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PURPOSE: To compare the types of facial fractures and their treatment in bicyclists admitted to a level 1 trauma centre with major and minor-moderate head injury. METHODS: Retrospective analysis of data from bicycle-related injuries in the period 2005-2016 extracted from the Oslo University Hospital trauma registry. RESULTS: A total of 967 bicyclists with head injuries classified according to the Abbreviated Injury Scale (AIS) were included. The group suffering minor-moderate head injury (AIS Head 1-2) included 518 bicyclists, while 449 bicyclists had major head injury (AIS Head 3-6). The mean patient age was 40.2 years (range 3-91 years) and 701 patients (72%) were men. A total of 521 facial fractures were registered in 262 patients (on average 2 facial fractures per bicyclist). Bicyclists with major head injury exhibited increased odds for facial fractures compared to bicyclists with minor-moderate head injury (sex and age adjusted odds ratio (OR) 2.75, 95% confidence interval (CI) 2.03-3.72, p < 0.001. More specifically, there was increased odds for all midface fractures, but no difference for mandible fractures. There was also increased odds for orbital reconstruction in cyclist with major head injury compared to bicyclist with minor-moderate head injury (adjusted OR 3.34, 95% CI 1.30-8.60, p = 0.012). CONCLUSION: Bicyclists with more severe head injuries had increased odds for midface fractures and surgical correction of orbital fractures. During trauma triage, the head and the face should be considered as one unit.
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Traumatismos Craneocerebrales , Fracturas Craneales , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto Joven , Accidentes de Tránsito , Ciclismo/lesiones , Estudios Retrospectivos , Centros TraumatológicosRESUMEN
This study investigates the impact of helmet use on the incidence of facial fractures in bicycle accidents. Analyzing data from hospitalized bicyclists between 2005 and 2016, the research focused on the correlation between helmet usage and various facial fractures. The study included 1256 bicyclists with known helmet use, among whom 277 individuals (22%) were identified with a total of 521 facial fractures. The findings revealed a significant reduction in the likelihood of facial fractures among helmeted cyclists compared with those without helmets (odds ratio, 0.65; confidence interval, 0.50-0.85; P=0.002). Specifically, the odds of sustaining fractures in the zygoma, orbit, nose, and maxilla were decreased by 47%, 46%, 43%, and 33%, respectively, among helmeted cyclists. However, helmet use did not significantly alter the odds of mandible fractures. Overall, the use of helmets in bicycling significantly lowered the risk of midface fractures but showed no notable effect on mandible fractures in severe cycling incidents.
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Ciclismo , Dispositivos de Protección de la Cabeza , Fracturas Craneales , Humanos , Dispositivos de Protección de la Cabeza/estadística & datos numéricos , Ciclismo/lesiones , Masculino , Femenino , Adulto , Fracturas Craneales/prevención & control , Fracturas Craneales/epidemiología , Centros Traumatológicos , Persona de Mediana Edad , Huesos Faciales/lesiones , Incidencia , AdolescenteRESUMEN
Molecular alterations nowadays play a crucial role in the diagnosis of brain tumors. Some of these alterations are associated with outcome and/or response to treatment, including sequence variants of isocitrate dehydrogenase (IDH) at position p.R132 or p.R172. Such IDH variants have so far been described in histone H3-wildtype primary brain tumors only in adult-type diffuse gliomas and are associated with a better outcome compared to their IDH-wildtype counterpart, the glioblastoma. Moreover, homozygous loss of CDKN2A and/or CDKN2B in IDH-mutant astrocytomas shortens the median overall survival regardless of histological features of malignancy. Such tumors are therefore considered to be aggressive and graded as WHO central nervous system (CNS) grade 4 lesions. The coexistence of an IDH-sequence variation and a BRAF p.V600E alteration has only rarely been described in diffuse astrocytomas. Due to the small number of cases, little is known about such neoplasms in terms of clinical behavior and response to treatment. Herein we describe the first case, to our knowledge, of an astrocytoma (CNS WHO grade 4), IDH-mutant, and BRAF p.V600E-mutant with homozygous deletion of CDKN2A. Pathologists should be aware that such an expression profile does exist even in WHO CNS grade 4 astrocytomas, IDH-mutant, and are encouraged to test for the BRAF p.V600E sequence variant as such an alteration may provide additional treatment options.
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Astrocitoma , Neoplasias Encefálicas , Glioblastoma , Adulto , Humanos , Isocitrato Deshidrogenasa/genética , Proteínas Proto-Oncogénicas B-raf/genética , Homocigoto , Mutación , Eliminación de Secuencia , Astrocitoma/patología , Glioblastoma/patología , Neoplasias Encefálicas/patología , Organización Mundial de la Salud , Inhibidor p16 de la Quinasa Dependiente de Ciclina/genética , Inhibidor p16 de la Quinasa Dependiente de Ciclina/metabolismoRESUMEN
PURPOSE: Treatment of craniopharyngiomas (CP) is challenging due to their proximity to critical neural structures, risk of serious complications and impaired quality of life after treatment. Recurrences may occur many years after surgical resection. However, long-term outcome data are still scarce. The purpose of this retrospective study was therefore to assess the long-term results after treatment of patients with CP. MATERIAL AND METHOD: Patients surgically treated for a histologically verified CP at Oslo University Hospital between 1992 and 2015 and with at least a 5-year follow-up were included. Patients' medical records and radiological studies were reviewed. RESULTS: Sixty-one patients (mean age 35.8 ± 22.2 years) were included; 18 patients (30%) were children <18 years of age. The incidence for the study period and the referral population was 1.1 cases/million/year, with trimodal peak incidence at 6, 32 and 59 years of age. The commonest presenting symptoms were visual disturbances (62%), headache (43%) and endocrine dysfunction (34%). The transcranial approach was utilized in 79% of patients. Gross total resection (GTR) was achieved in 59%. The surgical complication rate was 20%. Three patients (5%) received radiotherapy or radiosurgery after primary resection. The mean follow-up was 139 ± 76 months, with no patients lost to follow-up. Postoperatively, 59% of patients had panhypopituitarism and 56% diabetes insipidus. Eighteen patients (30%) developed tumour recurrence after a mean follow-up of 26 ± 25 months. The 10-year overall survival (OS) rate was 75%, whereas the disease-specific survival (DSS) rate was 84%, and recurrence-free survival (RFS) 61%. Subtotal resection (STR) (p = .01) and systemic comorbidity (p = .002) were associated with worse DSS. CONCLUSION: Surgical treatment of CP, even though combined with adjuvant radiotherapy in only selected cases, provides good long-time OS and DSS, and relatively good functional outcome in long-term survivors despite postoperative morbidity, particularly endocrine dysfunction. Systemic comorbidity and STR are individual negative prognostic factors.
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Bicyclists are vulnerable road users. The authors aimed to characterise facial fractures and their association with head and neck injuries in bicyclists admitted to a Scandinavian Level 1 trauma center with a catchment area of ~3 million inhabitants. Data from bicycle-related injuries in the period 2005 to 2016 were extracted from the Oslo University Hospital trauma registry. Variables included were age; sex; date of injury; abbreviated injury scale (AIS) codes for facial skeletal, head and neck injuries; and surgical procedure codes for treatment of facial fractures. Anatomical injury was classified according to AIS98. A total of 1543 patients with bicycle-related injuries were included. The median age was 40 years (quartiles 53, 25), and 1126 (73%) were men. Overall, 652 fractures were registered in 339 patients. Facial fractures were observed in all age groups; however, the proportion rose with increasing age. Bicyclists who suffered from facial fractures more often had a concomitant head injury (AIS head >1) than bicyclists without facial fractures (74% vs. 47%), and the odds ratio for facial fracture(s) in the orbit, maxilla and zygoma were significantly increased in patients with AIS head >1 compared to patients with AIS head=1. In addition, 17% of patients with facial fractures had a concomitant cervical spine injury versus 12% of patients without facial fractures. This results showed that facial fractures were common among injured bicyclists and associated with both head and cervical spine injury. Thus, a neurological evaluation of these patients are mandatory, and a multidisciplinary team including maxillofacial and neurosurgical competence is required to care for these patients.
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Traumatismos Craneocerebrales , Traumatismos Faciales , Traumatismos del Cuello , Fracturas Craneales , Traumatismos Vertebrales , Masculino , Humanos , Adulto , Femenino , Fracturas Craneales/epidemiología , Fracturas Craneales/complicaciones , Traumatismos Vertebrales/epidemiología , Traumatismos Vertebrales/cirugía , Traumatismos Vertebrales/complicaciones , Traumatismos Craneocerebrales/complicaciones , Traumatismos del Cuello/epidemiología , Traumatismos del Cuello/cirugía , Traumatismos del Cuello/complicaciones , Vértebras Cervicales/lesiones , Traumatismos Faciales/complicaciones , Accidentes de Tránsito , Ciclismo/lesionesRESUMEN
OBJECTIVES: Deep brain stimulation of the anterior thalamic nucleus (ANT-DBS) is an established option in treatment-resistant epilepsy and obtained FDA approval in 2018. Increased psychiatric comorbidity is well known in epilepsy. The main objective of this study was to investigate possible neuropsychiatric treatment-related changes in patients receiving ANT-DBS. MATERIALS AND METHODS: Bilateral ANT electrodes were implanted in 18 adult patients with refractory epilepsy in a randomized, double-blinded study. Immediately after implantation, patients were randomized to stimulation ON (n = 8) or OFF (n = 10) for the first 6 months (blinded phase). During the next six months (open phase), both groups received active stimulation. Neuropsychiatric assessment was conducted before implantation (T1), at the end of the blinded period (T2), and 1 year after implantation (T3). RESULTS: Comparing preoperative status (T1) and 12 months (T3), postoperative outcome in all patients did not show significant differences between the two groups for any of the applied tests. Groupwise comparisons across the two first time points (the blinded period, representing the randomized controlled trial) showed no significant differences between the two groups in any of the neuropsychiatric parameters studied. Comparing test results after 6 months of stimulation in both groups (sum of ON group T1 to T2 and OFF group T2 to T3) did not show significant changes for any of the psychiatric assessments. CONCLUSIONS: Our results indicate that ANT-DBS has limited effect concerning psychiatric issues. Subjective side effects were, however, reported in individual patients.
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Núcleos Talámicos Anteriores , Estimulación Encefálica Profunda , Epilepsia Refractaria , Epilepsia , Adulto , Núcleos Talámicos Anteriores/fisiología , Estimulación Encefálica Profunda/métodos , Método Doble Ciego , Epilepsia Refractaria/terapia , Epilepsia/terapia , HumanosRESUMEN
BACKGROUND/AIM: The mandible makes up a substantial part of the lower face, and is susceptible to injury. Even in helmeted cyclists, accidents may lead to fractures of the mandible because conventional helmets provide little protection to the lower part of the face. In addition, some studies indicate that helmets may lead to an increased risk of mandibular fractures. Thus, the aim of this study was to examine the anatomic distribution of mandibular fractures in injured cyclists and to assess if helmet use influenced the fracture locations. MATERIAL AND METHODS: Data from a Norwegian Level 1 trauma center were collected in the Oslo University Hospital Trauma Registry over a 12-year period. Of 1543 injured cyclists, the electronic patient charts of 62 cyclists with fractures of the mandible were retrospectively evaluated in detail. Demographic data, helmet use, and fracture type were assessed. RESULTS: Sixty-two patients (4%) had fractures of the mandible, and women had an increased risk (OR 2.49, 95% CI 1.49-4.16, p < .001). The most common fracture site was the mandibular body, followed by the condyle. Isolated mandibular fractures occurred in 45% of the patients and 55% had other concomitant facial fractures. There were 42% of the patients with fractures in multiple sites of the mandible, and 42% had a concomitant dentoalveolar injury. Half of the cyclists were wearing a helmet at the time of the accident and 39% were not. There was no significant difference in fracture distribution between the helmeted and non-helmeted groups. CONCLUSIONS: Fracture of the mandibular body was the most prevalent mandibular fracture type following bicycle accidents. Women had an increased risk of mandibular fractures compared with men, whereas helmet wearing did not affect the anatomical fracture site.
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Ciclismo , Fracturas Mandibulares , Accidentes de Tránsito , Ciclismo/lesiones , Femenino , Dispositivos de Protección de la Cabeza , Humanos , Masculino , Fracturas Mandibulares/epidemiología , Fracturas Mandibulares/etiología , Estudios Retrospectivos , Centros TraumatológicosRESUMEN
BACKGROUND: Brain abscess is a life-threatening condition. Congenital cardiovascular malformations can create right-to-left shunting and be an underlying cause. CASE PRESENTATION: A young man was admitted due to headache and deteriorating general condition. He had a history of a surgically treated brain abscess 19 years earlier. Investigations now showed a new brain abscess. The patient was operated and received a peripherally inserted central catheter in his left arm for antibiotic treatment. A chest X-ray showed abnormal positioning of the catheter lying in a persistent left superior vena cava. One day later he experienced headache and photophobia. MRI showed reoccurrence of the brain abscess and he was reoperated. Persistent left superior vena cava was considered to be the cause of the brain abscesses and he underwent endovascular embolisation and placement of a vascular plug in his left superior vena cava. INTERPRETATION: The oxygen-rich pulmonary circulation and its immune system make it difficult for anaerobic bacteria to pass to the arterial side. In most cases persistent left superior vena cava drains into the right atrium and is asymptomatic. In 10 % of patients the persistent left superior vena cava drains directly to the left atrium and gives a right-to-left shunt. This may cause arterial bacteraemia and brain abscesses.
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Absceso Encefálico , Vena Cava Superior Izquierda Persistente , Masculino , Humanos , Vena Cava Superior/diagnóstico por imagen , Absceso Encefálico/diagnóstico por imagen , Absceso Encefálico/etiología , Absceso Encefálico/cirugía , Imagen por Resonancia Magnética , CefaleaRESUMEN
BACKGROUND/AIM: Despite its many benefits, bicycling carries the risk of accidents. Although numerous studies have reported the effect of helmet use on traumatic brain injury, it remains unclear if, and to what extent, helmet use reduces the risk of facial injuries. This is particularly true in regard to injuries of the lower face. In addition, there is limited evidence of the effect of helmet use on dentoalveolar injuries. Thus, the aim of this study was to determine the frequency and distribution of dentoalveolar injuries in bicycling accidents and to explore the influence of helmet use. MATERIAL AND METHODS: A total of 1543 bicyclists were included from the trauma registry of a Norwegian tertiary trauma center over a 12-year period. Data were collected prospectively, including patient characteristics, type of injury, and helmet use. The prevalence of dentoalveolar injuries was assessed in conjunction with helmet use and facial fractures. RESULTS: Twenty-five percent of the patients had maxillofacial injuries, and 18% of those with facial fractures exhibited concomitant dentoalveolar injuries. The most common type of dentoalveolar injury was tooth fracture (39%). The most frequent location of facial fractures with combined dentoalveolar injuries was the maxilla, which had fractured in 32 patients. Women had a higher risk of sustaining dentoalveolar injuries compared to men (odds ratio 1.50, 95% confidence interval 1.02-2.22). There were 1257 patients (81%) who had reliable registration of helmet use; 54% of these wore a helmet, while 46% did not. Helmet users had an increased risk of dentoalveolar injuries compared to non-helmeted bicyclists (adjusted odds ratio 1.54, 95% confidence interval 1.02-2.31). CONCLUSIONS: Dentoalveolar injuries are fairly common in trauma patients admitted to a trauma center following bicycling accidents. Bicycling helmets are associated with an increased risk of dentoalveolar injuries.
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Dispositivos de Protección de la Cabeza , Centros Traumatológicos , Accidentes de Tránsito , Ciclismo , Femenino , Humanos , Masculino , Estudios ProspectivosRESUMEN
OBJECTIVES: Deep brain stimulation (DBS) of the anterior thalamic nucleus (ANT) may be used against refractory focal epilepsy, but only two randomized double-blinded trials have been performed. The Oslo study was discontinued prematurely since reduction in seizure frequency was less than expected. The aim of the present study was to review the targeting used in the Oslo study and to identify the actual positions of the contacts used for stimulation. MATERIAL AND METHODS: BrainLab MRI data were available from 12 Oslo study patients. Based on MRI the coordinates of the center of the ANT were identified. The coordinates were considered as the visually identified preferred target and were compared with the target originally used for ANT electrode implantation and with the actual electrode positions estimated from post-operative CT scans. RESULTS: We found considerable differences between the visually identified preferred target, the originally planned target, and the actual electrode position. The total distance between the active electrode position and the visually identified preferred target was on average 3.3 mm on the right and 2.9 mm on the left side. CONCLUSION: Indirect targeting based on preset coordinates may contribute to explain the modest effect of ANT-DBS on seizure frequency seen in the Oslo study. Observed differences between the center of the ANT and the actual electrode position may at least in part be explained by variations in position and size of the ANT. Direct identification of the target using better MRI imaging protocols is recommended for future ANT-DBS surgery.
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Núcleos Talámicos Anteriores/fisiología , Estimulación Encefálica Profunda/métodos , Epilepsia/terapia , Adulto , Método Doble Ciego , Epilepsia Refractaria/terapia , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Neuroimagen/métodos , Ensayos Clínicos Controlados Aleatorios como Asunto , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVES: The safety and effect on seizure frequency of anterior thalamic nucleus deep brain stimulation were studied in this prospective, randomized, double-blinded study. Patients were followed for 12 months. The first 6 months were blinded with regard to active stimulation or not. After 6 months, all patients received active stimulation. MATERIAL AND METHODS: Bilateral ANT electrodes were implanted into 18 patients suffering from focal, pharmacoresistant epilepsy. Antiepileptic treatment was kept unchanged from three months prior to operation. The Liverpool seizure severity scale (LSSS) was used to measure the burden of epilepsy. RESULTS: There was no significant difference between the 2 groups at the end of the blinded period at 6 months. However, when considering all patients and comparing 6 months of stimulation with baseline, there was a significant, 22% reduction in the frequency of all seizures (P = 0.009). Four patients had ≥50% reduction in total seizure frequency and 5 patients ≥50% reduction in focal seizures after 6 months of stimulation. No increased effect over time was shown. LSSS at 6 months compared to baseline showed no significant difference between the 2 groups, but a small, significant reduction in LSSS was found when all patients had received stimulation for 6 months. CONCLUSIONS: Our study supports results from earlier studies concerning DBS as a safe treatment option, with effects even in patients with severe, refractory epilepsy. However, our results are not as encouraging as those reported from many other, mainly unblinded, and open studies.
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Núcleos Talámicos Anteriores/fisiología , Estimulación Encefálica Profunda/métodos , Epilepsia Refractaria/terapia , Adolescente , Adulto , Método Doble Ciego , Femenino , Humanos , Masculino , Estudios Prospectivos , Resultado del TratamientoRESUMEN
A case with cerebral venous air embolism (CVAE) after neurosurgery and treated with hyperbaric oxygen therapy (HBOT) is presented. This is a rare and potentially fatal complication that neurosurgeons should be aware of. A 52-year-old male was diagnosed with an intracerebral hematoma. An emergency evacuation of the hematoma was performed with a craniotomy and the postoperative CT scan showed a complete evacuation of the hematoma, but it also revealed a CVAE. The patient was immediately referred to HBOT and received three sessions within 48 h. The CT scan after the first HBOT showed no CVAE, venous thrombosis, or new hematoma.
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Craneotomía/efectos adversos , Embolia Aérea/etiología , Hematoma/cirugía , Oxigenoterapia Hiperbárica/métodos , Complicaciones Posoperatorias/etiología , Venas Cerebrales/patología , Senos Craneales/patología , Embolia Aérea/terapia , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/terapiaRESUMEN
BACKGROUND: Resection of clivus chordomas through extensive skull base approaches is associated with high mortality and morbidity even in experienced hands. We report our experience with endoscopic trans-sphenoidal surgery, or a "wait-and-scan" strategy in selected patients. METHOD: Ten patients were diagnosed with clivus chordomas during an 8-year period. Six patients underwent primary treatment with endoscopic trans-sphenoidal surgery, followed by adjuvant proton-beam therapy in three of these patients. Four patients with minor symptoms were followed-up untreated. Mean follow-up was 91 months. RESULTS: Of the six patients operated on, total or gross total resection was achieved in four, partial resection in one and biopsy was taken in one. Preoperative cranial neuropathies resolved in three out of five patients, and no new cranial nerve palsies were encountered. Postoperative cerebrospinal fluid leak occurred in one patient. Four patients were initially followed-up without any treatment, and three of these have remained stable without tumour progression for a mean of 94 months. Due to a slow, though progressive growth of tumour, one patient was operated on after 80 months of initial observation. CONCLUSIONS: The natural course of clivus chordomas has yet to be defined. The endoscopic trans-sphenoidal approach is a valid, minimally invasive alternative for the treatment of clival chordomas, and in selected patients a "wait and scan" strategy can be considered. Our long-term results show low mortality and good functional outcome. An endonasal endoscopic trans-sphenoidal approach should be a principal part of the armamentarium of surgeons treating clivus chordomas.
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Cordoma/cirugía , Fosa Craneal Posterior/cirugía , Endoscopía/métodos , Procedimientos Neuroquirúrgicos/métodos , Neoplasias de la Base del Cráneo/cirugía , Adolescente , Adulto , Anciano , Progresión de la Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Nariz/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: Cushing's disease is an ACTH-producing pituitary adenoma, and the primary treatment is microscopic or endoscopic transsphenoidal selective adenectomy. The aims of the present study were to evaluate whether the early postoperative S-cortisol level can serve as a prognostic marker for short- and long-term remission, and retrospectively review our own short and long term results after surgery for Cushing's disease. METHODS: This single centre, retrospective study consists of 19 consecutive patients with Cushing's disease who underwent transsphenoidal surgery. S-cortisol was measured every 6 h after the operation without any glucocorticoid replacement. We have follow-up on all patients, with a mean follow-up of 68 months. RESULTS: At the three-month follow-up, 16 patients (84 %) were in remission; at 12 months, 18 (95 %) were in remission and at the final follow-up (mean 68 months), 13 (68 %) were in remission. Five-years recurrence rate was 26 %. The mean postoperative S-cortisol nadir was significantly lower in the group of patients in remission than in the non-remission group at 3 months, but there was no difference between those in long-term remission compared to those in long-term non-remission. The optimal cut-off value for classifying 3-month remission was 74 nmol/l. CONCLUSION: We achieved a 95 % 1-year remission rate with transsphenoidal surgery for Cushing's disease in this series of consecutive patients. However, the 5-year recurrence rate was 26 %, showing the need for regular clinical and biochemical controls in this patient group. The mean postoperative serum-cortisol nadir was significantly lower in patients in remission at 3 months compared to patients not in remission at 3 months, but a low postoperative S-cortisol did not predict long-term remission.
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Biomarcadores/sangre , Hidrocortisona/sangre , Hipersecreción de la Hormona Adrenocorticotrópica Pituitaria (HACT)/sangre , Enfermedades de la Hipófisis/sangre , Complicaciones Posoperatorias , Adolescente , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Hipersecreción de la Hormona Adrenocorticotrópica Pituitaria (HACT)/complicaciones , Hipersecreción de la Hormona Adrenocorticotrópica Pituitaria (HACT)/cirugía , Enfermedades de la Hipófisis/complicaciones , Enfermedades de la Hipófisis/cirugía , Valor Predictivo de las Pruebas , Recurrencia , Inducción de Remisión , Estudios Retrospectivos , Adulto JovenRESUMEN
BACKGROUND: This single-institution, consecutive series of transsphenoidal procedures included all patients in a defined population of 2.6 million inhabitants who underwent surgery during a specific time period. OBJECTIVE: We sought to determine the surgical complication rate and overall survival rate after transsphenoidal surgery for pituitary adenoma. METHODS: All transsphenoidal procedures for histologically verified pituitary adenomas performed between September 2002 and February 2011 at our institution were included in this study. The data were obtained from a prospectively collected database and from reviewing medical records. No patients were lost to follow-up, and the median follow-up time was 28 months. RESULTS: A total of 506 transsphenoidal procedures were performed on 446 patients. There were 268 microscopic and 238 endoscopic procedures involving 352 non-functioning and 154 hormone-secreting adenomas. A total of 73% of the procedures were primary surgeries, and 27% were repeat surgeries for tumor recurrence. The overall complication rate was 9.1%. The three most frequent complications were cerebrospinal fluid (CSF) leakage (4.7%), meningitis (2%), and visual deterioration (2%). Multivariate analyses showed that the overall risk for complications increased with older age, surgery for recurrent tumors, and surgery performed by a low-volume surgeon. There was no significant difference in the overall complication rate between the microsurgical and endoscopic techniques. The rate of surgical mortality was 0.6%, and the overall survival rates at 1 and 5 years were 95% and 90%, respectively. The only negative predictor of survival was older age. CONCLUSIONS: Transsphenoidal surgery for pituitary adenomas has a low complication rate and a low rate of mortality. We did not find a significant difference in the complication rate between endoscopic and microscopic techniques.
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Adenoma/cirugía , Endoscopía/efectos adversos , Procedimientos Neuroquirúrgicos/efectos adversos , Neoplasias Hipofisarias/cirugía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Niño , Estudios de Cohortes , Intervalos de Confianza , Endoscopía/estadística & datos numéricos , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/epidemiología , Recurrencia Local de Neoplasia/cirugía , Procedimientos Neuroquirúrgicos/estadística & datos numéricos , Complicaciones Posoperatorias/clasificación , Reoperación/estadística & datos numéricos , Tasa de Supervivencia , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Severe traumatic brain injury (TBI) is a condition burdened by high morbidity and mortality. Prevention of secondary insults is one of the main goals of management and intracranial pressure monitoring is a cornerstone in management of TBI. The relationship between intracranial pressure and optic nerve sheath is known from the literature. Optic nerve sheath ultrasonography could represent a method added to our armamentarium for monitoring intracranial pressure. METHODS: We investigated how ultrasound-measured optic nerve sheath diameter varies as a function of intracranial pressure in a cohort of patients with severe blunt head injury in whom an intraparenchymal sensor was placed. We evaluated the accuracy of optic nerve sheet diameter (ONSD) in distinguishing dichotomized ICP cut-offs and analyzed the learning curve and its potential as screening tool to select TBI patients most in need of invasive ICP monitoring in a setting with constraints on resources. RESULTS: ONSD and ICP have a linear relationship. Nevertheless, there are limits of evaluating the one-to-one correspondence between those two variables. We selected a cut-off of sonographic ONSD above which there is a concernable elevation of intracranial pressure (ICP>15 mmHg) worthy of invasive second line invasive monitoring. Thus, it is possible to use ONSD as a first line non-invasive tool to intercept patients at risk of developing frank intracranial hypertension. CONCLUSIONS: We propose the use of ONSD ultrasound as a screening investigation for post-traumatic intracranial hypertension in the context of an emergency department, especially in contexts where there is limited availability of intracranial pressure monitors.
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BACKGROUND: Primary, preoperative medical treatment is an option in selected patients with acromegaly, but a subset of patients respond poorly. Valid prediction of response to somatostatin analogues (SA) might thus alter treatment stratification. The aims of this study were to assess whether T2 signal intensity could determine long-term response to first-line SA treatment and to assess clinical and biochemical baseline characteristics, as well as histological subtype in relation to the magnetic resonance imaging (MRI) appearances. METHODS: In 45 newly diagnosed patients, T2-weighted signal intensity of the tumour was classified into hypo-, iso- or hyperintense. Biochemical and clinical baseline variables for the three groups were compared. In 25 patients primarily treated with long-acting SA for a median of 6 months [interquartile range (IQR):155-180 days], GH and IGF-1 reduction was assessed, and in 34 cases, immunohistochemical granulation pattern was evaluated. RESULTS: The results showed that 12 (27%) adenomas were hypointense, 15 (33%) isointense and 18 (40%) hyperintense. Median IGF-1 [ratio IGF-1/ULN; (upper limit of normal)] was 3·5 (2·3-4·9), 2·9 (2·6-3·8) and 1·9 (1·3-2·6), respectively (P = 0·006 for difference between groups). Median GH values (µg/l) of a 3- to 5-point profile were 17·5 (6·1-35), 9·3 (6·0-32·5) and 4·1 (1·5-8·3), (P = 0·025). Median IGF-1 reduction (% of baseline) after first-line SA treatment was 51 (49-70), 36 (19-74) and 13 (5-42) (P = 0·03); median reduction in GH (% of baseline) was 86 (72-94), 78 (62-85) and 46 (1-70) (P = 0·02). T2 hyperintensity was associated with sparse granulation pattern on immunohistochemistry. CONCLUSION: In patients with acromegaly, T2 signal intensity at diagnosis correlates with histological features and predicts biochemical outcome of first-line SA treatment.
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Acromegalia/tratamiento farmacológico , Adenoma/diagnóstico por imagen , Adenoma/tratamiento farmacológico , Imagen por Resonancia Magnética/métodos , Octreótido/uso terapéutico , Neoplasias Hipofisarias/diagnóstico por imagen , Neoplasias Hipofisarias/tratamiento farmacológico , Acromegalia/diagnóstico , Acromegalia/epidemiología , Acromegalia/etiología , Adenoma/complicaciones , Adulto , Edad de Inicio , Antineoplásicos Hormonales/uso terapéutico , Femenino , Humanos , Procesamiento de Imagen Asistido por Computador , Masculino , Persona de Mediana Edad , Neoplasias Hipofisarias/complicaciones , Radiografía , Estudios Retrospectivos , Procesamiento de Señales Asistido por ComputadorRESUMEN
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.
Asunto(s)
Citocinas/inmunología , Hematoma Subdural Crónico/inmunología , Adulto , Anciano , Anciano de 80 o más Años , Citocinas/sangre , Femenino , Hematoma Subdural Crónico/sangre , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
Importance: When society introduces and accepts new transportation modes, it is important to map risks and benefits. Objective: To compare electric scooter (e-scooter) and bicycle injuries. Design, Setting, and Participants: This cohort study is based on prospectively collected data on Norwegian patients who sustained e-scooter or bicycle injuries and presented to an emergency department affiliated with Oslo University Hospital between January 1, 2019, and March 31, 2020. Main Outcomes and Measures: e-Scooter and bicycle injuries were evaluated for associations with sex, age, time of injury, helmet use, intoxication, body region, and injury severity. Descriptive statistics are presented as mean (SD) or number with percentage, with significance set at P < .05 (2-tailed). Results: During the study period, 3191 patients were included (850 e-scooter riders, 2341 bicyclists) with 3839 injuries recorded (997 e-scooter, 2842 bicycle). The mean (SD) age of those injured was 34 (17) years, 2026 riders (63.5%) were male, 1474 (46.2%) were helmeted at the time of injury, and 516 (16.2%) were intoxicated by alcohol or other drugs. The annual incidence of injuries was 120 per 100â¯000 inhabitants for e-scooters and 340 per 100â¯000 inhabitants for bicycles. Men were overrepresented in both groups (529 e-scooter riders [62.2%] and 1497 bicyclists [63.9%]). e-Scooter riders were younger than bicyclists (mean [SD] age, 31 [12] vs 35 [18] years). Most injured e-scooter riders were aged 20 to 40 years, whereas injured bicyclists had a broader age distribution. e-Scooter injuries commonly occurred on weekends (378 [46.6%]) and during evening (230 [32.3%]) or nighttime (242 [34.1%]) hours. Most bicycle injuries occurred during weekdays (1586 [69.7%]) and daytime (1762 [61.3%]). e-Scooter riders were more often intoxicated (336 [39.5%] vs 180 [7.7%]) and had a lower rate of helmet use (18 [2.1%] vs 1456 [62.2%]). During nighttime, 230 injured e-scooter riders (91.3%) and 86 bicyclists (69.4%) were intoxicated. e-Scooter riders had more head and neck (317 [31.7%] vs 636 [22.4%]) and lower-limb (285 [28.6%] vs 632 [22.2%]) injuries and fewer upper-limb (341 [34.2%] vs 1276 [44.9%]), thoracic (41 [4.1%] vs 195 [6.9%]), and abdominal, pelvic, and lumbar (13 [1.3%] vs 103 [3.6%]) injuries. Conclusions and Relevance: In this cohort study, e-scooter riders were younger than bicyclists, did not use helmets, were more often intoxicated, and were more often injured during nighttime. The rate of intoxication among e-scooter riders injured at night was high. Preventive measures, including awareness campaigns, regulating e-scooter availability, improving infrastructure, and implementing stricter helmet and alcohol policies, may prove effective for reducing injuries.
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Ciclismo , Dispositivos de Protección de la Cabeza , Adulto , Distribución por Edad , Ciclismo/lesiones , Estudios de Cohortes , Servicio de Urgencia en Hospital , Femenino , Humanos , MasculinoRESUMEN
Background: Bicyclists are vulnerable road users. The aim of this paper was to describe all bicycle-related traumatic cervical spine injuries (CSIs) in the South-East region of Norway (2015-2019), and to investigate whether certain types of CSIs are typical for bicyclists. Methods: Retrospective cohort study of prospectively collected registry data of all CSIs in the South-East region of Norway (3.0 million inhabitants), from 2015 to 2019. Patient characteristics, injury types, and treatment were summarized with descriptive statistics. Bayesian multivariable logistic regression was used to identify potential factors associated with occipital condyle fractures (OC-Fx) or odontoid fractures (OFx). Results: During the five-year study period, 2,162 patients with CSIs were registered, and 261 (12%) were bicycle-related. The incidence of bicycle-related CSIs was 1.7/100,000 person-years. The median age of the patients with bicycle-related CSIs was 55 (IQR: 22) years, 83% were male, 71% used a helmet, 16% were influenced by ethanol, 12% had a concomitant cervical spinal cord injury (SCI), and 64% sustained multiple traumas. The three most common bicycle-related CSIs were C6/C7 fracture (Fx) (28%), occipital condyle Fx (OC-Fx) (23%) and C5/C6 Fx (19%). Patients with bicycle-related CSIs compared to patients with non-bicycle related CSIs were younger, more often male, had fewer comorbidities, more likely multiple traumas, more often had OC-Fx, and less often sustained an odontoid fracture (OFx). Multivariable logistic regression of potential risk factors for OC-Fx demonstrated a significantly increased risk of OC-Fx for bicyclists compared to non-bicyclists (OR=2.8).The primary treatment for bicycle-related CSIs was external immobilization in 187/261 (71.6%) cases, open surgical fixation in 44/261 (16.8%), and no treatment in 30/261 (11.5%). Conclusion: Bicycle crashes are a frequent cause of CSIs in the Norwegian population and should be of concern to the public society. The three most common bicycle-related CSIs were C6/C7 fracture, occipital condyle fracture and C5/C6 fracture.