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Tiit Mathiesen, Göran Edner, and Lars Kihlström

Object. The goal of this study was to provide epidemiological and clinical data on the management of cavernomas of the basal ganglia and brainstem from a long-term series at one institution.

Methods. All 68 patients who were referred to the authors' department between 1992 and 2000 for deep cavernomas were evaluated by clinic examinations, review of neuroimaging examinations, and review of charts and operative notes.

Twenty-nine patients underwent microsurgical procedures, which carried a 69% risk of transitory neurological deterioration. Radical excision was achieved in 25 of these patients, as determined by a review of neuroimages; the remaining four patients all experienced new hemorrhages that led to increased morbidity or even to mortality. Surgical results were better if surgery was performed early, within 1 month posthemorrhage, than if operations were postponed. In selected patients, deep lesions not reaching a pial surface could be safely removed from the thalamus, basal ganglia, or medulla oblongata. Of five patients who underwent gamma knife surgery, two experienced hemorrhages, one at 2 and the other at 5 years following treatment. Patients who did not undergo surgery had a yearly incidence of hemorrhage that was 2% in cases of incidental cavernomas and 7% in symptomatic ones.

Conclusions. Over the long term, outcomes were worse following conservative treatment or shunt insertion surgery than after microsurgery of symptomatic cavernomas. Incidental cavernomas carried a low risk of neurological deterioration.

Surgery should follow generally accepted indications, but only with the confidence that total removal can be safely achieved. Surgery that is performed within 10 to 30 days following ictus may be preferable to delayed surgery.

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Overall outcome in aneurysmal subarachnoid hemorrhage

A prospective study from neurosurgical units in Sweden during a 1-year period

Hans Säveland, Jan Hillman, Lennart Brandt, Göran Edner, Karl-Erik Jakobsson, and Göran Algers

✓ The present prospective study, with participation of five of the six neurosurgical centers in Sweden, was conducted to evaluate the overall management results in patients with aneurysmal subarachnoid hemorrhage (SAH). The participating centers covered 6.93 million (81%) of Sweden's 8.59 million inhabitants. All patients with verified aneurysmal SAH admitted between June 1, 1989, and May 31, 1990, were included in this prospective study. A uniform management protocol was adopted involving ultra-early referral, earliest possible surgery, and aggressive anti-ischemic treatment.

A total of 325 patients were admitted during the study period, 69% within 24 hours after hemorrhage. On admission, the patients were graded according to the scale of Hunt and Hess: 43 patients (13%) were classified in Grade I, 119 (37%) in Grade II, 53 (16%) in Grade III, 76 (23%) in Grade IV, and 34 (II%) in Grade V. Nimodipine was administered to 269 of the 325 patients: intravenously in 218, orally in 15, and intravenously followed by orally in 36. At follow-up examination 3 to 6 months after SAH, 183 patients (56%) were classified as having made a good neurological recovery, 73 patients (23%) suffered some morbidity, and 69 (21%) were dead. Surgery was performed in 276 (85%) of the patients; emergency surgery with evacuation of an associated intracerebral hematoma was carried out in 30 patients. Early surgery (within 72 hours after SAH) was performed in 170 individuals, intermediate surgery (between Days 4 and 6 post-SAH) in 29 patients, and late surgery (Day 7 or later after SAH) in 47 individuals. Of 145 patients with supratentorial aneurysms who were preoperatively in Hunt and Hess Grades I to III and who were treated within 72 hours, 81 made a good recovery; in 5.5% of patients, the unfavorable outcome was ascribed to delayed ischemia. It is concluded that, among patients with all clinical grades and aneurysmal locations, almost six of 10 SAH victims referred to a neurosurgical unit can be saved and can recover to a normal life.

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Tiit Mathiesen, Göran Edner, Elfar Ulfarsson, and Birger Andersson

✓ Subarachnoid hemorrhage (SAH) causes an inflammatory reaction and may lead to ischemic brain damage. Experimental ischemia has been shown to be connected with the alarm-reaction cytokines interleukin-1 receptor antagonist (IL-1Ra) and tumor necrosis factor—α (TNFα). Increased levels of these cytokines, however, have not been detected thus far in patients following an SAH event.

For this reason daily cerebrospinal fluid (CSF) samples were collected from 22 consecutively enrolled patients with SAH and from 10 non-SAH patients (controls). The CSF samples were studied using immunoassays for IL-1Ra and TNFα to investigate whether an SAH caused increased cytokine levels.

The mean IL-1Ra levels were significantly higher in patients with SAH who were in poor clinical condition on admission than in those who were in good condition (318 pg/ml vs. 82 pg/ml, p < 0.02). The IL-1Ra levels increased during delayed ischemic episodes and after surgery in patients who were in poor clinical condition. Significant increases in IL-1Ra and TNFα were detected during Days 4 through 10 in patients suffering from SAH who eventually had a poor outcome (p < 0.05). Patients with good outcomes and control patients had low levels of these cytokines.

The levels of IL-1Ra increased after surgery in patients with Hunt and Hess Grades III through V, but not in those with Grade I or II. This finding indicates that patients in poor clinical condition have a labile biochemical state in the brain that is reflected in increased cytokine levels following the surgical trauma.

Both IL-1Ra and TNFα are known to induce fever, malaise, leukocytosis, and nitric oxide synthesis and to mediate ischemic and traumatic brain injuries. The present study shows that levels of these cytokines increase after SAH occurs and that high cytokine levels correlate with brain damage. It is therefore likely that fever, leukocytosis, and nitric oxide synthesis are also mediated by IL-1 in patients suffering from SAH and it is probable that the inflammatory mediators contribute to brain damage.

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Göran Edner, David M. C. Forster, Ladislau Steiner, and Ulf Bergvall

✓ A case of spontaneous intra-aneurysmal thrombosis, verified angiographically, is reported in a patient with subarachnoid hemorrhage and without surgical intervention. The frequency of such an occurrence and the factors involved are reviewed and discussed.

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Steen Fridriksson, Hans Säveland, Karl-Erik Jakobsson, Göran Edner, Stefan Zygmunt, Lennart Brandt, and Jan Hillman

Object. With increasing use of endovascular procedures, the number of aneurysms treated surgically will decline. In this study the authors review complications related to the surgical treatment of aneurysms and address the issue of maintaining quality standards on a national level.

Methods. A prospective, nonselected amalgamation of every aneurysm case treated in five of six neurosurgical centers in Sweden during 1 calendar year was undertaken (422 patients; 7.4 persons/100,000 population/year). The treatment protocols at these institutions were very similar. Outcome was assessed using clinical end points. In this series, 84.1% of the patients underwent surgery, and intraoperative complications occurred in 30% of these procedures. Poor outcome from technical complications was seen in 7.9% of the surgically treated patients. Intraoperative aneurysm rupture accounted for 60% and branch sacrifice for 12% of all technical difficulties. Although these complications were significantly related to aneurysm base geometry and the competence of the surgeon, problems still occurred apparently at random and also in the best of hands (17%). The temporary mean occlusion time in the patients who suffered intraoperative aneurysm rupture was twice as long as the temporary arrest of blood flow performed to aid dissection.

Conclusions. The results obtained in this series closely reflect the overall management results of this disease and support the conclusion that surgical complications causing a poor outcome can be estimated on a large population-based scale. Intraoperative aneurysm rupture was the most common and most devastating technical complication that occurred. Support was found for a more liberal use of temporary clips early during dissection, regardless of the experience of the surgeon. Temporary regional interruption of arterial blood flow should be a routine method for aneurysm surgery on an everyday basis. A random occurrence of difficult intraoperative problems was clearly shown, and this factor of unpredictability, which is present in any preoperative assessment of risk, strengthens the case for recommending neuroprotection as a routine adjunct to virtually every aneurysm operation, regardless of the surgeon's experience.

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Jan Hillman, Hans SäVeland, Karl-Erik Jakobsson, Göran Edner, Stefan Zygmunt, Sten Fridriksson, and Lennart Brandt

✓ A study of the overall management of ruptured posterior fossa aneurysms was conducted over a 1-year period (1993) in five neurosurgical centers in Sweden, serving a population of 6.93 million people. Forty-nine cases were identified and treated. One-third of the patients were in the seventh or eighth decade of life. Good overall management outcomes at 6 months were achieved in 30 cases (61%). The overall mortality rate was 27%. Patients with Hunt and Hess Grades I and II had a good overall recovery rate of 87%. On admission, 69% of the patients were assigned Hunt and Hess Grades III to V. The impact on patient outcomes of the intraoperative difficulties encountered, especially in the basilar tip area, is stressed. The authors found that delayed operation is not warranted in most cases. Frequent devastating rebleeding was observed among patients not offered early aneurysm clipping and the operative results were not at significant variance between the early and late surgical groups. Only 50% of the patients scheduled for delayed surgery ultimately made a good recovery, whereas 72% of patients scheduled for early operation did so. The data demonstrate that overall management results with posterior fossa aneurysms, comparable to achievements with supratentorial lesions, are within the reach of modern strategies, even in centers not specializing in these problems.

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Karl-Erik Jakobsson, Hans Säveland, Jan Hillman, Göran Edner, Stefan Zygmunt, Lennart Brandt, and Luigi Pellettieri

✓ The impact of warning leaks on management results in patients with aneurysmal subarachnoid hemorrhage (SAH) was evaluated in this prospective study. In a consecutive series of 422 patients with aneurysmal SAH, 84 patients (19.9%) had an episode suggesting a warning leak; 34 (40.5%) of these patients were seen by a physician without the condition being recognized. The warning leak occurred less than 2 weeks before a major SAH in 75% of the patients.

A good outcome was experienced by 53.6% of patients who had a warning leak versus 63.3% of those who had no warning leak. In a subgroup of patients who had an interval of 3 days or less from warning leak to SAH, only 36.4% had a good outcome.

The proportion of patients in good neurological condition (Hunt and Hess Grades I and II) who had a good outcome was 88.1% in the group with no warning leak versus 53.6% in the group whose SAH was preceded by a warning leak. A difference of 35% between these two groups reflects the impact of an undiagnosed warning leak on patient outcome, based on the assumption that patients with a warning leak had clinical conditions no worse than Hunt and Hess Grade II at the time of the episode. In the subgroup of patients with the short interval between warning leak and SAH, the difference was almost 52%. The difference in outcome also reflects the potential improvement in outcome that can be achieved by a correct diagnosis of the warning leak. If the correct diagnosis is made in patients seeking medical attention due to a warning leak, favorable outcomes in the overall management of aneurysmal SAH are estimated to increase by 2.8%.

An active diagnostic attitude toward patients experiencing a sudden and severe headache is warranted as it offers a means of improving overall outcome in patients with SAH.

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Michael Söderman, Göran Edner, Kaj Ericson, Bengt Karlsson, Tiit Rähn, Elfar Ulfarsson, and Tommy Andersson

Object

The aim of this study was to assess the clinical efficacy of gamma knife surgery (GKS) in the treatment of dural arteriovenous shunts (DAVSs).

Methods

From a database of more than 1600 patients with intracranial arteriovenous shunts that had been treated with GKS, the authors retrospectively and prospectively identified 53 patients with 58 DAVSs from the period between 1978 and 2003. Four patients were lost to follow-up evaluation and were excluded from the series. Thus, this study is based on the remaining 49 patients with 52 DAVSs. Thirty-six of the shunts drained into the cortical venous system, either directly or indirectly, and 22 of these were associated with intracranial hemorrhage on patient presentation. The mean prescription radiation dose was 22 Gy (range 10–28 Gy).

All patients underwent a clinical follow-up examination. In 41 cases of DAVS a follow-up angiography study was performed. At the 2-year follow-up visit, 28 cases (68%) had angiographically proven obliteration of the shunt and in another 10 cases (24%) there was significant flow regression. Three shunts remained unchanged.

There was one immediate minor complication related to the administration of radiation. Furthermore, one patient had a radiation-induced complication 10 years after treatment, although she recovered completely. There was one posterior fossa bleed 2 months after radiosurgery; a hematoma, as well as a lesion, was evacuated, and the patient recovered uneventfully. A second patient had an asymptomatic occipital hemorrhage approximately 6 months postradiosurgery.

The clinical outcome after GKS was significantly better than that in patients with naturally progressing shunts (p < 0.01, chi-square test); figures on the latter have been reported previously.

Conclusions

Gamma knife surgery is an effective treatment for DAVSs, with a low risk of complications. Major disadvantages of this therapy include the time elapsed before obliteration and the possibility that not all shunts will be obliterated. Cortical venous drainage from a DAVS, a risk factor for intracranial hemorrhage, is therefore a relative contraindication. Consequently, GKS can be used in the treatment of both benign DAVSs with subjectively intolerable bruit and aggressive DAVSs not responsive to endovascular treatment or surgery.

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Jason Sheehan