Cerebellar Stroke Score and Grading Scale for the Prediction of Mortality and Outcomes in Ischemic Cerebellar Stroke.

BACKGROUND: Several individual predictors for outcomes in patients with cerebellar stroke (CS) have been previously identified. There is, however, no established clinical score for CS. Therefore, the aim of this study was to develop simple and accurate grading scales for patients with CS in an effort to better estimate mortality and outcomes. METHODS: This multicentric retrospective study included 531 patients with ischemic CS presenting to 5 different academic neurosurgical and neurological departments throughout Germany between 2008 and 2021. Logistic regression analysis was performed to determine independent predictors related to 30-day mortality and unfavorable outcome (modified Rankin Scale score of 4-6). By weighing each parameter via calculation of regression coefficients, an ischemic CS-score and CS-grading scale (CS-GS) were developed and internally validated. RESULTS: Independent predictors for 30-day mortality were aged ≥70 years (odds ratio, 5.2), Glasgow Coma Scale score 3 to 4 at admission (odds ratio, 2.6), stroke volume ≥25 cm3 (odds ratio, 2.7), and involvement of the brain stem (odds ratio, 3.9). When integrating each parameter into the CS-score, age≥70 years and brain stem stroke were assigned 2 points, Glasgow Coma Scale score 3 to 4, and stroke volume≥25 cm3 1 point resulting in a score ranging from 0 to 6. CS-score of 0, 1, 2, 3, 4, 5, and 6 points resulted in 30-day mortality of 1%, 6%, 6%, 17%, 21%, 55%, and 67%, respectively. Independent predictors for 30-day unfavorable outcomes consisted of all components of the CS-score with an additional variable focused on comorbidities (CS-GS). Except for Glasgow Coma Scale score 3 to 4 at admission, which was assigned 3 points, all other parameters were assigned 1 point resulting in an overall score ranging from 0 to 7. CS-GS of 0, 1, 2, 3, 4, 5, 6, and 7 points resulted in 30-day unfavorable outcome of 1%, 17%, 33%, 40%, 50%, 80%, 77%, and 100%, respectively. Both 30-day mortality and unfavorable outcomes increased with increasing CS-score and CS-GS (P<0.001). CONCLUSIONS: The CS-score and CS-GS are simple and accurate grading scales for the prediction of 30-day mortality and unfavorable outcome in patients with CS. While the score systems proposed here may not directly impact treatment decisions, it may help discuss mortality and outcome with patients and caregivers.

Surgical timing and indications for decompressive craniectomy in malignant stroke: results from a single-center retrospective analysis.

PURPOSE: Acute ischemic stroke induces rapid neuronal death and time is a key factor in its treatment. Despite timely recanalization, malignant cerebral infarction can ensue, requiring decompressive surgery (DC). The ideal timing of surgery is still a matter of debate; in this study, we attempt to establish the ideal time to perform surgery in this population. METHODS: We conducted a retrospective study of patients undergoing DC for stroke at our department. The indication for DC was based on drop in level of consciousness and standard imaging parameters. Patients were stratified according to the timing of DC in four groups: (a) "ultra-early" ≤12 h, (b) "early" >12≤24 h, (c) "timely" >24≤48 h, and (d) "late" >48 h. The primary endpoint of this study was in-house mortality, as a dependent variable from surgical timing. Secondary endpoint was modified Rankin scale at discharge. RESULTS: In a cohort of 110 patients, the timing of surgery did not influence mortality or functional outcome (p=0.060). Patients undergoing late DC were however significantly older (p=0.008), and those undergoing ultra-early DC showed a trend towards a lower GCS at admission. CONCLUSIONS: Our results add to the evidence supporting an extension of the time window for DC in stroke beyond 48 h. Further criteria beyond clinical and imaging signs of herniation should be considered when selecting patients for DC after stroke to identify patients who would benefit from the procedure.

Surgery for brain metastases: radiooncology scores predict survival-score index for radiosurgery, graded prognostic assessment, recursive partitioning analysis.

BACKGROUND: Radiooncological scores are used to stratify patients for radiation therapy. We assessed their ability to predict overall survival (OS) in patients undergoing surgery for metastatic brain disease. METHODS: We performed a post-hoc single-center analysis of 175 patients, prospectively enrolled in the MetastaSys study data. Score index of radiosurgery (SIR), graded prognostic assessment (GPA), and recursive partitioning analysis (RPA) were assessed. All scores consider age, systemic disease, and performance status prior to surgery. Furthermore, GPA and SIR include the number of intracranial lesions while SIR additionally requires metastatic lesion volume. Predictive values for case fatality at 1 year after surgery were compared among scoring systems. RESULTS: All scores produced accurate reflections on OS after surgery (p ≤ 0.003). Median survival was 21-24 weeks in patients scored in the unfavorable cohorts, respectively. In cohorts with favorable scores, median survival ranged from 42 to 60 weeks. Favorable SIR was associated with a hazard ratio (HR) of 0.44 [0.29, 0.66] for death within 1 year. For GPA, the HR amounted to 0.44 [0.25, 0.75], while RPA had a HR of 0.30 [0.14, 0.63]. Overall test performance was highest for the SIR. CONCLUSIONS: All scores proved useful in predicting OS. Considering our data, we recommend using the SIR for preoperative prognostic evaluation and counseling.

International Women in Neurosurgery.

The history of women in neurosurgery worldwide has been characterized by adversity and hardships in a male-dominated field, where resilient, tenacious, and ingenious women have nevertheless left their mark. The first women in neurosurgery appeared in Europe at the end of the 1920s, and since then have emerged in all continents in the world. Women neurosurgeons all over the globe have advanced the field in numerous directions, introducing neurosurgical subspecialties to their countries, making scientific and technical advances, and dedicating themselves to humanitarian causes, to name a few. The past 30 years, in particular, have been a period of increasing involvement and responsibility for women in neurosurgery. We must now focus on continual system improvements that will promote a diverse and talented workforce, building a welcoming environment for all aspiring neurosurgeons, in order to advance the specialty in the service of neurosurgical patients.

Microsurgical clipping vs Woven EndoBridge (WEB) device for the management of unruptured wide-neck bifurcation aneurysms.

The Woven EndoBridge device (WEB) was introduced in 2010 to treat wide-neck bifurcation aneurysms (WNBAs). Three landmark studies have been conducted to assess its safety and efficacy: WEBCAST, WEBCAST 2, and French Observatory Study. However, these studies have not compared its safety and efficacy to other treatment modalities. In this study, we compare WEB versus microsurgical clipping in the management of unruptured WNBA. We conducted a retrospective study of unruptured WNBA meeting the morphological criteria to be amenable for WEB treatment operated on at our institution. Surgical morbidity, mortality, and occlusion rates were assessed. We compared our results to those reported in the cumulative population of the three WEB landmark studies at 1 year. A total of 84 patients with 89 WNBA were included. The most common aneurysm location was the middle cerebral artery bifurcation (n = 67/89, 75%). No operative mortality was observed. Morbidity comprised small-vessel vasospasm (n = 1/89, 1%) resulting in hemiparesis vs. 3% morbidity for WEB (p = .324). All but one (n = 1/89, 1%) WNBA were completely occluded vs WEB occlusion rate of 53% at 1 year, statistically significantly worse (p < .001). In our analysis, we were not able to show superiority of WEB in terms of procedural morbidity in comparison to microsurgical clipping, defined as worsening in mRS. Microsurgical clipping achieves statistically significantly higher rates of complete aneurysm occlusion, thus posing the question of whether the WEB should be presented as a viable, comparable alternative to patients amenable to surgical treatment.

A matter of frailty: the modified Subdural Hematoma in the Elderly (mSHE) score.

The Subdural Hematoma in the Elderly (SHE) score was developed as a model to predict 30-day mortality from acute, chronic, and mixed subdural hematoma in the elderly population after minor or no trauma. Emerging evidence suggests frailty to be predictive of mortality and morbidity in the elderly. In this study, we aim to externally validate the SHE for chronic subdural hematoma (CSDH) alone, and we hypothesize that the incorporation of frailty into the SHE may increase its predictive power. A retrospective cohort of elderly patients with CSDH after minor or no trauma being treated at our institution was evaluated with the SHE. Thirty-day mortality and outcome were documented. Patients were assessed with the Clinical Frailty Scale (CFS), which was incorporated into a modified SHE (mSHE). Both the SHE and the mSHE were then assessed in their predictive powers through receiver operating characteristic statistics. We included 168 patients. Most (n = 124, 74%) had a favorable outcome at 30 days. Mortality was low at n = 7, 4%. The SHE failed to predict mortality (AUC = .564, p = .565). Contrarily, the mSHE performed well in both mortality (AUC = .749, p = .026) and outcome (AUC = .862, p < .001). A threshold of mSHE = 3 is predictive of mortality with a sensitivity of 50% and a specificity of 75% and of poor outcome with a sensitivity of 88% and a specificity of 64%. Frailty should be routinely evaluated in elderly individuals, as it can predict outcome and mortality, providing the possibility for medical, surgical, nutritional, cognitive, and physical exercise interventions.

Invasive Monitoring of Intracranial Pressure After Decompressive Craniectomy in Malignant Stroke.

BACKGROUND AND PURPOSE: The role of decompressive hemicraniectomy (DC) in malignant cerebral infarction (MCI) has clearly been established, but little is known about the course of intracranial pressure (ICP) in patients undergoing this surgical measure. In this study, we investigated the role of invasive ICP monitoring in patients after DC for MCI, postulating that postoperative ICP predicts mortality. METHODS: In this retrospective observational study of MCI patients undergoing DC, ICP were recorded continuously in hourly intervals for the first 72 hours after DC. For every hour, mean ICP was calculated, pooling ICP of every patient. A receiver operating characteristic analysis was performed for hourly mean ICP. A subgroup analysis by age (≥60 years and <60 years) was also performed. RESULTS: A total of 111 patients were analyzed, with 29% mortality rate in patients <60 years, and 41% in patients ≥60 years. A threshold of 10 mm Hg within the first 72 postoperative hours was a reliable predictor of mortality in MCI, with an acceptable sensitivity of 70% and high specificity of 97%. Established predictors of mortality failed to predict mortality. CONCLUSIONS: Our study suggests the need to reevaluate postoperative ICP after DC in MCI and calls for a redefinition of ICP thresholds in these patients to indicate further therapy.

Is the unruptured intracranial aneurysm treatment score (UIATS) sensitive enough to detect aneurysms at risk of rupture?

To evaluate if the unruptured intracranial aneurysm treatment score (UIATS) is a sensitive tool to detect aneurysms at risk of rupture, we conducted an a posteriori retrospective study on ruptured intracranial aneurysms. We performed a retrospective analysis of adult patients admitted to our center from January 2010 to April 2016 with aneurysmal subarachnoid hemorrhage. The UIATS was applied to all ruptured aneurysms. Patients for whom the UIATS recommended treatment were labeled as "true positives," whereas patients for whom the UIATS recommended observation were labeled as "false negatives." Patients for whom the UIATS was inconclusive were excluded from the final analysis. Based on the UIATS recommendation, a sensitivity analysis was performed. A total of 262 patients with aneurysmal subarachnoid hemorrhage were screened. Of these, 212 were included in our analysis. Median age was 53 years (23-90). Most patients were females (n = 134, 63%), with an equal distribution between low-grade and high-grade hemorrhages (Hunt & Hess ≥ 3 n = 107, 50%). UIATS recommended treatment in n = 52, 25% cases (TP), was inconclusive in n = 93, 44% (excluded), and recommended observation in n = 67, 32% (FN). Based on these data, the UIATS showed a sensitivity of 44% (CI 35-53%). The UIATS exhibits rather low sensitivity for detecting aneurysms at risk of rupture.

Mechanical Ventilation, Sedation and Neuromonitoring of Patients with Aneurysmal Subarachnoid Hemorrhage in Germany: Results of a Nationwide Survey.

OBJECTIVE: Current evidence-based guidelines for the management of aneurysmal subarachnoid hemorrhage (aSAH) focus primarily on timing, modality and technique of aneurysm occlusion, and on prevention and treatment of delayed cerebral ischemia. Significant aspects of management in the intensive care unit (ICU) during the later course of aSAH such as ventilation and sedation (VST) remain unaddressed. aSAH patients present unique challenges not accounted for in general ICU recommendations and guidelines, which is why we attempted to further characterize ICU practices in aSAH patients in Germany. METHODS: We conducted a nationwide survey on ICU practices in aSAH in Germany. Secondarily, we assessed the existence of and compliance with current guidelines regarding ICU practices. The questionnaire was designed in interdisciplinary fashion and distributed online through the kwiksurvey® platform (Bristol, UK). RESULTS: A total of 50 responses were received, accounting for a response rate of 49%. Twenty-one were university hospitals (UH), 23 high-volume centers (HVC), 6 low-volume centers (LVC). Half of the participating centers do not take into consideration WFNS at presentation to indicate ventilation. While 42% of centers rely on the P/F ratio to indicate ventilation, 62% of them have a cutoff value of < 200, and 38% of < 100. While most UH and HVC used propofol for the first phase of sedation (95%), LVC employed benzodiazepines (100%). Sedation deepening was done with ketamine in UH (75%) and HVC (60%), whereas LVC used predominantly clonidine (100%). CONCLUSIONS: Our study clearly demonstrates that attitudes and practices pertaining to ICU management in aSAH are enormously heterogeneous, reflecting the lack of good quality evidence and differing interpretations thereof.

Volumetric analysis of bilateral spinal canal decompression via hemilaminectomy versus laminoplasty in cervical spondylotic myelopathy.

BACKGROUND: Cervical spondylotic myelopathy (CSM) is a degenerative process of the cervical spine requiring surgical decompression to prevent neurological deterioration. While both anterior and posterior approaches yield satisfactory results, posterior decompression is preferred in cases of the multilevel disease. In 2015, we described a muscle-sparing, novel technique of bilateral osteoligamentous decompression via hemilaminectomy (OLD) for CSM. In this study, we investigate whether this technique offers comparable volumetric results to laminoplasty in terms of spinal canal enlargement and whether this technique can yield significant clinical improvement. METHODS: Patients undergoing OLD due to CSM were prospectively enrolled in this study and then matched to and compared with a historic cohort of patients with CSM treated by laminoplasty. An independent sample t test was performed to analyze whether the volumetric gain in the two separate groups was statistically significant. Patients in the OLD cohort were clinically evaluated with the mJOA score preoperatively and 3 months postoperatively. To assess clinical improvement, a paired sample t test was performed. RESULTS: A total of 38 patients were included in the analysis: 19 underwent OLD and 19 underwent laminoplasty. Both groups were well matched in terms of sex, age, preoperative spinal canal volume, and involved levels. Both surgical methods yielded statistically significant volumetric gain in the cervical spinal canal, but a trend towards a greater volume gain was seen in the OLD group. In the OLD group, a statistically significant clinical improvement was also demonstrated. CONCLUSIONS: Our study reveals that OLD can yield a comparable extent of decompression to laminoplasty in CSM while also delivering statistically significant clinical improvement.

Cerebral metastases: do size, peritumoral edema, or multiplicity predict infiltration into brain parenchyma?

BACKGROUND: Brain metastases (BMs) are the most frequent malignancy of the central nervous system. Previous research suggested that some metastases show infiltrative behavior rather than sharp demarcation. We hypothesized that three magnetic resonance (MR) imaging parameters-(a) tumor size, (b) extent of peritumoral edema, and (c) presence of multiple BMs-are predictors of cellular invasion beyond the surgically identifiable tumor margins. METHODS: We performed a post hoc analysis on prospectively collected data of patients with BMs. Biopsies beyond the resection margin and immunohistochemistry were performed to assess infiltration status. The three MR imaging parameters were dichotomized into diameters ≤ 30 mm ("small") and > 30 mm ("large"), amount of peritumoral edema "extended" and "limited," and "multiple BMs" and "single BMs," respectively. The association between infiltration status and imaging parameters was calculated using chi-square test. RESULTS: Biopsy beyond the resection margin was performed in 77 patients; 49 (63.6%) had supramarginal infiltration and 28 patients (36.4%) showed no infiltration. Histological evidence of tumor infiltration was found in 25/41 patients with smaller lesions (61%) and in 24/36 with larger lesions (66.7%, p = 0.64), in 28/44 patients with limited (63.6%) and in 21/33 patients with extended edema (63.6%, p = 1.0), in 28/45 patients (62.2%) with single BM and in 21/32 patients (65.6%) with multiple BMs (p = 0.81). CONCLUSIONS: Based on the post hoc analysis of our prospective trial data, we could not confirm the hypothesis that infiltration of brain parenchyma beyond the glial pseudocapsule is associated with the MR imaging parameters tumor size, extent of edema, or multiplicity of metastases.

The application of the unruptured intracranial aneurysm treatment score: a retrospective, single-center study.

The unruptured intracranial aneurysm treatment score (UIATS) was published in April 2015 as a multidisciplinary consensus regarding treatment of unruptured intracranial aneurysms (UIA). As a tertiary center with focus on vascular neurosurgery, we aimed to investigate whether our treatment decision-making in patients with UIA has been in accordance with the recently published UIATS. A retrospective analysis of patients admitted to our center with UIA was performed. UIATS was applied to all identified UIA. Three decision groups were defined: (a) UIATS favoring treatment, (b) UIATS favoring observation, and (c) UIATS inconclusive. These results were then compared to our clinical decisions. Spearman's rank-order correlation (ρ) was run to determine the relationship between the UIATS and our clinical decisions. Cases of discrepancies between UIATS and our clinical decisions were then examined for complications, defined as periprocedural adverse events in treated aneurysms, or aneurysm rupture in untreated aneurysms. Ninety-three patients with 147 UIA were included. A total of 118/147 (80.3%) UIA were treated. In 70/118 (59.3%), UIATS favored treatment, in 18/118 (15.3%), it was inconclusive, and in 30/118 (25.4%), it favored observation. A total of 29/147 (19.7%) UIA were not treated. In 15/29 (51.7%), UIATS favored observation, in 9/29 (31%), it favored treatment, and in 5/29 (17.2%), it was inconclusive (ρ = 0.366, p < 0.01). Discrepancies between UIATS and our clinical decisions did not correlate with complications (ρ = 0.034, p = 0.714). Our analysis shows that our more intuitive clinical decision-making has been in line with UIATS. Our treatment decisions did not correlate with an increased rate of complications.

The role of stereotactic radiosurgery in the treatment of intramedullary spinal cord neoplasms: a systematic literature review.

Advances in imaging technology and microsurgical techniques have made microsurgical resection the treatment of choice in cases of symptomatic intramedullary tumors. The use of stereotactic radiosurgery (SRS) for spinal tumors is a recent development, and its application to intramedullary lesions is debated. We conducted a literature search through PubMed's MeSH system, compiling information regarding intramedullary neoplasms treated by SRS. We compiled histology, tumor location and size, treatment modality, radiation dose, fractionation, radiation-induced complications, follow-up, and survival. Ten papers reporting on 52 patients with 70 tumors were identified. Metastatic lesions accounted for 33%, while 67% were primary ones. Tumor location was predominantly cervical (53%), followed by thoracic (33%). Mean volume was 0.55 cm(3) (95% confidence interval (CI), 0.26-0.83). Preferred treatment modality was CyberKnife® (87%), followed by Novalis® (7%) and linear particle accelerator (LINAC) (6%). Mean radiation dose was 22.14 Gy (95% CI, 20.75-23.53), with mean fractionation of 4 (95% CI, 3-5). Three hemangioblastomas showed cyst enlargement. Symptom improvement or stabilization was seen in all but two cases. Radionecrotic spots adjacent to treated areas were seen at autopsy in four lesions, without clinical manifestations. Overall, clinical and radiological outcomes were favorable. Although surgery remains the treatment of choice for symptomatic intramedullary lesions, SRS can be a safe and effective option in selected cases. While this review suggests the overall safety and efficacy of SRS in the management of intramedullary tumors, future studies need randomized, homogeneous patient populations followed over a longer period to provide more robust evidence in its favor.

Clinical outcomes of patients with vertebral artery dissection treated endovascularly: a meta-analysis.

The purpose of this study was to present a meta-analysis on the safety and efficacy of different endovascular modalities when treating vertebral artery dissections, since ideal treatment remains controversial. We performed a meta-analysis of 39 retrospective studies involving different treatment modalities for vertebral artery dissections in adults and obtained weighted pooled proportional outcome and mortality ratios with a random effects model. Overall, 75.11 % (confidence interval (CI) 68.89-80.84, I (2) 66.89 %) had excellent outcomes, 10.10 % (CI 6.83-15.56, I (2) 65.64 %) had good outcomes, and 13.70 % (CI 9.64-18.35, I (2) 60.33 %) had poor outcomes. Postoperative complications occurred in 10.52 % (CI 6.87-14.84, I (2) 62.48 %), with 2.73 % (CI 1.64-4.10, I (2) 0.0 %) exhibiting vasospasm, 3.03 % (CI 1.88-4.46, I (2) 0.0 %) experiencing postoperative rebleeding, and 6.31 % (CI 3.57-9.76, I (2) 60.92 %) showing ischemia. Overall mortality was 8.69 % (CI 6.13-11.64, I (2) 33.76 %). When compared to these overall ratios, different treatment modality subgroups did not differ significantly, except for the proximal occlusion group, with poor outcome ratio = 26.96 % (difference 13.26, CI 0.02-30.04, p = 0.0403) and mortality ratio = 21.36 % (difference 12.67, CI 0.94-28.86, p = 0.0189). Different endovascular treatment modalities are comparatively safe and effective in the management of vertebral artery dissection. Their reduced operative time, minimal invasiveness, and overall safety render them a suitable option for intervention-amenable dissections.

Parenthood and neurosurgery in Europe, a white paper from the European association of neurosurgical societies' diversity in neurosurgery committee, part II - practice with children.

Introduction: In the first part of this White Paper, the European Association of Neurosurgical Societies (EANS) Diversity in Neurosurgery Committee (DC) addressed the obstacles faced by neurosurgeons when planning to have a family and practice during pregnancy, attempting to enumerate potential, easily implementable solutions for departments to be more family-friendly and retain as well as foster talent of parent-neurosurgeons, regardless of their gender identity and/or sexual orientation. Attrition avoidance amongst parent-neurosurgeons is at the heart of these papers. Research question: In this second part, we address the obstacles posed by practice with children and measures to mitigate attrition rates among parent-neurosurgeons. For the methodology employed to compose this White Paper, please refer to Supplementary Electronic Materials (SEM) 1. Materials and methods: For composing these white papers, the European Association of Neurosurgical Societies (EANS)'s Diversity Committee (DC) recruited neurosurgeon volunteers from all member countries, including parents, aspiring parents, and individuals without any desire to have a family to create a diverse and representative working group (WG). Results: In spite of the prevailing heterogeneity in policies across the continent, common difficulties can be identified for both mothers and fathers considering the utilization of parental leave. Discussion and conclusion: Reconciliation of family and a neurosurgical career is challenging, especially for single parents. However, institutional support in form of childcare facilities and/or providers, guaranteed lactation breaks and rooms, flexible schedule models including telemedicine, and clear communication of policies can improve working conditions for parent-neurosurgeons, avoid their attrition, and foster family-friendly work environments.

Surgical infarct volume reduction and functional outcomes in patients with ischemic cerebellar stroke: results from a multicentric retrospective study.

OBJECTIVE: Recent work on ischemic cerebellar stroke has suggested that the resection of infarcted tissue may lead to improved functional outcomes compared with decompressive surgery alone. Nonetheless, no studies have assessed the extent to which necrotic tissue should be resected or if there are any volumetric thresholds capable of predicting functional outcomes in this patient population. In this study, the authors aimed to determine potential thresholds for volume reduction in ischemic cerebellar stroke in an effort to optimize the management of ischemic cerebellar stroke and, in so doing, improve functional outcomes. METHODS: This study is a multicentric retrospective study of patients who underwent surgery for the management of ischemic cerebellar stroke. Volumetric analyses of infarcted tissue present on CT scans were performed before and after surgical intervention(s). The final infarct volume (FIV) was computed as a percentage of the initial infarct volume (postoperative infarct volume/preoperative infarct volume × 100). The primary endpoint was functional outcome at 3 months, as determined by the modified Rankin Scale (mRS) score; mRS scores 0-2 were considered as favorable and mRS scores 3-6 as unfavorable. Receiver operating characteristic curves were used to explore the relationship between postoperative infarct volumes and FIV versus mRS score, and Youden's index was used to estimate potential volumetric thresholds. RESULTS: A total of 91 patients were included in the study. The mean pre- and postoperative infarct volumes were 45.25 (SD 18.32) cm3 and 29.56 (SD 26.61) cm3, respectively. Patients undergoing necrosectomy, regardless of whether via craniotomy or craniectomy, were more likely to have a favorable outcome at discharge (OR 16.62, 95% CI 2.12-130.33; p = 0.008) and at 3 months (OR 24.12, 95% CI 3.03-192.18; p = 0.003) postoperatively. Postoperative infarct volumes ≤ 17 cm3 yielded a sensitivity of 77% and a specificity of 68% with regard to the prediction of favorable outcome at 3 months. The resection ≥ 50% of infarcted tissue was also predictive of favorable outcomes at 3 months (OR 7.7, 95% CI 2.7-21.8; p < 0.001). CONCLUSIONS: The reduction of necrotic tissue volumes by at least 50% and/or the reduction of the infarct volume by ≤ 17 cm3 appear to be associated with favorable outcomes in patients with surgically managed ischemic cerebellar strokes.

Necrosectomy Versus Stand-Alone Suboccipital Decompressive Craniectomy for the Management of Space-Occupying Cerebellar Infarctions-A Retrospective Multicenter Study.

BACKGROUND AND OBJECTIVES: Space-occupying cerebellar stroke (SOCS) when coupled with neurological deterioration represents a neurosurgical emergency. Although current evidence supports surgical intervention in such patients with SOCS and rapid neurological deterioration, the optimal surgical methods/techniques to be applied remain a matter of debate. METHODS: We conducted a retrospective, multicenter study of patients undergoing surgery for SOCS. Patients were stratified according to the type of surgery as (1) suboccipital decompressive craniectomy (SDC) or (2) suboccipital craniotomy with concurrent necrosectomy. The primary end point examined was functional outcome using the modified Rankin Scale (mRS) at discharge and at 3 months (mRS 0-3 defined as favorable and mRS 4-6 as unfavorable outcome). Secondary end points included the analysis of in-house postoperative complications, mortality, and length of hospitalization. RESULTS: Ninety-two patients were included in the final analysis: 49 underwent necrosectomy and 43 underwent SDC. Those with necrosectomy displayed significantly higher rate of favorable outcome at discharge as compared with those who underwent SDC alone: 65.3% vs 27.9%, respectively ( P < .001, odds ratios 4.9, 95% CI 2.0-11.8). This difference was also observed at 3 months: 65.3% vs 41.7% ( P = .030, odds ratios 2.7, 95% CI 1.1-6.7). No significant differences were observed in mortality and/or postoperative complications, such as hemorrhagic transformation, infection, and/or the development of cerebrospinal fluid leaks/fistulas. CONCLUSION: In the setting of SOCS, patients treated with necrosectomy displayed better functional outcomes than those patients who underwent SDC alone. Ultimately, prospective, randomized studies will be needed to confirm this finding.

Functional Outcomes in Conservatively vs Surgically Treated Cerebellar Infarcts.

Importance: According to the current American Heart Association/American Stroke Association guidelines, decompressive surgery is indicated in patients with cerebellar infarcts that demonstrate severe cerebellar swelling. However, there is no universal definition of swelling and/or infarct volume(s) available to support a decision for surgery. Objective: To evaluate functional outcomes in surgically compared with conservatively managed patients with cerebellar infarcts. Design, Setting, and Participants: In this retrospective multicenter cohort study, patients with cerebellar infarcts treated at 5 tertiary referral hospitals or stroke centers within Germany between 2008 and 2021 were included. Data were analyzed from November 2020 to November 2023. Exposures: Surgical treatment (ie, posterior fossa decompression plus standard of care) vs conservative management (ie, medical standard of care). Main Outcomes and Measures: The primary outcome examined was functional status evaluated by the modified Rankin Scale (mRS) at discharge and 1-year follow-up. Secondary outcomes included the predicted probabilities for favorable outcome (mRS score of 0 to 3) stratified by infarct volumes or Glasgow Coma Scale score at admission and treatment modality. Analyses included propensity score matching, with adjustments for age, sex, Glasgow Coma Scale score at admission, brainstem involvement, and infarct volume. Results: Of 531 included patients with cerebellar infarcts, 301 (57%) were male, and the mean (SD) age was 68 (14.4) years. After propensity score matching, a total of 71 patients received surgical treatment and 71 patients conservative treatment. There was no significant difference in favorable outcomes (ie, mRS score of 0 to 3) at discharge for those treated surgically vs conservatively (47 [66%] vs 45 [65%]; odds ratio, 1.1; 95% CI, 0.5-2.2; P > .99) or at follow-up (35 [73%] vs 33 [61%]; odds ratio, 1.8; 95% CI, 0.7-4.2; P > .99). In patients with cerebellar infarct volumes of 35 mL or greater, surgical treatment was associated with a significant improvement in favorable outcomes at 1-year follow-up (38 [61%] vs 3 [25%]; odds ratio, 4.8; 95% CI, 1.2-19.3; P = .03), while conservative treatment was associated with favorable outcomes at 1-year follow-up in patients with infarct volumes of less than 25 mL (2 [34%] vs 218 [74%]; odds ratio, 0.2; 95% CI, 0-1.0; P = .047). Conclusions and Relevance: Overall, surgery was not associated with improved outcomes compared with conservative management in patients with cerebellar infarcts. However, when stratifying based on infarct volume, surgical treatment appeared to be beneficial in patients with larger infarct volumes, while conservative management appeared favorable in patients with smaller infarct volumes.