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Purpose: The aim of this study was to explore risk factors for intraoperative events and postoperative complications of endoscopic transsphenoidal surgery (ETS) for pituitary tumors, and the role of intrasellar pressure (ISP) in relation to complications.

Methods: The study was a single-center, retrospective, consecutive, observational study, with ISP data collected prospectively. After exclusions, the study population encompassed 69 patients. All had ISP measured intraoperatively during ETS for a pituitary adenoma and underwent standardized postoperative observations and follow-up. Data on complications within 3 months after surgery and some risk factors were collected retrospectively.

Results: Decreased risk of postoperative cerebrospinal fluid leakage was seen with higher age. Large tumor volume was associated with higher risk of intraoperative events. ISP was not associated with complication frequency, but patients with ISP > 20 mmHg had increased frequency of postoperative epistaxis.

Conclusion: This study confirms earlier findings of low age as a possible risk factor for postoperative cerebrospinal fluid leakage. Tumor volume is suggested to be associated with higher complication risk. ISP does not seem to be a significant risk factor for intraoperative events or postoperative complications following ETS. Predictive risk factors for surgical complications after ETS are still not satisfactorily explained and heterogeneous definitions of complications are problematic in this context.

Introduction: Decompressive craniectomy (DC) in patients with severe aneurysmal subarachnoid hemorrhage (aSAH) can be a life-saving procedure. The aim of this nationwide prospective study was to investigate the use of DC in aSAH patients in Sweden. Research question: To explore the risk factors and functional outcome associated with DC in patients with aSAH.

Material and methods: Patients treated for aSAH at all neurosurgical centers in Sweden during a 3.5-year period (2014–2018) were prospectively registered. Clinical, radiological and treatment-related factors with regard to DC were analyzed using Chi-Square and logistic regression analysis. Functional outcome was assessed by the extended Glasgow outcome scale one year after the bleeding.

Results: During the study period, 1037 patients were treated for aSAH. Thirty-five patients (3.4%) underwent DC. At one year follow-up, 25 of these (71%) had unfavorable functional outcome. Multivariate logistic regression analysis revealed that poor clinical grade before aneurysm treatment, middle cerebral artery (MCA) aneurysm, edema on the initial computed tomography (CT), and adverse events during aneurysm occlusion were independent and significant risk factors for performing DC.

Discussion and conclusion: DC is relatively uncommon in aSAH patients and is related to increased risk of unfavorable outcome. However, favorable functional outcome was seen in 29% of patients with DC. Adverse events during aneurysm occlusion were significant risk factors for DC.

Background: Decompressive craniectomy (DC) is a last-tier treatment for managing refractory intracranial hypertension in patients with aneurysmal subarachnoid hemorrhage (aSAH), though concerns persist about whether it primarily prolongs survival in a state of severe disability. This study investigated patient characteristics, surgical indications, complications, and outcomes following DC in aSAH.

Methods: In this Swedish, retrospective multi-center study, 123 aSAH patients treated with DC between 2008–2022 were included. Data collection included demographic details, aSAH characteristics, injury severity, DC indication, complications, and outcome at roughly six months post-DC (modified Rankin scale [mRS]) dichotomized as survival vs. mortality (0–5 vs. 6) and favorable vs. unfavorable (0–3 vs. 4–6).

Results: The median age was 53 years and 66% were females. Two thirds presented with a WFNS grade 4–5 and 83% with a Fisher grade 4 hemorrhage. Most aneurysms were located at the middle cerebral artery (65%) and treated with clip ligation (59%). DC significantly reduced midline shift from 9 to 2 mm and obliteration rates of basal cisterns from 95 to 22% (p < 0.05). Reoperation for hematomas or extension of the DC were rare (< 5%). At follow-up, 20% were deceased, while 33% had recovered favorably. In univariate logistic regressions, younger age was associated with favorable outcome and reduced mortality. Other patient demographics, injury severity, and factors related to the DC surgery lacked association with outcome.

Conclusions: aSAH patients treated with DC presented with severe primary brain injuries and signs of intracranial hypertension. DC resulted in radiological improvements regarding mass effect and a low rate of postoperative complications. Although the results were based on a selected population of aSAH patients, an encouraging rate of favorable outcome was found, particularly among younger patients. However, the absence of additional outcome predictors underscores the ongoing challenges in improving patient selection for DC in aSAH.

Objective: To study associations of clinical characteristics and treatment choice with functional outcome, mortality, and time to death in a national sample of aneurysmal subarachnoidal hemorrhage patients.

Methods: Data were extracted from a prospective nationwide multicenter study performed in September 2014 to March 2018. Glasgow Outcome Scale Extended (GOSE) grade, 1-year mortality, and survival probability were assessed at one year after ictus. Logistic univariate, multivariate, and Cox regression analyses were used to study the variables' associations with the outcomes.

Results: Unfavorable dichotomized GOSE (dGOSE; grades 1–4) was observed in 35.4% of patients. Microsurgery was preferred for middle cerebral artery aneurysms and Fisher grade 4. Treatment modality was not associated with any outcome measure. Dichotomized World Federation of Neurosurgical Societies (dWFNS), age, and delayed ischemic neurological deficit (DIND) showed significant correlations with dGOSE and 1-year mortality in multivariate regression analyses. Pupil dilatation was associated with a 1-year mortality outcome. Cox regression analysis showed lower survival probability for pupil dilatation (hazard ratio [HR]: 3.546), poor dWFNS (HR: 3.688), higher age (HR: 1.051), and DIND occurrence (HR: 2.214).

Conclusions: The patient selection in Sweden after aneurysmal subarachnoidal hemorrhage showed similar values for dGOSE, 1-year mortality, and survival probability between patients treated with microsurgery or endovascular technique. Poor dWFNS, higher age, and DIND were significantly associated with unfavorable dGOSE, mortality, and survival probability. Pupil dilatation was significantly associated with mortality and survival probability.

Background: The EORTC questionnaires QLQ-C30 and QLQ-BN20 are commonly used to evaluate health-related quality of life in patients with meningiomas but have not undergone a disease-specific validation. The study aimed to address this issue and to determine the interrater reliability of WHO performance status (PS) assessments in these patients.

Methods: This population-based study included prospectively enrolled intracranial meningiomas treated at Umeå University Hospital between October 14, 2010, and December 31, 2021, followed up until March 30, 2023. Patients were assessed by the EORTC questionnaires before and at 3 months after surgery. WHO PS categorized as high (0–1) or low (2–5) were evaluated for interrater reliability and used together with sick-leave status to determine the questionnaires’ clinical validity. Remaining psychometric properties of the questionnaires were analyzed by conventional methods.

Results: Of 513 eligible surgeries, 454 (88.5%) had responded to at least 1 questionnaire. WHO PS interrater agreement was 94.4%. The EORTC questionnaires’ ability to distinguish between clinically distinct groups was high. Items correlated better with their own scale than others (most r > 0.70). Items measuring various aspects of the same construct showed good internal consistency (nearly all α > 0.70). Questionnaire responsiveness to symptom changes over time was acceptable. Several scales displayed floor and ceiling effects.

Conclusions: The EORTC QLQ-C30 and QLQ-BN20 are overall valid instruments to evaluate patients with intracranial meningiomas but require awareness of certain limitations when specific functions and symptoms are addressed. WHO PS assessments can be applied to meningioma patients with high reproducibility between observers.

Background: Adverse events (AEs) or complications may arise secondary to the treatment of aneurysmal subarachnoid haemorrhage (SAH). The aim of this study was to identify AEs associated with microsurgical occlusion of ruptured aneurysms, as well as to analyse their risk factors and impact on functional outcome.

Methods: Patients with aneurysmal SAH admitted to the neurosurgical centres in Sweden were prospectively registered during a 3.5-year period (2014-2018). AEs were categorised as intraoperative or postoperative. A range of variables from patient history and SAH characteristics were explored as potential risk factors for an AE. Functional outcome was assessed approximately 1 year after the bleeding using the extended Glasgow Outcome Scale.

Results: In total, 1037 patients were treated for ruptured aneurysms, of which, 322 patients were treated with microsurgery. There were 105 surgical AEs in 97 patients (30%); 94 were intraoperative AEs in 79 patients (25%). Aneurysm rerupture occurred in 43 patients (13%), temporary occlusion of the parent artery >5 min in 26 patients (8%) and adjacent vessel injury in 25 patients (8%). High Fisher grade and brain oedema on CT were related to increased risk of AEs. At follow-up, 38% of patients had unfavourable outcome. Patients suffering AEs were more likely to have unfavourable outcome (OR 2.3, 95% CI 1.10 to 4.69).

Conclusion: Intraoperative AEs occurred in 25% of patients treated with microsurgery for ruptured intracerebral aneurysm in this nationwide survey. Although most operated patients had favourable outcome, AEs were associated with increased risk of unfavourable outcome.

Introduction: A range of adverse events (AEs) may occur in patients with subarachnoid hemorrhage (SAH). Endovascular treatment is commonly used to prevent aneurysm re-rupture.

Research question: The aim of this study was to identify AEs related to endovascular treatment, analyze risk factors for AEs and how AEs affect patient outcome.

Material and methods: Patients with aneurysmal SAH admitted to all neurosurgical centers in Sweden during a 3.5-year period (2014–2018) were prospectively registered. AEs related to endovascular aneurysm treatment were thromboembolic events, aneurysm re-rupture, vessel dissection and puncture site hematoma. Potential risk factors for the AEs were analyzed using multivariate logistic regression. Functional outcome was assessed at one year using the extended Glasgow outcome scale.

Results: In total, 1037 patients were treated for ruptured aneurysms. Of which, 715 patients were treated with endovascular occlusion. There were 115 AEs reported in 113 patients (16%). Thromboembolic events were noted in 78 patients (11%). Aneurysm re-rupture occurred in 28 (4%), vessel dissection in 4 (0.6%) and puncture site hematoma in 5 (0.7%). Blister type aneurysm, aneurysm smaller than 5 mm and endovascular techniques other than coiling were risk factors for treatment-related AEs. At follow-up, 230 (32%) of the patients had unfavorable outcome. Patients suffering intraprocedural aneurysm re-rupture were more likely to have unfavorable outcome (OR 6.9, 95% CI 2.3–20.9).

Discussion and conclusion: Adverse events related to endovascular occlusion of a ruptured aneurysm were seen in 16% of patients. Aneurysm re-rupture during endovascular treatment was associated with increased risk of unfavorable functional outcome.

Conditions involving intracranial vascular anomalies are increasingly diagnosed, not least incidentally, with the increasing availability of neuroradiological investigations. Acute deterioration and development of symptoms due to a vascular condition could require neurosurgical intervention depending on the nature of the condition and status of the patient. On the other hand, asymptomatic patients with incidental findings require careful consideration and risk assessment when deciding on whether or not to treat the condition, and if so, how. In this review article we provide a summary of some of the most common neurosurgical vascular conditions and outline management considerations in both the acute and elective setting.

Tre överläkare i neurokirurgi och neurologi: Nivåstruktureringsprocessen inom epilepsikirurgiområdet behöver avbrytas oberoende av om Karolinska drabbas av den eller ej.

Objective: The aim of this study was to investigate the association between intraoperative intrasellar pressure (ISP) and pre- and postoperative endocrine disturbances with focus on hyperprolactinemia and hypopituitarism in patients with pituitary tumors.

Methods: The study is a consecutive, retrospective study with ISP collected prospectively. One hundred patients operated with transsphenoidal surgery due to a pituitary tumor, who had their ISP measured intraoperatively, were included. Data on patient endocrine status preoperatively and from 3-month postoperative follow-up were collected from medical records.

Results: The risk of preoperative hyperprolactinemia in patients with nonprolactinoma pituitary tumors increased with ISP (unit odds ratio 1.067, n = 70) (P = 0.041). Preoperative hyperprolactinemia was normalized at 3 months after surgery. Mean ISP was higher in patients with preoperative thyroid-stimulating hormone (TSH) deficiency (25.3 ± 9.2 mmHg, n = 37) than in patients with intact thyroid axis (21.6 ± 7.2 mmHg, n = 50) (P = 0.041). No significant difference in ISP was found between patients with and without adrenocorticotropic hormone(ACTH) deficiency. No association was found between ISP and postoperative hypopituitarism at 3 months after surgery.

Conclusions: In patients with pituitary tumors, preoperative hypothyroidism and hyperprolactinemia may be associated with higher ISP. This is in line with the theory of pituitary stalk compression, suggested to be mediated by an elevated ISP. ISP does not predict the risk of postoperative hypopituitarism 3 months after surgical treatment.