Search Results (85)

Traumatic intracranial aneurysms (TICAs) are rare lesions accounting for <1% of intracranial aneurysms and are associated with high morbidity and mortality. They frequently arise after blunt trauma and may develop days to months following the initial injury, often evading early vascular imaging. Pseudoaneurysms predominate and carry a high risk of rupture. We report the case of a patient who sustained a severe head injury with a comminuted open depressed temporoparietal skull fracture, epidural hematoma, subarachnoid hemorrhage, and mandibular fracture after a road traffic accident. Initial vascular imaging revealed no aneurysm. At six-month follow-up, CT angiography demonstrated a 7 × 5 mm pseudoaneurysm arising from the rolandic branch of the right M3 middle cerebral artery, within an area of post-traumatic encephalomalacia. The aneurysm was confirmed by MRI/MRA and treated successfully with microsurgical clipping. This case underscores the importance of delayed vascular imaging in trauma patients with skull fractures or parenchymal injury, even when early angiography is normal. TICAs may develop over several months, and timely identification permits definitive management before rupture. Full article

Background/Objectives: Older adults undergoing surgery for intracranial hemorrhagic lesions after head trauma are clinically heterogeneous, and burr-hole drainage for trauma-related chronic or localized subdural hematoma differs substantially from craniotomy for acute lesions. We evaluated whether a protected-airway local/regional analgesia-dominant strategy (LA), in which airway protection was maintained but continuous maintenance-dose general anesthesia was not planned, was associated with shorter intensive care unit (ICU) stay than conventional general anesthesia (GA). Materials and Methods: In this single-center propensity score-matched retrospective cohort study, 330 patients aged ≥65 years with admission Glasgow Coma Scale (GCS) ≤ 8 who underwent surgery between 2015 and 2024 were analyzed. The LA approach was a pragmatic, jointly selected anesthesiologist–neurosurgeon strategy for carefully selected short burr-hole or localized subdural hematoma procedures; it was not an awake technique and not a protocol of leaving an intubated patient without drugs for airway-device tolerance. A protected airway could include a tracheal tube, supraglottic airway, or preexisting endotracheal tube according to clinical context, and titrated analgesic, sedative, or rescue anesthetic medications were permitted when clinically required. Propensity scores were estimated using age, sex, admission GCS, American Society of Anesthesiologists class, and Charlson Comorbidity Index; lesion category, procedure type, antithrombotic therapy, and intraoperative hypotension were examined as major sources of residual confounding. Results: After matching, the LA group had shorter ICU stay (4 [IQR 2–6] vs. 6 [4–10] days; p < 0.001). Negative binomial regression showed a 28% lower expected ICU stay with LA (incidence rate ratio 0.72, 95% CI 0.58–0.89; p = 0.003), and competing-risk analysis showed faster alive ICU discharge (subdistribution hazard ratio 1.41, 95% CI 1.08–1.84; p = 0.012). Conclusions: In this heterogeneous retrospective cohort, the LA strategy was associated with shorter ICU stay, particularly within selected burr-hole-dominant cases. These findings are hypothesis-generating and should not be interpreted as proof of superiority across acute traumatic brain injury, all lesion types, or all neurosurgical procedures. Full article

Background/Objectives: Spontaneous intracranial hypotension (SIH) is a functionally limiting condition caused by cerebrospinal fluid leakage. This study aims to evaluate the clinical outcomes of surgical management based on precise leak localization and to describe the characteristics of a surgically treated SIH cohort. Methods: We enrolled 23 patients who underwent surgical treatment for SIH between March 2024 and November 2025. Clinical outcomes included maximum headache severity and total daily upright hours. Radiologic outcomes were evaluated using the Bern score and the resolution of spinal extradural fluid at 2 months postoperatively. Results: The cohort comprised 19 patients (82.6%) with Type 1 and four patients (17.4%) with Type 3 leak. Exploratory subgroup analyses suggested that patients with Type 3 leak were significantly older (mean 65.3 vs. 38.2 years, p < 0.01) with lower thoracic leak (p = 0.02) compared to Type 1 patients. In the 20 patients who completed follow-up, significant improvements were observed in maximum headache intensity (Numeric Rating Scale 4.6 to 1.4, p < 0.01), daily upright time (3 to 12 h, p < 0.01), and Bern score (3.4 to 0.9, p < 0.01). Postoperative rebound headache occurred in 52.2% of patients. Complete resolution of spinal epidural fluid was achieved in 87.5% of Type 1 patients and normalization of the Bern score was achieved in all Type 3 patients. Conclusions: Surgical intervention based on precise leak localization offers substantial clinical and radiological benefits for SIH patients refractory to conservative management. These findings support a treatment-oriented approach based on precise leak localization in patients with SIH. Full article

Background/Objectives: Acute subdural hematomas (aSDH) represent a frequent and potentially life-threatening form of traumatic intracranial hemorrhage. This study aims to assess prognostic factors associated with mortality and clinical outcome, with particular emphasis on coagulation-related parameters, especially international normalized ratio (INR). Methods: A single-center retrospective cohort study was performed. We included 151 patients with traumatic aSDH, admitted between January 2020 and June 2025 to the Department of Neurosurgery of the Clinical Emergency Hospital “Saint Pantelimon”. Demographic, clinical, laboratory, and imaging parameters obtained at admission were analyzed. Univariate and multivariable regression analyses were performed to identify predictors of in-hospital mortality. Internal validation included bootstrap resampling, calibration analysis, penalized regression and spline modeling. Results: The cohort had a mean age of 67.4 years and was predominantly male (72.8%). Overall, in-hospital mortality was 36.4%, while 58.3% of patients underwent surgical intervention. Admission Glasgow Coma Scale (GCS) score represented the strongest predictor of mortality. Hematoma thickness was significantly associated with midline shift, mortality, and surgical intervention. Elevated INR was significantly associated with increased hematoma thickness, greater midline shift, lower GCS, and increased mortality. In multivariable analysis, INR ≥ 1.4 remained independently associated with mortality (OR 4.08, 95% CI 1.56–11.29, p = 0.005), together with lower GCS. The final model demonstrated very good discrimination (AUC 0.887) and good calibration. Conclusions: Outcome in traumatic aSDH appears to be influenced by neurological severity, hematoma burden, and coagulation status. Admission GCS remained the strongest predictor of mortality, while elevated INR independently predicted poor outcome. Full article

Background and Clinical Significance: Chronic subdural hematomas (cSDHs) present characteristic imaging findings, making the diagnosis straightforward. In rare cases, arachnoid cysts (ACs) may be associated with their formation. There is still no consensus regarding their treatment; Case Presentation: A young adult male presented with occipital headache. Neurological examination was normal. Laboratory investigations were within physiological limits. A CT scan revealed the presence of a Galassi Grade III temporo-parietal AC accompanied by a parietal epidural hematoma (EDH) on the right side. His medical history was significant for treated hypertension. There was no use of anticoagulants, antiplatelets, or history of trauma. Vascular pathology was excluded by MRA/MRV. He was discharged for home care and was readmitted 10 days later after a repeat CT scan. A brief cognitive assessment with the Mini-Mental State Examination (MMSE) revealed mild cognitive impairment. A burr-hole evacuation was performed, and a drainage catheter was left in place for 24 h. Intraoperative findings were consistent with a chronic subdural hematoma. The patient was discharged with complete resolution of symptoms. A follow-up CT scan performed one month postoperatively confirmed the favorable result. Cognitive functions were normal on follow-up; Conclusions: A SDH may mimic the characteristics of an EDH in the presence of an AC. The most common symptom is cephalalgia. Neurocognitive impairment may occur secondary to elevated intracranial pressure. A burr-hole hematoma evacuation may be sufficient. Further treatment should be considered only in the case of complications associated with ACs. Full article

Background/Objectives: Spontaneous intracranial hypotension (SIH) is a rare pathology that arises in the context of a known or suspected cerebral spinal fluid (CSF) leak. A key symptom of SIH is an orthostatic headache; however, additional neurological complications are common. This case study not only highlights the co-existence of Menière’s disease and SIH but describes a subsequent complication of benign paroxysmal positional vertigo (BPPV) and management thereof. Case Description: The patient is a 61-year-old female who presented to the emergency department due to an intractable headache, right sided weakness and aphasia. CT/MRI revealed a subdural hematoma overlying the left cerebral hemisphere measuring up to 8 mm with 4 mm left to right midline shift. Fluoro-guided total spine myelogram, cisternogram, and lumbar epidural blood patch were performed for suspected SIH. As headache, right sided weakness and aphasia resolved, the patient began reporting onset of constant “spinning” dizziness, tinnitus and aural fullness mimicking symptoms of a Menière’s attack. The vestibular examination was consistent with compensated bilateral Menière’s disease (left > right) and right horizontal canalithiasis BPPV. The patient was treated with Gufoni and Lempert maneuvers with complete resolution of positional dizziness and associated nystagmus along with improved balance and gait. Discussion/Conclusions: This case study highlights the importance of multidisciplinary assessment in complex neurological cases and specifically recommends that patients with Menière’s disease accompanied by intractable headaches undergo extended neuroradiological examination of the brain to exclude underlying spontaneous intracranial hypotension syndrome. Full article

Background/Objectives: Intracranial hypotension is a rare and underdiagnosed serious condition characterized by low cerebrospinal fluid (CSF) pressure, often resulting from trauma to the dura mater. While manual therapy is increasingly used for musculoskeletal complaints, it is not without risk and may, in rare cases, result in complications such as dural tears. Although these complications are rare, they require early recognition and appropriate treatment to prevent further morbidity. This case report aims to highlight a rare presentation of multilevel dural defects in temporal association with manual therapy and to demonstrate the efficacy of epidural blood patch (EBP) treatment. Case Presentation: We report a case of a 46-year-old woman without chronic illness who developed worsening orthostatic headaches, weakness, and vomiting after multiple manual therapy sessions. Only after 6 months did the patient undergo magnetic resonance imaging (MRI), which revealed intracranial hypotension due to dural damage in the spinal dura mater at C6–T1 and T8–T10, brain sagging, and an increased risk of subdural hematoma. After excluding other causes of dural defects, EBP was performed under CT guidance at C6–C7 and T8–T9, which resulted in symptom regression. Follow-up MRI was recommended for the patient. Conclusions: This case highlights a rare but clinically significant occurrence of multilevel dural defects and intracranial hypotension in temporal association with manual therapy. This emphasizes the critical role of timely diagnosis using MRI and the clinical effectiveness of EBP as a minimally invasive procedure. Full article

Background: Sarcopenia is increasingly recognized as a prognostic factor in surgical populations. This study evaluated the association between cranial CT-based markers of sarcopenia and neurological outcomes in patients undergoing surgery for chronic subdural hematoma (CSDH). Methods: This retrospective case–control study included 82 patients who underwent surgery for unilateral CSDH. Demographic data, comorbidities, use of anticoagulant and antiplatelet therapy, postoperative complications and length of hospital stay were collected from patients’ medical records. Radiological parameters of sarcopenia, including temporal muscle thickness, temporal muscle area, and occipital fat pad thickness, as well as standard radiological features of CSDH, were measured preoperatively on the initial CT scan. Neurological outcome 3 months after surgery was assessed using the Glasgow Outcome Scale, with scores ≥ 4 defined as favourable and scores 1–3 as poor. Results: Demographic and clinical characteristics, including age, sex, comorbidities, hematoma thickness and intracranial midline shift, did not differ significantly between outcome groups. Temporal muscle thickness (4.7 vs. 2.8 mm, p < 0.001), temporal muscle area (160 vs. 106 mm², p = 0.04), and occipital fat pad thickness (4.7 vs. 3.4 mm, p = 0.04) were significantly greater in patients with favourable neurological outcomes. After corrections for age and comorbidities, multivariate logistic regression with temporal muscle thickness, area and density, temporal bone thickness and density, and occipital fat pad thickness demonstrated that temporal muscle thickness was the only independent predictor of good neurological recovery (OR 3.20, 95% CI 1.37–7.46, p = 0.007). ROC analysis showed good discriminatory power of temporal muscle thickness (AUC 0.812, 95% CI 0.695–0.930, p < 0.001), with a cut-off value of ≥3.37 mm for its ability to predict favourable neurological outcome. Conclusions: Temporal muscle thickness is a reliable, non-invasive imaging biomarker for predicting good neurological recovery after CSDH surgery and may aid in risk stratification, particularly in elderly or frail patients. Full article

Traumatic intracranial aneurysms are rare consequences of blunt or penetrating head injury, carrying significant morbidity and mortality. We report a 33-year-old male who sustained severe head trauma with base of skull fracture and subarachnoid hemorrhage following a motor vehicle accident. He underwent craniotomy with evacuation of an intracerebral hematoma and fixation of depressed fracture segments. During the third week, he deteriorated due to a re-bleed at the operated site. Cerebral digital subtraction angiography revealed a pseudoaneurysm from the proximal A2 segment of the left anterior cerebral artery, prompting re-exploration. This case highlights the importance of considering post-traumatic aneurysm in patients with delayed neurological decline after head injury associated with skull bone fracture and subarachnoid hemorrhage. Full article

Background: Traumatic head injury (THI) includes a diverse range of hemorrhagic brain lesions (HBL), which are distinct phenotypes with characteristic pathophysiological mechanisms. Computed tomography (CT) is the cornerstone of the initial assessment and diagnosis; however, its sensitivity is limited, especially in mild head injury. Blood-derived biomarkers, including Neuron-Specific Enolase (NSE) and S-100B, have been extensively studied; however, their efficacy in distinguishing HBL subtypes remains unclear. We evaluated whether circulating serum levels of S-100B and NSE can discriminate between distinct intracranial HBLs and extracranial hemorrhagic lesions (ECH). Methods: This is an interim analysis of a prospective, randomized, double-blind clinical trial including 434 adult patients with blunt THI. HBL phenotypes identified by CT scan included subarachnoid hemorrhage (SAH), subdural hematoma (SDH), epidural hematoma (EDH), and brain contusion (BC). Unique lesions were considered while overlapping lesions were excluded. Subgaleal hematoma (SGH) was included as an example of ECH. Serum S-100B was assessed within 6 h post-injury, while serum NSE was evaluated at admission, 24 h, and 48 h thereafter. Serum NSE and inflammatory cytokines were quantified in duplicates using a Human Magnetic Luminex 5-plex assay, while serum S-100B concentrations were measured separately. Serum epinephrine concentrations were quantified using an ELISA. Biomarker profiles were analyzed based on lesion phenotype, lesion multiplicity, injury pattern, and clinical outcomes, including hospital length of stay (HLOS) and the Glasgow Outcome Scale—Extended (GOSE). Results: Admission median S-100B levels were higher in patients with SAH (495 pg/mL) and lower in those with SGH (191 pg/mL); however, they did not show statistically significant difference among HBL phenotypes. They were significantly higher in patients with polytrauma TBI (420 pg/mL) compared to isolated TBI (258 pg/mL). Baseline and 48 h NSE concentrations were significantly higher in SDH (25,089 and 28,438 pg/mL) than in other THI lesions (p = 0.04). There were no statistically significant changes in NSE values over time across all THI lesions except for SDH in which they raised more after 48 h (p = 0.02). They had a significant drop in polytrauma over the time (p = 0.001). Compared to intracranial lesions, S-100 B levels were significantly lower in SGH and in skull fractures without intracranial hematomas. Both S-100B and NSE levels were elevated in individuals with unfavorable GOSE scores. Conclusions: In this secondary exploratory analysis, elevated serum NSE and S-100B levels discriminate between extra- and intracranial lesions and appear to represent distinct but complementary aspects of THI, indicating neuronal damage and its temporal evolution, and predicting clinical and functional outcomes. The present findings reflect association and not causation. Future studies incorporating larger or multicenter cohorts, volumetric imaging, and long-term outcomes are required to validate and refine biomarker-guided algorithms for personalized THI care. Full article

Background: Intravenous thrombolysis (IVT), used in acute ischemic stroke (AIS), may be complicated by the development of intracranial hemorrhage. The role of fibrinogen levels, including their decrease, as a possible predictor of intracranial hemorrhage, has not yet been fully clarified. We aimed to evaluate the association between fibrinogen levels and their decrease 6 and 24 h after IVT and the risk of parenchymal hematoma (PH), as the clinically most significant type of intracranial hemorrhage. Methods: In an observational, nationwide, multicenter study, data from adult patients who underwent IVT for AIS from the Registry of Stroke Care Quality (RES-Q) in the Czech Republic (2019–2021) were analyzed. An association between fibrinogen levels and their decrease 6 and 24 h after IVT and the risk of PH was assessed. Results: We analyzed a set of 27 patients with PH (13 males; median age 78.0 years) and a control group (CG) of 97 patients without intracranial hemorrhage (58 males; median age 78.0 years). Fibrinogen levels 6 h after IVT (median 1.93 [PH] vs. 2.57 [CG] g/L, p = 0.012) and the ratio of baseline fibrinogen to fibrinogen 6 h after IVT (median 1.78 [PH] vs. 1.26 [CG]; p = 0.008) were associated with the development of PH. The optimal cut-off value of fibrinogen 6 h after IVT for predicting PH was <2.0 g/L. Conclusions: Fibrinogen levels 6 h after IVT and the ratio of baseline fibrinogen to fibrinogen 6 h after IVT are associated with an increased risk of PH in patients with acute ischemic stroke treated with IVT. Full article

Background/Objectives: Postoperative intracerebral hematomas (POHs) are a common complication following brain tumor surgery and are typically associated with unfavorable outcomes. While extensive hemorrhages have been studied extensively, smaller, Non-Space-Occupying hemorrhages are frequently detected, yet their clinical relevance and associated risk factors remain insufficiently understood. This study aimed to identify predictive factors for the occurrence of Non-Space-Occupying postoperative cerebral hemorrhages in patients undergoing brain tumor resection. Methods: A total of 1481 patients without a history of anticoagulant or antiplatelet therapy underwent brain tumor surgery at our neurosurgical institute over a ten-year period. Non-Space-Occupying postoperative hemorrhages were diagnosed in 84 patients using cranial computed tomography (cCT) or magnetic resonance imaging (cMRI) performed after the tumor resection. Demographic data, pre-existing comorbidities, and tumor characteristics were collected and analyzed. Results: Non-Space-Occupying POHs occurred in 5.6% of patients. The most frequent tumor type associated with POHs was glioblastoma multiforme (N = 33; 39.3%), followed by metastatic lesions (N = 9; 10.7%) and benign primary intracranial neoplasms (N = 31; 38%). None of the affected patients exhibited new neurological deficits or signs of increased intracranial pressure. A multivariate analysis identified the tumor size as an independent risk factor for Non-Space-Occupying POHs (p = 0.002), with patient age emerging as the strongest predictor (p = 0.001). Conclusions: Non-Space-Occupying POHs after a brain tumor resection are significantly associated with the tumor size, an advanced patient age, and the presence of pre-existing liver disease. The recognition of these risk factors may facilitate targeted perioperative monitoring and guide postoperative management strategies. Full article

Background: Routine admission inflammatory and metabolic biomarkers have been proposed as adjunctive tools in mild traumatic brain injury (mTBI). However, their association with specific traumatic intracranial lesion types remains unclear. Methods: We conducted a prospective observational study including adult patients with isolated mTBI who underwent head computed tomography (CT) on admission. Admission laboratory parameters included the platelet-to-lymphocyte ratio (PLR), systemic immune-inflammation index (SII), and glucose-to-potassium ratio (GPR). Two predefined endpoints were assessed. The first compared biomarker values between CT-positive and CT-negative patients. The second evaluated associations between biomarkers and individual intracranial lesion subtypes, including analyses restricted to isolated lesions. Results: A total of 125 patients were included, of whom 95 (76%) were CT-positive. No significant differences were observed between CT-positive and CT-negative patients for PLR (p = 0.793), GPR (p = 0.531), or SII (p = 0.291). In lesion-specific analyses including all intracranial injuries, subdural hematoma (SDH) was associated with higher GPR compared with patients without SDH (p = 0.016). In analyses restricted to patients with isolated lesions, SDH was associated with higher PLR (p = 0.018) and higher GPR (p = 0.015). No significant associations were observed between any biomarker and intraparenchymal hemorrhage, subarachnoid hemorrhage, or epidural hematoma (all p > 0.05). Patients with multiple intracranial injuries exhibited higher PLR (p = 0.012) and higher SII (p = 0.021) compared with those with isolated lesions. After correction for multiple comparisons, none of the observed associations remained statistically significant. Conclusions: These findings suggest that routine systemic biomarkers have limited global discriminatory value in mTBI. Exploratory lesion-specific associations with SDH did not remain significant after correction for multiple comparisons, underscoring the preliminary nature of these findings. Full article

Background: The management of spontaneous intracerebral hemorrhage (ICH) has centered around controlling blood pressure in order to prevent hematoma expansion (HE). Rate-pressure product (RPP) has emerged as a hemodynamic marker that accounts for heart rate (HR) and systolic blood pressure (SBP), both of which are crucial in modifying shear stress to the vasculature. We hypothesized that RPP in the pre-hospital hyperacute phase is positively associated with initial hematoma volume and HE. Methods: We analyzed 263 patients with primary ICH from the Field Administration of Stroke Therapy-Magnesium (FAST-MAG) study with initial and interval neuroimaging. RPP was calculated as the product of HR and SBP in pre-hospital and pre-treatment phases, stratified into quintiles. HE was defined by volume expansion of >6 mL or >33% from baseline volume on repeat neuroimaging performed within 48 h of the first scan. The primary outcome was the initial hematoma volume by quintiles of hyperacute RPP. The secondary outcome was the occurrence of HE across RPP quintiles. Multivariable logistic regression was used to assess the degree to which RPP affects HE. Results: Of the 263 patients analyzed, 116 (44%) had HE. The proportion of patients with HE or the initial hematoma volume was not statistically significant across RPP quintiles overall. HE was significantly more common in female patients or patients on anticoagulation. Conclusions: Elevated RPP was not associated with increased initial hematoma volume or subsequent HE in the hyperacute period after spontaneous ICH. Future research is necessary to determine the clinical importance of RPP as a biomarker in the clinical outcome of ICH. Full article

Postoperative hemorrhage (POH) is a rare but serious complication of cranial neurosurgery, often resulting in neurological deterioration and necessitating urgent surgical intervention. Despite its clinical relevance, POH remains underreported and insufficiently understood. This study aimed to identify potential risk factors including perioperative variables and tumor-related characteristics associated with POH requiring surgical evacuation. A total of 1862 cranial tumor procedures were performed in our department over a 10-year period. Data on perioperative parameters and tumor characteristics were retrospectively collected and analyzed. Statistical analyses were conducted to assess associations of them to POH. Statistical analysis revealed several peri- and postoperative variables significantly associated with POH in univariate analyses. These included intraoperative blood loss (p = 0.012) and length of postoperative hospital stay (p = 0.016). Furthermore, the outcomes measured using the Glasgow Outcome Scale (p < 0.001) and the Karnofsky Performance Scale (p < 0.001) showed also statistical relevance as a result of postoperative bleeding in these patients. The findings suggest that specific perioperative factors particularly intraoperative blood loss are associated with an increased risk of POH after intracranial tumor surgery. Additionally, prolonged hospitalization and worsened functional outcomes were linked to the occurrence of postoperative hemorrhage. In contrast, tumor-specific characteristics and routine laboratory values showed no significant association with hemorrhagic complications in this cohort. Full article