Search Results (57)

Background and Objectives: Acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) remains a major cause of disability and mortality. Mechanical thrombectomy (MT) improves outcomes, but recovery varies. This study assessed the prognostic value of hypoperfusion intensity ratio (HIR), collateral circulation, and other clinical/imaging factors. Materials and Methods: This retrospective cohort study included 96 LVO patients treated with MT with or without intravenous thrombolysis (IVT) between 2020 and 2024 at a tertiary hospital. Inclusion required multimodal CT (CT, CTA, CTP) and clinical data (NIHSS, mRS). HIR, core volume, CBV index, mismatch ratio, and collateral status were evaluated using artificial intelligence (AI)-based software. Univariate/multivariate logistic regression identified predictors of poor outcome (mRS > 3 at 90 days). Results: Lower HIR (<0.5) and good collaterals were associated with favourable outcomes (p < 0.001). Multivariate analysis identified HIR, initial NIHSS, and procedure duration as independent predictors of poor outcome. CTP-derived core volume, cerebral blood volume index, and mismatch ratio were also significant predictors. ROC analysis showed the highest AUC for core volume (0.810). Diabetes mellitus was associated with a worse prognosis compared to other clinical factors. Conclusions: HIR and collateral status are independent predictors of functional recovery after MT. CTP-derived core volume and CBV index have strong prognostic value. AI-based perfusion analysis supports patient selection and risk stratification. Full article

Background: The optimal timing of cranioplasty (CP) after decompressive craniectomy (DC) remains debated. Early reconstruction may enhance neurological recovery through restoration of cerebral perfusion and cerebrospinal fluid dynamics, yet concerns persist regarding postoperative complications. Objective: To evaluate the impact of early versus delayed cranioplasty on neurological outcomes and postoperative complications in adults following decompressive craniectomy. Methods: A systematic review was conducted in accordance with PRISMA guidelines (PROSPERO ID: CRD420251123808). PubMed, OVID, and Web of Science were searched for studies published between January 2017 and December 2025. Eligible studies compared early and delayed CP in adults and reported neurological outcomes and/or complications. Results: Twenty-one retrospective cohort studies including 8462 patients were analyzed. Neurological improvement was observed in both groups across multiple validated scales (GOSE, GOS, GCS, mRS, BI, FIM, NIHSS, MMSE). Early CP was consistently associated with superior recovery, including higher one-year Barthel Index improvement (74.1% vs. 54.8%), greater FIM gains (7.31% vs. 4.66%), and higher composite recovery rates (95.6% vs. 80.0%). No study demonstrated superior recovery with delayed CP. Infection, hydrocephalus, and seizure rates were comparable between groups. However, hematoma (21% vs. 10.4%) and hygroma (7.49% vs. 4.73%) were more frequent after early CP, although hematoma rates were influenced by a large database study. Bone flap resorption was less frequent with early CP (1.44% vs. 6.26%). Conclusions: Early cranioplasty is associated with improved neurological recovery but carries an increased risk of select complications, particularly hematoma and hygroma, representing a clinically relevant trade-off. Delayed CP does not demonstrate overall superior safety due to higher bone flap resorption. Timing should be individualized, and prospective multicenter studies with standardized definitions are needed. Full article

Background: Neonatal and infant aortic arch reconstruction remains a high-risk cardiovascular procedure requiring effective cerebral and myocardial protection. Variability in perfusion strategies may influence early hemodynamic stability and postoperative recovery. This study aimed to evaluate the early and short-term cardiovascular outcomes of a standardized beating-heart aortic arch reconstruction strategy incorporating simultaneous antegrade selective cerebral and continuous coronary perfusion. Methods: In this retrospective single-center cohort study, 31 consecutive neonates and infants undergoing aortic arch reconstruction between November 2022 and December 2025 were analyzed. A standardized surgical protocol was applied, consisting of extensive ductal tissue resection, interdigitating posterior end-to-end anastomosis, anterior autologous pericardial patch augmentation, and moderate hypothermic antegrade selective cerebral perfusion combined with continuous coronary perfusion via innominate artery cannulation. Early postoperative outcomes and short-term echocardiographic follow-up results were assessed. Results: The cohort included 31 patients, 22.6% of whom had complex associated cardiac anomalies requiring concomitant procedures. Median cardiopulmonary bypass and aortic cross-clamp times were 119 and 64 min, respectively. There was no in-hospital mortality. Major complications were infrequent, and median intensive care unit stay was 5 days. During a median follow-up of 6.8 months, one patient (3.2%) developed recoarctation requiring reintervention. No late mortality was observed. Conclusions: A fully standardized beating-heart aortic arch reconstruction strategy incorporating simultaneous cerebral and coronary perfusion demonstrated favorable early cardiovascular and short-term outcomes, even in anatomically complex cases. Preservation of continuous coronary perfusion may be associated with improved myocardial stability and early postoperative recovery; however, these findings should be interpreted as observational and hypothesis-generating given the absence of a control group. Larger multicenter studies with longer follow-up are warranted to confirm these findings. Full article

Background/Objectives: Selection of the optimal recipient artery in superficial temporal artery to middle cerebral artery (STA–MCA) extracranial–intracranial bypass surgery is essential to ensure adequate cerebral perfusion. Various pre- and intraoperative tools for target vessel selection have been proposed. Indocyanine green fluorescence video angiography (ICG-VA) enables real-time visualization of cerebral hemodynamics, facilitating recipient vessel selection and anastomotic evaluation. Here, we review the literature and present the use of qualitative ICG-VA to support intraoperative decision-making during double-barrel (DB) STA–MCA bypass surgery. Case description: We report the case of a 68-year-old patient with bilateral steno-occlusive cerebrovascular disease, who developed progressive hemodynamic compromise of the left hemisphere after prior right-sided STA-MCA bypass. Preoperative imaging demonstrated impaired perfusion and posterior-to-anterior leptomeningeal collateralization from the posterior cerebral artery. During the left-sided DB bypass surgery, intravenous ICG-VA was used to assess relative cortical perfusion. Two superficial M4 branches with the most pronounced perfusion delay were selected as recipients based on the ICG-VA and anatomical criteria. Postoperative angiography confirmed graft patency. At short-term follow-up, the patient remained neurologically stable, with complete regression of preoperative symptoms. Conclusions: This case illustrates the application of qualitative ICG-VA for perfusion-oriented recipient vessel selection in DB STA-MCA bypass for steno-occlusive disease. Real-time perfusion assessment may complement conventional anatomical criteria for recipient vessel selection in flow-augmentation procedures. Further studies incorporating quantitative hemodynamic analysis are warranted. Full article

Introduction: Severe traumatic brain injury (sTBI) frequently coexists with polytrauma and often necessitates damage control neurosurgery (DCNS), where rapid decompression and temporary stabilization take precedence over definitive reconstruction. Within this context, anesthetic management must balance cerebral protection with ongoing resuscitation, yet high-quality DCNS-specific evidence remains limited. Materials and Methods: A comprehensive search of PubMed, Scopus, and Google Scholar (2015–2025) was conducted using MeSH terms and keywords related to neurotrauma, anesthesia, intracranial pressure, and perioperative management. Studies were included if they examined anesthetic or hemodynamic strategies in severe TBI or DCNS and reported relevant clinical or physiologic outcomes. Results: Nineteen articles addressing perioperative strategies for optimizing DCNS outcomes were analyzed. Discussion: Preoperative care emphasizes hemodynamic stabilization and permissive hypertension, damage control resuscitation including massive transfusion protocols, optimization of cerebral perfusion pressure (CPP) and neuromonitoring, and the use of hyperosmolar therapy. Transexamic acid can be used in sTBI safely but with unclear improvement in outcomes. Intraoperatively, propofol-based total intravenous anesthesia is generally preferred over volatile agents due to favorable effects on intracranial pressure (ICP), cerebral blood flow (CBF), autoregulation, and emergence. While historically contraindicated, ketamine and etomidate are now increasingly used as hemodynamically protective induction agents. Analgesic and sedative strategies prioritize dexmedetomidine and carefully titrated opioids to minimize respiratory depression and reduce postoperative complications. CPP and ICP-directed management relies on individualized blood pressure targets, vasopressor selection, lung-protective ventilation, and strict temperature control. Conclusions: Emerging evidence has suggested the benefit of DCNS for patient survival. Overall, perioperative care is guided largely by physiology and extrapolation, highlighting the need for standardized protocols. Full article

Aortic arch diseases represent one of the most complex domains in cardiovascular surgery due to the need for cerebral protection, anatomical precision, and durable reconstruction. Their management requires highly individualized strategies that balance cerebral protection, systemic organ perfusion, anatomical complexity, and long-term durability. Over recent decades, antegrade cerebral perfusion has significantly reduced neurological morbidity. In parallel, vascular prostheses have progressed from conventional Dacron grafts to hybrid stent graft systems simplifying arch reconstruction and expanded treatment options in high-risk cohorts. Total endovascular arch repair using branched or fenestrated devices has emerged for selected high-risk patients; however, current data remain limited, with early stroke rates of approximately 5–8% and restricted long-term durability evidence. From both clinical and economic perspectives, open and hybrid approaches remain central to durable arch management. Full article

Background: Aortic arch reconstruction in neonates is often challenging, owning its surgical complexity and postoperative complication risk. To assess intestinal damage, we compared selective anterograde cerebral perfusion (SACP) and SACP with additional distal perfusion (SACP + DP) used in aortic arch surgery in a neonatal piglet model. Methods: Piglets underwent cardiac arrest for 60 min with SACP (n = 9) or SACP + DP (n = 9), followed by a 120 min recovery. Hemodynamic parameters, blood gases and electrolytes were monitored. Biopsies of the small intestine and colon were analyzed for histopathological changes, intestinal barrier function, and oxidative stress. Results: Hemodynamic measurements and electrolyte concentrations were comparable between SACP and SACP + DP (p > 0.05), except for potassium levels during cardiac arrest (p = 0.03). Blood lactate levels (p < 0.01) were elevated and pH values (p < 0.01) were reduced in the SACP group during cardiac arrest. Morphometric analysis of the intestinal tissue revealed longer crypts (p = 0.02) and a thicker mucosal layer (p = 0.05) of colonic structures in the SACP group. Compared to SACP, the mRNA expression of cytoprotective Parkinson’s disease protein DJ-1 (p = 0.02) and hypoxia-inducible nuclear factor erythroid 2-related factor 2 (p = 0.04) were higher in the small intestine of the SACP + DP group. The marker of epithelial barrier function, E-cadherin, showed lower mRNA expression in the colon of the SACP + DP group (p = 0.02). Conclusions: Our study results showed that SACP + DP revealed less intestinal tissue damage and loss of structural integrity, as well as an upregulation of cytoprotective molecules and anti-oxidative stress mechanisms. Therefore, SACP + DP is a reliable procedure in our model for aortic arch surgery that can contribute to better postoperative outcomes by reducing intestinal damage. Full article

Background: Aortic arch surgery using the frozen elephant trunk (FET) technique remains one of the most complex scenarios in cardiac anesthesia. The anesthesiologist plays a central role in maintaining neuroprotection, organ perfusion and hemodynamic stability during hypothermic circulatory arrest and selective cerebral perfusion. This review summarizes key anesthetic principles aimed at improving neurologic and systemic outcomes. Methods: This narrative review examines current evidence and expert recommendation on temperature and perfusion management, neuromonitoring, coagulation control and postoperative strategies specific to FET procedures. Results: Modern approaches emphasize moderate hypothermia with tailored selective cerebral perfusion, multimodal neuromonitoring and structured organ protection bundles. Evidence supports the use of physiology-guided perfusion, viscoelastic-based coagulation management and coordinated teamwork with surgical and perfusion specialists to reduce neurologic injury, bleeding and postoperative organ dysfunction. Conclusions: Anesthetic management in FET surgery requires an integrated, physiology-based strategy supported by advanced monitoring and close interdisciplinary coordination. Adoption of standardized organ-protection and perfusion protocols is essential to optimize neurologic and systemic outcomes in this high-risk population. Full article

Brain metastases have a distinctive vascular ecosystem—shaped by sprouting angiogenesis, vessel co-option, vasculogenic mimicry, and tumor cell transdifferentiation—that governs tumor perfusion, drug exposure, and therapeutic responsiveness. These heterogeneous vascularization patterns exhibit characteristic differences in enhancement morphology, perfusion levels, and metabolic uptake on contrast-enhanced MRI, perfusion imaging, and amino acid PET, providing crucial imaging cues for identifying routes of blood supply, inferring the state of the blood–tumor barrier, and guiding individualized therapeutic strategies. Anti-VEGF therapy is primarily used to alleviate cerebral edema and radiation necrosis, yet it confers limited survival benefit, underscoring the spatiotemporal heterogeneity of the blood–tumor barrier and the persistence of non-classical vascularization pathways. Building on the concept of “vascular normalization,” combinations of anti-angiogenic therapy with immunotherapy, radiotherapy, or targeted agents have shown encouraging intracranial activity in selected settings—most robustly in melanoma brain metastases—but remain insufficiently validated in randomized, brain-metastasis-focused trials. By integrating mechanistic, imaging, and therapeutic perspectives, this review outlines how vascular-ecosystem-based stratification and physics-informed drug-delivery strategies may help transition anti-vascular therapy from symptomatic control toward mechanism-driven precision intervention. Full article

Objective: This study aimed to evaluate clinical and radiological outcomes of Ascyrus Medical Dissection Stent (AMDS^®, Artivion Inc.) for acute type A aortic dissection (ATAAD). Methods: Between January 2021 and January 2025, all consecutive patients undergoing emergent surgery for ATAAD and hybrid aortic arch repair using the AMDS from two centers were retrospectively analyzed. Demographic, intraoperative, and postoperative data were collected. Patients were stratified based on 30-day or in-hospital mortality. Survival analysis was performed for patients who survived hospital discharge. Radiological evaluation focused on the presence of distal anastomotic new entries (DANEs), false lumen thrombosis, and aortic remodeling on follow-up computed tomography angiography. A total of 46 patients (12 female, mean age 66.1 ± 13.8 years) were included in the study. Results: The 30-day or in-hospital mortality rate was 21.7% (10 patients). There were no significant differences in demographic variables between survivors and non-survivors. All patients underwent hemiarch replacement with AMDS stent placement, with 54.3% also requiring aortic root replacement. Median cross-clamp time, hypothermic circulatory arrest (HCA) time, and time of antegrade selective cerebral perfusion did not differ significantly between the two groups. However, significant differences were observed in median cardiopulmonary bypass (CPB) time (151 vs. 274 min, p = 0.02) and HCA temperature (27 °C vs. 25 °C, p = 0.021). Postoperatively, the non-survivor group showed a significantly higher incidence of dialysis requirement (7.7% vs. 60.0%, p = 0.02), use of mechanical circulatory support (3.9% vs. 44.4%, p = 0.01), and re-exploration for bleeding (15.4% vs. 66.7%, p = 0.023). Conclusions: The AMDS^® is an effective adjunct in hemiarch replacement for ATAAD. Moderate hypothermia and optimized perfusion were linked to better early survival, while the device reliably promoted true-lumen expansion with few DANEs. Its rapid deployment may further facilitate the use of moderate hypothermia by balancing procedural efficiency with systemic protection. Full article

Background/Objectives: To evaluate whether incorporating both diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) in pituitary MRI examinations improves differential diagnosis by providing additional diagnostic value. Methods: A retrospective analysis was performed on 88 patients with histologically confirmed sellar or parasellar tumors who underwent 1.5T MRI with DWI and dynamic susceptibility contrast PWI (DSC-PWI) between October 2007 and April 2023. DWI parameters included minimum apparent diffusion coefficient (ADCmin) and relative ADCmin (rADCmin). PWI parameters included mean and maximum relative cerebral blood volume (rCBV, rCBVmax) and relative peak height (rPH, rPHmax), normalized to white matter. Tumor regions of interest were manually segmented, excluding calcified or hemorrhagic areas. Group comparisons and ROC analyses assessed diagnostic performance of individual and combined parameters. Results: Significant differences in diffusion and perfusion metrics were observed among the five tumor types. The combined analysis of DWI and PWI improved diagnostic accuracy in selected comparisons. The greatest benefit occurred in distinguishing meningiomas from solid non-functional pituitary adenomas (pituitary neuroendocrine tumors-PitNET), where the combination of ADCmin and rPHmax yielded an AUC of 0.818, sensitivity of 88%, and specificity of 76%, exceeding the performance of either parameter alone. In other comparisons, including meningiomas versus invasive PitNETs and adamantinomatous craniopharyngiomas, combined analysis did not substantially improve accuracy when single parameters, particularly rCBVmax (AUC = 0.995), already demonstrated excellent performance. Conclusions: Integration of DWI and PWI into pituitary MRI protocols enhances diagnostic performance in selected tumor groups. The additive value is context-dependent, supporting the tailored application of these sequences in the evaluation of sellar and parasellar tumors. Full article

Background/Objectives: Behavioral variant frontotemporal dementia (bvFTD), the most prevalent clinical subtype within the frontotemporal lobar degeneration spectrum disorders, is characterized by early and prominent changes that significantly disrupt everyday functioning. This study aims to identify the key correlates of functional status in bvFTD by investigating the relative contributions of cognitive deficits, behavioral disturbances, personality changes, and brain perfusion abnormalities. Additionally, it seeks to develop a theoretical framework to elucidate how these factors may interconnect and shape unique functional profiles. Methods: A total of 26 individuals diagnosed with bvFTD were recruited from the 2nd Neurology Clinic of “AHEPA” University Hospital in Thessaloniki, Greece, and underwent a comprehensive neuropsychological assessment to evaluate their cognitive functions. Behavioral disturbances, personality traits, and functional status were rated using informant-based measures. Regional cerebral blood flow was assessed using Single Photon Emission Computed Tomography (SPECT) imaging to evaluate brain perfusion patterns. Penalized Least Absolute Shrinkage and Selection Operator (LASSO) regression analysis was performed to identify the most robust correlates of functional impairment, followed by path analyses using structural equation modeling to explore how these factors may interrelate and contribute to functional disability. Results: The severity of negative behavioral symptoms (e.g., apathy), conscientiousness levels, and performance on neuropsychological measures of semantic verbal fluency, visual attention, visuomotor speed, and global cognition were identified as the strongest correlates of performance in activities of daily living. Neuroimaging analysis revealed hypoperfusion in the right prefrontal (Brodmann area 8) and inferior parietal (Brodmann area 40) cortices as statistically significant neural correlates of functional impairment in bvFTD. Path analyses indicated that reduced brain perfusion was associated with attentional and processing speed deficits, which were further linked to more severe negative behavioral symptoms. These behavioral disturbances were subsequently correlated with declines in global cognition and conscientiousness, which were ultimately associated with poorer daily functioning. Conclusions: Hypoperfusion in key prefrontal and parietal regions, along with the subsequent cognitive and neuropsychiatric manifestations, appears to be associated with the pronounced functional limitations observed in individuals with bvFTD, even in early stages. Understanding the key determinants of the disease can inform the development of more targeted, personalized treatment strategies aimed at mitigating functional deterioration and enhancing the quality of life for affected individuals. Full article

Objective: The role of the frozen elephant trunk technique in the treatment of acute aortic dissections is currently based on results from high-volume centers only. We investigated the patient selection process, intraoperative data, the evolution of surgical practice and outcomes from a low-volume center. Methods: A retrospective analysis was conducted on 202 acute aortic dissection (AAD) patients treated between October 2014 and December 2023. Patients were categorized into those receiving less invasive open aortic repair (group 1, n = 136) and those undergoing frozen elephant trunk procedures (FETs) (group 2, n = 66). Data on demographics, surgical procedures, and outcomes were analyzed. Results: Overall 30-day mortality was 16% (13% vs. 23%; p = 0.068). Rates of postoperative disabling stroke were similar (9% vs. 8%, p = 0.190). FET procedures required longer cardiopulmonary bypass (195 min vs. 234 min, p = 0.011), hypothermic circulatory arrest (26 min vs. 43 min, p < 0.001), and selective cerebral perfusion times (26 min vs. 47 min, p < 0.001). Follow-up indicated that 17% of FET patients received completion thoracic endovascular aortic repair (TEVAR) versus 4% in non-FET patients (p = 0.002), whereas no difference was seen in open surgical reintervention. Median follow-up at 33 months showed an overall mortality of 27%, with no significant difference between groups (23% in group 1 vs. 35% in group 2, p = 0.123). Conclusions: The FET technique is feasible in low-volume centers, yielding outcomes comparable to high-volume centers. FET proximalization and a liberal use of extra-anatomical left subclavian artery (LSA) grafts ease the learning curve. Completion treatments can be effectively conducted following FET implantation to further induce positive aortic remodelling. Full article

Background: Carotid artery stenting (CAS) is a common revascularization approach for carotid artery stenosis. While its impact on the internal carotid artery (ICA) has been extensively studied, the effects on the external carotid artery (ECA)—a key collateral pathway for cerebral perfusion—remain insufficiently explored. This study aimed to assess structural changes in the ECA following CAS and their clinical significance. Methods: A retrospective observational cohort study of 963 patients treated with CAS between 2018 and 2024 was conducted. Demographic data, comorbidities, and procedural characteristics were collected. Pre- and postprocedural ICA and ECA diameters were measured via angiography. Spearman’s correlation, regression modeling, and receiver operating curver (ROC) analysis were used to identify predictors of ECA narrowing and occlusion and their relationship with neurological outcomes. Results: The median ECA diameter decreased post-CAS (from 4.7 mm to 3.8 mm, p < 0.001). ECA overstenting occurred in 96.4% of cases, with 71.7% exhibiting diameter reduction. De novo ECA occlusion occurred in 2.5% of patients and was associated with a higher incidence of stroke, transient ischemic attack, and in-stent restenosis (ISR). Multivariate analysis identified preoperative ECA diameter (p < 0.001), ICA diameter (p = 0.001), and second-generation stents (p = 0.02) as independent predictors of ECA narrowing. ROC analysis confirmed that a preoperative ECA diameter ≤ 3.05 mm strongly predicted occlusion (Area under the curve (AUC) = 0.93, p < 0.001). Conclusions: CAS frequently leads to ECA remodeling, including occlusion, compromising collateral perfusion and contributing to adverse ischemic incidences and ISR. Preprocedural ECA assessment may aid in optimizing patient selection and procedural planning. Full article

Vascular dementia (VaD) represents the second-most common dementia type after Alzheimer’s disease since it results from complications of cerebrovascular disease. Mixed pathologies combining vascular and neurodegenerative processes are the rule rather than exception in elderly dementia patients. The condition known as VaD includes various types of vascular damage that affect both large and small blood vessels in the brain which results in cerebral hypoperfusion, blood–brain barrier disruption, glymphatic dysfunction, and molecular cascades causing neuronal damage. The mechanisms of VaD include endothelial dysfunction, oxidative stress, chronic neuroinflammation, impaired glymphatic clearance, white matter demyelination, and synaptic failure. The disease susceptibility of individuals depends on genetic factors which include NOTCH3 mutations and vascular risk polymorphisms. The diagnostic field uses neuroimaging tools and fluid biomarkers such as neurofilament light chain, inflammatory markers, and Aβ/tau ratios for mixed pathology. The current practice of vascular risk management combines with new therapeutic approaches that use phosphodiesterase inhibitors for cerebral perfusion and NLRP3 inflammasome inhibitors for neuroinflammation, senolytics for cellular senescence, and remyelination agents for white matter repair. However, the majority of new treatment methods remain investigational with limited Phase III data. Future medical treatment development will depend on precision medicine approaches which use biomarker-guided treatment selection and combination strategies targeting multiple pathological mechanisms. Full article