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Background: Malignant middle cerebral artery infarction (MMI) can cause life-threatening edema with high mortality rates. Randomized controlled trials (RCTs) have shown that decompressive hemicraniectomy (DC) can improve survival rate and functional outcome in selected MMI patients. However, real-world outcomes are less well described.

Objective: To investigate DC indications, timing, and outcomes in MMI patients treated at 4 Swedish neurosurgical centers and the degree of alignment of real-world patient selection with eligibility criteria from 2 landmark RCTs–DESTINY I & II.

Methods: This retrospective, Swedish multicenter (n = 4) cohort study included 335 MMI patients treated with DC between 2008 and 2022. Demographics, clinical and radiological status, surgical factors, and 6-month outcomes (modified Rankin Scale [mRS]) were collected and compared across centers and with DESTINY trials.

Results: Median age was 55 (48–61) years, and 75% were male. Pre-DC, median Glasgow Coma Scale Motor score was 5 (5–6) and Charlson Comorbidity Index score was 3 (3–4). DC was performed at a median of 38 (25–56) hours from stroke onset. Median mRS at 6 months was 4 (4–5), 24% had mRS ≤ 3, and mortality was 17%. Only 19% and 12% of patients would have qualified for DESTINY I and II trials, respectively.

Conclusions: Indication and timing of DC as a treatment of MMI demonstrated notable discrepancies in surgical practice across centers and compared to landmark RCTs. However, despite differences in timing and indications for DC, the outcome did not differ significantly across centers. Our findings provide insight into the outcome of DC performed for MMI outside the strict criteria supported by level 1 evidence.

Higher-Level Gait Disorder (HLGD) is a type of gait disorder estimated to affect up to 6% of the older population. By definition, its symptoms originate from the higher-level nervous system, yet its association with brain morphology remains unclear. This study hypothesizes that there are patterns in brain morphology linked to HLGD. For the first time in the literature, this work investigates whether deep learning, in the form of convolutional neural networks, can capture patterns in magnetic resonance images to identify individuals affected by HLGD. To handle this new classification task, we propose setting up an ensemble of models. This leverages the benefits of combining classifiers instead of determining which network is the most suitable, developing a new architecture, or customizing an existing one. We introduce a computationally cost-effective search algorithm to find the optimal ensemble by leveraging a cost function of both traditional performance scores and the diversity among the models. Using a unique dataset from a large population-based cohort (VESPR), the ensemble identified by our algorithm demonstrated superior performance compared to single networks, other ensemble fusion techniques, and the best linear radiological measure. This emphasizes the importance of implementing diversity into the cost function. Furthermore, the results indicate significant morphological differences in brain structure between HLGD-affected individuals and controls, motivating research about which areas the networks base their classifications on, to get a better understanding of the pathophysiology of HLGD.

Purpose: The aim of this study was to explore risk factors for intraoperative events and postoperative complications of endoscopic transsphenoidal surgery (ETS) for pituitary tumors, and the role of intrasellar pressure (ISP) in relation to complications.

Methods: The study was a single-center, retrospective, consecutive, observational study, with ISP data collected prospectively. After exclusions, the study population encompassed 69 patients. All had ISP measured intraoperatively during ETS for a pituitary adenoma and underwent standardized postoperative observations and follow-up. Data on complications within 3 months after surgery and some risk factors were collected retrospectively.

Results: Decreased risk of postoperative cerebrospinal fluid leakage was seen with higher age. Large tumor volume was associated with higher risk of intraoperative events. ISP was not associated with complication frequency, but patients with ISP > 20 mmHg had increased frequency of postoperative epistaxis.

Conclusion: This study confirms earlier findings of low age as a possible risk factor for postoperative cerebrospinal fluid leakage. Tumor volume is suggested to be associated with higher complication risk. ISP does not seem to be a significant risk factor for intraoperative events or postoperative complications following ETS. Predictive risk factors for surgical complications after ETS are still not satisfactorily explained and heterogeneous definitions of complications are problematic in this context.

Background: Higher-level gait disorders (HLGDs) are slow, unsteady neurological GDs in older people. GDs can reduce quality of life (QoL) and cause depression. This has not been investigated in HLGD even though some HLGD causes are treatable, potentially affecting associated problems. We aimed to investigate gait and balance confidence, depressive symptoms and QoL in HLGD.

Methods: In a population (n=3769, 65-84y), 798 reported gait impairment (questionnaire) and were clinically examined together with 249 age- and sex-matched controls. Gait property groups were formed: 'HLGD', 'other neurological GD', 'non-neurological GD' or 'no GD'. Swedish Falls Efficacy Scale (FES(S)), Modified Gait Efficacy Scale (mGES), Euro Quality of Life 5-Dimension 5-Level index, Euro Quality of Life Visual Analogue Scale (EQ VAS) and Geriatric Depression Scale-15 (GDS-15) were compared.

Results: In the general population, 38% had GDs, of which 16% (n=87/561) were HLGDs, giving an HLGD prevalence of 5.8%; 26% (n=145/561) were other neurological GDs; and 59% (n=329/561) non-neurological GDs. HLGD had more depressive symptoms than non-neurological GD and no GD (GDS-15 HLGD, 3.9 +/- 3.4; non-neurological GD, 2.5 +/- 2.8; no GD, 1.4 +/- 2.0; p<0.05), lower EQ VAS (HLGD, 63 +/- 17; non-neurological GD, 71 +/- 18; no GD, 82 +/- 14; p<0.001), lower gait confidence (mGES HLGD, 60 +/- 22; non-neurological GD, 74 +/- 21; no GD, 90 +/- 13; p<0.001) and lower balance confidence (FES(S) HLGD, 93 +/- 32; non-neurological GD, 111 +/- 25; no GD, 124 +/- 13; p<0.001).

Conclusions: HLGDs are common and associated with reduced QoL, reduced confidence in gait and balance, and depressive symptoms, emphasising awareness of mental health among older people with slow unsteady gait.

Purpose: The aim of this study was to evaluate if intrasellar pressure (ISP) is associated with the risk of visual impairment in patients with a pituitary tumor, and the prognosis for visual function after tumor surgery.

Method: Retrospective, single-center study including 100 consecutive patients operated for a pituitary tumor, who had their ISP measured. Data on patient and tumor characteristics, pre- and postoperative visual acuity, visual fields, and cranial nerve III, IV, and VI deficits were collected from patient files.

Results: Before surgery, 64% had visual acuity impairment and 65% visual field deficits. Postoperatively, the frequencies were 40% for visual acuity impairment and 41% for visual field deficits. Risk factors for preoperative visual impairment were tumor volume, suprasellar tumor extension (SIPAP grade 3–4), and female sex. ISP was associated with higher risk of visual acuity impairment at postoperative follow up. No other correlations between ISP and pre- or postoperative visual and cranial nerve outcome were found. Age was associated with lower chance of visual acuity improvement and increased risk of visual field deficits postoperatively.

Conclusion: Overall, ISP does not seem to play an important role as a risk factor or prognostic factor for visual and cranial nerve impairment in pituitary tumor disease. However, ISP showed an association with postoperative visual acuity impairment. The clinical relevance of this results is not straight-forward. Tumor size, suprasellar growth pattern, and female sex are confirmed risk factors for preoperative visual symptoms. High age appears to negatively influence visual outcome after surgery.

White matter hyperintensities (WMH), perivascular spaces (PVS) and lacunes are common MRI features of small vessel disease (SVD). However, no shared underlying pathological mechanism has been identified. We investigated whether SVD burden, in terms of WMH, PVS and lacune status, was related to changes in the cerebral arterial wall by applying global cerebral pulse wave velocity (gcPWV) measurements, a newly described marker of cerebral vascular stiffness. In a population-based cohort of 190 individuals, 66–85 years old, SVD features were estimated from T1-weighted and FLAIR images while gcPWV was estimated from 4D flow MRI data. Additionally, the gcPWV’s stability to variations in field-of-view was analyzed. The gcPWV was 10.82 (3.94) m/s and displayed a significant correlation to WMH and white matter PVS volume (r = 0.29, p < 0.001; r = 0.21, p = 0.004 respectively from nonparametric tests) that persisted after adjusting for age, blood pressure variables, body mass index, ApoB/A1 ratio, smoking as well as cerebral pulsatility index, a previously suggested early marker of SVD. The gcPWV displayed satisfactory stability to field-of-view variations. Our results suggest that SVD is accompanied by changes in the cerebral arterial wall that can be captured by considering the velocity of the pulse wave transmission through the cerebral arterial network.

Background: Traumatic brain injury (TBI) is a common cause of death and disability, the incidence of which in northern Sweden is not fully investigated. This study classifies and characterize epidemiological and demographic features of TBIs in a defined population in Umeå county, Sweden. Specifically, to evaluate frequencies of (1) intracranial lesions detected with computed tomography (CT), (2) need for emergency intervention, and (3) hospital admission, in minimal, mild, moderate, and severe TBI, respectively.

Methods: The data were gathered from 4057 TBI patients visiting our emergency room (ER) during a two-year period (2015–2016), of whom 56% were men and approximately 95% had minimal TBIs (Glasgow Coma Scale (GCS), score 15).

Results: Of all injuries, 97.8% were mild (GCS 14–15), 1.7% were moderate (GCS 9–13), and 0.5% were severe (GCS < 9). CT scans were performed on 46% of the patients, with 28% being hospitalized. A high annual TBI incidence of 1350 cases per 100,000 citizens was found. The mortality rate was 0.5% with the majority as expected in the elderly group (>80 years).

Conclusions: Minimal TBIs were not as mild as previously reported, with a relatively high frequency of abnormal CT findings and a high mortality rate. No emergency intervention was required in patients in the GCS 13–15 group with normal CT scans. These findings have implications for clinical practice in the ER with the suggestion to include biomarkers to reduce unnecessary CT scans.

BACKGROUND: Limited evidence existed on the comparative effectiveness of decompressive craniectomy (DC) versus craniotomy for evacuation of traumatic acute subdural hematoma (ASDH) until the recently published randomised clinical trial RESCUE-ASDH. In this study, that ran concurrently, we aimed to determine current practice patterns and compare outcomes of primary DC versus craniotomy.

METHODS: We conducted an analysis of centre treatment preference within the prospective, multicentre, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (known as CENTER-TBI) and NeuroTraumatology Quality Registry (known as Net-QuRe) studies, which enrolled patients throughout Europe and Israel (2014-2020). We included patients with an ASDH who underwent acute neurosurgical evacuation. Patients with severe pre-existing neurological disorders were excluded. In an instrumental variable analysis, we compared outcomes between centres according to treatment preference, measured by the case-mix adjusted proportion DC per centre. The primary outcome was functional outcome rated by the 6-months Glasgow Outcome Scale Extended, estimated with ordinal regression as a common odds ratio (OR), adjusted for prespecified confounders. Variation in centre preference was quantified with the median odds ratio (MOR). CENTER-TBI is registered with ClinicalTrials.gov, number NCT02210221, and the Resource Identification Portal (Research Resource Identifier SCR_015582).

FINDINGS: Between December 19, 2014 and December 17, 2017, 4559 patients with traumatic brain injury were enrolled in CENTER-TBI of whom 336 (7%) underwent acute surgery for ASDH evacuation; 91 (27%) underwent DC and 245 (63%) craniotomy. The proportion primary DC within total acute surgery cases ranged from 6 to 67% with an interquartile range (IQR) of 12-26% among 46 centres; the odds of receiving a DC for prognostically similar patients in one centre versus another randomly selected centre were trebled (adjusted median odds ratio 2.7, p < 0.0001). Higher centre preference for DC over craniotomy was not associated with better functional outcome (adjusted common odds ratio (OR) per 14% [IQR increase] more DC in a centre = 0.9 [95% CI 0.7-1.1], n = 200). Primary DC was associated with more follow-on surgeries and complications [secondary cranial surgery 27% vs. 18%; shunts 11 vs. 5%]; and similar odds of in-hospital mortality (adjusted OR per 14% IQR more primary DC 1.3 [95% CI (1.0-3.4), n = 200]).

INTERPRETATION: We found substantial practice variation in the employment of DC over craniotomy for ASDH. This variation in treatment strategy did not result in different functional outcome. These findings suggest that primary DC should be restricted to salvageable patients in whom immediate replacement of the bone flap is not possible due to intraoperative brain swelling.

FUNDING: Hersenstichting Nederland for the Dutch NeuroTraumatology Quality Registry and the European Union Seventh Framework Program.

Mild traumatic brain injury (mTBI) can be accompanied by structural damage to the brain. Here, we investigated how the presence of intracranial traumatic computed tomography (CT) pathologies relates to the global functional outcome in young patients one year after mTBI. All patients with mTBI (Glasgow Coma Scale: 13-15) ≤24 years in the multi-center, prospective, observational Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study were included. Patient demographics and CT findings were assessed at admission, and the Glasgow Outcome Scale Extended (GOSE) was evaluated at 12 months follow-up. The association between a "positive CT" (at least one of the following: epidural hematoma, subdural hematoma, traumatic subarachnoid hemorrhage (tSAH), intraventricular hemorrhage, subdural collection mixed density, contusion, traumatic axonal injury) and functional outcome (GOSE) was assessed using multi-variable mixed ordinal and logistic regression models. A total of 462 patients with mTBI and initial brain CT from 46 study centers were included. The median age was 19 (17-22) years, and 322 (70%) were males. CT imaging showed a traumatic intracranial pathology in 171 patients (37%), most commonly tSAH (48%), contusions (40%), and epidural hematomas (37%). Patients with a positive CT scan were less likely to achieve a complete recovery 12 months post-injury. The presence of any CT abnormality was associated with both lower GOSE scores (odds ratio [OR]: 0.39 [0.24-0.63]) and incomplete recovery (GOSE <8; OR: 0.41 [0.25-0.68]), also when adjusted for demographical and clinical baseline factors. The presence of intracranial traumatic CT pathologies was predictive of outcome 12 months after mTBI in young patients, which might help to identify candidates for early follow-up and additional care.

Objective: The aim of this study was to investigate the association between intraoperative intrasellar pressure (ISP) and pre- and postoperative endocrine disturbances with focus on hyperprolactinemia and hypopituitarism in patients with pituitary tumors.

Methods: The study is a consecutive, retrospective study with ISP collected prospectively. One hundred patients operated with transsphenoidal surgery due to a pituitary tumor, who had their ISP measured intraoperatively, were included. Data on patient endocrine status preoperatively and from 3-month postoperative follow-up were collected from medical records.

Results: The risk of preoperative hyperprolactinemia in patients with nonprolactinoma pituitary tumors increased with ISP (unit odds ratio 1.067, n = 70) (P = 0.041). Preoperative hyperprolactinemia was normalized at 3 months after surgery. Mean ISP was higher in patients with preoperative thyroid-stimulating hormone (TSH) deficiency (25.3 ± 9.2 mmHg, n = 37) than in patients with intact thyroid axis (21.6 ± 7.2 mmHg, n = 50) (P = 0.041). No significant difference in ISP was found between patients with and without adrenocorticotropic hormone(ACTH) deficiency. No association was found between ISP and postoperative hypopituitarism at 3 months after surgery.

Conclusions: In patients with pituitary tumors, preoperative hypothyroidism and hyperprolactinemia may be associated with higher ISP. This is in line with the theory of pituitary stalk compression, suggested to be mediated by an elevated ISP. ISP does not predict the risk of postoperative hypopituitarism 3 months after surgical treatment.