Surgical resection versus watchful waiting in low-grade gliomas.

BACKGROUND: Infiltrating low-grade gliomas (LGG; WHO grade 2) typically present with seizures in young adults. LGGs grow continuously and usually transform to higher grade of malignancy, eventually causing progressive disability and premature death. The effect of up-front surgery has been controversial and the impact of molecular biology on the effect of surgery is unknown. We now present long-term results of upfront surgical resection compared with watchful waiting in light of recently established molecular markers. MATERIALS AND METHODS: Population-based parallel cohorts were followed from two Norwegian university hospitals with different surgical treatment strategies and defined geographical catchment regions. In region A watchful waiting was favored while early resection was favored in region B. Thus, the treatment strategy in individual patients depended on their residential address. The inclusion criteria were histopathological diagnosis of supratentorial LGG from 1998 through 2009 in patients 18 years or older. Follow-up ended 1 January 2016. Making regional comparisons, the primary end-point was overall survival. RESULTS: A total of 153 patients (66 from region A, 87 from region B) were included. Early resection was carried out in 19 (29%) patients in region A compared with 75 (86%) patients in region B. Overall survival was 5.8 years (95% CI 4.5-7.2) in region A compared with 14.4 years (95% CI 10.4-18.5) in region B (P < 0.01). The effect of surgical strategy remained after adjustment for molecular markers (P = 0.001). CONCLUSION: In parallel population-based cohorts of LGGs, early surgical resection resulted in a clinical relevant survival benefit. The effect on survival persisted after adjustment for molecular markers.

Introduction of endovascular embolization for intracranial aneurysms in a low-volume institution.

BACKGROUND: Studies indicate a relationship between hospital caseload and health outcomes after both surgical and endovascular repair of intracranial aneurysms. PURPOSE: To evaluate outcomes after introduction of endovascular embolization for intracranial aneurysms in a low-volume regional university hospital. MATERIAL AND METHODS: Retrospective study of 243 consecutive patients treated for 284 intracranial aneurysms with endovascular embolization or surgical clipping from 2000 to 2006 at the University Hospital of North Norway. Postoperative complications were registered. The Glasgow Outcome Scale (GOS) was used for assessment of outcome. RESULTS: The mean annual number of procedures was 39 (microsurgery 23, embolization 16). Seventy-four percent of patients with ruptured aneurysms and all patients with unruptured aneurysms had a favorable outcome (GOS 4 or 5) at 1 year follow-up. Patients with subarachnoid hemorrhage were more likely to experience postoperative complications than patients treated for unruptured aneurysms (42% versus 8% of the patients, P<0.01). The immediate incomplete occlusion rate (Raymond II-III) in the initial embolization procedure was 29%. Ten endovascularly treated patients and one surgically treated patient required retreatments due to residual aneurysm or neck remnants. CONCLUSION: The present study indicates that acceptable outcome from aneurysm treatment, both endovascular and microsurgical, is possible in a low-volume institution.

When should an epidural blood patch be performed in postlumbar puncture headache? A theoretical approach based on a cohort of 79 patients.

The aim of the present study was to decide on which day in the course of postlumbar puncture headache (PPH) an epidural blood patch (EBP) should be performed to minimize suffering. A cohort of 79 patients (64 female, 15 male) was followed prospectively for 14 days and the consequences of performing an EBP on different days were studied. If no EBP was performed, the patients would accumulate 141 days with PPH5 (bedridden most of the day), 216 days with PPH4-5 (bedridden more than half the day), and 293 days with PPH3-5 (bedridden half the day or more). If these patients were patched on day 2, 3 or 4 after an initial observation of the PPH grade on day 1, the expected suffering was substantially reduced, and the more the earlier in the course the EBP was performed. If the strategy was to treat only patients with PPH5 with an expected 90% success rate, the reduction compared with no treatment was 50% if treated on day 2, 37% if treated on day 3, and 29% if treated on day 4. The corresponding figures for treating patients with PPH4-5 was a 51, 44 and 29% reduction, and for PPH3-5 the reduction was 62, 49 and 35%, respectively. Irrespective of strategy, the expected reduction of suffering in the cohort was greatest when the EBP was performed early in the course of PPH. It is suggested that the decision to perform an EBP should be made at an early stage and offered to patients who have to lie in bed for more than half a day despite conservative treatment.

Results of surgery for aneurysmal subarachnoid haemorrhage in northern Norway: a retrospective study with special focus on timing of surgery in a rural area.

OBJECTIVES: This study reports data on time consumption before aneurysm surgery and the results of treatment in northern Norway. MATERIAL AND METHODS: A total of 279 cases were identified and included in our analysis of time span from bleeding to arrival at our department. Fifty-one patients were treated conservatively, either because of bad clinical condition or because angiography revealed no aneurysm. The remaining 228 patients were operated and included in our analysis of outcome after early aneurysm surgery. RESULTS: Among all 279 patients with aneurysmal subarachnoid haemorrhage (SAH), median time from ictus to arrival at the university hospital was 1 (0-30) day. Forty-one per cent arrived at the day of bleeding and 86% within the first 3 days after bleeding. Among the 228 patients who underwent surgical aneurysm repair, median time from bleeding to operation was 2 (0-33) days. Early aneurysm surgery (< 72 h) was performed in 146 patients (64%). Fifty patients (22%) underwent intermediate surgery (days 4-10) and 32 patients (14%) were operated later (day 11 or later). A significant association was found between Hunt and Hess (HH) grade and Glasgow Outcome Scale (GOS) score (P < 0.001). CONCLUSIONS: Most patients suffering aneurysmal SAH in northern Norway undergo early aneurysm surgery and the outcome is comparable with that obtained in other Scandinavian centres. Initial Hunt and Hess grade is a major determinant for outcome in aneurysmal subarachnoid haemorrhage.

A four-year experience with a stereotactic computer in a small neurosurgical department.

BACKGROUND: A stereotactic computer with a mechanical, proprioceptive arm was acquired in 1996. The aim of this report is to review the 4-year experience with frameless, computer-aided stereotaxy in a small neurosurgical department. METHODS: From 1996 to 1999 the computer was used for 121 operations. The surgical files from these operations were either retrospectively or prospectively registered. Patient and computer data, type of surgery, complications and number of surgeons were noted. The versatility, benefits, and drawbacks of the stereotactic computer were evalued based on these findings. RESULTS: Seven surgeons performed a total of 121 computer-assisted operations. The procedures consisted of 63 stereotactic tissue samplings, 44 craniotomies, 7 abscess punctures and 3 insertions of intracerebral devices (shunts and microelectrodes). Technical complications were seen in 6 cases (4.8%), but this did not affect the surgical outcome. CONCLUSIONS: The stereotactic computer has enabled the department to broaden its spectrum of procedures. High precision surgery such as stereotactic biopsy has been possible without the use of a framebased system. The results indicate that even small neurosurgical units with a limited number of procedures can safely and successfully implement neuronavigation in daily routines.

The importance of sex, age, needle size, height and body mass index in post-lumbar puncture headache.

In this prospective study 37% of 239 patients developed a post-lumbar puncture headache (PPH) after a diagnostic lumbar puncture. PPH was more prevalent in females than males (46% vs. 21%; P = 0.0003) as were the severest form of PPH (64% vs. 23%; P = 0.02) and nausea (74% vs. 39%; P = 0.01) in those who developed PPH. Females scored their pain in the upright position more severe on a 100-mm visual analogue scale than males (median 60 mm vs. 47.5 mm; P = 0.02). The frequency of PPH was higher with the use of a 20-gauge compared with a 22-gauge needle in all patients (50% vs. 26%; P = 0.0002) and in females (57% vs. 36%; P = 0.02) and males (38% vs. 10%; P = 0.004), separately. Neither age, weight, height, nor body mass index (BMI), influenced the prevalence of PPH, but tinnitus was more prevalent in tall compared with smaller patients (53% vs. 17%; P = 0.02). Old age was associated with a long median pain delay upon rising, and also, small patients tended to report a longer median pain delay than tall patients. The pain intensity changed more slowly upon rising and reclining in patients with a high BMI than in those with a lower BMI (median 60 s vs. 12 s; P = 0.02). The results concerning height, BMI and needle size might be anticipated according to the leakage theory. In a multivariate analysis sex (P = 0.0003) and needle size (P = 0.0002) were related to the development of PPH on a statistically significant level. Furthermore, the pain severity was positively related to female sex (P = 0.03) and young age (P = 0.03). The pain delay increased with age (P = 0.008) and the pain decrease time increased with an increasing BMI (P = 0.04).

Recovery of function in adjacent nerve roots after surgery for lumbar disc herniation: use of quantitative sensory testing in the exploration of different populations of nerve fibers.

Results from experimental and clinical studies indicate that adjacent nerve roots may be affected in sciatica because of lumbar disc hemiation. This may be caused by proinflammatory mediators in the epidural space being transported into nerve roots at the same or neighboring lumbar segments. The aim of the present study was to investigate the recovery of function of sensory nerve fibers in the adjacent noncompressed nerve roots. Thirty-nine patients undergoing microdiscectomy for monoradiculopathy were investigated with quantitative sensory testing immediately before surgery, and at 6 weeks, 4 months, and 12 months after the operation. Twenty-one healthy volunteers were used as controls. The patients were classified as having a good or a poor result at the 1-year follow-up according to a clinical score. Significant improvement of function in the noncompressed nerve roots were only observed in the 31 patients with a good result. The improvement in small myelinated nerve fibers came within 12 months in the adjacent nerve roots in both the symptomatic as well as the asymptomatic leg. The improvement of function in small unmyelinated fibers also came within 12 months after surgery; however, significant improvement was only observed in the ipsilateral neighboring nerve root. The function in large myelinated fibers did not improve in any of the adjacent nerve roots during the observation period. The observed recovery of function in adjacent noncompressed nerve roots after successful surgical decompression in monoradiculopathy may be because of less production of proinflammatory mediators when the disc herniation is removed.

Acupuncture in intractable epilepsy: lack of effect on health-related quality of life.

The objective of this study was to assess the effect on health-related quality of life of acupuncture and sham acupuncture as adjunctive treatment in intractable epilepsy. We performed a randomized controlled trail with two parallel treatment arms at The National Center for Epilepsy in Norway, a comprehensive epilepsy center. Thirty-four patients with long-standing drug resistant epilepsy completed the study. The intervention consisted of 20 acupuncture treatments (bilateral needling of three acupoints plus one or two individually chosen points) or sham acupuncture (bilateral needling with smaller needles of three points outside the traditional meridians) over 8 weeks. The main outcome measures were changes in mean health-related quality of life scores for the two groups after 8 weeks, using the 89-item Quality of Life in Epilepsy (QOLIE-89) questionnaire. We found no difference between the acupuncture and sham acupuncture groups in score changes in any dimension of the QOLIE-89 questionnaire, despite testing a large number of dimensions. We also found no change in QOLIE-89 scores between baseline and 8 weeks in either groups. In conclusion, we could not demonstrate a significant effect of traditional acupuncture or sham acupuncture on the health-related quality of life of patients with intractable epilepsy.

Duration of leg pain as a predictor of outcome after surgery for lumbar disc herniation: a prospective cohort study with 1-year follow up.

OBJECT: The aim of this study was to investigate different variables in the duration of symptoms that can be used to predict outcome after lumbar microdiscectomy. METHODS: In a prospective study of 132 consecutive patients who underwent surgery for lumbar disc herniation, the authors evaluated the prognostic value of different variables in the duration of symptoms for the 1-year period after surgery. The 1-year follow-up investigation was conducted by an independent observer. Assessment of outcome was performed using a clinical overall score (COS), which was recently assessed for its reliability and validity. As for factors predictive of outcome, only duration of leg pain and sick leave reached statistical significance in the multivariate analysis. Results of the univariate analysis demonstrated that in patients experiencing preoperative leg pain fewer than 4 months and between 4 and 8 months, a significantly lower COS at the 1-year follow up was demonstrated compared with those in whom the duration of leg pain was longer (> 8 months). One hundred eight patients returned to work within the 1st year after surgery. Patients who took a sick leave of more than 28 weeks before the operation were at higher risk of not returning to work. CONCLUSIONS: Analysis of these results indicates that leg pain lasting more than 8 months correlates with an unfavorable postoperative outcome in patients with lumbar disc herniation, as well as a high risk of not returning to work.

Postoperative nerve root displacement and scar tissue. A prospective cohort study with contrast-enhanced MR imaging one year after microdiscectomy.

PURPOSE: To investigate the association between postoperative nerve root displacement and epidural scar tissue. MATERIAL AND METHODS: One hundred patients who had undergone lumbar microdiscectomy were included in a prospective cohort study with a 1-year follow-up. The patients were classified as failures or successes at the 12-month follow-up according to a clinical score. Patients with signs of recurrent disc herniation on MR were excluded from the study. All the 13 patients classified as failures were investigated with MR at the 1-year follow-up, and 40 patients classified as successes were picked at random for MR imaging; thus MR was performed in 53 patients. The MR images were independently evaluated by two neuroradiologists. The images were rated according to the presence or absence of nerve root displacement at the surgically treated disc interspace. Scar formation was rated according to two different classification systems. RESULTS: Nerve root displacement was observed in 13 patients. No evidence of scar formation was found in 4 patients, a small amount in 11, intermediate in 37 and extensive scar formation in 1 patient. No association between nerve root displacement and the amount of scar tissue was found. CONCLUSION: Postoperative nerve root displacement seems to be an independent clinical entity not associated to postoperative scar tissue.

[Primary lymphoma of the central nervous system]. / Primaert lymfom i sentralnervesystemet.

Primary lymphoma of the central nervous system is an important diagnosis to consider in any patient with an expansive lesion of unknown origin. The incidence of this cancer is reported to be increasing. We collected retrospective data from the files on all patients with brain tumours treated surgically at the University Hospital of Tromsø in the 1986-98 period (n = 513). Of 283 patients operated for brain tumours from 1986 to 1994, only one (0.4%) had a primary lymphoma. Of 230 patients treated from 1995 to 1998 seven (3%) suffered from the same condition. Two of the eight patients had T-cell lymphomas. Primary lymphoma of the central nervous system is a highly invasive tumour and should preferably be treated with chemotherapy and irradiation. The use of surgery is controversial. In most cases, surgery should be restricted to biopsy only.

Sudden unexpected death in epilepsy (SUDEP): a clinical perspective and a search for risk factors.

OBJECTIVES: To examine the risk factors and their relative importance and possible role in sudden unexpected death in epilepsy (SUDEP). METHODS: The study was conducted as a retrospective analysis of deaths in an outpatient population of a tertiary referral centre, based on clinical and pathological data. RESULTS: Of a total of 140 deaths, 61 (44%) had not been to postmortem and were excluded, 37 (26%) had a verified cause of death and formed the non-SUDEP group, and 42 (30%) were classified as SUDEP. In the SUDEP group there was pulmonary oedema in 62%, signs of preceding seizures in 67%, no visible seizures in three of six observed deaths. A high seizure frequency prevailed in SUDEP as well as non-SUDEP. Sixty per cent of deaths were sleep related. Various other circumstances were temporally associated with death. The prone position at death was seen in 71% of the SUDEP patients; possible interpretations are discussed. Supposedly subtherapeutic serum concentrations of one or more antiepileptic drugs were found in 57% of those with reported serum concentrations. Alcohol was not a factor in the material, whereas hyponatraemia was seen in two cases. CONCLUSIONS: Most cases of SUDEP are preceded by seizures; their presence, frequency, type, aetiology, tractability, and the use of antiepileptic drugs are factors in the demise. No common risk factor, present in all cases of SUDEP, could be found, suggesting the probability of multiple mechanisms behind SUDEP.

The effect of acupuncture in chronic intractable epilepsy.

We examined the effect of acupuncture on epileptic seizures in humans in a controlled clinical setting. Treatment was administered by two Chinese professors of acupuncture. Effect was measured by change in seizure frequency. Twenty-nine patients with chronic intractable epilepsy completed the study. They were randomized in two groups; 15 were given classical acupuncture and 14 were given sham acupuncture. There was a reduction in seizure frequency in both groups, which did not reach a level of statistical significance. There was also an increase in the number of seizure-free weeks in both groups, which reached a level of significance in the sham group. Thus, we have not been able to prove a beneficial effect of acupuncture in chronic intractable epilepsy.

Burr hole evacuation of chronic subdural haematomas followed by continuous inflow and outflow irrigation.

Chronic subdural haematomas are prone to recollect, increasing the risk of further complications and death. Burr hole evacuation followed by continuous irrigation of a Ringer solution into the remaining subdural cavity, allows remaining blood to be washed out and the brain to re-expand. This technique was compared with burr hole evacuation either without or with a passive drainage and craniotomy, respectively. Reformation of haematomas after continuous irrigation occurred in 2.6% (2/77); more than a twelve (32.6%; 15/46) and a nine (23.8%; 5/21) times rate reduction compared to burr hole evacuation without and with passive drainage, respectively. Compared to the craniotomy results, the rate dropped seventeen times (44.4%; 4/9). Expect from the two rebleedings in 77 haematomas operated on through burr holes followed by irrigation, all patients recovered including nine recurrent haematomas re-operated on by this method. Recurrent haematomas operated on through burr hole evacuation alone or with insertion of a passive drainage, recollected in 50% (2/4) and 33.3% (2/6). Similar rate after craniotomies was 11.1% (1/9). Neither infections nor deaths followed burr hole evacuation combined with continuous irrigation, whereas 5.3% (2/38) and 5.9% (1/17) suffered from empyema after burr hole evacuation alone or combined with a passive drainage, respectively. Five (9.1%) of these 55 patients died either from empyemas (three) or rebleedings (two). Recurrent haematomas evacuated through a craniotomy had no complications from infections. Compared to other methods, continuous irrigation reduces the need for re-operation significantly by preventing haematoma recurrence and empyema formation. Contrary to other surgical techniques, haematoma recurrence after second time surgery did not occur.

Nerve root signs on postoperative lumbar MR imaging. A prospective cohort study with contrast enhanced MRI in symptomatic and asymptomatic patients one year after microdiscectomy.

The association between postoperative nerve root signs and outcome was investigated in 54 out of one hundred patients operated on by lumbar microdiscectomy in a prospective cohort study with one year follow up. The patients were classified as failures or successes at the 12 month follow up according to a clinical overall score. All the 14 failures were investigated with MRI at the one year follow up, and 40 patients classified as successes were picked at random for MRI. Three patients with signs of recurrent disc herniation on MRI were excluded from the study. The MRI scans were independently read by two neuroradiologists who were ignorant of treatment outcome. No association between nerve root thickening, nerve root enhancement or nerve root displacement and the clinical outcome was found when patients with recurrent disc herniation were excluded.

[Decompression craniectomy--life-saving treatment in acute cerebral infarction]. / Dekomprimerende kraniektomi--livreddende behandling ved akutt hjerneinfarkt.

Massive cerebral infarction is often accompanied by early death secondary to transtentorial herniation. Decompressive hemicraniectomy has been suggested as a lifesaving procedure. We report the case of a 61 year old man who had an acute infarction in the distribution area of the right middle cerebral artery. Initially, he was awake and suffered from total left-sided hemiparalysis. Over the next two days, his level of consciousness deteriorated to a Glasgow Coma Scale score of 5. Intracranial pressure (ICP) monitoring was then established. Three days later, the ICP increased from 20 to 40 mm Hg. We performed a right-sided decompressive hemicraniectomy, and the ICP was normalized immediately. Ten months after surgery the patient was at home and functioning with minimal assistance. He had moderate paresis of the left leg and was able to walk, but his left arm was paralytic. The presented case confirms that decompressive hemicraniectomy may prevent death and allow survival without severe disability in patients with massive cerebral infarction.

Sudden death in two patients with epilepsy and the syndrome of inappropriate antidiuretic hormone secretion (SIADH).

We report two cases with complex partial and secondarily generalized seizures, both on oxcarbazepine and vigabatrin, with additional lamotrigine in one case. Both died in a manner resembling SUDEP, i.e. suddenly, unexpectedly, probably following a seizure with pulmonary oedema at autopsy. Both had SIADH. A number of drugs may cause SIADH, among them carbamazepine and oxcarbazepine. A search for SIADH in patients on carbamazepine and oxcarbazepine, and in cases of sudden death in epilepsy, is recommended.

[Thyroid-associated ophthalmopathy]. / Dystyreot oftalmopati.

Thyroid-associated ophthalmopathy is a local autoimmune reaction in the orbit. Typical signs are retraction of the eyelid, periorbital oedema, proptosis and impaired eye motility. Exposure keratopathy or compression of the optic nerve may be a complication. Patients with severe proptosis or progressive loss of vision need an efficient and safe treatment modality. Immunosuppression may be the first choice, followed by surgical decompression of the orbit. We describe a combined external and endoscopic approach with resection of the lateral, inferior and medial orbital walls. In this way, the increased intraorbital pressure is relieved. Retraction of the upper eyelid is corrected by transconjunctival approach and the release of muscles from the tarsus.

The time course of post-lumbar puncture headache.

According to the leakage theory, the time taken for pain to develop upon rising to the upright position will increase during the time course of post-lumbar puncture headache (PPH) as a consequence of the decreasing size of the healing dural rent, and the pain will decline. The aim of the present prospective study was to test this hypothesis, and to describe the temporal course of time and pain variables in PPH. The study showed that the course was fairly stable for all variables except on the first day, the second last day, and the last day. In the recumbent position, the headache was more severe on the first day (p<0.05) and milder on the last day (p<0.001) compared with the interim days; maximal headache in the upright position was milder on the second last (p<0.005) and last days (p<0.0001). Compared with the interim days, the time prior to increase of pain upon rising was shorter on the first day (p<0.05) and longer on the last day (p<0.001), and from start of increase until maximum was longer on the last day (p<0.01). The time to pain relief upon lying down did not vary significantly throughout the PPH period. The mobility of the patient as expressed by the PPH grade was fairly stable throughout the course of PPH until it increased in the last 2 days. The results are in good accord with the leakage theory.

Recovery of sensory nerve fibres after surgical decompression in lumbar radiculopathy: use of quantitative sensory testing in the exploration of different populations of nerve fibres.

Thirty nine patients with unilateral lumbar nerve root compression at one level were examined with quantitative sensory testing immediately before microdiscectomy and at six weeks, four months, and 12 months after surgery. Twenty one healthy volunteers were used as controls. The patients were classified as having a good or a poor result at the one year follow up. The improvement of function in small unmyelinated nerve fibres came within six weeks in the patients with a good result. By contrast the improvement of function in small myelinated fibres was not found before 12 months after surgery. The function in large myelinated fibres did not improve during the observation period. The difference in the time course of the recovery between large and small nerve fibres is assumed to reflect differing severity in the damage to the fibres before surgical decompression. The preoperative warmth detection threshold reflecting the function in small unmyelinated C fibres was significantly higher in the patients with a poor result and this may indicate that damage to C fibres before surgery is a negative prognostic factor.