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The partial pressure of carbon dioxide (PaCO2) in the arterial blood is a strong vasomodulator affecting cerebral blood flow and the risk of cerebral edema and ischemia after acute brain injury. In turn, both complications are related to poor outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). We aimed to analyze the effect of PaCO2 levels on the course and outcome of aSAH. All patients of a single institution treated for aSAH over 13.5 years were included (n = 633). Daily PaCO2 values from arterial blood gas measurements were recorded for up to 2 weeks after ictus. The study endpoints were: delayed cerebral ischemia (DCI), need for decompressive craniectomy due to increased intracranial pressure > 20 mmHg refractory to conservative treatment and poor outcome at 6-months follow-up (modified Rankin scale > 2). By correlations with the study endpoints, clinically relevant cutoffs for the 14-days mean values for the lowest and highest daily PaCO2 levels were defined by receiver operating characteristic curve analysis. Association with the study endpoints for the identifies subgroups was analyzed using multivariate analysis. The optimal range for PaCO2 values was identified between 30 and 38 mmHg. ASAH patients with poor initial condition (WFNS 4/5) were less likely to show PaCO2 values within the range of 30–38 mmHg (p < 0.001, OR = 0.44). In the multivariate analysis, PaCO2 values between 30 and 38 mmHg were associated with a lower risk for decompressive craniectomy (p = 0.042, aOR = 0.27), DCI occurrence (p = 0.035; aOR = 0.50), and poor patient outcome (p = 0.004; aOR = 0.42). The data from this study shows an independent positive association between low normal mean PaCO2 values during the acute phase of aSAH and patients' outcome. This effect might be attributed to the reduction of intracranial hypertension and alterations in the cerebral blood flow. [ABSTRACT FROM AUTHOR]

Pituitary adenomas are one of the most common mass lesions of the brain and are associated with a reduced quality of life. While transnasal and transsphenoidal endoscopic approaches are considered to deliver similar recovery rates for sino-nasal health (SNH), the impact of radiological tumor growth patterns on SNH has not been evaluated. In the present study, the influence of radiological tumor growth on SNH was examined before and after endoscopic transsphenoidal tumor resection. Patient data were prospectively collected between August 1, 2016 and August 31, 2022. The Knosp and Hardy classifications were used to dichotomize pituitary adenoma lesions into low- and high-graded lesions. SNH was assessed shortly before surgery and at follow-up examinations 3–6 months after operation using the Sino-Nasal Outcome Test for Neurosurgery (SNOT-NC) questionnaire. Fully completed SNOT-NC questionnaires were collected before and after surgery from a total of 101 patients. Independent t-tests showed significantly higher rates of deterioration after surgery in patients with Knosp low-graded lesions compared with those with high-graded tumors for the SNOT-NC total score P=0.048, nasal discomfort P=0.034, sleep problems P=0.024 and visual impairment P=0.042. Pre- and post-operative comparisons for the Knosp low-graded tumor cohort showed an increase of nasal discomfort (P=0.004), while the Knosp high-graded tumor cohort reported decreased visual impairment (P=0.016) after surgery. Assessing the Hardy classification, increased nasal discomfort was reported in patients with high-graded infrasellar tumors after surgery (P=0.046). Growth characteristics of pituitary adenomas based on Knosp and Hardy classifications may influence SNH. Patients with less invasive lesions were revealed to be more prone to experiencing a decrease in SNH, which went beyond the assumed deterioration of 1–3 months. These findings indicate the importance of detailed information regarding SNH as part of every pre-operative patient briefing. [ABSTRACT FROM AUTHOR]

Purpose: Conventional saturation pulses cannot be used for 7 Tesla ultra-high-resolution time-of-flight magnetic resonance angiography (TOF MRA) due to specific absorption rate (SAR) limitations. We overcome these limitations by utilizing low flip angle, variable rate selective excitation (VERSE) algorithm saturation pulses. Material and Methods: Twenty-five neurosurgical patients (male n = 8, female n = 17; average age 49.64 years; range 26–70 years) with different intracranial vascular pathologies were enrolled in this trial. All patients were examined with a 7 Tesla (Magnetom 7 T, Siemens) whole body scanner system utilizing a dedicated 32-channel head coil. For venous saturation pulses a 35° flip angle was applied. Two neuroradiologists evaluated the delineation of arterial vessels in the Circle of Willis, delineation of vascular pathologies, presence of artifacts, vessel-tissue contrast and overall image quality of TOF MRA scans in consensus on a five-point scale. Normalized signal intensities in the confluence of venous sinuses, M1 segment of left middle cerebral artery and adjacent gray matter were measured and vessel-tissue contrasts were calculated. Results: Ratings for the majority of patients ranged between good and excellent for most of the evaluated features. Venous saturation was sufficient for all cases with minor artifacts in arteriovenous malformations and arteriovenous fistulas. Quantitative signal intensity measurements showed high vessel-tissue contrast for confluence of venous sinuses, M1 segment of left middle cerebral artery and adjacent gray matter. Conclusion: The use of novel low flip angle VERSE algorithm pulses for saturation of venous vessels can overcome SAR limitations in 7 Tesla ultra-high-resolution TOF MRA. Our protocol is suitable for clinical application with excellent image quality for delineation of various intracranial vascular pathologies. [ABSTRACT FROM AUTHOR]

Purpose: To prospectively evaluate 7 Tesla time-of-flight (TOF) magnetic resonance angiography (MRA) in comparison to 1.5 Tesla TOF MRA and 7 Tesla non-contrast enhanced magnetization-prepared rapid acquisition gradient-echo (MPRAGE) for delineation of unruptured intracranial aneurysms (UIA). Material and Methods: Sixteen neurosurgical patients (male n = 5, female n = 11) with single or multiple UIA were enrolled in this trial. All patients were accordingly examined at 7 Tesla and 1.5 Tesla MRI utilizing dedicated head coils. The following sequences were obtained: 7 Tesla TOF MRA, 1.5 Tesla TOF MRA and 7 Tesla non-contrast enhanced MPRAGE. Image analysis was performed by two radiologists with regard to delineation of aneurysm features (dome, neck, parent vessel), presence of artifacts, vessel-tissue-contrast and overall image quality. Interobserver accordance and intermethod comparisons were calculated by kappa coefficient and Lin's concordance correlation coefficient. Results: A total of 20 intracranial aneurysms were detected in 16 patients, with two patients showing multiple aneurysms (n = 2, n = 4). Out of 20 intracranial aneurysms, 14 aneurysms were located in the anterior circulation and 6 aneurysms in the posterior circulation. 7 Tesla MPRAGE imaging was superior over 1.5 and 7 Tesla TOF MRA in the assessment of all considered aneurysm and image quality features (e.g. image quality: mean MPRAGE7T: 5.0; mean TOF7T: 4.3; mean TOF1.5T: 4.3). Ratings for 7 Tesla TOF MRA were equal or higher over 1.5 Tesla TOF MRA for all assessed features except for artifact delineation (mean TOF7T: 4.3; mean TOF1.5T 4.4). Interobserver accordance was good to excellent for most ratings. Conclusion: 7 Tesla MPRAGE imaging demonstrated its superiority in the detection and assessment of UIA as well as overall imaging features, offering excellent interobserver accordance and highest scores for all ratings. Hence, it may bear the potential to serve as a high-quality diagnostic tool for pretherapeutic assessment and follow-up of untreated UIA. [ABSTRACT FROM AUTHOR]

Background and purpose To test the hypothesis that sporadic cerebral cavernous malformations (CCMs) are systematically associated with venous malformations (VMs) using susceptibility weighted imaging (SWI) at 7 Tesla (T) field MRI. Methods A prospective unselected series of 20 patients with symptomatic or asymptomatic sporadic CCM diagnosed using 1.5 T MRI was additionally scanned using high resolution (250 mm2 in-plane) SWI at 7 T MRI. Imaging data were analysed to examine the presence and formation of CCM associated venous vessel structures. Interobserver agreement was assessed using kappa statistics. Results In the 20 patients harbouring 23 CCMs, a solitary or multiple venous drainage was found in all lesions. A 'typical' VM was found in seven lesions. In the other cases, associated abnormal venous structures were also depicted although they appeared structurally different. Excellent interobserver agreement was achieved (95% confidence interval 0.92 to 0.99). Conclusions Our data support previous assumptions that sporadic CCMs are systematically associated with local venous abnormalities involving larger outflow vessels. However, the typical appearance of a VM was not confirmed in all cases. The role of the venous environment in the pathomechanism of CCMs remains unclear. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: The aim of this study was to objectively assess the patients’ acceptance for awake craniotomy in a group of neurosurgical patients, who underwent this procedure for removal of lesions in or close to eloquent brain areas. Patients and methods: Patients acceptance for awake craniotomy under local anesthesia and conscious sedation was assessed by a formal questionnaire (PPP33), initially developed for general surgery patients. The results are compared to a group of patients who had brain surgery under general anesthesia and to previously published data. Results: The awake craniotomy (AC) group consisted of 37 male and 9 female patients (48 craniotomies) with age ranging from 18 to 71 years. The general anesthesia (GA) group consisted of 26 male and 15 female patients (43 craniotomies) with age ranging from 26 to 83 years. All patients in the study were included in the questionnaire analysis. In comparison to GA the overall PPP33 score for AC was higher (p =0.07), suggesting better overall acceptance for AC. The subscale scores for AC were also significantly better compared to GA for the two subscales “postoperative pain” (p =0.02) and “physical disorders” (p =0.01) and equal for the other 6 subscales. The results of the overall mean score and the scores for the subscales of the PPP33 questionnaire verify good patients’ acceptance for AC. Conclusion: Previous studies have shown good patients’ acceptance for awake craniotomy, but only a few times using formal approaches. By utilizing a formal questionnaire we could verify good patient acceptance for awake craniotomy for the treatment of brain tumors in or close to eloquent areas. This is a novel approach that substantiates previously published experiences. [Copyright &y& Elsevier]

Aneurysms of the distal part of the anterior–inferior cerebellar artery (AICA) are rare. Most are located in the cerebellopontine angle close to the internal auditory meatus. To our knowledge, only 13 patients with the aneurysm located inside the internal auditory meatus have been reported in the literature. We present two cases of ruptured intrameatal AICA aneurysms that were treated in our center in the past year. The locations and clinical manifestations are discussed and all 13 previously published cases are reviewed. Exposure and decompression of all structures in the internal auditory meatus, careful manipulation of the nerves and vessels, temporary trapping of the aneurysm, and careful dissection of the neck to avoid partial clipping are the essential steps when treating intrameatal AICA aneurysms to reduce the risk of postoperative neurological deficits. [ABSTRACT FROM AUTHOR]

Background: Aneurysmal subarachnoid hemorrhage (aSAH) remains a devastating diagnosis. A poor outcome is known to be highly dependent on the initial neurological status. Our goal was to identify other parameters that favor the risk of complications and poor outcome in patients with aSAH and initially favorable neurologic status. Methods: Consecutive aSAH cases treated at our hospital between 01/2003 and 06/2016 with the initial World Federation of Neurosurgical Societies grades I–III were included. Data on demographic characteristics, previous medical history, initial aSAH severity, and functional outcome after aSAH were collected. The study endpoints were the occurrence of cerebral infarcts, in-hospital mortality, and unfavorable outcome at 6 months after aSAH (modified Rankin scale > 3). Results: In the final cohort (n= 582), the rate of cerebral infarction, in-hospital mortality, and unfavorable outcome was 35.1%, 8.1%, and 17.6% respectively. The risk of cerebral infarction was independently related to the presence of acute hydrocephalus (adjusted odds ratio [aOR]=2.33, p<0.0001), aneurysm clipping (aOR=1.78, p=0.003), and use of calcium channel blockers concomitant to nimodipine (aOR=2.63, p=0.002). Patients' age (>55 years, aOR=4.24, p<0.0001), acute hydrocephalus (aOR=2.43, p=0.036), and clipping (aOR=2.86, p=0.001) predicted in-hospital mortality. Baseline characteristics associated with unfavorable outcome at 6 months were age (aOR=2.77, p=<0.0001), Fisher grades III–IV (aOR=2.81, p=0.016), acute hydrocephalus (aOR=2.22, p=0.012), clipping (aOR=3.98, p<0.0001), admission C-reactive protein>1mg/dL (aOR=1.76, p=0.035), and treatment intervals (aOR=0.64 per-5-year-intervals, p=0.006). Conclusions: Although cerebral infarction is a common complication in aSAH individuals with favorable initial clinical condition, >80% of these patients show favorable long-term outcome. The knowledge of outcome-relevant baseline characteristics might help to reduce the burden of further complications and poor outcome in aSAH patients who tolerated the initial bleeding event well. [ABSTRACT FROM AUTHOR]

Background: Aneurysmal subarachnoid hemorrhage (aSAH) remains a devastating diagnosis. A poor outcome is known to be highly dependent on the initial neurological status. Our goal was to identify other parameters that favor the risk of complications and poor outcome in patients with aSAH and initially favorable neurologic status. Methods: Consecutive aSAH cases treated at our hospital between 01/2003 and 06/2016 with the initial World Federation of Neurosurgical Societies grades I–III were included. Data on demographic characteristics, previous medical history, initial aSAH severity, and functional outcome after aSAH were collected. The study endpoints were the occurrence of cerebral infarcts, in-hospital mortality, and unfavorable outcome at 6 months after aSAH (modified Rankin scale > 3). Results: In the final cohort (n= 582), the rate of cerebral infarction, in-hospital mortality, and unfavorable outcome was 35.1%, 8.1%, and 17.6% respectively. The risk of cerebral infarction was independently related to the presence of acute hydrocephalus (adjusted odds ratio [aOR]=2.33, p<0.0001), aneurysm clipping (aOR=1.78, p=0.003), and use of calcium channel blockers concomitant to nimodipine (aOR=2.63, p=0.002). Patients’ age (>55 years, aOR=4.24, p<0.0001), acute hydrocephalus (aOR=2.43, p=0.036), and clipping (aOR=2.86, p=0.001) predicted in-hospital mortality. Baseline characteristics associated with unfavorable outcome at 6 months were age (aOR=2.77, p=<0.0001), Fisher grades III–IV (aOR=2.81, p=0.016), acute hydrocephalus (aOR=2.22, p=0.012), clipping (aOR=3.98, p<0.0001), admission C-reactive protein>1mg/dL (aOR=1.76, p=0.035), and treatment intervals (aOR=0.64 per-5-year-intervals, p=0.006). Conclusions: Although cerebral infarction is a common complication in aSAH individuals with favorable initial clinical condition, >80% of these patients show favorable long-term outcome. The knowledge of outcome-relevant baseline characteristics might help to reduce the burden of further complications and poor outcome in aSAH patients who tolerated the initial bleeding event well. [ABSTRACT FROM AUTHOR]

Objective Although most neurovascular centers currently have a coil first policy, the percentage of coiled versus clipped aneurysms, as well as treatment outcomes, varies strongly between these centers. This study evaluates the impact of an increase in clipping caseload on treatment outcome in a large single-center series. Methods All consecutive patients who underwent microsurgical clipping of unruptured intracranial aneurysms between January 2003 and April 2014 in our department were analyzed retrospectively. According to the change of the chairman in the neurosurgical department (1 September 2008) with a subsequent increase in the clipping volume, the entire cohort was divided into 2 groups with equal time intervals (historic and current cohorts). Results There were 94 clipped unruptured intracranial aneurysms in the historic cohort and 252 in the current cohort. Unfavorable outcome at 6 months postoperatively (defined as modified Rankin Score >2) was observed in 8 cases (8.5%) in the historic cohort and 7 cases (2.8%) in the current cohort ( P < 0.0001). The surgical mortality decreased from 3.2% to 0%. Cerebral infarction on postoperative computed tomography scan was observed in 25 cases (26.6%) in the historic cohort and 19 cases (7.5%) in the current cohort ( P < 0.0001). Within the current cohort, there was a progressive improvement of surgical outcome over the time. Conclusions The improvement of the surgical outcome after increasing the clipping caseload underlines the importance of sufficient surgical volume for maintenance of competitive treatment results. [ABSTRACT FROM AUTHOR]

Knowledge of the bleeding risk and the long-term outcome of conservatively treated patients with cavernous malformations (CM) is poor. In this work, we studied the occurrence of CM-associated hemorrhage over a 10-year period and investigated risk factors for bleeding. Our institutional database was screened for patients with cerebral (CCM) or intramedullary spinal cord (ISCM) CM admitted between 2003 and 2021. Patients who underwent surgery and patients without completed follow-up were excluded. Analyses were performed to identify risk factors and to determine the cumulative risk for hemorrhage. A total of 91 CM patients were included. Adjusted multivariate logistic regression analysis identified bleeding at diagnosis (p = 0.039) and CM localization to the spine (p = 0.010) as predictors for (re)hemorrhage. Both risk factors remained independent predictors through Cox regression analysis (p = 0.049; p = 0.016). The cumulative 10-year risk of bleeding was 30% for the whole cohort, 39% for patients with bleeding at diagnosis and 67% for ISCM. During an untreated 10-year follow-up, the probability of hemorrhage increased over time, especially in cases with bleeding at presentation and spinal cord localization. The intensity of such increase may decline throughout time but remains considerably high. These findings may indicate a rather aggressive course in patients with ISCM and may endorse early surgical treatment. [ABSTRACT FROM AUTHOR]

Objective: The quantity of ultra-high field MRI neuroimaging studies has rapidly increased. This study tests function, safety, and image artifacts of two frequently implanted programmable ventriculo-peritoneal (VP) shunt valves in a 7T MRI system. Methods: All tests were performed using a whole-body 7T MRI system. Three proGAV 2.0 and 3 CODMAN CERTAS® Plus programmable VP-shunt valves were tested in three steps. 1) Deflection angle tests close to the bore opening at the location of a static magnetic field gradient of 3–5 T/m. 2) Valves were fixed on a spherical phantom in 3 positions (a. lateral, b. cranial, c. cranial with 22.5° tilt anteriorly) and assessed for keeping the programmed pressure setting and reprogrammability. 3) Valves were fixed on the phantom and positioned lateral in a radiofrequency head coil. MRI scans were performed for both models, including MPRAGE, GRE and SE sequences. Results: Deflection angles were moderate (13°, 14°, 13°) for the proGAV valves and close to critical (43°, 43°, 41°) for the CODMAN valves at the test location. Taking a scaling factor of 2–3 for the maximum spatial magnetic field gradient accessible to a patient within the magnet bore into account renders both valves MR unsafe regarding ferromagnetic attraction. The proGAV valves kept the pressure settings in all positions and were reprogrammable in positions a. and b. In position c., reprogrammability was lost. The CODMAN valves changed their pressure setting and reprogrammability was lost in all positions. MR image signal homogeneity was unaltered in the phantom center, artifacts limit the assessability of structures in close vicinity to the valves. Conclusion: Both tested programmable VP-shunt valves are MR unsafe for 7T systems. Novel programming mechanisms using permanent magnets with sufficient magnetic coercivity or magnet-free mechanisms may allow the development of programmable VP-shunt valves that are conditional for 7T MR systems. [ABSTRACT FROM AUTHOR]

Craniotomes have shown to be fast and precise in performing bone flaps. Nevertheless, in everyday practice, the neurosurgeon can experience breakage of the blade and other complications like dural tears during cutting of the bone. We developed a test procedure for craniotomies and used it to compare two blade types. We used bovine scapulae to perform three tests. Five testers carried out every trial. Test 1: a 4-cm straight line was performed with both blades. Test 2: each tester performed a spiral cut. Test 3: a zig-zag cut with angles of 90° was performed by all testers with both blade types. The mean time needed to achieve the 4-cm cut in test 1 was 29.50 and 17.88 s, respectively, for the previous and new blade. In test 2, the calculated mean speed (cm/s) was 0.138 using the previous blade model and 0.178 using the new one. In test 3, the mean number of 90° angles per second performed with both blades is comparable with values of 0.058 and 0.063, respectively, for the previous and new blade. The variable considered: speed of cutting and resistance to breakage shows that the novel blade is faster in performing all the three types of cut and has higher compliance with stress. [ABSTRACT FROM AUTHOR]

Knowledge of the bleeding risk and the long-term outcome of conservatively treated patients with cavernous malformations (CM) is poor. In this work, we studied the occurrence of CM-associated hemorrhage over a 10-year period and investigated risk factors for bleeding. Our institutional database was screened for patients with cerebral (CCM) or intramedullary spinal cord (ISCM) CM admitted between 2003 and 2021. Patients who underwent surgery and patients without completed follow-up were excluded. Analyses were performed to identify risk factors and to determine the cumulative risk for hemorrhage. A total of 91 CM patients were included. Adjusted multivariate logistic regression analysis identified bleeding at diagnosis (p = 0.039) and CM localization to the spine (p = 0.010) as predictors for (re)hemorrhage. Both risk factors remained independent predictors through Cox regression analysis (p = 0.049; p = 0.016). The cumulative 10-year risk of bleeding was 30% for the whole cohort, 39% for patients with bleeding at diagnosis and 67% for ISCM. During an untreated 10-year follow-up, the probability of hemorrhage increased over time, especially in cases with bleeding at presentation and spinal cord localization. The intensity of such increase may decline throughout time but remains considerably high. These findings may indicate a rather aggressive course in patients with ISCM and may endorse early surgical treatment. [ABSTRACT FROM AUTHOR]

A benign peripheral nerve sheath tumor (bPNST) is a rare lesion associated with peripheral nerval structures. Symptoms may be heterogeneous, complicating diagnosis finding. Additionally, management concepts of bPNST may vary. In some cases, initial misdiagnosis leads to mistreatment resulting in severe functional deficits and chronic pain syndromes. Therefore, we analyzed patients treated for bPNST in our specialized institution with a primary focus on prior misdiagnosis and possible mistreatment. Patients with bPNSTs (schwannomas, neurofibromas, hybrid nerve sheath tumors, and perineuriomas) treated at the Neurosurgical Department between January 1, 2015, and July 31, 2021, were included. Assessment of demographics, tumor entity, tumor location, symptoms, the interval between the onset of symptoms and surgery, involved medical specialties, and outpatients' treatment, with particular focus on initial misdiagnosis and inappropriate medical treatment, was performed. Eighty-five patients were included in the final analysis with schwannoma being the most prevalent histopathological diagnosis (schwannoma (75.3%, n=64), neurofibroma (12.9%, n=11), hybrid nerve sheath tumor (5.9%, n=5), and perineurioma (5.9%, n=5)). An incorrect primary diagnosis was detected in 44.7% (n=38), leading to suboptimal or insufficient treatment in these cases. Of those, 28.9% (n=11/38) were treated suboptimal, while 18.5% (n=7/38) underwent unnecessary invasive diagnostics. Inappropriate surgery based on prior misdiagnosis, which led to severe neurological deficits in all these cases, was reported in 26.3% (n=10/38). For the first time, our data shows the quantity and impact of incorrect initial diagnosis in bPNST causing a delay in causative treatment or resulting in unnecessary or potentially harmful treatment. [ABSTRACT FROM AUTHOR]

Background and purpose: Data on the temporal distribution of the bleeding time of intracranial aneurysms are limited to a few small studies. With this study, the aim was to analyze time patterns of the occurrence of aneurysmal subarachnoid hemorrhage (SAH), particularly focusing on the impact of patients' socio‐demographic and clinical characteristics on the ictus timing. Methods: The study is based on an institutional SAH cohort with 782 consecutive cases treated between January 2003 and June 2016. Data were collected on the ictus time, patients' socio‐demographic and clinical characteristics, as well as the initial severity and outcome. Univariate and multivariate analyses were performed on the bleeding timeline. Results: There were two peaks in the circadian rhythm of SAH, one in the morning (7–9 a.m.) and the other in the evening (7–9 p.m.). The strongest alterations in the bleeding time patterns were observed for weekdays, patients' age, sex and ethnicity. Individuals with chronic alcohol and painkiller consumption showed a higher bleeding peak between 1 and 3 p.m. Finally, the bleeding time showed no impact on the severity, clinically relevant complications and the outcome of SAH patients. Conclusions: This study is one of the very few detailed analyses of the impact of specific socio‐demographic, ethnic, behavioral and clinical characteristics on the rupture timing of aneurysms. Our results point to the possible relevance of the circadian rhythm for the rupture event, and therefore might be useful in the elaboration of preventive measures against aneurysm rupture. [ABSTRACT FROM AUTHOR]

Objective: Chronic hydrocephalus requiring shunt placement is a common complication of aneurysmal subarachnoid hemorrhage (SAH). Different risk factors and prediction scores for post-SAH shunt dependency have been evaluated so far. We analyzed the value of ventricle measurements for prediction of the need for shunt placement in SAH patients. Methods: Eligible SAH cases treated between 01/2003 and 06/2016 were included. Initial computed tomography scans were reviewed to measure ventricle indices (bifrontal, bicaudate, Evans', ventricular, Huckman's, and third ventricle ratio). Previously introduced CHESS and SDASH scores for shunt dependency were calculated. Receiver operating characteristic analyses were performed for diagnostic accuracy of the ventricle indices and to identify the clinically relevant cut-offs. Results: Shunt placement followed in 221 (36.5%) of 606 patients. In univariate analyses, all ventricular indices were associated with shunting (all: p<0.0001). The area under the curve (AUC) ranged between 0.622 and 0.662. In multivariate analyses, only Huckman's index was associated with shunt dependency (cut-off at ≥6.0cm, p<0.0001) independent of the CHESS score as baseline prediction model. A combined score (0–10 points) containing the CHESS score components (0–8 points) and Huckman's index (+2 points) showed better diagnostic accuracy (AUC=0.751) than the CHESS (AUC=0.713) and SDASH (AUC=0.693) scores and the highest overall model quality (0.71 vs. 0.65 and 0.67), respectively. Conclusions: Ventricle measurements are feasible for early prediction of shunt placement after SAH. The combined prediction model containing the CHESS score and Huckman's index showed remarkable diagnostic accuracy regarding identification of SAH individuals requiring shunt placement. External validation of the presented combined CHESS-Huckman score is mandatory. [ABSTRACT FROM AUTHOR]

Simple Summary: This scientific research characterizes the recurrence pattern of patients with glioblastoma after trimodality treatment, neurosurgery and radiation therapy, either intensity modulated radiation therapy (IMRT) or volumetric intensity modulated arc therapy (VMAT), as well as concurrent chemotherapy in a clinical setting based on daily image-guided radiation therapy (IGRT) at the West German Cancer Center. This study underlines the importance of reconsideration of clinical target volume margins in the clinical routine. Larger radiation therapy margins may decrease the proportion of out-field recurrences, but an effect on overall survival is highly questionable. Background: While prognosis of glioblastoma after trimodality treatment is well examined, recurrence pattern with respect to the delivered dose distribution is less well described. Therefore, here we examine the gain of additional margins around the resection cavity and gross-residual-tumor. Methods: All recurrent glioblastomas initially treated with radiochemotherapy after neurosurgery were included. The percentage overlap of the recurrence with the gross tumor volume (GTV) expanded by varying margins (10 mm to 20 mm) and with the 95% and 90% isodose was measured. Competing-risks analysis was performed in dependence on recurrence pattern. Results: Expanding the margins from 10 mm to 15 mm, to 20 mm, to the 95%- and 90% isodose of the delivered dose distribution with a median margin of 27 mm did moderately increase the proportion of relative in-field recurrence volume from 64% to 68%, 70%, 88% and 88% (p < 0.0001). Overall survival of patients with in-and out-field recurrence was similar (p = 0.7053). The only prognostic factor significantly associated with out-field recurrence was multifocality of recurrence (p = 0.0037). Cumulative incidences of in-field recurrences at 24 months were 60%, 22% and 11% for recurrences located within a 10 mm margin, outside a 10 mm margin but within the 95% isodose, or outside the 95% isodose (p < 0.0001). Survival from recurrence was improved after complete resection (p = 0.0069). Integrating these data into a concurrent-risk model shows that extending margins beyond 10 mm has only small effects on survival hardly detectable by clinical trials. Conclusions: Two-thirds of recurrences were observed within a 10 mm margin around the GTV. Smaller margins reduce normal brain radiation exposure allowing for more extensive salvage radiation therapy options in case of recurrence. Prospective trials using margins smaller than 20 mm around the GTV are warranted. [ABSTRACT FROM AUTHOR]

Purpose: The increasing number of clinically oriented MRI studies at 7 T motivates the safety assessment of implants, since many 7 T research sites conservatively exclude all subjects with metallic implants, regardless of type or location. The purpose of this study was to investigate potential RF-induced heating during a 7 T MRI scan using a self-built transmit/receive RF coil in patients with implants used for refixation of the bone flap after craniotomy. Going beyond standard ASTM safety tests, a comprehensive test procedure for safety assessments at 7 T is presented which takes into account the more complex coupling of the electromagnetic field with the human body and the implant as well as polarization effects. Methods: The safety assessment consisted of three main investigations using (1) numerical simulations in simplified models, (2) electric and magnetic field measurements and validation procedures in homogeneous phantoms, and (3) analysis of exposure scenarios in a heterogeneous human body model including thermal simulations. Finally, 7 T in vivo images show the degree of image artifact around the implants. Results: The simulations showed that the field distortions remain localized within the direct vicinity of the implants. A parallel E-field polarization was found to be the most relevant component in creating local SAR deviations, resulting in a 10% increase in 10-g-averaged SAR and 53% in 1-g-averaged SAR. Using a heterogeneous human head model, the implants caused field distortions and SAR elevations in the numerical simulations which were distinctly lower than the maximum local SAR value caused by the RF coil alone. Also, the position of the maximum 10-g-averaged SAR remained unchanged by the presence of the implants. Similarly, the maximum absolute local temperature remained below 39 °C in the thermal simulations. Only minor artifacts from the implants were observed in the in vivo images that would not likely affect the diagnostic image quality in patients. Conclusions: The findings suggested no evidence for noteworthy RF-related heating in humans after craniotomy using the described implants and for the particular RF coil that was used in this study. Here, identical transmit power restrictions apply with or without the implants. For other RF coils, the maximum permissible input power should be reduced by 10% until further simulations may indicate otherwise. [ABSTRACT FROM AUTHOR]

Background and purpose: We aimed to assess the course and predictors of functional outcome after single and multiple intracerebral hemorrhage (ICH) in pediatric patients with cerebral cavernous malformations (CCMs) and to conduct a risk assessment of a third bleed during the first follow‐up year after second ICH. Methods: We included patients aged ≤18 years with complete baseline characteristics, a magnetic resonance imaging dataset, ≥1 CCM‐related ICH and ≥1 follow‐up examination, who were treated between 2003 and 2021. Neurological functional status was obtained using modified Rankin Scale scores at diagnosis, before and after each ICH, and at last follow‐up. Kaplan–Meier analysis was performed to determine the cumulative 1‐year risk of third ICH. Results: A total of 55 pediatric patients (median [interquartile range] age 12 [11] years) were analyzed. Univariate analysis identified brainstem cavernous malformation (BSCM; p = 0.019) as a statistically significant predictor for unfavorable outcome after second ICH. Outcome after second ICH was significantly worse in 12 patients (42.9%; p = 0.030) than after first ICH and in five patients (55.6%; p = 0.038) after a third ICH compared to a second ICH. Cumulative 12‐month risk of rebleeding during the first year after a second ICH was 10.7% (95% confidence interval 2.8%–29.37%). Conclusions: Pediatric patients with a BSCM have a higher risk of worse outcome after second ICH. Functional outcome improves over time after an ICH but worsens following each ICH compared to baseline or previous ICH. Second bleed was associated with neurological deterioration compared to initial ICH, and this deteriorated further after a third ICH. [ABSTRACT FROM AUTHOR]

Background and purpose: The aim was to investigate the effect of modifiable vascular risk factors on the risk of first and recurrent bleeding for patients with a cavernous malformation (CM) of the central nervous system (CNS) over a 10‐year period. Methods: A retrospective review of our CM institutional database was performed spanning from 2003 to 2021. The inclusion criteria were non‐missing serial magnetic resonance imaging studies and clinical baseline metrics such as vascular risk factors. The exclusion criteria were patients who underwent surgical CM removal and patients with less than a decade of follow‐up. Kaplan–Meier and Cox regression analyses were performed to determine the cumulative risk (10 years) of hemorrhage. Results: Eighty‐nine patients with a CM of the CNS were included. Our results showed a non‐significant increased risk of hemorrhage during 10 years of follow‐up in patients using nicotine (hazard ratio 2.11, 95% confidence interval 0.86–5.21) and in patients with diabetes (hazard ratio 3.25, 95% confidence interval 0.71–14.81). For the presence of modifiable vascular risk factors at study baseline different cumulative 10‐year risks of bleeding were observed: arterial hypertension 42.9% (18.8%–70.4%); diabetes 66.7% (12.5%–98.2%); hyperlipidemia 30% (8.1%–64.6%); active nicotine abuse 50% (24.1%–76%); and obesity 22.2% (4%–59.8%). Overall cumulative (10‐year) hemorrhage risk was 30.3% (21.3%–41.1%). Conclusions: The probability of hemorrhage in untreated CNS CM patients increases progressively within a decade of follow‐up. None of the modifiable vascular risk factors showed strong indication for an influence on hemorrhage risk, but our findings may suggest a more aggressive course in patients with active nicotine abuse or suffering from diabetes. [ABSTRACT FROM AUTHOR]

Purpose: Spinal cavernous malformations (SCM) present a risk for intramedullary hemorrhage (IMH), which can cause severe neurologic deficits. Patient selection and time of surgery have not been clearly defined. Methods: This observational study included SCM patients who underwent surgery in our department between 2003 and 2021. Inclusion required baseline clinical factors, magnetic resonance imaging studies, and follow-up examination. Functional outcome was assessed using the Modified McCormick scale score. Results: Thirty-five patients met the inclusion criteria. The mean age was 44.7 ± 14.5 years, and 60% of the patients were male. In univariate analysis, the unfavorable outcome was significantly associated with multiple bleeding events (p =.031), ventral location of the SCM (p =.046), and incomplete resection (p =.028). The time between IMH and surgery correlated with postoperative outcomes (p =.004), and early surgery within 3 months from IMH was associated with favorable outcomes (p =.033). This association remained significant in multivariate logistic regression analysis (p =.041). Conclusions: Removal of symptomatic SCM should be performed within 3 months after IMH when gross total resection is feasible. Patients with ventrally located lesions might be at increased risk for postoperative deficits. [ABSTRACT FROM AUTHOR]

Objective: Acute hydrocephalus is a common complication in patients with aneurysmal subarachnoid hemorrhage (SAH). Several ventricular indices have been introduced to enable measurements of ventricular morphology. Previously, researchers have showed their diagnostic value for various neurological disorders. In this study, we evaluated the association between ventricular indices and the clinical course, occurrence of complications and outcome of SAH. Methods: A total of 745 SAH patients with available early admission computed tomography scans were included in the analyses. Six ventricular indices (bifrontal, bicaudate, ventricular and third ventricle ratios and Evans' and Huckman's indices) were measured. Primary endpoints included the occurrence of cerebral infarctions, in-hospital mortality and a poor outcome at 6 months. Secondary endpoints included different adverse events in the course of SAH. Clinically relevant cut-offs for the indices were determined using receiver operating curves. Univariate analyses were performed. Multivariate analyses were conducted on significant findings in a stepwise backward regression model. Results: The higher the values of the ventricular indices were and the older the patient was, the higher the WFNS and Fisher's scores were, and the lower the SEBES score was at admission. Patients with larger ventricles showed a shorter duration of intracranial pressure increase > 20 mmHg and required decompressive craniectomy less frequently. Ventricular indices were independently associated with the parameters of inflammatory response after SAH (C-reactive protein in serum and interleukin-6 in cerebrospinal fluid and fever). Finally, there were independent correlations between larger ventricles and all the primary endpoints. Conclusions: The lower risk of intracranial pressure increase and absence of an association with vasospasm or systemic infections during SAH, and the poorer outcome in individuals with larger ventricles might be related to a more pronounced neuroinflammatory response after aneurysmal bleeding. These observations might be helpful in the development of specific medical and surgical treatment strategies for SAH patients depending on the initial ventricle measurements. [ABSTRACT FROM AUTHOR]

Symptomatic epilepsy is a common complication of aneurysmal subarachnoid hemorrhage (aSAH) associated with poor outcome. We sought to analyze the risk factors leading to post-SAH epilepsy. All consecutive aSAH cases treated between 01/2003 and 06/2016 were retrospectively included. Post-aSAH period was followed up to 03/2020 for the occurrence of epilepsy. Demographic characteristics and previous medical history of the patients, parameters of initial severity, performed treatments, certain early and late complications of aSAH, as well as routine laboratory and vital parameter measurements were collected. Functional outcome was assessed at discharge and 6 months after aSAH using the modified Rankin scale (mRS). During the post-aSAH follow-up (median: 8.93 months/patient), 85 of 948 individuals (9%) in the final analysis developed symptomatic epilepsy (median: 3.43 months). In the majority of cases, epilepsy was diagnosed >3 weeks after aSAH (n = 67, 78.8%) and in survivors with poor outcome at discharge (mRS = 4–5, 15.8% vs. 5.3%, p < 0.0001). Of over 150 analyzed potential risk factors, the following parameters were independently associated with the risk of symptomatic epilepsy after aSAH: thyroid dysfunction (aHR = 1.81, p = 0.029), need for decompressive craniectomy (aHR = 2.32, p = 0.011) and shunt placement (aHR = 1.94, p = 0.022), prolonged tachycardia (≥4 days, aHR = 2.06, p = 0.025), as well as anemia signs (mean red blood cell count <3.6 × 1012 /L [aHR = 2.4, p = 0.015] and mean hematocrit <31% [aHR = 2.13, p = 0.044]) during first 2 weeks after aSAH. Symptomatic epilepsy occurs predominantly in individuals with poor outcome at discharge and after the acute phase of aSAH. Knowledge of risk factors associated with aSAH-related epilepsy might help in early identification and treatment of compromised individuals, and therefore, help to improve their outcome. • 948 patients treated over 13.5 years, median follow-up of 8.93 months per patient. • Over 150 possible risk factors were tested for epilepsy following aSAH. • Epilepsy is mainly observed in patients with poor outcome at discharge. • Risk factors: thyroid dysfunction, DC, shunt placement, tachycardia and anemia. [ABSTRACT FROM AUTHOR]

The purpose of this study was to investigate the functional outcome following surgical resection of cerebral cavernous malformations (CCM) in pediatric patients. We screened our institutional database of CCM patients treated between 2003 and 2021. Inclusion regarded individuals younger or equal than 18 years of age with complete clinical baseline characteristics, magnetic resonance imaging dataset, and postoperative follow-up time of at least three months. Functional outcome was quantified using the modified Rankin Scale (mRS) score and assessed at admission, discharge, and last follow-up examination. The primary endpoint was the postoperative functional outcome. As a secondary endpoint, predictors of postoperative functional deterioration were assessed. A total of 49 pediatric patients with a mean age of 11.3 ± 5.7 years were included for subsequent analyses. Twenty individuals (40.8%) were female. Complete resection of the lesion was achieved in 44 patients (89.8%), and two patients with incomplete resection were referred for successive remnant removal. The mean follow-up time after surgery was 44 months (IQR: 13 – 131). The mean mRS score was 1.6 on admission, 1.7 at discharge, and 0.9 at the latest follow-up. Logistic regression analysis adjusted to age and sex identified brainstem localization (aOR = 53.45 [95%CI = 2.26 − 1261.81], p =.014) as a predictor of postoperative deterioration. This study indicates that CCM removal in children can be regarded as safe and favorable for the majority of patients, depending on lesion localization. Brainstem localization implies a high risk of postoperative morbidity and indication for surgery should be balanced carefully. Minor evidence indicates that second-look surgery for CCM remnants might be safe and favorable. [ABSTRACT FROM AUTHOR]

Background and purpose: The purpose of this study was to investigate the 5‐year risk of a third bleeding event in cavernous malformations (CMs) of the central nervous system. Methods: Patients with cerebral or spinal CMs treated between 2003 and 2021 were screened using our institutional database. Patients with a complete magnetic resonance imaging dataset, clinical baseline characteristics, and history of two bleeding events were included. Patients who underwent surgical CM removal were excluded. Neurological functional status was obtained using the modified Rankin Scale score at the second and third bleeding. Kaplan–Meier and Cox regression analyses were performed to determine the cumulative 5‐year risk for a third haemorrhage. Results: Forty‐two patients were included. Cox regression analysis adjusted for age and sex did not identify risk factors for a third haemorrhage. 37% of patients experienced neurological deterioration after the third haemorrhage (p = 0.019). The cumulative 5‐year risk of a third bleeding was 66.7% (95% confidence interval [CI] 50.4%–80%) for the whole cohort, 65.9% (95% CI 49.3%–79.5%) for patients with bleeding at initial diagnosis, 72.7% (95% CI 39.3%–92.7%) for patients with a developmental venous anomaly, 76.9% (95% CI 55.9%–90.3%) for patients with CM localization to the brainstem and 75% (95% CI 50.6%–90.4%) for patients suffering from familial CM disease. Conclusions: During an untreated 5‐year follow‐up after a second haemorrhage, a significantly increased risk of a third haemorrhage compared to the known risk of a first and second bleeding event was identified. The third bleeding was significantly associated with neurological deterioration. These findings may justify a surgical treatment after a second bleeding event. [ABSTRACT FROM AUTHOR]

Cerebral infarction is a major contributor to poor outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Timing of treatment has been discussed as a possible contributor. We aimed to analyze the impact of treatment timing on the risk of cerebral infarction and poor outcome after aSAH. Consecutive cases of patients with aSAH treated at our institution between January 2003 and June 2016 were included. The cohort was divided into 2 groups, depending on the treatment during (day 4–14 after ictus) or beyond the vasospasm phase. Statistical assessment included a 1:1 propensity score matching analysis and multivariable logistic regression analysis within the whole cohort. Of 943 patients with aSAH, 111 underwent treatment in the vasospasm phase. In the propensity score matching analysis, patients treated during the vasospasm phase were at higher risk of vasospasm requiring intra-arterial spasmolysis (P < 0.0001), cerebral infarction distal to the treated vessel (P < 0.0001), and poor outcome (modified Rankin Scale score >2) at 6 months follow-up (P = 0.025). In the multivariable analysis, aneurysm treatment in the vasospasm phase was independently associated with higher risk of cerebral vasospasm necessitating intra-arterial spasmolysis (P < 0.0001; adjusted odds ratio [aOR], 3.62), cerebral infarction distal to the treated aneurysm (P = 0.01; aOR, 2.02), and poor outcome (P = 0.03; aOR, 2.05). Our data confirm a considerable risk of cerebral infarction and poor outcome in cases of aneurysm treatment between day 4 and 14 after aSAH. A more intense surveillance and prophylactic treatment of cerebral vasospasm might be necessary in cases of aneurysm treatment in the vasospasm phase. [ABSTRACT FROM AUTHOR]

Background: To estimate the quality of life, anxiety, depression, and illness perception in patients with medically treated cerebral cavernous malformation (CCM) and associated epilepsy. Methods: Nonsurgically treated patients with CCM‐related epilepsy (CRE) were included. Demographic, radiographic, and clinical features were assessed. All participants received established questionnaires (short‐form 36 health survey, SF‐36; hospital anxiety and depression score, HADS‐A/D; visual analogue scale score, VAS) assessing the functional and psychosocial burden of disease. To some extent, calculated values were compared with reference values from population‐based studies. Test results were related to seizure control. Results: A total of 37 patients were included. Mean age was 45.8 ± 14.4 years, and 54.1% were female. Diagnosis of CRE was significantly associated with attenuated quality of life and increased level of anxiety, affecting physical and psychosocial dimensions. The assessment of illness perception identified considerable burden. HADS was significantly associated with VAS and SF‐36 component scores. Efficacy of antiepileptic medication had no restoring impact on quality of life, anxiety, depression, or illness perception. Conclusions: CRE negatively influences quality of life and mood, independent of seizure control due to antiepileptic medication. Screening for functional and psychosocial deficits in clinical practice might be useful for assessing individual burden and allocating surgical or drug treatment. [ABSTRACT FROM AUTHOR]

Blood pressure management is crucial in the treatment of patients with aneurysmal subarachnoid hemorrhage (aSAH). Possible association between the blood pressure increase and the risk of delayed cerebral ischemia (DCI) and different systemic complications after aSAH is still a matter of debate. This study aims to elucidate the influence of blood pressure levels on the outcome of aSAH. All consecutive aSAH patients (n = 690) treated between 01/2003 and 06/2016 were included. The mean value of the mean arterial pressure (MAP) during 14 days after ictus was calculated for each individual. According to the institutional standards of vasospasm management, the mean 14 days MAP ≥ 95 mmHg was referred as increased (IMAP) and the patients with and without vasospasm were analyzed separately. Study endpoints were the occurrence of DCI on computed tomography scans, development of cardiac and nephrological complications, and poor outcome 6 months after aSAH (mRS > 2). Associations were tested in univariable/multivariable binary logistic regression analysis. IMAP was documented in 474 (68.7%) cases and was more common in individuals with poor neurological conditions at admission (p < 0.001), severe amount of intracranial blood (p = 0.001) and premorbid hypertension (p < 0.001). IMAP was independently associated with the occurrence of DCI (p = 0.014; aOR = 2.97; 95% CI 1.25–7.09) and poor functional outcome (p = 0.020; aOR = 3.14; 95% CI 1.20–8.22) in patients with vasospasm, but not in counterparts without vasospasm (p = 0.113/p = 0.086). IMAP had no influence on cardiac or nephrological complications. In aSAH individuals with cerebral vasospasm, sustained increase of blood pressure exceeding the therapeutic targets is strongly associated with the risk of DCI and poor outcome. Therefore, such an intrinsic increase of blood pressure might reflect the autoregulatory mechanisms against the impending cerebral ischemia in patients with cerebral vasospasm. Trial registration number: German clinical trial registry (DRKS, Unique identifier: DRKS00008749, 06/09/2015). [ABSTRACT FROM AUTHOR]

Background and Purpose: Analyze and compare the natural course of confirmed familial cerebral cavernous malformation (FCCM), assumed FCCM and non‐familial multiple cerebral cavernous malformation (CCM) disease over a 5‐year period. Methods: Our institutional database was screened for patients with CCM admitted between 2003 and 2020. Patients with complete magnetic resonance imaging dataset, evidence of multiple CCM, clinical baseline characteristics, and follow‐up examination were included. Patients were separated into confirmed familial cases, assumed familial cases or non‐familial multiple cavernous malformations. Kaplan–Meier and Cox regression analyses were performed to determine the cumulative 5‐year risk for hemorrhage and recurrent hemorrhage. Results: A total of 238 patients with multiple CCM were analyzed; 90 individuals had a confirmed FCCM disease, 115 an assumed FCCM, and 33 were allocated to the non‐FCCM group. Univariate Cox regression analysis identified intracerebral hemorrhage (ICH) as mode of presentation (p = 0.001) as a predictor for occurrence of recurrent hemorrhage during the 5‐year follow‐up (FU). The cumulative 5‐year risk of (re)bleeding was 21.6% for the entire cohort, 30.7% for patients with ICH at diagnosis, 22.1% for those patients with a confirmed diagnosis of FCCM, 23.5% for those with an assumed FCCM, and 21% for the non‐FCCM cases. Conclusions: FCCM patients with ICH at diagnosis are prone to develop rebleeding. During untreated 5‐year FU, FCCM patients and patients with sporadic multiple CCM reveal an almost equal susceptibility for (re)hemorrhage. Moreover, confirmed, assumed and non‐FCCM patients showed an equal cumulative 5‐year risk of symptomatic ICH. The probability of hemorrhage tends to increase over time, particularly in cases with ICH at presentation. [ABSTRACT FROM AUTHOR]

Simple Summary: The aim of the present retrospective study was to develop a new scoring system for prognosis of patients undergoing surgery for breast cancer brain metastasis. Our institutional cohort (n = 95) was analyzed with regard to independent predictors of short (<6 months) and long (≥3 years) survival. Breast-preserving surgery, presence of multiple brain metastases, and age ≥ 65 years at brain cancer diagnosis were associated with short survival. In turn, positive HER2 receptor status in brain metastasis, time interval ≥ 3 years between breast cancer and brain metastasis diagnosis and KPS ≥ 90% were the long survival predictors. The scores based on the above-mentioned independent predictors showed good diagnostic accuracy for the prediction of short (AUC = 0.773) and long (AUC = 0.775) survival. After external validation, the presented scores might become useful tools to support the interdisciplinary decision for the selection of treatment strategy in individuals with breast cancer brain metastases. Background: Brain metastases requiring surgical treatment determine the prognosis of patients with breast cancer. We aimed to develop the scores for the prediction of short (<6 months) and long (≥3 years) survival after BCBM surgery. Methods: Female patients with BCBM surgery between 2008 and 2019 were included. The new scores were constructed upon independent predictors for short and long postoperative survival. Results: In the final cohort (n = 95), 18 (18.9%) and 22 (23.2%) patients experienced short and long postoperative survival, respectively. Breast-preserving surgery, presence of multiple brain metastases and age ≥ 65 years at breast cancer diagnosis were identified as independent predictors of short postoperative survival. In turn, positive HER2 receptor status in brain metastases, time interval ≥ 3 years between breast cancer and brain metastases diagnosis and KPS ≥ 90% independently predicted long survival. The appropriate short and long survival scores showed higher diagnostic accuracy for the prediction of short (AUC = 0.773) and long (AUC = 0.775) survival than the breast Graded Prognostic Assessment score (AUC = 0.498/0.615). A cumulative survival score (total score) showed significant association with overall survival (p = 0.001). Conclusion: We identified predictors independently impacting the prognosis after BCBM surgery. After external validation, the presented scores might become useful tools for the selection of proper candidates for BCBM surgery. [ABSTRACT FROM AUTHOR]

To evaluate the predictive value of intraoperative neuromonitoring (IONM) in brainstem cavernous malformation (BSCM) surgery. Surgically treated patients with BSCM were included. All patients received IONM consisting of motor-evoked potentials (MEPs) and somatosensory-evoked potentials (SSEPs). Neurologic examination was conducted preoperatively and at discharge and follow-up >3 months after BSCM removal. Demographic, radiographic, and clinical features were assessed. Study end points were new motor or somatosensory deficits and functional disability. A total of 62 patients were included. MEP decrease was associated with new motor deficits at discharge (P = 0.022), and SSEP decrease was associated with new somatosensory deficits at discharge (P < 0.001) and follow-up (P < 0.001). Sensitivity and specificity values for MEPs (discharge: 31% and 93%; follow-up: 33% and 91%) and SSEPs (discharge: 82% and 80%; follow-up: 85% and 79%) were calculated, respectively. Receiver operating characteristic analyses with area under the curve (AUC) metrics revealed acceptable performance of MEPs (AUC, 0.75; P = 0.022) and SSEPs (AUC, 0.72; P = 0.004) in predicting early deficits. Intraoperative decrease of MEPs (P = 0.047) and SSEPs (P = 0.017) was associated with early functional disability. Surgery-related subdural air accumulation impaired IONM reliability in predicting early (P = 0.048) and long-term (P = 0.013) deficits. Established IONM warning criteria may be valid for BSCM removal. However, surgical approaches in the sitting position significantly limit the predictive value of IONM, to some extent because of intraoperative pneumocephalus. [ABSTRACT FROM AUTHOR]

Background and purpose: The severity of early brain edema (EBE) after aneurysm rupture was reported to be strongly associated with the risk of poor outcome after aneurysmal subarachnoid hemorrhage (SAH). Using the recently developed Subarachnoid Hemorrhage Early Brain Edema Score (SEBES), we analyzed the predictors of EBE and its impact on complications related to intracranial pressure (ICP) increase after SAH and on poor outcome. Methods: All consecutive SAH cases treated between January 2003 and June 2016 with assessable SEBES were included (n = 745). Data on demographic characteristics, medical history, initial severity of SAH, need for conservative ICP treatment and decompressive craniectomy, occurrence of cerebral infarctions and unfavorable outcome at 6 months (modified Rankin scale score > 2) were collected. Univariable and multivariable analyses were performed. Results: Younger age (<55 years; adjusted odds ratio [aOR] 3.16, 95% confidence interval [CI] 2.28–4.38), female sex (aOR 1.64, 95% CI 1.16–2.31), poor initial clinical condition (World Federation of Neurosurgical Societies score 4–5; aOR 1.74, 95% CI 1.23–2.46), presence of intracerebral hemorrhage (aOR 1.63, 95% CI 1.12–2.36), hypothyroidism (aOR 0.60, 95% CI 0.37–0.98) and renal comorbidity (aOR 0.29, 95% CI 0.11–0.78) were independently associated with SEBES (scores 3–4). There was an independent association between SEBES 3–4 and the need for conservative ICP treatment (aOR 2.43, 95% CI 1.73–3.42), decompressive craniectomy (aOR 2.68, 95% CI 1.84–3.89), development of cerebral infarcts (aOR 2.24, 95% CI 1.53–3.29) and unfavorable outcome (aOR 1.48, 95% CI 1.0–2.17). Conclusions: SEBES is a reliable predictor of ICP‐related complications and poor outcome of SAH. Our findings highlight the need for further research of the impact of patients' demographic characteristics and comorbidities on the severity of EBE after SAH. [ABSTRACT FROM AUTHOR]

Introduction: Brain natriuretic peptide (BNP) is a reliable biomarker in the acute phase of traumatic brain injury. However, the relationship between BNP and traumatic acute subdural hematoma (aSDH) has not yet been addressed. This study aimed to analyze BNP levels on admission in surgically treated patients and assess their relationship with early postoperative seizures (EPS) and functional outcomes. Methods: Patients with unilateral traumatic aSDH who were surgically treated in our department between July 2017 and May 2020 were included in the study. BNP was preoperatively measured. Patients' neurologic condition, radiographic variables on initial cranial computed tomography, sodium serum levels on admission, and occurrence of EPS were prospectively assessed. Functional outcome was assessed using the modified Rankin Scale (mRS) at discharge and follow-up (at 2–3 months). A poor outcome was defined by a mRS score > 3. Results: EPS occurred in 20 (19.6%) of 102 surgically treated patients in the final cohort on the median day 3. A significant association between EPS and a poor Glasgow Coma Scale score at the 7th postoperative day was found, which in turn independently predicted a poor functional outcome at discharge and follow-up. Nonetheless, EPS were not associated with poor functional outcomes. The multivariate analysis revealed BNP > 95.4 pg/ml (aOR = 5.7, p = 0.003), sodium < 137.5 mmol/l (aOR = 4.6, p = 0.009), and left-sided aSDH (aOR = 4.4, p = 0.020) as independent predictors of EPS. Conclusion: In the early postoperative phase of traumatic aSDH, EPS were associated with worse neurologic conditions, which in turn independently predicted poor outcomes at discharge and follow-up. Although several EPS risk factors have already been elucidated, this study presents BNP as a novel reliable predictor of EPS. Further larger studies are needed to determine whether a more precise estimate of EPS risk using BNP levels can be reached. [ABSTRACT FROM AUTHOR]

Traumatic acute subdural hematoma (aSDH) is associated with a high mortality rate caused by post-operative cerebral infarction. Recently, brain natriuretic peptide (BNP) was considered a reliable biomarker in the acute phase of traumatic brain injuries. We therefore aimed in this study to analyze BNP levels on admission, identify the predictors of their elevation, and assess the relationship between BNP and the risk of post-operative cerebral infarction. Patients with isolated, unilateral, traumatic aSDH who were admitted to our department between July 2017 and May 2020 were enrolled in this study. On admission, cranial computer tomography (CCT) and BNP sampling were simultaneously performed. Additionally, the time between head trauma and BNP sampling (TTS) was assessed. Admission radiographic variables included hematoma volumes, midline shift, and degree of brain edema. Cerebral infarction was detected on postoperative CCT. In total, 130 patients were included in this study. Surgical treatment was performed in 82.3% (n = 107) of cases. The multiple regression analysis showed that larger hematoma volumes (p = 0.032) and advanced age (p = 0.005) were independent predictors of elevated BNP when TTS <24 h. The binomial logistical regression analysis identified BNP with a cutoff value of <29.4 pg/mL (TTS = 3–12 h, adjusted odds ratio [aOR] = 16.5, p = 0.023) as an independent predictor of post-operative cerebral infarction. Elevated BNP levels in the first 24 h post-trauma were related to larger hematoma volumes and advanced age. Further, an increased risk of post-operative cerebral infarction was identified in patients with lower BNP levels in the post-traumatic period 3–12 h. [ABSTRACT FROM AUTHOR]

Background and Study Aims/Object Despite the relevance of molecular criteria for brain tumor diagnosis and prognosis, meningioma grading is still solely based on histologic features. Atypical meningiomas (AMs; WHO grade II) display a great histologic heterogeneity and individual courses of disease can differ significantly. This study aimed to identify clinically aggressive AMs that are prone to early recurrence after gross total resection (GTR) by assessing a specific histologic score. Patients and Methods A retrospective analysis of 28 consecutive patients (17 females and 11 males; mean age of 62 years [range: 35–88 years]) treated in our institution between January 2006 and December 2015 was performed. Basic demographic and clinical characteristics were assessed. A scoring scale was designed to address the histologic diversity by summing up the individual histologic features in every tumor sample. According to that, points were awarded as follows: major AM defining criterion (3 points) and minor criterion (1 point). Results The subclassification based on our specific histologic score revealed no significant difference in frequency of one (46.4%) or two (42.9%) AM defining features; three criteria were less frequently seen (10.7%). Mean follow-up was 61.89 ± 9.03 months. Local recurrence occurred in 35.7% after a mean time of 37.4 ± 22.6 months after primary surgery. Age > 60 years was significantly associated with a shorter progression-free survival (PFS). There was a trend toward shorter PFS with increasing scores, tantamount with the presence of several AM defining histologic criteria in one sample. No tumor relapse was seen when diagnosis was based only on minor criteria. Conclusion AMs display a histologic diversity. There is a trend toward shorter PFS with increasing numbers of AM defining histologic features. The inclusion of this score in the decision algorithm regarding further treatment for patients >60 years after GTR might be helpful and should be evaluated in further studies. [ABSTRACT FROM AUTHOR]

Background and purpose: In previous studies in patients with traumatic brain injury and ischemic stroke, the size of decompressive craniectomy (DC) was reported to be paramount with regard to patient outcomes. We aimed to identify the impact of DC size on treatment results in individuals with aneurysmal subarachnoid hemorrhage (SAH). Methods: The extent of DC in 232 patients with SAH who underwent bifrontal or hemicraniectomy between January 2003 and December 2015 was analyzed using semi‐automated surface measurements. The study endpoints were course of intracranial pressure (ICP) treatment after DC, occurrence of cerebral infarcts, in‐hospital mortality, and unfavorable outcome at 6 months (defined as modified Rankin scale score >3). The associations of DC size with the study endpoints were adjusted for DC timing, patient age, clinical and radiographic severity of SAH, aneurysm location, and treatment modality. Results: The mean DC surface area was 100.9 (±45.8) cm2. In multivariate analysis, a large DC (>105 cm2) was independently associated with a lower risk of cerebral infarcts (adjusted odds ratio [aOR] 0.30, 95% confidence interval [CI] 0.16–0.56), in‐hospital mortality (aOR 0.28, 95% CI 0.14–0.56) and unfavorable outcome (aOR 0.51, 95% CI 0.27–0.98). Moreover, SAH patients with a small DC size (<75 cm2) were more likely to require prolonged (>3 days, aOR 3.60, 95% CI 1.37–9.42) and enhanced (aOR 2.31, 95% CI 1.12–4.74) postoperative ICP treatment. Conclusion: This is the first study showing the impact of DC size on postoperative ICP control and patient outcome in the context of SAH; specifically, a large craniectomy flap (>105 cm2) might lead to better outcomes in SAH patients requiring decompressive surgery. [ABSTRACT FROM AUTHOR]

Objective: Seizures at the onset (SAO) of aneurysmal subarachnoid hemorrhage (aSAH) occur in up to one of every five cases. To date, there is no consensus on causal background and clinical value of these early bleeding-related seizures. This study aimed to analyze the predictors and the impact of SAO in aSAH. Methods: All aSAH patients from the institutional observational cohort (01/2003–06/2016) were retrospectively reviewed. Patients' charts and emergency protocols from first responders were screened for the occurrence of seizures in the first 24 h after aSAH. Patients' baseline characteristics and occurrence of post-hemorrhagic complications were analyzed. Outcome endpoints included in-hospital mortality and poor outcome at 6-month follow-up (modified Rankin Scale > 3). Results: Of 984 patients included in the final analysis, SAO occurred in 93 cases (9.5%) and were independently associated with younger age (< 51 years, p < 0.001), WFNS grade ≥ 4 (p < 0.001), aneurysm characteristics (location at the proximal branch of the anterior cerebral artery [p = 0.037] and irregular sac [p = 0.019]) and admission body temperature > 38.3 ℃ (p = 0.008). There was an association between SAO and early complications (early infarcts [p = 0.004] and primary decompressive craniectomy [p = 0.024]). Only in the subgroup analysis restricted to the younger individuals, SAO independently predicted poor outcome of aSAH (p = 0.002). Significance: Onset seizures following aSAH are rare and most likely related to the severity of early brain injury. Particularly, younger individuals are not only at higher risk for SAO, but are also prone to poor outcome in case of aSAH accompanied with SAO. Trial registration number: German clinical trial registry (DRKS, unique identifier: DRKS00008749, 06/09/2015) [ABSTRACT FROM AUTHOR]

The purpose of this study was to analyze brain natriuretic peptide (BNP) serum levels of patients with chronic subdural hematoma (cSDH) and their clinical implication. Patients with cSDH who underwent surgery in our department between November 2016 and October 2019 were eligible for enrollment in the study. Patients with recurrent bleedings, traumatic brain injury, cSDH associated with other intracranial pathologies, and those with a history of congestive heart failure, renal or endocrine disease were excluded. We measured BNP serum levels pre- and post-operatively and at discharge. The BNP values were analyzed with respect to patient medical history and neurological condition. The Glasgow Coma Scale score and the modified Rankin Scale score classified the clinical and neurological condition at the time of admission and discharge, respectively. The data of 100 surgically treated patients with cSDH (mean age 73.2, range 42 − 94 years, male/female 3.5:1) were analyzed. Pre-operative BNP serum levels (BNP-1) were elevated in 67% of the patients (n = 67; median = 101.6 pg/mL; p < 0.001). These serum levels increased after surgery (p < 0.001) and decreased thereafter (p < 0.001), reaching a level at discharge (day 7) that was not statistically different from BNP-1 (p > 0.05). In addition, elevated BNP-1 showed a significant statistical association with the presence of atrial fibrillation (p < 0.01) and antiplatelet and/or anticoagulant therapy (p < 0.01). This study provides new evidence regarding BNP serum levels and their secretion pattern in patients with cSDH. Whether BNP-1 can predict the long-term functional outcome of patients with cSDH is being investigated in this ongoing prospective study. [ABSTRACT FROM AUTHOR]

Delayed cerebral ischemia (DCI) is a severe complication of subarachnoid hemorrhage (SAH). Clinical and radiographic features of SAH may be helpful in identification of individuals prone to DCI. The aim of this systematic review was to analyze the present evidence on predictive value of blood and cerebrospinal fluid (CSF) biomarkers of DCI after SAH. We systematically searched in PubMed, Scopus, Web of Science, and Cochrane Library databases for publications before July 15, 2018, reporting correlations between blood/CSF biomarkers and occurrence of DCI and/or vasospasm in SAH patients. Included studies underwent quality assessment according to QUIPS and STARD guidelines. Level of evidence (I–IV) for each of tested biomarkers was assessed according to GRADE guidelines. Of 2181 unique records identified in four databases, 270 original articles and 5 meta-analyses were included to this review. Of 257 blood and CSF parameters analyzed in 16.914 SAH patients, there was no biomarker with positive association with DCI/vasospasm showing level I evidence. Twenty-one biomarkers achieved level II evidence and could be confirmed as predictive biomarkers. In this review, six single nucleotide polymorphisms (for EET metabolic pathways, COMT, HMGB1, ACE, PAI-1 promoter, and Hp genes) and 15 non-genetic biomarkers (pNF-H, ADAMTS13, NPY, Copeptin, HMGB1, GFAP, periostin, Tau, BNP, NT pro-BNP, hs-TnT, PA-TEGMA, MPV:PLT, NLR, and PLR) were selected as predictive DCI biomarkers. We propose that a panel analysis of the selected genetic and protein biomarker candidates would be needed for further validation in a large SAH cohort. [ABSTRACT FROM AUTHOR]

Objective: Despite recent advances in molecular biology and genetics, the development of intracranial aneurysms (IA) is still poorly understood. Elucidation of the processes occurring in the IA wall is essential for a better understanding of IA pathophysiology. We sought to analyze the current evidence from histological, molecular and genetic studies of IA. Methods: We systematically searched PubMed, Scopus, Web of Science and Cochrane Library for articles published before Mar 1, 2019 reporting on different diagnostic markers in human IA specimens. Expression of the markers in IA wall (vs. healthy arterial wall) and association with the rupture status were analyzed. The quality of the included studies and the level of the evidence for the markers were incorporated into the final data assessment. Results: We included 123 studies reporting on analyses of 3476 IA (median 19 IA/study) published between 1966 and 2018. Based on microscopic, biochemical, genetic and biomechanical analyses, data on 358 diagnostic targets in the IA wall were collected. We developed a scale to distribute the diagnostic markers according to their specificity for IA or healthy arterial wall, as well as for ruptured or unruptured IA. We identified different functional pathways, which might reflect the intrinsic and extrinsic processes underlying IA pathophysiology. Conclusions: Multiple histological and molecular markers and the related functional pathways contributing to the development of IA might present promising targets for future therapeutic interventions. Because of small numbers of IA samples in each study, 89% of the analyzed diagnostic markers presented with the lowest level of evidence. This underlines the need for the initiation of a multi‐centric prospective histological IA register for pooled data analysis. [ABSTRACT FROM AUTHOR]

Background: Perineuriomas are rare benign peripheral nerve sheath tumours of perineurial cell origin and can be classified into intraneural and extraneural perineuriomas. They most commonly present a mononeuropathy of gradual onset and slow progression, resulting in progressive neurological deficits like hypoesthesia or motor weakness. Therapy is still variable. Aim of the study was to compare our surgical treatment and our follow-up regime including high-resolution nerve sonography with the current literature to evaluate best treatment of perineuriomas.Methods: Retrospective analysis of our dataset "peripheral nerve lesion" to identify patients suffering from perineuriomas between 01.01.2012 until 31.12.2018. Surgical treatment and the follow-up examination of three patients were described. Additionally, a systematic review including PubMed, the Cochrane Collaboration Library, Scopus and Google Scholar was performed for literature published between January 1, 1990 and October 31, 2019 independently by 2 authors.Results: In the first case, the left ulnar nerve was affected. In the second case, the left peroneal nerve and in the third case the right median nerve was affected. High-resolution nerve sonography was performed in each case. All patients underwent interfascicular neurolysis combined with a targeted fascicular biopsy under electrophysiological monitoring. Neurological deficits improved subsidized by rehabilitation. Surgical therapy and the neurological outcome were compared with literature. Systematic review revealed 22 articles, which met the inclusion criteria. Therefore, demographics, surgical treatment and neurological outcome of 77 patients were analysed.Conclusions: Perineuriomas are rare benign nerve sheath tumours with a slow progression, sometimes difficult to diagnose. Decompression and neurolysis may improve neurological deficits. High resolution nerve sonography might serve as a helpful additional diagnostic tool in this process. [ABSTRACT FROM AUTHOR]

Cranial implants are commonly used for surgical repair of craniectomy-induced skull defects. These implants are usually generated offline and may require days to weeks to be available. An automated implant design process combined with onsite manufacturing facilities can guarantee immediate implant availability and avoid secondary intervention. To address this need, the AutoImplant II challenge was organized in conjunction with MICCAI 2021, catering for the unmet clinical and computational requirements of automatic cranial implant design. The first edition of AutoImplant (AutoImplant I , 2020) demonstrated the general capabilities and effectiveness of data-driven approaches, including deep learning, for a skull shape completion task on synthetic defects. The second AutoImplant challenge (i.e., AutoImplant II , 2021) built upon the first by adding real clinical craniectomy cases as well as additional synthetic imaging data. The AutoImplant II challenge consisted of three tracks. Tracks 1 and 3 used skull images with synthetic defects to evaluate the ability of submitted approaches to generate implants that recreate the original skull shape. Track 3 consisted of the data from the first challenge (i.e., 100 cases for training, and 110 for evaluation), and Track 1 provided 570 training and 100 validation cases aimed at evaluating skull shape completion algorithms at diverse defect patterns. Track 2 also made progress over the first challenge by providing 11 clinically defective skulls and evaluating the submitted implant designs on these clinical cases. The submitted designs were evaluated quantitatively against imaging data from post-craniectomy as well as by an experienced neurosurgeon. Submissions to these challenge tasks made substantial progress in addressing issues such as generalizability, computational efficiency, data augmentation, and implant refinement. This paper serves as a comprehensive summary and comparison of the submissions to the AutoImplant II challenge. Codes and models are available at https://github.com/Jianningli/Autoimplant_II. • The paper is a comprehensive summary of the AutoImplant II cranial implant design challenge. • The challenge provided clinical cases of defective skulls in the evaluation phase. • Neurosurgeons were invited to manually assess the feasibility of the submissions. • Novel solutions towards clinical applicability and computation efficiency in automatic cranial implant design were proposed within the challenge. [ABSTRACT FROM AUTHOR]

Purpose: To prospectively evaluate non-contrast-enhanced 7-Tesla (T) MRA for delineation of unruptured intracranial aneurysms (UIAs) in comparison with DSA.Material and Methods: Forty patients with single or multiple UIAs were enrolled in this IRB-approved trial. Sequences acquired at 7 T were TOF MRA and non-contrast-enhanced MPRAGE. All patients additionally underwent 3D rotational DSA. Two neuroradiologists individually analysed the following aneurysm and image features on a five-point scale in 2D and 3D image reconstructions: delineation of parent vessel, dome and neck; overall image quality; presence of artefacts. Interobserver accordance was assessed by the kappa coefficient.Results: A total of 64 UIAs were detected in DSA and in all 2D and 3D MRA image reconstructions. Ratings showed comparable results for DSA and 7-T MRA when considering all image reconstructions. Highest ratings for individual image reconstructions were given for 2D MPRAGE and 3D TOF MRA. Interobserver accordance was almost perfect for the majority of ratings.Conclusion: This study demonstrates excellent delineation of UIAs using 7-T MRA within a clinical setting comparable to the gold standard, DSA. The combination of 7-T non-enhanced MPRAGE and TOF MRA for assessment of untreated UIAs is a promising clinical application of ultra-high-field MRA.Key Points: • Non-enhanced 7-T MRA allowed excellent delineation of unruptured intracranial aneurysms (UIAs). • Image quality at 7-T was comparable with DSA considering both sequences. • Assessment of UIAs is a promising clinical application of ultra-high-field MRA. [ABSTRACT FROM AUTHOR]

Objectives: To investigate in-vivo microanatomy of the subcallosal artery branching from the anterior communicating artery (ACoA) using time-of-flight (TOF) magnetic resonance angiography (MRA) at 7 Tesla.Methods: Seventy-five subjects, including 15 healthy volunteers and 60 patients, were included in this prospective study. Three raters characterized branches from ACoA in maximum intensity projections of TOF MRA at 7 Tesla acquired with 0.22 × 0.22 × 0.41 mm(3) resolution. Furthermore, course patterns and anatomical features of the subcallosal artery (maximum diameter, length, and branching angle from ACoA) were measured.Results: Branches from the anterior communicating artery were visualized in 63 of 74 (85.1 %) subjects and were identified as the subcallosal artery (93.7 %) and the accessory anterior cerebral artery (6.3 %). The course of the subcallosal artery was classified into 3 groups; C-shaped (55.9 %), straight (16.9 %), and S-shaped (27.2 %). There was a significant difference between the branching angles of C-shaped and straight (p < 0.0001), between C-shaped and S-shaped (p < 0.0001), as well as between straight and S-shaped (p = 0.0113) course patterns.Conclusions: High-resolution in-vivo 7 T TOF MRA can delineate the microanatomy of the subcallosal artery. Three main variants of course patterns and branching angles from ACoA could be identified.Key Points: • In-vivo 7 Tesla TOF MRA can delineate the subcallosal artery microanatomy • Three distinct course patterns of the subcallosal artery were identified • Branching angles from ACoA significantly differed between subcallosal artery course patterns. [ABSTRACT FROM AUTHOR]

Objective: To evaluate prospectively 7 Tesla time-of-flight (TOF) magnetic resonance angiography (MRA) and 7 Tesla non-contrast-enhanced magnetization-prepared rapid acquisition gradient-echo (MPRAGE) for delineation of intracerebral arteriovenous malformations (AVMs) in comparison to 1.5 Tesla TOF MRA and digital subtraction angiography (DSA).Methods: Twenty patients with single or multifocal AVMs were enrolled in this trial. The study protocol comprised 1.5 and 7 Tesla TOF MRA and 7 Tesla non-contrast-enhanced MPRAGE sequences. All patients underwent an additional four-vessel 3D DSA. Image analysis of the following five AVM features was performed individually by two radiologists on a five-point scale: nidus, feeder(s), draining vein(s), relationship to adjacent vessels, and overall image quality and presence of artefacts.Results: A total of 21 intracerebral AVMs were detected. Both sequences at 7 Tesla were rated superior over 1.5 Tesla TOF MRA in the assessment of all considered AVM features. Image quality at 7 Tesla was comparable with DSA considering both sequences. Inter-observer accordance was good to excellent for the majority of ratings.Conclusion: This study demonstrates excellent image quality for depiction of intracerebral AVMs using non-contrast-enhanced 7 Tesla MRA, comparable with DSA. Assessment of untreated AVMs is a promising clinical application of ultra-high-field MRA.Key Points: • Non-contrast-enhanced 7 Tesla MRA demonstrates excellent image quality for intracerebral AVM depiction. • Image quality at 7 Tesla was comparable with DSA considering both sequences. • Assessment of intracerebral AVMs is a promising clinical application of ultra-high-field MRA. [ABSTRACT FROM AUTHOR]

Objective: Diffuse axonal injury (DAI) is a specific type of traumatic brain injury caused by shearing forces leading to widespread tearing of axons and small vessels. Traumatic microbleeds (TMBs) are regarded as a radiological marker for DAI. This study aims to compare DAI-associated TMBs at 3 Tesla (T) and 7 T susceptibility weighted imaging (SWI) to evaluate possible diagnostic benefits of ultra-high field (UHF) MRI. Material and Methods: 10 study participants (4 male, 6 female, age range 20-74 years) with known DAI were included. All MR exams were performed with a 3 T MR system (Magnetom Skyra) and a 7 T MR research system (Magnetom 7 T, Siemens AG, Healthcare Sector, Erlangen, Germany) each in combination with a 32-channel-receive coil. The average time interval between trauma and imaging was 22 months. Location and count of TMBs were independently evaluated by two neuroradiologists on 3 T and 7 T SWI images with similar and additionally increased spatial resolution at 7 T. Inter- and intraobserver reliability was assessed using the interclass correlation coefficient (ICC). Count and diameter of TMB were evaluated with Wilcoxon signed rank test. Results: Susceptibility weighted imaging revealed a total of 485 TMBs (range 1-190, median 25) at 3 T, 584 TMBs (plus 20%, range 1-262, median 30.5) at 7 T with similar spatial resolution, and 684 TMBs (plus 41%, range 1-288, median 39.5) at 7 T with 10-times higher spatial resolution. Hemorrhagic DAI appeared significantly larger at 7 T compared to 3 T (p = 0.005). Inter- and intraobserver correlation regarding the counted TMB was high and almost equal 3 T and 7 T. Conclusion: 7 T SWI improves the depiction of small hemorrhagic DAI compared to 3 T and may be supplementary to lower field strengths for diagnostic in inconclusive or medicolegal cases. [ABSTRACT FROM AUTHOR]

Simple Summary: To date, there is a discrepancy regarding the role of antiepileptic drugs on glioblastoma survival. In the present study, based on large institutional cohort and enhanced with a meta-analysis of seven previously published studies, we show a robust association between the perioperative start of levetiracetam treatment with increased overall and progression-free survival in glioblastoma. Our results encourage the initiation of a prospective clinical trial to analyze the antitumor effect of levetiracetam in glioblastoma patients. Despite multimodal treatment, the prognosis of patients with glioblastoma (GBM) remains poor. Previous studies showed conflicting results on the effect of antiepileptic drugs (AED) on GBM survival. We investigated the associations of different AED with overall survival (OS) and progression-free survival (PFS) in a large institutional GBM cohort (n = 872) treated January 2006 and December 2018. In addition, we performed a meta-analysis of previously published studies, including this study, to summarize the evidence on the value of AED for GBM prognosis. Of all perioperatively administered AED, only the use of levetiracetam (LEV) was associated with longer OS (median: 12.8 vs. 8.77 months, p < 0.0001) and PFS (7 vs. 4.5 months, p = 0.001). In the multivariable analysis, LEV was independently associated with longer OS (aHR = 0.74, p = 0.017) and PFS (aHR = 0.68, p = 0.008). In the meta-analysis with 5614 patients from the present and seven previously published studies, outcome benefit for OS (HR = 0.83, p = 0.02) and PFS (HR = 0.77, p = 0.02) in GBM individuals with LEV was confirmed. Perioperative treatment with LEV might improve the prognosis of GBM patients. We recommend a prospective randomized controlled trial addressing the efficacy of LEV in GBM treatment. [ABSTRACT FROM AUTHOR]

To investigate the role of brain natriuretic peptide (BNP) in predicting long-term functional outcome and develop a new predictive score of poor functional outcome after surgery for chronic subdural hematoma (cSDH). Patients with cSDH that were surgically treated in our department between November 2016 and December 2019 were included in the study. Pre- and postoperative plasma BNP and clinical condition were prospectively recorded. At follow-up (5–6 months), a simplified modified Rankin Scale (mRS) questionnaire was conducted through a standardized telephone interview. A poor outcome was defined by a mRS > 3. Based on predictors of the long-term functional outcome, a score was calculated. Its accuracy was tested using the area under the curve (AUC) of the receiver operating characteristic analysis. In total, 119 patients were analyzed (median age: 76 years, range: 44–94 years). Preoperative plasma BNP (BNP-1) was elevated in 77 patients (64.7%). For the follow-up phone interview, 101 patients (84.8%) were available. In the multivariate analysis, poor outcome at follow-up could be predicted using BNP-1 (p = 0.034), age (p = 0.036), motor deficit (p = 0.013) and Glasgow coma scale score on admission (p = 0.008). The "Functional Long-term Outcome Predictive score" (FLOP-score) was therefore computed, and revealed an excellent discriminative capacity compared to other scores, with an AUC of 0.86 (0.77–0.95). Preoperative plasma BNP is an independent predictor of functional outcome at follow-up. Using the FLOP-score, the risk of experiencing a poor outcome could accurately be predicted. • Preoperative plasma BNP is an independent predictor of long-term functional outcome after surgery for cSDH. • The FLOP-score allows an accurate prediction of poor functional outcome at follow-up • The FLOP-score provides a stratification of the risk and might guide neurosurgeons in surgical decision-making. [ABSTRACT FROM AUTHOR]