Intracerebral hemorrhage (ICH) is associated with high morbidity and mortality. Intraventricular extension (IVE) and hydrocephalus (HCP) frequently prompt external ventricular drain (EVD) insertion, but objective criteria to guide EVD use are lacking. This article aims to identify clinical and radiological predictors of EVD insertion in spontaneous ICH and to develop a simple bedside scoring system (EVD-ICH score) to support decision-making. This is a prospective observational study of 100 consecutive adults with spontaneous nontraumatic ICH admitted to a tertiary-care center (March 2023 to February 2024). Clinical and CT variables were recorded. Multivariable logistic regression identified independent predictors of EVD insertion. A points-based score was created from adjusted odds ratios and internally validated using receiver operating characteristic (ROC) analysis. Of 100 patients, predictors independently associated with EVD insertion were IVE, HCP, Glasgow coma scale (GCS) ≤ 8, hematoma volume ≥30 mL, and history of hypertension (HTN). The 7-point EVD-ICH score (IVE 2 pts, HCP 2 pts, GCS ≤8 1 pt, ICH ≥30 mL 1 pt, HTN 1 pt) achieved an area under the ROC curve (AUC) of 0.85 (95% CI: 0.78-0.92). Optimal cut-off ≥3 yielded a sensitivity of 80% and a specificity of 77%. Predicted EVD probability ranged from 8% (score 0) to 92% (score 7). The EVD-ICH score provides a concise bedside tool to stratify risk of requiring EVD in spontaneous ICH. External multicenter validation and assessment of impact on patient-centered outcomes are recommended before routine adoption.

External ventricular drainage (EVD) care bundle approaches are associated with reduced infection rates after EVD insertion. However, awareness and standardization of such protocols remain limited, and the current literature is sparse and has a high variability in analysis. We conducted a systematic review and meta-analysis of appropriate studies to identify the key components of an effective EVD care bundle for reducing EVD-related infections (ERIs). A systematic review of the literature was conducted to identify any studies presenting patient cohorts undergoing EVD placement and reporting the introduction of bundle care protocols including postoperative infection rates. Major scientific databases (PubMed/MEDLINE, EMBASE, and Scopus) were systematically searched for studies published up to December 31, 2024. Studies were screened, and data were extracted independently by 2 authors. Twenty-eight studies were included for analysis. ERI rates before and after the implementation of care bundle protocols were observed. Different care bundles were identified and categorized as follows: insertion bundles, manipulation bundles, dressing bundles, and others. Although the literature concerning the implementation of care bundles for ERI is deemed poor, our results show a significant reduction in the postoperative ERI rates; a meta-analysis of the studies comparing cohorts before and after the implementation of care bundle protocols reveals significant differences in the postoperative infection rate after EVD placement (odds ratio 3.70, 95% CI 2.89-4.74, P < .0001 for the overall effect, heterogeneity I2 = 46%). Implementation of care bundle approaches for EVD insertion is associated with a significant reduction in ERIs. The implementation of care bundle approaches and the strict knowledge, training, and adherence to these protocols permit a standardization of the procedure and a better postoperative management diminishing complication rates. The available evidence supports the broader adoption of care bundle protocols as a new standard of care in clinical practice.

Real-time monitoring of cerebrospinal fluid (CSF) is critical in intensive care units for the timely management of complications such as infection and mechanical malfunction in patients with external ventricular drainage systems. Current practice relies on intermittent CSF sampling for laboratory-based biomarker analysis and manual inspection, resulting in delayed reporting and intervention. To address these limitations, we developed NeuroSense, a multiplexed sensing platform that integrates with standard external ventricular drainage systems to enable near real-time monitoring of key CSF (bio)markers, including glucose, lactate, pH, and flow rate, that are essential for detecting infection and drain dysfunction. NeuroSense incorporates glucose and lactate aptamer-based electrochemical biosensors, a polydopamine pH sensor, and an impedance-based flow sensor. Validation in simulated conditions demonstrated sensor specificity, stability in human CSF for several days, and ethylene-oxide sterilization compatibility. Evaluation in patients hospitalized in intensive care unit demonstrated strong correlation with clinical reference standards. By providing near real-time bedside assessment, NeuroSense has the potential to improve temporal resolution for detection of biomarker trends and drain malfunction indicators.

Extracerebral cerebrospinal fluid drainage is a commonly used treatment in the management of neurosurgical intensive care patients, primarily including external ventricular drainage (EVD) and lumbar cistern drainage (LD). To further standardize the clinical application and management of extracerebral cerebrospinal fluid drainage in neurosurgical intensive care patients, Chinese Society of Neurosurgery and China Neurocritical Care Management Collaborative Group organized experts in the field to update and revise the Chinese expert consensus on external cerebrospinal fluid drainage in neurosurgery (2018 edition) based on the latest evidence-based medical evidence. This consensus systematically reviews domestic and international literature, covering the indications for EVD and LD, the management of drainage procedures, and the handling of complications. Through two rounds of Delphi method expert evaluations, 24 recommendations were ultimately formulated to provide scientific and standardized guidance for clinical practice, enhancing the safety and efficacy of extracerebral cerebrospinal fluid drainage.

Posterior fossa tumors are the most common solid pediatric neoplasms, and more than 60% of these tumors are associated with hydrocephalus, which can be managed using different strategies, including endoscopic third ventriculostomy (ETV), ventriculoperitoneal shunt (VPS), external ventricular drainage (EVD), or direct tumor resection without CSF diversion. The safest and most effective drainage method remains controversial, and most available studies are limited to single-center retrospective analyses, often constrained by small sample sizes. Therefore, multicenter prospective studies are needed to determine the optimal treatment strategy. This is a prospective, multicenter cohort study conducted across more than 20 pediatric neurosurgery centers in Latin America. Patients will be allocated into four groups according to the treatment selected for hydrocephalus (ETV, EVD, VPS, or resection). The primary outcome will be the number of surgical interventions related to the treatment of hydrocephalus during the follow-up period. Secondary outcomes will include mortality, infection, and other clinically relevant complications, analyzed as complementary endpoints. Patients will be followed prospectively for up to 12months after the index procedure, defined as the intervention performed for the treatment of hydrocephalus, and each group will include at least 50 patients. The REDCap online platform will be used for data collection in the PITCH study, enabling prospective data acquisition across multiple centers in Latin America. This will allow comparison of treatment modalities for obstructive hydrocephalus secondary to posterior fossa tumors (ETV, EVD, VPS, and resection) and evaluation of their impact during the first year after diagnosis.

Ventriculo-Abdominal Subcutaneous Tunnelled External Drainage as a Transition Therapy to Reduce Shunt Failure Rate in Post-infection Hydrocephalus Patients: A single-center retrospective cohort study.

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have shown neuroprotective and anti-inflammatory effects in cerebrovascular disease, and previous studies suggest reduced stroke risk and overall mortality. This study compared post-intracerebral hemorrhage (ICH) outcomes in patients with type 2 diabetes mellitus (T2DM) receiving GLP-1RAs vs other hypoglycemic drugs including insulin. We conducted a retrospective cohort study using the global TriNetX network database. Patients with ICH and T2DM were stratified by GLP-1RA exposure, initiation between 5 years before and the day of the ICH and compared with patients treated with other hypoglycemic agents. After 1:1 propensity matching, 3600 patients per cohort were included in the analysis. Outcomes were assessed at 7, 30, and 90 days (all-cause mortality, seizures, craniectomy/craniotomy procedures, and external ventricular drain placement) and at 1 and 5 years post-ICH (all-cause mortality, seizures, palliative care, and respiratory failure). GLP-1RA use was associated with lower 7-day mortality (adjusted hazard ratio [AHR] 0.831, 95% CI 0.703, 0.983), 30-day mortality (AHR 0.835, 95% CI 0.741-0.942), and 90-day mortality (AHR 0.805, 95% CI 0.725-0.894). External ventricular drain insertion was not significantly different at any time point. Craniectomy/craniotomy and seizure risk were not significantly different at 7 or 30 days but were lower by 90 days (craniectomy/craniotomy: 2.8% vs 3.6%; AHR 0.763; seizures: 6.4% vs 7.7%; AHR 0.804). The mortality and seizure benefit persisted at 1 and 5 years. At 1 and 5 years, GLP-1RA use was also associated with reduced need for palliative care (1 year: 10.4% vs 13.1%; AHR 0.754; 5 years: 13.1% vs 16.1%; AHR 0.775) and respiratory failure (1 year: 19.8% vs 22.7%; AHR 0.825; 5 years: 25.2% vs 28.1%; AHR 0.854). In this cohort of patients with ICH and T2DM, GLP-1RA use was associated with improved outcomes. Prospective trials are warranted to confirm these observations.

The glymphatic system facilitates cerebrospinal fluid (CSF)-interstitial fluid exchange and plays a key role in solute clearance and neurophysiological homeostasis. While dysfunction of this system has been shown in traumatic brain injury, stroke, meningitis, idiopathic normal pressure hydrocephalus and neurodegenerative diseases, direct measurement of glymphatic transport in humans remains elusive. We propose microGLYMPH as a translational, hypothesis-generating framework that combines established clinical cerebral microdialysis with controlled CSF tracer administration via existing clinical access routes, including an external ventricular drain, cisternal access during surgery, or lumbar intrathecal injection when clinically justified. The aim is to obtain time-resolved regional tracer profiles in microdialysate and to interpret these alongside arousal state, intracranial dynamics, and, where available, complementary imaging, thereby providing an indirect measure of CSF-interstitial exchange kinetics and peripheral tracer appearance. We further define the key design, analytical and practical limitations that must be resolved before the approach can extend beyond exploratory use, notably catheter-adjacent effects, blood-brain barrier disruption, drainage practices, and the intrinsically focal nature of microdialysis. microGLYMPH is therefore intended as a staged roadmap for first-in-human feasibility studies and subsequent hypothesis-driven investigations of neurofluid solute transport after acute brain injury.

Intracerebral haemorrhage with ventricular extension is associated with poor neurological outcome and high mortality. External ventricular drainage (EVD) is a standard intervention for acute hydrocephalus in such patients, yet the role of an additional early lumbar drainage (LD) remains uncertain. To evaluate whether early LD leads to improved functional outcomes in patients suffering from ICH with intraventricular haemorrhage (IVH) who require an EVD, compared to patients not receiving early LD. DRAIN IVH is a multi-centre, parallel-group, open-label randomised controlled trial with blinded endpoint evaluation. Key inclusion criteria are ICH with IVH in the third and/or fourth ventricle with the need for EVD placement due to acute hydrocephalus, age≥18 years and LD insertion within 72h after symptom onset or last-seen-well. A total of 354 patients will be randomised for either early LD plus standard of care (comprising EVD) or standard of care alone. The primary outcome is the rate of modified Rankin Scale score 0-3 at 180days. Secondary outcomes include need for VP shunt, need for tracheostomy and EQ-5D. Safety outcomes include mortality, bacterial ventriculitis/meningitis, EVD complications and LD complications. DRAIN IVH will provide evidence for physicians whether early LD in addition to standard of care treatment leads to better outcomes in ICH with IVH compared to standard of care alone. Clinicaltrials.gov; NCT06510842.

This boy in mid childhood presented with a sudden, excruciating occipital headache following a week of progressive gait unsteadiness and neck-accentuated meningeal pain. CT demonstrated tetraventricular haemorrhage with early obstructive hydrocephalus and perimesencephalic subarachnoid blood. CT angiography/magnetic resonance angiography (MRA) and digital subtraction angiography revealed a cervicomedullary perimedullary arteriovenous fistula (PMAVF) supplied by the anterior and posterior spinal arteries with a single venous pouch aneurysm at C3-4. Emergency external ventricular drain (EVD) placement was performed. Definitive endovascular cure was achieved 72 hours later using simultaneous bilateral micro-catheterisation of the venous pouch and 'parallel' coiling under multimodality neuromonitoring, completely occluding the shunt while preserving spinal arterial flow. The patient recovered without any neurological deficit, the EVD was gradually weaned over the first 5 postoperative days and removed without clinical or radiological difficulty, and the 12-week MRI/MRA confirmed complete occlusion; at that time, he had returned fully to school and sports including football. This case highlights the importance of cervicomedullary vascular imaging in atraumatic paediatric Subarachnoid Hemorrhage (SAH)/intraventricular haemorrhage and illustrates that complex type III/C PMAVFs can be safely cured in a single session using a dual-pedicle coiling strategy in select cases.

Ventriculovesical (VV) shunting is an uncommon salvage option for cerebrospinal fluid (CSF) diversion in pediatric patients with complex hydrocephalus when conventional distal shunts are no longer viable. Evidence regarding appropriate patient selection, urological safety, and long-term durability of this technique remains limited. This study aimed to evaluate the clinical outcomes and urological safety for VV shunting in children with neurogenic bladder, with particular attention to urodynamic factors that may influence shunt performance. A retrospective case series was conducted including pediatric patients who underwent VV-shunt placement after failure or contraindication of conventional CSF-diversion routes. Demographic characteristics, neurological diagnoses, bladder dynamics, prior shunt history, and clinical outcomes were reviewed. All patients had underlying neurogenic bladder managed with clean intermittent catheterization. Ten patients underwent VV shunt placement at a median age of 7years (range 2-13years). Median follow-up duration was 18.5months (range 10-42months). Hydrocephalus control was maintained in nine patients (90%) during follow-up. Distal shunt migration requiring revision occurred in two patients (20%). In one patient, persistent inability to achieve adequate bladder pressure control necessitated conversion to a ventriculo-gallbladder shunt following a period of external ventricular drainage. No intraoperative complications occurred, and no febrile urinary tract infections or bladder stone formation were observed during follow-up. VV shunting may represent a viable salvage option for CSF diversion in carefully selected pediatric patients with complex hydrocephalus and neurogenic bladder. Adequate bladder pressure control appears to be a critical determinant of shunt durability, whereas persistently high-pressure bladders may predispose to distal shunt-related complications. These findings highlight the importance of urodynamic assessment and integrated uro-neurosurgical evaluation when considering VV shunting as an alternative CSF diversion strategy and may assist neurosurgeons in identifying appropriate candidates when conventional distal sites are exhausted.

Traumatic brain injury is a leading cause of mortality in pediatric trauma, and intracranial pressure (ICP) monitoring is recommended in severe cases. Current guidelines do not favor one monitoring technique over another, and while combined approaches may offer benefits, individual effect of each technique on outcomes remains unclear. The study aim is to analyze differences in invasive monitors. This is analysis of American College of Surgeons Trauma Quality Improvement Program (2017-2021). We included all pediatric (younger than 18 years) trauma patients with severe traumatic brain injury who received invasive ICP monitoring and were admitted for at least 24 hours. Patients were stratified based on type of ICP monitoring: those with an extraventricular drain (EVD) or an intraparenchymal monitor (IPM). Patients who received both monitoring devices were excluded. Primary outcomes included mortality and need for surgical intervention. Multivariable regression analysis was performed. A total of 4,250 met our inclusion criteria. The median age was 13 years, with 67% being male. The median Injury Severity Score was 27. Majority of patients (64.6%) underwent IPM placement. Distribution of pediatric trauma center verification differed between groups (IPM had a higher proportion at pediatric Level II centers, 15.9% vs. 10.6%, while EVD had a higher proportion at pediatric Level III/below, 50.9% vs. 45.2%; p < 0.001). Overall rate of mortality was 20% with no significant differences between the two groups ( p = 0.432). However, patients in EVD group had a lower rate of surgical intervention (EVD: 46% vs. IPM: 56.9%, p < 0.001). On multivariable regression analysis, EVD was independently associated with decreased mortality (adjusted odds ratio, 0.750; p = 0.019) and need for surgical intervention (adjusted odds ratio, 0.702; p < 0.001). Despite lack of guidelines on choice of ICP monitoring for pediatric patients, EVD placement alone was associated with 30% reduction in need for surgical intervention and 25% lower mortality. These findings highlight the need to further evaluate relative benefits of EVD versus IPM in reducing surgical interventions in this population. ( J Trauma Acute Care Surg . 2026;100: 754-759. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). Therapeutic/Care Management; Level IV.

Impact of Drain Column Height setting on Intracranial Pressure Control and Outcomes After Severe Traumatic Brain Injury: A Retrospective Study.

Haemorrhage pattern and clinical outcomes after angiogram negative subarachnoid haemorrhage: a systematic review and meta analysis.

Elevated intracranial pressure (ICP) accompanies many neurological disorders, and delayed diagnosis can cause irreversible brain damage. Current diagnostic testing is invasive. Ultrasound elastography allows non-invasive assessment of tissue stiffness, which is influenced by pressure. Transcranial time-harmonic elastography (THE), using externally induced low-frequency vibrations and standard ultrasound to generate quantitative stiffness maps, has proven sensitive to ICP changes in adults. This study evaluated the quantitative correlation between ICP and brain stiffness in children and adolescents using a novel point-of-care THE system with a portable vibration unit. Ten pediatric and one young adult patient (four females; mean age 11±5 years; range 6-24 years) with an implanted sensor reservoir (n=7) or external ventricular drainage (EVD; n=4) underwent transcranial THE with a portable vibration driver providing external multifrequency vibration. Quantitative shear-wave speed maps (m/s) of the temporal lobe were acquired. ICP was measured via sensor reservoir within two hours of THE or via EVD simultaneously. Three patients with sensor reservoirs were examined repeatedly at intervals of at least one month, yielding 16 ICP-THE pairs. The median ICP was 8mmHg (range 2-13) and the median shear-wave speed was 1.54m/s (range 1.20-1.94). ICP correlated positively with brain stiffness measured by THE (r=0.72, p<0.05). Cerebral stiffness quantified by transcranial THE closely reflects invasively measured ICP. Therefore, portable, point-of-care THE may provide a cost-effective, non-invasive tool to monitor cerebral stiffness and detect increased ICP.

We assessed the technical utility and preliminary outcomes of endoscopic hematoma evacuation via the high parietal approach for thalamic hemorrhage with intraventricular extension (intraventricular hemorrhage) by retrospectively reviewing 270 patients treated between April 1, 2006, and July 31, 2024. Prior to 2017, the primary treatment was external ventricular drainage, and in selected patients with thick intraventricular hematoma, an anterior endoscopic approach was used primarily for intraventricular hemorrhage removal. Since April 2017, the high parietal approach technique has been used for the simultaneous removal of both thalamic hematoma and intraventricular hemorrhage in 21 patients. The high parietal approach group showed a median hematoma evacuation rate of 92.2% and, compared with the external ventricular drainage-only group, a significantly shorter duration of ventricular drainage and a lower incidence of tracheostomy. No cases of surgical site infection or meningitis occurred in the high parietal approach group. Complications included 1 death due to postoperative rebleeding and another due to worsening pneumonia and heart failure. Secondary hydrocephalus requiring shunt placement was observed only in the external ventricular drainage group. Although not statistically significant, the high parietal approach group showed a higher rate of early resumption of oral intake. These findings suggest that endoscopic evacuation via the high parietal approach is a minimally invasive technique that achieves high hematoma removal rates, facilitates early postoperative recovery, and may reduce complications such as prolonged drainage, tracheostomy, and hydrocephalus in selected patients with large thalamic hemorrhage and intraventricular hemorrhage.

Infantile hemangiomas (IHs) are the most common vascular tumors in infancy, typically occurring in the skin and soft tissues. Intracranial infantile hemangiomas (IIHs) are exceedingly rare, usually extra-axial, and often associated with PHACES syndrome. Hemorrhagic intra-axial IIHs in neonates are exceptionally uncommon. We report a newborn presenting at 7days of life with irritability, vomiting, and acute intracranial hypertension. Imaging revealed a hemorrhagic mass in the corpus callosum with intraventricular extension. Emergency external ventricular drainage was performed, followed by a right frontal-parietal parasagittal craniotomy. A well-circumscribed reddish-brown and vascular tumor was removed entirely. Histopathology showed capillary proliferation without atypia, and immunohistochemistry was positive for CD31, CD34, and GLUT1, consistent with infantile hemangioma. The postoperative course was uneventful. At 3years of follow-up, the child shows normal neurodevelopment and no evidence of recurrence on MRI. Isolated intra-axial IIH with neonatal hemorrhage is an exceptional presentation. This case highlights the importance of considering IIH in the differential diagnosis of highly vascular intracranial tumors, even in the absence of cutaneous hemangiomas. Prompt surgical resection can be curative and prevent life-threatening complications.

Background: : Spontaneous cerebellar hemorrhage (SCH) is a potentially life-threatening condition that results in early neurological deterioration, significant disability, and adverse consequences. Therefore, knowledge of the factors that potentially affect the outcome is crucial for a sound clinical decision-making framework and for implementing efficient therapeutic measures. Objectives: This study aimed to identify possible clinical, radiological, and therapeutic factors associated with 30-day outcomes in patients with acute SCH. Materials and Method: Sixty-six computerized tomography (CT) diagnosed cases of SCH above 18 years of age who were admitted and managed in the Department of Neurosurgery of Chittagong Medical College Hospital from October 2021 to September 2022 were enrolled prospectively in this study based on inclusion and exclusion criteria. Data regarding demographic, clinical, radiographic, and treatment modalities was recorded. The 30-day outcome was assessed by the Glasgow Outcome Scale (GOS) score and analyzed. A poor outcome was defined by GOS ≤3. Results: The mean age was 65.6±10.8 years and 56.1% were male. The median Glasgow Coma Scale (GCS) score on admission was 13 [interquartile range (IQR) = 8-14]. Twenty-five patients (37.9%) underwent surgical management [evacuation of the cerebellar hemorrhage and placement of an external ventricular drain (EVD) in 7 (28%); EVD alone in 12 (48%), and only evacuation in 6 (24%) cases of surgically managed] and 41 (62.1%) were treated conservatively. The 30 day mortality rate was 36.4%. Regarding 30-day outcomes, 47% (31) of patients had a poor outcome after 30 days. On univariate analysis, GCS score on admission, hematoma size, hematoma volume, ventricular extension, 4th ventricle obstruction, hydrocephalus, tight posterior fossa, ratio between transverse diameter of cerebellar hematoma and posterior fossa, intervention type, and need for mechanical ventilation were significantly associated with 30-day poor outcome. In multivariate analysis, only the GCS score on admission was a significant predictor of a 30 day poor outcome [odds ratio (OR) = 0.28; 95% confidence interval (CI) = 0.12–0.66; P = 0.003]. For prediction of a 30 day poor outcome, receiver operating characteristic (ROC) curve analysis confirmed that the best cut off point was a GCS score of 11 on admission [area under the curve (AUC): 0.94, 95% CI = 0.88–0.98, P &lt; 0.001] with the sensitivity of 94.3% and specificity of 87.1%. Conclusion: The 30-day outcome of SCH patients mostly depends on admission GCS score. A higher GCS score on their admission is strongly associated with a 30-day favorable outcome. Keywords: 30 day mortality, Cerebellar Hemorrhage, Outcome, Factors Associated with Cerebellar Hemorrhage Bang. J Neurosurgery 2024; 14(1): 3-12

Postintubation tracheal stenosis, a rare and life-threatening iatrogenic complication arising from the endotracheal intubation. This case is noteworthy for a very young adult with a neurosurgical background and clustered risk factors, who developed rapidly progressive high-grade subglottic/cervical tracheal stenosis with concomitant tracheomalacia. This report details a 19-year-old Han Chinese man, who is a university student, developed severe dyspnea after surgery of bilateral ventricular drainage due to cerebral hemorrhage 48 days ago. His intensive care unit course included 10 days of mechanical ventilation, gastric reflux, and bloodstream and airway infections. After first discharge, he developed recurrent, escalating inspiratory dyspnea (repeatedly misdiagnosed as pneumonia or asthma). Lack of response to bronchodilators and steroids, absence of diffuse lower-airway process on imaging, and direct visualization of a fixed, cicatricial, high-grade subglottic stenosis on bronchoscopy together argued against alternative diagnoses including asthma, vocal cord dysfunction, and recurrent pneumonia. Grade 3 subglottic tracheal stenosis that the 6 mm bronchoscope could not pass through was confirmed by three-dimensional reconstruction computed tomography. A diagnosis of upper tracheal obstruction caused by postintubation tracheal stenosis was considered. Multidisciplinary consensus favored emergency laryngotracheal stenosis resection, laryngeal function reconstruction, and tracheoplasty. Successful extubation was achieved on the first postoperative day and discharged on postoperative day 10. Follow-up imaging confirmed sustained airway patency without restenosis. He achieved complete symptomatic relief, then promptly returned to the university and successfully graduated 2 years later. Until now, he has been employed full-time without functional limitations. In young patients with high-grade, subglottic, cicatricial stenosis and tracheomalacia, primary resection with anastomosis can be definitive when endoscopic or stent options are unsuitable in an emergency. Early warning signals (reflux, infection, post-extubation cough/stridor, and poor response to pharmacotherapy) warrant timely evaluation. Durable outcomes depend on an experienced multidisciplinary team cooperation and standardization of diagnostic, therapeutic, and follow-up pathways.

Spontaneous cerebellar hemorrhage (sCH) is associated with high mortality, but favorable outcomes can be achieved with appropriate surgical management. We evaluated treatment strategies, complications, outcomes, and prognostic factors in sCH patients at a tertiary center. Adults with primary sCH treated at the neurointensive care unit in Uppsala, Sweden, between 2008 and 2024 were retrospectively included. Clinical and radiological data were collected. Patients were managed conservatively or surgically according to institutional protocols. Outcomes were mortality at discharge and 6months, and functional outcome at NIC discharge assessed with the Glasgow Outcome Scale-Discharge (GODS). Predictors of 6-month mortality and favorable outcome (GODS > 3) were analyzed. A total of 194 patients were included; 50% underwent surgery. Surgically treated patients had lower admission Glasgow Coma Scale motor scores, larger hematoma volumes, and more infratentorial mass effect. Among awake patients with hematomas > 15mL initially managed conservatively, 78% did not require delayed surgery and most achieved favorable outcomes. Combined hematoma evacuation, suboccipital decompression, and external ventricular drainage (EVD) was associated with low complication rates and low early mortality. Selected patients with hydrocephalus and smaller hemorrhages were successfully treated with EVD alone. Overall mortality was 11% at discharge and 28% at 6months. Age, neurological status, and hematoma volume independently predicted mortality. Favorable outcomes after sCH are achievable, including in elderly patients. Conservative management is appropriate in neurologically stable patients with moderate hematoma volumes, while EVD alone may suffice in selected cases with isolated hydrocephalus.