Purpose: The “no-reflow phenomenon” refers to persisting microvascular failure despite complete macrovascular reperfusion. We investigated whether parametric color coding (PCC) analysis of the DSA-series after successful mechanical thrombectomy could predict microvascular dysfunction. Methods: We retrospectively analyzed the STAMINA database for patients admitted to a single tertiary care center over a 5-year period with MCA-Occlusion (M1 or M2 branch), large penumbra, TICI 3 and infarct volume exceeding 15 ml on follow-up CT—presumed to reflect microvascular failure. These 55 patients were compared to 55 controls with infarcts < 15 ml on follow-up CT. As proof of concept, we included 42 non-stroke patients undergoing elective treatment of unruptured intracranial aneurysms. Using iFlow-PCC software, we calculated critical flow parameters, including cerebral circulation time (CirT), relative cortical time to peak (rTTP), and microvascular transit time (mTT). Results: Microvascular transit time (mTT) was significantly prolonged in the suspected microvascular failure group (3.22 ± 0.85 s) compared to the recanalization control group (2.79 ± 0.64 s; p = 0.003) and the non-stroke interventional control group (2.54 ± 0.90 s, p = 0.0003). The group with suspected microvascular failure exhibited a median modified Rankin Score at 3 months (mRS 3M: 4, IQR: 3–5) and a higher number of poor outcomes (mRS 5–6; n = 16) compared to the control group with similar strokes (median mRS 3M: 2, IQR: 1–4; mRS 5–6: n = 4). Conclusion: Prolonged microvascular transit time (mTT) can predict microvascular failure after thrombectomy. Angiographic flow analysis, performed directly in the angio-suite allows early identification of patients who may benefit from additional therapy like intra-arterial thrombolysis.

Objectives: We aimed to determine temporal patterns of blood–brain barrier (BBB) dysfunction, edema formation and functional recovery in acute stroke. Materials and Methods: Patients of two observational studies on ischemic and hemorrhagic stroke between 2006 and 2019 were analyzed. Blood–brain barrier dysfunction was assessed using the cerebrospinal fluid-to-plasma albumin ratio. Edema formation was measured on all available imaging scans during hospital stay. Relative edema was defined as the ratio of edema volume to stroke volume. Multivariable regression models were applied to analyze associations and calculate predicted probabilities. Results: Overall, 138 stroke patients, 103 (74.6%) with ischemic stroke and 35 (25.4%) with hemorrhagic stroke, were analyzed. The predicted probability of substantial BBB dysfunction was approximately 46 (37–55) % among patients analyzed on 1 day after symptom onset and declined with increasing time, thereafter reaching 10 (3–29) % on day 30. The maximal extent of edema was lower in ischemic versus hemorrhagic stroke (relative edema: 1.5 [1.2–1.8] vs. 2.6 [1.9–4.5], p = 0.003) and occurred earlier after stroke onset (5.9 [4.6–8.5] days vs. 12.3 [9.7–16.4] days, p = 0.009). BBB dysfunction was associated with increased edema formation (adjusted relative edema: 4.0 [2.8–4.5] vs. 2.3 [1.8–3.0], p = 0.037) and lower chances of functional recovery (20/48 [41.7%] vs. 51/90 [56.7%], adjusted Odds Ratio: 0.37 [0.16–0.88], p = 0.025) in both ischemic and hemorrhagic stroke patients. Conclusions: BBB dysfunction frequently occurred in acute ischemic and hemorrhagic stroke and was associated with secondary injury and worse clinical outcomes. Future studies should evaluate BBB dysfunction as a potential therapeutic target using advanced imaging techniques early after stroke onset. Edema formation was aggravated and prolonged in hemorrhagic versus ischemic stroke.

Endovascular therapy (EVT) has become the standard of care for selected patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). However, the impact of advanced age on EVT outcomes remains unclear. This study evaluated the safety, efficacy, and outcomes of EVT in elderly patients (≥85 years) compared to younger individuals in a real-world cohort. We conducted a retrospective analysis of the Stroke Research Consortium in Northern Bavaria (STAMINA) database, identifying 581 patients with occlusion in the anterior circulation who underwent EVT. Patients were stratified by age (≥85 years: n=95; <85 years: n=486). The primary outcome was functional recovery at 90 days, defined as a modified Rankin Scale (mRS) score ≤ pre-stroke mRS or pre-stroke mRS +1. Secondary outcomes included good functional outcome (mRS ≤2), mortality, successful EVT (TICI ≥ 2b), and symptomatic intracerebral hemorrhage (sICH). Elderly patients had a significantly higher 90-day mortality rate (53.8% vs 22.3%, p<0.001) and lower rates of good functional outcomes (1.1% vs. 27.0%, p<0.001). Functional recovery occurred in 13.7% of elderly patients compared to 21.0% in younger patients (p=0.14). Rates of sICH were similar (12.6% vs. 8.8%, p=0.34). Pre-stroke mRS was a significant predictor of good outcome in the elderly, with each one-point increase associated with a 56% decrease in the odds of achieving independence (OR 0.43, 95% CI 0.32-0.61; p<0.001). EVT is technically feasible in elderly patients but associated with worse outcomes and higher mortality. Age alone should not exclude patients from EVT, though careful consideration of pre-stroke status is essential for individualized decision-making.

Background: Glioblastoma (GB) is the most aggressive primary brain tumor in adults. Tumor-associated epilepsy (TAE) at diagnosis is common, yet its prognostic significance remains unclear. Methods: We analyzed a retrospective multicenter test cohort of 855 GB patients (Aachen, Hamburg, Bielefeld) and validated findings in a prospectively collected cohort of 344 patients (Erlangen). Survival was assessed using multivariable Cox regression, propensity score matching, and interaction modeling of TAE and extent of resection (EOR). Molecular profiling included methylation-based classification, epigenetic deconvolution, and spatial transcriptomics. Results: Tumor-associated epilepsy was independently associated with improved survival (hazard ratio [HR] 0.81, 95% CI 0.69-0.99, P = .036, absolute survival advantage ∼4-5 months). This effect was validated in the independent cohort (C-index 0.68, 95% CI 0.62–0.74) and persisted in propensity-matched analyses (HR 0.74, 95% CI 0.56-0.96, P = .027). Interaction modeling revealed that gross total resection (GTR) improved survival in both groups but particularly in patients with TAE (EOR interaction HR 0.69, 95% CI 0.49-0.99, P = .041). In this subgroup, partial resection provided no significant advantage over biopsy, whereas patients without seizures benefited incrementally from both partial resection and GTR. Molecular analysis demonstrated enrichment of the RTK II subtype, differentiated cell states, and an inflammatory microenvironment in GB with TAE; tumors without seizures displayed neuronal and stem-like features. Functional validation using electrogenomics showed that GB cortical slices with increased inflammatory score exhibited synchronization of action potentials characteristic for seizure-like epileptiform activity. Conclusions: Tumor-associated epilepsy at diagnosis is a favorable prognostic marker in GB, defining a biologically distinct subgroup. Seizure status modifies the prognostic effect of surgical resection, underscoring the importance of GTR particularly in patients presenting with TAE.

Objective: This study aimed to evaluate whether modifying the post-processing algorithm of Twin-Spiral Dual-Energy computed tomography (DECT) improves infarct detection compared to conventional Dual-Energy CT (DECT) and Single-Energy CT (SECT) following endovascular therapy (EVT) for large vessel occlusion (LVO). Methods: We retrospectively analyzed 52 patients who underwent Twin-Spiral DECT after endovascular stroke therapy. Ten patients were used to generate a device-specific parameter (“y”) using an AI-based neural network (SynthSR). This parameter was integrated into the post-processing algorithm for edema map generation. Quantitative Hounsfield unit (HU) measurements were used to assess density differences in ischemic brain tissue across conventional virtual non-contrast (VNC) images and edema maps. Results: The median HU of infarcted tissue in conventional mixed DECT was 33.73 ± 4.58, compared to 22.96 ± 3.81 in default VNC images. Edema maps with different smoothing filter settings showed values of 14.39 ± 4.96, 14.50 ± 3.75, and 15.05 ± 2.65, respectively. All edema maps demonstrated statistically significant HU differences of infarcted tissue compared to conventional VNC images ($p<0.001$) while maintaining the density values of non-infarcted brain tissue. Conclusions: Enhancing the post-processing algorithm of conventional virtual non-contrast imaging improves infarct detection compared to standard mixed or virtual non-contrast reconstructions in Dual-Energy CT.

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.