Prompt closure versus gradual weaning of external ventricular drainage for hydrocephalus following aneurysmal subarachnoid haemorrhage: Protocol for the DRAIN randomised clinical trial

Background: Aneurysmal subarachnoid haemorrhage (aSAH) is a life-threatening disease caused by rupture of an intracranial aneurysm. A common complication following aSAH is hydrocephalus, for which placement of an external ventricular drain (EVD) is an important first-line treatment. Once the patient is clinically stable, the EVD is either removed or replaced by a ventriculoperitoneal shunt. The optimal strategy for cessation of EVD treatment is, however, unknown. Gradual weaning may increase the risk of EVD-related infection, whereas prompt closure carries a risk of acute hydrocephalus and redundant shunt implantations. We designed a randomised clinical trial comparing the two commonly used strategies for cessation of EVD treatment in patients with aSAH. Methods: DRAIN is an international multi-centre randomised clinical trial with a parallel group design comparing gradual weaning versus prompt closure of EVD treatment in patients with aSAH. Participants are randomised to either gradual weaning which comprises a multi-step increase of resistance over days, or prompt closure of the EVD. The primary outcome is a composite outcome of VP-shunt implantation, all-cause mortality, or ventriculostomy-related infection. Secondary outcomes are serious adverse events excluding mortality, functional outcome (modified Rankin scale), health-related quality of life (EQ-5D) and Fatigue Severity Scale (FSS). Outcome assessment will be performed 6 months after ictus. Based on the sample size calculation (event proportion 80% in the gradual weaning group, relative risk reduction 20%, type I error 5%, power 80%), 122 patients are needed in each intervention group. Outcome assessment for the primary outcome, statistical analyses and conclusion drawing will be blinded

Døde og strandete krepsdyr - Nitti tilfeller rapportert til Havforskningsinstituttet i perioden 2014-2020

Havforskningsinstituttet begynte med en systematisk registrering av innrapporterte funn av strandet krill i 2014. Antall tilfeller var få fra 2014 til 2017, men økte kraftig i 2018 og har siden holdt seg på dette nivået. Det er vanskelig å vite om dette skyldes at krill har drevet i land oftere de siste tre årene enn tidligere, eller om flere nå melder ifra om funn. Antallet innrapporterte tilfeller økte akkurat da bruken av kjemiske avlusingsmidler i landet som helhet minket kraftig, mens antallet innrapporterte tilfeller var relativt lavt i de årene der bruken av avlusingsmidler var høyest. Hyppigheten av strandet krill kan også ha en sammenheng med mengden krill i sjøen. Mars, august, september og oktober skiller seg klart ut som månedene med flest funn. De aller fleste funnene er fra Rogaland og gamle Hordaland fylke. De eneste områdene i landet hvor det ikke er rapportert om funn av strandet krill, er Finnmark og Skagerakkysten.publishedVersio

Intracranial Hemorrhage From Dural Arteriovenous Fistulas: Symptoms, Early Rebleed, and Acute Management: A Single-Center 8-Year Experience

Abstract BACKGROUND Cerebral dural arteriovenous fistulas (dAVFs) presenting with hemorrhage are so rare that reports on their characteristics and guidelines for their acute management are scarce. OBJECTIVE To identify characteristics of the clinical and radiological presentation of hemorrhaging dAVFs, and establish their frequency of early rebleed so that implications for their acute management can be drawn. METHODS Retrospective analysis of all patients admitted with intracranial hemorrhage from a dAVF during the years 2011 to 2018. RESULTS Twenty patients (14 males) with a median age of 61 yr (27-75 yr) were included. Thunderclap headache was the presenting symptom in 13 (65%) patients. Rebleed prior to treatment occurred in 35% of the patients at median 7.5 h (range 3-96 h) after the ictus. All dAVFs had retrograde venous drainage and a venous aneurysm with a bleb was the source of hemorrhage in 16 (80%) patients, all of them presenting with headache. In contrast, patients bleeding due to diffuse venous hypertension presented with neurological deficits. Endovascular treatment was successful in 2 cases; hence, definite dAVF treatment was surgical in 18 (90%) patients. At median 7 mo (2-29 mo) after the ictus, 13 (65%) patients were in Glasgow Outcome Scale-Extended 7 or 8. CONCLUSION The typical presentation of hemorrhage from a cranial dAVF is thunderclap headache. The origin of hemorrhage is often a ruptured venous aneurysm with a bleb. The high frequency of early rebleeds warrants management strategies equivalent to those established for aneurysmal subarachnoid hemorrhage. Overall outcome is favorable

Endovascular versus surgical treatment of cranial dural arteriovenous fistulas: a single-center 8-year experience

Abstract Background Cranial dural arteriovenous fistulas (dAVFs) are rare lesions managed mainly with endovascular treatment (EVT) and/or surgery. We hypothesize that there may be subtypes of dAVFs responding better to a specific treatment modality in terms of successful obliteration and cessation of symptoms and/or risks. Methods All dAVFs treated during 2011–2018 at our hospital were analyzed retrospectively. Presenting symptoms, radiological variables, treatment modality, complications, and residual symptoms were related to dAVF type using the original Djindjian classification. Results We treated 112 dAVFs in 107 patients (71, 66% males). They presented with hemorrhage ( n  = 23; 21%), non-hemorrhagic symptoms ( n  = 75; 70%), or were discovered incidentally ( n  = 9; 8%). There were 25 (22%) type I, 29 (26%) type II, 26 (23%) type III, and 32 (29%) type IV fistulas. EVT was the primary treatment modality in 72/112 (64%) dAVFs whereas 40/112 (36%) underwent primary surgery with angiographic obliteration rates of 60% and 90%, respectively. Using a secondary treatment modality in 23 dAVFs, we obtained a final obliteration rate of 93%, including all type III/IV and 26/27 (96%) type II dAVFs. Except for headache, residual symptoms were rare and minor. Permanent neurological complications consisted of five cranial nerve deficits. Conclusions We recommend EVT as first treatment modality in types I, II, and in non-hemorrhagic type III/IV dAVFs. We recommend surgery as first treatment choice in acute hemorrhagic dAVFs and as secondary choice in type III/IV dAVFs not successfully occluded by EVT. Combining the two modalities provides obliteration in 9/10 dAVF cases at a low procedural risk

Management and long-term outcome of type II acute odontoid fractures: a population-based consecutive series of 282 patients

BACKGROUND CONTEXT The surgical fixation rate of type II odontoid fracture (OFx) in the elderly (≥65 years) is much lower than expected if the treatment adheres to current general treatment recommendations. Outcome data after conservative treatment for elderly patients with these fractures are sparse. PURPOSE The main aim of this study was to determine the long-term outcome after conservative and surgical treatments of type II OFx (all age-groups) to evaluate whether nonoperative treatment yields an acceptable outcome. STUDY DESIGN/SETTING Retrospective study based on a prospective database. PATIENT SAMPLE Two hundred eighty-two consecutive patients with type II OFx treated at Oslo University Hospital over an 8-year period. OUTCOME MEASURES Long-term rates of bony fusion, fibrous union, pseudarthrosis, crossover from primary conservative treatment to surgical fixation, new-onset spinal cord injury (SCI), and neck pain were the outcome measures used. METHODS The present study was based on data extracted from our quality control database for acute cervical spine fractures. All ages were included. In addition, long-term follow-up of alive patients was performed during the years 2018–2019. The follow-up included neurological examination, radiological examination, and scoring of bony fusion status, crossover from primary conservative treatment to surgical fixation, new-onset SCI, neck pain, and Neck Disability Index (NDI score). Data are described by counts, percentages, medians, means, ranges and standard deviations where appropriate. For statistical analyses the Mann-Whitney U test, Wilcoxon signed-rank test, and t tests were used. RESULTS During the eight-year study period, we registered 282 consecutive patients with type II OFx; 54% were males, patient age ranged from 15 to 101 years, 84% were ≥65 years of age (WHO definition of elderly), and 51% were ≥80 years of age. Severe comorbidities (American Society of Anesthesiologists, ASA ≥3) were seen in 67%, whereas nonindependent living was registered in 32%. Severe comorbidities and nonindependent living were significantly associated with increasing age (p<.001). SCI secondary to the OFx was seen in 5.3%. Primary treatment of the OFx was conservative (external immobilization alone) in 193 patients (68.4%), open surgical fixation in 87 patients (30.9%), and no treatment in two critically injured patients. At the time of long-term follow-up, 125 patients had died, nine patients declined the invitation to follow-up, and five patients did not respond. Thus, 143 patients were available for follow-up with a median follow-up time of 39 months (range 5–115 months). At long-term follow-up, the fusion status was bony fusion in 39.2% of patients, fibrous union in 57.3%, and pseudarthrosis in 3.5%. The proportion of bony fusion was significantly higher in the primary surgical fixation group (p=.005). No patients had new-onset SCI presenting after the start of primary treatment. The proportion of crossover from primary external immobilization to surgery was 14.4%, whereas proportion of revision surgery in the primary surgical group was 9.5%. There was no significant difference between the primary surgical fixation group and the primary conservative treatment group at long-term follow-up with respect to the proportion of pseudarthrosis and degree of neck pain. CONCLUSIONS Primary conservative treatment of elderly patients with type II OFx appears to be safe and should be regarded a viable treatment option

Favorable prognosis with nonsurgical management of type III acute odontoid fractures: a consecutive series of 212 patients

BACKGROUND CONTEXT The recommended primary treatment for type III odontoid fractures (OFx) is external immobilization, except for patients having major displacement of the odontoid fragment. The bony fusion rate of type III OFx has been reported to be >85%. High compliance to treatment recommendations is favorable only if the treatment leads to a good outcome. PURPOSE The primary aim of this study was to determine the long-term outcome after conservative and surgical treatment of type III OFx and to reaffirm that primary external immobilization is the best treatment for most type III fractures. STUDY DESIGN/SETTING Retrospective study based on a prospective database. PATIENT SAMPLE Two hundred twelve consecutive patients with type III OFx treated at Oslo University Hospital over an 8-year period (2009–2017). OUTCOME MEASURES Long-term rates of bony fusion, crossover from primary conservative treatment to surgical fixation, new onset spinal cord injury (SCI), severe persistent neck pain (visual analogue scale - VAS), and persistent disability measured with Neck Disability index (NDI). METHODS The present study was based on data extracted from our quality control database for acute cervical spine fractures from a general population. During the years 2018 to 2019 long-term follow-up of alive patients was performed (median follow-up time was 38.0 months; range 3.0–108.0 months). The follow-up included neurological examination, radiological examination and scoring of bony fusion status, crossover from primary conservative treatment to surgical fixation, new onset SCI, neck pain, and Neck Disability Index (NDI score). RESULTS In this consecutive series of 212 patients with type III acute OFx, median patient age was 72 years, 56% had severe preinjury comorbidities (ASA score ≥3) and 22% lived dependently. Severe comorbidities and dependent living were significantly associated with increasing age (p<.001). The trauma mechanism was fall injury in 82%. The median age of patients injured by falls was significantly higher than in patients with a nonfall injury (p<.001). At the time of diagnosis, 4% had an OFx related SCI. Primary treatment was external immobilization alone in 95.3% and open surgical fixation in 4.7%. Patients treated with primary external immobilization alone presented with significantly less translation of the odontoid fragment (p<.001) and less angulation of the odontoid fragment (p=.025) than patients treated with primary surgery. Subsequent crossover to surgical fixation was performed in 5.4%. At long-term follow-up, 95.7% of patients had bony fusion of the OFx, 80.5% had minimal/no neck pain, and none developed new onset SCI. There was no significant difference in long-term follow-up VAS (p=.444) or NDI (p=.562) between the primary external immobilization group and the primary surgical group. CONCLUSION This study reaffirms that nonsurgical treatment remains the preferable option in the majority of patients with type III OFx

Impact of Preinjury Antithrombotic Therapy on 30-Day Mortality in Older Patients Hospitalized With Traumatic Brain Injury (TBI)

Objective: Elderly patients are frequently in need of antithrombotic therapy for reducing thrombotic events. The association between antithrombotic drugs and survival after traumatic brain injury (TBI) is, nevertheless, unclear. Methods: This retrospective study included patients ≥65 years admitted to a Norwegian Level 1 trauma center with TBI identified on cerebral computed tomography (cerebral-CT) during 2014–2019. Preinjury use of antiplatelets and anticoagulants was compared to the prescription rate in the general Norwegian population. The primary outcome was 30-day mortality. Uni- and multivariate logistic regression analyses estimated the association between the use of antithrombotic drugs and mortality. Results: The study includes 832 consecutive TBI patients ≥65 years. The median age was 76 years, 58% were males, 51% had moderate or severe TBI, and 39% had multiple traumas. Preinjury use of antithrombotics was registered in 471/832 (55.6%) patients; antiplatelet therapy alone in 268, anticoagulant therapy alone in 172, and combined antiplatelet and anticoagulant therapy in 31. Antiplatelet use did not differ between the study cohort and the general Norwegian population ≥65 years (31 vs. 31%, p = 0.87). Anticoagulant therapy was used more commonly in the study cohort than in the general Norwegian population (24 vs. 19%, p = 0.04). Combined use of antiplatelet and anticoagulant therapy was significantly associated with 30-day mortality, while preinjury antiplatelet or anticoagulation treatment alone was not. No difference in 30-day mortality between patients using VKA, DOACs, or LMWH was encountered. Conclusions: In this cohort, neither antiplatelet nor anticoagulant therapy alone was associated with increased 30-day mortality. Anticoagulant use was more prevalent among TBI patients than the general population, suggesting that anticoagulation might contribute to the initiation of intracranial bleeding after blunt head trauma. Combined antiplatelet and anticoagulant therapy posed increased risk of 30-day mortality

Døde og strandete krepsdyr - Nitti tilfeller rapportert til Havforskningsinstituttet i perioden 2014-2020

Havforskningsinstituttet begynte med en systematisk registrering av innrapporterte funn av strandet krill i 2014. Antall tilfeller var få fra 2014 til 2017, men økte kraftig i 2018 og har siden holdt seg på dette nivået. Det er vanskelig å vite om dette skyldes at krill har drevet i land oftere de siste tre årene enn tidligere, eller om flere nå melder ifra om funn. Antallet innrapporterte tilfeller økte akkurat da bruken av kjemiske avlusingsmidler i landet som helhet minket kraftig, mens antallet innrapporterte tilfeller var relativt lavt i de årene der bruken av avlusingsmidler var høyest. Hyppigheten av strandet krill kan også ha en sammenheng med mengden krill i sjøen. Mars, august, september og oktober skiller seg klart ut som månedene med flest funn. De aller fleste funnene er fra Rogaland og gamle Hordaland fylke. De eneste områdene i landet hvor det ikke er rapportert om funn av strandet krill, er Finnmark og Skagerakkysten