has a substantial effect on social functioning in later life, although perceived health was positively found to be better than expected in young adults with hydrocephalus.

Cognitive functioning and health-related quality of life 1 year after aneurysmal subarachnoid hemorrhage in preoperative comatose patients (Hunt and Hess Grade V patients).

OBJECTIVE: The objective of this study was to determine cognitive functioning and health-related quality of life 1 year after aneurysmal subarachnoid hemorrhage in preoperative comatose patients (Hunt and Hess Grade V patients). METHODS: Patients who were comatose at hospital arrival and thereafter were investigated for 1 year using a comprehensive neuropsychological test battery and 2 HRQOL questionnaires. RESULTS: Thirty-five of 70 patients survived the bleed, and 26 underwent neuropsychological testing. Two distinct patient groups emerged, one (n = 14) with good cognitive function, having mild deficits only, and the other (n = 12) with poor cognitive and poor motor function. Patients performing poorly were older (P = .04), had fewer years of education (P = .005) and larger preoperative ventricular scores, and were more often shunted (P = .02). There were also differences between the 2 groups in the Glasgow Outcome Scale (P = .001), the modified Rankin Scale (P = .001), and employment status. HRQOL was more reduced in patients with poor cognitive function. CONCLUSION: A high fraction of survivors among preoperative comatose aneurysmal SAH patients (Hunt and Hess grade V) recover to good physical and cognitive function, enabling them to live a normal life.

Surgical repair of unruptured and ruptured middle cerebral artery aneurysms: impact on cognitive functioning and health-related quality of life.

OBJECTIVE: To assess the impact of surgical treatment of unruptured and ruptured middle cerebral artery (MCA) aneurysms on cognitive functioning and health-related quality of life (HRQOL). METHODS: This was a prospective study enrolling 15 patients with unruptured MCA aneurysms and 22 patients with ruptured MCA aneurysms in good clinical condition postictally. Patients with unruptured aneurysms underwent preoperative neuropsychological testing and answered 2 HRQOL questionnaires. All patients were investigated 3 and 12 months postoperatively with a comprehensive neuropsychological test battery, clinical investigation, and interview. The modified Rankin Scale score, Glasgow Outcome Scale score, employment status, and 2 HRQOL questionnaires were also used for assessment. RESULTS: Preoperative cognitive deficits were aggravated 3 months after surgery for the unruptured MCA aneurysm group, but after 12 months these patients performed at their preoperative level. Subjects who underwent clipping for ruptured MCA aneurysms had reduced verbal memory; otherwise, they had close to normal cognitive function 12 months postoperatively. There was no difference between the 2 groups in Rankin Scale score or Glasgow Outcome Scale score. High preoperative levels of anxiety and depression markedly decreased after repair of an unruptured aneurysm; however, in both groups, HRQOL was reduced on the same measures even 12 months after surgery. Patients treated for unruptured MCA aneurysms regained their preoperative employment status, whereas only 60% of those who had bled from their aneurysm had returned to full-time work after 12 months. CONCLUSION: Surgical treatment of unruptured MCA aneurysms does not cause new cognitive deficits, but it reduces some aspects of HRQOL in a similar manner as in patients who undergo clipping for ruptured MCA aneurysms.

Cognitive outcome after aneurysmal subarachnoid hemorrhage: time course of recovery and relationship to clinical, radiological, and management parameters.

OBJECTIVE: Although many patients show a satisfactory physical outcome after aneurysmal subarachnoid hemorrhage (SAH), disabling cognitive dysfunction may still be present. This study focuses on the time course of cognitive recovery during the first year after aneurysmal SAH, and relates the neuropsychological test results to clinical, radiological, and management parameters. METHODS: Thirty-two patients were followed prospectively with neuropsychological examinations at 3, 6, and 12 months after SAH. Test results were compared with clinical entry variables, management variables, and pre- and postoperative radiological findings. RESULTS: The time course of cognitive recovery after aneurysmal SAH is heterogeneous, with motor and psychomotor functions recovering within the first 6 months, whereas verbal memory did not improve significantly until at least 6 months after the ictus. Clinical and radiological parameters reflecting the impact of the bleed were related to memory function, intelligence, and aphasia. The site of aneurysm and mode of treatment could not be linked to neuropsychological outcome. The time length of volume-controlled mechanical ventilation as a reflector of the aggregated consequences of being subjected to an aneurysm rupture correlated with both motor and psychomotor functioning and memory performance, predominantly 6 to 12 months after SAH, but was not linked to intelligence or aphasia. CONCLUSION: The various cognitive functions have different time courses of recovery, with verbal memory requiring the longest time. Parameters reflecting the impact of the bleed and patient management can be linked to neuropsychological outcome.