Endoscopic third ventriculostomy for adults with hydrocephalus: creating a prognostic model for success: protocol for a retrospective multicentre study (Nordic ETV).

INTRODUCTION: Endoscopic third ventriculostomy (ETV) is becoming an increasingly widespread treatment for hydrocephalus, but research is primarily based on paediatric populations. In 2009, Kulkarni et al created the ETV Success score to predict the outcome of ETV in children. The purpose of this study is to create a prognostic model to predict the success of ETV for adult patients with hydrocephalus. The ability to predict who will benefit from an ETV will allow better primary patient selection both for ETV and shunting. This would reduce additional second procedures due to primary treatment failure. A success score specific for adults could also be used as a communication tool to provide better information and guidance to patients. METHODS AND ANALYSIS: The study will adhere to the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis reporting guidelines and conducted as a retrospective chart review of all patients≥18 years of age treated with ETV at the participating centres between 1 January 2010 and 31 December 2018. Data collection is conducted locally in a standardised database. Univariate analysis will be used to identify several strong predictors to be included in a multivariate logistic regression model. The model will be validated using K-fold cross validation. Discrimination will be assessed using area under the receiver operating characteristic curve (AUROC) and calibration with calibration belt plots. ETHICS AND DISSEMINATION: The study is approved by appropriate ethics or patient safety boards in all participating countries. TRIAL REGISTRATION NUMBER: NCT04773938; Pre-results.

Burr hole craniostomy versus minicraniotomy in chronic subdural hematoma: a comparative cohort study.

BACKGROUND: Chronic subdural hematoma (CSDH) is one of the most common neurosurgical diseases. In surgical management of CSDH, there is a lack of standardized guidelines concerning surgical techniques and a lack of consensus on which technique(s) are optimal. Neurosurgical centers have shown a wide variation in surgical techniques. The purpose of this study was to compare two different surgical techniques, one burr hole craniostomy with an active subgaleal drain (BHC) and minicraniotomy with a passive subdural drain (MC). METHODS: We conducted a multicenter retrospective cohort study at two neurosurgical centers in Sweden which included patients with unilateral CSDHs that received surgical treatment with either BHC or MC. The primary outcomes in comparison of the techniques were 30-day mortality, recurrence rate, and complications according to the Landriel Ibañez grading system for complications. RESULTS: A total of 1003 patients were included in this study. The BHC subgroup included 560 patients, and the MC subgroup included 443 patients. A 30-day mortality when comparing BHC (2.3%) and MC (2.7%) was similar (p = 0.701). Comparing recurrence rate for BHC (8.9%) and MC (10.8%) showed no significant difference (p = 0.336). We found that medical complications were significantly more common in the MC group (p = 0.001). Surgical complications (type IIb) was also associated with the MC group (n = 10, p = 0.003). Out of the 10 patients with type IIb complications in the MC group, 8 had postoperative acute subdural hematomas. CONCLUSIONS: BHC was comparable to MC concerning 30-day mortality rate and recurrence rates. We did, however, find that MC was significantly associated with medical complications and serious surgical postoperative complications.

Risk factors for need of reoperation in bilateral chronic subdural haematomas.

BACKGROUND: Chronic subdural haematoma (CSDH) is one of the most common neurosurgical diseases. A subtype of CSDH is bilateral chronic subdural haematoma (bCSDH) which represents 20-25% of patients with CSDH and has a higher recurrence rate. There is no clear consensus on how bCSDH should be treated regarding upfront unilateral- or bilateral evacuation of both haematomas. The purpose of this study was to identify risk factors associated with reoperation of bCSDH. METHODS: A total of 326 patients with radiological evidence of bCSDH were included in this retrospective cohort study where 133 (40.8%) patients underwent primary bilateral evacuation and 193 (59.2%) primary unilateral evacuation. The two centres operated using different surgical approaches. Analyses were performed to identify risk factors associated with reoperation of bCSDH. Reoperation rate was defined as reoperation of CSDH on either side of the hemisphere within 3 months after primary evacuation. RESULTS: The cohort had a total reoperation rate of 26.4%. Patients which underwent unilateral evacuation had a reoperation rate of 32.1%, and the bilateral group had a reoperation rate of 18.0% (p=0.005). Multivariable logistic regression identified unilateral evacuation (OR 1.91, p=0.022) and complications according to Ibanez (OR 2.20, p=0.032) to be associated with the need of reoperation of bCSDH. One-burr hole craniostomy with active subgaleal drain was primarily performed in bilateral approach (69.4%) whereas patients operated with minicraniotomy with passive subdural drain were primarily operated by unilateral evacuation of the larger symptomatic side (92.8%). CONCLUSIONS: Unilateral evacuation of bCSDH was associated with a higher risk for reoperation than upfront bilateral evacuations in this study. There is a need to further discuss the criteria for uni- or bilateral evacuation since patients are treated differently at different centres.

Does time from diagnostic CT until surgical evacuation affect outcome in patients with chronic subdural hematoma?

BACKGROUND: Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions. Patients diagnosed with CSDH's are often planned for subacute surgery. This means that time from diagnostic CT scan until actual surgery might often be prolonged. There are no previous studies that highlight the effect of delayed intervention in this population. METHOD: Patients that underwent surgical evacuation for a CSDH at Skåne University Hospital between 1 January 2015 and 31 December 2016 were included in this retrospective cohort study (n = 179). The primary aim was to determine if time from initial diagnosis by head-CT until surgical evacuation had a significant effect on outcome. The following was assessed by mortality, re-operation, number of days spent in hospital, discharge to home/institution, and functional outcome assessed by GOS. Secondary aims were to evaluate the effect of NOAC, vitamin K antagonists, and antiplatelet drugs on time from CT to surgery and re-operation frequency. RESULTS: Mean time from diagnostic CT scan until surgery was 76 h. No significant relationship was found between time from CT to surgical evacuation and number of days spent in hospital, discharge to own home/institution, 1-year mortality, or outcome assessed by GOS at discharge from hospital. The clear majority (95.5%) of the patients were GCS ≥ 13 pre-operatively. No correlation could be seen between use of NOAC, vitamin K antagonists, or antiplatelet drugs regarding the risk for reoperation within 6 months, and no correlation between the use of these agents and time from CT to surgery. The 30-day mortality was too low to draw any statistically significant conclusions (n = 4). CONCLUSION: In this retrospective cohort study, we could conclude that a delay from initial diagnosis confirming a CSDH to surgical evacuation had no negative effect on outcome when surgery was performed within the time frames and on patients with pre-operatively favorable GCS scores (≥ 13) outlined in our study.

Early postoperative haematomas in neurosurgery.

BACKGROUND: A postoperative haematoma can be a very serious complication following a neurosurgical procedure. Patients should be informed about the risks of such an event prior to surgery. From a practical point of view, it would be important to know when the patient is most likely to deteriorate and to require surgery because of a postoperative haematoma and when it might be safe to transfer the patient to the regular ward. The up-to-date studies regarding this topic are few. METHODS: We therefore undertook the present retrospective study, including a cohort of all patients operated on at the Department of Neurosurgery in Lund during the years 2011-2014, with the aim to define the time windows for clinical deterioration and reoperation, and whether risk factors such as anticoagulant agents/antiplatelet therapy, emergency versus elective surgery and abnormal coagulation blood values were present. We also defined the type of surgery resulting in postoperative haematoma and tried to find the clinical state of the patients when they deteriorated, as well as the outcome at 3 months postoperatively. RESULTS: During the time period from June 2011 to November 2014, a total of 7,055 surgical procedures of all kinds were registered at our department. By the search for the diagnosis codes AWE00 and AWD00 (reoperation for deep haemorrhage and for superficial haemorrhage respectively), we identified 93 reoperations, meaning a percentage of 1.3 %. Thirty-four of the reoperations were done within the first 24 h. Twenty-four patients were reoperated on >24 h but ≤72 h after the first operation. Only four patients who were initially doing well postoperatively showed a delayed clinical deterioration within the time frame from >6 h and ≤24 h postoperatively. This means that 0.06 % of the patients who were operated upon were doing well initially, being completely awake and with no new neurological deficit and no deterioration within the first 6 h postoperatively, and then deteriorated from a postoperative haematoma within the time frame of >6 h and ≤24 h postoperatively. CONCLUSIONS: We could conclude that no exact time window distinguished very early from somewhat later postoperative haematomas in our material. However, all but two patients deteriorating between 6 and 24 h after the operation had at least one of the following risk factors defined for post-operative haematoma: meningioma surgery, anticoagulant agents/antiplatelet therapy prior to surgery (including Dalteparin [Fragmin®], Enoxaparinnatrium [Klexane®], Warfarin [Waran®], ASA [Trombyl®] or ASA and caffeine [Treo®]), emergency operation, posterior fossa surgery or chronic subdural haematoma in a patient with a shunt. This material is too small to make any definitive conclusions, but a suggestion could be to include these factors when considering the transfer of a patient from the postoperative intensive care unit to the regular ward.

Aberrant immunostaining pattern of the CD24 glycoprotein in clinical samples and experimental models of pediatric medulloblastomas.

The CD24 glycoprotein is a mediator of neuronal proliferation, differentiation and immune suppression in the normal CNS, and a proposed cancer biomarker in multiple peripheral tumor types. We performed a comparative analysis of CD24 gene expression in a large cohort of pediatric and adult brain tumors (n = 813), and further characterized protein expression in tissue sections (n = 39), primary brain tumor cultures (n = 12) and a novel orthotopic group 3 medulloblastoma xenograft model. Increased CD24 gene expression was demonstrated in ependymomas, medulloblastomas, anaplastic astrocytomas and glioblastomas, although medulloblastomas displayed higher expression than all other tumor entities. Preferential expression of CD24 in medulloblastomas was confirmed at protein level by immunostaining and computerized image analysis of cryosections. Morphologies and immunophenotyping of CD24(+) cells in tissue sections tentatively suggested disparate functions in different tumor subsets. Notably, protein staining of medulloblastoma cells was associated with prominent cytoplasmic and membranous granules, enabling rapid and robust identification of medulloblastoma cells in clinical tissue samples, as well as in experimental model systems. In conclusion, our results implicate CD24 as a clinically and experimentally useful medulloblastoma immunomarker. Although our results encourage further functional studies of CD24 as a potential molecular target in subsets of brain tumors, the promiscuous expression of CD24 in vivo highlights the importance of specificity in the future design of such targeted treatment.

Cerebral energy metabolism during transient hyperglycemia in patients with severe brain trauma.

OBJECTIVE: To study whether transient hyperglycemia adversely affects cerebral energy metabolism in patients with severe traumatic brain lesions. DESIGN AND SETTING: Prospective, nonrandomized study in the neurosurgical intensive care unit of a university hospital. PATIENTS: 108 patients treated for severe traumatic brain lesions. INTERVENTIONS: All patients were treated according to neurosurgical intensive care routine including monitoring of intracranial pressure. One microdialysis catheter was inserted via a burr hole frontally to that used for the intraventricular catheter ("better" position). In patients with focal lesions one or more catheters were inserted into cerebral cortex surrounding an evacuated focal contusion or underlying an evacuated hematoma ("worse" position). Perfusion rate was 0.3 micro l/min and samples were taken every 30 or 60 min. The levels of glucose, pyruvate, lactate, glutamate, and glycerol were analyzed and displayed bedside. MEASUREMENTS AND RESULTS: There were 18 episodes of moderate (12-15 mmol/l) and 6 episodes of pronounced (>15 mmol/l) hyperglycemia. Moderate hyperglycemia did not change intracerebral levels of lactate, pyruvate, glutamate, glycerol, or lactate/pyruvate ratio. Lactate concentrations increased during pronounced hyperglycemia. Pronounced cerebral lactic acidosis and a moderate increase in interstitial glycerol concentration indicating cell membrane degradation was observed in a single patient with pronounced, long-lasting hyperglycemia. CONCLUSIONS: Cerebral energy metabolism was affected by transient hyperglycemia only at blood glucose concentration above 15 mmol/l as shown by a moderate increase in interstitial lactate level.