Publications by authors named "Angelika Sorteberg"

39 Publications

(-)-OSU6162 in the treatment of fatigue and other sequelae after aneurysmal subarachnoid hemorrhage: a double-blind, randomized, placebo-controlled study.

J Neurosurg 2021 Oct 29:1-11. Epub 2021 Oct 29.

3Department of Neurosurgery, Oslo University Hospital.

Objective: Fatigue after aneurysmal subarachnoid hemorrhage (aSAH) is common and usually long-lasting, and it has a considerable negative impact on health-related quality of life (HRQOL), social functioning, and the ability to return to work (RTW). No effective treatment exists. The dopaminergic regulator (-)-OSU6162 has shown promising results regarding the mitigation of fatigue in various neurological diseases, and therefore the authors aimed to investigate the efficacy of (-)-OSU6162 in alleviating fatigue and other sequelae after aSAH.

Methods: A double-blind, randomized, placebo-controlled, single-center trial was performed in which 96 participants with post-aSAH fatigue were administered 30-60 mg/day of (-)-OSU6162 or placebo over a period of 12 weeks. Efficacy was assessed using the Fatigue Severity Scale (FSS), the Mental Fatigue Scale (MFS), the Beck Anxiety Inventory (BAI), the Beck Depression Inventory II (BDI-II), the SF-36 questionnaire, and a neuropsychological test battery. Assessments were performed at baseline, after 1, 4, 8, and 12 weeks of treatment, and at follow-up, 8 weeks after treatment.

Results: The 96 participants with post-aSAH fatigue were randomized to treatment with (-)-OSU6162 (n = 49) or placebo (n = 47). The FSS, MFS, and BDI scores improved significantly in both groups after 12 weeks of treatment, whereas the BAI scores improved in the placebo group only. HRQOL improved significantly in the SF-36 domain "Vitality" in both groups. Neuropsychological test performances were within the normal range at baseline and not affected by treatment. The FSS score was distinctly improved in patients with complete RTW upon treatment with (-)-OSU6162. Concomitant use of antidepressants improved the efficacy of (-)-OSU6162 on the FSS score at week 1 beyond the placebo response, and correspondingly the use of beta- or calcium-channel blockers improved the (-)-OSU6162 efficacy beyond the placebo response in MFS scores at week 4 of treatment. There was a significant correlation between improvement in FSS, BAI, and BDI scores and the plasma concentration of (-)-OSU6162 at the dose of 60 mg/day. No serious adverse events were attributable to the treatment, but dizziness was reported more often in the (-)-OSU6162 group.

Conclusions: Fatigue and other sequelae after aSAH were similarly alleviated by treatment with (-)-OSU6162 and placebo. (-)-OSU6162 improved fatigue, as measured with the FSS score, significantly in patients with complete RTW. There seemed to be synergetic effects of (-)-OSU6162 and medications interfering with dopaminergic pathways that should be explored further. The strong placebo response may be exploited in developing nonpharmacological treatment programs for post-aSAH fatigue.
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http://dx.doi.org/10.3171/2021.7.JNS211305DOI Listing
October 2021

Endovascular versus surgical treatment of cranial dural arteriovenous fistulas: a single-center 8-year experience.

Acta Neurochir (Wien) 2022 Jan 6;164(1):151-161. Epub 2021 Sep 6.

Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, P.B. 0454 Nydalen, 0424, Oslo, Norway.

Background: Cranial dural arteriovenous fistulas (dAVFs) are rare lesions managed mainly with endovascular treatment (EVT) and/or surgery. We hypothesize that there may be subtypes of dAVFs responding better to a specific treatment modality in terms of successful obliteration and cessation of symptoms and/or risks.

Methods: All dAVFs treated during 2011-2018 at our hospital were analyzed retrospectively. Presenting symptoms, radiological variables, treatment modality, complications, and residual symptoms were related to dAVF type using the original Djindjian classification.

Results: We treated 112 dAVFs in 107 patients (71, 66% males). They presented with hemorrhage (n = 23; 21%), non-hemorrhagic symptoms (n = 75; 70%), or were discovered incidentally (n = 9; 8%). There were 25 (22%) type I, 29 (26%) type II, 26 (23%) type III, and 32 (29%) type IV fistulas. EVT was the primary treatment modality in 72/112 (64%) dAVFs whereas 40/112 (36%) underwent primary surgery with angiographic obliteration rates of 60% and 90%, respectively. Using a secondary treatment modality in 23 dAVFs, we obtained a final obliteration rate of 93%, including all type III/IV and 26/27 (96%) type II dAVFs. Except for headache, residual symptoms were rare and minor. Permanent neurological complications consisted of five cranial nerve deficits.

Conclusions: We recommend EVT as first treatment modality in types I, II, and in non-hemorrhagic type III/IV dAVFs. We recommend surgery as first treatment choice in acute hemorrhagic dAVFs and as secondary choice in type III/IV dAVFs not successfully occluded by EVT. Combining the two modalities provides obliteration in 9/10 dAVF cases at a low procedural risk.
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http://dx.doi.org/10.1007/s00701-021-04950-9DOI Listing
January 2022

Fatigue After Aneurysmal Subarachnoid Hemorrhage: Clinical Characteristics and Associated Factors in Patients With Good Outcome.

Front Behav Neurosci 2021 12;15:633616. Epub 2021 May 12.

Department of Neurosurgery, Division of Clinical Neuroscience, Oslo University Hospital, Oslo, Norway.

Fatigue after aneurysmal subarachnoid hemorrhage (post-aSAH fatigue) is a frequent, often long-lasting, but still poorly studied sequel. The aim of the present study was to characterize the nature of post-aSAH fatigue with an itemized analysis of the Fatigue Severity Scale (FSS) and Mental Fatigue Scale (MFS). We further wanted to assess the association of fatigue with other commonly observed problems after aSAH: mood disorders, cognitive problems, health-related quality of life (HRQoL), weight gain, and return to work (RTW). Ninety-six good outcome aSAH patients with fatigue completed questionnaires measuring fatigue, depression, anxiety, and HRQoL. All patients underwent a physical and neurological examination. Cognitive functioning was assessed with a neuropsychological test battery. We also registered prior history of fatigue and mood disorders as well as occupational status and RTW. The patients experienced fatigue as being among their three most disabling symptoms and when characterizing their fatigue they emphasized the questionnaire items "low motivation," "mental fatigue," and "sensitivity to stress." Fatigue due to exercise was their least bothersome aspect of fatigue and weight gain was associated with depressive symptoms rather than the severity of fatigue. Although there was a strong association between fatigue and mood disorders, especially for depression, the overlap was incomplete. Post-aSAH fatigue related to reduced HRQoL. RTW was remarkably low with only 10.3% of patients returning to their previous workload. Fatigue was not related to cognitive functioning or neurological status. Although there was a strong association between fatigue and depression, the incomplete overlap supports the notion of these two being distinct constructs. Moreover, post-aSAH fatigue can exist without significant neurological or cognitive impairments, but is related to reduced HRQoL and contributes to the low rate of RTW.
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http://dx.doi.org/10.3389/fnbeh.2021.633616DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8149596PMC
May 2021

How preventable are rebleeds? : Reply to: Letter to the editor of Acta Neurochirurgica: "Predictive factors and timelines of rebleeding in Aneurysmal SAH: What have we gleaned?"

Acta Neurochir (Wien) 2021 05 25;163(5):1481-1483. Epub 2021 Feb 25.

Department of Neurosurgery, Oslo University Hospital, Rikshospitalet, P.B. 0454 Nydalen, 0424, Oslo, Norway.

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http://dx.doi.org/10.1007/s00701-021-04775-6DOI Listing
May 2021

Timelines and rebleeds in patients admitted into neurosurgical care for aneurysmal subarachnoid haemorrhage.

Acta Neurochir (Wien) 2021 03 6;163(3):771-781. Epub 2021 Jan 6.

Department of Neurosurgery, Oslo University Hospital, Rikshospitalet, P.B. 0454, 0424, Nydalen, Oslo, Norway.

Background: Mortality and morbidity of aneurysmal subarachnoid haemorrhage (aSAH) remain high, and prognosis is influenced by multiple non-modifiable factors such as aSAH severity. By analysing the chronology of aSAH management, we aim at identifying modifiable factors with emphasis on the occurrence of rebleeds in a setting with 24/7 surgical and endovascular availability of aneurysm repair and routine administration of tranexamic acid.

Methods: Retrospective analysis of institutional quality registry data of aSAH cases admitted into neurosurgical care during the time period 01 January 2013-31 December 2017. We registered time and mode of aneurysm repair, haemorrhage patterns, course of treatment, mortality and functional outcome. Rebleeding was scored along the entire timeline from ictus to discharge from the primary stay.

Results: We included 544 patients (368, 67.6% female), aged 58 ± 14 years (range 1-95 years). Aneurysm repair was performed in 486/544 (89.3%) patients at median 7.4 h after arrival and within 3, 6, 12 and 24 h in 26.8%, 44.7%, 73.0% and 96.1%, respectively. There were circadian variations in time to repair and in rebleeds. Rebleeding prior to aneurysm repair occurred in 9.7% and increased with aSAH severity and often in conjunction with patient relocations or interventions. Rebleeds occurred more often during surgical repair outside regular working hours, whereas rebleeds after repair (1.8%) were linked to endovascular repair.

Conclusions: The risk of rebleed is imminent throughout the entire timeline of aSAH management even with ultra-early aneurysm repair. Several modifiable factors can be linked to the occurrence of rebleeds and they should be identified and optimised within neurosurgical departments.
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http://dx.doi.org/10.1007/s00701-020-04673-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7886745PMC
March 2021

Prevalence and predictors of fatigue after aneurysmal subarachnoid hemorrhage.

Acta Neurochir (Wien) 2020 12 18;162(12):3107-3116. Epub 2020 Aug 18.

Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway.

Background: Fatigue is a common and disabling sequel after aneurysmal subarachnoid hemorrhage (aSAH). At present, prevalence estimates of post-aSAH fatigue in the chronic phase are scarce and vary greatly. Factors from the acute phase of aSAH have hitherto barely been associated with post-aSAH fatigue in the chronic phase.

Methods: Prospective study assessing prevalence of fatigue using the Fatigue Severity Scale (FSS) in patients who were living independently 1 to 7 years after aSAH. We compared demographic, medical, and radiological variables from the acute phase of aSAH between patients with and without fatigue (FSS ≥ 4 versus < 4) and searched for predictors of fatigue among these variables applying univariable and multivariable regression analyses.

Results: Of 726 patients treated for aSAH in the period between January 2012 and December 2017, 356 patients completed the assessment. The mean FSS score was 4.7 ± 1.7, and fatigue was present in 69.7%. The frequency of patients with fatigue did not decline significantly over time. Univariable analysis identified nicotine use, loss of consciousness at ictus (LOCi), rebleed prior to aneurysm repair, reduced consciousness to Glasgow Coma Scale (GCS) < 14, large amounts of subarachnoid blood, the presence of acute hydrocephalus, and severe vasospasm as factors that were significantly associated with fatigue. In multivariable analysis, nicotine use, reduced GCS, and severe vasospasm were independent predictors that all more than doubled the risk to develop post-aSAH fatigue.

Conclusions: Fatigue is a frequent sequel persisting several years after aSAH. Nicotine use, reduced consciousness at admission, and severe vasospasm are independent predictors of fatigue from the acute phase of aSAH. We propose inflammatory cytokines causing dopamine imbalance to be a common denominator for post-aSAH fatigue and the presently identified predictors.
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http://dx.doi.org/10.1007/s00701-020-04538-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7593293PMC
December 2020

Survival and outcome in patients with aneurysmal subarachnoid hemorrhage in Glasgow coma score 3-5.

Acta Neurochir (Wien) 2020 03 24;162(3):533-544. Epub 2020 Jan 24.

Department of Neurosurgery, Oslo University Hospital, Rikshospitalet, P.B. 0454, Nydalen, 0424, Oslo, Norway.

Background: Outcome of early, aggressive management of aneurysmal subarachnoid hemorrhage (aSAH) in patients with Hunt and Hess grade V is hitherto limited, and we therefore present our results.

Methods: Retrospective study analyzing the medical data of 228 aSAH patients in Glasgow Coma Score 3-5 admitted to our hospital during the years 2002-2012. Background and treatment variables were registered. Outcome was evaluated after 3 and 12 months.

Results: We intended to treat 176 (77.2%) patients, but only 146 went on to aneurysm repair. Of 52 patients managed conservatively, 27 had abolished cerebral circulation around arrival and 25 were deemed unsalvageable. One-year overall mortality was 65.8% and most (84.7%) of the fatalities occurred within 30 days. One-year mortality was higher in patients > 70 years. Without aneurysm repair, mortality was 100%. After 1 year, 21.9% of all patients lived independently and 4.8% lived permanently in an institution. Outcome in the 78 survivors (34.2%) was favorable in 64.1% in terms of modified Rankin Scale score 0-2, and 85.9% of survivors were able to live at home. Return to work was low for all 228 patients with 14.0% of those employed prior to the hemorrhage having returned to paid work, and respectively, 26.3% in the subgroup of survivors.

Conclusions: Even with aggressive, early treatment, 1-year mortality is high in comatose aSAH patients with 65.8%. A substantial portion of the survivors have a favorable outcome at 1 year (64.1%, corresponding to 21.9% of all patients admitted) and 85.9% of the survivors could live at home alone or aided.
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http://dx.doi.org/10.1007/s00701-019-04190-yDOI Listing
March 2020

The path from ictus to Neurosurgery: chronology and transport logistics of patients with aneurysmal subarachnoid haemorrhage in the South-Eastern Norway Health Region.

Acta Neurochir (Wien) 2019 08 13;161(8):1497-1506. Epub 2019 Jun 13.

Department of Neurosurgery, Oslo University Hospital, Rikshospitalet, P.B. 0454, Nydalen, 0424, Oslo, Norway.

Background: Guidelines state that patients with aneurysmal subarachnoid haemorrhage (aSAH) require neurosurgical treatment as early as possible. Little is known about the time frame of transport from the ictus scene to Neurosurgery in large, partially remote catchment areas. We therefore analysed the chronology and transport logistics of aSAH patients in the South-Eastern Norway Health Region and related them to the frequency of aneurysm rebleed and 1-year mortality.

Methods: Retrospective analysis of aSAH patients bleeding within our region admitted to Neurosurgery during a 5-year period. Date, time and site of ictus and arrival at Neurosurgery, distance and mode of transport and admission were obtained from our institutional quality register and the emergency medical communication centre log. We scored the patients' clinical condition, rebleeds and 1-year mortality.

Results: Five hundred forty-four patients were included. Median time from ictus to arrival Neurosurgery was 4.5 h. Transport by road ambulance was most common at distances between the ictus scene and Neurosurgery below 50 km, whereas airborne transport became increasingly more common at larger distances. Direct admissions, frequency of intubation and airborne transport to Neurosurgery increased with the severity of haemorrhage, leading to shorter transport times. The risk of rebleed was 0.8%/hour of transport. The rebleed rate was independent of distances travelled, but increased with the severity of aSAH, reaching up to 6.54%/hour in poor-grade patients. Distance and time of transport had no impact on 1-year mortality, whereas poor-grade aSAH and rebleed were strong predictors of mortality.

Conclusions: Poor-grade aSAH patients have a high risk of rebleed independent of the distance between the ictus scene and Neurosurgery. As rebleeding triples 1-year mortality, patients with Glasgow Coma Score < 9 with suspected aSAH should be admitted directly to Neurosurgery without delay after best possible cardiovascular and airway optimisation on site by competent personnel.
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http://dx.doi.org/10.1007/s00701-019-03971-9DOI Listing
August 2019

The post-aSAH syndrome: a self-reported cluster of symptoms in patients with aneurysmal subarachnoid hemorrhage.

J Neurosurg 2019 Apr 19;132(5):1556-1565. Epub 2019 Apr 19.

2Neurosurgery, Oslo University Hospital; and.

Objective: Although many patients recover to a good functional outcome after aneurysmal subarachnoid hemorrhage (aSAH), residual symptoms are very common and may have a large impact on the patient's daily life. The particular cluster of residual symptoms after aSAH has not previously been described in detail and there is no validated questionnaire that covers the typical problems reported after aSAH. Many of the symptoms are similar to post-concussion syndrome, which often is evaluated with the Rivermead Post-Concussion Symptoms Questionnaire (RPQ). In the present study, the authors therefore performed an exploratory use of the RPQ as a template to describe post-aSAH syndrome.

Methods: The RPQ was administered to 128 patients in the chronic phase after aSAH along with a battery of quality-of-life questionnaires. The patients also underwent a medical examination besides cognitive and physical testing. Based on their RPQ scores, patients were dichotomized into a "syndrome" group or "recovery" group.

Results: A post-aSAH syndrome was seen in 33% of the patients and their symptom burden on all RPQ subscales was significantly higher than that of patients who had recovered on all RPQ subscales. The symptom cluster consisted mainly of fatigue, cognitive problems, and emotional problems. Physical problems were less frequently reported. Patients with post-aSAH syndrome scored significantly worse on mobility and pain scores, as well as on quality-of-life questionnaires. They also had significantly poorer scores on neuropsychological tests of verbal learning, verbal short- and long-term memory, psychomotor speed, and executive functions. Whereas 36% of the patients in the recovery group were able to return to their premorbid occupational status, this was true for only 1 patient in the syndrome group.

Conclusions: Approximately one-third of aSAH patients develop a post-aSAH syndrome. These patients struggle with fatigue and cognitive and emotional problems. Patients with post-aSAH syndrome report more pain and reduced quality of life compared to patients without this cluster of residual symptoms and have larger cognitive deficits. In this sample, patients with post-aSAH syndrome were almost invariably excluded from return to work. The RPQ is a simple questionnaire covering the specter of residual symptoms after aSAH. Being able to acknowledge these patients' complaints as a defined syndrome using the RPQ should help patients to accept and cope, thereby alleviating possible secondary distress produced.
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http://dx.doi.org/10.3171/2019.1.JNS183168DOI Listing
April 2019

"Bucket" cerebrospinal fluid bulk flow: when the terrain disagrees with the map.

Acta Neurochir (Wien) 2019 02 17;161(2):259-261. Epub 2018 Dec 17.

Department of Radiology and Nuclear Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway.

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http://dx.doi.org/10.1007/s00701-018-3775-6DOI Listing
February 2019

Efficiency and complications of Woven EndoBridge (WEB) devices for treatment of larger, complex intracranial aneurysms-a single-center experience.

Acta Neurochir (Wien) 2019 02 13;161(2):393-401. Epub 2018 Dec 13.

Institute of Clinical Medicine, University in Oslo, Problemveien 17, 0315, Oslo, Norway.

Background: Several recently published multicenter studies have reported high treatment feasibility, high safety, and good 6-month to 1-year efficiency when treating smaller intracranial aneurysms (IA) with WEB deployment. The purpose of the study was to evaluate the long-term efficiency and complications related to WEB treatment of larger, complex intracranial aneurysms in a small single-center cohort.

Methods: Patients with ruptured and unruptured IA were treated with WEB devices; data were collected prospectively and analyzed retrospectively. The study evaluates complications and clinical and radiological findings at immediate and last available follow-up.

Results: The study included 16 patients with 16 aneurysms and a median follow-up time of 36 months, range 13-49 months; 9/16 were females. Median age 59 with range 39-71 years. Mean aneurysm size 11.3 ± 1.7 mm, predominant location at the basilar artery bifurcation and anterior communicating artery. Three out of sixteen IAs were ruptured. Even though 75% of the IAs were immediately occluded completely, retreatment was eventually necessary in 7/15 (46.7%). Increasing neck remnants and recurrences were mainly observed past 1-year follow-up. The WEB device showed modifications over time, with six devices showing signs of compression in the long term. There was one fatality due to aneurysm rupture after 4 years.

Conclusions: The long-term efficiency of WEB deployment in larger, complex aneurysms is low with about half of the cases needing at least one retreatment. A large fraction of WEB collapse past 1-year follow-up.
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http://dx.doi.org/10.1007/s00701-018-3752-0DOI Listing
February 2019

Predictors of cognitive function in the acute phase after aneurysmal subarachnoid hemorrhage.

Acta Neurochir (Wien) 2019 01 8;161(1):177-184. Epub 2018 Dec 8.

Department of Neurosurgery, Oslo University Hospital, Rikshospitalet, P.B. 4950, Nydalen, 0424, Oslo, Norway.

Background: Cognitive dysfunction is the most common form of neurological impairment after aneurysmal subarachnoid hemorrhage (aSAH) in the chronic phase. Cognitive deficits in the acute phase after aSAH, however, remain scarcely investigated. The aim of the present study was to test cognitive function and to identify medical predictors of cognitive deficits in the acute phase of aSAH.

Methods: Prospective study including 51 patients treated for aSAH. Patients were treated in accordance with a standardized institutional protocol and subjected to neuropsychological evaluation around discharge from neurosurgical care. The neuropsychological test results were transformed into a global cognitive impairment index where an index value of 0.00 is considered normal and 1.00 is considered maximally pathological. Patients with an index score of less than 0.75 were considered having good global cognitive function while those with an index score equal to or above 0.75 were considered having poor global cognitive function. Univariate and multiple regression analysis were used to identify medical predictors of cognitive function.

Results: Fifty-seven percent of the patients had poor cognitive function. They showed severe cognitive deficits, with most tests falling well below two standard deviations from the expected normal mean. Poor cognitive function was not reflected in a poor modified Rankin score in almost half of the cases. Patients with good cognitive function showed only mild cognitive deficits with most tests falling only slightly below the normal mean. Delayed memory was the most affected function in both groups. Univariate analysis identified acute hydrocephalus and aSAH-acquired cerebral infarction to be predictors of poor cognitive function. Cerebrospinal fluid drainage in excess of 2000 ml six-folded the risk of poor cognitive function, whereas a new cerebral infarction 11-folded the respective risk of poor cognitive function.

Conclusion: More than half of aSAH patients have severe cognitive deficits in the acute phase. The modified Rankin Score should be combined with neuropsychological screening in the acute phase after aSAH to get a more accurate description of the patients' disabilities. Acute hydrocephalus and aSAH-acquired cerebral infarction are the strongest predictors of poor cognitive function in the acute phase.
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http://dx.doi.org/10.1007/s00701-018-3760-0DOI Listing
January 2019

Magnitude and direction of aqueductal cerebrospinal fluid flow: large variations in patients with intracranial aneurysms with or without a previous subarachnoid hemorrhage.

Acta Neurochir (Wien) 2019 02 15;161(2):247-256. Epub 2018 Nov 15.

Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.

Background: Net cerebrospinal fluid (CSF) flow within the cerebral aqueduct is usually considered to be antegrade, i.e., from the third to the fourth ventricle with volumes ranging between 500 and 600 ml over 24 h. Knowledge of individual CSF flow dynamics, however, is hitherto scarcely investigated. In order to explore individual CSF flow rate and direction, we assessed net aqueductal CSF flow in individuals with intracranial aneurysms with or without a previous subarachnoid hemorrhage (SAH).

Methods: A prospective observational study was performed utilizing phase-contrast magnetic resonance imaging (PC-MRI) to determine the magnitude and direction of aqueductal CSF flow with an in-depth, pixel-by-pixel approach. Estimation of net flow was used to calculate CSF flow volumes over 24 h. PC-MRI provides positive values when flow is retrograde.

Results: The study included eight patients with intracranial aneurysms. Four were examined within days after their SAH; three were studied in the chronic stage after SAH while one patient had an unruptured intracranial aneurysm. There was a vast variation in magnitude and direction of aqueductal CSF flow between individuals. Net aqueductal CSF flow was retrograde, i.e., directed towards the third ventricle in 5/8 individuals. For the entire patient cohort, the estimated net aqueductal CSF volumetric flow rate (independent of direction) was median 898 ml/24 h (ranges 69 ml/24 h to 12.9 l/24 h). One of the two individuals who had a very high estimated net aqueductal CSF volumetric flow rate, 8.7 l/24 h retrograde, later needed a permanent CSF shunt.

Conclusions: The magnitude and direction of net aqueductal CSF flow vary extensively in patients with intracranial aneurysms. Following SAH, PC-MRI may offer the possibility to perform individualized assessments of the CSF circulation.
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http://dx.doi.org/10.1007/s00701-018-3730-6DOI Listing
February 2019

Prerupture Intracranial Aneurysm Morphology in Predicting Risk of Rupture: A Matched Case-Control Study.

Neurosurgery 2019 01;84(1):132-140

Faculty of Health, UiT The Arctic University of Norway, Tromsø, Norway.

Background: Maximal size and other morphological parameters of intracranial aneurysms (IAs) are used when deciding if an IA should be treated prophylactically. These parameters are derived from postrupture morphology. As time and rupture may alter the aneurysm geometry, possible morphological predictors of a rupture should be established in prerupture aneurysms.

Objective: To identify morphological parameters of unruptured IAs associated with later rupture.

Methods: Nationwide matched case-control study. Twelve IAs that later ruptured were matched 1:2 with 24 control IAs that remained unruptured during a median follow-up time of 4.5 (interquartile range, 3.7-8.2) yr. Morphological parameters were automatically measured on 3-dimensional models constructed from angiograms obtained at time of diagnosis. Cases and controls were matched by aneurysm location and size, patient age and sex, and the PHASES (population, hypertension, age, size of aneurysm, earlier subarachnoid hemorrhage from another aneurysm, and site of aneurysm) score did not differ between the 2 groups.

Results: Only inflow angle was significantly different in cases vs controls in univariate analysis (P = .045), and remained significant in multivariable analysis. Maximal size correlated with size ratio in both cases and controls (P = .015 and <.001, respectively). However, maximal size and inflow angle were correlated in cases but not in controls (P = .004. and .87, respectively).

Conclusion: A straighter inflow angle may predispose an aneurysm to changes that further increase risk of rupture. Traditional parameters of aneurysm morphology may be of limited value in predicting IA rupture.
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http://dx.doi.org/10.1093/neuros/nyy010DOI Listing
January 2019

Adenosine-assisted clipping of intracranial aneurysms.

Neurosurg Rev 2018 Apr 17;41(2):585-592. Epub 2017 Aug 17.

Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, 0027, Oslo, Norway.

Temporary parent vessel clip occlusion in aneurysm surgery is not always practical or feasible. Adenosine-induced transient cardiac arrest may serve as an alternative. We retrospectively reviewed our clinical database between September 2011 and July 2014. All patients who underwent microsurgical clipping of intracranial aneurysms under adenosine-induced asystole were included. A total of 18 craniotomies were performed, and 18 aneurysms were clipped under adenosine-induced asystole (7 basilar arteries, 8 internal carotid arteries, 1 middle cerebral artery, and 1 anterior communicating artery) in 16 patients (10 females, 6 males). Nine cases were elective and seven after subarachnoid hemorrhage. Mean age was 54 years (range 39-70). The indications for adenosine use were proximal control in narrow surgical corridors in 13 cases and "aneurysm softening" in 4 cases. A single dose was used in 14 patients; 3 patients had multiple boluses. The median (range) total dose was 30 (18-135) mg. Adenosine induced a bradycardia with concomitant arterial hypotension in all patients, and the majority also had asystole for 5-15 sec. Transient cardiac arrhythmias were noted in one patient (AFib in need of electroconversion after two boluses). Nine clinical scenarios where adenosine-induced temporary cardiac arrest and deep hypotension was an effective adjunct to temporary clipping during microsurgical clipping of intracranial aneurysms were identified.
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http://dx.doi.org/10.1007/s10143-017-0896-yDOI Listing
April 2018

Cerebral Aneurysm Morphology Before and After Rupture: Nationwide Case Series of 29 Aneurysms.

Stroke 2017 04 6;48(4):880-886. Epub 2017 Mar 6.

From the UiT The Arctic University of Norway, Tromsø (T.Ø.S., J.G.I.); University Hospital of Northern Norway, Tromsø (L.-H.J., J.G.I.); Oslo University Hospital Rikshospitalet, Norway (Ø.G., A.S.); and Institute of Clinical Medicine, University of Oslo, Norway (A.S.).

Background And Purpose: Using postrupture morphology to predict rupture risk of an intracranial aneurysm may be inaccurate because of possible morphological changes at or around the time of rupture. The present study aims at comparing morphology from angiograms obtained prior to and just after rupture and to evaluate whether postrupture morphology is an adequate surrogate for rupture risk.

Methods: Case series of 29 aneurysms from a nationwide retrospective data collection. Two neuroradiologists who were blinded to pre- versus postrupture images assessed predefined morphological parameters independently and reached consensus regarding all measurements. Prerupture morphology and respective changes after rupture were quantified and linked to risk factors and to the risk of rupture according to the PHASES (population, hypertension, age, size of aneurysm, earlier subarachnoid hemorrhage from another aneurysm, site of aneurysm) and unruptured intracranial aneurysm treatment (UIAT) scores.

Results: All 1-dimensional parameter medians were significantly larger after rupture, except neck diameter. Number of aneurysms with daughter sacs was 9 (31%) before and 17 (59%) after rupture (=0.005). Aneurysm growth from the images prior to and just after rupture increased with the time elapsed between images. Aneurysms in patients with hypertension were significantly larger at diagnosis. Prerupture morphology did not differ in relation to smoke status. Clinical risk factors were not significantly associated with morphological change.

Conclusions: The changes in aneurysm morphology observed after rupture reflect the compound effect of time with successive growth and formation of irregularities and the impact of rupture per se. Postrupture morphology should not be considered an adequate surrogate for the prerupture morphology in the evaluation of rupture risk.
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http://dx.doi.org/10.1161/STROKEAHA.116.015288DOI Listing
April 2017

Impact of early mobilization and rehabilitation on global functional outcome one year after aneurysmal subarachnoid hemorrhage.

J Rehabil Med 2016 Oct;48(8):676-682

Dept of Physical Medicine and Rehabilitation, Oslo University Hospital, Ullevaal and Rikshospitalet, P.B. 4950 Nydalen, 0424 Oslo, Norway.

Objective: To assess the impact of early mobilization and rehabilitation on global functional outcome one year after aneurysmal subarachnoid haemorrhage.

Methods: Prospective, controlled, interventional study comprising patients managed in the neuro-intermediate ward following repair of a ruptured intracranial aneurysm. Patients in the Control group (n = 76) received standard treatment, whereas those in the Early Rehab group (n = 92) in addition underwent early mobilization and rehabilitation. Demographic, clinical and intervention data were registered. Global functional outcome was assessed using the modified Rankin Scale and the Glasgow Outcome Scale Extended.

Results: The 2 groups were similar in their demographic and clinical characteristics. Early Rehab group patients were mobilized more quickly (p < 0.001), median 1.4 days (range 0-23 days) after aneurysm repair. After 1 year, 47% of the patients had made a good recovery, whereas 6.5% had died. Regression analysis did not reveal any significant effect of early rehabilitation on functional outcome. However, in poor-grade patients, early rehabilitation more than doubled the chance of a favourable outcome (adjusted odds ratio = 2.33; confidence interval 1.04-5.2, p = 0.039).

Conclusion: Early mobilization and rehabilitation probably increases the chance of a good functional outcome in poor-grade aneurysmal subarachnoid haemorrhage patients.
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http://dx.doi.org/10.2340/16501977-2121DOI Listing
October 2016

Effect of early mobilization and rehabilitation on complications in aneurysmal subarachnoid hemorrhage.

J Neurosurg 2017 Feb 8;126(2):518-526. Epub 2016 Apr 8.

Neurosurgery, Oslo University Hospital, Oslo.

OBJECTIVE Early rehabilitation is effective in an array of acute neurological disorders but it is not established as part of treatment guidelines after aneurysmal subarachnoid hemorrhage (aSAH). This may in part be due to the fear of aggravating the development of cerebral vasospasm, which is the most feared complication of aSAH. The aim of this study was to evaluate the effect of early rehabilitation and mobilization on complications during the acute phase and within 90 days after aSAH. METHODS This was a prospective, interventional study that included patients with aSAH at the neuro-intermediate ward after aneurysm repair. The control group received standard treatment, whereas the early rehab group underwent early rehabilitation and mobilization in addition to standard treatment. Clinical and radiological characteristics of patients with aSAH, progression in mobilization, and treatment variables were registered. The frequency and severity of cerebral vasospasm, cerebral infarction acquired in conjunction with the aSAH, and acute and chronic hydrocephalus, as well as pulmonary and thromboembolic complications, were compared between the 2 groups. RESULTS Clinical and radiological characteristics of patients with aSAH were similar between the groups. The early rehab group was mobilized beginning on the first day after aneurysm repair. The significantly quicker and higher degree of mobilization in the early rehab group did not increase complications. Clinical cerebral vasospasm was not as frequent in the early rehab group and it also tended to be less severe. Each step of mobilization achieved during the first 4 days after aneurysm repair reduced the risk of severe vasospasm by 30%. Acute and chronic hydrocephalus were similar in both groups, but there was a tendency toward earlier shunt implantation among patients in the control group. Pulmonary infections, thromboembolic events, and death before discharge or within 90 days after the ictus were similar between the 2 groups. CONCLUSIONS Early rehabilitation of patients after aSAH is safe and feasible. The earlier and higher degree of mobilization does not increase neurosurgical complications. Rather, the frequency and severity of cerebral vasospasm following aSAH are alleviated and are not aggravated by early rehabilitation. Clinical trial registration no.: NCT01656317 ( www.clinicaltrials.gov ).
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http://dx.doi.org/10.3171/2015.12.JNS151744DOI Listing
February 2017

Computational fluid dynamics evaluation of flow reversal treatment of giant basilar tip aneurysm.

Interv Neuroradiol 2015 Oct 7;21(5):586-91. Epub 2015 Aug 7.

Department of Neurosurgery, Oslo University Hospital, Norway

Therapeutic parent artery flow reversal is a treatment option for giant, partially thrombosed basilar tip aneurysms. The effectiveness of this treatment has been variable and not yet studied by applying computational fluid dynamics. Computed tomography images and blood flow velocities acquired with transcranial Doppler ultrasonography were obtained prior to and after bilateral endovascular vertebral artery occlusion for a giant basilar tip aneurysm. Patient-specific geometries and velocity waveforms were used in computational fluid dynamics simulations in order to determine the velocity and wall shear stress changes induced by treatment. Therapeutic parent artery flow reversal lead to a dramatic increase in aneurysm inflow and wall shear stress (30 to 170 Pa) resulting in an increase in intra-aneurysmal circulation. The enlargement of the circulated area within the aneurysm led to a re-normalization of the wall shear stress and the aneurysm remained stable for more than 8 years thereafter. Therapeutic parent artery flow reversal can lead to unintended, potentially harmful changes in aneurysm inflow which can be quantified and possibly predicted by applying computational fluid dynamics.
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http://dx.doi.org/10.1177/1591019915597415DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4757336PMC
October 2015

The effect of tracheotomy on drug consumption in patients with acute aneurysmal subarachnoid hemorrhage: an observational study.

BMC Anesthesiol 2015 8;15:47. Epub 2015 Apr 8.

Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway.

Background: Patients with aneurysmal subarachnoid hemorrhage (aSAH) are common in intensive care units (ICU). In patients with aSAH, sedation is used as a neuroprotective measure in order to secure adequate cerebral perfusion pressure (CPP). Compared with the use of an endotracheal tube, a tracheotomy has the advantage of securing the airway at a much lower level of distress, and aSAH patients can often be awakened more rapidly. Little is known about the impact of tracheotomy on the consumption of sedative/analgesic and vasoactive drugs and the maintenance of CPP within defined limits in aSAH patients.

Methods: We conducted an observational study of aSAH patients who underwent percutaneous tracheotomy. A prospective registry of patient data was supplemented with retrospective retrievals from medical records. Sedative, analgesic and vasoactive drug doses were registered for 3 days prior to and after percutaneous tracheotomy, respectively. Blood pressure, CPP, and the mode of mechanical ventilation were registered 24 h prior to and after tracheotomy.

Results: Between January 2001 and June 2009, 902 aSAH patients were admitted to our hospital; 74 (8%) were deeply comatose/dying upon arrival. The ruptured aneurysm was repaired in 828 patients (surgical repair 50%) and percutaneous tracheotomy was performed 182 times in 178 patients (59 men and 119 women). This subpopulation (178 of 828 patients) was significantly older (56 vs. 53 years) and presented with a more severe Hunt & Hess grade (p < 0.001). Percutaneous tracheotomy caused a marked decline in mean daily consumption of the analgesics/sedatives fentanyl, midazolam, and propofol, as well as the vasoactive drugs noradrenaline and dopamine. These declines were statistically and clinically significant. The mean CPP was 76 mmHg (SD 8.6) the day before and 79 mmHg (SD 9.6) 24 h after percutaneous tracheotomy. After percutaneous tracheotomy, mechanical ventilatory support could be reduced to a patient-controlled ventilatory support mode in a significant number of patients (p < 0.001).

Conclusions: Percutaneous tracheotomy in aSAH patients is a swift procedure with low risk that is associated with a significant decline in the consumption of sedative/analgesic and vasoactive drugs while clinical surveillance parameters remain stable or improve.
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http://dx.doi.org/10.1186/s12871-015-0029-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4399106PMC
December 2015

Early rehabilitation in patients with acute aneurysmal subarachnoid hemorrhage.

Disabil Rehabil 2015 29;37(16):1446-54. Epub 2014 Sep 29.

Department of Physical Medicine and Rehabilitation, Oslo University Hospital , Ullevaal, Nydalen, Oslo , Norway .

Purpose: The aim of this study was to describe and quantify the content of early rehabilitation adapted to patients with acute aneurysmal subarachnoid hemorrhage (aSAH) and to assess its feasibility.

Methods: This was a prospective, observational study including 37 aSAH patients. Early rehabilitation was applied according to a mobilization algorithm. Clinical parameters, the time that rehabilitation team used on early rehabilitation and progression in mobilization were recorded. The patients' clinical conditions were graded according to the World Federation of Neurological Surgeons scale (WFNS).

Results: Poor-grade patients (WFNS 3, 4, 5) (n = 12) received more rehabilitation (median 412 min) than did good-grade patients (WFNS 1, 2) (median 240 min). Mobilization to 60° of head elevation in good-grade patients began on day one after securing the aneurysm. Out-of-bed mobilization was possible on day three. Poor-grade patients were mobilized to 60° after two days and were out of bed on day seven. At discharge, 67% of poor-grade patients were mobilized to walking versus 78% of good-grade patients. No serious adverse effects to early rehabilitation were observed.

Conclusions: Early rehabilitation in aSAH patients is feasible from the first day after securing the aneurysm. The rehabilitation content varied according to the patient's clinical grade. Implications for Rehabilitation Early rehabilitation is feasible from the first day after securing the ruptured aneurysm in patients with aneurysmal subarachnoid hemorrhage (aSAH). Early rehabilitation requires close monitoring and continuous adjustment for the content and amount according to the patient's clinical condition. Interdisciplinary collaboration is recommended to match the rehabilitation needs to the medical condition on a daily basis.
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http://dx.doi.org/10.3109/09638288.2014.966162DOI Listing
March 2016

Predictors of shunt dependency after aneurysmal subarachnoid hemorrhage: results of a single-center clinical trial.

Acta Neurochir (Wien) 2014 Nov 22;156(11):2059-69. Epub 2014 Aug 22.

Faculty of Medicine, University of Oslo, Oslo, Norway.

Background: Hydrocephalus (HC) after aneurysmal subarachnoid hemorrhage (aSAH) is a common sequel. Proper selection of patients in need of permanent cerebrospinal fluid (CSF) diversion is, however, not straightforward. The aim of this study was to identify predictors of CSF shunt dependency following aSAH.

Methods: We re-analyzed data acquired from aSAH patients previously enrolled in a prospective, controlled single-center clinical trial in which shunt dependency was not one of the end points. In the present study patients were allocated into two groups: those receiving a shunt (here denoted as shunt dependent) and those not receiving a shunt, based on a clinical decision process. Predictors of shunt dependency were identified by applying uni- and multivariable analysis. We tested a set of predefined possible risk factors based on the results of the clinical trial, including the impact of CSF drainage volume exceeding 1,500 ml during the 1st week after ictus.

Results: Ninety patients were included in the study. Significant predictors of shunt dependency were poor clinical grade at admission [odds ratio (OR) 4.7, 95% confidence interval (CI) 1.2-18.4], large amounts of subarachnoid blood (OR 3.8, 95% CI 1.0-14.0), large ventricular size on preoperative cerebral computer tomographic (CT) scans (OR 1.0, 95% CI 1.0-1.1), and CSF volume drainage exceeding 1,500 ml during the 1st week after the ictus (OR 16.3, 95% CI 4.0-67.1). Age ≥70 years, larger amounts of intraventricular blood, vertebrobasilar aneurysm, and endovascular treatment tended to increase the likelihood of receiving a shunt. Outcome was not significantly different between shunted and non-shunted patients.

Conclusions: In this cohort of patients with clinical grade aSAH at admission, larger amounts of subarachnoid blood and large ventricular size on preoperative cerebral CT, and CSF drainage in excess of 1,500 ml during the 1st week after the ictus were significant predictors of shunt dependency. Shunt dependency did not hamper outcome.
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http://dx.doi.org/10.1007/s00701-014-2200-zDOI Listing
November 2014

The effect of baseline pressure errors on an intracranial pressure-derived index: results of a prospective observational study.

Biomed Eng Online 2014 Jul 23;13:99. Epub 2014 Jul 23.

Department of Neurosurgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway.

Background: In order to characterize the intracranial pressure-volume reserve capacity, the correlation coefficient (R) between the ICP wave amplitude (A) and the mean ICP level (P), the RAP index, has been used to improve the diagnostic value of ICP monitoring. Baseline pressure errors (BPEs), caused by spontaneous shifts or drifts in baseline pressure, cause erroneous readings of mean ICP. Consequently, BPEs could also affect ICP indices such as the RAP where in the mean ICP is incorporated.

Methods: A prospective, observational study was carried out on patients with aneurysmal subarachnoid hemorrhage (aSAH) undergoing ICP monitoring as part of their surveillance. Via the same burr hole in the scull, two separate ICP sensors were placed close to each other. For each consecutive 6-sec time window, the dynamic mean ICP wave amplitude (MWA; measure of the amplitude of the single pressure waves) and the static mean ICP, were computed. The RAP index was computed as the Pearson correlation coefficient between the MWA and the mean ICP for 40 6-sec time windows, i.e. every subsequent 4-min period (method 1). We compared this approach with a method of calculating RAP using a 4-min moving window updated every 6 seconds (method 2).

Results: The study included 16 aSAH patients. We compared 43,653 4-min RAP observations of signals 1 and 2 (method 1), and 1,727,000 6-sec RAP observations (method 2). The two methods of calculating RAP produced similar results. Differences in RAP ≥ 0.4 in at least 7% of observations were seen in 5/16 (31%) patients. Moreover, the combination of a RAP of ≥ 0.6 in one signal and <0.6 in the other was seen in ≥ 13% of RAP-observations in 4/16 (25%) patients, and in ≥ 8% in another 4/16 (25%) patients. The frequency of differences in RAP >0.2 was significantly associated with the frequency of BPEs (5 mmHg ≤ BPE <10 mmHg).

Conclusions: Simultaneous monitoring from two separate, close-by ICP sensors reveals significant differences in RAP that correspond to the occurrence of BPEs. As differences in RAP are of magnitudes that may alter patient management, we do not advocate the use of RAP in the management of neurosurgical patients.
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http://dx.doi.org/10.1186/1475-925X-13-99DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4125597PMC
July 2014

Intracranial Non-traumatic Aneurysms in Children and Adolescents.

Curr Pediatr Rev 2013 Nov;9(4):343-352

Dept of Neurosurgery, Oslo University Hospital - Rikshsospitalet, The National Hospital, Oslo, Norway.

An intracranial aneurysm in a child or adolescent is a rare, but potentially devastating condition. As little as approximately 1200 cases are reported between 1939 and 2011, with many of the reports presenting diverting results. There is consensus, though, in that pediatric aneurysms represent a pathophysiological entity different from their adult counterparts. In children, there is a male predominance. About two-thirds of pediatric intracranial aneurysms become symptomatic with hemorrhage and the rate of re-hemorrhage is higher than in adults. The rate of hemorrhage from an intracranial aneurysm peaks in girls around menarche. The most common aneurysm site in children is the internal carotid artery, in particular at its terminal ending. Aneurysms in the posterior circulation are more common in children than adults. Children more often develop giant aneurysms, and may become symptomatic from the mass effect of the aneurysm (tumorlike symptoms). The more complex nature of pediatric aneurysms poses a larger challenge to treatment alongside with higher demands to the durability of treatment. Outcome and mortality are similar in children and adults, but long-term outcome in the pediatric population is influenced by the high rate of aneurysm recurrences and de novo formation of intracranial aneurysms. This urges the need for life-long follow-up and screening protocols.
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http://dx.doi.org/10.2174/221155281120100005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3970571PMC
November 2013

Baseline pressure errors (BPEs) extensively influence intracranial pressure scores: results of a prospective observational study.

Biomed Eng Online 2014 Jan 28;13. Epub 2014 Jan 28.

Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway.

Background: Monitoring of intracranial pressure (ICP) is a cornerstone in the surveillance of neurosurgical patients. The ICP is measured against a baseline pressure (i.e. zero - or reference pressure). We have previously reported that baseline pressure errors (BPEs), manifested as spontaneous shift or drifts in baseline pressure, cause erroneous readings of mean ICP in individual patients. The objective of this study was to monitor the frequency and severity of BPEs. To this end, we performed a prospective, observational study monitoring the ICP from two separate ICP sensors (Sensors 1 and 2) placed in close proximity in the brain. We characterized BPEs as differences in mean ICP despite near to identical ICP waveform in Sensors 1 and 2.

Methods: The study enrolled patients with aneurysmal subarachnoid hemorrhage in need of continuous ICP monitoring as part of their intensive care management. The two sensors were placed close to each other in the brain parenchyma via the same burr hole. The monitoring was performed as long as needed from a clinical perspective and the ICP recordings were stored digitally for analysis. For every patient the mean ICP as well as the various ICP wave parameters of the two sensors were compared.

Results: Sixteen patients were monitored median 164 hours (ranges 70 - 364 hours). Major BPEs, as defined by marked differences in mean ICP despite similar ICP waveform, were seen in 9 of them (56%). The BPEs were of magnitudes that had the potential to alter patient management.

Conclusions: Baseline Pressure Errors (BPEs) occur in a significant number of patients undergoing continuous ICP monitoring and they may alter patient management. The current practice of measuring ICP against a baseline pressure does not comply with the concept of State of the Art. Monitoring of the ICP waves ought to become the new State of the Art as they are not influenced by BPEs.
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http://dx.doi.org/10.1186/1475-925X-13-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3922657PMC
January 2014

Directional intraoperative Doppler ultrasonography during surgery on cranial dural arteriovenous fistulas.

Neurosurgery 2013 Dec;73(2 Suppl Operative):ons211-22; discussion ons222-3

*Department of Neurosurgery, Oslo University Hospital Rikshospitalet, Oslo, Norway; ‡Faculty of Medicine, University of Oslo, Oslo, Norway.

Background: Directional intraoperative Doppler (dioDoppler) ultrasonography is well established as a tool in the surgery of intracranial aneurysms and cerebral arteriovenous malformations. The literature provides little information about the possible usefulness of this method during surgery on cranial dural arteriovenous fistulas (dAVFs).

Objective: To present our experience with the use of dioDoppler during surgery on cranial dAVFs.

Methods: All patients undergoing craniotomy for cranial dAVF from January 2007 to October 2012 in which dioDoppler was used were included in the study. We reviewed patient records, operating protocols, radiological images, dioDoppler files, and intraoperative videos.

Results: During the study period, 12 patients with cranial dAVFs underwent surgical treatment facilitated by dioDoppler. Four patients were operated on acutely for cerebral bleeds, and 8 patients were treated for various cerebral symptoms and the assumption of a significant risk for intracranial bleed. Three advantages of dioDoppler were unequivocal identification of veins with cortical/deep venous reflux from the fistula, verification of completeness of occlusion of the fistula, and identification of dural arterial feeders not visualized under the microscope.

Conclusion: Reviewing our experience, we found that dioDoppler sonography is an easy, safe, effective, reliable, and instantaneous tool during surgery on cranial dAVFs.
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http://dx.doi.org/10.1227/NEU.0000000000000061DOI Listing
December 2013

Pressure-derived versus pressure wave amplitude-derived indices of cerebrovascular pressure reactivity in relation to early clinical state and 12-month outcome following aneurysmal subarachnoid hemorrhage.

J Neurosurg 2012 May 10;116(5):961-71. Epub 2012 Feb 10.

Department of Neurosurgery, Oslo University Hospital–Rikshospitalet, University of Oslo, Norway.

Object: Indices of cerebrovascular pressure reactivity (CPR) represent surrogate markers of cerebral autoregulation. Given that intracranial pressure (ICP) wave amplitude-guided management, as compared with static ICP-guided management, improves outcome following aneurysmal subarachnoid hemorrhage (SAH), indices of CPR derived from pressure wave amplitudes should be further explored. This study was undertaken to investigate the value of CPR indices derived from static ICP-arterial blood pressure (ABP) values (pressure reactivity index [PRx]) versus ICP-ABP wave amplitudes (ICP-ABP wave amplitude correlation [IAAC]) in relation to the early clinical state and 12-month outcome in patients with aneurysmal SAH.

Methods: The authors conducted a single-center clinical trial enrolling patients with aneurysmal SAH. The CPR indices of PRx and IAAC of Week 1 after hemorrhage were related to the early clinical state (Glasgow Coma Scale [GCS] score) and 12-month outcome (modified Rankin Scale score).

Results: Ninety-four patients were included in the study. The IAAC, but not the PRx, increased with decreasing GCS score; that is, the higher the IAAC, the worse the clinical state. The PRx could differentiate between survivors and nonsurvivors only, whereas the IAAC clearly distinguished the groups "independent," "dependent," and "dead." In patients with an average IAAC ≥ 0.2, mortality was approximately 3-fold higher than in those with an IAAC < 0.2.

Conclusions: The IAAC, which is based on single ICP-ABP wave identification, relates significantly to the early clinical state and 12-month outcome following aneurysmal SAH. Impaired cerebrovascular pressure regulation during the 1st week after a bleed relates to a worse outcome. CLINICAL TRIAL REGISTRATION NO.: NCT00248690.
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http://dx.doi.org/10.3171/2012.1.JNS111313DOI Listing
May 2012

A randomized and blinded single-center trial comparing the effect of intracranial pressure and intracranial pressure wave amplitude-guided intensive care management on early clinical state and 12-month outcome in patients with aneurysmal subarachnoid hemorrhage.

Neurosurgery 2011 Nov;69(5):1105-15

Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, Oslo, Norway.

Background: In patients with aneurysmal subarachnoid hemorrhage (SAH), preliminary results indicate that the amplitude of the single intracranial pressure (ICP) wave is a better predictor of the early clinical state and 6-month outcome than the mean ICP.

Objective: To perform a randomized and blinded single-center trial comparing the effect of mean ICP vs mean ICP wave amplitude (MWA)-guided intensive care management on early clinical state and outcome in patients with aneurysmal SAH.

Methods: Patients were randomized to 2 different types of ICP management: maintenance of mean ICP less than 20 mm Hg and MWA less than 5 mm Hg. Early clinical state was assessed daily using the Glasgow Coma Scale. The primary efficacy variable was 12-month outcome in terms of the Rankin Stroke Score.

Results: Ninety-seven patients were included in the study. There were no significant differences in treatment between the 2 groups apart from a larger volume of cerebrospinal fluid drained during week 1 in the MWA group. There was a tendency toward higher Glasgow Coma Scale scores in the MWA group during weeks 1 (P = .08) and 2 (P = .07). Outcome in terms of Rankin Stroke Score at 12 months was significantly better in the MWA group (P < .05).

Conclusion: This randomized and blinded trial disclosed a significant better primary efficacy variable (Rankin Stroke Score after 12 months) in the MWA patient group. We suggest that proactive intensive care management with MWA-tailored cerebrospinal fluid drainage during the first week improves aneurysmal SAH outcome.
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http://dx.doi.org/10.1227/NEU.0b013e318227e0e1DOI Listing
November 2011
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