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  • 1.
    Bader, Sam Er.
    et al.
    Örebro University, School of Medical Sciences. Department of Surgery.
    Sönnerqvist, Caroline
    Örebro University, School of Medical Sciences. Department of Paediatrics.
    Melander, Nils
    Örebro University, School of Medical Sciences. Deptartment of Neurology.
    Olivecrona, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Neurosurgery .
    A Validation Study of Kwon's Prognostic Scoring System for Chronic Subdural Haematoma2022In: World Neurosurgery, ISSN 1878-8750, E-ISSN 1878-8769, Vol. 165, p. e365-e372Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Surgery for chronic subdural haematoma (CSDH) is one of the most frequent operations in neurosurgical practice. CSDH afflicts the elderly population most. In 2018, Kwon and co-workers published the Kwon Scoring System (KSS), whereby six clinical and radiological factors are used to facilitate, and promote quality in, surgical decision-making and counselling of relatives. The aim of this study is to validate the KSS.

    METHOD: Patients operated on for unilateral CSDH at Orebro University Hospital, Sweden, between 2013 and 2019 constituted the study population. General data and the six outcome predictors according to the KSS were extracted from the electronic patient records. The pre-operative mRS score and the post-operative six-month mRS score were assessed.

    RESULTS: We identified 133 patients (69.2% male) with a median age of 80.2 years (IQR 72.6-85.9). The median GCS at admission was 15; 57.1% had motor deficits and 36.81% were disoriented. For 39.1% of the patients, the prognosis was a favourable outcome (mRS 0-1) at six months. The median KSS score was 9; 63.9% of the patients scored ≥ 9, and 36 (42.4%) of these patients actually achieved a favourable outcome. This corresponds to a prediction model sensitivity of 0.667 and specificity of 0.424. A ROC curve analysis of the model yielded an AUC of 0.62441.

    CONCLUSION: In our material, the KSS did not predict outcome precisely enough to base treatment decisions or counselling of relatives on the scores obtained.

  • 2.
    Chidiac, Christine
    et al.
    Örebro University, School of Medical Sciences. Department of Medical Sciences.
    Sundström, N.
    Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå, Sweden.
    Tullberg, M.
    Hydrocephalus Research Unit, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden.
    Arvidsson, L.
    Department of Clinical Neuroscience Karolinska Institutet, Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.
    Olivecrona, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Department of Neurosurgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Waiting time for surgery influences the outcome in idiopathic normal pressure hydrocephalus: a population-based study2022In: Acta Neurochirurgica, ISSN 0001-6268, E-ISSN 0942-0940, Vol. 164, no 2, p. 469-478Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Idiopathic normal pressure hydrocephalus (iNPH) is a disease that comes with a great impact on the patient's life. The only treatment for iNPH, which is a progressive disease, is shunt surgery. It is previously indicated that early intervention might be of importance for the outcome.

    AIM: To investigate if a longer waiting time for surgery, negatively influences the clinical outcome.

    METHODS: Eligible for this study were all iNPH patients (n = 3007) registered in the Swedish Hydrocephalus Quality Registry (SHQR) during 1st of January 2004-12th of June 2019. Waiting time, defined as time between the decision to accept a patient for surgery and shunt surgery, was divided into the intervals ≤ 3, 3.1-5.9 and ≥ 6 months. Clinical outcome was assessed 3 and 12 months after surgery using the modified iNPH scale, the Timed Up and Go (TUG) test and the mini mental state examination (MMSE).

    RESULTS: Three months after surgery, 57% of the patients with ≤ 3 months waiting time showed an improvement in modified iNPH scale (≥ 5 points) whereas 52% and 46% of patients with 3.1-5.9 and ≥ 6 months waiting time respectively improved (p = 0.0115). At 12 months of follow-up, the corresponding numbers were 61%, 52% and 51% respectively (p = 0.0536).

    CONCLUSIONS: This population-based study showed that in patients with iNPH, shunt surgery should be performed within 3 months of decision to surgery, to attain the best outcome.

  • 3.
    Hägglund, Linda
    et al.
    Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden.
    Olivecrona, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Anesthesia and Intensive Care, Section of Neurosurgery, Örebro University Hospital, Örebro, Sweden.
    Koskinen, Lars-Owe D.
    Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden.
    Correlation of Cerebral and Subcutaneous Glycerol in Severe Traumatic Brain Injury and Association with Tissue Damage2022In: Neurocritical Care, ISSN 1541-6933, E-ISSN 1556-0961, Vol. 36, no 3, p. 993-1001Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: This study is a substudy of a prospective consecutive double-blinded randomized study on the effect of prostacyclin in severe traumatic brain injury (sTBI). The aims of the present study were to investigate whether there was a correlation between brain and subcutaneous glycerol levels and whether the ratio of interstitial glycerol in the brain and subcutaneous tissue (glycerolbrain/sc) was associated with tissue damage in the brain, measured by using the Rotterdam score, S-100B, neuron-specific enolase (NSE), the Injury Severity Score (ISS), the Acute Physiology and Chronic Health Evaluation Score (APACHE II), and trauma type. A potential association with clinical outcome was explored.

    METHODS: Patients with sTBI aged 15-70 years presenting with a Glasgow Coma Scale Score ≤ 8 were included. Brain and subcutaneous adipose tissue glycerol levels were measured through microdialysis in 48 patients, of whom 42 had complete data for analysis. Brain tissue damage was also evaluated by using the Rotterdam classification of brain computed tomography scans and the biochemical biomarkers S-100B and NSE.

    RESULTS: In 60% of the patients, a positive relationship in glycerolbrain/sc was observed. Patients with a positive correlation of glycerolbrain/sc had slightly higher brain glycerol levels compared with the group with a negative correlation. There was no significant association between the computed tomography Rotterdam score and glycerolbrain/sc. S-100B and NSE were associated with the profile of glycerolbrain/sc. Our results cannot be explained by the general severity of the trauma as measured by using the Injury Severity Score or Acute Physiology and Chronic Health Evaluation Score.

    CONCLUSIONS: We have shown that peripheral glycerol may flux into the brain. This effect is associated with worse brain tissue damage. This flux complicates the interpretation of brain interstitial glycerol levels. We remind the clinicians that a damaged blood-brain barrier, as seen in sTBI, may alter the concentrations of various substances, including glycerol in the brain. Awareness of this is important in the interpretation of the data bedside as well in research.

  • 4.
    Koskinen, Lars-Owe D.
    et al.
    Department of Pharmacology and Clinical Neuroscience, Neurosurgery, Umeå University, Umeå, Sweden.
    Sundström, Nina
    Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden.
    Hägglund, Linda
    Department of Pharmacology and Clinical Neuroscience, Neurosurgery, Umeå University, Umeå, Sweden.
    Eklund, Anders
    Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden.
    Olivecrona, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Pharmacology and Clinical Neuroscience, Neurosurgery, Umeå University, Umeå, Sweden; Department of Anaesthesia and Intensive Care, Section for Neurosurgery, Faculty of Health and Medicine, Department for Medical Sciences, Örebro University, Örebro, Sweden.
    Prostacyclin Affects the Relation Between Brain Interstitial Glycerol and Cerebrovascular Pressure Reactivity in Severe Traumatic Brain Injury2019In: Neurocritical Care, ISSN 1541-6933, E-ISSN 1556-0961, Vol. 31, no 3, p. 494-500Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Cerebral injury may alter the autoregulation of cerebral blood flow. One index for describing cerebrovascular state is the pressure reactivity (PR). Little is known of whether PR is associated with measures of brain metabolism and indicators of ischemia and cell damage. The aim of this investigation was to explore whether increased interstitial levels of glycerol, a marker of cell membrane damage, are associated with PR, and if prostacyclin, a membrane stabilizer and regulator of the microcirculation, may affect this association in a beneficial way.

    MATERIALS AND METHODS: ) during the 96-h sampling period were calculated. The mean PR was calculated as the ICP/mean arterial pressure (MAP) regression coefficient based on hourly mean ICP and MAP during the first 96 h.

    RESULTS: (ρ = 0.490, p = 0.015) levels in the placebo group only.

    CONCLUSIONS: PR is correlated to the glycerol level in patients suffering from sTBI, a relationship that is not seen in the group treated with prostacyclin. Glycerol has been associated with membrane degradation and may support glycerol as a biomarker for vascular endothelial breakdown. Such a breakdown may impair the regulation of cerebrovascular PR.

  • 5.
    Koskinen, Lars-Owe D.
    et al.
    Clinical Neuroscience-neurosurgery, Umeå University, Umeå, Sweden.
    Sundström, Nina
    Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden.
    Hägglund, Linda
    Clinical Neuroscience-neurosurgery, Umeå University, Umeå, Sweden.
    Eklund, Anders
    Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden.
    Olivecrona, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Anaesthesia and Intensive Care, Section for Neurosurgery.
    THE RELATION BETWEEN BRAIN INTERSTITIAL GLYCEROL AND PRESSURE REACTIVITY IN TBI IS PROSTACYCLIN DEPENDENT2018In: Journal of Neurotrauma, ISSN 0897-7151, E-ISSN 1557-9042, Vol. 35, no 16, p. A185-A185Article in journal (Other academic)
    Abstract [en]

    Background: Cerebral injury may alter the autoregulation of cerebral blood flow. Pressure reactivity (PR) is considered as a surrogate measure of autoregulation. Little is known whether PR is associated with measures of brain metabolism and indicators of ischemia and cell damage. We speculate that prostacyclin may affect extracellular glycerol levels (a measure of cell membrane degradation), measured by microdialysis in the brain, and thus glycerol’s association with PR.

    Material and Methods: The study is a randomized, double-blinded placebo-control study on the effect of prostacyclin treatment (0.5 ng/kg/min) in severe traumatic brain injury (sTBI). The basic treatment was an intracranial pressure (ICP) targeted therapy based on the Lund concept. Inclusion criteria were verified blunt head trauma, GCS£8, age 15 -70 yrs, and a first measured cerebral perfusion pressure of ‡10 mmHg. Multimodal monitoring was applied. Samples from a brain microdialysis catheter placed on the worst affected side, close to the penumbra zone, were analysed. Mean (glycerolmean) and maximal glycerol (glycerolmax) during the 96 hrs sampling period were calculated. The mean PR was calculated as the ICP/MAP regression coefficient based on hourly mean ICP and MAP (mean arterial blood pressure) during the first 96 hrs.

    Results: 45 patients, mean age 35.5–2.2 yrs, GCS 6 (3-8) and ISS 29 (9-50) were included. In the placebo group there was a positive correlation between glycerolmean (r=0.503, p=0.01), glycerolmax (r=0.490, p=0.015) levels and PR levels. This correlation was attenuated/abolished in the prostacyclin group. Glycerol tended to be higher and PR was higher in the placebo group (p=0.0164) as compared to the prostacyclin group.

    Conclusion: PR is correlated to the glycerol level in patients suffering from sTBI. Prostacyclin attenuates this correlation. Glycerol is associated with membrane degradation and may support glycerol as a biomarker for vascular endothelial breakdown. Such a breakdown may impair the regulation of cerebrovascular pressure reactivity. We suggest that prostacyclin counteracts the breakdown and beneficially affect the cerebral blood flow autoregulation measured as PR.

  • 6.
    Koskinen, Lars-owe
    et al.
    Department of Clinical Neuroscience, Inst of Neurosurgery, Umeå University, Umeå, Sweden.
    Naredi, Silvana
    Department of Anaesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Olivecrona, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Anaesthesiology, Örebro University Hospital, Örebro, Sweden.
    Ten-year follow-up of patients in a double blinded randomized study on prostacyclin treatment in severe traumatic brain injury2017In: Brain Injury, ISSN 0269-9052, E-ISSN 1362-301X, Vol. 31, no 6-7, p. 770-771Article in journal (Other academic)
  • 7.
    Koskinen, L-O
    et al.
    Dept of Pharmacology and Clinical Neuroscience, Div of Neurosurgery, Umeå University, Umeå, Sweden.
    Sundström, N.
    Dept o Radiatio Sciences-Biomedical Engineering and Centre of Biomedical Engineering and Physics, Umeå University, Umeå, Sweden.
    Brorsson, C.
    Dept of Anaesthesia and Intensive Care, Inst of Surgery and Perioperative Sciences, Umeå University, Umeå , Sweden.
    Olivecrona, Magnus
    Örebro University, School of Medical Sciences. Dept of Anaesthesiology, Örebro University Hospital, Örebro, Sweden.
    Secondary peak of S-100b is associated with decompressive hemicraniectomy2016In: Journal of Neurotrauma, ISSN 0897-7151, E-ISSN 1557-9042, Vol. 33, no 3, p. A27-A27Article in journal (Other academic)
  • 8.
    Löfgren, David
    et al.
    Örebro University, School of Medical Sciences. Department of Oncology, Örebro, Sweden.
    Olivecrona, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Anaesthesia and Intensive Care, Section for Neurosurgery.
    P01.078 Glioma surgery in the elderly, a retrospective population based registry study2018In: Neuro-Oncology, ISSN 1522-8517, E-ISSN 1523-5866, Vol. 20, no Suppl. 3, p. iii247-iii248, article id P01.078Article in journal (Refereed)
    Abstract [en]

    Background: There is a trend in brain tumor treatments over time to treat patients at a higher age and to perform more advanced and radical surgery. Despite this little is known about the perioperative morbidity and mortality after intracranial tumor surgery, especially regarding the elderly. The Swedish brain tumor registry has collected data since 1999 with good coverage and is considered population based. Among the parameters registered are perioperative complications such as postoperative hematoma and thromboembolism as well as newly diagnosed epilepsy, new focal neurologic deficit and date of death.

    Methods: Data from the registry has been collected and analyzed in this retrospective population based study. This study includes patients in the registry at age 65 or older, with high grade glioma (GBM, astrocytoma grIII), low grade glioma (astrocytoma grI-II, oligodendroglioma grII-III and gangliogliomas) registered from 1999 to 2015. Formation of diagnose groups are in conjunction with suggestions from the Swedish National Brain Tumor Trialist Group. From this data we have excluded patients that have not undergone surgery, where surgery (or not) cannot be determined and where data on complications is unavailable. Only the national regions with a high enough coverage are included.

    Results: The material contains 1467 evaluable patients. High grade gliomas were 1277 (male 59%, female 41%), median age at surgery 71 (range 65 to 86), women not older (72 VS 71; NS). 17,5% (male 16,4%, female 20,0%; NS) had WHO/ECOG-PS >2. Perioperative mortality was 7,8% (male 9,2%, female 5,9%; p=0,03), associated with WHO/ECOG-PS >2 (p<0,0001). 15,7% (male 17,3%, female 13,5%; NS) had perioperative complications. The most common complication was worsening of neurologic function (7,6%, male 8,4%, female 6,5%; NS) and most patients (10,8%, male 12,8%, female 8,0%; NS) had one recorded complication. The mortality and morbidity remains consistent regardless of year of surgery. Low grade gliomas were 190 (male 55% VS female 45%), median age 70 (65 to 83), men not significantly older (71 VS 69; NS). 16,8% (male 15,7%, female 19,5%; NS) had WHO/ECOG-PS >2. Perioperative mortality was 5,3% (male 6,7%, female 3,5%; NS). 20,0% (male 21%, female 18,8%; NS) had perioperative complications. As with high grade gliomas the most common complication was worsening of neurologic function (13,7%, male 15,2%, female 11,8%; NS) and the mortality and morbidity remains without significant changes regardless of year of surgery.

    Conclusion: In this material we can conclude that the perioperative mortality as well as morbidity is higher than in published younger patient materials for gliomas. We cannot see an increase in perioperative mortality or morbidity with higher age within the material but this could be from lack of power and we hope to be able to get a clearer view in a later comparison with the younger patients in the registry.

  • 9.
    Löfgren, David
    et al.
    Örebro University, School of Medical Sciences. Department of Oncology, Örebro, Sweden.
    Olivecrona, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Anaesthesia and Intensive Care, Section for Neurosurgery.
    P05.54 Meningioma surgery in the elderly, a retrospective population based registry study2018In: Neuro-Oncology, ISSN 1522-8517, E-ISSN 1523-5866, Vol. 20, no Suppl 3, p. iii315-iii315, article id P05.54Article in journal (Other academic)
    Abstract [en]

    Meningioma surgery is often considered, even at a high age, and is regarded an acceptable practice in patients without severe health problems even though there is much that is not yet known about the perioperative morbidity and mortality. Since the start 1999 the Swedish brain tumor registry has collected data on a national level. It is accepted as population based and has demonstrated good coverage. In the registry perioperative parameters such as newly diagnosed epilepsy, new focal neurological deficit, thromboembolism and date of death can be found. &lt;h4&gt;Methods&lt;/h4&gt; We have collected retrospective data from the registry to perform a population based study of the perioperative period. Included are patients with meningioma at age 65 and older from regions with a high enough coverage of registration and with surgery dates from 1999 to 2015. Two diagnose groups were made (grade I and grade II+III) as suggested by the Swedish National Brain Tumor Trialist Group. Excluded are patients in the registry that have not undergone surgery, where surgery (or not) cannot be determined and where data on complications is unavailable. &lt;h4&gt;Results&lt;/h4&gt; 1109 patients were included (female 67,1%, male 32,9%). Median age was 72 (range 65–90) with an even gender distribution. Most patients had grade I meningioma (88,6%, female 91,0%, male 83,8%; p&lt;0,001) with an even age distribution. 14,1% (female 15,4%, male 11,5%, NS) had WHO-PS &gt;2, rising with age (Age&gt;80, 28,9%, p&lt;0,001). Perioperative mortality was 3,6% (male 4,7%, female 3,1%; NS) but clearly higher within the older age-groups (Age 65-69 1,4%; 70-74 3,3%; 75-79 4,6%; &gt;80 7,7%; p=0,004). In the gradeII-III group mortality was significantly higher 8,7% (p&lt;0,001) then the gradeI group and there is a statistical correlation between a WHO-PS &gt;2 and perioperative mortality (0–2=2,8%, 3–4=7,9%; p=0,002). 28,3% (male 33,4%, female 25,8%; p=0,008) had perioperative complications (other than death), with an even age distribution. As with mortality there is a correlation with tumor grade (grI 26,8%, grII-III 40,5%; p=0,001) and there is a correlation with WHO-PS &gt;2 (0-2 25,7%, 3-4 40,8%; p&lt;0,001). Surgery 1999–2007 is associated with less complications (1999-2007 16,4%, 2007-2015 37,5%; p&lt;0,001) but not with less mortality. The most common complications were hematoma and neurologic deficit (14,3% and 13,6%; NS), both evenly distributed by gender and age group. &lt;h4&gt;Conclusion&lt;/h4&gt; Our data shows similar perioperative mortality with published data. The risk of perioperative death is higher with rising age and a bad performancestatus correlates with a higher risk of both perioperative death and complications. The high rate of WHO-PS &gt;2 might be a contributing factor to the high rates of perioperative morbidity as compared with published material. This data suggests caution when operating on elderly patients, especially older than 75 and with compromised performancestatus.

  • 10.
    Löfgren, David
    et al.
    Örebro University, School of Medical Sciences. Department of Oncology.
    Valachis, Antonios
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Oncology.
    Olivecrona, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Neurosurgery.
    Older meningioma patients: a retrospective population-based study of risk factors for morbidity and mortality after neurosurgery.2022In: Acta Neurochirurgica, ISSN 0001-6268, E-ISSN 0942-0940, Vol. 164, p. 2987-2997Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Meningioma is the most common primary CNS tumour. Most meningiomas are benign, and most patients are 65 years or older. Surgery is usually the primary treatment option. Most prior studies on early surgical outcomes in older patients with meningioma are small, and there is a lack of larger population-based studies to guide clinical decision-making. We aimed to explore the risks for perioperative mortality and morbidity in older patients with meningioma and to investigate changes in surgical incidence over time.

    METHODS: In this retrospective population-based study on patients in Sweden, 65 years or older with surgery 1999-2017 for meningioma, we used data from the Swedish Brain Tumour Registry. We analysed factors contributing to perioperative mortality and morbidity and used official demographic data to calculate yearly incidence of surgical procedures for meningioma.

    RESULTS: The final study cohort included 1676 patients with a 3.1% perioperative mortality and a 37.6% perioperative morbidity. In multivariate analysis, higher age showed a statistically significant association with higher perioperative mortality, whereas larger tumour size and having preoperative symptoms were associated with higher perioperative morbidity. A numerical increased rate of surgical interventions after 2012 was observed, without evidence of worsening short-term surgical outcomes.

    CONCLUSIONS: Higher mortality with increased age and higher morbidity risk in larger and/or symptomatic tumours imply a possible benefit from considering surgery in selected older patients with a growing meningioma before the development of tumour-related symptoms. This study further underlines the need for a standardized method of reporting and classifying complications from neurosurgery.

  • 11.
    Löfgren, David
    et al.
    Örebro University, School of Medical Sciences. Department of Oncology, Faculty of Medicine & Health, Örebro University, Örebro, Sweden.
    Valachis, Antonios
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Oncology.
    Olivecrona, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Neurosurgery.
    Risk for morbidity and mortality after neurosurgery in older patients with high grade gliomas: a retrospective population based study2022In: BMC Geriatrics, ISSN 1471-2318, E-ISSN 1471-2318, Vol. 22, no 1, article id 805Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Although high grade gliomas largely affect older patients, current evidence on neurosurgical complications is mostly based on studies including younger study populations. We aimed to investigate the risk for postoperative complications after neurosurgery in a population-based cohort of older patients with high grade gliomas, and explore changes over time.

    METHODS: In this retrospective study we have used data from the Swedish Brain Tumour Registry and included patients in Sweden age 65 years or older, with surgery 1999-2017 for high grade gliomas. We analysed number of surgical procedures per year and which factors contribute to postoperative morbidity and mortality.

    RESULTS: The study included 1998 surgical interventions from an area representing 60% of the Swedish population. Over time, there was an increase in surgical interventions in relation to the age specific population (p < 0.001). Postoperative morbidity for 2006-2017 was 24%. Resection and not having a multifocal tumour were associated with higher risk for postoperative morbidity. Postoperative mortality for the same period was 5%. Increased age, biopsy, and poor performance status was associated with higher risk for postoperative mortality.

    CONCLUSIONS: This study shows an increase in surgical interventions over time, probably representing a more active treatment approach. The relatively low postoperative morbidity- and mortality-rates suggests that surgery in older patients with suspected high grade gliomas can be a feasible option. However, caution is advised in patients with poor performance status where the possible surgical intervention would be a biopsy only. Further, this study underlines the need for more standardised methods of reporting neurosurgical complications.

  • 12.
    Melander, Nils
    et al.
    Örebro University, School of Medical Sciences. Department of Neurology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Sönnerqvist, Caroline
    Örebro University, School of Medical Sciences. Department of Paediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Olivecrona, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Neurosurgery.
    Non-surgical patient characteristics best predict outcome after 6 months in patients surgically treated for chronic subdural haematoma2023In: Journal of clinical neuroscience, ISSN 0967-5868, E-ISSN 1532-2653, Vol. 114, p. 151-157Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Chronic subdural haematoma (CSDH) is one of the most common conditions encountered in neurosurgical practice. After surgery, the patients often improve dramatically; but their long-term outcome is more uncertain. The purpose of this study was to investigate predictors of outcome 6 months after surgery.

    METHODS: Retrospective data were collected on patients in Orebro County, Sweden, who had undergone surgery for CSDH at the Orebro University Hospital between 2013 and 2019. The outcomes were defined as favourable or unfavourable in terms of the modified Rankin Scale (mRS). A favourable outcome was defined as either mRS 0-2 or an unchanged mRS score in patients scoring 3-5 before surgery. From the variables in the data collected, a multiple logistic regression model was constructed.

    RESULTS: The study comprised 180 patients, of whom 134 (74.4%) were male. Median age was 79.2 years (IQR 71.7-85.5), and 129 (71.7%) patients had a favourable outcome at 6 months. In the group with an unfavourable outcome, 18 (10%) had died and 33 (18.3%) had either lost their independence in daily living or become somewhat less independent. The final multiple logistic regression model consisted of pre-surgery variables only: age (OR 0.92, 95% CI 0.87-0.97), CRP (OR 0.96, 95% CI 0.94-0.99), GCS > 13 (OR 3.66, 95% CI 1.09-12.3), Hb (OR 1.03, 95% CI 1.00-1.05), and ASA score < 3 (OR 2.58, 95% CI 0.98-6.79). The whole model had an AUC of 0.88.

    CONCLUSION: CSDH requiring surgery is associated with high morbidity and mortality at 6 months after surgery. Age, CRP, GCS, Hb and ASA score on admission for surgery are the variables that best predicts outcome. This knowledge can help to identify the patients at greatest risk for an unfavourable outcome, who may need additional support from the health care system.

    UNSTRUCTURED ABSTRACT: Chronic subdural haematoma (CSDH) is one of the most common conditions encountered in neurosurgical practice. After surgery, the patients often improve dramatically; but their long-term outcome is more uncertain. The purpose of this study was to investigate predictors of outcome, in terms of the modified Rankin Scale (mRS), 6 months after surgery. The study comprised 180 patients, of whom 134 (74.4%) were male. Median age was 79.2 years (IQR 71.7-85.5), and 129 (71.7%) patients had a favourable outcome at 6 months. In the group with an unfavourable outcome, 18 (10%) had died and 33 (18.3%) had either lost their independence in daily living or become somewhat less independent. The final multiple logistic regression model consisted of pre-surgery variables only: age (OR 0.92, 95% CI 0.87-0.97), CRP (OR 0.96, 95% CI 0.94-0.99), GCS > 13 (OR 3.66, 95% CI 1.09-12.3), Hb (OR 1.03, 95% CI 1.00-1.05), and ASA score < 3 (OR 2.58, 95% CI 0.98-6.79). The whole model had an AUC of 0.88. In conclusion, CSDH requiring surgery is associated with high morbidity and mortality at 6 months after surgery. Age, CRP, GCS, Hb and ASA score on admission for surgery are the variables that best predicts outcome. This knowledge can help to identify the patients at greatest risk for an unfavourable outcome, who may need additional support from the health care system.

  • 13.
    Nordström, Carl-Henrik
    et al.
    Department of Neurosurgery, Odense University Hospital, Odense, Denmark.
    Koskinen, Lars-Owe
    Department of Clinical Neuroscience, Division of Neurosurgery, Umeå University, Umeå, Sweden.
    Olivecrona, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Anesthesia and Intensive Care, Section for Neurosurgery, Örebro University Hospital, Örebro, Sweden.
    Aspects on the Physiological and Biochemical Foundations of Neurocritical Care2017In: Frontiers in Neurology, E-ISSN 1664-2295, Vol. 8, article id 274Article, review/survey (Refereed)
    Abstract [en]

    Neurocritical care (NCC) is a branch of intensive care medicine characterized by specific physiological and biochemical monitoring techniques necessary for identifying cerebral adverse events and for evaluating specific therapies. Information is primarily obtained from physiological variables related to intracranial pressure (ICP) and cerebral blood flow (CBF) and from physiological and biochemical variables related to cerebral energy metabolism. Non-surgical therapies developed for treating increased ICP are based on knowledge regarding transport of water across the intact and injured blood-brain barrier (BBB) and the regulation of CBF. Brain volume is strictly controlled as the BBB permeability to crystalloids is very low restricting net transport of water across the capillary wall. Cerebral pressure autoregulation prevents changes in intracranial blood volume and intracapillary hydrostatic pressure at variations in arterial blood pressure. Information regarding cerebral oxidative metabolism is obtained from measurements of brain tissue oxygen tension (PbtO2) and biochemical data obtained from intracerebral microdialysis. As interstitial lactate/pyruvate (LP) ratio instantaneously reflects shifts in intracellular cytoplasmatic redox state, it is an important indicator of compromised cerebral oxidative metabolism. The combined information obtained from PbtO2, LP ratio, and the pattern of biochemical variables reveals whether impaired oxidative metabolism is due to insufficient perfusion (ischemia) or mitochondrial dysfunction. Intracerebral microdialysis and PbtO2 give information from a very small volume of tissue. Accordingly, clinical interpretation of the data must be based on information of the probe location in relation to focal brain damage. Attempts to evaluate global cerebral energy state from microdialysis of intraventricular fluid and from the LP ratio of the draining venous blood have recently been presented. To be of clinical relevance, the information from all monitoring techniques should be presented bedside online. Accordingly, in the future, the chemical variables obtained from microdialysis will probably be analyzed by biochemical sensors.

  • 14.
    Olivecrona, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Neurokirurgi: Intraparencymatös monitorering av ICP2019In: Akutkirurgisk operationsmanual: Akuta ingrepp för allmänkirurgen / [ed] Mikael Öman, Studentlitteratur AB, 2019, 1, p. 231-233Chapter in book (Other academic)
  • 15.
    Olivecrona, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Neurokirurgi: Skallskador och hemikraniektomi2019In: Akutkirurgisk operationsmanual: Akuta ingrepp för allmänkirurgen / [ed] Mikael Öman, Studentlitteratur AB, 2019, 1, p. 237-242Chapter in book (Other academic)
  • 16.
    Olivecrona, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Neurokirurgi: Ventrikeldränage av CSF och ICP-mätning2019In: Akutkirurgisk operationsmanual: Akuta ingrepp för allmänkirurgen / [ed] Mikael Öman, Studentlitteratur AB, 2019, 1, p. 234-237Chapter in book (Other academic)
  • 17.
    Olivecrona, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    To Treat or Not to Treat in the Acute Setting (Withholding) and Withdrawal of Treatment2020In: Management of Severe Traumatic Brain Injury: Evidence, Tricks, and Pitfalls / [ed] Sundstrom, T., Grände, P.-O., Luoto, T., Rosenlund, C., Undén, J., Wester, K.G., Springer, 2020, 2, p. 135-144Chapter in book (Refereed)
  • 18.
    Olivecrona, Magnus
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Anaesthesia and Intensive Care, Section for Neurosurgery, Örebro University Hospital, Örebro, Sweden.
    Honeybul, Stephen
    Departement of Neurosurgery, Sir Charles Gairdner Hospital, Perth, Australia.
    A study of the opinions of Swedish healthcare personnel regarding acceptable outcome following decompressive hemicraniectomy for ischaemic stroke2018In: Acta Neurochirurgica, ISSN 0001-6268, E-ISSN 0942-0940, Vol. 160, no 1, p. 95-101Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Decompressive hemicraniectomy (DC) is an established lifesaving treatment for malignant infarction of the middle cerebral artery (mMCAI). However, surgical decompression will not reverse the effects of the stroke and many survivors will be left severely disabled. The objective of this study was to assess what neurological outcome would be considered acceptable in these circumstances amongst Swedish healthcare workers.

    METHOD: Healthcare workers were invited to participate in a presentation that outlined the pathophysiology of mMCAI, the rationale behind DC and outcome data from randomised controlled trials that have investigated efficacy of the procedure. They were then asked which neurological outcome would they feel to be acceptable based on the modified Rankin Score (mRS) and the Aphasia Handicap Scale (AHS). Information regarding sex, age, marital status, relatives, religion, earlier experience of stroke and occupation was also collected.

    RESULTS: Six hundred and nine persons participated. The median accepted mRS was 3. An mRS of 4 or 5 was perceived to be acceptable by only 30.5% of participants. Therefore the most likely outcome, based on the results of the randomised controlled trials, would be unacceptable to most of the participants [OR 0.39 (CI, 0.22-0.69)]. The median accepted AHS was 3. A worst language outcome of restricted autonomy of verbal communication (AHS 3) or better would be accepted by 44.6%.

    CONCLUSIONS: This study has highlighted the ethical problems when obtaining consent for DC following mMCAI, because for many of the participants the most likely neurological outcome would be deemed unacceptable. These issues need to be considered prior to surgical intervention and the time may have come for a broader societal discussion regarding the value of a procedure that converts death into survival with severe disability given the attendant financial and healthcare resource implications.

  • 19.
    Olivecrona, Magnus
    et al.
    Örebro University, School of Medical Sciences. Department of Anaesthesia and Intensive Care, Section for Neurosurgery, Örebro University Hospital, Örebro, Sweden.
    Olivecrona, Z.
    Department of Anaesthesia and Intensive Care, Sect for Neurosurgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Koskinen, L.
    Dept of Pharmacology and Clinical Neuroscience, Div of Neurosurgery, Örebro University Hospital, Örebro, Sweden.
    The Stockholm score for the prediction of outcome in persons with severe traumatic brain injury treated with an ICP-targeted therapy2016In: Journal of Neurotrauma, ISSN 0897-7151, E-ISSN 1557-9042, Vol. 33, no 3, p. A34-A34Article in journal (Other academic)
  • 20.
    Olivecrona, Magnus
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Olivecrona, Zandra
    Örebro University Hospital. Örebro University, School of Medical Sciences. Department of Anaesthesia.
    Transportation2020In: Management of Severe Traumatic Brain Injury: Evidence, Tricks, and Pitfalls / [ed] Sundstrom, T., Grände, P.-O., Luoto, T., Rosenlund, C., Undén, J., Wester, K.G., Springer, 2020, 2, p. 83-88Chapter in book (Refereed)
  • 21.
    Olivecrona, Magnus
    et al.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Anaesthesia and Intensive Care, Section for Neurosurgery.
    Olivecrona, Zandra
    Örebro University Hospital. Örebro University, School of Medical Sciences. Anaesthesia and Intensive Care, Section for Neurosurgery.
    Validation of the Canadian Assessment of Tomography for Childhood Head Injury, the CATCH-rule2018In: Journal of Neurotrauma, ISSN 0897-7151, E-ISSN 1557-9042, Vol. 35, no 16, p. A248-A248Article in journal (Other academic)
    Abstract [en]

    Background: Head trauma in children is a common cause for a visit to the A&E. Among the many children it is important to identify those at risk for developing a clinical important head injury (CITBI). The most important way of identifying the children at risk is to perform a CT scan of the head. There are reports indicating an induction of 1 cancer in children on 1000 – 5000 CT examinations. It is thus important to minimise the use of CT. In 2010 Osmond and co-workers introduced the Canadian Assessment of Tomography for Childhood Head injury: the CATCH rule (CATCH-R), with the aim of identifying those at most risk and to reduce the use of CT. The aim of this study is to validate the CATCH-R, using a large cohort of children.

    Material Methods: The study is a cohort study based on the data set from: ‘‘Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study’’(Kuppermanns et al 2009). It includes data from more than 43000 children. The cohort was identified using the basal criteria in the CATCH-R, i.e. children with a GCS of 13 – 15. The CATCH-R was then used to identify children who should perform a CT.

    Results: We identified 37277 children with a GCS of 13 – 15 of which 7774 fulfilled the criteria for MHI according to the CATCH-R. Of these 2699 had one or more risk factors, i.e. should perform a CT scan. In the CT group 117 children had a CITBI and in the non-CT group (n=5075) we identified 36 children with CITBI. At the division MHI and no-MHI according to the CATCH-R the NPV is 99.2 % (CI 99.1 – 99.2 %), and specificity 79.3% (CI 78.9 – 79.7). At the division MHI with risk factor/s and MHI without risk factor/s the NPV is 99.3% (CI 99.1 – 99.5 %), and specificity 66.1 % (CI 65.0 – 67.2 %).

    Conclusion: It seems that using the CATCH-R the risk of not detecting a child with a CITBI is very small.

  • 22.
    Sönnerqvist, Caroline
    et al.
    Örebro University, School of Medical Sciences.
    Brus, Ole
    Örebro University, School of Medical Sciences.
    Olivecrona, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Anaesthesiology and Intensive Care, Section for Neurosurgery.
    Validation of the scandinavian guidelines for initial management of minor and moderate head trauma in children2021In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 47, no 4, p. 1163-1173Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Head trauma in children is common, with a low rate of clinically important traumatic brain injury. CT scan is the reference standard for diagnosis of traumatic brain injury, of which the increasing use is alarming because of the risk of induction of lethal malignancies. Recently, the Scandinavian Neurotrauma Committee derived new guidelines for the initial management of minor and moderate head trauma. Our aim was to validate these guidelines.

    METHODS: We applied the guidelines to a population consisting of children with mild and moderate head trauma, enrolled in the study: "Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study" by Kuppermann et al. (Lancet 374(9696):1160-1170, https://doi.org/10.1016/S0140-6736(09)61558-0, 2009). We calculated the negative predictive values of the guidelines to assess their ability to distinguish children without clinically-important traumatic brain injuries and traumatic brain injuries on CT scans, for whom CT could be omitted.

    RESULTS: We analysed a population of 43,025 children. For clinically-important brain injuries among children with minimal head injuries, the negative predictive value was 99.8% and the rate was 0.15%. For traumatic findings on CT, the negative predictive value was 96.9%. Traumatic finding on CT was detected in 3.1% of children with minimal head injuries who underwent a CT examination, which accounts for 0.45% of all children in this group.

    CONCLUSION: Children with minimal head injuries can be safely discharged with oral and written instructions. Use of the SNC-G will potentially reduce the use of CT.

  • 23.
    Sönnerqvist, Caroline
    et al.
    School of Medical Sciences, Örebro University, Örebro, Sweden.
    Brus, Ole
    Örebro University, School of Medical Sciences.
    Olivecrona, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Anaesthesia and Intensive Care, Section for Neurosurgery.
    Validation of the Scandinavian Guidelines for the Initial Management of Minor and Moderate Head Injury in Children2018In: Journal of Neurotrauma, ISSN 0897-7151, E-ISSN 1557-9042, Vol. 35, no 16, p. A248-A248Article in journal (Other academic)
    Abstract [en]

    Background: Head trauma in children is common, with a low rate of clinically-important traumatic brain injury (ciTBI). CT scan is the reference standard for diagnosis of traumatic brain injury, of which the increasing use is alarming because of the risk of induction of lethal malignancies. Recently, the Scandinavian Neurotrauma Committee (SNC) derived new guidelines for the initial management of minor and moderate head trauma (GCS 9-15) in children. Our aim was to validate the SNC guidelines by assessing the risk of a child being discharged with a ciTBI. A secondary aim was to assess the risk of a child being discharged with a TBI on CT.

    Methods: We applied the SNC guidelines to a population consisting of children with mild and moderate head trauma, enrolled in the dataset ‘‘Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study’’ (Kuppermanns et al 2009). We calculated the SNC guidelines negative predictive values to assess their ability to distinguish children without ciTBI and traumatic brain injuries on CT scans, for whom CT would be unnecessary.

    Results: We enrolled and analysed 43 025 children (mean age 7.0 years, range 0-17, 62.3% males). The prevalence of ciTBI were statistically significant lower in the group of minimal head injury as compared to the mild low-risk head injury group (p<0.001). The rate of ciTBI in the minimal head injury group was 0,15% and the negative predictive value was 99.8% for ciTBI (minimal vs mild-moderate head injury groups). Traumatic finding on CT was detected in 3.1% of the children in the minimal group who underwent a CT examination, which accounts for 0.45% of all children in the minimal head injury group. The negative predictive value was 96.9% for traumatic finding on CT.

    Conclusion: It is safe to discharge children with oral and written instructions and, according to the SNC guidelines, minimal head injury. Use of the SNC guidelines will potentially reduce the use of CT.

  • 24.
    Trivedi, Dhanisha Jayesh
    et al.
    Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Örebro, Sweden.
    Bass, Gary Alan
    Örebro University, School of Medical Sciences. Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia PA, USA.
    Forssten, Maximilian Peter
    Örebro University, School of Medical Sciences. Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Örebro, Sweden.
    Scheufler, Kai-Michael
    Division of Neurosurgery, Department of Neurosurgery, Orebro University Hospital, Örebro, Sweden; Medical School, Heinrich-Heine-University, Düsseldorf, Germany.
    Olivecrona, Magnus
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Neurosurgery, Department of Neurosurgery.
    Cao, Yang
    Örebro University, School of Medical Sciences. Örebro University Hospital.
    Ahl Hulme, Rebecka
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Surgery, Karolinska University Hospital, Stockholm, Sweden.
    Mohseni, Shahin
    Örebro University, School of Medical Sciences. Örebro University Hospital. Division of Trauma and Emergency Surgery, Department of Surgery.
    The significance of direct transportation to a trauma center on survival for severe traumatic brain injury2022In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 48, no 4, p. 2803-2811Article in journal (Refereed)
    Abstract [en]

    Introduction: While timely specialized care can contribute to improved outcomes following traumatic brain injury (TBI), this condition remains the most common cause of post-injury death worldwide. The purpose of this study was to investigate the difference in mortality between regional trauma centers in Sweden (which provide neurosurgical services round the clock) and non-trauma centers, hypothesizing that 1-day and 30-day mortality will be lower at regional trauma centers.

    Patients and methods: This retrospective cohort study used data extracted from the Swedish national trauma registry and included adults admitted with severe TBI between January 2014 and December 2018. The cohort was divided into two subgroups based on whether they were treated at a trauma center or non-trauma center. Severe TBI was defined as a head injury with an AIS score of 3 or higher. Poisson regression analyses with both univariate and multivariate models were performed to determine the difference in mortality risk [Incidence Rate Ratio (IRR)] between the subgroups. As a sensitivity analysis, the inverse probability of treatment weighting (IPTW) method was used to adjust for the effects of confounding.

    Results: A total of 3039 patients were included. Patients admitted to a trauma center had a lower crude 30-day mortality rate (21.7 vs. 26.4% days, p = 0.006). After adjusting for confounding variables, patients treated at regional trauma center had a 28% [adj. IRR (95% CI): 0.72 (0.55-0.94), p = 0.015] decreased risk of 1-day mortality and an 18% [adj. IRR (95% CI): 0.82 (0.69-0.98)] reduction in 30-day mortality, compared to patients treated at a non-trauma center. After adjusting for covariates in the Poisson regression analysis performed after IPTW, admission and treatment at a trauma center were associated with a 27% and 17% reduction in 1-day and 30-day mortality, respectively.

    Conclusion: For patients suffering a severe TBI, treatment at a regional trauma center confers a statistically significant 1-day and 30-day survival advantage over treatment at a non-trauma center.

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