Survey of European neurosurgeons’ management of unruptured intracranial aneurysms: inconsistent practice and organization

Background - The discovery of an unruptured intracranial aneurysm creates a dilemma between observation and treatment. Neurosurgeons’ routines for risk assessment and treatment decision-making are unknown. The position of evidence-based medicine in European neurosurgery is considered to be weak, high-grade guidelines do not exist and variations between institutions are probable. We aimed to explore European neurosurgeons’ management routines for newly discovered unruptured intracranial aneurysms. Methods - In cooperation with the European Association of Neurosurgical Societies (EANS), we conducted an online, cross-sectional survey of 420 European neurosurgeons during Spring/Summer 2016 (1533 non-Norwegians invited through the EANS, and 16 Norwegians invited through heads of departments because of the need for additional information for a separate study). We asked about demographic variables, routines for management and risk assessment of newly discovered unruptured intracranial aneurysms and presented a case. We collected information about gross domestic product (GDP) per capita from the International Monetary Fund. Results - The respons rate to the invite from the EANS was 26%, with respondents from 47 countries. More than half of the respondents (n = 226 [54%]) reported that their department treated less than 25 unruptured aneurysms yearly. Forty percent said their department used aneurysm size cut-off to guide treatment decisions, with a mean size of 6 mm. Presented with a case, respondents from countries with a lower GDP per capita recommended intervention more often than respondents from higher-income countries. Vascular neurosurgeons more commonly recommended observation. Conclusion - The answers to this self-reported survey indicate that many centers have a treatment volume lower than recommended by international guidelines, and that there are socioeconomic differences in care. Better documentation of treatment and outcome, for example with clinical quality registries, is needed to drive improvements of care

Prevalence of unruptured intracranial aneurysms: impact of different definitions-the Tromsø Study

Background - Management of incidental unruptured intracranial aneurysms (UIAs) remains challenging and depends on their risk of rupture, estimated from the assumed prevalence of aneurysms and the incidence of aneurysmal subarachnoid haemorrhage. Reported prevalence varies, and consistent criteria for definition of UIAs are lacking. We aimed to study the prevalence of UIAs in a general population according to different definitions of aneurysm. Methods - Cross-sectional population-based study using 3-dimensional time-of-flight 3 Tesla MR angiography to identify size, type and location of UIAs in 1862 adults aged 40–84 years. Size was measured as the maximal distance between any two points in the aneurysm sac. Prevalence was estimated for different diameter cutoffs (≥1, 2 and 3 mm) with and without inclusion of extradural aneurysms. Results - The overall prevalence of intradural saccular aneurysms ≥2 mm was 6.6% (95% CI 5.4% to 7.6%), 7.5% (95% CI 5.9% to 9.2%) in women and 5.5% (95% CI 4.1% to 7.2%) in men. Depending on the definition of an aneurysm, the overall prevalence ranged from 3.8% (95% CI 3.0% to 4.8%) for intradural aneurysms ≥3 mm to 8.3% (95% CI 7.1% to 9.7%) when both intradural and extradural aneurysms ≥1 mm were included. Conclusion - Prevalence in this study was higher than previously observed in other Western populations and was substantially influenced by definitions according to size and extradural or intradural location. The high prevalence of UIAs sized <5 mm may suggest lower rupture risk than previously estimated. Consensus on more robust and consistent radiological definitions of UIAs is warranted

Emergency Craniotomy and Burr-Hole Trephination in a Low-Resource Setting: Capacity Building at a Regional Hospital in Cambodia

To evaluate the teaching effect of a trauma training program in emergency cranial neurosurgery in Cambodia on surgical outcomes for patients with traumatic brain injury (TBI). We analyzed the data of TBI patients who received emergency burr-hole trephination or craniotomy from a prospective, descriptive cohort study at the Military Region 5 Hospital between January 2015 and December 2016. TBI patients who underwent emergency cranial neurosurgery were primarily young men, with acute epidural hematoma (EDH) and acute subdural hematoma (SDH) as the most common diagnoses and with long transfer delay. The incidence of favorable outcomes three months after chronic intracranial hematoma, acute SDH, acute EDH, and acute intracerebral hematoma were 96.28%, 89.2%, 93%, and 97.1%, respectively. Severe traumatic brain injury was associated with long-term unfavorable outcomes (Glasgow Outcome Scale of 1–3) (OR = 23.9, 95% CI: 3.1–184.4). Surgical outcomes at 3 months appeared acceptable. This program in emergency cranial neurosurgery was successful in the study hospital, as evidenced by the fact that the relevant surgical capacity of the regional hospital increased from zero to an acceptable level.publishedVersio

Transpterygoid Trans-sphenoid Approach to the Lateral Extension of the Sphenoid Sinus to Repair a Spontaneous CSF Leak

Objective and Importance: Cerebrospinal fluid (CSF) fistula from the middle cranial fossa into the sphenoid sinus is a rare condition. In the past, the treatment of choice has been closure via a craniotomy. Only few geriatric cases are known, which were successfully operated by endoscopic surgery. We present a further case of nontraumatic CSF fistula originating from the middle cranial fossa. A new endoscopic technique was applied. We discuss treatment options for this rare defect. Clinical Presentation: A 76-year-old patient presented with a 2-year history of rhinorrhea. High levels of β-trace protein pointed to a diagnosis of CSF fistula. The defect was located at the anterior and inferior aspect of the pterygoid recess of the left sphenoid sinus. Intervention: The patient was operated using an endoscopic trans-sphenoidal approach. After endoscopic opening of the maxillary and sphenoid sinus, a complete posterior ethmoidectomy was performed. The medial part of the pterygoid process was removed, allowing endoscopic exposure and closure of the defect. At 1-year follow-up, the CSF fistula had not recurred and the patient had no sequel from the surgical procedure. Conclusion: In selected cases, this new endoscopic partial transpterygoid approach to the middle cranial fossa is recommended for surgical repair of CSF fistula involving the lateral extension of the sphenoid sinus. To our knowledge, ours is the oldest patient with this condition successfully operated by endoscopic means at the world's most northern university hospital

Outcome of aneurysmal subarachnoid hemorrhage in a population-based cohort: Retrospective registry study

BACKGROUND: Studies of aneurysmal subarachnoid hemorrhage report an association between higher patient volumes and better outcomes. In regions with dispersed settlement, this must be balanced against the advantages with shorter prehospital transport times and timely access. The aim of this study is to report outcome for unselected aneurysmal subarachnoid hemorrhage cases from a well-defined rural population treated in a low-volume neurosurgical center. METHODS: This is a retrospective, population-based, observational cohort study from northern Norway (population 486 450). The University Hospital of North Norway provides the only neurosurgical service. We retrieved data for all aneurysmal subarachnoid hemorrhage cases (n=332) admitted during 2007 through 2019 from an institution-specific register. The outcome measures were mortality rates and functional status assessed with the modified Rankin scale. RESULTS: The mean annual number of cases was 26 (range, 16–38) and the mean crude incidence rate 5.4 per 100 000 personyears. Two hundred seventy-nine of 332 (84%) cases underwent aneurysm repair, 158 (47.5%) with endovascular techniques and 121 (36.4%) with microsurgical clipping, while 53 (15.9%) did not. The overall mortality rate was 16.0% at discharge and 23.8% at 12 months. The proportion with a favorable outcome (modified Rankin scale scores 0–2) was 36.1% at discharge and 51.5% at 12 months. In subgroup analysis of cases who underwent aneurysm repair, the mortality rate was 4.7% at discharge and 11.8% at 12 months, and the proportion with a favorable outcome 42.3% at discharge and 59.9% at 12 months. CONCLUSIONS: We report satisfactory outcomes after treatment of aneurysmal subarachnoid hemorrhage in a low-volume neurosurgical department serving a rural population. This indicates a reasonable balance between timely access to treatment and hospital case volume

Nakkekirurgi i Helse Nord 2014-18

BAKGRUNN - Kunnskap om variasjon i behandlingsrater er nødvendig for å vurdere om tilgangen til helsetjenester er likeverdig. Formålet med denne studien var å undersøke rater for kirurgisk behandling av degenerative nakkelidelser i Norge og Helse Nord, samt egendekningen i Helse Nord, og å vurdere aktiviteten i regionen. MATERIALE OG METODE - Vi inkluderte operasjoner registrert i Norsk pasientregister i perioden 2014–18 og beregnet kjønns- og aldersstandardiserte behandlingsrater for Norge, helseregionene og helseforetakene i Helse Nord. Vi beregnet egendekning som andel bosatte i Helse Nord operert ved Universitetssykehuset Nord-Norge Tromsø. RESULTATER - Behandlingsraten var stabil med i gjennomsnitt 29,6 operasjoner per 100 000 innbyggere (alder 18–105 år) per år. Raten for bosatte i Helse Nord var 23,0 operasjoner per 100 000 innbyggere per år (78 % av landsgjennomsnittet). Ratene i boområdene Finnmark og Universitetssykehuset Nord-Norge var nær landsgjennomsnittet. Bosatte i Nordland og på Helgeland hadde lavere rater for alle årene i studieperioden med gjennomsnitt på henholdsvis 16,6 og 18,1 operasjoner per 100 000 innbyggere per år. Dette tilsvarer 56 % og 61 % av landsgjennomsnittet. Egendekningen i Helse Nord økte fra 69 % i 2014 til 91 % i 2018. FORTOLKNING - Behandlingsraten for kirurgisk behandling av degenerative nakkelidelser var lavere i Helse Nord enn i resten av landet. Hvis dette skal kompenseres og egendekningen i regionen økes til 100 %, har vi estimert at aktiviteten må økes med om lag 35 operasjoner per år

Behandlingsrater for ryggkirurgi i Norge og Helse Nord 2014-18

BAKGRUNN - Formålet med denne studien var å undersøke om behandlingstilbudet innen ryggkirurgi i Helse Nord er i henhold til den vedtatte funksjonsfordelingen mellom sykehusene i regionen, og om det er geografisk variasjon i tilbudet. Vi undersøkte derfor behandlingsrater i Norge og Helse Nord, samt egendekning i Helse Nord, og vurderte aktiviteten i regionen. MATERIALE OG METODE - Vi inkluderte ryggoperasjoner registrert i Norsk pasientregister fra 2014 til 2018 i en retrospektiv analyse, og beregnet kjønns- og aldersstandardiserte behandlingsrater for Norge, helseregionene og helseforetakene i Helse Nord. Vi beregnet egendekning som andel pasienter operert ved sykehus i eget boområde. RESULTATER - Behandlingsraten for ryggoperasjoner i Norge lå på omkring 120 operasjoner per 100 000 innbyggere per år i hele perioden. Antallet ryggoperasjoner på landsbasis økte fra 5 995 i 2014 til 6 494 i 2018 på grunn av økning i innbyggertallet. Behandlingsrater for bruddbehandling og lett ryggkirurgi var relativt like i hele landet, men for tung ryggkirurgi var gjennomsnittlig rate for bosatte i Helse Nord 57 % av landsgjennomsnittet. Egendekningen i Helse Nord økte fra 60 til 84 % i perioden. Lokalsykehusfunksjonene for lett ryggkirurgi ved Nordlandssykehuset og Helgelandssykehuset (om lag 30 %) og regionsfunksjonen for tung ryggkirurgi ved Universitetssykehuset Nord-Norge (55 %) hadde lav egendekning. FORTOLKNING - Behandlingsraten for tung ryggkirurgi og egendekningen for all kirurgisk behandling av degenerative rygglidelser var lavere i Helse Nord enn i resten av landet. Hvis dette skal kompenseres i regionen, har vi estimert at aktiviteten må økes med om lag 170 operasjoner per år

Behandlingsrater for ryggkirurgi i Norge og Helse Nord 2014-18

Bakgrunn: Formålet med denne studien var å undersøke om behandlingstilbudet innen ryggkirurgi i Helse Nord er i henhold til den vedtatte funksjonsfordelingen mellom sykehusene i regionen, og om det er geografisk variasjon i tilbudet. Vi undersøkte derfor behandlingsrater i Norge og Helse Nord, samt egendekning i Helse Nord, og vurderte aktiviteten i regionen. Materialet og metode: Vi inkluderte ryggoperasjoner registrert i Norsk pasientregister fra 2014 til 2018 i en retrospektiv analyse, og beregnet kjønns- og aldersstandardiserte behandlingsrater for Norge, helseregionene og helseforetakene i Helse Nord. Vi beregnet egendekning som andel pasienter operert ved sykehus i eget boområde. Resultater: Behandlingsraten for ryggoperasjoner i Norge lå på omkring 120 operasjoner per 100 000 innbyggere per år i hele perioden. Antallet ryggoperasjoner på landsbasis økte fra 5 995 i 2014 til 6 494 i 2018 på grunn av økning i innbyggertallet. Behandlingsrater for bruddbehandling og lett ryggkirurgi var relativt like i hele landet, men for tung ryggkirurgi var gjennomsnittlig rate for bosatte i Helse Nord 57 % av landsgjennomsnittet. Egendekningen i Helse Nord økte fra 60 til 84 % i perioden. Lokalsykehusfunksjonene for lett ryggkirurgi ved Nordlandssykehuset og Helgelandssykehuset (om lag 30 %) og regionsfunksjonen for tung ryggkirurgi ved Universitetssykehuset Nord-Norge (55 %) hadde lav egendekning. Fortolkning: Behandlingsraten for tung ryggkirurgi og egendekningen for all kirurgisk behandling av degenerative rygglidelser var lavere i Helse Nord enn i resten av landet. Hvis dette skal kompenseres i regionen, har vi estimert at aktiviteten må økes med om lag 170 operasjoner per år

Low Grade Gliomas in Eloquent Locations – Implications for Surgical Strategy, Survival and Long Term Quality of Life

Background: Surgical management of suspected LGG remains controversial. A key factor when deciding a surgical strategy is often the tumors’ perceived relationship to eloquent brain regions Objective: To study the association between tumor location, survival and long-term health related quality of life (HRQL) in patients with supratentorial low-grade gliomas (LGG). Methods: Adults ($18 years) operated due to newly diagnosed LGG from 1998 through 2009 included from two Norwegian university hospitals. After review of initial histopathology, 153 adults with supratentorial WHO grade II LGG were included in the study. Tumors’ anatomical location and the relationship to eloquent regions were graded. Survival analysis was adjusted for known prognostic factors and the initial surgical procedure (biopsy or resection). In long-term survivors, HRQL was assessed with disease specific questionnaires (EORTC QLQ-C30 and BN20) as well as a generic questionnaire (EuroQol 5D). Results: There was a significant association between eloquence and survival (log-rank, p,0.001). The estimated 5-year survival was 77% in non-eloquent tumors, 71% in intermediate located tumors and 54% in eloquent tumors. In the adjusted analysis the hazard ratio of increasing eloquence was 1.5 (95% CI 1.1–2.0, p = 0.022). There were no differences in HRQL between patients with eloquent and non-eloquent tumors. The most frequent self-reported symptoms were related to fatigue, cognition, and future uncertainty. Conclusion: Eloquently located LGGs are associated with impaired survival compared to non-eloquently located LGG, but in long-term survivors HRQL is similar. Although causal inference from observational data should be done with caution, the findings illuminate the delicate balance in surgical decision making in LGGs, and add support to the probable survival benefits of aggressive surgical strategies, perhaps also in eloquent locations

Emergency Craniotomy and Burr-Hole Trephination in a Low-Resource Setting: Capacity Building at a Regional Hospital in Cambodia

To evaluate the teaching effect of a trauma training program in emergency cranial neurosurgery in Cambodia on surgical outcomes for patients with traumatic brain injury (TBI). We analyzed the data of TBI patients who received emergency burr-hole trephination or craniotomy from a prospective, descriptive cohort study at the Military Region 5 Hospital between January 2015 and December 2016. TBI patients who underwent emergency cranial neurosurgery were primarily young men, with acute epidural hematoma (EDH) and acute subdural hematoma (SDH) as the most common diagnoses and with long transfer delay. The incidence of favorable outcomes three months after chronic intracranial hematoma, acute SDH, acute EDH, and acute intracerebral hematoma were 96.28%, 89.2%, 93%, and 97.1%, respectively. Severe traumatic brain injury was associated with long-term unfavorable outcomes (Glasgow Outcome Scale of 1–3) (OR = 23.9, 95% CI: 3.1–184.4). Surgical outcomes at 3 months appeared acceptable. This program in emergency cranial neurosurgery was successful in the study hospital, as evidenced by the fact that the relevant surgical capacity of the regional hospital increased from zero to an acceptable level