[Effects of Susac syndrome on the central vascular structure of the retina-An optical coherence tomography angiography study]. / Auswirkungen des Susac-Syndroms auf die zentrale Gefäßstruktur der Netzhaut ­ eine optische Kohärenztomographie-Angiographie-Studie.

BACKGROUND: Susac syndrome (SS) describes an endotheliopathy of vessels in the central nervous system. Retinal involvement plays a central role in the manifestation of the disease. OBJECTIVE: This case-control study investigated the macular microvasculature in patients with chronic SS compared to controls using optical coherence tomography angiography (OCTA). MATERIAL AND METHODS: 12 eyes of 12 patients with SS were compared with age-matched healthy control subjects with regard to their OCT angiographic parameters. The flow density (FD) of different macular layers, foveal avascular zone (FAZ) parameters and central retinal thickness and volume values were compared between the two groups. RESULTS: The FD of the choriocapillaris was reduced in Susac patients compared to healthy controls. The FD values of the superficial and deep capillary plexus of the inner retina, parameters of the FAZ as well as central retinal thickness and volume showed no significant differences between the two groups. DISCUSSION: Treated chronic SS does not appear to significantly affect the vascular and structural composition of the central inner retina; however, differences in the choriocapillaris indicate changes in deeper, highly vascularized capillary layers.

[Frequency and distribution of the active agent of intravitreal injections in German centers 2015-2021-An oregis study]. / Häufigkeit und Wirkstoffverteilung intravitrealer Injektionen in deutschen Zentren 2015 bis 2021 ­ eine oregis-Studie.

INTRODUCTION: Digitalization in medicine, especially the electronic documentation of patient data, is revolutionizing healthcare systems worldwide. The evaluation of real-world data collected under everyday conditions presents opportunities but also challenges. Electronic medical registries provide a means to compile extensive patient data for scientific inquiries. Oregis is the first nationwide digital registry for health services research established by the German Ophthalmological Society (DOG). Intravitreal operative medicinal injections (IVOM) are among the most frequently performed procedures in ophthalmology. Data on injection numbers and injection frequencies with anti-vascular endothelial growth factor (VEGF) are already available from other countries, whereas data at a national level are not yet available in Germany due to the lack of a nationwide register. It is known that the treatment success of anti-VEGF IVOMs depends largely on the adherence to treatment and thus on the number of injections. There are also differences in cost. In the context of this study, real-world data on the frequency and distribution of intravitreal injections in German centers from 2015 to 2021 were compiled for the first time since the introduction of oregis. The aim of this study is to collect data on the use of anti-VEGF IVOMs in Germany from oregis for the first time and to show the development of injection numbers and anti-VEGF drugs used. At the same time, the possibilities of data retrieval from oregis are demonstrated using a concrete example from daily ophthalmological practice. MATERIAL AND METHODS: An automated query of records was performed for all patients who received IVOM at oregis-affiliated healthcare facilities between 2015 and 2021. The number of treated patients and the use of anti-VEGF medications, including aflibercept, bevacizumab, brolucizumab, and ranibizumab, were determined. The data were collected in a pseudonymized and anonymized manner. RESULTS: At the time of data collection, 9 German ophthalmological healthcare facilities were affiliated with oregis. In total, 309,152 patients were registered during the observation period, with 8474 receiving IVOMs. Over the observation period, the number of participating centers, patients, and intravitreal injections increased. The proportional share of anti-VEGF agents among the total number of injections varied during the observation period. DISCUSSION: Real-world data captured in oregis offer significant potential for enhancing healthcare provision. Oregis enables the depiction of ophthalmological care conditions in Germany and contributes to research and quality assurance. The ability to query the presented data exemplifies the multitude of inquiries through which oregis can contribute to the representation of ophthalmological care in Germany.

Endovascular treatment of cerebral sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia.

INTRODUCTION: There is little data on the role of endovascular treatment (EVT) of cerebral venous sinus thrombosis (CVST) due to vaccine-induced immune thrombotic thrombocytopenia (VITT). Here, we describe clinical characteristics and outcomes of CVST-VITT patients who were treated with EVT. PATIENTS AND METHODS: We report data from an international registry of patients who developed CVST within 28 days of SARS-CoV-2 vaccination, reported between 29 March 2021 and 6 March 2023. VITT was defined according to the Pavord criteria. RESULTS: EVT was performed in 18/136 (13%) patients with CVST-VITT (92% aspiration and/or stent retrieval, 8% local thrombolysis). Most common indications were extensive thrombosis and clinical or radiological deterioration. Compared to non-EVT patients, those receiving EVT had a higher median thrombus load (4.5 vs 3). Following EVT, local blood flow was improved in 83% (10/12, 95% confidence interval [CI] 54-96). One (6%) asymptomatic sinus perforation occurred. Eight (44%) patients treated with EVT also underwent decompressive surgery. Mortality was 50% (9/18, 95% CI 29-71) and 88% (8/9, 95% CI 25-66) of surviving EVT patients achieved functional independence with a modified Rankin Scale score of 0-2 at follow-up. In multivariable analysis, EVT was not associated with increased mortality (adjusted odds ratio, 0.66, 95% CI 0.16-2.58). DISCUSSION AND CONCLUSION: We describe the largest cohort of CVST-VITT patients receiving EVT. Half of the patients receiving EVT died during hospital admission, but most survivors achieved functional independence.

The Preserflo MicroShunt Affects Microvascular Flow Density in Optical Coherence Tomography Angiography.

Intraocular pressure (IOP) lowering surgery has been shown to alter microvascular density in glaucoma patients. The aim of this study is to report changes in retinal flow density (FD) over the course of treatment with the Preserflo MicroShunt, using optical coherence tomography angiography (OCTA). 34 eyes from 34 patients who underwent Preserflo MicroShunt implantation were prospectively enrolled in this study. OCTA imaging was conducted at the superficial (SCP), deep (DCP) and radial peripapillary plexus (RPC) levels. The progression of FD and IOP was assessed at different time points from baseline to six months postoperatively for the entire patient population, as well as disease severity subgroups. The Preserflo MicroShunt achieved a significant reduction in IOP over the course of six months (median: 8 mmHg; p < 0.01). FD values of the SCP and DCP did not show significant fluctuations, even after adjusting for disease severity. FD of the RPC decreased significantly over the course of six months postoperatively from 42.31 at baseline to 39.59 at six months postoperatively (p < 0.01). The decrease in peripapillary FD was strongest in patients with advanced glaucoma (median: -3.58). These observations hint towards dysfunctional autoregulatory mechanisms in capillaries surrounding the optic nerve head in advanced glaucoma. In comparison, the microvascular structure of the macula appeared more resilient to changes in IOP.

Acute Idiopathic Blind Spot Enlargement Syndrome (AIBSES) in the Era of OCT - a Review. / Acute Idiopathic Blind Spot Enlargement Syndrome (AIBSES) ­ Nutzen der OCT: Übersichtsarbeit.

There are only about 100 case reports on the Acute Idiopathic Blind Spot Enlargement Syndrome (AIBSES). This is characterised by the eponymous visual field loss in the blind spot area, acute onset photopsia, and funduscopically little or no change in the optic disc area, with conspicuous outer retinal bands on optical coherence tomography (OCT). Typical is the unilateral occurrence. Predominantly young women are affected. While previous reviews of AIBSES either predate the introduction of OCT or focus on differentiation from potentially related outer retinal conditions (e.g., multiple evanescent white dot syndrome and acute zonal occult outer retinopathy), the present review will concentrate on the current perspective and treatment strategies that have been developed and will aim to help increase awareness. Since the first description of AIBSES in the late 1980s, the introduction of OCT has simplified the diagnosis and characterisation of AIBSES as a disease of the outer retina. Nevertheless, misdiagnosis remains common in the spectrum of optic neuritis, as AIBSES may be ignored in differential diagnosis.

[Münster standard: modified Paul® implantation in a condition following Preserflo® MicroShunt implantation. Video article]. / Münsteraner Standard: modifizierte PAUL®-Implantation bei Zustand nach PreserFlo® MicroShunt-Implantation. Videobeitrag.

OBJECTIVE OF SURGERY: The aim of this surgical technique is the modified placement of a Paul® implant (Fa. Advanced Ophthalmic Innovations, Singapur) in eyes after failure of Preserflo® MicroShunt (Fa. Santen, Osaka, Japan) implantation for the best possible adjustment of the intraocular pressure. INDICATIONS: The technique presented here is intended for patients suffering from more complex glaucomas, which were unsuccessfully previously treated with a Preserflo® Microshunt (Santen Inc.). SURGICAL TECHNIQUE: The special feature of the Münster standard is the choice of the surgical field and the waiver of a further tunnel placement. The patients receive a Paul® implant in the same quadrant as the previously inserted Preserflo® MicroShunt implant (superior temporal). The latter is explanted after preparation of the conjunctiva and priming of the Paul® implant with a Prolene 6.0 suture and fixation of the plate. In order to carry out the implantation of the Paul® tube through the existing 25-gauge tunnel, the latter is dilated laterally with an iris spatula under positioning of the anterior chamber. A surgical video, which is available online, shows the surgical technique in detail. ADVANTAGES OF THE MüNSTER STANDARD: The superior temporal surgical access promises easier handling. The fact that there is no need for a new tunnel effectively saves surgery time and is expected to reduce endothelial cell loss as only one tube remains in place in comparison to two anterior chamber tubes.

Position of the ISTENT Inject® Trabecular Micro-Bypass System Visualized with the NIDEK GS-1 Gonioscope-A Postoperative Analysis.

Glaucoma is one of the leading causes of irreversible blindness globally and is characterized by the gradual loss of retinal ganglion cells. The primary risk factor for the development and progression of glaucoma is increased intraocular pressure (IOP). Numerous surgical interventions exist to lower IOP should conservative therapy fail. One trend in recent years has been minimally invasive glaucoma surgery (MIGS) as an alternative to traditional methods. The ISTENT inject® is an ab interno trabecular micro-bypass implant designed to be implanted through the trabecular meshwork into the Schlemm's canal to lower IOP. The aim of the study was the postoperative visualization and description of the positioning of the ISTENT inject® using automated circumferential goniophotography. Patients with symptomatic cataracts and mild to moderate primary open-angle glaucoma (POAG), pseudoexfoliation glaucoma (PEX), and pigment-dispersion glaucoma were included who underwent combined cataract surgery with the ISTENT inject® and received postoperative automated gonioscopy with the NIDEK Gonioscope GS-1 to visualize the location of the implant. Twenty-four implants of 14 eyes in 11 patients could be visualized. Out of the implants, 14.3% were in the trabecular meshwork, 46.4% were at the border between the trabecular meshwork and scleral spur, 25% were below the trabecular meshwork, and 14.3% of the implants were not detectable in the gonioscopy. In the overall cohort, a statistically significant IOP reduction was found over the 12-month postoperative observation period. Even in three eyes, in each of which both stents were located below the trabecular meshwork, an IOP reduction over 12 months was observed compared to the baseline IOP. In this study, vertical two-dimensional positioning of the ISTENT inject® was performed for the first time using NIDKE GS-1 automated 360° goniophotography. The method is suitable for postoperative visualization, control, and documentation of positioning after ISTENT inject® implantation. Further studies are needed to analyze the correlation between positioning of the ISTENT inject® in the chamber angle and postoperative IOP reduction.

Characterizing Foveal Hypoplasia Using Optical Coherence Tomography Angiography: Evaluation of Microvascular Abnormalities and Clinical Significance.

This study aimed to evaluate foveal avascular zone (FAZ) features and macular flow density (FD) in various retinal layers in a cohort of patients with foveal hypoplasia (FH) using optical coherence tomography angiography (OCTA), in order to characterize microvascular abnormalities and explore their potential clinical significance. FAZ parameters and FD, as well as retinal thickness and volume values were analyzed and compared between patients with FH and an age- and gender-matched control cohort. Correlations between disease severity and visual acuity (VA), as well as between disease severity and FAZ features were evaluated. A total of 19 eyes with FH and 19 control eyes were included. The study group showed significantly higher FD values in the foveal sectors of the superficial and deep capillary plexus compared to controls. FAZ area, perimeter, and acircularity index (ACI) were noticeably altered in eyes with FH; however, they did not correlate with disease severity. Visual acuity was negatively correlated with disease severity. The results of this study provide evidence of altered microvasculature architecture specifically in the foveal sectors of patients with FH. The higher FD values in the foveal sectors of FH patients suggest a potential compensatory response of the retinal microvasculature. FAZ parameters and FD values of the foveal sectors could be used as part of an OCTA-based grading system in FH patients.

Long-Term Outcomes of the PRESERFLO MicroShunt Implant in a Heterogeneous Glaucoma Cohort.

The Preserflo MicroShunt represents a novel glaucoma treatment device, necessitating long-term follow-up data to accurately assess its efficacy. The aim of this study is to report real-world data of a heterogenous glaucoma cohort who received Preserflo implantation at a specialized glaucoma clinic. A total of 160 eyes of 160 patients who underwent Preserflo MicroShunt implantation were retrospectively enrolled in this study. Patient characteristics, as well as success and failure rates, were assessed. The numbers of adverse events and revision procedures were recorded, along with any reduction in supplementary medication. The progression of intraocular pressure (IOP) was assessed over the course of 12 months, and fluctuations were analyzed. The overall success rate was 61.9% (complete success: 51.3%, qualified success: 10.6%). Revision surgery was performed in 25% of cases. Excessive hypotony occurred postoperatively in 54.4% of patients and regressed after 7 days in 88.8% of all cases. Median IOP decreased from 22 (interquartile range (IQR): 17-27) mmHg preoperatively to 14 (IQR 12-16) mmHg at 12 months postoperatively (p < 0.01). The median number of antiglaucomatous agents decreased from three to zero at latest follow-up. The Preserflo MicroShunt achieved a noticeable reduction in IOP over the course of 12 months in glaucoma patients, irrespective of disease severity or disease subtype. The frequency of postoperative adverse events and number for revision surgeries over the course of the follow-up period were low.

Old Problem in a New Guise: Retinal Pigment Epithelium Tear after Intravitreal Faricimab (Vabysmo®) Injection.

This case report describes a 78-year-old patient who developed a tear of the retinal pigment epithelium (RPE) during faricimab (Vabysmo®) therapy. After three consecutive intravitreal aflibercept (Eylea®) injections with persistent disease activity, therapy was switched to faricimab. The patient experienced a tear in the RPE 4 weeks postinjection. We report the first published case of RPE tear development after intravitreal faricimab injection in neovascular age-related macular degeneration. Faricimab has a new target structure in the angiopoietin-2 receptor in addition to VEGF. Patients at risk for RPE rupture were excluded from pivotal studies. Further investigation is needed to understand the effect of faricimab not only on visual acuity and intraretinal and subretinal fluid but also on mechanical stress on the RPE monolayer.

Additive prognostic impact of the cerebrospinal fluid arginine/ornithine ratio to established clinical scores in aneurysmal subarachnoid hemorrhage.

Cerebrospinal fluid (CSF) metabolites are increasingly recognized as prognostic factors in aneurysmal subarachnoid hemorrhage (SAH). The CSF arginine/ornithine ratio (Arg/Orn) was shown to predict cerebral vasospasms and clinical outcome in SAH. The additive prognostic value of Arg/Orn over established prognostic scores has not been investigated. CSF Arg/Orn and the established prognostic scores SAH, FRESH, SAH-PDS, HAIR, Rosen-McDonald, Hunt and Hess, WFNS and modified Fisher scale were determined in a prospective cohort of patients with aneurysmal SAH. Logistic regression models to predict a favorable outcome, defined as a modified Rankin Scale score of 0-3 at 3 months follow-up, were constructed for each score, both with and without the addition of Arg/Orn. The impact of Arg/Orn was assessed comparing logistic regression models containing the respective score with and without Arg/Orn with the likelihood ratio chi-squared test. CSF Arg/Orn and clinical scores were determined in 38 SAH patients. Arg/Orn was an independent predictor of clinical outcome when added to established prognostic scores (p < 0.05) with the exception of HAIR (p = 0.078). All models were significantly improved if Arg/Orn was added as a covariable (p < 0.05). The results of this study confirm Arg/Orn as an independent prognostic factor and its addition improves established prognostic models in SAH.

Nasolacrimal intubation in transcanalicular endoscopic dacryoplasty: a long-term follow-up study.

Nowadays, transcanalicular endoscopic dacryoplasty represents the majority of lacrimal duct surgery procedures performed in adults in specialised centers. However, there are still hardly any data available regarding the intra- and postoperative care, particularly regarding the duration of silicone tube intubation (STI). Our aim was to evaluate the relation between tube duration and recurrence of symptoms in patients who underwent transcanalicular microdrill dacryoplasty (MDP) in a long-term setting. Medical records of 576 adult patients after MDP were retrospectively reviewed. A total of 256 eyes of 191 patients could be included. The median follow-up time was 7.83 [7.08; 9.25] years. In 57.0% of the cases there was still full resolution of symptoms at the time of the survey. The median duration of the STI was 6 [3.00; 6:00] months. When distinguishing between a tube duration < 3 months and ≥ 3 months there was a significant difference in the long-term success rate (< 3 months: 38%; ≥ 3 months: 61%; p = 0.011). In conclusion, an early removal of the STI (< 3 months) after transcanalicular MDP seems to be associated with a higher incidence of recurrence of symptoms. This should be considered in the intra- and postoperative care of patients following this minimally invasive first-step procedure.

FURTHER EVIDENCE AGAINST BILATERAL MANIFESTATION OF COATS DISEASE IN OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY OF THE MACULA.

PURPOSE: Recent studies have questioned the traditional view, which regards Coats disease as a strictly unilateral entity. Applying optical coherence tomography angiography, this prospective, monocentric study investigates quantitative capillary changes of the macula associated with Coats disease. METHODS: Twenty-four eyes (4 untreated, 8 pre-treated) of 12 patients with stage 2 Coats disease (age range: 9-61 years) and 15 eyes of healthy, age-matched controls from the University of Muenster Medical Center, Germany received macular optical coherence tomography angiography measurements of the superficial, deep, and choriocapillary capillary plexus. Flow density and parameters related to the foveal avascular zone were compared between Coats eyes and fellow eyes, and between fellow eyes and control eyes. Additional subanalyses investigated changes based on disease stage. RESULTS: Flow density did not differ between fellow eyes of Coats disease patients and control eyes in any of the parameters investigated. Comparison of Coats eyes to their respective fellow eyes revealed Coats disease to be associated with lower flow density in superficial, deep, and choriocapillary capillary plexus regions, irrespective of disease stage (all P < 0.03). There were no noticeable differences regarding the size or symmetry of the foveal avascular zone. CONCLUSION: In light of the recent discussion around the unilateral character of Coats disease, this trial provides evidence against a bilateral presentation of vascular changes in the macula.

The Diagnostic Value of Cerebrospinal Fluid Lactate for Detection of Sepsis in Community-Acquired Bacterial Meningitis.

Community-acquired bacterial meningitis conveys significant morbidity and mortality due to intracranial and systemic complications, and sepsis is a major contributor to the latter. While cerebrospinal fluid (CSF) analysis is essential in the diagnosis of bacterial meningitis, its predictive utility for detection of sepsis is unknown. We investigated the diagnostic performance of CSF parameters for sepsis defined by the Sepsis-3 criteria in a retrospective cohort of patients with community-acquired bacterial meningitis. Among 103 patients, 69.5% developed sepsis. CSF lactate was associated with sepsis with an odds ratio of 1.11 (p = 0.022), while CSF cell counts, glucose and protein levels were not (all p > 0.4). Employing the optimal cutoff of 8.2 mmol/L, elevated CSF lactate resulted in a sensitivity of 81.5% and specificity of 61.5% for sepsis. In exploratory analyses, CSF lactate was also associated with in-hospital mortality with an odds ratio of 1.21 (p = 0.011). Elevated CSF lactate might contribute to early diagnosis of sepsis as well as prognostication in patients with community-acquired bacterial meningitis.

Influence of Cilioretinal Arteries on Flow Density in Glaucoma Patients Measured Using Optical Coherence Tomography Angiography.

It has long been speculated whether the presence of a cilioretinal artery (CRA) can influence the development of glaucomatous damage in patients with open-angle glaucoma. Studies involving healthy patients have shown a change in flow density (FD) depending on the presence of a CRA. Similarly, studies that compared the optical coherence tomography angiography (OCTA) results of healthy controls and glaucoma cohorts identified a reduction in FD in certain retinal layers for glaucoma patients. These observations raise the question of whether FD is altered in glaucoma patients depending on the presence of CRA, with possible implications for the progression of glaucomatous damage. In this prospective study, 201 eyes of 134 primary and secondary open-angle glaucoma patients who visited the Department of Ophthalmology at the University of Muenster Medical Center, Germany were included. The patients were allocated to different groups according to the presence of CRAs and the level of glaucoma severity. The FD results obtained using OCTA for the CRA and non-CRA groups were compared. While FD differed noticeably between the CRA and non-CRA cohorts in the deep macular plexus, no differences in FD were observed between the two groups when adjusted for glaucoma severity. In both the CRA and non-CRA eyes, increasing glaucoma severity correlated most strongly with a reduction in peripapillary FD. Our results suggest that the presence of CRAs does not significantly affect retinal perfusion in glaucoma patients.

Parameters Associated with the Required Drug Dose of Intravenous Immunoglobulin in Stable Chronic Inflammatory Demyelinating Polyradiculoneuropathy.

BACKGROUND: Intravenous immunoglobulin (IVIg) is efficient and one of very few treatment options for patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). However, finding the optimal dose of IVIg for individual CIDP patients remains challenging. The dose of IVIg needs to be adjusted individually. Considering the high healthcare costs of IVIg therapy, the overtreatment of some patients seen in placebo studies and the shortage of IVIg we recently experienced, as well as identifying factors associated with the required dose of IVIg in maintenance treatment, is extremely important. Thus, in this retrospective study, we analyze characteristics of patients with stable CIDP, which are associated with the required drug dose. METHODS: 32 patients with stable CIDP treated with IVIg between July 2021 and July 2022 were identified from our database and included in this retrospective study. Patients' characteristics were registered, and parameters were identified that were associated with the IVIg dose. RESULTS: Age, cerebrospinal fluid protein elevation, disease duration, delay between symptom onset/diagnosis, Inflammatory Neuropathy Cause and Treatment (INCAT) score, and Medical Research Council Sum Score (MRC SS) were significantly associated with the required drug dose. In addition, an association of age, sex, elevated CSF protein, time interval between symptom onset and diagnosis, and the MRC SS with the required IVIg dose could be demonstrated in the multivariable regression analysis. CONCLUSIONS: Our model, which is based on routine parameters that are simple to address in the clinical practice, can be useful in adjusting the IVIg dose in patients with stable CIDP.

IL-17A Facilitates Entry of Autoreactive T-Cells and Granulocytes into the CNS During EAE.

Interleukin-17A plays a crucial role in multiple sclerosis and other autoimmune diseases. Although the link between IL-17 and disease activity has been clearly demonstrated, the precise function of this cytokine remains elusive. Here, we investigated the function of astrocyte-targeted IL-17A production in GF/IL-17 transgenic mice during EAE. In particular, IL-17A is important during disease induction. In mice with transgenic IL-17A production, disease occurs earlier and peak disease is more severe, whereas remission is unimpaired. IL-17A synthesis is associated with increased infiltration of granulocytes into the CNS and microglial activation. Moreover, IL-17A synthesis allows induction of MOG-EAE without the additional administration of the co-adjuvant pertussis toxin. Examination of double transgenic GF/IL-17 2D2 mice revealed that, in addition, local IL-17A production facilitates spontaneous infiltration of immune cells into the CNS in mice expressing a MOG-specific T-cell receptor. Overall, we provide evidence for a crucial effect of IL-17A in the induction phase of EAE, facilitating the infiltration of granulocytes and autoreactive T-cells into the CNS.

Quality contract 'prevention of postoperative delirium in the care of elderly patients' study protocol: a non-randomised, pre-post, monocentric, prospective trial.

INTRODUCTION: Postoperative delirium (POD) is seen in approximately 15% of elderly patients and is related to poorer outcomes. In 2017, the Federal Joint Committee (Gemeinsamer Bundesausschuss) introduced a 'quality contract' (QC) as a new instrument to improve healthcare in Germany. One of the four areas for improvement of in-patient care is the 'Prevention of POD in the care of elderly patients' (QC-POD), as a means to reduce the risk of developing POD and its complications.The Institute for Quality Assurance and Transparency in Health Care identified gaps in the in-patient care of elderly patients related to the prevention, screening and treatment of POD, as required by consensus-based and evidence-based delirium guidelines. This paper introduces the QC-POD protocol, which aims to implement these guidelines into the clinical routine. There is an urgent need for well-structured, standardised and interdisciplinary pathways that enable the reliable screening and treatment of POD. Along with effective preventive measures, these concepts have a considerable potential to improve the care of elderly patients. METHODS AND ANALYSIS: The QC-POD study is a non-randomised, pre-post, monocentric, prospective trial with an interventional concept following a baseline control period. The QC-POD trial was initiated on 1 April 2020 between Charité-Universitätsmedizin Berlin and the German health insurance company BARMER and will end on 30 June 2023. INCLUSION CRITERIA: patients 70 years of age or older that are scheduled for a surgical procedure requiring anaesthesia and insurance with the QC partner (BARMER). Exclusion criteria included patients with a language barrier, moribund patients and those unwilling or unable to provide informed consent. The QC-POD protocol provides perioperative intervention at least two times per day, with delirium screening and non-pharmacological preventive measures. ETHICS AND DISSEMINATION: This protocol was approved by the ethics committee of the Charité-Universitätsmedizin, Berlin, Germany (EA1/054/20). The results will be published in a peer-reviewed scientific journal and presented at national and international conferences. TRIAL REGISTRATION NUMBER: NCT04355195.

Decompressive surgery in cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia.

BACKGROUND AND PURPOSE: Cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia (CVST-VITT) is an adverse drug reaction occurring after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. CVST-VITT patients often present with large intracerebral haemorrhages and a high proportion undergoes decompressive surgery. Clinical characteristics, therapeutic management and outcomes of CVST-VITT patients who underwent decompressive surgery are described and predictors of in-hospital mortality in these patients are explored. METHODS: Data from an ongoing international registry of patients who developed CVST within 28 days of SARS-CoV-2 vaccination, reported between 29 March 2021 and 10 May 2022, were used. Definite, probable and possible VITT cases, as defined by Pavord et al. (N Engl J Med 2021; 385: 1680-1689), were included. RESULTS: Decompressive surgery was performed in 34/128 (27%) patients with CVST-VITT. In-hospital mortality was 22/34 (65%) in the surgical and 27/94 (29%) in the non-surgical group (p < 0.001). In all surgical cases, the cause of death was brain herniation. The highest mortality rates were found amongst patients with preoperative coma (17/18, 94% vs. 4/14, 29% in the non-comatose; p < 0.001) and bilaterally absent pupillary reflexes (7/7, 100% vs. 6/9, 67% with unilaterally reactive pupil, and 4/11, 36% with bilaterally reactive pupils; p = 0.023). Postoperative imaging revealed worsening of index haemorrhagic lesion in 19 (70%) patients and new haemorrhagic lesions in 16 (59%) patients. At a median follow-up of 6 months, 8/10 of surgical CVST-VITT who survived admission were functionally independent. CONCLUSIONS: Almost two-thirds of surgical CVST-VITT patients died during hospital admission. Preoperative coma and bilateral absence of pupillary responses were associated with higher mortality rates. Survivors often achieved functional independence.