Background: Cerebral vasospasm is a frequent and severe complication after aneurysmal subarachnoid hemorrhage (aSAH), often causing delayed cerebral ischemia (DCI) and poor outcomes. Despite progress in neurocritical care, early vasospasm prediction after aSAH remains challenging due to its multifactorial nature but is essential for timely intervention. Methods: We retrospectively analyzed 503 consecutive patients with spontaneous subarachnoid hemorrhage (SAH) treated between 2013 and 2018. Of these, 345 with angiographically confirmed aSAH were included in the primary analysis, and 158 SAH cases in a sensitivity analysis. We extracted demographic, clinical, and imaging parameters including age, sex, Hunt and Hess grade, Fisher scale, aneurysm and treatment features, external ventricular drainage (EVD), and central nervous system (CNS) infection. Seven supervised machine learning (ML) models, including logistic regression and gradient-boosted trees, were trained using nested cross-validation and evaluated by AUC-ROC, AUC-PR, accuracy, precision, sensitivity, specificity, and F1 score. Results: Over half of aSAH patients developed moderate to severe vasospasm. Independent predictors included younger age, higher Hunt and Hess and Fisher grades, and EVD placement (all p < 0.001). Logistic regression achieved the best discrimination (AUC-ROC 0.723), while tree-based models reached higher sensitivity (0.867) at the expense of specificity. Aneurysmal etiology further increased vasospasm risk (OR 4.72). Conclusions: Routinely available clinical and imaging parameters enable reliable ML-based vasospasm prediction after aSAH. Logistic regression provided the best balance between accuracy and interpretability, while tree-based models optimized sensitivity. This web-based, interpretable ML tool—one of the first using routine clinical data—may support the bedside prediction of vasospasm and requires prospective validation.

Background/Objectives: Microsurgical clipping has traditionally been considered a standard treatment for middle cerebral artery (MCA) aneurysms. Recently, a caseload reduction related to improved endovascular treatment options has occurred in cerebrovascular neurosurgery. Therefore, studies that report the clinical and radiological outcomes after clipping are highly warranted. Methods: Patients with an unruptured MCA bifurcation aneurysm, who were surgically treated at the Department of Neurosurgery in Linz between 2002 and 2019, were included in this study. Clinical and radiological outcome parameters were evaluated for each patient. Results: Overall, 272 patients were eligible for inclusion. Complete aneurysm occlusion was demonstrated in 266 (99.3%) of the 268 (98.5%) patients who underwent postoperative digital subtraction angiography. In six (2.2%) patients, a permanent new neurological deficit (pNND) persisted after treatment. Intraoperative aneurysm rupture was a significant factor (p = 0.0049) in the logistic regression. At the last follow-up, only two patients (0.7%) had an unfavorable outcome (mRS > 2). More recent surgeries were associated with fewer cases of pNND (p = 0.009). A transient new neurological deficit occurred in 13 patients (4.8%), with aneurysm size being a significant risk factor (p = 0.009). Surgical site infections were reported in four patients (1.5%), with patient age (p = 0.039) and time (p = 0.001) being significant factors. Two patients died (0.7%) perioperatively and two patients (0.7%) needed a retreatment in the long-term follow-up. Conclusions: The findings indicate that microsurgical clipping is a safe procedure with minimal need for retreatment. It achieves a high occlusion rate while maintaining a very low rate of adverse outcomes. Continuous intraoperative enhancements over time have contributed to a progressive improvement in clinical outcomes in recent years. This trend is exemplified by the absence of detectable pNND in the era of ICG angiography. Consequently, these data support the conclusion that microsurgical clipping should still be considered an appropriate treatment option for unruptured MCA bifurcation aneurysms.

Background/Objectives: Unruptured aneurysms of the anterior communicating artery (AComA) are associated with a higher risk of rupture and present unique anatomical challenges. Although endovascular techniques have advanced considerably, microsurgical clipping continues to represent an essential treatment option, particularly for complex cases. We conducted a retrospective analysis to evaluate outcomes of microsurgical clipping for unruptured AComA aneurysms over an 18-year period at a high-volume tertiary neurosurgical center. Methods: A retrospective analysis was conducted on 106 patients who underwent microsurgical clipping for unruptured AComA aneurysms between 2002 and 2020. Preoperative, intraoperative, and postoperative parameters were assessed. Excluded were previously ruptured or previously surgically treated aneurysms. Logistic regression models were used to identify predictors of postoperative complications with a focus on aneurysm projection. Results: Complete angiographic occlusion was achieved in 92.2% of cases, with a retreatment rate of 0.9%, which is comparable to the recent literature. Permanent neurological deficits occurred in 5.7% of patients. Posterior aneurysm projection was significantly associated with postoperative infarction and permanent neurological deficits. Intraoperative ICG angiography was associated with a reduced risk of ischemic complications. Conclusions: Microsurgical clipping remains a safe and effective treatment for unruptured AComA aneurysms in selected patients, offering durable occlusion and low complication rates. Aneurysm projection is a key predictor of outcome, and intraoperative ICG angiography significantly enhances surgical safety. These findings support the continued role of microsurgery in the interdisciplinary management of AComA aneurysms.

Background/Objectives: Superior cerebellar artery (SCA) infarction is a rare but clinically significant subtype of posterior circulation stroke. Extensive swelling in the SCA territory may cause downward brainstem compression and appear as brainstem hypodensity on computed tomography, potentially leading to premature treatment withdrawal. Methods: We report the case of a 50-year-old woman with acute SCA-territory infarction (NIHSS = 7) presenting with vertigo, dysphagia, dysarthria, and diplopia. Initial computed tomography suggested extensive brainstem infarction, prompting withdrawal of treatment. Diffusion-weighted MRI revealed reversible edema with brainstem sparing. The patient underwent suboccipital decompressive craniectomy and ventricular drainage with favorable neurological recovery. In addition, a systematic literature search was conducted according to PRISMA 2020 guidelines in PubMed, Web of Science, and Scopus (studies published since 1 January 2015). Fifteen studies met predefined eligibility criteria. Results: Magnetic resonance imaging findings were decisive in avoiding a falsely dismal prognosis and inappropriate withdrawal of care. Across the literature, infarct volume (>30–35 mL), brainstem involvement and bilateral cerebellar infarction emerged as key predictors of malignant course. Early decompressive surgery was consistently associated with improved survival, though functional outcomes varied. Fast magnetic resonance imaging techniques and volumetric imaging improved risk stratification and surgical decision-making. Conclusions: SCA infarction can mimic brainstem infarction on computed tomography due to secondary compression rather than true ischemia. Magnetic resonance imaging is essential to guide treatment and prevent avoidable mortality. Multimodal imaging combined with interdisciplinary management allows for accurate prognostication and optimized surgical timing in malignant SCA infarction.

Background: Superior cerebellar artery (SCA) infarction is a rare but clinically significant subtype of posterior circulation stroke. Extensive swelling in the SCA territory may cause downward brainstem compression and appear as brainstem hypodensity on computed tomography, potentially leading to premature treatment withdrawal. Methods: We report the case of a 50-year-old woman with acute SCA-territory infarction (NIHSS = 7) present-ing with vertigo, dysphagia, dysarthria, and diplopia. Initial computed tomography sug-gested extensive brainstem infarction, prompting withdrawal of treatment. Diffu-sion-weighted MRI revealed reversible edema with brainstem sparing. The patient un-derwent suboccipital decompressive craniectomy and ventricular drainage with favorable neurological recovery. In addition, a systematic literature search was conducted according to PRISMA 2020 guidelines in PubMed, Web of Science, and Scopus (studies published since 1 January 2015). Fifteen studies met predefined eligibility criteria. Results: Magnetic resonance imaging findings were decisive in avoiding a falsely dismal prognosis and in-appropriate withdrawal of care. Across literature, infarct volume (> 30–35 mL), brainstem involvement and bilateral cerebellar infarction emerged as key predictors of malignant course. Early decompressive surgery was consistently associated with improved survival, though functional outcomes varied. Fast magnetic resonance imaging techniques and volumetric imaging improved risk stratification and surgical decision-making. Conclu-sions: SCA infarction can mimic brainstem infarction on computed tomography due to secondary compression rather than true ischemia. Magnetic resonance imaging is essen-tial to guide treatment and prevent avoidable mortality. Multimodal imaging combined with interdisciplinary management allows for accurate prognostication and optimized surgical timing in malignant SCA infarction.

Background: Reliable and complete documentation is a prerequisite for quality improvement in neurosurgical care. To strengthen internal process monitoring and reduce variability in documentation practices, our department implemented a structured, web-based neurosurgical complication documentation and quality assurance registry combining automated data imports from the hospital information system with minimal standardized manual inputs. The year 2024 represented the first full operational cycle of the system. Methods: This quality-improvement study evaluated exclusively process-related parameters of the complication documentation registry and did not include analysis of clinical content or outcome variables. Although the registry contains prospectively documented clinical and treatment-related data, the present evaluation was limited to system integration, documentation completeness, frequency of missing mandatory documentation, and performance of reporting mechanisms. Analyses were based solely on de-identified system-level metadata reflecting documentation status. Documentation completeness and workflow adherence were analyzed descriptively over time. Results: The registry was successfully integrated into routine clinical workflow across all neurosurgical units and across all hospital wards responsible for the management or discharge of neurosurgical patients. Documentation completeness improved steadily throughout the year, increasing from 77% in the first quarter to 88% in the fourth quarter when assessed after a predefined follow-up interval. Automated reporting identified incomplete documentation entries primarily during the early implementation phase, with alert frequencies decreasing by approximately 48% over the course of the year. Documentation completeness continued to improve beyond the formal observation period, and all inpatient stays from the 2024 cohort were fully documented during follow-up. Progressive improvements across units indicated growing feasibility, acceptance, and compliance within the clinical teams. Conclusion: The structured multi-step design, combining automated data integration, binary discharge screening, and dedicated detailed documentation by designated clinicians, appeared effective in improving documentation completeness and workflow adherence. This process-oriented evaluation provides a useful structural basis for future quality improvement initiatives and ethically approved clinical research based on high-fidelity routinely collected data.