Long-term stroke risk in Moyamoya disease.

BACKGROUND: Moyamoya disease (MMD) is considered a progressive disease with an ongoing risk of recurrent stroke. However, there is a lack of long-term observational data to quantify the extent of the stroke risk. METHODS: This study aimed to provide insight into the long-term stroke risk in MMD and explore possible risk factors for stroke. Records from all patients diagnosed with MMD in 13 clinical departments from 6 different Danish hospitals between 1994 and 2017 were retrospectively reviewed until 2021. RESULTS: The cohort comprised 50 patients (33 females and 17 males). Patients were followed up for a median of 9.4 years, with more than 10 years of follow-up for 24 patients. Ten patients had 11 new stroke events-6 ischemic strokes and 5 brain hemorrhages. Events occurred at a median of 7 years and up to 25 years after diagnosis. The overall Kaplan-Meier 5-year stroke risk was 10%. Patients with bypass performed had significantly fewer events than conservatively treated patients (HR 0.25, 95% confidence interval (CI) 0.07-0.91, p < 0.05). All but one event occurred in females, a difference that reached statistical significance. CONCLUSIONS: The study provides data on the extent of the risk of recurrent stroke in MMD. Bypass surgery patients had fewer stroke events than those treated conservatively. There was a trend toward a higher stroke risk in females. DATA ACCESS STATEMENT: The data supporting this study's findings are available from the corresponding author upon reasonable request.

Mortality among patients treated for aneurysmal subarachnoid hemorrhage in Eastern Denmark 2017-2019.

OBJECTIVE: The aim of the study was to investigate (1) the 30-day, 3-month, and 12-month cumulative mortalities for patients who underwent aneurysm occlusion, and (2) the causes of death, and (3) the potential risk factors for death. METHODS: All patients who underwent surgical clipping or endovascular treatment of a ruptured aneurysm at Copenhagen University Hospital, during the period of January 1, 2017-December 31, 2019, were included and followed up for 12 months. Data regarding vital status, causes of death, comorbidities, treatment, and clinical presentations on admission was collected. The absolute mortality risk was estimated as a function of time with a 95% confidence interval. The associations between potential risk factors and death were estimated as odds ratios with 95% confidence intervals using logistic regression models. RESULTS: A total of 317 patients were included. The overall cumulative mortalities after 30 days, 3 months, and 12 months were 10.7%, 12.9%, and 16.1%, respectively. The most common cause of death was severe primary hemorrhage (52.9%), followed by infections (15.7%) and rebleeding (11.8%). WFNS score > 3 and Fisher score > 3 on admission, preprocedural hydrocephalus, and preprocedural rebleeding were found significantly associated with higher risk of death. CONCLUSIONS: Considerable mortality was seen. Possible preventable causes accounted for approximately 22% of the deaths. The occurrence of both pre- and postprocedural rebleeding's indicates an opportunity of further improvement of the mortality by (1) further reduction of time from aSAH to aneurysm occlusion and (2) continuous efforts in improving methods of aneurysm occlusion.

[Intraneural ganglioncyst from the "forgotten" knee joint].

Disorders in the proximal tibiofibular joint (PTFJ) is often missed or misinterpreted because healthcare professionals often do not consider it a source of pathology. This is a case report of the symptoms and treatment in a young man with intraneural ganglion cyst originating from the PTFJ. The diagnosis was verified by an MRI scan, since there were few objective findings. Treatment is decompression of the cyst, and to prevent recurrence it is important to disconnect the articular branch.

Unusual Cause of Unilateral Breast Swelling.

A 69-year-old woman with bilateral breast implants and a newly inserted ventriculoperitoneal shunt presented with a 4-day history of swelling of the right breast. There were no signs of infection and blood tests were normal. With the help of ultrasound, mammogram, and computed tomography, the distal catheter of the shunt was found to be surrounding the right breast implant. During surgery the catheter was tunneled away from the breast and reinserted into the peritoneal cavity. She was discharged the next day. Ventriculoperitoneal shunt migration to the breast is a rare complication that can lead to cerebrospinal fluid accumulation and may be avoided by carefully tunneling away from the implant.

[Screening for intracranial aneurysms].

This review states the reasons for considering screening for intracranial aneurysms in Denmark: if patients have two first-degree relatives with intracranial aneurysms, are 30-70 years old, do not have competing disorders, which could significantly shorten life expectancy, and subsequently in patients with autosomal dominant kidney disease and a family history of subarachnoid haemorrhage. MR angiography should be the imaging study of choice, unless contraindicated. Generally, the ethical consequences ought to be considered before carrying out screening.

Incidence of Moyamoya Disease in Denmark: A Population-Based Register Study.

In this first population-based study of moyamoya disease (MMD) in Europe, the authors identified 56 patients with MMD in Denmark during the period 1994-2015 using nationwide registers. The overall incidence was 0.047 per 100,000 person-years, which is about one-tenth that reported in Japan. Otherwise the epidemiological features were comparable: there was a bimodal age distribution with peaks in the age groups 0-9 years and 30-39 years, with twice as many females as males.

[The spinal dural arteriovenous fistula is an underdiagnosed vascular malformation].

The spinal dural arteriovenous fistula is the most common spinal vascular malformation, and it is severely underdiagnosed. The symptoms can mimic those of spinal stenosis. Today, the diagnosis is made by an advantageous combination of MR time-resolved imaging of contrast kinetics and digital subtraction angiography posing low risk to the patient. Treatment is primarily direct microsurgical obliteration. Early treatment is essential, since outcome is dependent on preoperative clinical status.

[Microsurgery in plastic surgery].

The most common indication for free flap surgery is breast reconstruction. Deep inferior epigastric perforator flaps are safe, quick and provide excellent cosmetic results. The reconstruction in head and neck cancer patients is more complex. The aims are preservation of function and appearance. Free flaps are important in traumatology and the timing of intervention can make the difference between amputation and extremity conserving treatment. Due to the improvement in surgical technique failure rates as low as 2% can be seen. Post-operative monitoring is well-established in all microsurgical centres.

[Microsurgery in reanimation, lymphoedema and hand surgery].

Microsurgery is defined as surgery performed with the aid of ocular magnification. In Denmark, this is undertaken by four units. This review describes the history of microsurgery which evolved during the 1960s. Microsurgery in hand surgery is primarily replantation and revascularisation but also peripheral nerve surgery as well as brachial plexus surgery. Lymphoedema is being treated with super microsurgery on an experimental basis. Dynamic reconstruction of facial palsy is performed in a two-stage operation with cross-over nerve graft and a free microvascular muscle flap, typically gracilis.

Intracranial Aneurysms in Sickle-Cell Disease Are Associated With the Hemoglobin SS Genotype But Not With Moyamoya Syndrome.

BACKGROUND AND PURPOSE: Intracranial aneurysms and aneurysmal subarachnoid hemorrhage may occur more frequently in sickle-cell disease (SCD), and this could be related to the sickle genotype and moyamoya syndrome seen in SCD. METHODS: Records from a total of 1002 patients with SCD attending 2 specialized adult hematologic services were retrospectively reviewed. We analyzed data of a cohort of 767 patients attending 1 SCD clinic between 2002 and 2013 and of 235 patients from the other clinic who have had neurovascular imaging between 2007 and 2014. RESULTS: We identified 4 patients in the cohort who had an aneurysmal subarachnoid hemorrhage during 9063 patient-years. The highest incidence rate was seen among women in the age group 30 to 39 years with the hemoglobin SS (HbSS) genotype (440 per 100 000 patient-years). Unruptured intracranial aneurysms were found in 20 of the 324 patients, who had imaging data; the prevalence was significantly higher in patients with HbSS genotype compared with other sickle genotypes with the highest prevalence (15%) observed in women in the age group 30 to 39 years. Fifty-one HbSS patients had a moyamoya vasculopathy, but only 3 of these had concomitant intracranial aneurysms. CONCLUSIONS: Intracranial aneurysms are common in HbSS SCD. There was also a trend toward more common occurrence of aneurysmal subarachnoid hemorrhage in HbSS; women in the age group 30 to 39 years were most at risk. There was no correlation between the occurrence of intracranial aneurysms and moyamoya syndrome.

Subdural haematoma complicating shunting for normal pressure hydrocephalus in the setting of concomitant antiplatelet medication - a report of 11 cases.

OBJECTIVE: To report on the occurrence and management of subdural haematoma after shunt implantation for normal pressure hydrocephalus and to determine the risk of recurrence in the setting of antiplatelet medication. METHODS: From a consecutive series of 80 patients implanted with a cerebrospinal fluid shunt for normal pressure hydrocephalus, records from 11 patients taking antiplatelet drugs, who subsequently had surgery for subdural haematoma were extracted and retrospectively reviewed. RESULTS: Patients were followed up for a mean of 1819 days after shunt implantation. Subdural haematomas occurred at a median of 335 days after shunt implantation - four ipsilateral, five contralateral and two bilateral with respect to the ventricular catheter. Three patients had reoperations done within a week without having resumed antiplatelet medication in the interim. One of them had three further reoperations done before the subdural collection disappeared. Only one patient had a late recurrence almost 11 years after shunt implantation. CONCLUSIONS: Subdural haematoma in the setting of a ventriculoperitoneal implantation for normal pressure hydrocephalus and concomitant antiplatelet medication can be managed along usual lines. Antiplatelet medication can be recommenced in due course with a low risk of recurrence.

[Diagnosis and treatment of cerebral venous sinus thrombosis]. / Diagnose og behandling af cerebral venøs sinustrombose.

Thrombosis of the cerebral sinuses most often affects younger adults. Headache is a common complaint and can be accom­panied by vomiting and papilloedema. The diagnosis rests on magnetic resonance imaging and the treatment consists of heparin or low-molecular weight heparin followed by vitamin K antagonists for three months or more. In fulminant cases local thrombolysis is administered, while symptomatic treatment for increased intracranial pressure is given. In retrospective analyses this approach has been associated with a good outcome ­ even in cases treated by decompressive craniectomy.

Operative treatment with nerve repair can restore function in patients with traction injuries in the brachial plexus.

INTRODUCTION: Brachial plexus injuries are usually a result of road traffic accidents and a cause of severe disability that typically affects young adult males. In 2010, a national centre was established for referral of these cases from Danish trauma centres. In this paper, we report on our surgical activity and reflect on the role for this new national centre. METHODS: Records from all our operated patients were reviewed retrospectively. For outcome analysis, we focused on patients who had sustained traction injuries with a surgical follow-up exceeding one year. We used either nerve grafting or transfers for nerve repairs based on the pattern of nerve injury seen intraoperatively. RESULTS: Overall, 24 patients were operated, and 12 patients were included in the outcome analysis. The six patients with upper brachial plexus palsies all regained shoulder function and useful elbow flexion. Of the six patients with complete brachial plexus palsies, four regained shoulder function, while only one regained useful elbow function, and this was after nerve transfers. CONCLUSION: Operative treatment provides satisfactory results in patients with upper brachial plexus palsies, while improvement is warranted in patients with complete brachial plexus palsies. Our data suggest that nerve transfers may result in a better functional outcome than nerve grafting. We believe that there is a role for a Danish centre for the treatment of these injuries. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Aspirin is associated with an increased risk of subdural hematoma in normal-pressure hydrocephalus patients following shunt implantation.

OBJECT: In this paper the authors investigate whether shunt-treated patients with normal-pressure hydrocephalus receiving aspirin therapy are at increased risk of developing subdural hematoma (SDH). METHODS: Records from 80 consecutive patients who had undergone implantation of a cerebrospinal fluid shunt for the treatment of normal-pressure hydrocephalus were retrospectively reviewed. RESULTS: Eleven cases of symptomatic SDH occurred, all among patients receiving aspirin or clopidogrel. The 5-year survival estimate was 0.3 (p < 0.0001) for users of aspirin and the hazard ratio was 12.8 (95% CI 3.1-53). CONCLUSIONS: Patients on an aspirin therapy regimen have a markedly increased risk of SDH after a shunt has been implanted for the treatment of normal-pressure hydrocephalus. Users of clopidogrel may have an even greater risk.

[Diagnosis and treatment of cerebral venous sinus thrombosis]. / Diagnose og behandling af cerebral venøs sinustrombose.

Thrombosis of the cerebral sinuses most often affects younger adults. Headache is a common complaint and can be accompanied by vomiting and papilloedema. The diagnosis rests on magnetic resonance imaging and the treatment consists of heparin or low-molecular weight heparin followed by vitamin K antagonists for three months or more. In fulminant cases local thrombolysis is administered, while symptomatic treatment for increased intracranial pressure is given. In retrospective analyses this approach has been associated with a good outcome - even in cases treated by decompressive craniectomy.

Good clinical outcome after combined endovascular and neurosurgical treatment of cerebral venous sinus thrombosis.

INTRODUCTION: A subgroup of patients suffering from cerebral venous sinus thrombosis (CVST) has a poor prognosis with standard anticoagulant treatment alone. Over a five-year period, we treated nine patients with aggressive endovascular therapy and neurosurgical/neurointensive treatment. In this study, the effect of this treatment is evaluated. MATERIAL AND METHODS: A retrospective analysis of electronic patient files and data was performed. RESULTS: All treated patients had partial or complete recanalization of the affected sinus after endovascular treatment. In three patients, a decompressive craniectomy was performed due to elevated intracranial pressure. Eight patients out of nine achieved a good outcome at follow-up (modified Rankin Scale 0-2). One patient died. No patients experienced recurrence of CVST. CONCLUSION: Aggressive combined endovascular and neurosurgical treatment of patients with severe CVST is associated with a good clinical outcome in the cases in which the patient's clinical condition deteriorates despite standard anticoagulation therapy. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

[Surgical treatment of thoracic outlet syndrome]. / Operativ behandling af thoracic outlet syndrome.

We present three cases with longstanding true neurogenic thoracic outlet syndrome. All patients had aching pain in the shoulder, arm and ulnar border of the hand. On examination, we found atrophy of the hand muscles. Electromyography revealed signs of compromised function of the inferior trunk of the brachial plexus. At surgery, we found and severed a fibrous band that compressed the inferior trunk. Postoperatively, the pain subsided and fine hand movements improved. One patient had no cervical rib, however, in the two other cases we found rudimentary cervical ribs. Magnetic resonance imaging was normal in all cases.

Multimodality treatment approach in children with cerebral arteriovenous malformation--a survey in the Danish population.

INTRODUCTION: Arteriovenous malformations are not a common disease in childhood. A national survey was conducted to reveal the Danish incidence of the disease, presentation, choice of treatment, and outcome. MATERIALS AND METHODS: Forty patients were admitted to any of the five neurosurgical centers during the years 2000-2008. A retrospective survey was conducted using hospital records. RESULTS: Twenty-three males and 17 females presented with AVM with a mean age of 11.3 (1 month-18 years). The incidence was found to be 0.4/100,000. Early fatal outcome was seen in three patients. Treatment was surgery (12), endovascular (5), radiosurgery (6), or a combination of the above (10). Four patients were treated conservatively. Complications of the treatment were seen in 27%. Occlusion rate was 74%. Good or excellent outcome was seen in 65%. CONCLUSION: A national survey may give a lower rate of success than in the specialized centers accepting patients more eligible for treatment. Still, the low number of children could call for centralization and collaboration in this population.