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Alice Senta Ryba, Juan Sales-Llopis, Stefan Wolfsberger, Aki Laakso, Roy Thomas Daniel, and Pablo González-López

Hemangioblastomas (HBs) are rare, benign, hypervascularized tumors. Fluorescent imaging with indocyanine green (ICG) can visualize tumor angioarchitecture. The authors report a case of multiple HBs involving two radiologically silent lesions only detected intraoperatively by ICG fluorescence. A 26-year-old woman presented with a cystic cerebellar mass on the tentorial surface of the left cerebellar hemisphere on MRI. A left paramedian suboccipital approach was performed to remove the mural nodule with the aid of ICG injection. The first injection, applied just prior to removing the nodule, highlighted the tumor and vessels. After resection, two new lesions, invisible on the preoperative MRI, surprisingly enhanced on fluorescent imaging 35 minutes after the ICG bolus. Both silent lesions were removed. Histological analysis of all three lesions revealed they were positive for HB. The main goal of this report is to hypothesize possible explanations about the mechanism that led to the behavior of the two silent lesions. Intraoperative ICG videoangiography was useful to understand the 3D angioarchitecture and HB flow patterns to perform a safe and complete resection in this case. Understanding the HB ultrastructure and pathophysiological mechanisms, in conjunction with the properties of ICG, may expand potential applications for their diagnosis and future treatments.

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Anna Piippo, Aki Laakso, Karri Seppä, Jaakko Rinne, Juha E. Jääskeläinen, Juha Hernesniemi, and Mika Niemelä

Object

The aim of this study was to assess the early and long-term excess mortality in patients with intracranial dural arteriovenous fistula (DAVF) compared with a matched general Finnish population in an unselected, population-based series.

Methods

The authors identified 227 patients with DAVFs admitted to 2 of the 5 Departments of Neurosurgery in Finland—Helsinki and Kuopio University Hospitals—between 1944 and 2006. All patients were followed until death or the end of 2009. Long-term excess mortality was estimated using the relative survival ratio compared with the general Finnish population matched by age, sex, and calendar year.

Results

The median follow-up period was 10 years (range 0–44 years). Two-thirds (67%) of the DAVFs were located in the region of transverse and sigmoid sinuses. Cortical venous drainage (CVD) was present in 28% of the DAVFs (18% transverse and sigmoid sinus, 42% others). Of the 61 deaths counted, 11 (18%) were during the first 12 months and were mainly caused by treatment complications (5 of 11, 45%). The 1-year survivors presenting with hemorrhage experienced excess mortality until 7 years from admission. However, DAVFs with CVD were associated with significant, continuous excess mortality. There were more cerebrovascular and cardiovascular deaths in this group of patients than expected in the general Finnish population. Location other than transverse and sigmoid sinuses was also associated with excess mortality.

Conclusions

In the patients with DAVF there was excess mortality during the first 12 months, mainly due to treatment complications. Thereafter, their overall long-term survival became similar to that of the matched general population. However, DAVFs with CVD and those located in regions other than transverse and sigmoid sinuses were associated with marked long-term excess mortality after the first 12 months.

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Elina Koskela, Johanna Pekkola, Riku Kivisaari, Tero Kivelä, Juha Hernesniemi, Kirsi Setälä, and Aki Laakso

Object

Terson's syndrome (TS) is a vitreous hemorrhage in association with subarachnoid hemorrhage (SAH). Its diagnosis is often delayed, which may result in vision loss secondary to treatable conditions. Methods to hasten early diagnosis and consequent ophthalmic referral are desirable. The aims of this study were 1) to assess the specificity and sensitivity of conventional head CT for diagnosing TS in patients with aneurysmal SAH (aSAH); and 2) to determine the incidence of TS and its association with age, sex, aSAH severity, and overall mortality.

Methods

Patients admitted to Helsinki University Central Hospital who underwent surgery or endovascular treatment for a ruptured intracranial aneurysm during 2011 were participants in this prospective study. They underwent serial dilated fundoscopic examinations during a 6-month period. Two radiologists independently reviewed ocular findings suggestive of TS on conventional CT head scans obtained in all patients as a routine diagnostic procedure. Associations between TS and relevant clinical, radiological, and demographic data were analyzed with uni- and multivariate logistic regression.

Results

Of 121 participants, 13 (11%) presented with TS, and another 22 (18%) with intraretinal hemorrhages. For reviewing CT head scans, the overall observed agreement between the 2 raters was 96% (116 of 121 cases), with a substantial κ of 0.69 (95% CI 0.56–0.82). The sensitivity of the CT findings for TS was 42%, and the specificity was 97%. Associations of the World Federation of Neurosurgical Societies (WFNS) and Hunt and Hess grades on admission, the presence of intracerebral hemorrhage, female sex, and aneurysm length with TS were all statistically significant. Logistic regression demonstrated that sex and WFNS grade were independently associated with TS and provided the best fit to the data.

Conclusions

Routinely looking for TS findings in CT head scans may prove valuable in clinical practice. Terson's syndrome is associated with female sex and poor clinical condition on admission.