Abstract Introduction Cerebral glucose (CGlu) is essential for maintaining neuronal function. Haemorrhagic shock (HS) impaires cerebral substrate delivery. Resuscitative endovascular balloon occlusion of the aorta (REBOA) effectively restores arterial pressure; however, its effects on cerebral glucose dynamics, particularly in the presence of elevated ICP, remain incompletely understood. The aim of this study is to investigate CGlu dynamics during HS and subsequent resuscitation with total REBOA (tREBOA), and to assess the influence of intracranial pressure (ICP) on cerebral metabolic responses. Methods 18 pigs were assigned to either a normal ICP group (NICPG) or an elevated ICP group (EICPG) and were subjected to controlled HS followed by resuscitation with tREBOA. CGlu concentrations were measured using cerebral microdialysis throughout baseline, HS, and aortic occlusion (AO). Proximal mean arterial pressure (pMAP) and ICP were continuously monitored. Data were analysed using linear mixed-effects models. Results HS was associated with a reduction in CGlu in both groups, indicating early cerebral metabolic stress. Following initiation of tREBOA, CPP increased markedly; however, CGlu concentrations did not immediately normalise, particularly in EICPG. Instead, CGlu availability demonstrated time-dependent changes during prolonged AO. No consistent differences in CGlu concentrations between groups were observed once perfusion pressure was restored. Discussion tREBOA restored CPP and supported recovery of CGlu availability, even in the presence of elevated ICP. However, haemodynamic restoration was not accompanied by immediate metabolic normalization, demonstrating a dissociation between perfusion and CGlu regulation. These findings provide important physiological insights into the cerebral effects of tREBOA and support its cautious, time-limited use in complex trauma scenarios.

Background In recent years, the use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as a less invasive procedure compared to aortic cross-clamping via thoracotomy (1) has increased as an adjunct resuscitative method and a bridge to damage control surgery, primarily in trauma settings involving haemodynamically unstable patients (2-4). The main function of REBOA in HS is to preserve the remaining blood to the upper part of the body, i.e. to the brain, the lungs, and the heart. Additionally, REBOA reduces ongoing bleeding distal to the occlusion until definitive haemostasis is achieved (5). REBOA increases blood pressure proximal to the occlusion zone (proximal mean arterial pressure (pMAP)); consequently, it might be lifesaving and mitigates cerebral damage and neurological sequelae following the reduction of cerebral perfusion in patients with HS (6, 7).

Abstract Introduction REBOA is used as an adjunct in haemorrhagic shock (HS) to restore proximal arterial pressure. Its cerebral metabolic effects particularly in the presence of elevated ICP, remain incompletely characterised. The aim of this study is to describe the changes in cerebral metabolism during total AO during HS in animals with normal and elevated ICP. Methods In a controlled porcine model, HS was induced by controlled bleeding to a mean arterial pressure of approximately 40 mmHg. Animals were allocated to a normal ICP group or an experimentally elevated ICP group. Total REBOA (zone 1) was applied for 90 min. Cerebral metabolism was assessed using intracerebral microdialysis with measurements of lactate, pyruvate, and lactate–pyruvate ratio (LPR). Cerebral haemodynamics and ICP were continuously monitored. Results HS was associated with a statistically significant increase in LPR in both groups, indicating cerebral metabolic disturbance. Following aortic occlusion, LPR gradually decreased toward baseline in both groups. Animals with elevated ICP demonstrated a transient delay in metabolic normalisation during the early post-occlusion phase. Statistically significant differences between groups were limited to the first 10 min following occlusion. Overall metabolic trajectories were similar thereafter. Discussion REBOA restored cerebral metabolic markers of ischaemia in HS, as reflected by normalisation of LPR, even in the presence of experimentally elevated ICP. These findings indicate acute metabolic recovery and so suggest that the use of REBOA in the setting of elevated ICP is not contra indicated and can be a bridge to further treatment.

Abstract BACKGROUND Meningioma is typically benign and is occasionally detected during examinations due to other reasons (e.g. suspected stroke, trauma). Reported incidence figures usually come from various registers, and most reported prevalence figures are estimations derived from incidence figures and survival data. The Region Örebro County meningioma project aims to gain a better understanding of the incidence and prevalence of meningioma in the population. With these preliminary data, we seek to ascertain the practical feasibility of our proposed search method. MATERIAL AND METHODS In the Swedish county of Örebro with 302,252 inhabitants (2019), all radiology departments are within the public healthcare system. The electronic radiology archive (ERA) includes all patients who have undergone any type of radiological examination in the region since its introduction in 1996. To determine the number of individuals with meningioma in the region and when they were diagnosed, we conducted free-text searches for the word “meningioma” with various spelling variations in ERA and included all patients where the word appears in ERA referrals or responses. Subsequently, using data from the region’s electronic medical records (EMR), we excluded all patients not residing within the region. We then manually reviewed these patients’ referrals, written reports and radiology examinations, to determine whether they have meningioma, the date of diagnosis, whether it was an incidental finding, and presence of multiple meningioma. RESULTS We identified 3,428 patients, of which 3,064 have been included in this study (being residents of the region). In a preliminary review, we have been able to identify 1,663 (55 %) patients with likely meningioma. Of the 1,663 patients, 5 % had a diagnosis date before the introduction of ERA. The median age was 73 (IQR 61-82) years. There were 24 % males and 76 % females. Multiple meningioma were found in 9 % of the patients. In the preliminary review 64 % were incidental findings, while 21 % and 15 % were classified as non-incidental and indeterminate, respectively. CONCLUSION Performing free-text ERA/EMR searches is a potential avenue to achieve better coverage when investigating incidence and prevalence of a disease such as meningioma in a public healthcare setting. In our initial review, it is evident that the method identifies and can retrieve meningioma patients from the ERA. Gender distribution, median age and multiple meningioma numbers are comparable to other reported meningioma populations. Based on our experience with this dataset, it is not advisable to rely solely on simple automated searches. Projects akin to this would likely be well suited for future automated image analysis (volumetric measurement, meningioma identification, etc.).

Purpose To assess changes of cerebral haemodynamic and intracranial pressure (ICP) in animals, with or without elevated ICP, during controlled haemorrhagic shock and resuscitation with Total REBOA (tREBOA). Method In 22 anesthetized and normoventilated pigs, after placement of catheters for monitoring invasive proximal blood pressure (pMAP), ICP, and vital parameters, and 60 minutes stabilization phase, a controlled haemorrhagic shock (HS), was conducted. In 11 pigs (EICPG), an elevated ICP of 25–30 mmHg at the end HS was achieved by simulating an epidural mass. In 11 pigs (NICPG), the ICP was normal. tREBOA was then applied for 120 minutes. The changes of pMAP and ICP was followed and cerebral perfusion pressure (CPP) calculated. The integrity of the autoregulation was estimated using a calculated modified PRx index. Results After stabilization, hemodynamics and physiological parameters were similar and normal in both groups. At the end of the HS, ICP was 16 mmHg in NICPG vs 32 in EICPG (p = 0.0010). CPP was 30 mmHg in NICPG vs 6 mmHg in EICPG (p = 0.0254). After aorta occlusion CPP increased immediately in both groups reaching after 15 minutes up to104 mmHg in NICPG vs 126 mmHg in EICPG. Cerebrovascular reactivity seems to be altered during bleeding and occlusion phases in both groups with positive PRx. The alteration was more pronounced in EICPG, but reversible in both groups. Conclusion tREBOA is lifesaving by restoration the cerebral circulation defined as CPP in animals with HS with normal or elevated ICP. Despite the observation of short episodes of cerebral autoregulation impairment during the occlusion, mainly in EICPG, tREBOA seems to be an effective tool for improving cerebral perfusion in HS that extends the crucial early window sometimes known as the “golden hour” for resuscitation even after a traumatic brain injury.

Traumatic brain injury (TBI) is the leading cause of death among the young, and has an increasing incidence among the elderly. In Sweden there are 20 000 new TBI cases each year, of which most are mild. The primary impact can lead to different types of brain hemorrhages, fractures and diffuse axonal injuries. The level of consciousness is used to define injury severity. Of all TBIs,  4-5 percent require surgical intervention. The primary impact initiates injury processes exacerbating the initial brain injury, and the goal of the acute management and neurointensive care treatment is to prevent these secondary insults. Among unconscious TBI patients, monitoring of intracranial pressure and cerebral perfusion pressure (CPP, defined as the difference between the mean arterial pressure and intracranial pressure) is routine. In this article we present an overview on different types of TBI, and describe the treatment of patients in the acute setting.

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.Unstructod 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.

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.

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.

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.

OBJECTIVE: Surgery for chronic subdural hematoma is one of the most frequent operations in neurosurgical practice. Chronic subdural hematoma mostly afflicts the elderly population. In 2018, Kwon and co-workers, pub-lished the Kwon scoring system (KSS), whereby 6 clinical and radiological factors are used to facilitate, and promote quality in, surgical decision-making and counseling of relatives. The aim of this study is to validate the KSS.METHODS: Patients operated on for unilateral chronic subdural hematoma at Orebro University Hospital, Sweden, between 2013 and 2019 constituted the study population. General data and the 6 outcome predictors according to the KSS were extracted from the electronic patient records. The preoperative modified Rankin Scale score and the postoperative 6-month modified Rankin Scale score were assessed. RESULTS: We identified 133 patients (69.2% male) with a median age of 80.2 years (interquartile range 72.6-85.9). The median Glasgow Coma Scale score at admission was 15; 57.1% had motor deficits and 36.81% were disoriented. For 39.1% of the patients, the prognosis was a favorable outcome (modified Rankin Scale 0-1) at 6 months. The median KSS score was 9; 63.9% of the patients scored double dagger 9, and 36 (42.4%) of these patients actually achieved a favorable outcome. This corresponds to a prediction model sensitivity of 0.667 and specificity of 0.424. A receiver operator characteristic curve analysis of the model yielded an area under the receiver operator characteristic curve of 0.62441.CONCLUSIONS: In our material, the KSS did not predict outcome precisely enough to base treatment decisions or counseling of relatives on the scores obtained.

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

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. 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. 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. 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.

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. Patients suffering severe traumatic brain injury (sTBI) were treated according to an intracranial pressure (ICP)-targeted therapy based on the Lund concept and randomized to an add-on treatment with prostacyclin or placebo. Inclusion criteria were verified blunt head trauma, Glasgow Coma Score ≤ 8, age 15–70 years, and a first measured cerebral perfusion pressure of ≥ 10 mmHg. Multimodal monitoring was applied. A brain microdialysis catheter was placed on the worst affected side, close to the penumbra zone. Mean (glycerolmean) and maximal glycerol (glycerolmax) 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. Of the 48 included patients, 45 had valid glycerol and PR measurements available. PR was higher in the placebo group as compared to the prostacyclin group (p = 0.0164). There was a positive correlation between PR and the glycerolmean (ρ = 0.503, p = 0.01) and glycerolmax (ρ = 0.490, p = 0.015) levels in the placebo group only. 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.

Background: 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 k ...

The Lund concept (LC) and the Brain Trauma Foundation (BTF) guidelines are used in Scandinavia and the Nordic countries to treat severe brain trauma (s-TBI). In this chapter, the authors focus on the LC developed in Scandinavia. When introduced in 1992, it was a theoretical approach, based mainly on principles of brain volume control and of optimization of brain perfusion. The BTF guidelines presented in 1996 were based on meta-analytic approaches. The LC gives relatively strict outlines regarding cerebral perfusion pressure, fluid therapy, ventilation, sedation, nutrition, the use of vasopressors, and osmotherapy. The treatment is standardized, with less need for individualization.

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. 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. 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. 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.

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.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.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%.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.

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 ( ...