Chronic subdural hematoma-incidence, complications, and financial impact.

OBJECTIVE: To examine the population-based incidence, complications, and total, direct hospital costs of chronic subdural hematoma (CSDH) treatment in a neurosurgical clinic during a 26-year period. The aim was also to estimate the necessity of planned postoperative follow-up computed tomography (CT). METHODS: A retrospective cohort (1990-2015) of adult patients living in Pirkanmaa, Finland, with a CSDH was identified using ICD codes and verified by medical records (n = 1148, median age = 76 years, men = 65%). Data collection was performed from medical records. To estimate the total, direct hospital costs, all costs from hospital admission until the last neurosurgical follow-up visit were calculated. All patients were followed until death or the end of 2017. The annual number of inhabitants in the Pirkanmaa Region was obtained from the Statistics Finland (Helsinki, Finland). RESULTS: The incidence of CSDH among the population 80 years or older has increased among both operatively (from 36.6 to 91/100,000/year) and non-operatively (from 4.7 to 36.9/100,000/year) treated cases. Eighty-five percent (n = 978) underwent surgery. Routine 4-6 weeks' postoperative follow-up CT increased the number of re-operations by 18% (n = 49). Most of the re-operations (92%) took place within 2 months from the primary operation. Patients undergoing re-operations suffered more often from seizures (10%, n = 28 vs 3.9%, n = 27; p < 0.001), empyema (4.3%, n = 12 vs 1.1%, n = 8; p = 0.002), and pneumonia (4.7%, n = 13 vs 1.4%, n = 12; p = 0.008) compared with patients with no recurrence. The treatment cost for recurrent CSDHs was 132% higher than the treatment cost of non-recurrent CSDHs, most likely because of longer hospital stay for re-admissions and more frequent outpatient follow-up with CT. The oldest group of patients, 80 years or older, was not more expensive than the others, nor did this group have more frequent complications, besides pneumonia. CONCLUSIONS: Based on our population-based study, the number of CSDH patients has increased markedly during the study period (1990-2015). Reducing recurrences is crucial for reducing both complications and costs. Greater age was not associated with greater hospital costs related to CSDH. A 2-month follow-up period after CSDH seems sufficient for most, and CT controls are advocated only for symptomatic patients.

Long-term excess mortality after chronic subdural hematoma.

OBJECTIVE: To assess possible long-term excess mortality and causes of death of patients with chronic subdural hematoma (CSDH). METHODS: A retrospective study (1990-2015) of adult patients (n = 1133, median age = 76 years old, men = 65%) with CSDH identified by ICD-codes and verified by medical records. All patients were followed until death or the end of 2017. Cumulative relative survival ratios and relative excess risks of death (RER) were estimated by comparing patients' mortality with that in the entire regional matched population. The causes of death were compared with a separate reference group formed by randomly choosing sex, age, and calendar time matched controls (4 controls per each CSDH patient). RESULTS: The median follow-up time was 4.8 years (range = 0-27 years), and 710 (63%) of the patients died (median age at death = 84 years old). The cumulative excess mortality was 1 year = 9%, 5 years = 18%, 10 years = 27%, 15 years = 37%, and 20 years = 48%. A subgroup of CSDH patients (n = 206) with no comorbidity had no excess mortality. Excess mortality was related to poor modified Rankin score at admission (RER = 4.93) and at discharge (RER = 8.31), alcohol abuse (RER = 4.47), warfarin (RER = 2.94), age ≥ 80 years old (RER = 1.83), non-operative treatment (RER = 1.56), and non-traumatic etiology (RER = 1.69). Hematoma characteristics or recurrence were unrelated to excess mortality. Dementia was the most common cause of death among the CSDH patients (21%) and the third most common cause in the reference group (15%, p < 0.001). CONCLUSIONS: Patients with CSDH have continuous excess mortality up to 20 years after diagnosis. Patient-related characteristics have a strong association with excess mortality, whereas specific CSDH-related findings do not. CSDH patients have an increased risk for dementia-related mortality.

The incidence of chronic subdural hematomas from 1990 to 2015 in a defined Finnish population.

OBJECTIVE: The aim of this study was to determine the population-based epidemiology of chronic subdural hematoma (CSDH) over a 26-year period. METHODS: A retrospective study was conducted of all adult patients (≥ 18 years and residents of Pirkanmaa [Finland]) with a diagnosis of CSDH between 1990 and 2015. The cases were identified using ICD codes. Detailed data collection was performed using medical records and death certificates. All patients were monitored until death or the end of year 2017. The annual number of inhabitants in the Pirkanmaa region was obtained from Statistics Finland (Helsinki, Finland). RESULTS: A total of 1168 patients with CSDH were identified from hospital records and death certificates; patients were considered as new-incidence cases if 2 years had elapsed following primary treatment and in cases involving a new contralateral CSDH. From 1990 to 2015, the overall incidence of CSDH doubled from 8.2 to 17.6/100,000/year. Among adults younger than 70 years, the incidence remained quite stable, whereas the incidence clearly increased among the ≥ 80-year-old population, from 46.9 to 129.5/100,000/year. The median age for a CSDH diagnosis increased from 73 to 79 years during the 26-year period. Head trauma was documented in 59% of cases. A ground-level fall was related to the CSDH in 31% of patients younger than 60 years and in 54% of those 80 years or older. The proportion of alcohol-related cases decreased toward the end of the study period (1990-1995: 16% and 2011-2015: 7%), because alcohol abuse was less frequent among the growing group of elderly patients. In contrast, the percentage of patients receiving anticoagulant or antiplatelet medication almost doubled toward 2015 (1990-1995, 27%; and 2011-2015, 49%). The patients' neurological condition on admission, based on both Glasgow Coma Scale score (score < 13: 1990-1995, 18%; and 2011-2015, 7%; p < 0.001) and the modified Rankin Scale score (score 0-2: 1990-1995, 8%; and 2011-2015, 19%; p < 0.001), was better in recent years than in the early 1990s. CONCLUSIONS: From 1990 to 2015, the incidence of CSDH has increased markedly. The incidence of CSDH among the population 80 years or older has nearly tripled since 1990. The use of anticoagulants has increased, but there has been no change regarding the ratio between a traumatic and a spontaneous CSDH etiology. As the world population becomes progressively older, the increasing incidence of CSDH will be a burden to patients and a future challenge for neurosurgical clinics.

Preventable diagnostic errors in fatal cervical spine injuries: a nationwide register-based study from 1987 to 2010.

BACKGROUND: Fall-induced injuries in patients are increasing in number, and they often lead to serious consequences, such as cervical spine injuries (CSI). CSI diagnostics remain a challenge despite improved radiological services. PURPOSE: Our aim is to define the incidence and risk factors for diagnostic errors among patients who died following a CSI. STUDY DESIGN/SETTING: A retrospective death certificate-based study of the whole population of Finland was carried out. PATIENT SAMPLE: We identified 2,041 patients whose death was, according to the death certificate, either directly or indirectly caused by a CSI. OUTCOME MEASURES: Demographics, injury- and death-related data, and adverse event (AE)-related data were the outcome measures. METHODS: All death certificates between the years 1987 and 2010 from Statistics Finland that identified a CSI as a cause death were reviewed to identify preventable AEs with the emphasis on diagnostic errors. RESULTS: Of the 2,041 patients with CSI-related deaths, 36.5% (n=744) survived at least until the next day. Errors in CSI diagnostics were found in 13.8% (n=103) of those who died later than the day of injury. Those with diagnostic errors were significantly older (median age 79.4 years, 95% confidence interval 75.9-80.1 vs. 74.9, 95% confidence interval 70.2-72.9, p<.001) and the mechanism of injury was significantly more often a fall (86.4%, n=89 vs. 69.7%, n=447, p=.002) compared with those who did not have a diagnostic error. The incidence of diagnostic errors increased slightly during the 24-year study period. CONCLUSIONS: Cervical spine injury diagnostics remain difficult despite improved radiological services. The majority of the patients subjected to diagnostic errors are fragile elderly people with reduced physical capacity. In our analysis, preventable AEs and diagnostic errors were most commonly associated with ground-level falls.

Cranioplasty with Adipose-Derived Stem Cells, Beta-Tricalcium Phosphate Granules and Supporting Mesh: Six-Year Clinical Follow-Up Results.

Several alternative techniques exist to reconstruct skull defects. The complication rate of the cranioplasty procedure is high and the search for optimal materials and techniques continues. To report long-term results of patients who have received a cranioplasty using autologous adipose-derived stem cells (ASCs) seeded on beta-tricalcium phosphate (betaTCP) granules. Between 10/2008 and 3/2010, five cranioplasties were performed (four females, one male; average age 62.0 years) using ASCs, betaTCP granules and titanium or resorbable meshes. The average defect size was 8.1 × 6.7 cm2 . Patients were followed both clinically and radiologically. The initial results were promising, with no serious complications. Nevertheless, in the long-term follow-up, three of the five patients were re-operated due to graft related problems. Two patients showed marked resorption of the graft, which led to revision surgery. One patient developed a late infection (7.3 years post-operative) that required revision surgery and removal of the graft. One patient had a successfully ossified graft, but was re-operated due to recurrence of the meningioma 2.2 years post-operatively. One patient had an uneventful clinical follow-up, and the cosmetic result is satisfactory, even though skull x-rays show hypodensity in the borders of the graft. Albeit no serious adverse events occurred, the 6-year follow-up results of the five cases are unsatisfactory. The clinical results are not superior to results achieved by conventional cranial repair methods. The use of stem cells in combination with betaTCP granules and supporting meshes in cranial defect reconstruction need to be studied further before continuing with clinical trials. Stem Cells Translational Medicine 2017;6:1576-1582.

Fatal cervical spine injuries: a Finnish nationwide register-based epidemiologic study on data from 1987 to 2010.

BACKGROUND CONTEXT: The number of cervical spine injuries (CSIs) is increasing. Cervical spine injuries are associated with high morbidity and mortality. Identifying those who are at risk for CSI-related death can help develop national and international interventions and policies to reduce mortality. PURPOSE: This study aimed to determine the trends in the incidence and the characteristics of fatal CSIs in Finland over a 24-year study period from 1987 to 2010. STUDY DESIGN/SETTING: A large nationwide, retrospective, register-based study was carried out. PATIENT SAMPLE: The population-based sample was collected from death certificates issued in Finland between 1987 and 2010. The death certificates were obtained from the official Cause-of-Death Register, coordinated by Statistics Finland, which covers all deaths occurring in Finland. OUTCOME MEASURES: Sociodemographics and injury- and death-related data were used for outcome measures. METHODS: All death certificates issued in Finland (1987-2010) containing a CSI as the cause of death were carefully reviewed. RESULTS: A total of 2,041 fatal CSIs were identified. These constituted 0.17% of all deaths in Finland within the study period. The average annual incidence of fatal CSIs was 16.5 per million (range: 12.5-21.2). The majority of the victims were male (72.9%) and had concurrent spinal cord injury (83.0%). Traffic accidents (40.1%) and falls (45.0%) were the most common injury mechanisms. Almost one-third (29.8%) of the deaths were alcohol-related. Among the young victims (<60 years) with upper CSI (C0-C2), the majority (91.8%) died within 24 hours post-injury. One-third of elderly victims' (≥60 years) CSI-related deaths occurred after 1 week post-injury and were mostly (74.2%) caused by respiratory and circulatory system diseases. Within the 24-year period, the incidence of fatal CSIs (+2/million), as well as the average age of sustaining a fatal CSI (+13.5 years), increased markedly. Fall-induced accidents among elderly males were the most prominently increasing subpopulation of fatal CSI victims. CONCLUSIONS: In recent decades, fatal CSI incidence (death certificate-based) has increased, being 18.6 per million in Finland in 2010. Victims of fatal CSIs tend to be older than in the past, and for a substantial number of males, low-energy falls lead to cervical trauma and death.

Stent-assisted embolization of recurrent or residual intracranial aneurysms.

INTRODUCTION: Intracranial stents have theoretical advantages in the treatment of wide-necked intracranial aneurysms, but the usability of intracranial stents in the retreatment of recurrent intracranial aneurysms is relatively unknown. In this study, we aim to evaluate the safety and efficacy of stent-assisted embolization in the retreatment of recurrent or residual intracranial aneurysms. METHODS: Retrospective evaluation was carried out for 55 consecutive patients (17 men and 38 women; mean age 51.5 years), with 56 recurrent or residual intracranial aneurysms electively retreated with stent-assisted embolization. RESULTS: The technical success rate was 91% (50/55 patients). Procedural complications were encountered with six patients (11%). Angiographic and clinical follow-up data were available for 51 patients (93%), with a mean follow-up period of 28.1 months. No rebleedings were encountered during the study period. The clinical outcome was favorable in 50 patients (91%), with a Glasgow Outcome Score of 4 (N = 14) or 5 (N = 36) at the end of the study period. Poor clinical outcome correlated with very large (>2 cm) total aneurysm size (P = 0.002), large (>10 mm) recurrent aneurysm size (P = 0.011), and occurrence of periprocedural complications (P < 0.001). CONCLUSION: Stent-assisted coil embolization is beneficial for the retreatment of wide-necked recurrent or residual intracranial aneurysms, but stability and permanent occlusion of the recurrent aneurysm is unlikely if the aneurysm exceeds 2 cm in diameter, the recurrent diameter of the aneurysm exceeds 10 mm, or if mass effect is present with the recurrent aneurysm.

The silk flow-diverting stent in the endovascular treatment of complex intracranial aneurysms: technical aspects and midterm results in 24 consecutive patients.

BACKGROUND: The flow-diverting stent is a new option in endovascular therapy specifically designed for the endovascular reconstruction of a segmentally diseased artery. The safety of flow-diverting stents is still equivocal. OBJECTIVE: To evaluate the technical aspects, thromboembolic events, adjunctive therapies, and midterm results in patients with complex intracranial aneurysms treated with a flow-diverting stent (Silk; Balt Extrusion, Montmorency, France). METHODS: We retrospectively examined angiographic images and clinical reports of 24 consecutive patients (29 stents) treated (n = 23) or attempted to treat (n = 1) with a flow-diverting device in 2 Finnish centers between March 2009 and October 2010. RESULTS: The primary technical success rate was 67% (16/24). Adjunctive therapies were required in 6 (25%) patients, including 4 cases where intra-arterial abciximab was administered for the treatment of intraprocedural thromboembolic events. Technique-related complication rate and the 30-day mortality rate were each 4% (1/24). Follow-up imaging revealed 1 case of delayed in-stent thrombosis resulting in permanent disability of the patient, 1 asymptomatic occlusion, and 1 asymptomatic stenosis of the stented artery. Complete occlusion of the aneurysm with fully patent parent artery was observed in 16 of the 23 aneurysms (70%) where follow-up images were available. CONCLUSION: Many previously untreatable cerebral aneurysms may be successfully treated with the Silk flow-diverting stent, but the associated risk of thromboembolic events is justifiable only if conventional endovascular or surgical treatment options are not applicable. Perioperative thromboembolic events should be prepared for and treated without unnecessary delays because they frequently respond to adjunctive medical therapy.

Long-term MRI findings of patients with embolized cerebral aneurysms.

BACKGROUND: Long-term follow-up studies after endovascular treatment for intracranial aneurysm are still rare and inconclusive. Parenchymal infarctions related to aneurysms have mostly been studied in patients with subarachnoidal hemorrhage (SAH) but infarction rates in patients with endovascularly treated unruptured aneurysms have been little studied. PURPOSE: To determine the frequency of permanent parenchymal lesions as detected in magnetic resonance imaging (MRI) in patients treated with endovascular coiling and to assess aneurysm-related infarctions after the initial treatment period. MATERIAL AND METHODS: A total of 64 patients (32 with primarily ruptured aneurysms) with 69 embolized aneurysms were examined neurologically and by MRI and magnetic resonance angiography (MRA) more than 9 years after the initial endovascular treatment. RESULTS: A total of 14 out of 32 (44%) SAH patients and 11 (34%) patients with unruptured aneurysms had parenchymal lesions in MRI. Infarctions were detected in 10 (31%) SAH patients and the majority (9/10, 90%) of them were aneurysm-related. All aneurysm-related infarctions were detected at the acute hospitalization stage. A total of six (55%) out of 11 infarctions in patients with unruptured aneurysms were aneurysm-related and two of them appeared after the treatment period. Patients with infarction had poorer clinical outcome than patients with no ischemic lesions in MRI. CONCLUSION: Nineteen percent of patients with unruptured and 41% with ruptured aneurysms had aneurysm-related parenchymal lesions in MRI. Most of these were detected during acute treatment period. Aneurysm-related infarctions after treatment period are uncommon.

Long term outcome after subarachnoid haemorrhage of unknown aetiology.

BACKGROUND AND PURPOSE: The aim of this study was to assess the long term outcome after non-aneurysmal subarachnoid haemorrhage (SAH). METHODS: 1154 patients with SAH were treated in our hospital between 1989 and 1999. From this patient population, 97 patients had a non-aneurysmal SAH. All hospital records and death certificates were studied and 33 patients were examined by MRI and MR angiography more than 9 years (mean 12 years) after the initial bleeding. RESULTS: The cohort consisted of 97 patients. Mean follow-up time was 9 years (range 0-19). During the follow-up period, 13 patients (13%) died. Four (4%) died from the initial bleeding less than 5 weeks after the initial haemorrhage. There was no delayed mortality due to SAH or subsequent bleedings. MR angiography revealed no new findings in 33 surviving patients. CONCLUSIONS: Excess mortality during the first year after SAH was higher than 4%, and remained thereafter comparable with the general population. There were no rebleedings and MR imaging did not reveal any vascular pathology that could explain the earlier SAH.

Cranioplasty with adipose-derived stem cells and biomaterial: a novel method for cranial reconstruction.

BACKGROUND: There is no optimal method for reconstruction of large calvarial defects. Because of the limitations of autologous bone grafts and alloplastic materials, new methods for performing cranioplasties are needed. OBJECTIVE: To create autologous bone to repair cranial defects. METHODS: We performed a cranioplasty procedure with this new method in 4 patients who had large calvarial defects of different etiologies. We used autologous adipose-derived stem cells seeded in beta-tricalcium phosphate granules. For 2 patients, we used a bilaminate technique with resorbable mesh. RESULTS: During follow-up, there were no clinically relevant postoperative complications. The computed tomography scans revealed satisfactory outcome in ossification, and in the clinical examinations, the outcomes were good. The cranioplasty was measured in Hounsfield units from each computed tomography scan. The Hounsfield units increased gradually to equal the value of bone. CONCLUSION: The combination of scaffold material such as beta-tricalcium phosphate and autologous adipose-derived stem cells constitutes a promising model for reconstruction of human large cranial defects. The success of these clinical cases paves way for further studies and clinical applications to turn this method into a reliable treatment regimen.

[Mild brain injuries in emergency medicine]. / Lievät aivovammat päivystyslääketieteessä.

Diagnostics and correct classification of mild brain injuries is challenging. Problems caused by insufficient documentation at the acute phase become more obvious in situations in which legal insurance issues are to be considered. A small proportion of patients with mild brain injury suffer from prolonged symptoms. Medical recording and classification of the brain injury at the initial phase should therefore be carried out in a structured manner. The review deals with the diagnostic problems of mild brain injuries and presents a treatment protocol for adult patients at the acute phase, aiming at avoiding prolonged problems.

Wide-necked intracranial aneurysms: treatment with stent-assisted coil embolization during acute (<72 hours) subarachnoid hemorrhage--experience in 61 consecutive patients.

PURPOSE: To evaluate the safety and efficacy of stent-assisted embolization of ruptured wide-necked intracranial aneurysms during acute subarachnoid hemorrhage (SAH). MATERIALS AND METHODS: Institutional review board approval for this retrospective study was obtained; the need to obtain informed consent was waived. Results in 61 consecutive patients (20 men, 41 women; mean age, 55.1 years; range, 26-83 years) with acutely ruptured wide-necked intracranial aneurysms who were treated with stent-assisted coil embolization were evaluated. The mean length of angiographic follow-up was 12.1 months (range, 0-52 months). Statistical analysis was performed to determine whether the features of the patient and the ruptured aneurysm affected the primary angiographic result or the patient's clinical outcome. Categoric and dichotomous variables were examined with the chi(2) test or the Fisher exact test; the Mann-Whitney U test and Kruskal-Wallis one-way analysis were used to compare continuous-scale data for non-normally distributed variables. RESULTS: The technical success rate was 72% (44 of 61). The technique-related complication rate was 21% (13 of 61), and the 30-day mortality rate was 20% (12 of 61). There was only one case of rebleeding, and clinical outcome was good for the majority of the patients (69% [42 of 61] had Glasgow Outcome Scale scores of 4 or 5 at the end of the study period). CONCLUSION: Stent-assisted coil embolization is a feasible method for the endovascular treatment of wide-necked intracranial aneurysms that are difficult to treat surgically or with balloon-assisted embolization during acute SAH. The risk of subsequent rerupture of the aneurysm seems to be reduced for aneurysms treated early compared with that for nonsecured aneurysms.

Association of the endothelial nitric oxide synthase gene polymorphism with risk of coronary artery disease and myocardial infarction in middle-aged men.

Nitric oxide (NO), formed by endothelial constitutive nitric oxide synthase (eNOS) maintains endothelium-dependent vasodilatation and also mediates antithrombotic actions. The eNOS gene harbours a common polymorphism in intron 4 (4a/b), and some clinical studies have suggested an association of the rare a-allele with coronary artery disease (CAD) and myocardial infarction (MI). However, contradictory results have also been reported. We studied associations of eNOS polymorphism with CAD and MI in two prospective autopsy series comprising altogether 700 Caucasian Finnish men, who died suddenly. In ANCOVA, no significant differences in areas of atherosclerotic lesions and coronary stenosis percentages were found between men carrying the a-allele (ba+aa) compared with those homozygous for the b-allele. Subjects with the a-allele had significantly lower risk of MI (odds ratio 0.44, 95% confidence interval 0.25-0.77, P=0.004) compared with those carrying the bb genotype. Men with the a-allele also tended to have coronary thrombosis less often (odds ratio 0.43, 95% confidence interval 0.18-1.01, P=0.055). The eNOS gene 4a/b polymorphism was not associated with the extent of coronary atherosclerosis, but the a-allele of the variant seems to protect to some degree against the development of MI.