Efficacy of surgical treatment in patients with trigeminal neuralgia secondary to multiple sclerosis: A prospective study of 18 cases with evaluation of outcome and complications by independent evaluators.

INTRODUCTION: Medical treatments for trigeminal neuralgia secondary to multiple sclerosis have low efficacy and tolerability and scientific evidence regarding efficacy of neurosurgery is scarce. We aimed to assess neurosurgical outcome and complications in trigeminal neuralgia secondary to multiple sclerosis. METHODS: Patients with trigeminal neuralgia secondary to multiple sclerosis who underwent microvascular decompression, glycerol rhizolysis or balloon compression were prospectively and consecutively included from 2012 to 2019. Preoperatively, we systematically obtained clinical characteristics and performed a 3.0 Tesla MRI. Follow-up at three, six and 12 months was performed by independent assessors. RESULTS: We included 18 patients. Of the seven patients treated with microvascular decompression, two patients (29%) had an excellent outcome (both had neurovascular contact with morphological changes), three patients (43%) had a good outcome, one patient (14%) had treatment failure and one patient (14%) had a fatal outcome. Three patients (43%) had major complications. Of 11 patients treated with percutaneous procedures, seven patients (64%) had an excellent or good outcome with major complications in three patients (27%). CONCLUSION: Percutaneous procedures provided acceptable outcome and complication rates and should be offered to the majority of patients with trigeminal neuralgia secondary to multiple sclerosis who need surgery. Microvascular decompression is less effective and has a higher complication rate in trigeminal neuralgia secondary to multiple sclerosis compared to microvascular decompression in classical and idiopathic trigeminal neuralgia. Microvascular decompression should only be considered in patients with trigeminal neuralgia secondary to multiple sclerosis when they have neurovascular contact with morphological changes.

Microvascular decompression in trigeminal neuralgia - a prospective study of 115 patients.

BACKGROUND: Trigeminal neuralgia is a severe facial pain disorder. Microvascular decompression is first choice surgical treatment of patients with classical TN. There exist few prospective studies with an independent evaluation of efficacy and complications after MVD. OBJECTIVES: We aimed to assess outcome and complications after microvascular decompression from our center. METHODS: We prospectively recorded clinical characteristics, outcome, and complications from consecutive patients with either classical or idiopathic (only patients with a neurovascular contact) trigeminal neuralgia undergoing microvascular decompression. Neurovascular contact was evaluated by 3.0 Tesla MRI. Patients were assessed before and 3, 6, 12, and 24 months after surgery by independent assessors. RESULTS: Of 115 included patients, 86% had a clinically significant outcome (i.e., BNI I - BNI IIIb). There was a significant association between an excellent surgical outcome and the male sex (OR 4.9 (CI 1.9-12.8), p = 0.001) and neurovascular contact with morphological changes (OR 2.5 (CI 1.1-6.0), p = 0.036). Significantly more women (12/62 = 19%) than men (2/53 = 4%) had a failed outcome, p = 0.019. The most frequent major complications were permanent hearing impairment (10%), permanent severe hypoesthesia (7%), permanent ataxia (7%), and stroke (6%). Most patients (94%) recommend surgery to others. CONCLUSION: Microvascular decompression is an effective treatment for classical and idiopathic (only patients with a neurovascular contact) trigeminal neuralgia with a high chance of a long-lasting effect. The chance of an excellent outcome was highest in men and in patients with classical trigeminal neuralgia. Complications are relatively frequent warranting thorough patient evaluation and information preoperatively. TRIAL REGISTRATION: Clinical. TRIALS: gov registration no. NCT04445766 .

Endocrine Function after Transsphenoidal Surgery in Patients with Non-Functioning Pituitary Adenomas: A Systematic Review and Meta-Analysis.

INTRODUCTION: Transsphenoidal surgery is the current treatment for mass reduction in patients with non-functional pituitary adenomas (NFPAs). The surgical procedure may deteriorate or recover pituitary endocrine function. The aim of this study was to systematically assess the benefits and harms of transsphenoidal surgery on pituitary endocrine function in patients with NFPAs. METHODS: This systematic review and meta-analysis was registered with PROSPERO (registration No. CRD42020210853). We searched Pubmed and EMBASE for studies reporting on pituitary function before and after transsphenoidal surgery in patients with NFPAs having a minimum follow-up of 1 month. The prespecified primary outcomes were the proportions of patients with improved or deteriorated pituitary function after surgery reported as weighted mean using random effects meta-analysis or in case of considerable heterogeneity, i.e., I2 ≥ 75%, as a range of reported proportions. Subgroup analyses were planned for the primary outcomes on study level. RESULTS: Of the 6,597 identified records, 24 studies enrolling 3,816 participants were eligible for assessment. Twenty-three studies were judged to have serious or critical risk of bias. The range of proportions of patients with recovery of at least one pituitary axis was between 10.2% and 97.7% (I2 = 93%), while the range of proportions of patients experiencing loss of at least one axis after pituitary surgery was between 0.0% and 36.6% (I2 = 91%). None of the a priori planned subgroup analyses explained the observed heterogeneity associated with deterioration of pituitary function after surgery, and the proportion of patients may be underestimated due to publication bias. CONCLUSIONS: The current systematic review finds that the endocrine effect of pituitary surgery is unclear both in terms of the chance of recovery and in terms of the risk of pituitary failure and hypopituitarism should be considered only a relative indication for surgery. However, the range of effects does include potentially clinically relevant rates of pituitary recovery calling for more systematic collection of data in future studies.

Long-term postoperative health-related quality of life in patients with subfrontal meningiomas.

OBJECTIVE: Subfrontal meningiomas grow insidiously in areas with high cerebral compliance and a relative scarcity of eloquent function. Symptoms develop progressively, are nonspecific, and include anosmia, changes in personality and cognition, depressive symptoms, headaches, visual disturbances, and seizures. Patients with subfrontal meningiomas carry the highest risk of developing psychological symptoms, which makes patient-reported outcome in terms of long-term health-related quality of life (HRQOL), anxiety, and depression of particular importance. This observational study aimed to investigate long-term HRQOL, anxiety, and depression in patients with subfrontal meningiomas who underwent a bifrontal craniotomy (subfrontal) approach between 2008 and 2017 at a single tertiary center. Correlations between preoperative, perioperative, and postoperative factors and HRQOL, anxiety, and depression were analyzed to detect prognostic factors. METHODS: Seventy-seven consecutive patients who underwent operations at Rigshospitalet, Copenhagen, Denmark, between 2008 and 2017 were retrospectively analyzed. Patients were prospectively invited to respond to the Functional Assessment of Cancer Therapy-General, Functional Assessment of Cancer Therapy-Brain, and Hospital Anxiety and Depression Scale. Information regarding preoperative, perioperative, and postoperative factors were collected from the patients' medical records and scans. RESULTS: Patients with subfrontal meningiomas exhibited better HRQOL and lower levels of anxiety and depression than general populations and other meningioma and glioblastoma cohorts. The only statistically significant prognostic factors for long-term HRQOL were number of symptoms at diagnosis and whether patients were discharged home or to a local hospital postoperatively. Tumor and peritumoral brain edema volumes were not prognostic factors. CONCLUSIONS: Patients with subfrontal meningiomas exhibited better long-term postoperative HRQOL and were less likely to have anxiety or depression than the reference populations. This information on long-term prognosis is very valuable for patients, next of kin, and neurosurgeons and has not been previously studied in detail.

Pituitary function after transsphenoidal surgery including measurement of basal morning cortisol as predictor of adrenal insufficiency.

INTRODUCTION: Patients with pituitary adenomas undergoing transsphenoidal surgery require pre- and post-surgery examination of pituitary hormones. There is currently no consensus on how to evaluate the adrenal axis post-surgery. The aims of this study were to investigate factors that may predict postoperative adrenal insufficiency (AI) and to investigate the overall effect of transsphenoidal surgery on pituitary function. METHODS: One hundred and forty-three consecutive patients who had undergone transsphenoidal surgery for pituitary adenomas were included. Data on tumour size, pituitary function pre-surgery, plasma basal cortisol measured within 48 h post-surgery and pituitary function 6 months post-surgery were collected. Patients with AI prior to surgery, perioperative glucocorticoid treatment, Cushing's disease and no re-evaluation after 1 month were excluded (n = 93) in the basal cortisol analysis. RESULTS: Low plasma basal cortisol post-surgery, tumour size and previous pituitary surgery were predictors of AI (all P < 0.05). A basal cortisol cut-off concentration of 300 nmol/L predicted AI 6 months post-surgery with sensitivity and negative predictive value of 100%, specificity of 81% and positive predictive value of 25%. New gonadal, thyroid and adrenal axis insufficiencies accounted for 2, 10 and 10%, respectively. The corresponding recovery rates were 17, 7 and 24%, respectively. CONCLUSION: Transsphenoidal surgery had an overall beneficial effect on pituitary endocrine function. Low basal plasma cortisol measured within 48 h after surgery, tumour size and previous surgery were identified as risk factors for AI. Measurement of basal cortisol post-surgery may help to identify patients at risk of developing AI.

Face-to-face four hand technique in vestibular schwannoma surgery: results from 256 Danish patients with larger tumors.

BACKGROUND: The objective of this study was to investigate the clinical outcome after microsurgical treatment of vestibular schwannomas using face-to-face four hand technique in 256 Danish patients treated in the Department of Neurosurgery at the Copenhagen University Hospital from 2009 to 2018. METHODS: Data were retrospectively collected from patient records. RESULTS: The mean tumor size was 30.6 mm and approximately 46% of the patients had tumors >30 mm. In around 1/3 of the patients a retrosigmoid approach was used and in 2/3 a translabyrinthine. In 50% of the patients, the tumor was completely removed, and in 38%, only smaller remnants were left to preserve facial function. The median operative time was approximately 2.5 h for retrosigmoid approach, and for translabyrinthine approach, it was around 3.5 h. One year after surgery, 84% of the patients had a good facial nerve function (House-Brackmann grade 1-2). In tumors ≤ 30 mm approximately 89% preserved good facial function, whereas this was only the case for around 78% of the patients with tumors > 30 mm. In 60% of the patients who had poor facial nerve function at hospital discharge, the function improved to good facial function within the 1 year follow-up period. Four patients died within 30 days after surgery, and 6% underwent reoperation for cerebrospinal fluid leakage. CONCLUSION: Surgery for vestibular schwannomas using face-to-face four hand technique may reduce operative time and can be performed with lower risk and excellent facial nerve outcome. The risk of surgery increases with increasing tumor size.

[Bicycle helmet prevents brain damage]. / Cykelhjelm forebygger hjerneskade

The relatively small and declining incidence of traffic-related death accidents in Scandinavia is a result of targeted infra-structural measures and policies. Bicycle accidents represent a large fraction of the total traffic accident load and are often underreported in statistics. We argue that there is scientific evidence of bicycle helmet efficacy with a protective effect on serious brain injury of 63-88%. There is no consensus in favour of the effect of bicycle helmet legislation, although a Cochrane review from 2007 showed a significant reduction of injuries among children.

[Guidelines for the initial management of adult patients with minimal to moderate head injury].

Mild to moderate head injuries are very common. Often diagnostics and symptomatic treatment is relatively uncomplicated and the clinical challenge is identification of patients who will later develop a potentially life-threatening complication. Based on updated knowledge, the Scandinavian Neurotrauma Committee has published new guidelines for the initial management of adult patients with minimal to moderate head injury. These categorize patients into five risk groups that should be handled by three different strategies: admission for observation, computed tomography or assessment of the biomarker S100B.

Association of the NOS3 intron-4 VNTR polymorphism with aneurysmal subarachnoid hemorrhage.

OBJECT: The nitric oxide system has been linked to the pathogenesis of aneurysmal subarachnoid hemorrhage (SAH). The authors performed a case-control study to investigate the association between SAH and common genetic variants within the endothelial nitric oxide synthase gene (NOS3). METHODS: Three hundred thirty-three Caucasian SAH patients and 498 controls were genotyped for the -922A > G (rs 1800779), -786T > C (rs2070744), and 894G > T (rs1799983) single nucleotide polymorphisms and the intron-4 27-bp variable number of tandem repeats polymorphism (27-bp-VNTR). RESULTS: The b/b (5 repeats) genotype of the 27-bp-VNTR was overrepresented in cases (77%) versus controls (69%) (p = 0.02). In male patients the b/b genotype was found in 85% compared with 67% in male controls, whereas in women, the frequencies were 73% and 72%, respectively. This corresponds to an odds ratio of 2.8 (95% CI 1.5-5.6, p = 0.0005) for SAH in men with the b/b genotype versus men with a/b or a/a. In women, no such association was found (OR 1.1, 95% CI 0.7-1.6, p = 0.76). Stepwise logistic regression including arterial hypertension, smoking, sex, and age with interactions yielded similar effect estimates of the 27-bp-VNTR. Haplotype analysis revealed that no single haplotype containing the b-allele was responsible for the observed genotype effect. CONCLUSIONS: The authors' results suggest that the NOS3 27-bp-VNTR b/b genotype independent of other risk factors act in concert with male sex to substantially increase risk of SAH. This effect is not mediated by any single NOS3 haplotype.

Accuracy of tunnelated vs. bolt-connected external ventricular drains.

BACKGROUND: Ventriculostomy is one of the most common neurosurgical procedures and an important tool in the treatment and monitoring of elevated intracranial pressure. Low accuracy has frequently been reported in the literature with risk of drain misplacement over 20% and with a need for reinsertion in up to 40%. As an alternative to the tunnelated EVD technique we often use a bolt-connected EVD. The aim of the present study was to investigate whether the use of bolt-connected EVDs would lead to higher accuracy, fewer passes and reoperations due to poor placement compared to tunnelated EVDs. PATIENTS AND METHODS: We retrospectively identified all patients who received an EVD from January 1st 2008 to December 31st 2010. Postoperative images were evaluated for anatomical placement of the EVD-tip, distance from tip to optimal placement and were categorized as optimal, suboptimal and undesired. Patient files were evaluated for EVD technique, number of passes and postoperative complications and handling. RESULTS: 147 patients with 154 separate EVDs met the inclusion criteria. We found a statistical significant higher accuracy in the bolt-group compared to the tunnelated-group (p=0.023). Eleven patients were reoperated following ventriculostomy and we found a statistical significant 11.9% reduction in reoperations due to poor placement in the bolt-group (p=0.006). CONCLUSIONS: We have showed in this study that by using a bolt-connected EVD and maintaining the freehanded technique we can significantly increase precision and decrease the number of reoperations due to poor placement.

First clinical experience with intranasal cooling for hyperthermia in brain-injured patients.

INTRODUCTION: Hyperthermia is common in brain-injured patients and associated with a worse outcome. As brain rather than body temperature reduction, theoretically, is the most important in cerebral protection, there is logic in targeting cooling at the brain. Selective brain cooling can, in theory, be obtained by cooling the skull or by heat loss from the upper airways. In this preliminary safety and efficacy study, we report clinical data from brain-injured patients who because of hyperthermia were treated with intranasal cooling. METHODS: Nine intubated brain-injured patients with hyperthermia were treated using a prototype intranasal balloon system perfused with cold saline. Temperature in the cerebrum, esophagus, and bladder was monitored together with intracranial pressure. RESULTS: In only two of nine patients, normothermia was reached in the esophagus and in only four of nine patients it was reached in the bladder. When normothermia was reached, the time to normothermia was delayed. In the brain, normothermia was reached in two of five patients after approximately 72 h. Median temperature curves from the first 72 h of cooling showed that normothermia was not reached in any of the three compartments. The temperature in the brain and bladder were on average 0.6 and 0.5 °C higher than in the esophagus. ICP increased with increasing brain temperature. We found no signs of clinical important injury to the nasal mucosa from the cold saline or pressure in the balloons. CONCLUSION: In brain-injured patients with hyperthermia, cooling with a prototype intranasal balloon system was clinically inadequate as the effect was delayed and not brain selective.

Outcome after translabyrinthine surgery for vestibular schwannomas: report on 1244 patients.

The objective of this article is to study the outcome after translabyrinthine surgery for vestibular schwannomas, with special focus on the facial nerve function. The study design is a case series from a national centralized database and it is set in two University Hospitals in Denmark. Participants were 1244 patients who underwent translabyrinthine surgery during a period of 33 years from 1976 to 2009. Main outcome measures were tumor removal, intraoperative facial nerve preservation, complications, and postoperative facial nerve function. In 84% patients, the tumor was totally resected and in ~85% the nerve was intact during surgery. During 33 years, 12 patients died from complications to surgery and ~14% had cerebrospinal fluid leakage. Before surgery, 74 patients had facial paresis and 46% of these improved after surgery. In patients with normal facial function, overall ~70% had a good outcome (House-Brackmann grade 1 or 2). The chance of a good outcome was related to tumor size with a higher the chance the smaller the tumor, but not to the degree of tumor removal. In ~78% of the patients with facial paresis at discharge the paresis improved over time, in ~42% from a poor to a good function. The translabyrinthine approach is generally efficient in tumor control and with satisfactory facial nerve outcome. With larger tumors the risk of a poor outcome is evident and more data on patients managed with alternative strategies are warranted.

Common variants of the ACE gene and aneurysmal subarachnoid hemorrhage in a Danish population: a case-control study.

OBJECTIVE: The intron 16 insertion/deletion (I/D) polymorphism in the angiotensin-converting enzyme (ACE) gene has been associated with rupture of intracranial aneurysms, but the effect of haplotypes within ACE has not been studied. This study investigated whether ACE haplotypes including the I/D polymorphism are associated with aneurysmal subarachnoid hemorrhage. METHODS: The hypothesis was tested with a case-control design in 176 patients with aneurysmal subarachnoid hemorrhage and with 498 hospital controls. Through the pairwise tagging principle, single nucleotide polymorphisms (rs4291 A/T, rs4295 C/G, rs4305 C/T, rs4311 C/T, rs4331 T/C, rs4343 C/T) in the ACE gene were genotyped along with the I/D polymorphism. Haplotypes were estimated using the PHASE software. RESULTS: Fifty-five haplotypes were identified with 3 of these having a frequency above 5%: ACCCCIT (41.6±0.4%), TGTTTDC (32.1±0.5%), and ACCTTDC (9.5±0.2%). No significant difference in distribution of alleles, genotypes, haplotypes, or haplotype pairs between the 2 populations was found. Specifically, we could not reproduce previously reported associations between the ACE I genotype and intracranial aneurysms. When subdivided into groups of aneurysm location, we found a trend toward an association between homozygotes of the ACCCCIT haplotype and middle cerebral artery aneurysms, odds ratio=2.9 (1.0 to 7.6), which however proved insignificant (P=0.22) after correction for multiple testing. CONCLUSION: In this Danish population, ACE haplotypes and the I/D polymorphism did not contribute significantly to the overall risk of intracranial aneurysm rupture. Larger studies are needed to delineate the association between ACE polymorphism and ruptured middle cerebral artery aneurysms.

Anterior cervical discectomy with or without fusion with ray titanium cage: a prospective randomized clinical study.

STUDY DESIGN: A prospective randomized clinical study. OBJECTIVE: To compare 2 surgical methods in the treatment of cervical radiculopathy caused by hard or soft disc herniation; namely, simple discectomy versus discectomy with an additional interbody fusion with a Ray titanium cage. SUMMARY OF BACKGROUND DATA: Although an interbody fusion after anterior decompressive surgery for hard or soft disc herniation is widely accepted, there is no scientific evidence that convincingly demonstrates that insertion of graft material for interbody fusion is necessary after discectomy and decompression of the nervous elements have been performed. To date, no randomized studies have compared simple discectomy with discectomy followed by an interbody fusion with a titanium cage. METHODS: Eighty-six patients with symptoms of nerve root compression at 1 level were randomly allocated to either discectomy followed by fusion with a Ray titanium cage (40 patients) or to discectomy alone (46 patients). Clinical and radiologic follow-up was performed 3, 12, and 24 months after surgery. RESULTS: There was no statistically significant difference between the 2 groups concerning self-reported satisfaction or severity of pain in the neck and arm. Two years after the operation, 86.1% of the patients treated with cage stated a good outcome versus 76.7% in the discectomy group (P = 0.44). The rate of fusion was 83.3% in the cage group versus 81.0% in the discectomy group (P = 0.30). Furthermore, after 2 years, also the rates of new adjacent disc degeneration or spondylosis were the same in both groups. CONCLUSION: This study showed no statistically significant difference between simple discectomy and discectomy followed by interbody fusion with a titanium cage in the surgical treatment of cervical radiculopathy caused by disc herniation.

Nonvestibular schwannoma tumors in the cerebellopontine angle: a structured approach and management guidelines.

The most common cerebellopontine angle (CPA) tumor is a vestibular schwannoma, but one in five CPA tumors are not vestibular schwannomas. These tumors may require different management strategies. Compared with vestibular schwannomas, symptoms and signs from cranial nerve VIII are less frequent: other cranial nerve and cerebellar symptoms and signs predominate in patients with these less common CPA tumors. Computed tomography and magnetic resonance imaging often show features leading to the correct diagnosis. Treatment most often includes surgery, but a policy of observation or subtotal resection is often wiser. This review provides a structured approach to the diagnosis of nonvestibular schwannoma CPA lesions and also management guidelines.

Erythropoietin improves place learning in fimbria-fornix-transected rats and modifies the search pattern of normal rats.

The acquisition of a water-maze-based allocentric place learning task was studied in four groups of rats: two groups subjected to bilateral transections of the fimbria-fornix and two groups undergoing a sham control operation. At the moment of surgery all animals were given one systemic (intraperitoneal) injection of either human recombinant erythropoietin (EPO) (at a dosage of 5000 IU/kg body weight), given to one of the fimbria-fornix-transected groups and one of the sham-operated groups, or vehicle (saline), given to the two remaining groups. The 25-day task acquisition period (one session/day) began 6 or 7 days after the day of surgery. The fimbria-fornix-transected and saline-injected group exhibited a pronounced and long-lasting impairment of task acquisition. In contrast, the fimbria-fornix-transected and EPO-treated group demonstrated a less pronounced and more transient lesion-associated impairment. The two sham-operated groups did not differ with respect to the proficiency of task acquisition. But administration of EPO to intact animals caused a significant modification of swim patterns-apparently reflecting a somewhat modified strategy of task solution. It is concluded that systemic administration of EPO significantly improves the posttraumatic functional recovery of the presently studied place learning task after transections of the fimbria-fornix. Additionally, administration of EPO influences the strategy, although not quality, of task solution in normal (sham-operated) rats.

Erythropoietin in the cerebrospinal fluid of patients with aneurysmal subarachnoid haemorrhage originates from the brain.

Recent years' research has revealed a specific, neuroprotective erythropoietin (EPO) system in the central nervous system (CNS) that is upregulated by hypoxia. The presence and dynamics of EPO in the cerebrospinal fluid (CSF) of patients with subarachnoid haemorrhage (SAH) has not been investigated. We collected a total of 83 corresponding serum and CSF samples from 18 patients with aneurysmal SAH and compared the concentrations of EPO with those of blood-derived markers of blood-brain barrier function (albumin, transferrin, alpha(2)-macroglobulin) and with those of proteins with well-known CNS synthesis (prealbumin, apolipoprotein E). The EPO concentration in CSF was 0.93 (0.82) mU/ml (median and inter-quartile range). Nine patients presented CSF-EPO values above 1 mU/ml. CSF levels did not correlate with serum concentrations and were independent of blood-brain barrier integrity suggesting a synthesis in CNS rather than a blood-derived origin. Furthermore, the median CSF:serum ratio (Q(protein)) of EPO was similar to those of prealbumin and apolipoprotein E, and much higher than those of albumin, transferrin and alpha(2)-macroglobulin. When the Q(protein) of all proteins were plotted against Q(albumin), EPO showed dynamics similar to CNS-derived proteins. Our data indicate that EPO in the CSF of patients with aneurysmal SAH originates mainly from the CNS.