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Fibrinolytic therapy with tissue plasminogen activator (rtPA) is considered a promising treatment option for intracerebral hemorrhage (ICH), but a large randomized controlled study (i.e., MISTIE III) failed to show a benefit for the long-term outcome. This study investigated whether the rapidity of hematoma volume reduction influences outcome of ICH-patients undergoing fibrinolytic therapy. Patients with supratentorial ICH with or without a secondary extension to the ventricular system receiving fibrinolytic therapy from 2010 to 2020 were retrospectively analyzed. Patients with primarily intraventricular hemorrhage were excluded. A catheter was placed into the hematoma via burr hole and by means of neuronavigation. After confirming a correct catheter position rtPA was injected through the catheter with subsequent passive drainage of the hematoma. Hematoma volume was measured initially and 24/48/72 hours after treatment and the relative volume reduction was calculated. The functional outcome at discharge was assessed using the modified Rankin scale (mRS) regarding a mRS of 4 or lower as favorable outcome. A total of 280 patients with mean age of 69.6 years and mean hematoma volume of 55.6 ml were analyzed. The odds of reaching favorable outcome were four-fold higher in patients with a volume reduction of more than 50% after 24 h (OR 4.23, 95%CI 3.05 to 5.66, p  = 0.007). Patients with a residual volume of less than 30 ml after 24 h had a two-fold higher chance of having favorable outcome (OR 2.9, 95%CI 1.78 to 4.63, p  < 0.0001). A fast volume reduction of at least 50% within 24 h resulted into a favorable outcome in ICH-patients undergoing fibrinolytic therapy. Not just the amount but also the rapidity of hematoma volume reduction seems to be an important factor for a good clinical result after fibrinolytic therapy.

Aneurysmal subarachnoid hemorrhage (aSAH) not only causes neurological deficits but also influences extracerebral organ functions. The Logistic Organ Dysfunction System (LODS) reliably captures organ dysfunctions and predicts mortality of critically ill patients. This study investigated LODS in the setting of aSAH as a surrogate marker for early brain injury (EBI). Patients with aSAH treated between 2012 and 2020 were retrospectively analyzed. LODS was calculated within 24 h upon admission applying functional parameters for each organ system. The EBI was evaluated based on 1-persistent loss of consciousness, 2-global cerebral edema, and 3-intracranial blood burden. The outcome was assessed with the modified Rankin scale (mRS) at 3-months after ictus (mRS > 2 = unfavorable outcome). A total of 324 patients with a mean age of 55.9 years were included. Severe EBI (EBI grade ≥ 3) was found in 38% (124/324) of patients. Higher LODS score correlated with severe EBI ( p  < 0.0001) and poor outcome ( p  < 0.0001). LODS with a cutoff of 7 allowed a reliable discrimination (AUC 78%, p  < 0.0001) of patients with severe from those with mild EBI. The LODS-calculation as an early risk stratification and prognostic tool reliably reflected the severity of EBI after aSAH and correlated with outcome.

Disturbed cerebral autoregulation (CA) increases the dependency of cerebral blood flow (CBF) on cerebral perfusion pressure (CPP). Thus, induced hypertension (IHT) is used to prevent secondary ischemic events. The pressure reactivity index (PRx) assesses CA and can determine the optimal CPP (CPPopt). This study investigates CPPopt in patients with subarachnoid hemorrhage (SAH) treated with IHT and its impact on delayed cerebral infarction and functional outcome. This is a retrospective observational study including SAH patients treated between 2012 and 2020. PRx defines the correlation coefficient of intracranial pressure (ICP) and the mean arterial pressure (MAP). The CPP corresponding to the lowest PRx-value describes CPPopt. Primary outcome parameters were deleayed cerebral infarction and functional outcome. In patients without IHT, higher deviations of measured CPP from CPPopt were associated with delayed cerebral infarction ( p  = 0.001). Longer time spent with a CPP below the calculated CPPopt during IHT led to an increased risk of developing delayed cerebral infarction ( r  = 0.39, p  = 0.002). A larger deviation of measured CPP from CPPopt correlated with an unfavorable outcome in patients treated with IHT ( p  = 0.04) and without IHT ( p  = 0.0007). Patients with severe aneurysmal SAH may benefit from an individualized CPP management and the calculation of CPPopt may help to guide IHT.

The amount of extravasated blood is an established surrogate marker for subarachnoid hemorrhage (SAH) severity, which varies in different experimental SAH (eSAH) models. A comprehensive eSAH grading system would allow a more reliable correlation of outcome parameters with SAH severity. The aim of this study was to define a severity score for eSAH related to the Fisher-Score in humans. SAH was induced in 135 male rats using the modified double hemorrhage model. A sham group included 8 rats, in which saline solution instead of blood was injected. Histological analysis with HE(hematoxylin-eosin)-staining for the visualization of blood was performed in all rats on day 5. The amount and distribution of blood within the subarachnoid space and ventricles (IVH) was analyzed. The mortality rate was 49.6% (71/143). In all except five SAH rats, blood was visible within the subarachnoid space. As expected, no blood was detected in the sham group. The following eSAH severity score was established (ESAS-score): grade I: no SAH visible; grade II: local or diffuse thin SAH, no IVH; grade III: diffuse / thick layers of blood, no IVH; grade IV: additional IVH. Grade I was seen in five rats (7.9%), grade II in 28.6% (18/63), grade III in 41.3% (26/63) and grade IV in 22.2% (14/63) of the rats with eSAH. The double hemorrhage model allows the induction of a high grade SAH in more than 60% of the rats, making it suitable for the evaluation of outcome parameters in severe SAH.

Approximately 25% of glioblastomas show at diagnosis a corpus callosum infiltration, which is associated with poor prognosis. The extent of corpus callosum involvement, however, ranges from partial unilateral to complete bilateral infiltration. The role of surgery in glioblastoma with corpus callosum involvement is controversial. In this study, we aimed to examine prognostic differences between glioblastoma with unilateral and glioblastoma with bilateral corpus callosum infiltration, and to evaluate possible treatment strategy implications. Patients with newly diagnosed glioblastoma from 2010 to 2019 were included. Corpus callosum infiltration was assessed in contrast-enhanced T1-weighted preoperative magnetic resonance imaging. Extent of resection, adjuvant treatments and overall survival were evaluated. Corpus callosum involvement was found in 96 (26.4%) out of 363 patients with newly diagnosed glioblastoma. Bilateral corpus callosum infiltration was found in 27 out of 96 patients (28%), and 69 patients had unilateral corpus callosum infiltration. Glioblastoma with corpus callosum affection had significantly lower median overall survival compared to glioblastoma without corpus callosum involvement (9 vs. 11 months, p  = 0.02). A subgroup analysis of glioblastoma with unilateral corpus callosum infiltration revealed a significant difference in median overall survival dependent on extent of resection (6.5 without gross total resection vs. 11 months with gross total resection, Log-rank test p  = 0.02). Our data confirms a shorter overall survival in glioblastoma subpopulation with corpus callosum involvement, especially for glioblastoma with bilateral corpus callosum infiltration. However, patients with partial corpus callosum infiltration undergoing gross total resection exhibited a significant survival benefit compared to their counterparts without gross total resection. Whenever reasonably achievable gross total resection should be considered as an integral part of the treatment strategy in glioblastoma with partial corpus callosum infiltration.

Decompressive craniectomy (DHC) can prevent mortality in patients with malignant ischemic stroke. However, no clear criteria have been established to early identify patients, who will develop malignant stroke requiring DHC. In this retrospective observational study, a large patient cohort with ischemic stroke treated between 2010 and 2021, was analyzed. Clinical and radiological parameters were analyzed. Univariate and multivariate regression analyses were performed to identify the parameters to be included in the score. A cohort of 534 patients was included. A malignant stroke indicator (MSI) score was created including age < 70 years with 7 points, midline shift with up to 6 points, unsuccessful recanalization (TICI < 2b) with 6 points, basal cistern effacement with 4 points, and CBV ASPECTS < 6 with 3 points assigned. A MSI score with a cutoff value of 9 showed a high discrimination power concerning the need for DHC (AUC 0.90, p  < 0.0001). Patients with MSI-score ≥ 9 had a 22-fold higher probability of needing DHC (odds ratio 22.90, p  < 0.0001). The MSI score is a promising tool to predict the need for DHC in patients at risk for developing a malignant stroke and needs to be validated in external cohorts.

BACKGROUND:Indocyanine green (ICG) angiography is used to detect vessel compromise by the clip, residual aneurysms after clipping, or persistent aneurysm filling due to incomplete clipping. For ICG angiography, the microscope must be in a direct line-of-sight with the region of interest, limiting the identification of hidden arteries and dog-ear remnants. OBJECTIVE:To use a prototype endoscope for visualization of ICG fluorescence in hidden regions of the microsurgical field and evaluate its potential usefulness compared with microscopic ICG angiography (m-ICG-A) in a consecutive series of 30 aneurysms in 26 patients. METHODS:In selected cases, before and routinely after microsurgical clip application, m-ICG-A and endoscopic ICG angiography (e-ICG-A) were performed. The information gained by m-ICG-A was compared with that gained by e-ICG-A. RESULTS:E-ICG-A was technically feasible in all operations. Intra-arterial fluorescence could be visualized up to 10 times longer with the endoscope than with the microscope. The endoscope allowed a closer view on the fluorescent artery-aneurysm-complex. e-ICG-A provided more information than m-ICG-A in 11 operations (confirmation of unhindered blood flow in microscopically hidden vessels [n = 6], neck remnant identification [n = 2], neck remnant exclusion [n = 2], blood flow control in 2 distant clipped aneurysms [n = 1]). In 14 operations, identical information was obtained, and in 1 operation e-ICG-A was inferior because of trapped intra-aneurysmal fluorescence. CONCLUSION:In selected cases, e-ICG-A provides the neurosurgeon with information that cannot be obtained by m-ICG-A. e-ICG-A is capable of emerging as a useful adjunct in aneurysm surgery and has the potential to further improve operative results. ABBREVIATIONS:e-ICG,A, endoscopic indocyanine green angiographyDSA, digital subtraction angiographyETV, endoscopic third ventriculostomyICG, indocyanine greenMCA, middle cerebral arteryMDU, micro-Doppler ultrasonographym-ICG,A, microscopic indocyanine green angiographySAH, subarachnoid hemorrhage

Objective Glioblastoma with multiple foci (mGBM) and multiple brain metastases share several common features on magnetic resonance imaging (MRI). A reliable preoperative diagnosis would be of clinical relevance. The aim of this study was to explore the differences and similarities between mGBM and multiple brain metastases on MRI. Methods We performed a retrospective analysis of 50 patients with mGBM and compared them with a cohort of 50 patients with multiple brain metastases (2–10 lesions) histologically confirmed and treated at our department between 2015 and 2020. The following imaging characteristics were analyzed: lesion location, distribution, morphology, (T2-/FLAIR-weighted) connections between the lesions, patterns of contrast agent uptake, apparent diffusion coefficient (ADC)-values within the lesion, the surrounding T2-hyperintensity, and edema distribution. Results A total of 210 brain metastases and 181 mGBM lesions were analyzed. An infratentorial localization was found significantly more often in patients with multiple brain metastases compared to mGBM patients (28 vs. 1.5%, p  < 0.001). A T2-connection between the lesions was detected in 63% of mGBM lesions compared to 1% of brain metastases. Cortical edema was only present in mGBM. Perifocal edema with larger areas of diffusion restriction was detected in 31% of mGBM patients, but not in patients with metastases. Conclusion We identified a set of imaging features which improve preoperative diagnosis. The presence of T2-weighted imaging hyperintensity connection between the lesions and cortical edema with varying ADC-values was typical for mGBM.

Background Deep brain stimulation (DBS) is an established treatment for patients with medical refractory movement disorders with continuously increasing use also in other neurological and psychiatric diseases. Early and late complications can lead to revision surgeries with partial or complete DBS-system removal. In this study, we aimed to report on our experience with a frameless x-ray-based lead re-implantation technique after partial hardware removal or dysfunction of DBS-system, allowing the preservation of intracerebral trajectories. Methods We describe a surgical procedure with complete implant removal due to infection except for the intracranial part of the electrode and with non-stereotactic electrode re-implantation. A retrospective analysis of a patient series treated using this technique was performed and the surgical outcome was evaluated including radiological and clinical parameters. Results A total of 8 DBS-patients with lead re-implantation using the frameless x-ray-based method were enrolled in the study. A revision of 14 leads was performed, whereof a successful lead re-implantation could be achieved without any problems in 10 leads (71%). In two patients (one patient with dystonia and one patient with tremor), the procedure was not successful, so we placed both leads frame-based stereotactically. Conclusions The described x-ray-based technique allows a reliable frameless electrode re-implantation after infection and electrode dysfunction and might represent an efficient alternative to frame-based procedures for lead revision making the preservation of intracerebral trajectories possible.

Intraoperative microelectrode recording (MER) and test-stimulation are regarded as the gold standard for proper placement of subthalamic (STN) deep brain stimulation (DBS) electrodes in Parkinson's disease (PD), requiring the patient to be awake during the procedure. In accordance with good clinical practice, most attending neurologists will request the clinically most efficacious trajectory for definite lead placement. However, the necessity of microelectrode-test-stimulation is disputed, as it may limit the access to DBS therapy, excluding those not willing or incapable of undergoing awake surgery. We retrospectively analyzed the MERs and microelectrode-test-stimulation results with regard to the decision on definite lead placement and clinical outcome in a cohort of 67 PD-patients with STN-DBS. All patients received bilateral quadripolar ring electrodes. To ascertain overall procedural efficacy, we calculated the surgical index (SI) by comparing preoperative motor improvement induced by levodopa to that induced by stimulation 7 to 18 months after surgery, measured as the relative difference between ON and OFF-states on the Unified Parkinson's Disease Rating Scale motor part (UPDRS-3). Additionally, a side-specific surgical index (SSSI) was calculated using the unilateral assessable items of the UPDRS-3. The SSSI where microelectrode-test-stimulation overruled MER were compared to those where the result of microelectrode-test-stimulation was congruent to MER results. A total of 134 electrodes were analyzed. For final lead placement, the central trajectory was chosen in 54% of patient hemispheres. The mean SI was 0.99 (± 0.24). SSSI averaged 1.04 (± 0.45). In 37 lead placements, microelectrode-test-stimulation overruled MER in the final trajectory selection, in 27 of these lead placements adverse effects during microelectrode-test-stimulation were decisive. Neither the number of test electrodes used nor the STN-signal length had an impact on the SSSI. The SSSI did not differ between lead placements with MER/microelectrode-test-stimulation congruency and those where the results of microelectrode-test-stimulation initiated lead placement in a trajectory with shorter STN signal. Intraoperative testing is mandatory to ensure an optimal motor outcome of STN DBS in PD-patients when using quadripolar ring electrodes. However, we also demonstrated that neither the length of the STN-signal on MER nor the number of test electrodes influenced the motor outcome.