Background: Innovative automated perfusion software solutions offer support in the management of acute stroke by providing information about the infarct core and penumbra. While the performance of different software solutions has mainly been investigated in patients with successful recanalization, the prognostic accuracy of the hypoperfusion maps in cases of futile recanalization has hardly been validated. Methods: In 39 patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) in the anterior circulation and poor revascularization (thrombolysis in cerebral infarction (TICI) 0-2a) after mechanical thrombectomy (MT), hypoperfusion analysis was performed using three different automated perfusion software solutions (A: RAPID, B: Brainomix e-CTP, C: Syngo.via). The hypoperfusion volumes (HV) as Tmax > 6 s were compared with the final infarct volumes (FIV) on follow-up CT 36–48 h after futile recanalization. Bland–Altman analysis was applied to display the levels of agreement and to evaluate systematic differences. Based on the median hypoperfusion intensity ratio (HIR, volumetric ratio of tissue with a Tmax > 10 s and Tmax > 6 s) patients were dichotomized into high- and low-HIR groups. Subgroup analysis with favorable (<0.6) and unfavorable (≥0.6) HIR was performed with respect to the FIV. HIR was correlated to clinical baseline and outcome parameters using Pearson’s correlation. Results: Overall, there was good correlation without significant differences between the HVs and the FIVs with package A (r = 0.78, p < 0.001) being slightly superior to B and C. However, levels of agreement were very wide for all software applications in Bland-Altman analysis. In cases of large infarcts exceeding 150 mL the performance of the automated software solutions generally decreased. Subgroup analysis revealed the FIV to be generally underestimated in patients with HIR ≥ 0.6 (p < 0.05). In the subgroup with favorable HIR, however, there was a trend towards an overestimation of the FIV. Nevertheless, packages A and B showed good correlation between the HVs and FIVs without significant differences (p > 0.2), while only package C significantly overestimated the FIV (−54.6 ± 56.0 mL, p = 0.001). The rate of modified Rankin Scale (mRS) 0–3 after 3 months was significantly higher in favorable vs. unfavorable HIR (42.1% vs. 13.3%, p = 0.02). Lower HIR was associated with higher Alberta Stroke Program Early CT Score (ASPECTS) at presentation and on follow-up imaging, lower risk of malignant edema, and better outcome (p < 0.05). Conclusion: Overall, the performance of the automated perfusion software solutions to predict the FIV after futile recanalization is good, with decreasing accuracy in large infarcts exceeding 150 mL. However, depending on the HIR, FIV can be significantly over- and underestimated, with Syngo showing the widest range. Our results indicate that the HIR can serve as valuable parameter for outcome predictions and facilitate the decision whether or not to perform MT in delicate cases.

Background: Heart rate variability (HRV) is a well-established marker of autonomic nervous system (ANS) activity. It is also an important tool for investigating cardiovascular and neurological health. Changes in HRV have been associated with epilepsy and sudden unexpected death in epilepsy (SUDEP), conditions in which autonomic dysregulation is believed to play a significant role. HRV is traditionally measured using electrocardiography (ECG) under standardized laboratory conditions. Recently, however, wearable devices such as the Empatica E4 wristband have emerged as promising tools for continuous, noninvasive HRV monitoring in real-life, ambulatory, and clinical settings where laboratory infrastructure may be lacking. Methods: We evaluated the validity and clinical utility of the Empatica E4 wristband in two cohorts. In the first cohort of healthy controls (n = 29), we compared HRV measures obtained with the E4 against those obtained with a gold-standard laboratory ECG device under seated rest and metronomic breathing conditions. In persons with epilepsy (PWE, n = 42), we assessed HRV across wake and sleep states, as well as during exposure to sodium channel blockers. This was done to determine whether the device could detect physiologically and clinically meaningful changes in autonomic nervous system (ANS) function. Results: In healthy participants, the Empatica E4 provided heart rate (HR), root mean square of successive R-R intervals (RMSSD), and standard deviation of all interbeat intervals (SDNN) values that were strongly correlated with laboratory measurements. Both devices detected the expected increase in RMSSD during metronomic breathing; however, the E4 consistently reported higher absolute values than the ECG. In patients with epilepsy (PWE), the E4 reliably captured parasympathetic activation during sleep and detected a significant reduction in heart rate variability (HRV) in patients taking sodium channel blockers, demonstrating its sensitivity to clinically relevant autonomic changes. Conclusions: The Empatica E4 wristband is valid for measuring HRV in research and clinical contexts. It can detect modulations of ANS activity that are physiologically meaningful. While HRV metrics were robust, other signals, such as electrodermal activity and temperature, were less reliable. These results highlight the potential of wearable devices as practical alternatives to laboratory-based autonomic testing, especially in emergency and resource-limited settings, and emphasize their importance in epilepsy care risk assessment.

Postpump chorea is a rare hyperkinetic movement disorder following cardiac surgery with cardiopulmonary bypass. Although initially described in pediatric patients, postpump chorea is increasingly recognized in adults. We report the case of a 65‐year‐old woman who developed severe choreiform movements approximately 2 weeks after cardiac surgery. Extensive diagnostic workup including cerebrospinal fluid analysis revealed no alternative etiology. Notably, hypothermia had only been mild during cardiac surgery, and there were no characteristic basal‐ganglia MRI abnormalities. Treatment with tiapride, a selective dopamine D2/D3 receptor antagonist with established antichoreic effects was followed by rapid neurological improvement and complete remission of symptoms. This is one of the first reports of tiapride in adult postpump chorea, supporting its role as a potentially useful symptomatic therapeutic option in this rare complication.

Background/Objectives: Several imaging scores have been developed for subarachnoid hemorrhage (SAH), but their prognostic performance for long-term functional outcome and post-hospital complications remains insufficiently characterized. We evaluated whether five admission imaging scores (modified Fisher, Claassen, Hijdra, Graeb, IVH) independently predict 12-month functional outcome and major secondary endpoints. Methods: We performed a retrospective cohort study of 479 consecutive patients with atraumatic SAH recorded in a prospectively maintained institutional registry. Admission CT/MRI was scored by two board-certified neuroradiologists blinded to clinical outcomes. The primary endpoint was unfavorable functional outcome at 12 months (modified Rankin scale [mRS] 4–6). Secondary endpoints included 12-month mortality, delayed cerebral ischemia (DCI), post-hemorrhagic epilepsy, shunt-dependent hydrocephalus, return to work, and patient-reported health. Receiver operating characteristic (ROC) analyses and multivariable logistic regression adjusted for established predictors were conducted. Results: All imaging scores were significantly associated with the primary endpoint and demonstrated adequate discrimination (area under the curve [AUC] ~0.70–0.74), with the Graeb and IVH scores performing highest for long-term functional outcome, mortality, and shunt dependence. Associations with DCI and epilepsy were modest. In multivariable analyses, all imaging scores remained independently associated with mRS 4–6. Subgroup analyses showed stronger prognostic performance in good-grade SAH, aneurysmal SAH, and cases with concomitant intraventricular hemorrhage. Conclusions: Admission imaging burden independently predicts 12-month functional outcome, mortality, and shunt dependence after SAH. Incorporating IVH-oriented measures alongside established clinical grading may improve individualized risk stratification, particularly in good-grade and aneurysmal SAH.

Background: To assess associations between possible dysfunction of autonomic cardiovascular modulation and hemispheric localization, seizure frequency, disease duration, and antiseizure medication (ASM) in temporal lobe epilepsy (TLE). Methods: In this prospective observational study, cardiovascular autonomic modulation was monitored in 31 patients with TLE (12 patients with right TLE, 19 patients with left TLE). From 5 min time series of R–R intervals (RRI) and blood pressure (BP) recordings, we calculated autonomic parameters of sympathetic, parasympathetic, and total autonomic cardiovascular modulation. Data were compared to those of 30 healthy volunteers. Subgroup analyses were performed according to (1) disease localization (right vs. left hemispheric TLE), (2) seizure frequency (< vs. >1/month) and disease duration (< vs. >10 years), (3) number of ASMs, and (4) participants’ age (< vs. >30 years). Results: Between right TLE patients, left TLE patients, and controls, there were no significant differences in the assessed bio-signals. Parameters of sympathetic and total autonomic modulation were slightly lower in right TLE patients than in controls. Additionally, reduced vagal modulation was observed in right TLE patients taking three ASMs or not taking any ASMs at all (applicable to one patient) compared to healthy controls. In general, TLE patients with <1 seizure/month showed lower parameters of sympathetic modulation than healthy controls, with differences reaching statistical significance in left TLE patients. In contrast, parameters reflecting vagal tone showed insignificantly, yet consistently, lower values in left TLE patients with increasing seizure frequency. Alterations in autonomic cardiovascular modulation observed across age-matched subgroups were comparable. Conclusions: A trend towards lower values of sympathetic modulation in patients with right TLE supports previous findings suggesting right hemispheric mediation of sympathetic regulation. A decrease in parasympathetic modulation with increasing seizure frequency underscores the importance of sufficient seizure control in order to prevent autonomic complications. In contrast, the absence of significant associations between disease duration and autonomic alterations suggests that epilepsy exerts an early and clinically relevant effect on the autonomic nervous system. Due to comparable alterations in autonomic modulation in a patient without antiseizure medication and in patients undergoing polytherapy, ASM side effects may not account solely for the observed autonomic dysregulation of our TLE patients.

Background: This study aims to assess associations between occurrence of delayed cerebral ischemia (DCI) in spontaneous subarachnoid hemorrhage (SAH) and possible dysfunction of autonomic cardiovascular modulation compared to transcranial Doppler ultrasound (TCD). Methods: In this prospective observational study, 53 patients with spontaneous SAH were enrolled, and 17 patients met DCI criteria, i.e., new cerebral infarction > 72 h after SAH onset on follow-up CT scans. Autonomic modulation as well as TCD-frequencies were monitored within 24 h after SAH onset and then daily until day 10. From 5 min time-series of R–R-interval (RRI) and blood-pressure (BP) recordings, parameters of sympathetic, parasympathetic and total autonomic cardiovascular modulation were calculated, including time- and frequency-domain parameters. Data were compared between patients with and without DCI. Further subgroup analyses were performed according to functional outcome after 3 to 6 months (i.e., favorable outcome, modified Rankin Scale (mRS) ≤ 3 vs. unfavorable outcome, mRS > 3) regardless of DCI. Results: RRI and BP values as well as TCD frequencies did not differ between patients with and without DCI. Compared to No DCI patients, the cohort of DCI patients had significantly lower values of sympathetic modulation (RRI-LF powers, SBP-LF powers) on days 5 and 9 after SAH, significantly lower values of total autonomic modulation (RRI-SD, RRI-CV, RRI-total powers) and insignificantly lower values of parasympathetic modulation (RMSSDs, RRI-HF powers) on day 5 after SAH. Parameters of sympathetic, parasympathetic, and total autonomic modulation did not differ significantly between patients with favorable and unfavorable outcomes, but showed slightly lower values in the unfavorable outcome group. Yet, additionally calculated value of normalized RRI-LF and normalized RRI-HF powers, as well as LF/HF ratios were significantly different in the unfavorable outcome cohort. Conclusions: Not only within the acute phase, but also during the first days after disease onset, spontaneous SAH induces a decrease in sympathetic, parasympathetic and total autonomic cardiovascular modulation. In contrast to standard diagnostic evaluation for detecting clinically relevant vasospasms—i.e., TCD—autonomic dysfunction was associated with development of DCI and poor clinical outcome. Thus, assessment of heart rate variability may predict augmented risk of cardiovascular complications and may represent a promising adjunctive marker within multimodal neuromonitoring in SAH patients.