Nils Hecht

Background: Sex differences in cerebrovascular disease are established determinants of outcome in acute stroke care and vascular interventions, but evidence in cerebrovascular bypass surgery remains limited. This study examined whether biological sex was associated with outcome after superficial temporal artery to middle cerebral artery (STA-MCA) bypass in patients with atherosclerotic cerebrovascular disease (ACVD). Methods: We retrospectively screened adults undergoing extracranial-to-intracranial (EC-IC) bypass (2012–2025) and included ACVD patients treated by STA-MCA bypass with available follow-up. The primary outcome was modified Rankin Scale (mRS) at latest follow-up, analyzed using proportional odds regression. Multivariable models adjusted for age, preoperative mRS, and vascular comorbidities. Cerebrovascular reserve capacity (CVRC) was analyzed in a subgroup. Results: A total of 140 patients (30.7% female) were included. Disease morphology varied by sex, with more multivessel (65.1% vs. 47.4%) and stenotic disease (39.5% vs. 20.6%) in females and more isolated internal carotid artery occlusion in males (43.3% vs. 16.3%). The 30-day risk of symptomatic ischemic stroke was higher in females than in males (9.3% vs. 1.0%). A similar pattern was observed at follow-up (median 13.5 months), with ischemic events predominating in females (16.3% vs. 7.2%) and hemorrhagic events occurring exclusively in males (5.2%). Female sex was independently associated with worse functional outcome (OR 2.59, 95% CI 1.28–5.30, p=0.008). Preoperative mRS was the strongest determinant of outcome (OR 4.30, 95% CI 3.07–6.18, p<0.001). Adjusted analysis detected no significant association between CVRC and outcome (OR 0.80, 95% CI 0.24–2.70, p=0.721). Conclusions: Female sex was independently associated with worse functional outcome after STA-MCA bypass, independent of preoperative functional status, hemodynamic impairment and cardiovascular comorbidities. These findings identify sex as a clinically relevant determinant of outcome in cerebrovascular bypass surgery and should be considered in future risk stratification and trial design.

Delayed cerebral ischemia (DCI) occurs several days after subarachnoid hemorrhage (SAH) and could therefore be mitigated by treatment intervention. As testament to the great challenge of designing effective trials, however, the prevalence and severity of DCI have remained unchanged for decades. A critical need in the development of novel prophylactic treatments is optimizing initial prediction for DCI, since improved risk stratification based on prognosis could increase the statistical power of randomized trials, thereby increasing the probability of success and reducing costs. The primary objective of this study, using secondary analysis of data from the DISCHARGE-1 trial, was to evaluate the power of initial variables (medical history, clinical examination, and pre-interventional CT) for predicting the volume of delayed infarcts in SAH survivors. In multivariate analysis of 164 early survivors with pre-interventional CT within 72 hours of the initial hemorrhage, the modified Hijdra scale (mHS) (β= -0.016, p<0.001) was the only independent predictor of infarct volume due to DCI, outperforming common clinical scores und manually segmented hemorrhage volumes. Furthermore, early brain injury (EBI) volume identified high-risk patients for early death early on. Thus, we propose a combined approach using mHS and EBI volume for early risk stratification in randomized trials targeting DCI.

Background: External ventricular drainage (EVD)-associated ventriculitis is a serious complication in neurocritical care. Diagnostic uncertainty and heterogeneous infection prevention and control (IPC) practices may contribute to variable ventriculitis rates and potentially avoidable antibiotic exposure. We evaluated the impact of implementing an interdisciplinary standard operating procedure (SOP) on ventriculitis incidence and antimicrobial stewardship (ABS)-related outcomes. Methods: We conducted a retrospective single-centre pre–post study in one intensive care unit (ICU) at Charité–Universitätsmedizin Berlin (2019–2023). Adult patients with EVDs were assigned to a pre-SOP cohort (Group 1) or a post-SOP cohort (Group 2). The SOP comprised standardized IPC protocols, an algorithm-based diagnostic workup and evidence-based anti-infective strategies. The primary endpoint was study-defined EVD-associated ventriculitis, adjudicated retrospectively using uniform criteria. Secondary endpoints included empirical antibiotic initiation, duration of therapy, antibiotic consumption, ICU length of stay (LOS), mortality, and SOP adherence. Cerebrospinal fluid (CSF) parameters and clinical signs were summarized descriptively. Results: A total of 166 patients were included (pre-SOP, Group 1: n = 50; post-SOP, Group 2: n = 116). The study-defined ventriculitis rate decreased from 22% [95% CI 0.13–0.35] to 9.5% [95% CI 0.05–0.16] with an unadjusted OR 0.37 [95% CI 0.13–1.04]; p = 0.053, attenuated with an adjusted OR of 0.50 [95% CI 0.19–1.35]; p  = 0.169. Incidence density declined from 21.1 to 12.0 per 1000 EVD days. Empirical antibiotic use fell from 28.0% [95% CI 17.5–41.7] to 12.9% [95% CI 8.0–20.2], corresponding to an unadjusted OR of 0.38 [95% CI 0.17–0.87] and median therapy duration decreased from 16 [95% CI 13.5–18.5] to 10 days [95% CI 6.5–13.5]. ICU LOS shortened by 4 days, while ICU mortality remained unchanged (26% vs. 27%). Conclusion: An interdisciplinary SOP was associated with reduced empirical antibiotic exposure and shorter treatment duration without affecting ICU mortality. The SOP appeared to improve diagnostic consistency and standardization of the workup rather than diagnostic test performance. Trial registration: The study is registered in the German Clinical Trial Register (DRKS ID: 00036075) in February 2025.

Background: Continuous, wearable-based vital sign monitoring can enhance patient safety and reduce intensive care demands but is not routinely used on standard neurosurgical wards. This study assessed alarm events and technology acceptance during the implementation of such a system for postoperative patients in a university hospital’s neurosurgical ward. Methods: In this pilot feasibility study, selected patients were continuously monitored for 12 to 24 hours after elective neurosurgery on a 44-bed ward. Phase 1 (June to December 2019) used 12 mobile units with manual alarm documentation; Phase 2 (August 2023 to January 2024) used 44 fixed bedside units with automatic documentation. Alarm patterns and nurse-rated technology acceptance (4-point Likert scale) were analyzed. Results: Vital signs were monitored in 214 patients (median age: 58, IQR: 42 to 70) in Phase 1 and 290 patients (median age: 60, IQR: 43 to 77) in Phase 2. Procedures included cranial, spinal, and peripheral nerve surgeries. Phase 1 recorded 30 nonclinical alarms and no clinical alarms. In contrast, Phase 2 registered 14,500 clinical and 185,744 nonclinical alarms, mostly from detached sensors (177,989/185,744; 96%). Clinical alarms were mainly due to hypoxia (8305/14,500; 57%) and tachycardia (3487/14,500; 30%). Most alarms were acknowledged within 30 seconds (clinical: 12,969/14,500; 90% and nonclinical: 181,447/185,744; 98%), with delayed responses mostly for nonclinical events (3625/4189; 87%). Nurses reported improved convenience, usability, and system connection in Phase 2. Conclusions: Wearable-based vital sign monitoring is feasible on neurosurgical wards, but high nonclinical alarm rates highlight the need to refine alarm management strategies for effective clinical integration.