Intracerebellar haemorrhage constitutes around 10% of all spontaneous, non-aneurysmal intracerebral haemorrhages (ICHs) and often carries a grim prognosis. In symptomatic patients, surgical evacuation is usually regarded the standard treatment. Our objective was to compare the in-hospital mortality and functional outcome at hospital discharge in either medically or surgically treated patients, and the impact of either treatment on long-term mortality after a cerebellar ICH.An observational, retrospective, single-centre consecutive series of 114 patients with cerebellar ICH. We assessed the effect of different demographic factors on functional outcome and in-hospital mortality using logistic regression. We also divided the patients in medical and surgical treatment groups based on how they had been treated and compared the clinical and radiological parameters, in-hospital, and long-term mortality in the different groups.In our series, 38 patients (33.3%) underwent haematoma evacuation and 76 (66.7%) received medical treatment. Glasgow coma scale <8, blocked quadrigeminal cistern, and severe hydrocephalus were associated with in-hospital death or poor functional outcome at discharge (modified Rankin scale 4-6). Surgically treated patients were younger, had larger haematomas both in volume and diameter, were in a worse clinical condition, and suffered more from hydrocephalus and brainstem compression. There were no statistically significant differences in in-hospital or long-term mortality. However, the surgically treated patients remained in a poor clinical condition.Surgical treatment of cerebellar ICH can be life-saving but often leads to a poor functional outcome. New studies are needed on long-term functional outcome after a cerebellar ICH.
Introduction Endoscopic third ventriculostomy (ETV) is becoming an increasingly widespread treatment for hydrocephalus, but research is primarily based on paediatric populations. In 2009, Kulkarni et al created the ETV Success score to predict the outcome of ETV in children. The purpose of this study is to create a prognostic model to predict the success of ETV for adult patients with hydrocephalus. The ability to predict who will benefit from an ETV will allow better primary patient selection both for ETV and shunting. This would reduce additional second procedures due to primary treatment failure. A success score specific for adults could also be used as a communication tool to provide better information and guidance to patients. Methods and analysis The study will adhere to the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis reporting guidelines and conducted as a retrospective chart review of all patients≥18 years of age treated with ETV at the participating centres between 1 January 2010 and 31 December 2018. Data collection is conducted locally in a standardised database. Univariate analysis will be used to identify several strong predictors to be included in a multivariate logistic regression model. The model will be validated using K-fold cross validation. Discrimination will be assessed using area under the receiver operating characteristic curve (AUROC) and calibration with calibration belt plots. Ethics and dissemination The study is approved by appropriate ethics or patient safety boards in all participating countries. Trial registration number NCT04773938 ; Pre-results.
Abstract Background The benefits of early surgery in cases of superficial supratentorial spontaneous intracerebral hemorrhage (ICH) are unclear. This study aimed to assess the association between early ICH surgery and outcome, as well as the cost-effectiveness of early ICH surgery. Methods We conducted a retrospective, register-based multicenter study that included all patients who had been treated for supratentorial spontaneous ICH in four tertiary intensive care units in Finland between 2003 and 2013. To be included, patients needed to have experienced supratentorial ICHs that were 10–100 cm 3 and located within 10 mm of the cortex. We used a multivariable analysis, adjusting for the severity of the illness and the probability of surgical treatment, to assess the independent association between early ICH surgery (≤ 1 day), 12-month mortality rates, and the probability of survival without permanent disability. In addition, we assessed the cost-effectiveness of ICH surgery by examining the effective cost per 1-year survivor (ECPS) and per independent survivor (ECPIS). Results Of 254 patients, 27% were in the early surgery group. Overall 12-month mortality was 39%, while 29% survived without a permanent disability. According to our multivariable analysis, early ICH surgery was associated with lower 12-month mortality rates (odds ratio [OR] 0.22, 95% confidence intervals [CI] 0.10–0.51), but not with a higher probability of survival without permanent disability (OR 1.23, 95% CI 0.59–2.56). For the early surgical group, the ECPS and ECPIS were €111,409 and €334,227, respectively. For the non-surgical cohort, the ECPS and ECPIS were €76,074 and €141,471, respectively. Conclusions Early surgery for superficial ICH is associated with a lower 12-month mortality risk but not with a higher probability of survival without a permanent disability. Further, costs were higher and cost-effectiveness was, thus, worse for the early surgical cohort.
Abstract Background Diffuse intrinsic pontine gliomas (DIPGs) have a dismal prognosis. Previously, diagnosis was based on a typical clinical presentation and magnetic resonance imaging findings. After the start of the era of biopsies, DIPGs bearing H3 K27 mutations have been reclassified into a novel entity, diffuse midline glioma, based on the presence of this molecular alteration. However, it is not well established how clinically diagnosed DIPG overlap with H3 K27‐mutated diffuse midline gliomas, and whether rare long‐term survivors also belong to this group. Methods We studied tumor samples obtained at diagnosis or upon autopsy from 23 children, including two long‐term survivors. Based on clinical, radiological, and histological findings, all tumors were previously diagnosed as DIPGs. All samples were analyzed for genetic alterations by next‐generation sequencing (NGS) and for protein expression by immunohistochemistry (IHC). Results H3 K27 was mutated in NGS or IHC in 20 patients, excluding both long‐term survivors. One of these long‐term survivors harbored a mutation in IDH1 , formerly considered to be an alteration absent in pediatric diffuse brainstem gliomas. Other altered genes in NGS included TP53 (10 patients), MET and PDGFRA (3 patients each), VEGFR and SMARCA4 (2 patients each), and PPARγ, PTEN and EGFR in 1 patient, respectively. IHC revealed cMYC expression in 15 of 24 (63%) of all samples, exclusively in the biopsies. Conclusions Eighty‐seven percent of the tumors formerly diagnosed as DIPGs could be reclassified as H3 K27‐mutated diffuse midline gliomas. Both long‐term survivors lacked this alteration. Contrary to former conceptions, IDH1 mutations may occur also in pediatric brainstem gliomas.
Patient and radiological characteristics of intracerebral hemorrhage (ICH), surgical treatment, and outcome after ICH are interrelated. Our purpose was to define whether these characteristics or surgical treatment correlate with mortality among young adults.We retrospectively reviewed clinical and imaging data of all first-ever nontraumatic patients with ICH between 16 and 49 years of age treated in our hospital between January 2000 and March 2010 and linked these data with national causes of death registry. A logistic regression analysis of factors associated with 3-month mortality and a propensity score comparison between patients treated conservatively and operatively was performed.Among the 325 eligible patients (59.4% men), factors associated with 3-month mortality included higher National Institutes of Health Stroke Scale score, infratentorial location, hydrocephalus, herniation, and multiple hemorrhages. Adjusted for these factors, as well as demographics, ICH volume, and the underlying cause, surgical evacuation was associated with lower 3-month mortality (odds ratio, 0.06; 95% confidence interval, 0.02-0.21). In propensity score-matched analysis, 3-month case fatality rates were 3-fold in those treated conservatively (27.5% versus 7.8%; P<0.001).The predictors of short-term case fatality are alike in young and elderly patients with ICH. However, initial hematoma evacuation was associated with lower 3-month case fatality in our young patients with ICH.
Background and Purpose: Intracerebral hemorrhage (ICH) related seizures have not been thoroughly investigated. We evaluated their frequency, predictors, and influence on patient outcome. We then created and validated a simple score to estimate the risk of developing late seizures (LS). Methods: Consecutive ICH patients’ (n=993) province-wide electronic patient records were retrospectively evaluated for onset seizures (OS), acute seizures (AS, occurring within 7 days from stroke), and among 7-day survivors (n=764), also LS occurring >7 days from stroke. A Cox regression model estimating variables associated with risk of LS was used to derive a simple integer-based prognostic score. The score was validated externally in a prospective cohort of ICH patients from Lille, France (n=325). Results: Of the total cohort, 64 (6.5%) had OS and 61 (6.1%) AS. Among the 7-day survivors, during a median follow-up of 2.7 years, 70 (9.2%) patients developed LS. The cumulative risk of LS among survivors was 7.1% at 1 year after ICH, 10.0% at 2 years, 10.2% at 3 years, 11.0% at 4 years, and 11.8% at 5 years. Seizures at any time point were not associated with increased mortality. We created the CAVE score (0 to 4 points) to predict risk of LS, with one point for each of: Cortical involvement, Age<65 years, Volume >10 mL, and Early seizures at onset or within 7 days of ICH. The corresponding risk of LS was 0.6%, 3.6%, 9.8%, 34.8%, and 46.2%, for CAVE scores 0-4, respectively, with AUC-ROC of 0.81 (0.76-0.86). The score stratified risk of LS also in the validation cohort, being 3.1%, 5.0%, 15.8%, 13.5%, and 37.5% respectively, with AUC-ROC of 0.69 (0.59-0.78). Conclusion: One in ten patients will develop seizures after ICH. This adverse outcome can be predicted by a simple score based on baseline variables.
Introduction Chronic subdural haematomas (CSDHs) are one of the most common neurosurgical conditions. The goal of surgery is to alleviate symptoms and minimise the risk of symptomatic recurrences. In the past, reoperation rates as high as 20%–30% were described for CSDH recurrences. However, following the introduction of subdural drainage, reoperation rates dropped to approximately 10%. The standard surgical technique includes burr-hole craniostomy, followed by intraoperative irrigation and placement of subdural drainage. Yet, the role of intraoperative irrigation has not been established. If there is no difference in recurrence rates between intraoperative irrigation and no irrigation, CSDH surgery could be carried out faster and more safely by omitting the step of irrigation. The aim of this multicentre randomised controlled trial is to study whether no intraoperative irrigation and subdural drainage results in non-inferior outcome compared with intraoperative irrigation and subdural drainage following burr-hole craniostomy of CSDH. Methods and analysis This is a prospective, randomised, controlled, parallel group, non-inferiority multicentre trial comparing single burr-hole evacuation of CSDH with intraoperative irrigation and evacuation of CSDH without irrigation. In both groups, a passive subdural drain is used for 48 hours as a standard of treatment. The primary outcome is symptomatic CSDH recurrence requiring reoperation within 6 months. The predefined non-inferiority margin for the primary outcome is 7.5%. To achieve a 2.5% level of significance and 80% power, we will randomise 270 patients per group. Secondary outcomes include modified Rankin Scale, rate of mortality, duration of operation, length of hospital stay, adverse events and change in volume of CSDH. Ethics and dissemination The study was approved by the institutional review board of the Helsinki and Uusimaa Hospital District (HUS/3035/2019 §238) and duly registered at ClinicalTrials.gov. We will disseminate the findings of this study through peer-reviewed publications and conference presentations. Trial registration number NCT04203550
To the Editor: Over the past 2 decades, the number of open cerebrovascular surgical caseloads has rapidly decreased.1,2 Among the various cerebrovascular procedures, clipping of intracranial aneurysms (IAs) has declined particularly following the rise of endovascular options.3 Microsurgical clipping is a complex task demanding clinical and surgical experience to understand indications, master microsurgical techniques, and manage complications. Thus, large caseloads and hands-on practice are of utmost importance. However, residents’ exposure to clipping procedures has declined alongside the decreasing number of clippings.2,4 Concurrently, overall hands-on opportunities during European residencies have decreased due to work-hour restrictions and multidimensional training programs.5-7 Clipping is nevertheless still relevant for certain IAs based on patient and aneurysm characteristics.8 Hence, there remains a be it limited demand for microsurgical clipping, and a need for neurosurgeons adequately trained in open vascular neurosurgery. Given these developments, we must develop a strategy to pass on the craft of clipping IAs to next-generation neurosurgeons while maintaining quality standards. We believe that the establishment of cerebrovascular surgery fellowship programs could form a solid strategy. In this letter, we aim at outlining the potential of structured vascular neurosurgery fellowships in Europe, where these fellowships are still few. Overseas, fellowships stimulating subspecialty training are well established. Hence, we consider it worthwhile to learn from the North American experience. FRAMEWORK FOR A CEREBROVASCULAR FELLOWSHIP A structured cerebrovascular fellowship is a postgraduate clinical and surgical subspecialty training. In North American countries, where fellowships are well established, cerebrovascular fellowships cover 1 to 2 yr, and often include endovascular training, resulting in hybrid neurosurgeons. We will here focus on open vascular fellowships, as the discussion on hybrid training is beyond our scope. To establish a structure for cerebrovascular fellowships, we need to acknowledge certain prerequirements. First, fellowships should take place in subspecialized host departments with sufficient caseloads and multiple neurovascular surgeons. Regarding the caseload, a recent study showed that North American cerebrovascular fellowships offer a median number of 246 vascular cases, including 105 open vascular cases and 80 open aneurysm cases.4 Secondly, external training evaluation and accreditation are important to guarantee the fellowship's quality, and to strengthen the establishment of the fellowship. North American experience has allowed us to learn that accredited fellowships often provide a larger exposure to vascular cases.4 Lastly, dedicated young neurosurgeons with a particular interest in vascular neurosurgery, and a willingness to travel abroad, are needed to make the most of the fellowship. Further training facilities could include structured surgical videos, practical microsurgical simulations, realistic aneurysm simulations, and the opportunity to attend live courses and dissection courses.9,10 Whether this can compensate for the declining hands-on training remains to be elucidated. BENEFITS On first sight, training of fellows may appear like “resource squandering.” However, important benefits should hereby be considered by host departments. Fellows may bridge the gap between residents and consultants, and unburden the department's staff. In North America, fellows are an integral part in the patient's treatment. They are actively involved in residents’ training, on-calls, as well as research, and can also deliver new inputs, which they have acquired during residency at other institutions. Therefore, fellows are fully compensated by the host departments and need not to apply for separate funding. Moreover, the established networks often remain intact after completion of the fellowship, enabling continuous collaborations between centers and alumni. For young neurosurgeons, the opportunity to be involved in the management of a large number of aneurysm cases is the major benefit of a cerebrovascular fellowship. As the spindle of a cerebrovascular team, the fellow is trained in microsurgical techniques, while improving his understanding of decision making, complication management, and outcome evaluation. Inclusion in the department's research lines stimulates the fellows’ development in their theoretical and scientific basis. In this way, a vascular fellowship offers a broad skill set to young neurosurgeons, thereby accelerating their expertise in the field. Although fellowships may form a solid base, fellows will still need time and support to gradually gain experience and improve their skills afterward. BARRIERS Europe consists of many individual countries with their own language, legal constraints, and socio-economic situation. All these factors affect fellowship opportunities. The recently introduced “European Board Certification” may help to bring pan-European neurosurgical education closer together; however, it is yet lacking legal status. Further synchronization and more similar structured competency-based programs across Europe may contribute to opportunity equality.11,12 The organization and accreditation of fellowship programs needs an overarching coordination. We believe that the European Association of Neurosurgical Societies (EANS) could play a leading role in this. Moreover, the EANS has recently accredited centers throughout Europe as “Centers of Excellence in Neurosurgical Training.” In this line, large and scientifically active vascular neurosurgical centers could be appointed to host fellowships. As such, the EANS and these centers could form a driving force for establishing structured vascular fellowships. CONCLUSION Cerebrovascular, particularly open aneurysm, surgery opportunities are decreasing. Improving training by establishing cerebrovascular fellowships may compensate for this to maintain quality standards. We believe European vascular neurosurgical education would greatly benefit in the long term from these potential developments. Funding Dr Schwartz and Dr Haeren were awarded the Helsinki C. Ehrnrooth clinical skull base and vascular neurosurgery fellowship. Disclosures Dr Satopää received financial compensation from Sanofi. The other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
