Introduction Aneurysmal subarachnoid haemorrhage is a severe condition with reported in-hospital mortality ranging from 7.1% to 24.1%, but the term in-hospital mortality is not consistently defined, and methodological limitations persist in studies investigating mortality and potential risk factors for mortality. In Denmark, nearly all patients with aSAH are admitted to a neurosurgical department and recorded in a nationwide registry. Research question Using nationwide clinical data we aimed to estimate mortality within the primary admission to a neurosurgical department and identify risk factors associated with mortality in an unselected aSAH cohort. Material and methods All patients with aSAH recorded in the Danish Stroke Registry between January 1st 2017 and August 31st, 2022 were included. Associations between potential risk factors and mortality were examined using univariate and multivariate logistic regression models, adjusting for age, sex and neurosurgical admission. Subgroup analyses were conducted among patients who underwent closure of the aneurysm. Results The cohort comprised 1374 patients. Overall mortality was 22.0%. Mortality among patients who underwent aneurysm treatment was 11.9%. Lower Glasgow Coma Scale score, higher World Federation of Neurological Surgeons score, higher Fisher scale score, aneurysm size >12 mm, posterior circulation location, rebleeding and cerebral infarction were significantly associated with mortality. Discussion and conclusion In conclusion, this nationwide clinical register-based study showed that mortality after aSAH remained substantial, with 22.0% among all patients admitted to a neurosurgical department in Denmark and 11.9% among those who underwent closure of the aneurysm. Mortality was mainly related to initial clinical severity and complications rather than pre-existing comorbidity.

INTRODUCTION:Intracranial aneurysms are a serious clinical condition. Recent annual reports from the Danish Stroke Registry indicate a 30-day mortality rate of 27%, with notable regional variation ranging from 20% to 36%. This study aimed to examine whether these regional disparities in mortality are attributable to differences in demographic, clinical or treatment-related factors among the four Danish neurosurgical departments. METHODS:This multicentre registry-based cohort study utilised data from DanStroke. Differences in risk factors, mortality and neurological complications are presented as odds ratios with 95% confidence intervals calculated in a logistic regression model. RESULTS:A total of 1,426 patients were registered. The results of this study show that the patient population varies regionally, with patients admitted to Odense University Hospital (OUH) and Aalborg University Hospital (AaUH) generally being older and in a poorer clinical condition than patients admitted to Rigshospitalet (RH), which explains why fewer patients at the OUH and the AaUH received closure of the aneurysm. These regional differences contribute to the observed differences in mortality between the four neurosurgical departments. Importantly, among patients who received closure of the aneurysm, no significant difference in mortality was observed across departments. CONCLUSIONS:The mortality rate following intracranial aneurysmal haemorrhage is high in Denmark. Regional differences in mortality may reflect variations in the patient population and logistical aspects of transport, highlighting the importance of considering these parameters when comparing departments. FUNDING:None. TRIAL REGISTRATION:The study was approved by the Danish Stroke Register and the Data Protection Board of Copenhagen University Hospital (reference number p-2023-14241).

INTRODUCTION:Cortical spreading depolarisation (SD) is a pathological wave of depolarisation in the cortex. SDs occur frequently after severe acute brain injury, and SDs in clusters can contribute to secondary brain damage in patients with severe acute brain injury through hypoperfusion and upregulation of cerebral metabolism in vulnerable brain tissue. Ketamine appears to inhibit SDs both in vitro and in patient series of severe acute brain injury. The KETA-BID trial aims to examine the efficacy and safety of S-ketamine for SDs in severe acute brain injury, as well as the feasibility of the trial design. METHODS AND ANALYSIS:This randomised, blinded feasibility and pilot trial includes adults (≥ 18 years) undergoing a supratentorial craniotomy or craniectomy for severe acute brain injury (ie, traumatic brain injury, aneurysmal subarachnoid haemorrhage or spontaneous intracerebral haemorrhage). During surgery, an electrocorticography (ECoG) strip is placed adjacent to injured brain tissue. Patients are continuously monitored throughout their stay at the neurointensive care unit and the neurosurgical step-down unit. In the case of an SD, physiological optimisation of intracranial pressure, brain tissue oxygen tension (PbtO2), core temperature and blood glucose is initiated. Participants developing SD clusters are randomised for continuous infusion with S-ketamine or matching placebo in a 1:1 allocation with full blinding of the treatment allocation. Infusion rates (ie, dose) and duration of trial medication are adjusted following a dosing algorithm according to SD occurrence. Surviving participants are followed until 6 months after the injury with recording of functional outcome. The primary outcome is occurrence of SDs per hour of monitoring after randomisation. ETHICS AND DISSEMINATION:The Scientific Ethics Committee of the Capital Region of Denmark (H-21056972), the Danish Medicines Agency (EudraCT 2021-003716-12), as well as the Clinical Trials Information System (CTIS 2024-515315-22-00) approved this trial. This trial will provide insight into both SD and the clinical effects of ketamine following severe acute brain injury, presenting a potential new treatment for these patients. The findings will be submitted for publication in peer-reviewed publications. TRIAL REGISTRATION NUMBER:NCT05095857.

Background and ObjectivesThe aim of this study was to estimate incidence rates, changes in incidence rates, and prognosis of pediatric stroke in Denmark from 2013 to 2020.MethodsThrough a nationwide register, we identified all children (age 29 days-17 years) registered with a first-ever stroke or stroke-related diagnosis between 2013 and 2020. Possible stroke events were validated by medical record review. Age-adjusted incidence rates and absolute changes in incidence rates were estimated by Poisson regression analysis. Kaplan-Meier analysis was used to estimate 30-day, 1-year, and 5-year cumulative mortality risks.ResultsBetween 2013 and 2020, the age-adjusted stroke incidence rate increased in male individuals while no change was noted in female individuals. The trend observed in male individuals was driven by the increased incidence rate of arterial ischemic stroke (AIS) (yearly absolute change per 100,000 person-years: 0.14, 95% CI 0.018-0.26). The 30-day, 1-year, and 5-year cumulative mortality risks were 7.7% (95% CI 4.2-11.2), 10.0% (95% CI 6.0-13.9), and 11.0% (95% CI 6.8-15.2), respectively. Mortality risk remained stable over time (p value = 0.77). Among children alive at follow-up, moderate-severe neurologic impairment was present in 20.2% with AIS and 23.1% with intracerebral hemorrhage.DiscussionFrom 2013 through 2020, the age-adjusted incidence rate of pediatric stroke increased in male individuals while remaining stable in female individuals. Morbidity and mortality after stroke were substantial, highlighting the need for further improvements in pediatric stroke management.

Detecting covert consciousness in unresponsive patients is challenging. Although functional magnetic resonance imaging and advanced electroencephalography paradigms can identify volitional brain activity, the limited accessibility of these technologies necessitates alternative approaches. Functional near-infrared spectroscopy may provide a portable solution in the intensive care unit. We assessed the feasibility of functional near-infrared spectroscopy with verbal motor commands to detect volitional brain activity in acute disorders of consciousness (DoC). Functional near-infrared spectroscopy recordings and clinical assessments were obtained from 50 patients with DoC with acute brain injury, with data analyzed post hoc and visually at the bedside. Twenty healthy volunteers served as controls. After quality control, data from 19 controls and 36 patients were analyzed. Cortical activation was detected in 18 (96

Abstract:BackgroundStudies suggest that high intensities of tumor treating fields (TTFields) correlate with prolonged survival in newly diagnosed glioblastoma. However, no randomized clinical studies have tested different doses of TTFields, and the treatment remains controversial for recurrent glioblastoma. This study examined the clinical efficacy of dose-enhanced TTFields in first recurrence glioblastoma (rGBM). Methods:This open-label, randomized, multicenter, phase 2 clinical trial was conducted nationwide in Denmark (2020-2024) with planned enrollment of 84 rGBM patients. Inclusion criteria were focal disease, KPS ≥ 70, and eligibility for resection. Patients were randomized (1:1) to receive standard or dose-enhanced TTFields in addition to standard-of-care. Dose enhancement (25%-70%) in the tumor was achieved by placing five small cranial burr holes over the tumor bed with overlapping TTFields transducer arrays. The primary outcome was the overall survival (OS) rate at 12 months (OS12). Secondary outcomes included progression-free survival, toxicity, steroid use, objective response rate (ORR), and quality of life. Results:We enrolled 58 participants with a mean (SD) age of 59.2 (11.1) years and a median (IQR) KPS of 90 (10). Preplanned interim analysis of the first 52 patients resulted in early trial termination due to futility. Intent-to-treat analysis of the complete cohort showed an OS12 of 56% vs 46% (P = .38) and a median OS of 12.3 vs 11.1 months (P = .93) for intervention and control, respectively. Differences in the secondary outcomes were insignificant. Conclusion:Dose-enhanced TTFields utilizing burr holes over the resection cavity were not associated with improved survival in rGBM, with low study power as the primary limitation.

In the intensive care unit (ICU), management of unresponsive patients with brain injury focuses on preventing secondary brain damage. Therapeutic strategies that directly promote the recovery of consciousness are urgently needed. In an investigator-initiated, randomized, placebo-controlled, double-blind, cross-over trial, we studied the effects of apomorphine and methylphenidate in ICU patients with acute disorders of consciousness (DoC). We hypothesized that these stimulants would improve consciousness biomarkers assessed by automated pupillometry (primary outcome) and clinical signs of consciousness (secondary outcome). We randomized 50 ICU patients with DoC (14 female; mean age 63 ± 10 years; 48 with non-traumatic brain injuries) to strata consisting of three consecutive treatment sessions during which apomorphine, methylphenidate or placebo were administered. In total, we administered 112 study medications, including 36 doses of apomorphine, 39 doses of methylphenidate and 37 doses of placebo. Missing administrations were due to death, ICU discharge or spontaneous consciousness recovery. Plasma concentrations of stimulants confirmed drug exposure. We found no adverse events related to the trial drugs. Pupillometry recordings of sufficient quality (n = 590) were available from 48 (96%) patients. A pupillary response to a verbal arithmetic command (i.e. ≥3 pupillary dilations on five verbal arithmetic tasks) was identified during 70 (12%) of these recordings. Seven (15%) patients without any other observable response to spoken commands also passed a stricter threshold of ≥4 pupillary dilations, suggesting cognitive motor dissociation. Apomorphine [odds ratio (OR) 1.35, 95% confidence interval (CI): 0.93 to 1.96] and methylphenidate (OR 1.29, 95% CI: 0.89 to 1.86) did not significantly increase pupillary responses. However, after study drug administration, 10 (20%) patients showed improved clinical arousal at least once. Signs of arousal were noted after one dose of placebo, four doses of apomorphine (OR 5.04, 95% CI: 0.56 to 120.7) and seven doses of methylphenidate (OR 9.96, 95% CI: 1.36 to 235.8). Changes toward higher consciousness level categories were observed once after placebo, four times after apomorphine (OR 5.67, 95% CI 0.63 to 169.46) and three times after methylphenidate (OR 3.41, 95% CI 0.34 to 88.00). In a post hoc analysis, patients with greater pupillary responsiveness showed better arousal, suggesting that this condition may predict stimulant drug effects. In conclusion, while pupillometry revealed no direct drug effects on overall pupillary responses, stimulants may have triggered clinical arousal in some patients, particularly in those with greater pupillary responsiveness. These findings require replication but should guide future pharmacological trials aimed at improving consciousness recovery after brain injury.

BACKGROUND AND OBJECTIVES:The aim of this study was to estimate incidence rates, changes in incidence rates, and prognosis of pediatric stroke in Denmark from 2013 to 2020. METHODS:Through a nationwide register, we identified all children (age 29 days-17 years) registered with a first-ever stroke or stroke-related diagnosis between 2013 and 2020. Possible stroke events were validated by medical record review. Age-adjusted incidence rates and absolute changes in incidence rates were estimated by Poisson regression analysis. Kaplan-Meier analysis was used to estimate 30-day, 1-year, and 5-year cumulative mortality risks. RESULTS:Between 2013 and 2020, the age-adjusted stroke incidence rate increased in male individuals while no change was noted in female individuals. The trend observed in male individuals was driven by the increased incidence rate of arterial ischemic stroke (AIS) (yearly absolute change per 100,000 person-years: 0.14, 95% CI 0.018-0.26). The 30-day, 1-year, and 5-year cumulative mortality risks were 7.7% (95% CI 4.2-11.2), 10.0% (95% CI 6.0-13.9), and 11.0% (95% CI 6.8-15.2), respectively. Mortality risk remained stable over time (p value = 0.77). Among children alive at follow-up, moderate-severe neurologic impairment was present in 20.2% with AIS and 23.1% with intracerebral hemorrhage. DISCUSSION:From 2013 through 2020, the age-adjusted incidence rate of pediatric stroke increased in male individuals while remaining stable in female individuals. Morbidity and mortality after stroke were substantial, highlighting the need for further improvements in pediatric stroke management.

Patients with acute brain injury are vulnerable to secondary deterioration, which may go undetected by traditional monitoring. However, multimodal neuromonitoring of brain tissue oxygen tension (PbtO2) and energy metabolism may be able to detect such episodes. We report a retrospective, observational study of 94 patients with aneurysmal subarachnoid haemorrhage (SAH) or traumatic brain injury (TBI) who underwent multimodal neuromonitoring during admission. We examined the co-occurrence of pathological neuromonitoring values: elevated intracranial pressure (ICP, > 20 mmHg), inadequate cerebral perfusion pressure (CPP, < 60 mmHg), brain hypoxia (PbtO2 < 20 mmHg), and metabolic crisis (lactate/pyruvate ratio > 40 and a glucose level < 0.2 mmol/L in cerebral microdialysate). Mixed effects linear regression demonstrated significant associations between abnormal ICP/CPP, cerebral hypoxia and metabolic crisis. However, brain hypoxia occurred in 40% and 31% of observations in patients with SAH and TBI, respectively, despite normal concurrent values of ICP. Similarly, metabolic crisis was observed in 8% and 16% of measurements for SAH and TBI, respectively, despite a normal ICP. The pattern was identical for CPP. In conclusion, although all neuromonitoring variables are interrelated, brain hypoxia and metabolic crisis are common despite an absence of abnormalities in conventional monitoring. Multimodal neuromonitoring may help identify such episodes and guide individualised treatment.

In intensive care patients with disorders of consciousness, the pupillary light reflex is a measure of pupillary parasympathetic function. By contrast, the pupillary light-off reflex leads to pupil dilation in response to an abrupt change from light to darkness (“light-off”) and reflects combined parasympathetic and sympathetic pupillary function. To our knowledge, this reflex has not been systematically investigated in patients with disorders of consciousness. We hypothesized that the pupillary light-off reflex correlates with consciousness levels after acute brain injury. From November 2022 to March 2023, we enrolled 100 study participants: 25 clinically unresponsive (coma or unresponsive wakefulness syndrome) and 25 clinically low-responsive (minimally conscious state or better) patients from the intensive care units of a tertiary referral center, and 50 age-matched and sex-matched healthy controls. Exclusion criteria were active or chronic eye disease. We used automated pupillometry to assess the pupillary light-off reflex and the pupillary light reflex of both eyes under scotopic conditions in all study participants. The pupillary light-off reflex was strongly correlated with consciousness levels (r = 0.62, p < 0.001), the increase in pupillary diameters being smallest in unresponsive patients (mean ± standard deviation 20

Subarachnoid haemorrhages (SAH) caused by rupture of intracranial aneurysms (IA) are a severe condition. Earlier studies found a higher incidence of SAH in Greenlandic patients compared to Danish patients, with familial aggregation also higher in Greenland. However, updated data is lacking. To investigate the contemporary incidence, outcome, and familial disposition of SAH/IA in Greenlandic patients in 2018-2021. Greenlandic patients diagnosed with ruptured or unruptured IA (UIA) during 2018-2021 were included. Data was obtained from patient files, x-ray department, and discharge registry. Incidence rates were estimated as cases/100,000/year. Direct age-standardised incidence rates were calculated using WHO 2000-2025 as standards. Of 30 SAH patients, 20 (66.7%) were females, 10 (33.3%) males. Of 36 UIA patients, 27 (75.0%) were females, 9 (25.0%) males. For SAH, crude incidence was 13.4/100,000/year, age-standardised incidence was 10.8/100,000/year. Familial history was observed in 30.0% of SAH patients. 5 patients (16.7%) died before treatment, 28-day case-fatality rate (CFR) for all patients was 23.3%. Overall and age-standardised incidence rates were similar to previous studies but higher among females and compared to neighbouring countries. A high occurrence of familial history was reported. SAH remains a serious condition in Greenland, as evidenced by five fatalities before treatment was administered.

Background Ventriculostomy-associated infection (VAI) is common after external ventricular drains (EVD) insertion but is difficult to diagnose in patients with acute brain injury. Previously, we proposed a set of criteria for ruling out VAI in traumatic brain injury. This study aimed to validate these criteria. For exploratory purposes, we sought to develop and validate a score for VAI risk assessment in patients with different types of severe acute brain injury. Methods This retrospective cohort study included adults with acute brain injury who received an EVD and in whom CSF samples were taken over a period of 57 months. As standard non-coated bolt-connected EVDs were used. The predictive performance of biomarkers was analyzed as defined previously. A multivariable regression model was performed with five variables. Results A total of 683 patients with acute brain injury underwent EVD placement and had 1272 CSF samples; 92 (13.5%) patients were categorized as culture-positive VAI , 130 (19%) as culture-negative VAI , and 461 (67.5%) as no VAI . A low CSF WBC/RBC ratio (< 0.037), high CSF/plasma glucose ratio (> 0.6), and low CSF protein (< 0.5g/L) showed a positive predictive value of 0.09 (95%CI, 0.05–0.13). In the multivariable logistic regression model, days to sample (OR 1.09; 95%CI, 1.03–1.16) and CSF WBC/RBC ratio (OR 34.86; 95%CI, 3.94–683.15) were found to predict VAI. Conclusion In patients with acute brain injury and an EVD, our proposed combined cut-off for ruling out VAI performed satisfactorily. Days to sample and CSF WBC/RBC ratio were found independent predictors for VAI in the multivariable logistic regression model.

Background. In intensive care patients with disorders of consciousness (DoC), the pupillary light reflex is a measure of pupillary parasympathetic function. By contrast, the pupillary dark reflex leads to pupil dilation in response to darkness and primarily reflects the sympathetic function of the pupil. To our knowledge, this reflex has not been systematically investigated in DoC patients. We hypothesized that the pupillary dark reflex correlates with consciousness levels after acute brain injury, and that this correlation is not necessarily the same as that of the pupillary light reflex. Methods. From November 2022 to March 2023, we enrolled 100 study participants: 25 clinically unresponsive (coma or unresponsive wakefulness syndrome) and 25 clinically low-responsive (minimally conscious state or better) patients from the intensive care units of a tertiary referral center, and 50 age- and sex-matched healthy controls. Exclusion criteria were active or chronic eye disease. We used automated pupillometry to assess the pupillary dark reflex and the pupillary light reflex of both eyes under scotopic conditions in all study participants. Results. The pupillary dark reflex was strongly correlated with consciousness levels (r = 0.62, p < 0.001), the increase in pupillary diameters being smallest in unresponsive patients (mean ± SD: 20% ± 21%), followed by low-responsive patients (47% ± 26%) and healthy controls (67 % ± 17%; p < 0.001). Similar, yet less pronounced patterns were observed for the pupillary light reflex. Twenty-one of 25 unresponsive patients had preserved pupillary light reflexes, but only seven had preserved pupillary dark reflexes (p < 0.0001). Of these seven patients, five regained awareness. Conclusion. The pupillary dark reflex is more sensitive to consciousness levels after brain injury than the pupillary light reflex. The clinical implications of this finding seem worthy of further investigation, particularly regarding possible benefits for neuromonitoring and prognostication after brain injury.

To investigate patients with disorders of consciousness (DoC) for residual awareness, guidelines recommend quantifying glucose brain metabolism using positron emission tomography. However, this is not feasible in the intensive care unit (ICU). Cerebral blood flow (CBF) assessed by arterial spin labeling magnetic resonance imaging (ASL-MRI) could serve as a proxy for brain metabolism and reflect consciousness levels in acute DoC. We hypothesized that ASL-MRI would show compromised CBF in coma and unresponsive wakefulness states (UWS) but relatively preserved CBF in minimally conscious states (MCS) or better. We consecutively enrolled ICU patients with acute DoC and categorized them as being clinically unresponsive (i.e., coma or UWS [≤ UWS]) or low responsive (i.e., MCS or better [≥ MCS]). ASL-MRI was then acquired on 1.5 T or 3 T. Healthy controls were investigated with both 1.5 T and 3 T ASL-MRI. We obtained 84 ASL-MRI scans from 59 participants, comprising 36 scans from 35 patients (11 women [31.4

BackgroundStudies on complications following titanium mesh cranioplasty have predominantly focused on patients with cranial defects after decompressive craniectomy. This study investigates possible risk factors for complications using titanium mesh for smaller cranial defects.MethodsAll patients treated with titanium mesh cranioplasty over a 5-year period at Copenhagen University Hospital were identified. Demographics, comorbidities, and active smoking and drinking status were recorded in addition to indication for cranioplasty and operative findings. Severe complications recorded included superficial and deep infection, delayed wound defects, postoperative hematomas, and death within 30 days postoperatively. Minor complications recorded included skin atrophy, cosmetic complaints, pain, and loosening of the mesh. The management of complications was also documented.ResultsA total of 247 patients with primary titanium mesh cranioplasty were included in the study. The overall complication rate was 17.4%. 15.0% suffered from severe complications and 2.4% developed minor complications. Elderly smokers, patients previously treated with radiation, and patients operated via a posterolateral approach to the skull base had the strongest association with complications. The complication rate was not higher in patients with cranioplasty after postoperative infections or in those with a frontobasal approach to the skull base compared with patient operated on for smaller cranial tumors.ConclusionThe risk of complications following titanium mesh for smaller cranial defects is higher in elderly smokers, patients with a history of radiation, and those undergoing a posterolateral approach to the skull base.

Background In intensive care unit (ICU) patients with coma and other disorders of consciousness (DoC), outcome prediction is key to decision-making regarding prognostication, neurorehabilitation, and management of family expectations. Current prediction algorithms are largely based on chronic DoC, whereas multimodal data from acute DoC are scarce. Therefore, the Consciousness in Neurocritical Care Cohort Study Using Electroencephalography and Functional Magnetic Resonance Imaging (i.e. CONNECT-ME; ClinicalTrials.gov identifier: NCT02644265) investigates ICU patients with acute DoC due to traumatic and nontraumatic brain injuries, using electroencephalography (EEG) (resting-state and passive paradigms), functional magnetic resonance imaging (fMRI) (resting-state) and systematic clinical examinations. Methods We previously presented results for a subset of patients ( n = 87) concerning prediction of consciousness levels in the ICU. Now we report 3- and 12-month outcomes in an extended cohort ( n = 123). Favorable outcome was defined as a modified Rankin Scale score ≤ 3, a cerebral performance category score ≤ 2, and a Glasgow Outcome Scale Extended score ≥ 4. EEG features included visual grading, automated spectral categorization, and support vector machine consciousness classifier. fMRI features included functional connectivity measures from six resting-state networks. Random forest and support vector machine were applied to EEG and fMRI features to predict outcomes. Here, random forest results are presented as areas under the curve (AUC) of receiver operating characteristic curves or accuracy. Cox proportional regression with in-hospital death as a competing risk was used to assess independent clinical predictors of time to favorable outcome. Results Between April 2016 and July 2021, we enrolled 123 patients (mean age 51 years, 42% women). Of 82 (66%) ICU survivors, 3- and 12-month outcomes were available for 79 (96%) and 77 (94%), respectively. EEG features predicted both 3-month (AUC 0.79 [95% confidence interval (CI) 0.77–0.82]) and 12-month (AUC 0.74 [95% CI 0.71–0.77]) outcomes. fMRI features appeared to predict 3-month outcome (accuracy 0.69–0.78) both alone and when combined with some EEG features (accuracies 0.73–0.84) but not 12-month outcome (larger sample sizes needed). Independent clinical predictors of time to favorable outcome were younger age (hazard ratio [HR] 1.04 [95% CI 1.02–1.06]), traumatic brain injury (HR 1.94 [95% CI 1.04–3.61]), command-following abilities at admission (HR 2.70 [95% CI 1.40–5.23]), initial brain imaging without severe pathological findings (HR 2.42 [95% CI 1.12–5.22]), improving consciousness in the ICU (HR 5.76 [95% CI 2.41–15.51]), and favorable visual-graded EEG (HR 2.47 [95% CI 1.46–4.19]). Conclusions Our results indicate that EEG and fMRI features and readily available clinical data predict short-term outcome of patients with acute DoC and that EEG also predicts 12-month outcome after ICU discharge.

Cerebellar mutism syndrome (CMS) is a well-known complication of posterior fossa (PF) tumour surgery. CMS has previously been reported in cases of non-tumour surgical aetiology in a limited number of publications. We report a case of a 10-year-old girl who suffered a cerebellar haemorrhage and subsequent CMS following surgical treatment of a ruptured arteriovenous malformation (AVM) in the cerebellar vermis. The AVM was removed acutely through a transvermian access, and hydrocephalus was treated with temporary external drainage. In the postoperative period, she suffered diffuse vasospasms of the anterior cerebral circulation and had a permanent shunt placed for hydrocephalus. Her mutism resolved after 45 days but severe ataxia persisted. To our knowledge, this is the first reported case of CMS related to a vermian haemorrhagic stroke with postoperative diffuse vasospasms. Based on this case, we present a literature review on CMS of non-tumour surgical origin in children.

The aim of the study was to investigate (1) the 30-day, 3-month, and 12-month cumulative mortalities for patients who underwent aneurysm occlusion, and (2) the causes of death, and (3) the potential risk factors for death. All patients who underwent surgical clipping or endovascular treatment of a ruptured aneurysm at Copenhagen University Hospital, during the period of January 1, 2017–December 31, 2019, were included and followed up for 12 months. Data regarding vital status, causes of death, comorbidities, treatment, and clinical presentations on admission was collected. The absolute mortality risk was estimated as a function of time with a 95% confidence interval. The associations between potential risk factors and death were estimated as odds ratios with 95% confidence intervals using logistic regression models. A total of 317 patients were included. The overall cumulative mortalities after 30 days, 3 months, and 12 months were 10.7%, 12.9%, and 16.1%, respectively. The most common cause of death was severe primary hemorrhage (52.9%), followed by infections (15.7%) and rebleeding (11.8%). WFNS score > 3 and Fisher score > 3 on admission, preprocedural hydrocephalus, and preprocedural rebleeding were found significantly associated with higher risk of death. Considerable mortality was seen. Possible preventable causes accounted for approximately 22% of the deaths. The occurrence of both pre- and postprocedural rebleeding’s indicates an opportunity of further improvement of the mortality by (1) further reduction of time from aSAH to aneurysm occlusion and (2) continuous efforts in improving methods of aneurysm occlusion.

While intracranial aneurysms rarely develop after neurosurgical procedures, delayed pseudoaneurysm formation after foramen magnum decompression (FMD) has never been reported. A 52-year-old woman presented with an atypical subarachnoid hemorrhage in the posterior fossa 12 years after a FMD for symptomatic Chiari malformation type I was performed. A pseudoaneurysm on a dural-pial anastomosis was identified as the bleeding source and successfully occluded by endovascular means with full clinical recovery of the patient. Injury to the distal posterior inferior cerebellar artery related to surgery and postoperative infection likely caused formation of a dural-pial anastomosis. Additionally, hemodynamic stress or dissection may have contributed to delayed pseudoaneurysm formation and rupture.

Ventriculostomy‐related infection (VRI) is a common complication in patients with traumatic brain injury (TBI) treated with an external ventricular drain (EVD). The aim of this study was to investigate incidence and characteristics of patients with VRI, and to explore diagnostic criteria to confidently rule out VRI in patients with TBI.