Background: Malignant swelling is a fatal complication that can occur abruptly in space-occupying cerebellar infarction. We aimed to establish markers that predict malignant swelling in cerebellar infarction. Methods: We retrospectively analysed data of stroke patients who were treated in our hospital between 2014 and 2020. Malignant swelling was defined as a mass effect in the posterior cranial fossa, accompanied by a decrease in consciousness due to compression of the brainstem and/or the development of obstructive hydrocephalus. Statistical analyses were performed on multiple variables to identify predictors of malignant swelling. Results: Among 7284 stroke patients, we identified 487 patients with an infarct in the cerebellum. 93 patients were suitable for analysis having space-occupying cerebellar infarction. 33 of 93 (35.5%) patients developed malignant swelling. Multivariable analysis revealed infarct volume as the main predictor being independently associated with the development of malignant swelling with a cut-off infarct volume of 38 cm³ being associated with a swelling rate of >50% (OR 32.0, p<0.001). Higher NIHSS (National Institutes of Health Stroke Scale) score on admission (median NIHSS 12 vs 4, OR 1.078; p=0.008) and the presence of additional brainstem infarction (51.5% vs 16.7%, OR 5.312; p=0.013) were associated with the development of malignant swelling in univariate analyses. 13 of 33 (39.4%) cases of malignant swellings occurred after more than 3 days. Conclusions: Infarct volume was the key significant predictor of malignant swelling in space-occupying cerebellar infarction. With many cases of malignant swelling occurring after more than 72 hours, we advocate prolonged neurological monitoring.

Background: Increased peak systolic velocity (PSV) in transcranial Doppler or Duplex sonography (TCD) of the middle cerebral artery (MCA) after endovascular thrombectomy (EVT) for large vessel occlusion in acute ischemic anterior circulation stroke has been associated with poor functional outcome and increased risk of symptomatic intracranial hemorrhage (ICH). Objective: We evaluated whether increased MCA-PSV is associated with the development of malignant media infarction after EVT. Methods: We retrospectively identified all patients who underwent EVT for acute anterior circulation ischemic stroke at our stroke center from January 2021 to July 2024. Increased MCA-PSV on TCD was defined as >30% mean PSV in the treated MCA compared with the contralateral MCA. The development of malignant media infarction was evaluated according to predefined clinical and neuroimaging criteria. Multivariable regression models were used to identify associations between MCA-PSV and the development of malignant media infarction. Results: Out of a total cohort of 377 patients, 49 (13.0%) developed malignant media infarction. In multivariable analysis, MCA-PSV increase was significantly associated with malignant media infarction (odds ratio (OR), 53.3 (95% confidence interval (CI): 18.74, 151.54); p < 0.001). Furthermore, the development of malignant media infarction was also associated with secondary ICH (OR, 6.4 (95% CI: 2.16, 19.03); p < 0.001) and higher baseline National Institutes of Health Stroke Scale (OR, 1.25 (95% CI: 1.14, 138); p < 0.001). Conclusion: Increased MCA-PSV can act as a predictive marker for the development of malignant media infarction. TCD may serve as a valuable bedside tool in individual risk assessment in early postinterventional surveillance.

Background and Purpose: Decompressive surgery is a potentially life-saving treatment in patients with malignant space-occupying cerebellar infarction. However, there is only limited literature on functional outcomes and complications after surgery. Our aim was to establish markers which predict poor outcome. Methods: We retrospectively analyzed data of all patients who underwent surgery due to malignant swelling of a space-occupying cerebellar infarction in our hospital between 2005 and 2023. Statistical analyses were conducted on multiple parameters to identify predictors of poor functional outcome (mRS 4–6) 90 days after surgery. Complications during hospitalization were reviewed for each patient. Results: In total, 58 patients received decompressive surgery. The 90-day mortality rate was 27.6% (n = 16). A good functional outcome (mRS 0–3) 90 days after surgery was achieved in 24 patients (41.4%). Multivariable analysis revealed multiple factors associated with a poor outcome on day 90 (mRS 4–6): a higher premorbid mRS score (OR 2.715 [95% CI, 1.166–6.323]; p = 0.021), higher NIHSS score on admission (OR 1.088 [95% CI, 1.014, 1.168]; p = 0.019) and the presence of an additional brainstem infarction (OR 7.035, [95% CI, 1.255, 39.424], p = 0.027). Hyperactive delirium was associated with good clinical outcome (OR 0.020 [95%CI, 0.001–0.623]; p = 0.026). Aspiration pneumonia (n = 22, 37.9%), urinary tract infection (n = 15, 25.9%), and hyperactive delirium (n = 8, 13.8%) were the most common complications during hospitalization. Conclusions: Decompressive surgery is a safe, life-saving treatment for malignant space-occupying cerebellar infarction. Higher premorbid mRS, higher NIHSS score on admission and the presence of brainstem infarction are associated with a poor functional outcome.

Background: In addition to infectious fever, stroke-related disturbances in thermoregulation, referred to as central fever, are frequently observed in patients with stroke, particularly in those with intracerebral haemorrhage (ICH). Rapid identification of the underlying cause of fever is crucial for treatment decisions. This study aims to identify clinical, laboratory and radiological parameters that differentiate central fever from infectious fever in patients with ICH. Methods: We included 547 ICH patients in this retrospective, single-centre cohort study. Fever was defined as a body temperature exceeding 38.3°C for at least 2 consecutive days. Central fever was characterised by the absence of an infection diagnosis, cultured pathogens and any other identified cause of fever. CT scans were assessed visually and with a 3D nn-UNet for segmentation and subsequent quantification of all ICH components. Voxel-based lesion-symptom mapping was performed to identify lesion locations related to central fever. Univariate analyses and multiple logistic regression were conducted. Results: Fever occurred in 213 patients: 54 with central fever, 156 with infectious fever and 3 with other causes. Central fever was linked to higher scores on the National Institutes of Health Stroke Scale and worse outcomes (p<0.01). It had an earlier onset (median day 2 (1–3) vs 6 (4–9) p<0.01) and was more frequent in patients with lesions affecting the left midbrain and hypothalamic region (p<0.01). In contrast, infectious fever was associated with higher levels of infectious parameters (ie, C reactive protein, procalcitonin and leucocyte count). Its early onset (p<0.001) and affection of the left hypothalamic region (OR=9.7 (1.6 to 58.837), p=0.013) emerged as independent predictors of central fever. Conclusions: Early onset and hypothalamic involvement are the strongest indicators of central fever, which may help guide evidence-based treatment decisions for patients with fever following ICH.

Background: Bilateral mydriasis is usually associated with severe brain stem damage or drug-induced sympathomimetic stimulation. Herein we report it as a unique neurologic complication of Hodgkin’s lymphoma. Case presentation: A 23-year-old woman presented at our emergency department with dilated pupils unresponsive to light stimuli. MRI and CT scans showed bilaterally enlarged lymph nodes in the mediastinum and supraclavicular compressing the carotid artery on both sides. The histologic examination of lymph node biopsy specimens confirmed the diagnosis of Hodgkin’s lymphoma. Conclusion: Pathologies around the carotid artery causing oculosympathetic spasm should be considered among the possible causes of a mydriasis, especially when other common causes like brain stem impairment are excluded.

Background: Fever occurs frequently in patients with intracerebral hemorrhage (ICH) and is associated with worse functional outcomes. Rapid identification of the fever’s cause is crucial for guiding diagnostics and treatment. Data on the distribution of different fever causes in ICH are limited, and the diagnostic value of the day of fever onset remains uncertain. This study aimed to assess the distribution of fever causes in a large cohort of ICH patients and to evaluate whether temporal patterns of fever onset are associated with its underlying cause in a clinically meaningful manner. Methods: This retrospective single-center study included 547 patients with spontaneous ICH. Fever was defined as a body temperature exceeding 38.3 °C for at least two consecutive days. Fever causes were evaluated by two blinded investigators and categorized as infectious, central, or other causes. Infectious fever causes were further specified. Results: Fever occurred in 213 patients (39%) and was associated with longer hospital and ICU stays (both p < 0.01) and poor functional outcome (odds ratio 2.0, 95% CI 1.1–3.6). The three most frequent fever etiologies (>90% of cases) were pneumonia, central fever, and catheter-associated infections (i.e., urethral tract infections, ventriculitis, and central line-associated bloodstream infections). Median onset day differed across etiologies (overall p < 0.001): central fever developed earliest (2 [IQR 1–3] days), followed by pneumonia (5 [IQR 4–7] days) and catheter-associated infections (8 [IQR 5–12] days). Conclusions: In ICH, the day of fever onset may provide a useful clue to its etiology and could support clinical decision-making, but prospective validation is needed.