Patients with an acutely injured brain may resist the mechanical physics of the ventilator. Neurogenic respiratory breathing patterns generated by the patient may result in the ventilator failing to synchronize with this abnormal drive. This asynchrony may be perceived as distress and with a high respiratory drive could also lead to global lung stress and diaphragmatic myoinjury, and affect liberation from the mechanical ventilator at a later point. Patient-ventilator synchrony concerns have rarely been prioritized in neurocritical care guidelines and are often inappropriately treated with escalating sedation. Starting with the essentials of waveform interpretation and moving towards more complex interpretations of these asynchronies, this review provides insight into the common themes of neurogenic synchrony concerns in mechanically ventilated patients. High respiratory drive, double-triggering/ breath-stacking, and reverse triggering are the most prevalent observations. Adjusting the ventilator can improve patient-ventilator interaction and a number of options to remediate these synchrony concerns are provided.

Intracranial electroencephalography (iEEG) has been increasingly explored as part of multimodal neuromonitoring in acute brain injury, yet its diagnostic benefit compared with continuous surface EEG (suEEG) remains uncertain. We have performed a meta-analysis to quantify seizure and rhythmic and periodic pattern detection rates and concordance with suEEG. Secondary objectives were the assessment of correlations with brain injury, safety, and techniques. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, PubMed, Scopus, and Embase were searched for studies reporting iEEG monitoring in adults with acute brain injury. Epileptic patterns were harmonized to the American Clinical Neurophysiology Society Standardized EEG Nomenclature for Critically Ill Patients (ACNS) 2021 terminology, classifying events as seizures/status epilepticus (SZ/SE) or rhythmic and periodic/ictal-interictal continuum patterns (RPP/IIC). Risk of bias was assessed using the Newcastle-Ottawa scale and custom bias domains. Random-effects meta-analyses were conducted for (i) pooled proportions and (ii) pooled paired within-patient comparisons. Twelve cohorts (n = 864 participants) with aneurysmal subarachnoid hemorrhage (n = 343), traumatic brain injury (n = 351), and mixed etiologies (n = 170) were included. Six studies provided paired iEEG-suEEG data (n = 273). Techniques were based on a strip or depth electrode. No severe adverse events were reported. Pooled iEEG versus suEEG incidence rates were respectively: 26% vs. 15% for SZ/SE, 47% vs. 34% for RPP/IIC, and 57% vs. 37% for clinically relevant epileptic activity. Pooled paired analysis demonstrated that iEEG additionally detected SZ/SE in 16.5% of patients [pooled McNemar odds ratio (OR) 3.46 (0.51-23.6); I[2] = 63%; p = 0.158] and RPP/IIC in 26% [pooled OR 4.25 (0.19-96.1); I[2] = 73%; p = 0.236], while suEEG was negative. Sensitivity analyses for high-risk studies or cohort overlap did not alter the results. Invasive EEG monitoring substantially increased the detection of seizures and RPP/IIC patterns compared with suEEG alone in patients with acute brain injury, serving as a promising monitoring adjunct.

Neuro-point-of-care ultrasound (NeuroPOCUS) is an emerging bedside modality that extends the neurological examination through real-time assessment of cerebral structure and hemodynamics in neurocritical care. Despite increasing integration into clinical pathways and endorsement of transcranial ultrasound-based neuromonitoring by international guidelines, implementation is often hampered by inadequate acoustic windows and poor image and Doppler signal quality, frequently leading to nondiagnostic examinations. Ultrasound contrast agents (UCAs), traditionally used in specialist neurosonology, may overcome these barriers and recover diagnostic information in patients with limited acoustic windows. This clinically oriented narrative review synthesizes the available evidence on contrast-enhanced transcranial ultrasound and examines its potential translation into NeuroPOCUS as a bedside tool for frontline clinicians across vasospasm monitoring, intracranial pressure assessment, evaluation of steno-occlusive cerebrovascular disease, assessment of cerebral circulatory arrest, and other neurocritical care applications. A literature search of PubMed/Medical Literature Analysis and Retrieval System Online (MEDLINE), Embase, and Scopus was conducted through June 2026, and relevant studies, reviews, and guideline documents were descriptively synthesized according to clinical application. Available evidence indicates that UCAs improve Doppler signal quality, enhance visualization of intracranial vessels, and increase the proportion of diagnostic examinations in patients with limited acoustic windows, thereby improving the interpretability of bedside hemodynamic assessments. However, implementation remains constrained by operator dependence, heterogeneous acquisition and interpretation protocols, limited standardization, and the need for structured training and validated, application-specific velocity cutoffs. Looking ahead, contrast enhancement may expand the scope of bedside neurovascular assessment, including in emergency and acute-care settings where dedicated probes and presets are not readily available. Its favorable safety profile and enhanced bedside feasibility may help bridge the gap between guideline recommendations and clinical practice, although further technical and clinical validation is needed to define its role in frontline NeuroPOCUS.