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Lewén, Anders
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Publications (10 of 29) Show all publications
Wettervik, T. S., Lenell, S., Nyholm, L., Howells, T., Lewén, A. & Enblad, P. (2018). Decompressive craniectomy in traumatic brain injury: usage and clinical outcome in a single centre. Acta Neurochirurgica, 160(2), 229-237
Open this publication in new window or tab >>Decompressive craniectomy in traumatic brain injury: usage and clinical outcome in a single centre
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2018 (English)In: Acta Neurochirurgica, ISSN 0001-6268, E-ISSN 0942-0940, Vol. 160, no 2, p. 229-237Article in journal (Refereed) Published
Abstract [en]

Background: Two randomised controlled trials (RCTs) of decompressive craniectomy (DC) in traumatic brain injury (TBI) have shown poor outcome, but there are considerations of how these protocols relate to real practice. The aims of this study were to evaluate usage and outcome of DC and thiopental in a single centre.

Method: The study included all TBI patients treated at the neurointensive care unit, Akademiska sjukhuset, Uppsala, Sweden, between 2008 and 2014. Of 609 patients aged 16 years or older, 35 treated with DC and 23 treated with thiopental only were studied in particular. Background variables, intracranial pressure (ICP) measures and global outcome were analysed.

Results: Of 35 DC patients, 9 were treated stepwise with thiopental before DC, 9 were treated stepwise with no thiopental before DC and 17 were treated primarily with DC. Six patients received thiopental after DC. For 23 patients, no DC was needed after thiopental. Eighty-eight percent of our DC patients would have qualified for the DECRA study and 38% for the Rescue-ICP trial. Favourable outcome was 44% in patients treated with thiopental before DC, 56% in patients treated with DC without prior thiopental, 29% in patients treated primarily with DC and 52% in patients treated with thiopental with no DC.

Conclusions: The place for DC in TBI management must be evaluated better, and we believe it is important that future RCTs should have clearer and less permissive ICP criteria regarding when thiopental should be followed by DC and DC followed by thiopental.

Place, publisher, year, edition, pages
SPRINGER WIEN, 2018
Keyword
Traumatic brain injury, Neurointensive care, Standardised treatment protocol, Decompressive craniectomy, Thiopental
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-341558 (URN)10.1007/s00701-017-3418-3 (DOI)000419961200003 ()29234973 (PubMedID)
Available from: 2018-02-13 Created: 2018-02-13 Last updated: 2018-02-13Bibliographically approved
Borota, L., Mahmoud, E., Nyberg, C., Lewén, A., Enblad, P. & Ronne-Engström, E. (2018). Dual lumen balloon catheter - An effective substitute for two single lumen catheters in treatment of vascular targets with challenging anatomy.. Journal of clinical neuroscience, 51, 91-99, Article ID S0967-5868(17)31621-1.
Open this publication in new window or tab >>Dual lumen balloon catheter - An effective substitute for two single lumen catheters in treatment of vascular targets with challenging anatomy.
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2018 (English)In: Journal of clinical neuroscience, ISSN 0967-5868, E-ISSN 1532-2653, Vol. 51, p. 91-99, article id S0967-5868(17)31621-1Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to describe our experience in the treatment of various pathological conditions of the cranial and spinal blood vessels and hypervascularized lesions using dual lumen balloon catheters. Twenty-five patients were treated with endovascular techniques: two with vasospasm of cerebral blood vessels caused by subarachnoid hemorrhage, one with a hypervascularized metastasis in the vertebral body, two with spinal dural fistula, four with cerebral dural fistula, three with cerebral arteriovenous malformations, and 13 with aneurysms. The dual lumen balloon catheters were used for remodeling of the coil mesh, injection of various liquid embolic agents, particles and nimodipine, for the prevention of reflux and deployment of coils and stents. The diameter of catheterized blood vessels varied from 0.7 mm to 4 mm. Two complications occurred: perforation of an aneurysm in one case and gluing of the tip of balloon catheter by embolic material in another case. All other interventions were uneventful, and therapeutic goals were achieved in all cases except in the case with gluing of the tip of balloon catheter. The balloons effectively prevented reflux regardless of the type of the embolic material and diameter of blood vessel. The results of our study show that dual lumen balloon catheters allow complex interventions in the narrow cerebral and spinal blood vessels where the safe use of two single lumen catheters is either limited or impossible.

Keyword
Balloon catheter, Dual lumen, Neurointervention
National Category
Radiology, Nuclear Medicine and Medical Imaging
Identifiers
urn:nbn:se:uu:diva-350827 (URN)10.1016/j.jocn.2018.01.070 (DOI)29483004 (PubMedID)
Available from: 2018-05-16 Created: 2018-05-16 Last updated: 2018-05-30Bibliographically approved
Johnson, U., Engquist, H., Lewén, A., Howells, T., Nilsson, P., Ronne-Engström, E., . . . Enblad, P. (2017). Increased risk of critical CBF levels in SAH patients with actual CPP below calculated optimal CPP. Acta Neurochirurgica, 159(6), 1065-1071
Open this publication in new window or tab >>Increased risk of critical CBF levels in SAH patients with actual CPP below calculated optimal CPP
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2017 (English)In: Acta Neurochirurgica, ISSN 0001-6268, E-ISSN 0942-0940, Vol. 159, no 6, p. 1065-1071Article in journal (Refereed) Published
Abstract [en]

Background Cerebral pressure autoregulation can be quantified with the pressure reactivity index (PRx), based on the correlation between blood pressure and intracranial pressure. Using PRx optimal cerebral perfusion pressure (CPPopt) can be calculated, i.e., the level of CPP where autoregulation functions best. The relation between cerebral blood flow (CBF) and CPPopt has not been examined. The objective was to assess to which extent CPPopt can be calculated in SAH patients and to investigate CPPopt in relation to CBF.

Methods Retrospective study of prospectively collected data. CBF was measured bedside with Xenon-enhanced CT (Xe-CT). The difference between actual CPP and CPPopt was calculated (CPPa dagger). Correlations between CPPa dagger and CBF parameters were calculated with Spearman's rank order correlation coefficient (rho). Separate calculations were done using all patients (day 0-14 after onset) as well as in two subgroups (day 0-3 and day 4-14).

Results Eighty-two patients with 145 Xe-CT scans were studied. Automated calculation of CPPopt was possible in adjunct to 60% of the Xe-CT scans. Actual CPP < CPPopt was associated with higher numbers of low-flow regions (CBF < 10 ml/100 g/min) in both the early phase (day 0-3, n = 39, Spearman's rho = -0.38, p = 0.02) and late acute phase of the disease (day 4-14, n = 35, Spearman's rho = -0.39, p = 0.02). CPP level per se was not associated with CBF.

Conclusions Calculation of CPPopt is possible in a majority of patients with severe SAH. Actual CPP below CPPopt is associated with low CBF.

Keyword
cerebral blood flow, autoregulation, CPP, subarachnoid haemorrhage
National Category
Clinical Medicine
Research subject
Neurosurgery
Identifiers
urn:nbn:se:uu:diva-294191 (URN)10.1007/s00701-017-3139-7 (DOI)000401117700016 ()28361248 (PubMedID)
Available from: 2016-09-21 Created: 2016-05-18 Last updated: 2017-06-13Bibliographically approved
Rostami, E., Engquist, H., Howells, T., Ronne-Engström, E., Nilsson, P., Hillered, L. T., . . . Enblad, P. (2017). The Correlation between Cerebral Blood Flow Measured by Bedside Xenon-CT and Brain Chemistry Monitored by Microdialysis in the Acute Phase following Subarachnoid Hemorrhage. Frontiers in Neurology, 8, Article ID 369.
Open this publication in new window or tab >>The Correlation between Cerebral Blood Flow Measured by Bedside Xenon-CT and Brain Chemistry Monitored by Microdialysis in the Acute Phase following Subarachnoid Hemorrhage
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2017 (English)In: Frontiers in Neurology, ISSN 1664-2295, E-ISSN 1664-2295, Vol. 8, article id 369Article in journal (Refereed) Published
Abstract [en]

Cerebral microdialysis (MD) may be used in patients suffering from subarachnoid hemorrhage (SAH) to detect focal cerebral ischemia. The cerebral MD catheter is usually placed in the right frontal lobe and monitors the area surrounding the catheter. This generates the concern that a fall in cerebral blood flow (CBF) and ischemic events distant to the catheter may not be detected. We aimed to investigate if there is a difference in the association between the MD parameters and CBF measured around the MD catheter compared to global cortical CBF and to CBF in the vascular territories following SAH in the early acute phase. MD catheter was placed in the right frontal lobe of 30 SAH patients, and interstitial glucose, lactate, pyruvate, glycerol, and lactate/pyruvate ratio were measured hourly. CBF measurements were performed during day 0-3 after SAH. Global cortical CBF correlated strongly with CBF around the microdialysis catheter (CBF-MD) (r = 0.911, p ≤ 0.001). This was also the case for the anterior, middle, and posterior vascular territories in the right hemisphere. A significant negative correlation was seen between lactate and CBF-MD (r = -0.468, p = 0.009). The same relationship was observed between lactate and CBF in anterior vascular territory but not in the middle and posterior vascular territories. In conclusion, global CBF 0-3 days after severe SAH correlated strongly with CBF-MD. High lactate level was associated with low global CBF and low regional CBF in the right anterior vascular territory, when the MD catheter was placed in the right frontal lobe.

Keyword
Xenon-CT, cerebral blood flow, lactate, microdialysis, subarachnoid hemorrhage
National Category
Neurosciences
Identifiers
urn:nbn:se:uu:diva-330939 (URN)10.3389/fneur.2017.00369 (DOI)000407574600001 ()28824527 (PubMedID)
Available from: 2017-10-07 Created: 2017-10-07 Last updated: 2018-01-13Bibliographically approved
Nyholm, L., Howells, T., Lewén, A., Hillered, L. & Enblad, P. (2017). The influence of hyperthermia on intracranial pressure, cerebral oximetry and cerebral metabolism in traumatic brain injury. Upsala Journal of Medical Sciences, 122(3), 177-184
Open this publication in new window or tab >>The influence of hyperthermia on intracranial pressure, cerebral oximetry and cerebral metabolism in traumatic brain injury
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2017 (English)In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 122, no 3, p. 177-184Article in journal (Refereed) Published
Abstract [en]

Background: Hyperthermia is a common secondary insult in traumatic brain injury (TBI). The aim was to evaluate the relationship between hyperthermia and intracranial pressure (ICP), and if intracranial compliance and cerebral blood flow (CBF) pressure autoregulation affected that relationship. The relationships between hyperthermia and cerebral oximetry (B(ti)pO(2)) and cerebral metabolism were also studied. Methods: A computerized multimodality monitoring system was used for data collection at the neurointensive care unit. Demographic and monitoring data (temperature, ICP, blood pressure, microdialysis, B(ti)pO(2)) were analyzed from 87 consecutive TBI patients. ICP amplitude was used as measure of compliance, and CBF pressure autoregulation status was calculated using collected blood pressure and ICP values. Mixed models and comparison between groups were used. Results: The influence of hyperthermia on intracranial dynamics (ICP, brain energy metabolism, and B(ti)pO(2)) was small, but individual differences were seen. Linear mixed models showed that hyperthermia raises ICP slightly more when temperature increases in the groups with low compliance and impaired CBF pressure autoregulation. There was also a tendency (not statistically significant) for increased B(ti)pO(2), and for increased pyruvate and lactate, with higher temperature, while the lactate/pyruvate ratio and glucose were stable. Conclusions: The major finding was that the effects of hyperthermia on intracranial dynamics (ICP, brain energy metabolism, and B(ti)pO(2)) were not extensive in general, but there were exceptional cases. Hyperthermia treatment has many side effects, so it is desirable to identify cases in which hyperthermia is dangerous. Information from multimodality monitoring may be used to guide treatment in individual patients.

Keyword
Cerebral oximetry, hyperthermia, ICP, microdialysis, traumatic brain injury
National Category
Neurology Surgery
Identifiers
urn:nbn:se:uu:diva-340977 (URN)10.1080/03009734.2017.1319440 (DOI)000414107800004 ()28463046 (PubMedID)
Available from: 2018-02-05 Created: 2018-02-05 Last updated: 2018-02-05Bibliographically approved
Ekmark-Lewén, S., Flygt, J., Fridgeirsdottir, G. A., Kiwanuka, O., Hanell, A., Meyerson, B. J., . . . Marklund, N. (2016). Diffuse traumatic axonal injury in mice induces complex behavioural alterations that are normalized by neutralization of interleukin-1β. European Journal of Neuroscience, 43(8), 1016-1033
Open this publication in new window or tab >>Diffuse traumatic axonal injury in mice induces complex behavioural alterations that are normalized by neutralization of interleukin-1β
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2016 (English)In: European Journal of Neuroscience, ISSN 0953-816X, E-ISSN 1460-9568, Vol. 43, no 8, p. 1016-1033Article in journal (Refereed) Published
Abstract [en]

Widespread traumatic axonal injury (TAI) results in brain network dysfunction, which commonly leads to persisting cognitive and behavioural impairments following traumatic brain injury (TBI). TBI induces a complex neuroinflammatory response, frequently located at sites of axonal pathology. The role of the pro-inflammatory cytokine interleukin (IL)-1 has not been established in TAI. An IL-1-neutralizing or a control antibody was administered intraperitoneally at 30min following central fluid percussion injury (cFPI), a mouse model of widespread TAI. Mice subjected to moderate cFPI (n=41) were compared with sham-injured controls (n=20) and untreated, naive mice (n=9). The anti-IL-1 antibody reached the target brain regions in adequate therapeutic concentrations (up to similar to 30g/brain tissue) at 24h post-injury in both cFPI (n=5) and sham-injured (n=3) mice, with lower concentrations at 72h post-injury (up to similar to 18g/g brain tissue in three cFPI mice). Functional outcome was analysed with the multivariate concentric square field (MCSF) test at 2 and 9days post-injury, and the Morris water maze (MWM) at 14-21days post-injury. Following TAI, the IL-1-neutralizing antibody resulted in an improved behavioural outcome, including normalized behavioural profiles in the MCSF test. The performance in the MWM probe (memory) trial was improved, although not in the learning trials. The IL-1-neutralizing treatment did not influence cerebral ventricle size or the number of microglia/macrophages. These findings support the hypothesis that IL-1 is an important contributor to the processes causing complex cognitive and behavioural disturbances following TAI.

Keyword
axonal injury, behavioural outcome, central fluid percussion injury, interleukin-1, traumatic brain injury
National Category
Neurology
Identifiers
urn:nbn:se:uu:diva-297130 (URN)10.1111/ejn.13190 (DOI)000374645700004 ()27091435 (PubMedID)
Funder
Swedish Research Council
Available from: 2016-06-22 Created: 2016-06-21 Last updated: 2017-11-28Bibliographically approved
Blomquist, E., Ronne Engström, E., Borota, L., Gál, G., Nilsson, K., Lewén, A., . . . Enblad, P. (2016). Positive correlation between occlusion rate and nidus size of proton beam treated brain arteriovenous malformations (AVMs). Acta Oncologica, 55(1), 105-112
Open this publication in new window or tab >>Positive correlation between occlusion rate and nidus size of proton beam treated brain arteriovenous malformations (AVMs)
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2016 (English)In: Acta Oncologica, ISSN 0284-186X, E-ISSN 1651-226X, Vol. 55, no 1, p. 105-112Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Proton beam radiotherapy of arteriovenous malformations (AVM) in the brain has been performed in Uppsala since 1991. An earlier study based on the first 26 patients concluded that proton beam can be used for treating large and medium sized AVMs that were considered difficult to treat with photons due to the risk of side effects. In the present study we analyzed the result from treating the subsequent 65 patients.

MATERIAL AND METHODS: A retrospective review of the patients' medical records, treatment protocols and radiological results was done. Information about gender, age, presenting symptoms, clinical course, the size of AVM nidus and rate of occlusion was collected. Outcome parameters were the occlusion of the AVM, clinical outcome and side effects.

RESULTS: The rate of total occlusion was overall 68%. For target volume 0-2cm(3) it was 77%, for 3-10 cm(3) 80%, for 11-15 cm(3) 50% and for 16-51 cm(3) 20%. Those with total regress of the AVM had significantly smaller target volumes (p < 0.009) higher fraction dose (p < 0.001) as well as total dose (p < 0.004) compared to the rest. The target volume was an independent predictor of total occlusion (p = 0.03). There was no difference between those with and without total occlusion regarding mean age, gender distribution or symptoms at diagnosis. Forty-one patients developed a mild radiation-induced brain edema and this was more common in those that had total occlusion of the AVM. Two patients had brain hemorrhages after treatment. One of these had no effect and the other only partial occlusion from proton beams. Two thirds of those presenting with seizures reported an improved seizure situation after treatment.

CONCLUSION: Our observations agree with earlier results and show that proton beam irradiation is a treatment alternative for brain AVMs since it has a high occlusion rate even in larger AVMs.

National Category
Cancer and Oncology
Identifiers
urn:nbn:se:uu:diva-254040 (URN)10.3109/0284186X.2015.1043023 (DOI)000367007700015 ()25972265 (PubMedID)
Available from: 2015-06-04 Created: 2015-06-04 Last updated: 2017-12-04Bibliographically approved
Merzo, A., Lenell, S., Nyholm, L., Enblad, P. & Lewen, A. (2016). Promising clinical outcome of elderly with TBI after modern neurointensive care. Acta Neurochirurgica, 158(1), 125-133
Open this publication in new window or tab >>Promising clinical outcome of elderly with TBI after modern neurointensive care
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2016 (English)In: Acta Neurochirurgica, ISSN 0001-6268, E-ISSN 0942-0940, Vol. 158, no 1, p. 125-133Article in journal (Refereed) Published
Abstract [en]

The increasing number of elderly patients with traumatic brain injury (TBI) leads to specific neurointensive care (NIC) challenges. Therefore, elderly subjects with TBI need to be further studied. In this study we evaluated the demographics, management and outcome of elderly TBI patients receiving modern NIC. Patients referred to our NIC unit between 2008 and 2010 were included. Patients were divided in two age groups, elderly (E) a parts per thousand yen65 years and younger (Y) 64-15 years. Parameters studied were the dominant finding on CT scans, neurological motor skills and consciousness, type of monitoring, neurosurgical procedures/treatments and Glasgow Outcome Scale Extended score at 6 months after injury. Sixty-two E (22 %) and 222 Y (78 %) patients were included. Falls were more common in E (81 %) and vehicle accidents were more common in Y patients (37 %). Acute subdural hematoma was significantly more common in E (50 % of cases) compared to Y patients (18 %). Intracranial pressure was monitored in 44 % of E and 57 % of Y patients. Evacuation of significant mass lesions was performed more common in the E group. The NIC mortality was similar in both groups (4-6 %). Favorable outcome was observed in 72 % of Y and 51 % of E patients. At the time of follow-up 25 % of E and 7 % of Y patients had died. The outcome of elderly patients with TBI was significantly worse than in younger patients, as expected. However, as much as 51 % of the elderly patients showed a favorable outcome after NIC. We believe that these results encourage modern NIC in elderly patients with TBI. We need to study how secondary brain injury mechanisms differ in the older patients and to identify specific outcome predictors for elderly patients with TBI.

Keyword
Traumatic brain injury, Outcome, Elderly, Neurointensive care, Secondary injury
National Category
Neurology
Identifiers
urn:nbn:se:uu:diva-274421 (URN)10.1007/s00701-015-2639-6 (DOI)000366975000016 ()
Funder
Swedish Research Council
Available from: 2016-01-21 Created: 2016-01-21 Last updated: 2017-11-30Bibliographically approved
Lenell, S., Nyholm, L., Lewen, A. & Enblad, P. (2015). Updated periodic evaluation of standardized neurointensive care shows that it is possible to maintain a high level of favorable outcome even with increasing mean age. Acta Neurochirurgica, 157(3), 417-425
Open this publication in new window or tab >>Updated periodic evaluation of standardized neurointensive care shows that it is possible to maintain a high level of favorable outcome even with increasing mean age
2015 (English)In: Acta Neurochirurgica, ISSN 0001-6268, E-ISSN 0942-0940, Vol. 157, no 3, p. 417-425Article in journal (Refereed) Published
Abstract [en]

Periodic evaluation of neurointensive care (NIC) is important. There is a risk that quality of daily care declines and there may also be unrecognized changes in patient characteristics and management. The aim of this work was to investigate the characteristics and outcome for traumatic brain injury (TBI) patients in the period 2008-2009 in comparison with 1996-1997 and to some extent also with earlier periods. TBI patients 16-79 years old admitted from 2008 to 2009 were selected for the study. Glasgow Coma Scale Motor score at admission (GCS M), radiology, surgery, and outcome (Glasgow Outcome Extended Scale) were collected from Uppsala Traumatic Brain Injury Register. The study included 148 patients (mean age, 45 years). Patients > 60 years old increased from 16 % 1996-1997 to 30 % 2008-2009 (p < 0.01). The proportion of GCS M 4-6 were similar, 92 vs. 93 % (NS). In 1996-1997 patients, 73 % had diffuse injury (Marshall classification) compared to 77 % for the 2008-2009 period (NS). More patients underwent surgery during 2008-2009 (43 %) compared to 1996-1997 (32 %, p < 0.05). Good recovery increased and mortality decreased substantially from 1980-1981 to 1987-1988 and to 1996-1997, but then the results were unchanged in the 2008-2009 period, with 73 % favorable outcome and 11 % mortality. Mortality increased in GCS M 6-4, from 2.8 % in 1996-1997 to 10 % in 2008-2009 (p < 0.05); most of the patients that died had aggravating factors, e.g., high age, malignancy. A large-proportion favorable outcome was maintained despite that patients > 60 years with poorer prognosis doubled, indicating that the quality of NIC has increased or at least is unchanged. More surgery may have contributed to maintaining the large proportion of favorable outcome. For future improvements, more knowledge about TBI management in the elderly is required.

Keyword
Traumatic brain injury, Standardized neurosurgical intensive care, Periodic evaluation, Outcome, Quality register
National Category
Neurosciences
Identifiers
urn:nbn:se:uu:diva-248427 (URN)10.1007/s00701-014-2329-9 (DOI)000350027700009 ()25591801 (PubMedID)
Available from: 2015-04-10 Created: 2015-03-30 Last updated: 2018-01-11Bibliographically approved
Fischerström, A., Nyholm, L., Lewen, A. & Enblad, P. (2014). Acute neurosurgery for traumatic brain injury by general surgeons in Swedish county hospitals: A regional study. Acta Neurochirurgica, 156(1), 177-185
Open this publication in new window or tab >>Acute neurosurgery for traumatic brain injury by general surgeons in Swedish county hospitals: A regional study
2014 (English)In: Acta Neurochirurgica, ISSN 0001-6268, E-ISSN 0942-0940, Vol. 156, no 1, p. 177-185Article in journal (Refereed) Published
Abstract [en]

Traditionally acute life-saving evacuations of extracerebral haematomas are performed by general surgeons on vital indication in county hospitals in the Uppsala-A-rebro health care region in Sweden, a region characterized by long distances and a sparsely distributed population. Recently, it was stated in the guidelines for prehospital care of traumatic brain injury from the Scandinavian Neurosurgical Society that acute neurosurgery should not be performed in smaller hospitals without neurosurgical expertise. The aim of this study was to investigate: how often does acute decompressive neurosurgery occur in county hospitals in the Uppsala-A-rebro region today, what is the indication for surgery, and what is the clinical outcome? Finally, the goal was to evaluate whether the current practice in the Uppsala-A-rebro region should be revised. Patients referred to the neurointensive care unit at the Department of Neurosurgery in Uppsala after acute evacuation of intracranial haematomas in the county hospitals 2005-2010 were included in the study. Data was collected retrospectively from the medical records following a predefined protocol. The presence of vital indication, radiological and clinical results, and long-term outcome were evaluated. A total of 49 patients (17 epidural haematomas and 32 acute subdural haematomas) were included in the study. The operation was judged to have been performed on vital indication in all cases. The postoperative CT scan was improved in 92 % of the patients. The reaction level and pupillary reactions were significantly improved after surgery. Long-term outcomes showed 51 % favourable outcome, 33 % unfavourable outcome, and in 16 % the outcome was unknown. Looking at the indication for acute neurosurgery, the postoperative clinical and radiological results, and the long-term outcome, it appears that our regional policy regarding life-saving decompressive neurosurgery in county hospitals by general surgeons should not be changed. We suggest a curriculum aimed at educating general surgeons in acute neurosurgery.

Keyword
Traumatic brain injury, Acute subdural haematoma, Epidural haematoma, Acute neurosurgery, General surgeons, Local hospitals, Glasgow outcome score, Scandinavian guidelines
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-216721 (URN)10.1007/s00701-013-1932-5 (DOI)000329093100027 ()
Available from: 2014-01-27 Created: 2014-01-24 Last updated: 2017-12-06Bibliographically approved
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