| 1. |
- Bartley, Andreas, et al.
(författare)
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The Swedish study of Irrigation-fluid temperature in the evacuation of Chronic subdural hematoma (SIC!) : study protocol for a multicenter randomized controlled trial
- 2017
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Ingår i: Trials. - : BIOMED CENTRAL LTD. - 1745-6215. ; 18
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Tidskriftsartikel (refereegranskat)abstract
- Background: Chronic subdural hematoma (cSDH) is one of the most common conditions encountered in neurosurgical practice. Recurrence, observed in 5-30% of patients, is a major clinical problem. The temperature of the irrigation fluid used during evacuation of the hematoma might theoretically influence recurrence rates since irrigation fluid at body temperature (37 degrees C) may beneficially influence coagulation and cSDH solubility when compared to irrigation fluid at room temperature. Should no difference in recurrence rates be observed when comparing irrigation-fluid temperatures, there is no need for warmed fluids during surgery. Our main aim is to investigate the effect of irrigation-fluid temperature on recurrence rates and clinical outcomes after cSDH evacuation using a multicenter randomized controlled trial design.Methods: The study will be conducted in three neurosurgical departments with population-based catchment areas using a similar surgical strategy. In total, 600 patients fulfilling the inclusion criteria will randomly be assigned to either intraoperative irrigation with fluid at body temperature or room temperature. The power calculation is based on a retrospective study performed at our department showing a recurrence rate of 5% versus 12% when comparing irrigation fluid at body temperature versus fluid at room temperature (unpublished data). The primary endpoint is recurrence rate of cSDH analyzed at 6 months post treatment. Secondary endpoints are mortality rate, complications and health-related quality of life.Discussion: Irrigation-fluid temperature might influence recurrence rates in the evacuation of chronic subdural hematomas. We present a study protocol for a multicenter randomized controlled trial investigating our hypothesis that irrigation fluid at body temperature is superior to room temperature in reducing recurrence rates following evacuation of cSDH.
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| 2. |
- Ronne-Engström, Elisabeth, et al.
(författare)
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Outcome from spontaneous subarachnoid haemorrhage : results from 2007-2011 and comparison with our previous series
- 2014
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Ingår i: Upsala Journal of Medical Sciences. - : Uppsala Medical Society. - 0300-9734 .- 2000-1967. ; 119:1, s. 38-43
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Tidskriftsartikel (refereegranskat)abstract
- ObjectivesThe management of patients with spontaneous subarachnoid haemorrhage (SAH) has changed, in part due to interventions now being extended to patients who are older and in a worse clinical condition. This study evaluates the effects of these changes on a complete 5-year patient material.MethodsDemographic data and results from 615 patients with SAH admitted from 2007 to 2011 were put together. Aneurysms were found in 448 patients (72.8%). They were compared with the aneurysm group (n = 676) from a previously published series from our centre (2001-2006). Linear regression was used to determine variables predicting functional outcome in the whole aneurysm group (2001-2011).ResultsPatients in the more recent aneurysm group were older, and they were in a worse clinical condition on admission. Regarding younger patients admitted in World Federation of Neurosurgical Societies SAH grading (WFNS) 3, there were fewer with a good outcome. In the whole aneurysm group 2001-2011, outcome was best predicted by age, clinical condition at admission, and the size of the bleeding, and not by treatment mode or localization of aneurysm.ConclusionIt seems important for the outcome that aneurysms are treated early. The clinical course after that depends largely on the condition of the patient on admission rather than on aneurysm treatment method. This, together with the fact that older patients and those in worse condition are now being admitted, increases demands on neurointensive care. Further improvement in patient outcome depends on better understanding of acute brain injury mechanisms and improved neurointensive care as well as rehabilitation measures.
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| 3. |
- Hossain, Iftakher, et al.
(författare)
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The management of severe traumatic brain injury in the initial postinjury hours : current evidence and controversies
- 2023
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Ingår i: Current Opinion in Critical Care. - : Wolters Kluwer. - 1070-5295 .- 1531-7072. ; 29:6, s. 650-658
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Forskningsöversikt (refereegranskat)abstract
- Purpose of review To provide an overview of recent studies discussing novel strategies, controversies, and challenges in the management of severe traumatic brain injury (sTBI) in the initial postinjury hours.Recent findings Prehospital management of sTBI should adhere to Advanced Trauma Life Support (ATLS) principles. Maintaining oxygen saturation and blood pressure within target ranges on-scene by anesthetist, emergency physician or trained paramedics has resulted in improved outcomes. Emergency department (ED) management prioritizes airway control, stable blood pressure, spinal immobilization, and correction of impaired coagulation. Noninvasive techniques such as optic nerve sheath diameter measurement, pupillometry, and transcranial Doppler may aid in detecting intracranial hypertension. Osmotherapy and hyperventilation are effective as temporary measures to reduce intracranial pressure (ICP). Emergent computed tomography (CT) findings guide surgical interventions such as decompressive craniectomy, or evacuation of mass lesions. There are no neuroprotective drugs with proven clinical benefit, and steroids and hypothermia cannot be recommended due to adverse effects in randomized controlled trials.Summary Advancement of the prehospital and ED care that include stabilization of physiological parameters, rapid correction of impaired coagulation, noninvasive techniques to identify raised ICP, emergent surgical evacuation of mass lesions and/or decompressive craniectomy, and temporary measures to counteract increased ICP play pivotal roles in the initial management of sTBI. Individualized approaches considering the underlying pathology are crucial for accurate outcome prediction.
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| 4. |
- Hutchinson, Peter J, et al.
(författare)
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Consensus statement from the 2014 International Microdialysis Forum
- 2015
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Ingår i: Intensive Care Medicine. - : Springer Science and Business Media LLC. - 0342-4642 .- 1432-1238. ; 41:9, s. 1517-1528
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Tidskriftsartikel (refereegranskat)abstract
- Microdialysis enables the chemistry of the extracellular interstitial space to be monitored. Use of this technique in patients with acute brain injury has increased our understanding of the pathophysiology of several acute neurological disorders. In 2004, a consensus document on the clinical application of cerebral microdialysis was published. Since then, there have been significant advances in the clinical use of microdialysis in neurocritical care. The objective of this review is to report on the International Microdialysis Forum held in Cambridge, UK, in April 2014 and to produce a revised and updated consensus statement about its clinical use including technique, data interpretation, relationship with outcome, role in guiding therapy in neurocritical care and research applications.
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| 5. |
- Abu Hamdeh, Sami, et al.
(författare)
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Extended anatomical grading in diffuse axonal injury using MRI : Hemorrhagic lesions in the substantia nigra and mesencephalic tegmentum indicate poor long-term outcome
- 2017
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Ingår i: Journal of Neurotrauma. - : Mary Ann Liebert Inc. - 0897-7151 .- 1557-9042. ; 5:34, s. 341-352
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Tidskriftsartikel (refereegranskat)abstract
- Clinical outcome after traumatic diffuse axonal injury (DAI) is difficult to predict. In this study, three magnetic resonance imaging (MRI) sequences were used to quantify the anatomical distribution of lesions, to grade DAI according to the Adams grading system, and to evaluate the value of lesion localization in combination with clinical prognostic factors to improve outcome prediction. Thirty patients (mean 31.2 years ±14.3 standard deviation) with severe DAI (Glasgow Motor Score [GMS] <6) examined with MRI within 1 week post-injury were included. Diffusion-weighted (DW), T2*-weighted gradient echo and susceptibility-weighted (SWI) sequences were used. Extended Glasgow outcome score was assessed after 6 months. Number of DW lesions in the thalamus, basal ganglia, and internal capsule and number of SWI lesions in the mesencephalon correlated significantly with outcome in univariate analysis. Age, GMS at admission, GMS at discharge, and low proportion of good monitoring time with cerebral perfusion pressure <60 mm Hg correlated significantly with outcome in univariate analysis. Multivariate analysis revealed an independent relation with poor outcome for age (p = 0.005) and lesions in the mesencephalic region corresponding to substantia nigra and tegmentum on SWI (p = 0.008). We conclude that higher age and lesions in substantia nigra and mesencephalic tegmentum indicate poor long-term outcome in DAI. We propose an extended MRI classification system based on four stages (stage I—hemispheric lesions, stage II—corpus callosum lesions, stage III—brainstem lesions, and stage IV—substantia nigra or mesencephalic tegmentum lesions); all are subdivided by age (≥/<30 years).
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| 6. |
- Bobinski, Lukas, 1977-
(författare)
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On evolution of intracranial changes after severe traumatic brain injury and its impact on clinical outcome
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Severe traumatic brain injury (sTBI) is a cause of death and disability worldwide and requires treatment at specialized neuro-intensive care units (NICU) with a multimodal monitoring approach. The CT scan imaging supports the monitoring and diagnostics. The level of S100B and neuron specific enolase (NSE) reflects the severity of the injury. The therapy resistant intracranial hypertension requires decompressive craniectomy (DC). After DC, the cranium must be reconstructed to recreate the normal intracranial physiology as well as to address cosmetic issues. The evolution of the pathological intracranial changes was analyzed in accordance with the three CT classifications: Marshall, Rotterdam and Morris-Marshall. The Rotterdam scale was best in describing the dynamics of the pathological evolution. Both the Rotterdam score and Morris- Marshall classification showed strong correlation with the clinical outcome, a finding that suggests that they could be used for prognostication. We demonstrated a clear correlation between the CT classifications and concentrations of S100B and NSE. The results revealed a concomitant correlation between NSE and S100B and clinical outcome. We found that the interaction between the ICP, Rotterdam CT classification, and concentrations of biochemical biomarkers are all associated with DC. We found a high percentage of complications following cranioplasty. Our results call into question whether custom-made allograft should be considered the best material for cranioplasty. It is concluded that both the Rotterdam and Morris-Marshall classification contribute to clinical evaluation of intracranial dynamics after sTBI, and might be used in combination with biochemical biomarkers for better assessment. The decision to perform DC should include a re-assesment of ICP evolution, CT scan images and concentration of the biochemical biomarkers. Furthermore, when determining whether DC treatment should be used, surgeon should also consider the risks of the following cranioplasty.
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| 7. |
- Gard, Anna, et al.
(författare)
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Quality of life of ice hockey players after retirement due to concussions
- 2020
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Ingår i: Concussion. - : Future Medicine. - 2056-3299. ; 5:3
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Tidskriftsartikel (refereegranskat)abstract
- Background: Sports-related concussion (SRC) is increasingly recognized as a potential health problem in ice hockey. Quality of life (QoL) in players retiring due to SRC has not been thoroughly addressed. Materials & methods: QoL using the Sports Concussion Assessment Tool 5th Edition, Impact of Event Scale-Revised and Short Form Health Survey was measured in Swedish ice hockey players who retired due to persistence of postconcussion symptoms or fear of attaining additional SRC. Results: A total of 76 players were assessed, on average of 5 years after their most recent SRC. Overall, retired players had a high burden of postconcussion symptoms and reduced QoL. Conclusion: Retired concussed ice hockey players have a reduced QoL, particularly those retiring due to postconcussion symptoms. Symptom burden should be continuously evaluated and guide the decision to retire.
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| 8. |
- Skoglund, Karin, et al.
(författare)
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The Neurological Wake-up Test Does not Alter Cerebral Energy Metabolism and Oxygenation in Patients with Severe Traumatic Brain Injury
- 2014
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Ingår i: Neurocritical Care. - New York : Springer Science and Business Media LLC. - 1541-6933 .- 1556-0961. ; 20:3, s. 413-426
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Tidskriftsartikel (refereegranskat)abstract
- The neurological wake-up test (NWT) is used to monitor the level of consciousness in patients with traumatic brain injury (TBI). However, it requires interruption of sedation and may elicit a stress response. We evaluated the effects of the NWT using cerebral microdialysis (MD), brain tissue oxygenation (PbtiO2), jugular venous oxygen saturation (SjvO(2)), and/or arterial-venous difference (AVD) for glucose, lactate, and oxygen in patients with severe TBI. Seventeen intubated TBI patients (age 16-74 years) were sedated using continuous propofol infusion. All patients received intracranial pressure (ICP) and cerebral perfusion pressure (CPP) monitoring in addition to MD, PbtiO2 and/or SjvO(2). Up to 10 days post-injury, ICP, CPP, PbtiO2 (51 NWTs), MD (49 NWTs), and/or SjvO(2) (18 NWTs) levels during propofol sedation (baseline) and NWT were compared. MD was evaluated at a flow rate of 1.0 mu L/min (28 NWTs) or the routine 0.3 mu L/min rate (21 NWTs). The NWT increased ICP and CPP levels (p < 0.05). Compared to baseline, interstitial levels of glucose, lactate, pyruvate, glutamate, glycerol, and the lactate/pyruvate ratio were unaltered by the NWT. Pathological SjvO(2) (< 50 % or > 71 %; n = 2 NWTs) and PbtiO2 (< 10 mmHg; n = 3 NWTs) values were rare at baseline and did not change following NWT. Finally, the NWT did not alter the AVD of glucose, lactate, or oxygen. The NWT-induced stress response resulted in increased ICP and CPP levels although it did not negatively alter focal neurochemistry or cerebral oxygenation in TBI patients.
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| 9. |
- Åkerlund, Cecilia, 1983-
(författare)
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Pathophysiological characterization of traumatic brain injury using novel analytical methods
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Severity of traumatic brain injury is usually classified by Glasgow coma scale (GCS) as “mild”, "moderate" or "severe’, which does not capture the heterogeneity of the disease. According to current guidelines, intracranial pressure (ICP) should not exceed 22 mmHg, with no further recommendations concerning individualization or tolerable duration of intracranial hypertension. The aims of this thesis were to identify subgroups of patients beyond characterization using GCS, and to investigate the impact of duration and magnitude of intracranial hypertension on outcome, using data from the observational prospective study Collaborative European neurotrauma effectiveness research in TBI (CENTER-TBI). To investigate the temporal aspect of tolerable ICP elevations, we examined the correlation between dose of ICP and outcome represented by 6-month Glasgow outcome scale extended (GOSE). ICP dose was represented both by the number of events above thresholds for ICP magnitude and duration and by area under the ICP curve (i.e., “pressure time dose” (PTD)). A variation in tolerable ICP thresholds of 18 mmHg +/- 4 mmHg (2 standard deviations (SD)) for events with duration longer than five minutes was identified using a bootstrapping technique. PTD was correlated to both mortality and unfavorable outcome. A cerebrovascular autoregulation (CA) dependent ICP tolerability was identified. If CA was impaired, no tolerable ICP magnitude and duration thresholds were identified, while if CA was intact, both 19 mmHg for 5 minutes or longer and 15 mmHg for 50 minutes or longer were correlated to worse outcome. While no significant difference in PTD was seen between favorable and unfavorable outcome if CA was intact, there was a significant difference if CA was impaired. In a multivariable analysis, PTD did not remain a significant predictor of outcome when adjusting for other known predictors in TBI. In a causal inference analysis, both cerebrovascular autoregulation status and ICP-lowering therapies represented by the therapy intensity level (TIL) have a directional relationship with outcome. However, no direct causal relationship of ICP towards outcome was found. By applying an unsupervised clustering method, we identified six distinct admission clusters defined by GCS, lactate, oxygen saturation (SpO2), creatinine, glucose, base excess, pH, PaCO2, and body temperature. These clusters can be summarized in clinical presentation and metabolic profile. When clustering longitudinal features during the first week in the intensive care unit (ICU), no optimal number of clusters could be seen. However, glucose variation, a panel of brain biomarkers, and creatinine consistently described trajectories. Although no information on outcome was included in the models, both admission clusters and trajectories showed clear outcome differences, with mortality from 7 to 40% in the admission clusters and 4 to 85% in the trajectories. Adding cluster or trajectory labels to the established outcome prediction IMPACT model significantly improved outcome predictions. The results in this thesis support the importance of cerebrovascular autoregulation status as it was found that CA status was more informative towards outcome than ICP magnitude and duration. There was a variation in tolerable ICP intensity and duration dependent on whether CA was intact. Distinct clusters defined by GCS and metabolic profiles related to outcome suggest the importance of an extracranial evaluation in addition to GCS in TBI patients. Longitudinal trajectories of TBI patients in the ICU are highly characterized by glucose variation, brain biomarkers and creatinine.
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| 10. |
- Bartley, Andreas, et al.
(författare)
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Effect of Irrigation Fluid Temperature on Recurrence in the Evacuation of Chronic Subdural Hematoma A Randomized Clinical Trial
- 2023
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Ingår i: Jama Neurology. - : American Medical Association (AMA). - 2168-6149 .- 2168-6157.
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Tidskriftsartikel (refereegranskat)abstract
- ImportanceThe effect of a physical property of irrigation fluid (at body vs room temperature) on recurrence rate in the evacuation of chronic subdural hematoma (cSDH) needs further study.ObjectiveTo explore whether irrigation fluid temperature has an influence on cSDH recurrence.Design, Setting, and ParticipantsThis was a multicenter randomized clinical trial performed between March 16, 2016, and May 30, 2020. The follow-up period was 6 months. The study was conducted at 3 neurosurgical departments in Sweden. All patients older than 18 years undergoing cSDH evacuation during the study period were screened for eligibility in the study.InterventionsThe study participants were randomly assigned by 1:1 block randomization to the cSDH evacuation procedure with irrigation fluid at room temperature (RT group) or at body temperature (BT group).Main Outcomes and MeasuresThe primary end point was recurrence requiring reoperation within 6 months. Secondary end points were mortality, health-related quality of life, and complication frequency.ResultsAt 6 months after surgery, 541 patients (mean [SD] age, 75.8 [9.8] years; 395 men [73%]) had a complete follow-up according to protocol. There were 39 of 277 recurrences (14%) requiring reoperation in the RT group, compared with 16 of 264 recurrences (6%) in the BT group (odds ratio, 2.56; 95% CI, 1.38-4.66; P < .001). There were no significant differences in mortality, health-related quality of life, or complication frequency.Conclusions and RelevanceIn this study, irrigation at body temperature was superior to irrigation at room temperature in terms of fewer recurrences. This is a simple, safe, and readily available technique to optimize outcome in patients with cSDH. When irrigation is used in cSDH surgery, irrigation fluid at body temperature should be considered standard of care.
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