En mann i 30-årene med gjenta hjerneabscesser

Background: Brain abscess is a life-threatening condition. Congenital cardiovascular malformations can create right-to-left shunting and be an underlying cause. Case presentation: A young man was admitted due to headache and deteriorating general condition. He had a history of a surgically treated brain abscess 19 years earlier. Investigations now showed a new brain abscess. The patient was operated and received a peripherally inserted central catheter in his left arm for antibiotic treatment. A chest X-ray showed abnormal positioning of the catheter lying in a persistent left superior vena cava. One day later he experienced headache and photophobia. MRI showed reoccurrence of the brain abscess and he was reoperated. Persistent left superior vena cava was considered to be the cause of the brain abscesses and he underwent endovascular embolisation and placement of a vascular plug in his left superior vena cava. Interpretation: The oxygen-rich pulmonary circulation and its immune system make it difficult for anaerobic bacteria to pass to the arterial side. In most cases persistent left superior vena cava drains into the right atrium and is asymptomatic. In 10 % of patients the persistent left superior vena cava drains directly to the left atrium and gives a right-to-left shunt. This may cause arterial bacteraemia and brain abscesses.publishedVersio

Intra-operative MRI facilitates tumour resection during trans-sphenoidal surgery for pituitary adenomas

Background During trans-sphenoidal microsurgical resection of pituitary adenomas, the extent of resection may be difficult to assess, especially when extensive suprasellar and parasellar growth has occurred. In this prospective study, we investigated whether intra-operative magnetic resonance imaging (iMRI) can facilitate tumour resection. Methods Twenty patients with macroadenomas, (16 non-functioning, three growth-hormone secreting and one pharmaco-resistant prolactinoma) were selected for surgery in the iMRI. The mean tumour diameter was 27 mm (range 11–41). The mean parasellar grade, according to the Knosp classification, was 2.3. Pre-operative coronal and sagittal T1-weighted and T2-weighted images were obtained. The trans-sphenoidal tumour resection was performed at the edge of the tunnel of a Signa SP 0.5-Tesla MRI. The surgeon aimed at a radical tumour resection that was followed by a peri-operative MRI scan. When a residual tumour was visualised and deemed resectable, an extended resection was performed, followed by another MRI scan. This procedure was repeated until the imaging results were satisfactory. In all patients, we were able to obtain images to assess the extent of resection and to classify the resection as either total or subtotal. Results After primary resection, eight out of 20 cases were classified as total resections. A second resection was performed in 11 of 12 cases classified as subtotal resections, and in four of these, total resection was achieved. A third resection was performed in three of the remaining seven cases with subtotal resections, but we did not achieve total resection in any of these cases. Therefore, the use of iMRI increased the number of patients with total resection from 8/20 (40%) to 12/20 (60%). The only observed complication was a transient spinal fluid leakage. Conclusion Intra-operative MRI during trans-sphenoidal microsurgery is useful in selected patients for a safe and more complete resection. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited

Low immediate postoperative serum-cortisol nadir predicts the short-term, but not long-term, remission after pituitary surgery for Cushing’s disease

Background Cushing’s disease is an ACTH-producing pituitary adenoma, and the primary treatment is microscopic or endoscopic transsphenoidal selective adenectomy. The aims of the present study were to evaluate whether the early postoperative S-cortisol level can serve as a prognostic marker for short- and long-term remission, and retrospectively review our own short and long term results after surgery for Cushing’s disease. Methods This single centre, retrospective study consists of 19 consecutive patients with Cushing’s disease who underwent transsphenoidal surgery. S-cortisol was measured every 6 h after the operation without any glucocorticoid replacement. We have follow-up on all patients, with a mean follow-up of 68 months. Results At the three-month follow-up, 16 patients (84 %) were in remission; at 12 months, 18 (95 %) were in remission and at the final follow-up (mean 68 months), 13 (68 %) were in remission. Five-years recurrence rate was 26 %. The mean postoperative S-cortisol nadir was significantly lower in the group of patients in remission than in the non-remission group at 3 months, but there was no difference between those in long-term remission compared to those in long-term non-remission. The optimal cut-off value for classifying 3-month remission was 74 nmol/l. Conclusion We achieved a 95 % 1-year remission rate with transsphenoidal surgery for Cushing’s disease in this series of consecutive patients. However, the 5-year recurrence rate was 26 %, showing the need for regular clinical and biochemical controls in this patient group. The mean postoperative serum-cortisol nadir was significantly lower in patients in remission at 3 months compared to patients not in remission at 3 months, but a low postoperative S-cortisol did not predict long-term remission

Anterior thalamic deep brain stimulation in refractory epilepsy: A randomized, double-blinded study

Objectives The safety and effect on seizure frequency of anterior thalamic nucleus deep brain stimulation were studied in this prospective, randomized, double‐blinded study. Patients were followed for 12 months. The first 6 months were blinded with regard to active stimulation or not. After 6 months, all patients received active stimulation. Material and methods Bilateral ANT electrodes were implanted into 18 patients suffering from focal, pharmacoresistant epilepsy. Antiepileptic treatment was kept unchanged from three months prior to operation. The Liverpool seizure severity scale (LSSS) was used to measure the burden of epilepsy. Results There was no significant difference between the 2 groups at the end of the blinded period at 6 months. However, when considering all patients and comparing 6 months of stimulation with baseline, there was a significant, 22% reduction in the frequency of all seizures (P = 0.009). Four patients had ≥50% reduction in total seizure frequency and 5 patients ≥50% reduction in focal seizures after 6 months of stimulation. No increased effect over time was shown. LSSS at 6 months compared to baseline showed no significant difference between the 2 groups, but a small, significant reduction in LSSS was found when all patients had received stimulation for 6 months. Conclusions Our study supports results from earlier studies concerning DBS as a safe treatment option, with effects even in patients with severe, refractory epilepsy. However, our results are not as encouraging as those reported from many other, mainly unblinded, and open studies

The number of patients hospitalized with bicycle injuries is increasing - A cry for better road safety

Introduction Norwegian authorities encourage people to commute by bicycle to improve public health, decrease rush-hour traffic jams and reduce pollution. However, increasing the number of bicyclists, especially in the rush-hour traffic, may increase the number of serious bicycle injuries. Objective To explore trends in hospitalized bicycle injuries at a Norwegian level I trauma centre during the last decade. Methods Data was extracted from the prospectively registered institutional trauma registry. We identified patients admitted after bicycle injuries between 2005 and 2016. Results A total of 1543 patients were identified. Median age was 40 years (range 3–91) and 73 % were males. The majority of weekday injuries occurred in the morning and during the afternoon rush-hour, peaking at 8 am. and 4 pm. The annual number of admitted bicycle injuries increased from 79 to 184 during the study period. Also, an increase in the share of bicyclists using helmets was observed. The median Injury Severity Score (ISS) of 10 remained unchanged. 63 % had serious trauma (ISS ≥ 9), while 34 % suffered severe trauma (ISS ≥ 16). The absolute number of both serious and severe trauma increased annually. 36 % had head and neck injuries, while 16 % had chest injuries graded with Abbreviated Injury Scale ≥3. Loss of consciousness with Glasgow Coma Scale score <9 was seen in 7%. Median length of hospitalization was 3 days, and 39 % had surgery in one or more body regions. The 30-day mortality was 2.3 %. Conclusions The number of admitted bicycle injuries to our trauma centre is increasing. Rush-hour injuries dominate during weekdays. Bicycle injuries can be devastating and deserve more public attention to promote road safety

ANT-DBS in epilepsy shows no effect on selected neuropsychiatric tests

Objectives Deep brain stimulation of the anterior thalamic nucleus (ANT-DBS) is an established option in treatment-resistant epilepsy and obtained FDA approval in 2018. Increased psychiatric comorbidity is well known in epilepsy. The main objective of this study was to investigate possible neuropsychiatric treatment-related changes in patients receiving ANT-DBS. Materials and Methods Bilateral ANT electrodes were implanted in 18 adult patients with refractory epilepsy in a randomized, double-blinded study. Immediately after implantation, patients were randomized to stimulation ON (n = 8) or OFF (n = 10) for the first 6 months (blinded phase). During the next six months (open phase), both groups received active stimulation. Neuropsychiatric assessment was conducted before implantation (T1), at the end of the blinded period (T2), and 1 year after implantation (T3). Results Comparing preoperative status (T1) and 12 months (T3), postoperative outcome in all patients did not show significant differences between the two groups for any of the applied tests. Groupwise comparisons across the two first time points (the blinded period, representing the randomized controlled trial) showed no significant differences between the two groups in any of the neuropsychiatric parameters studied. Comparing test results after 6 months of stimulation in both groups (sum of ON group T1 to T2 and OFF group T2 to T3) did not show significant changes for any of the psychiatric assessments. Conclusions Our results indicate that ANT-DBS has limited effect concerning psychiatric issues. Subjective side effects were, however, reported in individual patients

Direct visual targeting versus preset coordinates for ANT-DBS in epilepsy

Objectives Deep brain stimulation (DBS) of the anterior thalamic nucleus (ANT) may be used against refractory focal epilepsy, but only two randomized double‐blinded trials have been performed. The Oslo study was discontinued prematurely since reduction in seizure frequency was less than expected. The aim of the present study was to review the targeting used in the Oslo study and to identify the actual positions of the contacts used for stimulation. Material and methods BrainLab MRI data were available from 12 Oslo study patients. Based on MRI the coordinates of the center of the ANT were identified. The coordinates were considered as the visually identified preferred target and were compared with the target originally used for ANT electrode implantation and with the actual electrode positions estimated from post‐operative CT scans. Results We found considerable differences between the visually identified preferred target, the originally planned target, and the actual electrode position. The total distance between the active electrode position and the visually identified preferred target was on average 3.3 mm on the right and 2.9 mm on the left side. Conclusion Indirect targeting based on preset coordinates may contribute to explain the modest effect of ANT‐DBS on seizure frequency seen in the Oslo study. Observed differences between the center of the ANT and the actual electrode position may at least in part be explained by variations in position and size of the ANT. Direct identification of the target using better MRI imaging protocols is recommended for future ANT‐DBS surgery

Dentoalveolar injuries, bicycling accidents and helmet use in patients referred to a Norwegian Trauma Centre: A 12‐year prospective study

Background/Aim Despite its many benefits, bicycling carries the risk of accidents. Although numerous studies have reported the effect of helmet use on traumatic brain injury, it remains unclear if, and to what extent, helmet use reduces the risk of facial injuries. This is particularly true in regard to injuries of the lower face. In addition, there is limited evidence of the effect of helmet use on dentoalveolar injuries. Thus, the aim of this study was to determine the frequency and distribution of dentoalveolar injuries in bicycling accidents and to explore the influence of helmet use. Material and Methods A total of 1543 bicyclists were included from the trauma registry of a Norwegian tertiary trauma center over a 12‐year period. Data were collected prospectively, including patient characteristics, type of injury, and helmet use. The prevalence of dentoalveolar injuries was assessed in conjunction with helmet use and facial fractures. Results Twenty‐five percent of the patients had maxillofacial injuries, and 18% of those with facial fractures exhibited concomitant dentoalveolar injuries. The most common type of dentoalveolar injury was tooth fracture (39%). The most frequent location of facial fractures with combined dentoalveolar injuries was the maxilla, which had fractured in 32 patients. Women had a higher risk of sustaining dentoalveolar injuries compared to men (odds ratio 1.50, 95% confidence interval 1.02‐2.22). There were 1257 patients (81%) who had reliable registration of helmet use; 54% of these wore a helmet, while 46% did not. Helmet users had an increased risk of dentoalveolar injuries compared to non‐helmeted bicyclists (adjusted odds ratio 1.54, 95% confidence interval 1.02‐2.31). Conclusions Dentoalveolar injuries are fairly common in trauma patients admitted to a trauma center following bicycling accidents. Bicycling helmets are associated with an increased risk of dentoalveolar injuries