Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening condition with high morbidity and mortality, particularly in poor-grade patients (World Federation of Neurosurgical Societies grades IV–V). Intraventricular hemorrhage (IVH) is associated with worse outcomes, but its predictive value and interaction with demographic and clinical factors remain unclear. To evaluate the prognostic value of IVH volume (IVHV) quantified on admission computed tomography (CT) in association with mortality and long-term disability, as well as its interaction with demographic and clinical variables in patients with poor-grade aSAH. We retrospectively analyzed all consecutive patients with poor-grade aSAH and IVH that were admitted to nine Italian tertiary centers between 1 January 2015 and 31 May 2023. Bivariate and multivariable analyses were performed to identify factors associated with mortality and disability (modified Rankin Scale [mRS]). Global intracranial hemorrhage volume (GHV) as well as the volumes of ICH (ICHV), IVH (IVHV), and SAH (SAHV) were calculated by means of analytical software in a semiautomated setting. We employed an explainable machine learning approach to examine the interplay between hemorrhage volume distribution, demographic and clinical variables to define prognostic thresholds, and to develop a decision tree model. Among 326 patients with IVH (median age 61 years [IQR: 53–70], 65.6

To investigate predictors and clinical impact of delayed cerebral infarction (CI) in a national multicentric poor grade aneurysmal subarachnoid hemorrhage (aSAH) population. Retrospective analysis of prospectively collected data from the multi-centric POGASH (Poor Grade aSAH) registry of consecutive patients treated from January 1st, 2015, to June 30th, 2023. Poor grade was defined according to the worst-pretreatment WFNS scale. CI was defined as a new ischemic lesion/s within 6 weeks of aSAH onset, not present on CT acquired within 48hrs and not related to treatment or hematoma. Clinical outcome was assessed by the modified Rankin Scale. Among 532 consecutive WFNS grades IV-V aSAH patients, CI occurred in 106 (19.9

Visual complications represent common deficits following surgical or endovascular repair of paraclinoid aneurysms. Different etiologies should be investigated to prevent devastating consequences. Herein we present a point-of-care evaluation to investigate sudden visual loss after coiling of paraclinoid aneurysms. A 20-year-old male was admitted for a sudden headache. Head computed tomography showed a subarachnoid hemorrhage and subsequent angiography revealed a 9-mm left supraclinoid aneurysm of the internal carotid artery treated with endovascular coil embolization. Thirty minutes after intensive care unit admission, the patient reported a left amaurosis. To exclude secondary etiologies, an immediate evaluation with point-of-care devices (color-doppler and B-mode ultrasound and automated pupillometry) was performed. Sonographic evaluations were negative for ischemic/thrombotic events and neurologic pupil index within physiological ranges provide evidence of third cranial nerve responsiveness. The symptomatology resolved progressively over 120 minutes with low-dose steroid therapy, 30° head-of-bed elevation, and blood pressure management. Visual deficits can occur after endovascular procedure and should be investigated. Suspected visual loss is a neurological emergency that deserves a prompt evaluation. Ultrasound and automated pupillometry have proved to be an effective, rapid, reliable, and non-invasive combination for a clinical decision-making strategy in the management of post-procedural acute visual deficits.

Intracranial hypertension (IH) is a life-threatening complication that may occur after acute brain injury. Early recognition of IH allows prompt interventions that improve outcomes. Even if invasive intracranial monitoring is considered the gold standard for the most severely injured patients, scarce availability of resources, the need for advanced skills, and potential for complications often limit its utilization. On the other hand, different non-invasive methods to evaluate acutely brain-injured patients for elevated intracranial pressure have been investigated. Clinical examination and neuroradiology represent the cornerstone of a patient's evaluation in the intensive care unit (ICU). However, multimodal neuromonitoring, employing widely used different tools, such as brain ultrasound, automated pupillometry, and skull micro-deformation recordings, increase the possibility for continuous or semi-continuous intracranial pressure monitoring. Furthermore, artificial intelligence (AI) has been investigated to as a tool to predict elevated intracranial pressure, shedding light on new diagnostic and treatment horizons with the potential to improve patient outcomes. This narrative review, based on a systematic literature search, summarizes the best available evidence on the use of non-invasive monitoring tools and methods for the assessment of intracranial pressure.

Background/Objectives: The percutaneous insertion of an external ventricular drain (EVD) is a common neurosurgical procedure that is crucial in managing acute brain injuries because of the drain's role in monitoring intracranial pressure and draining cerebrospinal fluid. The primary indication is acute hydrocephalus, which often results from subarachnoid hemorrhage, intracranial hemorrhage, traumatic brain injury, stroke, or infection. Standard EVD placement targets the frontal horn of the lateral ventricle. However, complications such as hemorrhage, infection, and catheter occlusion frequently arise, with occlusion rates ranging from 19% to 47%. Occlusion can lead to increased intracranial pressure, necessitating interventions such as saline flushes or fibrinolytic drug administration. The placement of an EVD is a very specific choice that must be tailored to the individual patient, often in scenarios in which multiple interpretations of the data are possible: the question of which patient is eligible for EVD placement may be subjective. Intraventricular fibrinolysis (IVF) with urokinase-type plasminogen activator (uPA) or tissue-type plasminogen activator is used with the aim of lysing intraventricular clots and preventing EVD occlusion. Despite numerous studies, conclusive evidence on their efficacy is lacking. The CLEAR III trial confirmed the safety of IVF but showed uncertain benefits in neurological outcomes. Given the limited literature on uPA, this study evaluates its intrathecal administration for the prevention of EVD occlusion. Not all therapies are appropriate for all patients, and customizing strategies is often the right way to get the best result. Methods: This retrospective study analyzed 20 patients with EVDs receiving intrathecal uPA. The patients had a mean age of 56.4 years, with 95% presenting with hydrocephalus and 80% presenting with intraventricular hemorrhage. uPA dosages varied (25,000-100,000 IU), with an average of 3.9 doses per patient. Results: IVF effectively maintained EVD patency in 95% of cases. One patient experienced asymptomatic bleeding, while four (20%) developed post-treatment infections, the development of which was potentially influenced by the prolonged duration of EVD retention (>21 days). Analysis of Graeb scores showed faster clot resolution with early uPA administration. A higher initial Graeb score correlated with increased total uPA load but not with mortality or discharge outcomes. Although infection rates were slightly higher than in CLEAR III, multiple confounding factors, including duration of EVD retention and bilateral placement, were present. Conclusions: This study supports the feasibility and safety of intrathecal uPA administration for management of EVD occlusion in certain contexts. The appropriate choice in the context of 'personalized medicine' must necessarily consider the risk-benefit ratio.

OBJECTIVE:Intracranial dissecting aneurysms (DAs) are rare and challenging lesions, often associated with high rates of rebleeding and poor clinical outcomes. There is limited evidence regarding optimal treatment strategies, timing, and outcomes, especially in the context of poor-grade subarachnoid hemorrhage (pSAH). The authors aimed to describe the clinical features and treatment outcomes of patients with DAs included in a national multicentric registry of pSAH and to identify independent outcome predictors within this subpopulation. METHODS:The authors conducted a retrospective analysis of prospectively collected data from the multicenter Poor-Grade Aneurysmal Subarachnoid Hemorrhage (POGASH) registry, including consecutive patients admitted between January 1, 2015, and June 30, 2024. Poor grade was defined as a pretreatment World Federation of Neurosurgical Societies grade IV-V. Outcomes were assessed using the modified Rankin Scale. DAs were classified according to the Mizutani classification. RESULTS:Of the 693 consecutive pSAH patients included in the registry, data from 60 patients with DA were analyzed. Among the 54 treated patients, 88.9% underwent endovascular treatment (vessel occlusion [48%], flow diversion [26%], and coiling [26%]), while 11.1% were treated surgically. The median (IQR) time to treatment was 6 (4-9) hours from symptom onset. Rebleeding occurred in 23.3% of patients, significantly more frequently than in the overall cohort (p < 0.048). Rebleeding independently predicted in-hospital mortality (adjusted OR 7.4; 95% CI 1.5-35.1; p = 0.011) and long-term disability (adjusted OR 0.08; 95% CI 0.007-0.98; p = 0.04). Internal carotid artery blister aneurysms were independently associated with rebleeding (adjusted OR 8; 95% CI 1.2-50; p = 0.027). CONCLUSIONS:In the context of pSAH, DAs are characterized by distinct clinicoradiological features and carry a significant risk of ultra-early rebleeding, which strongly influences clinical outcome. These findings suggest a potential benefit of ultra-early or immediate treatment in this patient population, pending further validation.

Prone positioning is recommended in acute respiratory distress syndrome (ARDS) to ensure adequate gas exchange. However, it may lead to an increase in intracranial pressure (ICP), mostly due to a reduction of venous return from the brain. ICP can be noninvasively estimated with transcranial color-coded Doppler (TCCD) using methods based on the relationships between the pulsatility index (PI) and ICP or methods based on the estimate of cerebral perfusion pressure (eCPP) and estimate of ICP (eICP). This study was aimed at assessing the effects of a 30° reverse Trendelenburg (‘head up’) prone position on two noninvasive estimators of ICP (eICP and PI). This is a cross-over, longitudinal, physiological study conducted on a cohort of adult patients fulfilling Berlin definition criteria for moderate to severe ARDS without brain injury but with clinical indication to prone positioning. We registered TCCD parameters of cerebral hemodynamic and systemic hemodynamic parameters, blood gas exchange data, and respiratory mechanics parameters in a horizonal supine position, in a 30° semirecumbent supine position, in the standard prone position, and, finally, in the 30° ‘head up’ prone position, obtained by tilting the entire bed to a reverse Trendelenburg position. One-way repeated measures analysis of variance was used to analyze data. In 20 patients included, switching from a supine position to the standard prone position resulted in a significant increase in mean ± SD PI (from 0.99 ± 0.22 to 1.29 ± 0.25, p < 0.01) and eICP (from 12.5 ± 3.8 to 17.5 ± 4.1, p < 0.01), whereas moving from this latter position to the ‘head up’ prone position resulted in a decrease in the mean ± SD PI (from 1.29 ± 0.25 to 1.0 ± 0.23, p < 0.01). Hemodynamic and respiratory mechanics parameters did not differ. The 30° ‘head up’ prone position may limit the increase in PI in moderate to severe ARDS without brain injury. As a noninvasive estimator of ICP, PI may allow detection of changes in ICP when moving from the ‘head up’ semirecumbent supine position to the standard prone position and from this latter position to the ‘head up’ prone position.

The data available at the national level in Italy regarding elective neurosurgical and neuroradiological procedures are limited. This survey aimed to explore clinical practices across Italian centers, focusing on anesthetic strategies, monitoring, and postoperative management. A nationwide survey was conducted, collecting data from centers performing elective craniotomies and interventional neuroradiology. Questions addressed procedural volumes, anesthesia type, monitoring tools, and intraoperative and postoperative management. Among 49 responding centers, 21 were high-volume (>150 craniotomies/year). Intravenous anesthesia was the preferred anesthesia method, though not uniformly applied across volume groups. Awake craniotomy was rarely performed, even in high-volume centers. Bispectral Index™ monitoring was reported in 71.7

Spontaneous intracerebral hemorrhage (ICH) accounts for 9–27

Aims: : Some is known from studies on burn animal models. Burn patients can develop intracranial hypertension. The aim of study is to evaluate feasibility of non-invasive methods for the diagnosis of intracranial hypertension. Methods: : Burns patients were enrolled and studied through ultrasound measurement of optic nerve sheath diameter and transcranial Doppler. Results: : In the 20 patients studied, no pathological values were identified fied without correlations with the extension of the burn. Conclusions: : Starting from animal models, it is legitimate to suspect an underestimation of neuro-complications. The study demonstrates that these methods are applicable to this population, representing an effective method reducing the incidence of neuro-complications.

Intensive Care Medicine is a relatively new discipline that now deals with increasingly complex patients. Aside from the various specificities of the Intensive Care Unit, there are transversal skills that can aid in the care of critically ill patients. Some neurocritical care tools, in particular, deserve adequate dissemination because they have the potential to be useful for a variety of purposes. This manuscript discusses specific indications for electroencephalographic monitoring systems, the use of ultrasonography to measure the diameter of the optic nerve, and, finally, the use of transcranial Doppler. The last two are for the diagnosis or suspicion of intracranial hypertension. Multidisciplinarity and the culture of “patient-centered approach to care” are non-technical skills that are indispensable for quality personalized medicine.

The authors present the life and art of Giuseppe Dagnini, a renowned Italian physician who was born in Bologna in 1866. He was the chief of the Maggiore Hospital in Bologna and authored valuable scientific works on the trigeminocardiac reflex which is still applied in modern clinical practice. Dr. Dagnini firstly described the reflex in 1908 postulating that stimulation of one of the 3 branches of the trigeminal nerve triggers the afferent pathway in lowering heart rate. The authors also provide a modern outlook on the clinical implications of the TCR in neurosurgery, neuroanesthesia, and other medical specialties.

Burn patients still represent an important challenge in critical care medicine today. These patients can develop significant neurological conditions up to intracranial hypertension, but as they find themselves hospitalized outside of neurocritical care and are often subjected to sedation for the complex management, they are sometimes underestimated. The aim of this study is to evaluate the feasibility of non-invasive methods for the early diagnosis of intracranial hypertension in these patients. In this prospective observational study, adult burn patients admitted to intensive care within the first 8 hours of the event were enrolled. These patients were studied through ultrasound measurement of optic nerve sheath diameter and intracranial vessel velocimetry with transcranial Doppler. In the 20 patients studied, no frankly pathological values were identified in the 3 different measurement stages (within 8 hours of the burn, then at 48 and 96 hours) and no correlations were identified between the measured values and the extension of the burn with the related risk of mortality. However, this study, one of a kind, demonstrates that these non-invasive methods are applicable to this specific patient population, and can represent an effective method for reducing the incidence of complications that are dangerous for survival.

BACKGROUND AND PURPOSE: Early brain injury is a major determinant of clinical outcome in poor-grade (World Federation of Neurosurgical Societies [WFNS] IV?V) aneurysmal SAH and is radiologically defined by global cerebral edema. Little is known, though, about the effect of global intracranial hemorrhage volume on early brain injury development and clinical outcome. MATERIALS AND METHODS: Data from the multicentric prospective Poor-Grade Aneurysmal Subarachnoid Hemorrhage (POGASH) Registry of consecutive patients with poor-grade aneurysmal SAH admitted from January 1, 2015, to August 31, 2022, was retrospectively evaluated. Poor grade was defined according to the worst-pretreatment WFNS grade. Global intracranial hemorrhage volume as well as the volumes of intracerebral hemorrhage, intraventricular hemorrhage, and SAH were calculated by means of analytic software in a semiautomated setting. Outcomes included severe global cerebral edema (defined by Subarachnoid Hemorrhage Early Brain Edema Score grades 3?4), in-hospital mortality (mRS 6), and functional independence (mRS 0?2) at follow-up. RESULTS: Among 400 patients (median global intracranial hemorrhage volume of 91?mL; interquartile range, 59?128), severe global cerebral edema was detected in 218/400 (54.5%) patients. One hundred twenty-three (30.8%) patients died during the acute phase of hospitalization. One hundred fifty-five (38.8%) patients achieved mRS 0?2 at a median of 13 (interquartile range, 3?26) months of follow-up. Multivariable analyses showed global intracranial hemorrhage volume as independently associated with severe global cerebral edema (adjusted OR, 1.009; 95% CI, 1.004?1.014; P < .001), mortality (adjusted OR, 1.006; 95% CI, 1.001?1.01; P = .018) and worse clinical outcome (adjusted OR, 0.992; 95% CI, 0.98?0.996; P < .010). The effect of global intracranial hemorrhage volume on clinical-radiologic outcomes changed significantly according to different age groups (younger than 50, 50?70, older than 70?year of age). Volumes of intracerebral hemorrhage, intraventricular hemorrhage, and SAH affected the 3 predefined outcomes differently. Intracerebral hemorrhage volume independently predicted global cerebral edema and long-term outcome, intraventricular hemorrhage volume predicted mortality and long-term outcome, and SAH volume predicted long-term clinical outcome. CONCLUSIONS: Global intracranial hemorrhage volume plays a pivotal role in global cerebral edema development and emerged as an independent predictor of both mortality and long-term clinical outcome. Aging emerged as a reducing predictor in the relationship between global intracranial hemorrhage volume and global cerebral edema.

Background: A subarachnoid hemorrhage due to an aneurysmal rupture (aSAH) is a serious condition with severe neurological consequences. The World Federation of Neurosurgical Societies (WFNS) classification is a reliable predictor of death and long-term disability in patients with aSAH. Poor-grade neurological conditions on admission in aSAH (PG-aSAH) are often linked to high mortality rates and unfavorable outcomes. However, more than one-third of patients with PG-aSAH may recover and have good functional outcomes if aggressive treatment is provided. We developed a risk model called Identifying POor GRade Outcomes (IPOGRO) to predict 6-month mRS outcomes in PG-aSAH patients as a secondary analysis of a previously published study. Methods: All consecutive patients in poor-grade neurological conditions (WFNS IV-V) admitted to our institute from 2010 to 2020 due to aSAH were considered. Clinical and neuroradiological parameters were employed in the univariable analysis to evaluate the relationship with a 6-month modified Rankin Scale (mRS). Then, a multivariable multinomial regression model was performed to predict 6-month outcomes. Results: 149 patients with PG-aSAH were included. Most patients were surgically treated, with only 33.6% being endovascularly treated. The 6-month mRS score was significantly associated with clinical parameters on admission, such as lowered Glasgow Coma Scale (GCS), leukocytosis, hyperglycemia, raised Systolic Blood Pressure (SBP), greater Simplified Acute Physiology Score (SAPS II score), increased initial serum Lactic Acid (LA) levels, and the need for Norepinephrine (NE) administration. Neuroradiological parameters on the initial CT scan showed a significant association with a worsening 6-month mRS. The IPOGRO risk model analysis showed an association between a WFNS V on admission and a poor outcome (mRS 4-5), while raised SBP was associated with mortality. Conclusions: Our IPOGRO risk model indicates that PG-aSAH patients with higher SBP at admission had an increased risk of death at 6-month follow-up, whereas patients with WFNS grade V at admission had an increased risk of poor outcome but not mortality.

BackgroundThe management of patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is burdened by an unfavorable prognosis even with aggressive treatment. The aim of the present study is to investigate the risk factors affecting 30-day mortality in poor-grade aSAH patients.MethodsWe performed a retrospective analysis of a prospectively collected database of poor-grade aSAH patients (World Federation of Neurosurgical Societies, WFNS, grades IV and V) treated at our institution from December 2010 to December 2020. For all variables, percentages of frequency distributions were analyzed. Contingency tables (Chi-squared test) were used to assess the association between categorical variables and outcomes in the univariable analysis. Multivariable analysis was performed by using the multiple logistic regression method to estimate the odds ratio (OR) for 30-day mortality.ResultsA total of 149 patients were included of which 32% had WFNS grade 4 and 68% had WFNS grade 5. The overall 1-month mortality rate was 21%. On univariable analysis, five variables were found to be associated with the likelihood of death, including intraventricular hemorrhage (IVH ≥ 50 mL, p = 0.005), the total amount of intraventricular and intraparenchymal hemorrhage (IVH + ICH ≥ 90 mL, p = 0.019), the IVH Ratio (IVH Ratio ≥ 40%, p = 0.003), posterior circulation aneurysms (p = 0.019), presence of spot sign on initial CT scan angiography (p = 0.015).Nonetheless, when the multivariable analysis was performed, only IVH Ratio (p = 0.005; OR 3.97), posterior circulation aneurysms (p = 0.008; OR 4.05) and spot sign (p = 0.022; OR 6.87) turned out to be independent predictors of 30-day mortality.ConclusionThe risk of mortality in poor-grade aSAH remains considerable despite maximal treatment. Notwithstanding the limitations of a retrospective study, our report highlights some neuroradiological features that in the emergency setting, combined with leading clinical and anamnestic parameters, may support the multidisciplinary team in the difficult decision-making process and communication with family members from the earliest stages of poor-grade aSAH. Further prospective studies are warranted.

Transcranial Doppler (TCD) is a repeatable, at-the-bedside, helpful tool for confirming cerebral circulatory arrest (CCA). Despite its variable accuracy, TCD is increasingly used during brain death determination, and it is considered among the optional ancillary tests in several countries. Among its limitations, the need for skilled operators with appropriate knowledge of typical CCA patterns and the lack of adequate acoustic bone windows for intracranial arteries assessment are critical. The purpose of this review is to describe how to evaluate cerebral circulatory arrest in the intensive care unit with TCD and transcranial duplex color-coded doppler (TCCD).