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The purpose of this study was to describe the impact of enteral glyburide on cerebral edema formation and hypoglycemia when used to treat patients diagnosed with acute ischemic stroke (AIS). This study was a single-center, retrospective medical record review that included all patients aged ≥18 years diagnosed with AIS who received ≥1 dose of enteral glyburide for the prevention of cerebral edema from January 1, 2018 to March 31, 2022. The primary outcome was the percentage of patients requiring intervention for cerebral edema management after glyburide initiation, and the safety outcome was the occurrence of hypoglycemia in this patient population. The final evaluation included 44 patients, with 6 patients (14%) requiring intervention for cerebral edema after glyburide initiation. The average baseline National Institutes of Health stroke scale score was 19. Overall, in-hospital mortality was 36% (n = 17), and hypoglycemia occurred in 7 patients (15%). Of the 44 patients, 20 (45%) received a partial duration of enteral glyburide (1–4 doses) and 24 (55%) received a full duration of enteral glyburide (5–7 doses). The rate of intervention for cerebral edema (10% vs. 17%) and the incidence of hypoglycemia (5% vs. 23%) were lower in the partial duration than in the full duration group. The in-hospital all-cause mortality rate was higher in the partial duration group than in the full duration group (43% vs. 31%). Despite the relatively low rates of intervention for cerebral edema, hypoglycemia was common, especially for patients receiving 5–7 doses of enteral glyburide for the prevention of cerebral edema after moderate-to-severe AIS. [ABSTRACT FROM AUTHOR]

Patients with leptomeningeal carcinomatosis (LMC) experience a poor prognosis and rapid progression, and cerebrospinal fluid drainage (CSFD) is used to manage intracranial hypertension and hydrocephalus in LMC patients. This study aims to describe a novel discovery of preoperative radiological features in patients who underwent CSFD for LMC. A retrospective review was conducted during the past 5 years of LMC patients with intracranial hypertension and hydrocephalus who underwent CSFD. We evaluated the patients' preoperative radiological features, clinical characteristics, and survival times. A total of 36 patients were included. Of the 36 patients, 34 underwent ventriculoperitoneal shunting, and 2 patients underwent only external ventricular drainage due to rapid progression. The median preoperative Karnofsky performance scale score was 40.0 (interquartile range [IQR], 20.0–40.0). The median survival time after surgery was 5 months (IQR, 0.00–10.43 months). Of the 36 patients, 24 (66.7%) had supratentorial cerebral edema before surgery, including 14 patients (38.9%) with features of disproportionately enlarged subarachnoid space hydrocephalus (DESH). Four patients (11.1%) exhibited cerebellar swelling and had a median survival time of 0.27 month (IQR, 0.00–0.56 month). Nine patients (25%) have enhancement lesions on the cerebellum. The survival curve analysis shows that patients with features of cerebellar enhancement have shorter survival times than other patients. Patients with DESH features have longer survival times compared with those with global cerebral edema. Patients with radiological features of cerebellar enhancement have shorter postoperative survival than other patients; however, those with supratentorial cerebral edema, especially features of DESH, could benefit from CSFD. Patients with cerebellar swelling should avoid undergoing CSFD. [ABSTRACT FROM AUTHOR]

Ischemic stroke significantly contributes to high mortality and disability rates. Cerebral edema is a common consequence of ischemic stroke and can lead to aggravation or even death. Current treatment strategies are limited to decompressive craniectomy and the intravascular administration of hypertonic drugs, which have significant side effects. Acetazolamide (ACZ) plays a therapeutic role in cerebral edema by inhibiting aquaporin-4 (AQP-4) and improving collateral circulation. This study aimed to perform a meta-analysis and systematic review of ACZ therapy for ischemic stroke and evaluate its efficacy in animal models. We searched Embase, Cochrane Library, PubMed, Web of Science, Chinese National Knowledge Infrastructure, Wanfang Database, and Chinese Biomedical Literature Database until April 2023 for studies on ACZ in ischemic animal models. The quality of the animal trials was assessed using the Collaborative Approach to Meta-Analysis and Review of Animal Data from Experimental Stroke. After screening 376 articles, only 5 studies were included. We found that ACZ reduced brain edema in cerebral ischemia 24 hours after onset (standard mean difference, −2.00; 95% confidence interval, −3.57 to −0.43, P = 0.01). ACZ also inhibited AQP-4 expression 24 hours after onset (standard mean difference−1.46; 95% confidence interval, −2.01 to −0.91, P < 0.001). Brain edema and AQP-4 expression also showed a declining trend on the third day after onset, although there were not enough data to support this. The effect of ACZ on brain ischemia in animals' neurological function is uncertain because of the limited research data. ACZ inhibited AQP-4 and alleviated brain edema after ischemic stroke in the early stages but seemingly could not improve the neurological function. [ABSTRACT FROM AUTHOR]

To identify risk factors associated with in-hospital seizures and new-onset epilepsy in patients with aneurysmal subarachnoid hemorrhage (SAH) who underwent coiling embolization or clipping surgery. This retrospective descriptive study included 195 patients diagnosed with aneurysmal SAH and treated with coiling embolization or clipping surgery between January 2018 and June 2022. Among the 195 patients meeting inclusion criteria, 9 experienced an onset seizure at the time of SAH. In-hospital seizures were observed in 33 patients, of which 24 were electrographic seizures detected in 24 patients with suspected subclinical seizures. After 12 months of follow-up, 11 patients met criteria for diagnosis of epilepsy. The incidence of epilepsy after discharge at 12 months was 2.41% in the coiling group and 8.03% in the clipping group. The risk of in-hospital seizures was significantly higher in the clipping group (P = 0.007), although the difference was not statistically significant after 12 months of follow-up (P = 0.121). Epilepsy following aneurysmal SAH was relatively common. Clipping surgery and brain edema emerged as independent predictive factors for in-hospital seizures, while onset seizures and in-hospital seizures were identified as independent predictors of epilepsy during follow-up. Patients presenting with these risk factors may benefit from long-term electroencephalogram monitoring and should be considered for prophylactic antiepileptic drugs. Additionally, lumbar drainage proved effective in improving both early and late epileptic outcomes in the group with Fisher grades 3 and 4. [ABSTRACT FROM AUTHOR]

We assessed the effectiveness and safety of target temperature management (TTM) in treating patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). The primary objective was to evaluate the neurological outcome at 3 months. Secondary objectives were to assess mortality, delayed cerebral ischemia, cerebral edema, hydrocephalus, midline shift, and laboratory indicators related to TTM. A single-blind, nonrandomized controlled trial was conducted. After admission, patients with poor-grade aSAH (Hunt-Hess scores IV ∼ V) were assigned to a TTM group or a control group in a 1:1 ratio. TTM with core temperatures ranging from 36°C to 37°C was performed immediately and maintained until microclipping or endovascular embolization. Subsequently, rapid induction to 33°C ∼ 35°C was carried out and maintained for 3 to 5 days. Then, the patients underwent slow rewarming to 36°C ∼ 37°C and maintained at that temperature for a minimum of 48 hours. Sixty patients (30 treated with TTM and 30 with standard treatment) were included in the study. At 3 months, a favorable prognosis (modified Rankin scale score 0 to 3) was significantly higher in the TTM group than in the control group (n = 14, 46.7% vs. n = 6, 20.0%, P = 0.028). Adjusted multivariate logistics regression analysis indicated that TTM (odds ratio = 0.20, 95% confidence interval: 0.05–0.77, P = 0.019) reduced the number of unfavorable prognoses 3 months after admission. This study demonstrated the effectiveness and safety of TTM in patients with poor-grade aSAH, and its implementation improved neurological outcomes. Multicenter randomized controlled studies with a large number of patients are needed to confirm these observations. [ABSTRACT FROM AUTHOR]

After craniectomy, autologous bone flaps may be stored using wet or dry cryopreservation. After brain edema subsides, they are replaced during an operation termed cranioplasty. Cranioplasty is associated with 15% infection incidence. We conducted a retrospective comparison of infection outcomes between wet and dry cryopreservation of cranioplasty bone flaps. Historically, bone flaps were stored utilizing wet cryopreservation—bone flap storage in 1 L of lactated Ringer's solution containing 80 mg gentamicin and 2 g nafcillin in a sterile plastic container secured in an unsterile plastic bag. Our newer dry cryopreservation protocol involved storage in gauze soaked in 80 mg gentamicin and 2 g nafcillin within a 3-layer sterile bag system. A total of 119 autologous bone flaps were included, with median follow-up of 3.9 months from cranioplasty. Overall, 10.9% became infected, requiring subsequent surgery; 18.4% of 49 bone flaps stored using wet cryopreservation became infected compared with only 5.7% of 70 dry cryopreservation bone flaps (P = 0.038; relative risk [RR] 0.311; absolute risk reduction 12.7%). Tobacco use (P = 0.076; RR 3.17) was not associated with increased infection risk. Infection incidence was similar for traumatic craniectomy indications compared to the other indications (12.0% trauma vs. 10.1% other; P = 0.750). On average, infected cranioplasty patients spent 8.5 more days hospitalized and faced increased risk of additional complications. Dry cryopreservation significantly decreases infection after cranioplasty when compared with wet cryopreservation, and this mitigates additional morbidity, mortality, and costs attributable to cranioplasty infection. Other nonmodifiable risk factors for cranioplasty infection were identified. [ABSTRACT FROM AUTHOR]

The aim of this study was to examine associations between genomic alterations in brain metastases and common preoperative imaging findings including overt intratumoral hemorrhage, cystic features, and edema. A single-center, retrospective study was performed including patients who underwent surgical resection of brain metastasis with available preoperative magnetic resonance imaging (MRI). Next-generation sequencing of more than 500 coding genes was performed on the resected brain metastases. Preoperative MRI was reviewed to identify the presence of intratumoral hemorrhage, cystic features, and edema in the resected brain metastasis. Genomic data were then correlated with the imaging features using univariate and multivariate nominal logistic regression analyses. We included 144 brain metastases from 141 patients in the study cohort. Half (72) of the metastases had an intratumoral hemorrhage, 26 (18%) had cystic features, and 130 (90%) had edema. Mutations in TP53 were associated with a reduced risk of intratumoral hemorrhage (odds ratio [OR] 0.2, 95% confidence interval [CI] 0.07–0.5, P < 0.001). Mutations in RB1 and CCND1 were associated with elevated risk of the metastasis having cystic features (OR 10.3, 95% CI 2.0–52.6, P = 0.005, OR 18.4, 95% CI 2.2–155.3, P = 0.008, respectively). PIK3CA mutations were associated with a reduced risk of peritumoral edema (OR 0.2, 95% CI 0.04–0.8, P = 0.03). Several genomic alterations in brain metastases are associated with MRI features including hemorrhage, cystic features, and edema. These results provide insight into tumor biology and patients at risk of developing these imaging features. [ABSTRACT FROM AUTHOR]

Neurosurgeons occasionally encounter cases of subarachnoid hemorrhage (SAH) in admitted walk-in patients, termed "walk-in SAH." However, their clinical characteristics have not been fully understood. We thus, aimed to investigate several characteristics of patients with walk-in SAH and compare them with those of patients with good grade SAH who arrived at the hospital by ambulance. Between January 2011 and January 2018, consecutive patients with World Federation of Neurosurgical Society (WFNS) grade I and II aneurysmal SAH were enrolled. They were dichotomized into walk-in and ambulance groups, and their demographic and disease-related characteristics were compared. Furthermore, predictors associated with unfavorable outcomes were investigated in patients with walk-in SAH. Of 171 patients with World Federation of Neurosurgical Society grade I and II SAH, 68 (39.8%) were categorized as walk-in SAH. The mean time for diagnosis in patients with walk-in SAH was significantly longer than that in patients who arrived by ambulance (P < 0.01). Multivariate analysis demonstrated that a lower rate of hypertension, high grades on the Barrow Neurological Institute scale, and Early Brain Edema Score were significantly associated with walk-in SAH (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.21–0.91, P = 0.03; OR 0.32, 95% CI 0.13–0.76, P = 0.007; OR 0.11, 95% CI 0.02–0.51, P < 0.0001, respectively). Additionally, severe angiographic vasospasm was a significant predictor of unfavorable outcomes in walk-in SAH (OR 37.7, 95% CI 1.10–1290.90, P = 0.04). Patients with walk-in SAH exhibit radiological characteristics associated with a more favorable outcome among patients with good grade SAH. Therefore, these patients may have a positive prognosis. [ABSTRACT FROM AUTHOR]

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with increased blood-brain barrier permeability, disrupted tight junctions, and increased cerebral edema. Sulfonylureas are associated with reduced tight-junction disturbance and edema and improved functional outcome in aSAH animal models, but human data are scant. We analyzed neurological outcomes in aSAH patients prescribed sulfonylureas for diabetes mellitus. Patients treated for aSAH at a single institution (August 1, 2007–July 31, 2019) were retrospectively reviewed. Patients with diabetes were grouped by presence or absence of sulfonylurea therapy at hospital admission. The primary outcome was favorable neurologic status at last follow-up (modified Rankin Scale score ≤2). Variables with an unadjusted P -value of <0.20 were included in a propensity-adjusted multivariable logistic regression analysis to identify predictors of favorable outcomes. Of 1013 aSAH patients analyzed, 129 (13%) had diabetes at admission, and 16 of these (12%) were receiving sulfonylureas. Fewer diabetic than nondiabetic patients had favorable outcomes (40% [52/129] vs. 51% [453/884], P = 0.03). Among diabetic patients, sulfonylurea use (OR 3.90, 95% CI 1.05–15.9, P = 0.046), Charlson Comorbidity Index <4 (OR 3.66, 95% CI 1.24–12.1, P = 0.02), and absence of delayed cerebral infarction (OR 4.09, 95% CI 1.20–15.5, P = 0.03) were associated with favorable outcomes in the multivariable analysis. Diabetes was strongly associated with unfavorable neurologic outcomes. An unfavorable outcome in this cohort was mitigated by sulfonylureas, supporting some preclinical evidence of a possible neuroprotective role for these medications in aSAH. These results warrant further study on dose, timing, and duration of administration in humans. [ABSTRACT FROM AUTHOR]

To compare shallow machine learning models and deep neural network (DNN) model in prediction of vestibular schwannoma (VS) surgical outcome. One hundred eighty-eight patients with VS were included; all underwent suboccipital retrosigmoid sinus approach, and preoperative magnetic resonance imaging recorded a series of patient characteristics. Degree of tumor resection was collected during surgery, and facial nerve function was evaluated on the eighth day after surgery. Potential predictors of VS surgical outcome were obtained by univariate analysis, including tumor diameter, tumor volume, tumor surface area, brain tissue edema, tumor property, and tumor shape. This study proposes a DNN framework to predict the prognosis of VS surgical outcomes based on potential predictors and compares it with a series of classic machine learning algorithms including logistic regression. The results showed that 3 predictors of tumor diameter, tumor volume, and tumor surface area were the most important prognostic factors for VS surgical outcomes, followed by tumor shape, while brain tissue edema and tumor property were the least influential. Different from shallow machine learning models, such as logistic regression with average performance (area under the curve: 0.8263; accuracy: 81.38%), the proposed DNN shows better performance, where area under the curve and accuracy were 0.8723 and 85.64%, respectively. Based on potential risk factors, DNN can be exploited to achieve preoperative automatic assessment of VS surgical outcomes, and its performance is significantly better than other methods. It is therefore highly warranted to continue to investigate their utility as complementary clinical tools in predicting surgical outcomes preoperatively. [ABSTRACT FROM AUTHOR]

Malignant cerebral edema (MCE) is a common and feared complication after endovascular thrombectomy (EVT) in acute ischemic stroke (AIS). This study aimed to establish a nomogram to predict MCE in anterior circulation large vessel occlusion stroke (LVOS) patients receiving EVT in order to guide the postoperative medical care in the acute phase. In this retrospective cohort study, 381 patients with anterior circulation LVOS receiving EVT were screened from 636 hospitalized patients with LVOS at 2 stroke medical centers. Clinical baseline data and imaging data were collected within 2–5 days of admission to the hospital. The patients were divided into 2 groups based on whether MCE occurred after EVT. Multivariate logistic regression analysis was used to evaluate the independent risk factors for MCE and to establish a nomogram. Sixty-six patients out of 381 (17.32%) developed MCE. The independent risk factors for MCE included admission National Institutes of Health Stroke Scale (NIHSS) ≥16 (odds ratio [OR] 1.851; 95% CI 1.029–3.329; P = 0.038), ASPECT score (OR 0.621; 95% CI 0.519–0.744; P < 0.001), right hemisphere (OR 1.636; 95% CI 0.941–2.843; P = 0.079), collateral circulation (OR 0.155; 95% CI 0.074–0.324; P < 0.001), recanalization (OR 0.223; 95% CI 0.109–0.457; P < 0.001), hematocrit (OR, 0.937; 95% CI: 0.892–0.985; P =0.010), and glucose (OR 1.118; 95% CI 1.023–1.223; P = 0.036), which were adopted as parameters of the nomogram. The receiver operating characteristic curve analysis showed that the area under the curve of the nomogram in predicting MCE was 0.901(95% CI 0.848–0.940; P < 0.001). The Hosmer-Lemeshow test results were not significant (P = 0.685), demonstrating a good calibration of the nomogram. The novel nomogram composed of admission NIHSS, ASPECT scores, right hemisphere, collateral circulation, recanalization, hematocrit, and serum glucose provide a potential predictor for MCE in patients with AIS after EVT. [ABSTRACT FROM AUTHOR]

Decompressive hemicraniectomy (DHC) is performed to relieve life-threatening intracranial pressure elevations. After swelling abates, a cranioplasty is performed for mechanical integrity and cosmesis. Cranioplasty is costly with high complication rates. Prior attempts to obviate second-stage cranioplasty have been unsuccessful. The Adjustable Cranial Plate (ACP) is designed for implantation during DHC to afford maximal volumetric expansion with later repositioning without requiring a second major operation. The ACP has a mobile section held by a tripod fixation mechanism. Centrally located gears adjust the implant between the up and down positions. Cadaveric ACP implantation was performed. Virtual DHC and ACP placement were done using imaging data from 94 patients who had previously undergone DHC to corroborate our cadaveric results. Imaging analysis methods were used to calculate volumes of cranial expansion. The ACP implantation and adjustment procedures are feasible in cadaveric testing without wound closure difficulties. Results of the cadaveric study showed total volumetric expansion achieved was 222 cm3. Results of the virtual DHC procedure showed the volume of cranial expansion achieved by removing a standardized bone flap was 132 cm3 (range, 89–171 cm3). Applied to virtual craniectomy patients, the total volume of expansion achieved with the ACP implantation operation was 222 cm3 (range, 181–263 cm3). ACP implantation during DHC is technically feasible. It achieves a volume of cranial expansion that will accommodate that observed following survivable hemicraniectomy operations. Moving the implant from the up to the down position can easily be performed as a simple outpatient or inpatient bedside procedure, thus potentially eliminating second-stage cranioplasty procedures. [ABSTRACT FROM AUTHOR]

Dialysis disequilibrium syndrome is a rare, well-known, potentially life-threatening complication of renal replacement therapy (RRT), often involving cerebral edema and increased intracranial pressure (ICP). However, the impact of RRT on ICP and rate of dialysis disequilibrium syndrome in neurosurgical patients have not been systematically assessed. In February 2022, a systematic review following PRISMA guidelines was conducted using various combinations of 9 keywords in the MEDLINE database. Eleven papers were selected. Individual patient data were extracted, pooled, and analyzed. Fifty-eight patients, 44 men and 14 women with a mean age of 48 years (6–78 years), were analyzed. Neurosurgical conditions included the following: spontaneous intracranial hemorrhage (n = 27), traumatic brain injury (n = 16), ischemic stroke/anoxic brain injury (n = 6), intracranial tumor (n = 6), and others (n = 3). Neurosurgical interventions included the following: craniotomy/craniectomy (n = 23), external ventricular drain or ICP monitor placement (n = 16), and burr hole or twist drill craniostomy (n = 4). Intermittent dialysis was used in 33 patients, continuous RRT in 20, and a combination thereof in 4. During RRT, ICP increased in 35 patients (60.3%), remained unchanged in 20, and decreased in 3. Thirty-four patients (65.4%) died. Intermittent dialysis was associated with increased ICP (73% vs. 37.5%, P = 0.01) and mortality (75% vs. 39.1%, P = 0.01). In neurosurgical patients, ICP increases during RRT are common, affecting up to 60%, and potentially life-threatening, with mortality rates as high as 65%. The use of a continuous rather than intermittent RRT technique may reduce the risk of this complication. Prospective studies are warranted. [ABSTRACT FROM AUTHOR]

Intracranial solitary fibrous tumor (SFT) is characterized by aggressive local behavior and high post-resection recurrence rates. It is difficult to distinguish between SFT and meningiomas, which are typically benign. The goal of this study was to systematically review radiological features that differentiate meningioma and SFT. We performed a systematic review in accordance with PRISMA guidelines to identify studies that used imaging techniques to identify radiological differentiators of SFT and meningioma. Eighteen studies with 1565 patients (SFT: 662; meningiomas: 903) were included. The most commonly used imaging modality was diffusion weighted imaging, which was reported in 11 studies. Eight studies used a combination of diffusion weighted imaging and T1- and T2-weighted sequences to distinguish between SFT and meningioma. Compared to all grades/subtypes of meningioma, SFT is associated with higher apparent diffusion coefficient, presence of narrow-based dural attachments, lack of dural tail, less peritumoral brain edema, extensive serpentine flow voids, and younger age at initial diagnosis. Tumor volume was a poor differentiator of SFT and meningioma, and overall, there were less consensus findings in studies exclusively comparing angiomatous meningiomas and SFT. Clinicians can differentiate SFT from meningiomas on preoperative imaging by looking for higher apparent diffusion coefficient, lack of dural tail/narrow-based dural attachment, less peritumoral brain edema, and vascular flow voids on neuroimaging, in addition to younger age at diagnosis. Distinguishing between angiomatous meningioma and SFT is much more challenging, as both are highly vascular pathologies. Tumor volume has limited utility in differentiating between SFT and various grades/subtypes of meningioma. [ABSTRACT FROM AUTHOR]

To evaluate the prognostic value of the buffer coefficient, calculated as the ratio of the buffer volume (volume of intracranial cerebrospinal fluid) at the peak of brain edema to the baseline brain volume, and some other parameters in patients with massive cerebral infarction (MCI). The cohort comprised 161 patients with MCI who were divided into good and poor prognosis groups according to modified Rankin Scale score at 90 days after onset. Differences in clinical and imaging parameters between these groups were analyzed by univariate analysis, and multifactorial binary logistic regression analysis was used to further identify influencing factors that were significantly different. Receiver operating characteristic curve was used to evaluate the diagnostic performance between the buffer volume and the buffer coefficient. The findings showed that a history of atrial fibrillation, intravenous tissue-type plasminogen activator administration, successful reperfusion, successful craniectomy, low-density lesion volume, brain volume, buffer volume, and buffer coefficient were significantly different between the poor and good prognosis groups (P < 0.05 for all comparisons). Multifactorial binary logistic regression analyses revealed that patients who had large low-density lesion volume and patients who had not achieved successful reperfusion or received intravenous tissue-type plasminogen activator were likely to have a poor prognosis (P < 0.05). The buffer coefficient was identified as an independent predictive factor for MCI (P < 0.001). The area under the receiver operating characteristic curve for the buffer coefficient was 0.862. When the cutoff value was 9.3%, sensitivity of predicting poor prognosis of patients with MCI was 94.7%. The buffer coefficient has potential benefits as a prognostic indicator for MCI that can be used to detect even subtle changes in brain edema. [ABSTRACT FROM AUTHOR]

Bilaterally fixed and dilated pupils in the setting of transtentorial herniation have traditionally been considered a sign of futility. Such patients are often denied life-saving surgery based on the premise that meaningful functional recovery would be extremely unlikely. We sought to determine the survival and functional outcome in a cohort of patients who underwent aggressive medical and surgical management. Charts of all patients managed by a single surgeon over a 42-month period were retrospectively reviewed. Functional outcome was determined using modified Rankin Scale (mRS). Outcome was classified as good (mRS score 0–3), acceptable (mRS score 4), or poor (mRS score 5–6). Patients were 7 men and 2 women with a mean age of 36 years (range, 16–66 years). Etiologies included stroke (4 patients), traumatic brain injury (4 patients), and malignant cerebral edema (1 patient). Preoperative Glasgow Coma Scale scores ranged from 3 to 7, and midline shift was 7–16 mm. All patients received emergency osmotic therapy before decompressive surgery. Time to surgery (from pupillary changes) was <150 minutes for all patients (median 94 minutes; range, 50–148 minutes). At 3 months, 5 patients (55.6%) had recovered, achieving a good (n = 3) or acceptable (n = 2) outcome. The other 4 patients failed to recover and ultimately died of their injury. In well-selected patients with transtentorial herniation and bilaterally fixed and dilated pupils, aggressive and timely medical and surgical management may lead to substantial rates of survival and favorable functional outcome. Preconceived notions of a universally grim prognosis in such patients can lead to self-fulfilling prophecies. [ABSTRACT FROM AUTHOR]

The Subarachnoid Hemorrhage Early Brain Edema Score (SEBES) is a radiographic marker for early brain injury after aneurysmal subarachnoid hemorrhage (aSAH). We evaluated the role of the SEBES in performing decompressive craniectomy (DC) for poor-grade aSAH. We retrospectively analyzed all cases of poor-grade (World Federation of Neurosurgical Societies [WFNS] grade IV and V) aSAH in adults who underwent microsurgery at our center between April 2017 and March 2021. Patient demographics, clinical presentation, imaging findings, and surgical data were obtained. The study endpoints of DC rate, complications, and functional outcomes (modified Rankin Scale score >3) were compared between the traditional surgery and SEBES-informed groups. A survival analysis was performed to estimate 180-day survival and hazard ratios for death. The study included 116 patients (mean age, 60.8 ± 9.5 years, DCs [n = 63, 54.3%]). In the univariate analysis, age, intracranial pressure, midline shift, pupil changes, SEBES grade III–IV, traditional group, and WFNS grade Ⅴ were associated with DC. DC (46.4% vs. 67.4%) and in-hospital mortality rates (9.6% vs. 25.6%) were significantly lower in the SEBES-informed group. At day 180 after admission, modified Rankin Scale scores did not significantly differ between the 2 groups, but 180-day survival was significantly higher in the SEBES-informed group (78.1% vs. 53.5%). In the multivariable analysis, age, pupil changes, being in the traditional group, and delayed cerebral ischemia were independently associated with 180-day postadmission mortality. The SEBES provides good imaging support for preoperative and intraoperative intracranial pressure management in poor-grade aSAH, allowing for improved DC-related decision-making and better 180-day survival. [ABSTRACT FROM AUTHOR]

Falcine meningioma is usually approached ipsilaterally, and the technique for tumor removal has traditionally been performed under microscopy. We report a surgical procedure for large falcine meningioma by an endoscopic contralateral interhemispheric transfalcine keyhole approach. The study period was from September 2019 to March 2021. Study participants were patients with World Health Organization grade I meningioma showing falx attachment, excluding neurofibromatosis, who underwent initial surgery at our institution. The surgical procedure begins with a small contralateral craniotomy of about 3 cm, followed by insertion of an endoscope. The tumor attachment to the falx is excised, exposing the tumor. Internal decompression is performed, and the lesion is dissected from the surrounding brain before removal through the falx. An endoscopic contralateral interhemispheric transfalcine keyhole approach was used to resect 4 cases of large falcine meningioma. The mean operation time was 265 minutes (range: 216–294 minutes), achieving Simpson grade I removal in all cases. No evidence of cerebral infarction, cerebral edema, or new neurological complaints related to impaired venous return was seen using this surgical method. In the case of falcine meningioma, the endoscopic keyhole contralateral technique allows detachment of the tumor from the falx and safe manipulation in a minor field of view. In addition, because the craniotomy is smaller and the operation time is shorter, this procedure offers a less-invasive approach for the patient. This technique is thus, in our opinion, quite advantageous. [ABSTRACT FROM AUTHOR]

Secretory meningioma (SM) is a rare subtype of World Health Organization (WHO) grade 1 meningioma, associated with significant peritumoral brain edema (PTBE). Because of this, SM may be mistaken preoperatively to be a WHO grade 2 meningioma (G2M). In this study, we identified radiographic features to differentiate these 2 tumor types preoperatively to help inform surgical decision-making. We performed a retrospective review of all patients with histologically confirmed intracranial SM and G2M at a single institution from 2000 to 2019. Relevant clinic, demographic and radiographic data were collected. We performed a stepwise multivariable logistic regression to identify independent predictors of SM. A total of 43 SM and 140 G2M patients were included in this study. In multivariable analysis, severe PTBE, meaning edema size greater than tumor size (odds ratio [OR] 4.44, P = 0.01), tumor hyperintensity on fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging sequences (OR 7.80, P = 0.002), and higher normalized apparent diffusion coefficient (nADC) values (OR 1.54, P < 0.001) were strong predictors of SM. Conversely, larger tumor volume (OR 1.79 per 10 mL volume increase, P < 0.001) and cystic component (OR 12.50, P = 0.007) correlated with G2M. In this study, we found that preoperative FLAIR hyperintensity, severe PTBE, and higher nADC values correlated with SM pathology, and larger size and cystic component were associated with G2M. Accurate identification of SM on preoperative imaging may provide surgeons useful information in decision-making. [ABSTRACT FROM AUTHOR]

Patients with World Federation of Neurosurgical Societies (WFNS) grade V subarachnoid hemorrhage (SAH) frequently have poor outcomes. The current understanding of the predictors of functional outcome only in WFNS grade V SAH is limited. Patients with WFNS grade V SAH were retrospectively analyzed between April 2008 and August 2019. Surgical treatment is commonly delayed until clinical improvement is observed using a less aggressive approach. Clinical and radiologic data on admission were assessed, and disease-related characteristics were compared between patients with favorable outcomes (modified Rankin Scale score 0–3) and those with unfavorable outcomes (modified Rankin Scale score 4–6). A total of 144 patients were included, and 22 patients (15.3%) achieved favorable outcomes, whereas 122 patients (84.7%) had unfavorable outcomes. Surgical aneurysm repair was performed in all patients with favorable outcomes and in 21.3% of those with unfavorable outcomes. Multivariate analysis showed that Glasgow Coma Scale score of 3, high-grade Early Brain Edema Score, absence of bilaterally light reflex and neurologic improvement, and hypertension were significantly associated with unfavorable outcomes (odds ratio [OR], 9.54, P = 0.03; OR, 5.37, P = 0.04; OR, 11.80, P = 0.009; OR, 0.14, P = 0.02 and OR, 6.53, P = 0.04, respectively). The final outcome of patients with WFNS grade V SAH was still poor and highly predicted by Glasgow Coma Scale score of 3, high-grade Early Brain Edema Score, absence of bilaterally light reflex and neurologic improvement, and a history of hypertension. The efficacy of aggressive surgical treatment for these patients remains controversial, and the indications should be clearly defined in patients with desolate clinical status on admission. [ABSTRACT FROM AUTHOR]

Bilaterally fixed and dilated pupils (BFDP) in the setting of transtentorial herniation due to a space-occupying lesion have traditionally been considered a sign of futility. As a result, such patients may be denied life-saving decompressive surgery, resulting in very high mortality rates. We sought to determine the survival rate and functional outcomes in patients with transtentorial herniation and BFDP following emergency decompressive surgery. This was a systematic review of MEDLINE, Embase, Cochrane, and Google Scholar databases, using a combination of 15 prespecified keywords, according to Preferred Reporting Items for Systematic reviews and Meta-Analyses methodology. Individual patient data were extracted, pooled, and analyzed. Twenty-two studies totaling 503 patients were included. Study designs were as follows: prospective cohort (n = 1), retrospective cohort (n = 15), and case report (n = 6). Nearly two thirds of patients (67.7%) were male. The mean age was 41 years (range = 3–82). The median preoperative Glasgow coma scale was 3 (range = 3–6). Nearly two thirds (66.9%) underwent surgical decompression within 2 hours of pupillary changes. The mean follow-up was 7 months (range = 1–40). Two thirds (67%) died. Among survivors, 50.5% had severe disability (Glasgow outcome scale = 2–3), while 49.5% had a good outcome (Glasgow outcome scale 4–5), representing 17% of the whole population. Given the methodological limitations, the prognostic value of age, Glasgow coma scale, and time to surgery could not be determined. The literature suggests a rate of favorable recovery approaching 17% following decompressive surgery in patients with transtentorial herniation and BFDP, secondary to space-occupying lesions. In the setting of stroke or trauma, the clinical finding of BFDP should not be solely relied on as an indicator of futility. Prospective studies are warranted. [ABSTRACT FROM AUTHOR]

In the present study, we aimed to identify the obliteration outcomes, complications, and predictors in gamma knife radiosurgery (GKRS) treatment of brain arteriovenous malformations (AVMs) at a tertiary center in a developing country in a 15-year experience. We retrospectively reviewed the clinical data and GKRS procedures of patients who had undergone GKRS from 2006 to 2011 (cohort 1) and from 2011 to 2020 (cohort 2) at Cho Ray Hospital, Vietnam. The exclusion criteria included patients with <24 months of follow-up without obliteration or AVM-related hemorrhage during the study period. A total of 870 patients were included in the final analysis. The patients in cohort 1 had had significantly smaller AVMs (8.4 ± 11.6 cm3 vs. 11.2 ± 12.8 cm3; P < 0.001), and the AVMs were less frequently located in eloquent locations (46.6% vs. 65.5%; P < 0.001) than in cohort 2. The mean follow-up time was 49.6 ± 22.6 months (range, 5.9–102.6). The overall AVM obliteration rate was 66.6%. Cohort 1 had a significantly higher rate of complete obliteration compared with cohort 2 (81.0% vs. 55.1%; P < 0.001). The post-GKRS annual hemorrhage risk was 1.0%. Significant radiosurgery-induced brain edema and radiosurgery-induced cyst formation was reported in 24 (2.6%) and 4 (0.5%) patients in cohorts 1 and 2, respectively. Using multivariate analysis, we identified prior AVM hemorrhage (hazard ratio [HR], 1.430; 95% confidence interval [CI], 1.182–1.729), a higher margin dose (HR, 1.136; 95% CI, 1.086–1.188), a noneloquent location (HR, 0.765; 95% CI, 0.647–0.905), and smaller AVM volume (HR, 0.982; 95% CI, 0.968–0.997) as predictive factors for obliteration. GKRS is a safe and effective treatment of brain AVMs. The lack of prior AVM hemorrhage, an eloquent location, and higher AVM were unfavorable predictors for post-GKRS obliteration. [ABSTRACT FROM AUTHOR]

This study aimed to elucidate the clinicoradiologic features of spontaneous hemorrhagic meningiomas (HMs) and examine risk factors associated with meningioma hemorrhage. We retrospectively reviewed 651 consecutive meningioma patients who underwent surgical resection in our hospital between January 2011 and January 2021. After exclusions, 169 patients were included for analysis. Patients were grouped according to presence of hemorrhage in the meningioma: the HM group (n = 19) and non-HM group (n = 150). Clinicoradiologic patient data were examined and compared using univariate and multivariate analysis. HMs accounted for 2.9% of the entire series of meningiomas. HMs were mainly located at the convexity (63.2%). Mean diameter of HMs was 4.8 cm. On computed tomography, most HMs appeared as mixed isodensity and hyperdensity (84.2%). On magnetic resonance imaging, most appeared as mixed isointensity and hyperintensity on T1-weighted imaging and mixed hypointesity and hyperintensity on T2-weighted imaging (52.6%). Seventeen tumors exhibited heterogeneous enhancement, a dural tail, and peritumoral brain edema. Thirteen showed intratumoral cystic change. The misdiagnosis rate was significantly higher in HMs than non-HMs (31.6% vs. 7.3%; P = 0.005). Intratumoral cystic change was the only independent predictor of meningioma hemorrhage in multivariate analysis (odds ratio 4.116; 95% confidence interval 1.138–14.894; P = 0.031). Mixed isodensity/intensity and hyperdensity/intensity on computed tomography/magnetic resonance imaging in conjunction with heterogenous enhancement, a dural tail, and varying degrees of peritumoral brain edema suggest a high possibility of HM. Presence of intratumoral cystic change was an independent risk factor associated with meningioma hemorrhage. [ABSTRACT FROM AUTHOR]

The goal of treatment of traumatic brain injury (TBI) is to avoid secondary brain injury. Decompressive craniectomy has been shown to reduce intracranial pressure (ICP), but it actually provides an outlet for brain tissue to expand without reducing edema. Basal cisternostomy is an emerging microsurgical technique to manage cerebral edema in TBI. Cerebrospinal fluid is released from basal cisterns, which reduces cerebral edema. We compared outcomes of cisternostomy with decompressive craniectomy in a randomized controlled trial and studied the effectiveness of cisternostomy in decreasing cerebral edema. All enrolled patients were randomly assigned to 2 groups and assessed clinically and radiologically. TBIs were categorized as mild, moderate, and severe injuries, and Marshall computed tomography–based score was assessed. Intraoperative ICP was measured in both groups. Outcomes were assessed based on postoperative intensive care unit stay, days on ventilator support, and Glasgow Outcome Scale score. There were 50 patients randomly assigned to 2 groups (25 patients in each group). Mortality rate was 32% (8 deaths) in the cisternostomy group and 44% (11 deaths) in the decompressive craniectomy group. Patients in the cisternostomy group had decreased mean days of ventilator support and intensive care unit stay. Cisternostomy resulted in significant decreases in ICP after craniotomy. Age, time from trauma to surgery, and Marshall score showed prognostic importance on outcomes. Cisternostomy was effective in reducing ICP in patients with TBI. Good Glasgow Outcome Scale scores and low rates of complications were found in the postoperative period after cisternostomy. Age, presenting Glasgow Coma Scale score, Marshall score, other major injuries, and time from trauma to surgery had a significant prognostic impact on outcome in management of TBI. [ABSTRACT FROM AUTHOR]

Decompressive craniectomy (DC) is an established optional treatment for malignant hemispheric infarction (MHI). We analyzed relevant clinical factors and computed tomography (CT) measurements in patients with DC for MHI to identify predictors of functional outcome 3–6 months after stroke. This study was performed at 2 comprehensive stroke centers. The inclusion criteria required DC for MHI, no additional intraoperative procedures (strokectomy or cerebral ventricular drain placement), and documented functional status 3–6 months after the stroke. We classified functional outcome as acceptable if the modified Rankin Scale score was <5, or as unacceptable if it was 5 or 6 (bedbound and totally dependent on others or death). Multiple logistic regression analyzed relevant clinical factors and multiple perioperative CT measurements to identify predictors of acceptable functional outcome. Of 87 identified consecutive patients, 66 met the inclusion criteria. Acceptable functional outcome occurred in 35 of 66 (53%) patients. Likelihood of acceptable functional outcome decreased significantly with increasing age (OR 0.92, 95% CI 0.82–0.97, P = 0.004) and with increasing post-DC midline brain shift (OR 0.78, 95% CI 0.64–0.96, P = 0.016), and decreased non-significantly with left-sided stroke (OR 0.30, 95% CI 0.08–1.10, P = 0.069) and with increasing craniectomy barrier thickness (OR 0.92, 95% CI 0.85–1.01, P = 0.076). Patient age and the post-DC midline shift may be useful in prognosticating functional outcome after DC for MHI. Stroke side and craniectomy barrier thickness merit further ideally prospective outcome prediction testing. [ABSTRACT FROM AUTHOR]

The role of cerebral pressure autoregulation (CPA) in brain injury and disorders has gained increased interest. The CPA is often disturbed as a consequence of acute brain injury, which contributes to further brain damage and worse outcome. Specifically, in severe traumatic brain injury, CPA disturbances predict worse clinical outcome and targeting an autoregulatory-oriented optimal cerebral perfusion pressure threshold may improve brain energy metabolism and clinical outcome. In aneurysmal subarachnoid hemorrhage, cerebral vasospasm in combination with distal autoregulatory disturbances precipitate delayed cerebral ischemia. The role of optimal cerebral perfusion pressure targets is less clear in aneurysmal subarachnoid hemorrhage, but high cerebral perfusion pressure targets are generally favorable in the vasospasm phase. In acute ischemia, autoregulatory disturbances may occur and autoregulatory-oriented blood pressure (optimal mean arterial pressure) management reduces the risk of hemorrhagic transformation, brain edema, and unfavorable outcome. In chronic occlusive disease such as moyamoya, the gradual reduction of the cerebral circulation leads to compensatory distal vasodilation and the residual CPA capacity predicts the risk for cerebral ischemia. In spontaneous intracerebral hemorrhage, the role of autoregulatory disturbances is less clear, but CPA disturbances correlate with worse clinical outcome. Also, in community-acquired bacterial meningitis, CPA dysfunction is frequent and correlates with worse clinical outcome, but autoregulatory management is yet to be evaluated. In this review, we discuss the role of CPA in different types of brain injury and disease, the strengths and limitations of the monitoring methods, the potentials of autoregulatory management, and future directions in the field. [ABSTRACT FROM AUTHOR]

The role of continuous hypertonic saline (HS) infusion in the management of malignant cerebral edema is controversial. We evaluated patients presenting with large anterior circulation territory infarcts and compared radiographic and clinical outcomes to evaluate the effects of continuous HS. This was a retrospective review of patients with malignant ischemic strokes who were initially managed with continuous HS versus routine medical management. Radiographic parameters of cerebral edema and clinical parameters were collected at different time intervals after admission. Rates and timing of surgery, mortality, and complications were also collected. The study included 43 patients: 26 in group 1 (HS) and 17 in group 2 (no HS). Both cohorts had comparable baseline clinical and radiographic parameters. There was no difference between rates and timing of surgery, complications, and mortality. Mean midline shift was significantly greater in the HS group at interval 1 (12–36 hours, P = 0.003) and interval 2 (36–60 hours, P = 0.030), and mean change in midline shift from initial interval to interval 1 was significantly greater in the HS group (P = 0.019). Despite the widespread use of continuous HS in acute ischemic infarcts, only a limited number of studies have evaluated its efficacy, and virtually no studies have studied its effect on radiographic progression and rates of decompressive surgery. Results of this study indicate that there is no benefit of continuous HS. In fact, there may be worsening of cerebral edema with administration of continuous HS. In addition, there are no differences in prevention or delay of decompressive surgery or in overall mortality. [ABSTRACT FROM AUTHOR]

Although previous studies have made significant contributions to establishing animal traumatic brain injury (TBI) models for simulation of human TBI, the accuracy, controllability, and modeling efficiency of animal TBI models need to be further improved. This study established a novel high-efficiency graded mouse TBI model induced by shock wave. A total of 125 mice were randomly divided into sham, 0.7 mm, 0.6 mm, and 0.5 mm groups according to the depth of the cross groove of the aluminum sheets. The stability and repeatability of apparatus were evaluated, and the integrity of the blood-brain barrier, cerebral edema, neuropathologic immunohistochemistry, apoptosis-related protein, and behavioral tests of neurologic function were used to validate this new model. The results showed that 4 mice were injured simultaneously in 1 experiment. They received the same intensity of shock waves. Moreover, the mortality rates caused by 3 different aluminum sheets were consistent with the mortality rates of mild TBI, moderate TBI, and severe TBI. Compared with the sham group, mice in different injured groups significantly increased brain water content, blood-brain barrier permeability, and neuronal apoptosis. And the mice in all injured groups showed poor motor ability, balancing, spatial learning, and memory abilities. The novel TBI apparatus has advantages in its small size, simple operation, high repeatability, high efficiency, and graded severity. Our TBI apparatus provides a novel tool to investigate the neuropathologic changes and underlying mechanisms of TBI with various levels of severities. [ABSTRACT FROM AUTHOR]

Focal brain edema in unruptured brain arteriovenous malformations (AVMs) is rare and associated with venous outflow abnormalities and aneurysm growth. These patients have an increased rate of progressive neurologic symptoms, as well as a potentially increased risk of hemorrhage. In this study, we aim to assess in further detail the relationship between perifocal edema and enhancement of the vessel wall in symptomatic patients with an unruptured brain AVM. A single-center retrospective cohort study of all patients presenting with an unruptured AVM at Toronto Western Hospital from 2009 to 2019 was performed. Patients were included for review if they had focal edema surrounding an AVM on magnetic resonance imaging (MRI) and a contrast-enhanced MRI scan. Associated digital subtraction angiography studies were reviewed. A total of 122 patients presented with an unruptured AVM. Twelve symptomatic patients presented with focal edema surrounding the AVM. Six patients had focal edema and contrast-enhanced MRI performed. All 6 demonstrated luminal thrombosis at the level of the brain edema on MRI. Moreover, the vessel wall demonstrated enhancement at the level of the luminal thrombus in all. Vessel wall enhancement, perifocal edema, and luminal thrombosis demonstrated in all patients with unruptured AVM points towards a common mechanism. We suspect an interplay between vascular hypoxia, the innate immune system, and thrombosis formation. Current research in the field of immunothrombosis supports this theory. Unravelling the mechanisms involved is important because it might guide therapy for patients with an unruptured AVM towards noninvasive options. [ABSTRACT FROM AUTHOR]

Variability, with no general consensus, exists in how patients' blood pressure should be managed after successful mechanical thrombectomy (MT) for large vessel ischemic stroke. We examined whether exceeding the systolic blood pressure (SBP) targets in patients during the first 24 hours after successful MT led to worse outcomes. We retrospectively studied a consecutive sample of adult patients who had undergone MT. We collected SBP data for the first 24 hours after MT and categorized the patients into 3 groups according to cases of the SBP exceeding 140, 160, or 180 mm Hg. The primary and secondary outcomes were the modified Rankin scale score at discharge and 90 days of follow-up, the incidence of symptomatic intracranial hemorrhage, malignant cerebral edema, and hemicraniectomy, mortality within 90 days, and discharge disposition. A total of 117 patients were included (mean age, 65 ± 13.12 years; 53% female). The occurrence of ≥1 instance of SBP ≥180 mm Hg was significantly associated with poor functional outcomes at discharge (adjusted odds ratio [OR], 5.83; 95% confidence interval [CI], 1.41–32.9; P = 0.025) but not at 90 days of follow-up. The occurrence of SBP ≥160 mm Hg resulted in an independently increased odds of malignant cerebral edema (adjusted OR, 17.07; 95% CI, 2.56–174.4; P = 0.01), with a trend toward increased odds of symptomatic intracranial hemorrhage (adjusted OR, 4.42; 95% CI, 1.03–21.2; P = 0.0503). These results suggest that individual instances of SBP elevation alone after successful MT, rather than a necessarily prolonged increased blood pressure as reflected by the mean or median SBP values, can significantly affect the clinical outcomes after successful MT. [ABSTRACT FROM AUTHOR]

Increased brain edema in head injury is due to shift of cerebrospinal fluid (CSF) from cisterns at high pressure to brain parenchyma at low pressure. By opening basal cisterns and decreasing the increased cisternal pressure, basal cisternostomy (BC) results in reversal of CSF shift from parenchyma to cisterns, leading to decreased brain edema. Though the CSF-shift edema hypothesis is based on pressure difference between cisterns and brain parenchyma, the relationship of these pressures has not been studied. A prospective clinical study was conducted from November 2018 to March 2020 including adult patients with head injury who were candidates for standard decompressive hemicraniectomy (DHC). All patients had neurological assessment and head computed tomography preoperatively and postoperatively. All patients underwent BC with DHC. Postoperatively, parenchymal and cisternal pressures and neurological condition were monitored hourly for 72 hours. Nine (5 men, 4 women) patients with head injury (mean age, 45.7 years; range, 25–72 years) underwent DHC-BC. Median Glasgow Coma Scale score of patients at admission was 8 (range, 4–14), and median midline shift on computed tomography was 8 mm (range, 7–12 mm). There was a significant difference between opening (25.70 ± 10.48 mm Hg) and closing (11.30 ± 5.95 mm Hg) parenchymal pressures (t 9 = 3.963, P = 0.003). Immediate postoperative cisternal pressure was 1–11 mm Hg and was lower than immediate postoperative parenchymal pressure in all except 1 patient. Postoperatively, if cisternal pressure remained low, parenchymal pressure also decreased, and patients showed clinical improvement. Patients showing increased cisternal pressure showed increased parenchymal pressure and clinical worsening. Our study supports the CSF-shift edema hypothesis. Following DHC-BC, cisternal pressure is lowered to near-atmospheric pressure, and its relationship to parenchymal pressure predicts the future course of patients by reversal or re-reversal of CSF shift. [ABSTRACT FROM AUTHOR]

Intravenous glyburide has demonstrated safety when used for attenuation of cerebral edema, although safety data are lacking for enteral glyburide when used for this indication. We aimed to determine the prevalence of and risk factors for hypoglycemia in neurocritical care patients receiving enteral glyburide. We performed a retrospective case-control chart review (hypoglycemia vs. no hypoglycemia) of adult patients who received enteral glyburide for prevention or treatment of cerebral or spinal cord edema. Hypoglycemia was defined as a blood glucose <55.8 mg/dL. Descriptive statistics were used, with multivariate analysis to measure the association of risk factors and outcomes. Logistic regression was applied to outcomes with an exposure. Potential confounders were evaluated using the t -test or the Wilcoxon rank-sum test for continuous variables, and the χ2 test or the Fisher exact test for categorical variables. Seventy-one patients (60.6% men, median age 60 years) were included. The majority received 2.5 mg of enteral glyburide twice daily. Diagnoses included tumors (35.2%), intracerebral hemorrhage (28.2%), postspinal surgery (12.7%), and ischemic stroke (12.7%). Hypoglycemia occurred in 17 (23.9%) patients. Multivariate analysis identified admission serum creatinine (odds ratio, 27.2; [1.661, 445.3]; P < 0.05) as a risk factor for hypoglycemia, whereas body mass index >30 (odds ratio, 0.085; [0.008, 0.921]; P < 0.05) was protective. Hypoglycemic episodes are common following enteral glyburide in neurocritical care patients. Both patients with and without diabetes mellitus are at risk of hypoglycemia. Elevated admission serum creatinine may increase the risk of hypoglycemia when utilizing glyburide for prevention or treatment of cerebral or spinal cord edema. [ABSTRACT FROM AUTHOR]

Secretory meningioma (SM) is a rare subtype of benign meningioma reported to cause significant peritumoral brain edema (PTBE). Therefore, patients with SM may have more severe presenting symptoms and possibly increased postoperative complications. Our aim was to perform a statistically rigorous comparison of patients with SM with other nonsecretory World Health Organization grade I meningiomas and examine PTBE, postsurgical outcomes, and recurrence in a large series of cases. A retrospective review of all patients at our institution with pathologically confirmed SM between 2000 and 2017 was performed. A control group of nonsecretory grade I meningiomas was matched 1:1 according to tumor location and size. Study groups were compared on clinical characteristics and outcomes using logistic, cumulative logit, and normal linear generalized estimating equations regression models. Fifty-five patients with SM met inclusion criteria and were matched with 55 control patients. After adjusting for size and location, the odds of a patient with SM having a more severe T2 edema grade were 8.9 (95% confidence interval, 3.8–21.1; P < 0.001) times higher, and the odds of any T2 edema were 6.2 (95% confidence interval, 2.2–17.6; P < 0.001) times higher. Significance remained even when adjusting for age. Postoperative complications, Simpson grade resection, neurologic outcome, and recurrence were not significantly different. Patients with SM have significantly greater odds of having PTBE compared with patients with nonsecretory World Health Organization grade I meningiomas of a similar size and location. Despite this situation, surgical outcome and recurrence rates are similar. [ABSTRACT FROM AUTHOR]

Achieving optimal brain relaxation is paramount in aneurysm surgery. Despite proper positioning and the use of newer anesthetic drugs and the administration of decongestants, it is often not possible to achieve satisfactory relaxation, which can lead to neurological deficits owing to excessive brain retraction. The present study aimed to provide detailed surgical notes regarding the novel technique of temporal horn tapping for intraoperative ventriculostomy. The hospital records of anterior circulation aneurysm surgery performed during the previous 5 years were retrieved. Only those cases in which we had used temporal horn tapping were included. Ventriculostomy was performed only in those cases in which the brain was tense despite the administration of decongestants. A small corticectomy was performed over the middle temporal gyrus and deepened to access the temporal horn. This technique was used in 84 surgical cases. The mean patient age was 52.8 years. The male/female ratio was 1:1.4. Anterior communicating artery aneurysms were the most common. Adequate brain relaxation was satisfactorily achieved in all cases. Two patients had developed a small temporal hematoma attributable to the temporal corticectomy, both managed conservatively. We believe that this new trajectory through the middle temporal gyrus to access the temporal horn is very safe because of the lack of proximity to any blood vessel or critical structures. We recommend the use of this technique during pterional approaches for acute aneurysmal surgery in the tight, bulging brain to achieve relaxation and avoid secondary complications such as retraction contusions and resultant cerebral edema. [ABSTRACT FROM AUTHOR]

Decompressive hemicraniectomy (DH) is widely recommended as a surgical treatment for intractable increased intracranial pressure after malignant cerebral infarction. Many patients given recombinant tissue plasminogen activator (rtPA) develop cerebral edema after reperfusion or failed recanalization. However, the safety and efficacy of DH after rtPA administration remain largely unknown. A systematic review was performed using PubMed, Embase, Scopus, Cochrane, and HERDIN. Studies were eligible if they included patients who underwent DH after intravenous thrombolysis for acute ischemic stroke. Unweighted odds ratio (OR) for mortality (primary outcome) and good functional outcome defined as modified Rankin Scale score 0–3 or Glasgow Outcome Scale score 4–5 at 3–6 months (secondary outcome) were compared between the DH + rtPA group and DH alone group. Four studies with a total of 98 patients undergoing DH + rtPA were compared with 110 patients undergoing DH alone without previous thrombolysis. Age, vascular risk factors, and cause of stroke were comparable between the 2 groups. Pooled analysis showed that mortality and functional outcomes were not statistically different between the DH + rtPA and DH alone groups (OR, 0.56, P = 0.07 and OR, 0.83, P = 0.30, respectively). Likewise, both minor and major hemorrhagic rates were similar between the 2 groups (37.76% vs. 27.27%; P = 0.053). DH for malignant cerebral infarction after intravenous rtPA administration is a viable treatment option, with a comparable mortality and functional outcome to those who had DH without previous thrombolysis. [ABSTRACT FROM AUTHOR]

Contrast-induced neurotoxicity (CIN) is an infrequent complication of endovascular procedures, and its understanding remains poor. We aimed to study and characterize the clinical and imaging features of a case series of CIN after neurointerventional surgery. We reviewed all neuroendovascular consecutive procedures from September 2014 to November 2018. CIN was defined as new onset of neurologic deficits that occurred postoperatively after excluding other conditions. All demographic, clinical, procedural, and radiologic data were retrospectively analyzed and collected. Eleven cases of CIN in 1587 patients were identified out of 2510 procedures. The median age was 76 years (interquartile range [IQR], 65–81). The most common comorbidity was hypertension (82%). Median procedure time was 100 minutes (IQR, 80–130.5 minutes). All patients showed wide variability in intraprocedural blood pressure (BP) recordings with fluctuations from the baseline BP. Systolic BP ranged from 83 mm Hg below the patient baseline to 80 mm Hg above baseline. The median symptom onset was 4 hours (IQR, 0.8–9.5 hours). The CIN signs and symptoms presented gradually, initially with encephalopathy and later with focal signs. All patients had an initial computed tomography scan, which showed ipsilateral cerebral edema in 82% of patients. Two had contrast enhancement. Complete resolution of CIN symptoms was obtained in a median time of 3 days (IQR, 2.5–3 days). CIN should be considered in the context of the progressive onset of neurologic deficits after neuroendovascular procedures. A distinct imaging pattern of ipsilateral hemisphere edema in the absence of ischemia is usually identified. Variability in procedural BP might be a predisposing factor. [ABSTRACT FROM AUTHOR]

Pediatric cerebral malaria (CM) is a severe complication of Plasmodium falciparum that often leaves survivors with severe neurologic impairment. Increased intracranial pressure (ICP) as a result of cerebral edema has been identified as a major predictor of morbidity and mortality in CM. Past studies have demonstrated that survivors are more likely to have resolution of elevated ICP and that efficient management of ICP crises may lead to better outcomes. However, data on invasive brain tissue oxygen monitoring are unknown. We report a case of a pediatric patient with cerebral malaria who developed encephalopathy and cerebral edema and describe the pathophysiology of this disease process with invasive ICP and brain tissue oxygen multimodality neuromonitoring. The utilization of both ICP and brain tissue oxygen monitoring allowed prompt diagnosis and successful treatment of severe intracranial hypertension and low brain tissue oxygenation crisis. The patient was discharged to home in good neurologic condition. Multimodality neuromonitoring may be considered in pediatric patients who have cerebral edema and encephalopathy from CM. [ABSTRACT FROM AUTHOR]

The operative microscope, a commonly used tool in neurosurgery, is critical in many supratentorial tumor cases. However, use of operating microscope for supratentorial tumor varies by surgeon. To assess complication rates, readmissions, and costs associated with operative microscope use in supratentorial resections. A retrospective analysis was conducted using a national administrative database to identify patients with glioma or brain metastases who underwent supratentorial resection between 2007 and 2016. Univariate and multivariate analyses were used to assess 30-day complications, readmissions, and costs between patients who underwent resection with and without use of microscope. The cohort included 12,058 glioma patients and 5433 metastasis patients. Rates of microscope use varied by state from 19.0% to 68.6%. Microscope use was associated with $5228.90 in additional costs of index hospitalization among glioma patients (P <0.001), and $2824.00 among metastasis patients (P <0.001). Rates of intraoperative cerebral edema were lower among the microscope cohort than among the nonmicroscope cohort (P <0.027). Microscope use was associated with a slight reduction in 30-day rates of neurological complications (14.7% vs. 16.7%, P = 0.048), specifically in nonspecific cerebrovascular complications. There were no differences in rates of other complications, readmissions, or 30-day postoperative costs. Use of operative microscope for supratentorial resections varies by state and is associated with higher cost of surgery. Microscope use may be associated with lower rates of intraoperative cerebral edema and some cerebrovascular complications, but is not associated with significant differences in other complications, readmissions, or 30-day costs. [ABSTRACT FROM AUTHOR]

Mitochondrial dysfunction plays an essential role in secondary brain injury following traumatic brain injury (TBI). Interestingly, accumulating evidence has shown that therapeutic benefits of mitochondrial transplantation exist. Therefore, we hypothesized that the injection of exogenous mitochondria would contribute to the mitigation of cellular energy metabolism disorders and neurologic functions after TBI. We first extracted isolated mitochondria from fresh brain tissue using a kit and then identified their activity and purity. The role of exogenous mitochondria was assessed using the glucose oxygen deprivation–induced cellular damage model and controlled cortical impact–induced mice with TBI. The results showed that treatment with exogenous mitochondria improved the cellular respiratory control rate, the expression of tight junction-associated proteins, and synaptic plasticity-related proteins in vitro. Moreover, the application of exogenous mitochondria significantly reduced cellular apoptosis, promoted angiogenesis and alleviated brain edema and blood–brain barrier leakage in mice subjected to TBI. Additionally, exogenous mitochondria significantly reduced excessive inhibition of long-term depression in the hippocampus 7 days after TBI. Taken together, the data suggested that exogenous mitochondrial intervention ameliorated glucose oxygen deprivation–induced cell damage and controlled cortical impact–induced TBI in a mouse model. The new discovery in the current study inspires us to suggest that mitochondrial transplantation might serve as a new therapeutic strategy for TBI. [ABSTRACT FROM AUTHOR]

Decompressive craniectomy (DC) is a widely used treatment for refractory high intracranial pressure (ICP). While the Brain Trauma Foundation guidelines favor large DC, there remains a lack of consensus regarding the optimal size of DC in relationship to the patient's head size. The aim of this study is to determine the optimal size of DC to effectively control refractory ICP in traumatic brain injury and to measure that size with a method that takes into consideration the patient's head size. All cases of unilateral DC performed to control refractory increased ICP due to cerebral edema during a 7½-year period were included. Demographic and injury-related data were collected by retrospective chart review. The patients were categorized in 2 groups: 21 patients with a "small flaps" and 9 patients with a "large flap." Two groups had similar preoperative characteristics. The amount of cerebrospinal fluid drained and the doses of hyperosmolar therapy given were not different between the 2 groups. The postoperative ICP was significantly lower for the large craniectomy flap group: 13.3 mm Hg confidence interval 99% [12.7, 13.8] versus 16.9 mm Hg confidence interval 99% [16.5, 17.2] (P = 0.01), and this difference was maintained for 96 hours postoperatively. Better ICP control was achieved in patients who underwent a large decompressive craniectomy (ratio >65%) when compared with smaller craniectomy sizes. The proposed method of measuring the craniectomy size, to our knowledge, is the first to take into account the patient's head size and can be easily measured intraoperatively. [ABSTRACT FROM AUTHOR]

To compare clinical outcomes and payments between glioma resections with and without functional mapping. The Thomas Reuters MarketScan national longitudinal database was used to identify patients undergoing resection of supratentorial primary malignant glioma with or without functional mapping between 2007 and 2016. Patients were stratified into mapped and unmapped (conventional) groups and subsequently propensity-matched based on demographics, clinical comorbidities, and surgical characteristics (i.e., use of stereotactic navigation, microscope, and intratumoral chemotherapy). Outcomes and charges were compared between matched groups using bivariate analyses. A total of 14,037 patients were identified, of whom 796 (6.0%) received functional mapping. Propensity matching (1:1) resulted in 796 mapped patients and 796 propensity-matched controls. Thirty-day postoperative rates of new-onset seizures, cerebral edema, hemorrhage, and neurologic deficits were significantly lower for the functional mapping group (all P < 0.05). Functional mapping was also associated with shorter hospital length of stay (P = 0.0144), lower 30-day rates of emergency department visits (P = 0.0001), and fewer reoperations (P = 0.0068). Total costs of initial admission were not significantly different between groups. Intraoperative functional mapping during glioma resection was associated with decreased complications, reoperations, emergency department visits, and shorter lengths of stay. Furthermore, total charges of mapped resections were not significantly different from those of conventional resections. These findings support the usefulness of functional mapping for resection of supratentorial primary malignant gliomas. [ABSTRACT FROM AUTHOR]

Cerebral edema is a major cause of morbidity in patients with severe traumatic brain injury (TBI). Intraparenchymal thermal conductivity-based probes that measure local cerebral blood flow can measure percent brain tissue water (%BTW) content, but such measures have been insufficiently characterized in patients with TBI. We retrospectively reviewed physiologic data from patients with severe TBI treated at our institution (2014–2016) who underwent cerebral blood flow monitoring. Sixteen patients underwent focal %BTW measurements at a 15-minute sampling rate. %BTW measurements showed characteristic temporal profiles, with a mean time to peak of 3.7 ± 1.7 days. The mean minimum and maximum %BTWs were 71.0 ± 3.9% and 82.7 ± 7.4%, respectively (overall mean %BTW, 77.0 ± 2.9%). Intracranial pressure (ICP) values of 22 mm Hg (the current treatment threshold for patients with trauma) corresponded to 75.8 ± 5.4 %BTW. Repeated measures correlation showed that %BTW is negatively correlated with serum sodium concentration (r = –0.3; P < 0.001) and weakly positively correlated with ICP (r = 0.08; P = 0.01) and regional cerebral blood flow (r = 0.06; P < 0.001). These effects were consistent in a multivariable model including time from injury. In the best model, time was modeled as a quadratic term because the %BTW followed a parabolic trajectory. %BTW may be a clinically useful, real-time measurement of cerebral edema in patients with TBI. It is closely associated with the serum sodium concentration and follows a characteristic temporal course with characteristic trajectory and stability over time. [ABSTRACT FROM AUTHOR]

A rare but important complication related to otherwise uneventful brain and spine surgery is becoming more recognized and more frequently reported in the medical literature. This has been variably labeled as pseudohypoxic brain swelling or postoperative hypotension-associated venous congestion. This poorly understood condition occurs in the setting of surgical intervention and is thought to be related to cerebrospinal fluid leak or evacuation, decreased intracranial pressure, and subsequent development of deep venous congestion affecting the basal ganglia, thalami, and cerebellum. Clinically, patients may have global neurologic deficit and outcomes range from full recovery to vegetative state or death. The imaging correlate includes atypical edema, infarction, or hemorrhage and can overlap the appearance of diffuse hypoxic injury, for which this condition can be mistaken both clinically and radiologically. Although this deep brain tissue edema can be associated with other signs of cerebrospinal fluid hypotension such as dural thickening, brain sagging, and cerebellar herniation, it can be isolated, making the diagnosis challenging. We present 2 cases of unexpected clinical deterioration occurring in patients with otherwise uncomplicated neurosurgery, 1 with craniotomy and the other with lumbar spine intervention. Both patients exhibit similar appearing edema in the deep gray structures on postoperative magnetic resonance imaging scans. In addition to reviewing the prior literature and imaging findings, we evaluate the imaging findings to determine if there are unique features or signatures that might allow differentiation of PHBS from hypoxic-ischemic encephalopathy. The lentiform rim sign can be helpful for differentiation of pseudohypoxic brain swelling versus hypoxic-ischemic encephalopathy. [ABSTRACT FROM AUTHOR]

Intrameningioma metastasis is a rare differential diagnosis. The clinical implications of these lesions are poorly understood. We screened our database to identify all patients who had been undergone surgery between January 2000 and December 2018 and had been diagnosed with intrameningioma metastasis. Medical charts and radiographic images were reviewed. Brain edema was related to tumor size on preoperative T2-weighted magnetic resonance imaging and classified as little (i.e., less than the tumor size), moderate (i.e., less than triple the size of the tumor), and extensive (i.e., more than triple the size of the tumor). We identified 7 patients (3 men and 4 women) with a median age of 61 years (range, 33–63 years). A systemic cancer had been diagnosed preoperatively in all patients (lung adenocarcinoma, n = 5; breast adenocarcinoma, n = 1; pancreas adenocarcinoma, n = 1). Mean time interval between diagnosis of the systemic cancer and the intracranial dural mass was 32 months (SD 23.05). The preoperative working diagnosis was meningioma in 5 patients, and metastasis in 2 patients. All patients were symptomatic at the time of diagnosis with a short history of headache (n = 2), nausea (n = 1), and dizziness (n = 1), and 5 patients harbored neurologic deficits, including hemiparesis (n = 2), hemihypesthesia (n = 2), and paresthesia (n = 1). Preoperative images showed brain edema in all patients (extensive, n = 4; moderate, n = 3). Intrameningioma metastases show an aggressive clinical behavior prompting early surgical intervention. Clinicians should be aware of this rare entity when counseling patients. [ABSTRACT FROM AUTHOR]

Before the advent of radiosurgery, neurosurgical treatment of meningiomas typically involved gross total resection of the mass whenever surgery was deemed possible. Over the past 4 decades, though, Gamma Knife radiosurgery (GKRS) has proved to be an effective, minimally invasive means to control the growth of these tumors. However, the variables associated with treatment failure (regrowth or clinical progression) after GKRS and GKRS-related complications, such as cerebral edema, are less well understood. We retrospectively collected data between 2009 and 2018 for patients who underwent GKRS for meningiomas. After data collection, we performed univariate and multivariable modeling of the factors that predict treatment failure and cerebral edema after GKRS. Hazard ratios (HR) and P values were determined for these variables. Fifty-two patients were included our analysis. The majority of patients were female (38/52,73%), and nearly all patients presented with a suspected or confirmed World Health Organization grade 1 meningioma (48/52, 92%). The median tumor volume was 3.49 cc (range, 0.22–20.11 cc). Evidence of meningioma progression after treatment developed in 5 patients (10%), with a median time to continued tumor growth of 5.9 months (range, 2.7–18.3 months). In multivariable analysis, patients in whom treatment failed were more likely to be male (HR = 8.42, P = 0.045) and to present with larger tumor volumes (HR = 1.27, P = 0.011). In addition, 5 patients (10%) experienced treatment-related cerebral edema. On univariate analysis, patients who experienced cerebral edema were more likely present with larger tumors (HR = 1.16, P = 0.028). Increasing meningioma size and male gender predispose to meningioma progression after treatment with GKRS. Increasing tumor size also predicts the development of postradiosurgery cerebral edema. [ABSTRACT FROM AUTHOR]

Extradural subtemporal keyhole approach could provide adequate removal for some specific middle skull base tumors. The combination of endoscopy and keyhole technique might further help to minimize the complications and provide optimal surgical visualization. Here, a series of attempts with endoscopy by mini-invasive subtemporal extradural approach for 5 middle skull base tumors were successfully achieved. From November 2015 to November 2018, resections of 5 cases of middle cranial fossa tumors were performed with pure endoscopy via subtemporal extradural keyhole approach. Patient medical records, imaging data, surgical procedures, pathology results, and follow-up outcomes were collected and analyzed. Adequate extradural subtemporal space was successfully established for endoscopy, and tumor resection was performed. Postoperative pathology confirmed cholesteatoma, cholesterol granuloma, schwannoma, granuloma, and osteoblastoma, respectively. Two patients with osteoblastoma and granuloma received subtotal resection, and the other 3 achieved total resection. One patient suffered from brain edema and was relieved after systematic mannitol treatment. No other complications were observed, and no progression was found during follow-up. This exploratory series demonstrated the safety and effectiveness of pure endoscopic surgery via subtemporal extradural route for satisfactory middle cranial base tumor resection. [ABSTRACT FROM AUTHOR]

Increased intracranial pressure (ICP) is frequently encountered in the neurosurgical setting. A multitude of tactics exists to reduce ICP, ranging from patient position and medications to cerebrospinal fluid diversion and surgical decompression. A vast amount of literature has been published regarding ICP management in the critical care setting, but studies specifically tailored toward the management of intraoperative acute increases in ICP or brain bulk are lacking. Compartmentalizing the intracranial space into blood, brain tissue, and cerebrospinal fluid and understanding the numerous techniques available to affect these individual compartments can guide the surgical team to quickly identify increased brain bulk and respond appropriately. Rapidly instituting measures for brain relaxation in the operating room is essential in optimizing patient outcomes. Knowledge of the efficacy, rapidity, feasibility, and risks of the various available interventions can aid the team to properly tailor their approach to each individual patient. In this article, we present the first evidence-based review of intraoperative management of ICP and brain bulk. [ABSTRACT FROM AUTHOR]

Early brain injury after subarachnoid hemorrhage (SAH), which is considered a main factor leading to poor outcome, is believed to be caused by the increase of intracranial pressure (ICP) and/or the presence of subarachnoid blood clots (SBC) itself. The purpose of this study was to examine whether ICP or SBC is more important to neurologic deficit in the presence of apoptosis or edema. A total of 50 rats were allocated to 3 groups: an endovascular perforation SAH model (the SAH group), a cisterna magna saline injection model (the saline injection group), and a cisterna magna sham injection model (the sham injection group). Statistical analysis of correlations among the ICP, the grade of clot volume, neuronal apoptosis, brain water content (brain edema), and neurologic deficit was performed. In the SAH group, each of increased ICP and clot volume was correlated with neuronal apoptosis and brain edema. In the saline injection group, increased ICP was associated with apoptosis, but it did not correlate with brain edema. Neuronal apoptosis (r = 0.75; P < 0.01) and brain edema (r = 0.89; P < 0.01) correlated independently with neurologic deficit in the SAH group. The present study suggests that neuronal apoptosis is caused mainly by increased ICP, whereas brain edema is induced by SBC, and increased ICP could aggravate it in the presence of SBC. Brain edema could affect neurologic deficit, but apoptosis alone may be less influential. Not only ICP but also SBC seem important for brain damage in the acute stage of SAH. [ABSTRACT FROM AUTHOR]

Spontaneous reossification is a very rare phenomenon following a large calvarial defect, particularly in adults. A 29-year-old woman with acute subdural hematoma and brain edema underwent emergent decompressive craniectomy and evacuation of hematoma. Follow-up examination 2 years later showed a well-formed bone along the craniectomy site. To our knowledge, this is the first case report with total spontaneous reossification in adults. A literature review is provided, and the physiology of the process is suggested. Pericranium, diploë, and, above all, dura mater collaborate in spontaneous bone formation. All these layers are very important, and they must be respected during dissection. [ABSTRACT FROM AUTHOR]

Gamma-Knife radiosurgery can be the treatment of choice for small cerebral arteriovenous malformations (AVMs) in eloquent brain areas or, in association with endovascular treatment, for large and complex AVMs. Among the possible delayed complications occurring after radiosurgery of AVMs, de novo formation of a cavernoma has only recently been described. The authors report a unique case of communicating hydrocephalus with highly proteinaceous cerebrospinal fluid due to a cavernoma-like lesion of an obliterated cerebral AVM treated by embolization and radiosurgery. A 43-year-old female patient with a left parieto-occipital AVM (Spetzler-Martin grade III) underwent a multimodality treatment comprising several endovascular procedures and Gamma-Knife radiosurgery. At the follow-up angiograms, the AVM was completely obliterated. Twelve years later, she came back to our attention for headache and vomit with the radiological evidence of brain edema, severe hydrocephalus, and a chronic encapsulated intracerebral hematoma. At the beginning, the drainage of hydrocephalus proved ineffective to improve symptoms and edema. Therefore, the surgical resection of both the obliterated AVM and the cavernoma-like lesion—histologically confirmed—was necessary. The hydrocephalus resolved as well as the cerebral edema after 3 weeks, without necessity of a ventriculoperitoneal shunt. In previous neurosurgical literature, the association of a caveroma-like lesion in an obliterated AVM and communicating hydrocephalus with highly proteinaceous cerebrospinal fluid has not yet been discussed. We believe that only the surgical resection of both the obliterated AVM and the cavernoma-like lesion can lead to complete clinical recovery of the hydrocephalus. [ABSTRACT FROM AUTHOR]