Cardiac arrest is a major cause of hypoxic-ischemic brain injury, often resulting in coma even after the return of spontaneous circulation. In this severely ill population, accurate neurologic prognostication is essential for guiding treatment decisions. Continuous electroencephalography (EEG) has become a cornerstone of postcardiac arrest care, offering real-time monitoring of cerebral activity and facilitating early detection of electrographic seizures and other pathologic patterns. This narrative review focuses on the standardized interpretation of EEG findings using the 2021 American Clinical Neurophysiology Society Critical Care EEG terminology. Key EEG patterns-such as generalized periodic discharges, suppression-burst, and status epilepticus (SE)-are discussed in the context of their prognostic significance and therapeutic implications. Particular attention is given to the progressive restoration of background EEG continuity and amplitude over the first 24 hours after the arrest, which is increasingly recognized as a marker of the extent of neuronal damage and potential for recovery. Seizure and SE management remains complex in comatose postcardiac arrest patients, with recent studies highlighting variable outcomes and the potential risks of both under- and overtreatment. We underscore the importance of individualized treatment strategies informed by EEG characteristics and integrated with clinical examination, neuroimaging, and serum biomarkers. Multimodal prognostication helps identify patients with a potential for meaningful recovery while avoiding unnecessary interventions in those with poor neurologic prognosis. EEG-guided care is crucial in optimizing outcomes after cardiac arrest and enhancing the precision of neurocritical care.

Postcardiac arrest (CA) care in the intensive care unit is pivotal to mitigating hypoxic-ischemic brain injury (HIBI), the leading cause of death and disability in resuscitated patients. This narrative review synthesizes current evidence and guideline recommendations on key domains of post-CA management, including diagnostic evaluation, hemodynamic optimization, oxygenation and ventilation strategies, temperature control, and sedation. Immediate coronary angiography is indicated in patients with ST-segment elevation, while a selective approach is warranted in others, guided by clinical findings. Whole-body computed tomography facilitates early identification of extracardiac causes and resuscitation-related injuries. Current consensus supports maintaining mean arterial pressure above 60 to 65 mm Hg, normoxemia (PaO2 75-100 mm Hg), and normocapnia (PaCO2 35-45 mm Hg). Lung-protective ventilation and head-up positioning are standard practices. Recent high-quality trials have challenged the neuroprotective role of therapeutic hypothermia; current guidelines recommend active fever prevention targeting a temperature of ≤37.5° C for at least 72 hours after CA. Sedation should be tailored to facilitate neurologic assessment, with short-acting intravenous agents preferred.

Background and Objectives: Traumatic brain injury (TBI) affects millions of people worldwide. The Glasgow Coma Scale (GCS) is commonly used to characterize its severity. Head computed tomography (CT) is frequently the diagnostic imaging modality of choice. Recently, blood-based biomarkers such as ubiquitin C-terminal hydrolase-L1 (UCH-L1) and glial fibrillary acidic protein (GFAP) have emerged as possible adjuncts to head CT in evaluating mild TBI (mTBI). We aim to validate the performance of the Abbott Alinity i TBI test (UCH-L1 and GFAP) compared to head CT in an Asian cohort with mTBI and GCS 15. Materials and Methods: This prospective observational study was conducted at a tertiary academic medical center from 2 December 2024 to 19 March 2025. Patients aged 21 years and above who sustained head injury within 12 h of ED attendance had GCS of 15 and required head CT as per attending physician were eligible. Plasma was separated from whole blood within 10 min of collection and immediately stored at -20 °C. UCH-L1 and GFAP levels were analyzed in batches within 28 days of recruitment at the hospital central laboratory using the Alinity i TBI test. Results: Among 120 patients enrolled, there was predominance of males (55.8%, 67/120) and Chinese ethnicity (75.8%, 91/120). The median age was 73 (interquartile range [IQR] 56 to 79) years. Overall incidence of positive head CT was 9.2% (11/120); all 11 patients had positive Alinity i TBI tests. The sensitivity and negative predictive value of the biomarkers in our cohort were both 100% (95% confidence intervals [CIs] 71.5% to 100% and 78.2% to 100%, respectively), specificity 13.8% (95% CI 7.9% to 21.7%) and positive predictive value 10.5% (95%CI 5.4% to 18%). Exploratory post hoc analysis suggested that GFAP alone, at the prespecified assay threshold, was associated with modestly higher specificity [21.1% (95% CI 13.9% to 30.0%)] in this cohort. Conclusions: The Alinity i TBI test can safely rule out intracranial injury in patients with mTBI and GCS 15 presenting within 12 h of injury. However, specificity was low, limiting its ability to reduce head CT use in its current form. Exploratory post hoc analyses of the individual biomarkers, particularly GFAP alone, should be interpreted cautiously. Future studies should focus on optimizing specificity while maintaining a high degree of sensitivity.

Background: Stroke significantly increases morbidity and mortality in patients receiving extracorporeal membrane oxygenation (ECMO). This study evaluates the prognostic impact of stroke subtypes, acute ischemic stroke (AIS) and hemorrhagic stroke (HS), and neurologic injury severity in a contemporary adult population. Methods: We conducted a retrospective cohort study using the TriNetX federated electronic health record network, including adult patients who underwent ECMO between 1 October 2015 and 31 December 2025. Stroke was defined as a first-instance diagnosis of AIS, HS, or unspecified cerebrovascular event occurring within 24 h of ECMO cannulation during the index hospitalization. Propensity score matching (1:1 nearest neighbor) was performed to balance baseline demographics, comorbidities, anticoagulant use, and ECMO modality between the stroke and non-stroke cohorts. Primary outcomes included all-cause mortality at 30 days, 90 days, and 1 year. Secondary outcomes included cardiac arrest, seizures, palliative care utilization, and hospital readmission. Kaplan-Meier survival analysis and multivariable Cox proportional hazards modeling were performed. Results: Among 18,981 ECMO patients, 1481 (7.8%) developed a stroke within 24 h of ECMO cannulation, including 814 AIS (54.9%), 454 HS (30.6%), and 213 unspecified cerebrovascular events (14.4%). After propensity score matching, stroke was associated with significantly higher all-cause mortality at 30 days (RR 1.16), 90 days (RR 1.18), and 1 year (RR 1.18), all p < 0.05. Stroke was also associated with higher rates of cardiac arrest, seizures, hospital readmission, and palliative care utilization (all p < 0.001). AIS was associated with significantly lower mortality than HS at 30 days, 90 days, and 1 year (all p < 0.0001). In multivariable Cox regression, only HS was independently associated with increased 30-day mortality compared with no stroke. Markers of neurologic injury severity, including cerebral edema, brain compression, and coma, were among the strongest independent predictors of mortality. Conclusions: Stroke occurring early after ECMO cannulation is associated with substantially worse short- and long-term survival, with hemorrhagic subtype and markers of neurologic injury severity driving the strongest prognostic signals. These findings support early stroke recognition and subtype-informed prognostic discussions in ECMO patients.

Background: In patients with traumatic brain injury (TBI), proteins are considered the main source of energy. Previous studies have suggested that an increase in the urea-to-creatinine ratio (UCR) indicates the onset of protein catabolism. Therefore, we aimed to investigate the associations of the UCR with the functional independence measure (FIM). Methods: This single-center retrospective study included 291 patients aged 17-87 years who underwent inpatient rehabilitation within the first 6 months post-TBI. Their demographic, clinical, neuroradiological, and laboratory data (eGFR, urea, creatinine, UCR) were collected. Spearman's correlation and hierarchical multivariate regression analyses adjusted for clinical covariates were performed. Results: The strongest significant positive correlation was found between the Glasgow Coma Scale (GCS) and FIM at admission (ρ = 0.488, p < 0.001) and between GCS and FIM at discharge (ρ = 0.340, p < 0.001). A significant negative correlation was found between the discharge UCR and FIM at discharge (ρ = -0.262, p < 0.003), as well as with the change in FIM (ρ = -0.207, p < 0.02). Patients with UCRs ≥ 80 had a significantly lower discharge FIM compared to patients with UCRs < 80 (median 27 vs. 40; p = 0.02). The significant independent predictors of discharge FIM were the nutritional route (NGT/PEG), level of consciousness, and FIM at admission. The UCR did not remain independently associated with the discharge FIM (ΔR2 = 0.004, Cohen's f2 = 0.014). Conclusions: Although UCR is associated with functional outcomes measured by FIM in TBI patients, it is not an independent predictor of these outcomes but rather a biomarker of catabolic burden.

Objectives: This study aimed to develop a prognostic model for isolated moderate-to-severe traumatic brain injury (TBI) (Glasgow Coma Scale [GCS] ≤ 12) using readily available variables and to explore paired blood-cerebrospinal fluid (CSF) metabolomic signatures. Methods: Consecutive TBI patients admitted between January 2019 and June 2025 were retrospectively analyzed. Multivariate logistic regression with bootstrap internal validation identified predictors of 6-month unfavorable outcome and in-hospital mortality. Untargeted metabolomics was performed on paired blood and CSF samples from 30 matched male patients. Results: Among 405 patients, 266 (65.7%) had unfavorable outcomes and 54 (13.3%) died in hospital. Rotterdam CT Score (odds ratio [OR] 10.59, 95% confidence interval [CI] 6.19-18.14), initial lactate (OR 1.81, 95% CI 1.38-2.36), and blood glucose (OR 1.40, 95% CI 1.21-1.64) predicted unfavorable outcome (area under the receiver operating characteristic curve [AUC] 0.97). GCS motor score (OR 0.50, 95% CI 0.37-0.66), initial lactate (OR 1.57, 95% CI 1.31-1.91), and follow-up lactate (OR 1.57, 95% CI 1.34-1.88) predicted mortality (AUC 0.96). Blood metabolomics revealed enrichment in energy and lipid metabolism pathways. CSF metabolomics highlighted neurotransmitter pathway dysregulation and neuroinflammatory markers, with depleted kynurenic acid in both biofluids. Conclusions: Readily available admission variables enable early bedside risk stratification in TBI. Metabolomic profiling links unfavorable outcomes to systemic energy-lipid dysregulation and central neuroinflammatory-neurotransmitter disturbances, with the tryptophan-kynurenine axis as a potential therapeutic target for neuroprotective strategies.

Background: Traumatic brain injury (TBI) and substance use disorder (SUD) frequently co-occur due to shared risk factors and a potentially bidirectional relationship. However, epidemiological patterns in rural populations remain understudied despite known disparities in access and outcomes. This study aimed to characterize the relationship between TBI and SUD in a rural Southwestern population, including demographic and clinical patterns of diagnostic sequencing. Methods: A retrospective observational study was conducted using electronic health records and trauma registry data (2022-2023) from a rural trauma center. Cohort one included 24,389 emergency department encounters with ICD-10 codes for TBI or SUD. Cohort two included 248 trauma registry patients with TBI and SUD diagnoses. Descriptive statistics and multinomial logistic regression models were used to evaluate diagnostic patterns and associated demographic factors. Results: Males were more likely to have co-occurring TBI and SUD (Relative Risk Ratio [RRR] = 1.35), while increasing age was associated with TBI-only diagnoses. Among patients with multiple visits and diagnoses, 16% had co-diagnoses, while 9% had sequential diagnoses. American Indian/Alaska Native patients had higher co-diagnosis risk compared to White patients (RRR = 2.21, p < 0.001). Higher blood alcohol concentration was associated with lower Glasgow Coma Scale scores (r = -0.15, p = 0.022), indicating greater severity. Conclusions: TBI and SUD frequently co-occur in rural populations, with notable disparities by sex and race/ethnicity. Emergency Departments are critical points of care for interventions such as screening for both substance use and head injury when either is suspected, and employing culturally responsive education and referral pathways upon discharge.

Traumatic injury is one of the most common causes of disorders of consciousness (DoC) worldwide, but the management and prognosis of DoC remain enigmatic. The uncertainty surrounding the natural course of DoC, the tendency of consciousness to wax and wane, and a lack of effective treatments outside of avoiding additional insults renders trauma-associated DoC complex for both providers and patient surrogates to navigate. This review explores the acute clinical course of DoC after traumatic injury chronologically and aims to compile recommendations based on the current best practices for diagnosis, management, and prognostication when caring for these patients during their acute hospitalization. Updates from trauma and Traumatic Brain Injury (TBI) resources, such as the American College of Surgeons, as well as new recommendations in the field of DoC are summarized. Serial clinical assessment with a standardized neurobehavioral battery such as the CRSR-FAST remains the mainstay of clinical care and research for DoC. Accurate diagnosis, multifaceted management, and humility surrounding prognostic discussions are all critical to caring for patients with DoC after trauma. Most of the care for trauma patients with a DoC remains supportive and aimed at avoiding secondary insults while allowing time for the patient's recovery. In the same way that clinical care focuses on a cycle of diagnosis, treatment, and prognosis with each providing insight for the next, ongoing and future DoC research will compound on itself and hopefully lead to more advances in the future.

Background/Objectives: The technique used for flap creation in laser in situ keratomileusis (LASIK) may influence postoperative optical quality and visual outcomes. This prospective randomized paired-eye study compared higher-order aberrations (HOAs) and visual acuity outcomes following femtosecond laser-assisted versus mechanical microkeratome-assisted LASIK. Materials and Methods: Forty-four patients (88 eyes) underwent bilateral LASIK. In each patient, one eye was randomly assigned to high-frequency femtosecond laser flap creation (Femto LDV), and the fellow eye to mechanical microkeratome flap creation (Amadeus II). Inclusion criteria were stable refraction, central corneal thickness ≥ 520 µm, and normal corneal topography. HOAs were measured using Hartmann-Shack wavefront aberrometry over a 6 mm pupil diameter. Uncorrected and corrected distance visual acuity (UDVA and CDVA) were evaluated preoperatively and postoperatively at 1 day, 1 week, and 1, 3, and 6 months. Results: Both techniques induced significant postoperative changes in specific Zernike coefficients and an increase in total HOA root mean square (RMS) values (p < 0.05). A reduction in spherical aberration (Z4,0) was observed in both groups, while technique-specific changes were noted in individual aberration components including an increase in horizontal trefoil (Z3,3) in the femtosecond and a decrease in horizontal coma (Z5,1) in the microkeratome group. However, paired-eye comparisons revealed no statistically significant differences in total HOA six months postoperative. Despite comparable aberrometric outcomes, femtosecond-treated eyes demonstrated significantly better UDVA and CDVA at all postoperative time points (p < 0.05). Conclusions: Femtosecond laser-assisted and microkeratome-assisted LASIK resulted in comparable changes in higher-order aberrations, despite differing pattern in individual aberration components. The observed differences in visual acuity outcomes were not reflected in wavefront metrics, suggesting that postoperative visual performance may be influenced by factors.

Background/Objectives: Acute subdural hematomas (aSDH) represent a frequent and potentially life-threatening form of traumatic intracranial hemorrhage. This study aims to assess prognostic factors associated with mortality and clinical outcome, with particular emphasis on coagulation-related parameters, especially international normalized ratio (INR). Methods: A single-center retrospective cohort study was performed. We included 151 patients with traumatic aSDH, admitted between January 2020 and June 2025 to the Department of Neurosurgery of the Clinical Emergency Hospital "Saint Pantelimon". Demographic, clinical, laboratory, and imaging parameters obtained at admission were analyzed. Univariate and multivariable regression analyses were performed to identify predictors of in-hospital mortality. Internal validation included bootstrap resampling, calibration analysis, penalized regression and spline modeling. Results: The cohort had a mean age of 67.4 years and was predominantly male (72.8%). Overall, in-hospital mortality was 36.4%, while 58.3% of patients underwent surgical intervention. Admission Glasgow Coma Scale (GCS) score represented the strongest predictor of mortality. Hematoma thickness was significantly associated with midline shift, mortality, and surgical intervention. Elevated INR was significantly associated with increased hematoma thickness, greater midline shift, lower GCS, and increased mortality. In multivariable analysis, INR ≥ 1.4 remained independently associated with mortality (OR 4.08, 95% CI 1.56-11.29, p = 0.005), together with lower GCS. The final model demonstrated very good discrimination (AUC 0.887) and good calibration. Conclusions: Outcome in traumatic aSDH appears to be influenced by neurological severity, hematoma burden, and coagulation status. Admission GCS remained the strongest predictor of mortality, while elevated INR independently predicted poor outcome.

Background/Objectives: Delirium is a frequent and clinically significant complication in cardiac surgery patients and is associated with prolonged mechanical ventilation, longer Intensive Care Unit (ICU) stay, increased mortality, and long-term cognitive impairment. However, evidence regarding perioperative factors associated with delirium occurrence in cardiac surgery ICU patients remains limited. This study aims to investigate clinical factors associated with postoperative delirium in cardiac surgery patients admitted to the ICU. Methods: A single-center, prospective, observational study was conducted in a 14-bed cardiothoracic ICU in central Italy. Consecutively enrolled adult patients undergoing cardiac surgery were assessed for delirium using the Italian-validated Intensive Care Delirium Screening Checklist (ICDSC) every eight hours for five days. Univariate analysis and multivariate logistic regression were performed to identify factors associated with delirium occurrence. Results: A total of 175 patients were included, and delirium occurred in 44.6%. In the univariate analysis, patients with delirium presented significantly longer mechanical ventilation (10.5 vs. 8.0 h; p = 0.04) and higher APACHE II scores (p = 0.01). In the multivariable analysis, lower Glasgow Coma Scale (GCS) scores were independently associated with delirium occurrence (OR = 0.84; 95% CI: 0.71-0.99; p = 0.04). Urgent admission (OR = 2.02; p = 0.06) and mean arterial pressure (OR = 0.97; p = 0.08) did not reach statistical significance in the multivariable model. Conclusions: Delirium is highly prevalent after cardiac surgery. Lower postoperative GCS scores may represent an early marker of postoperative neurological vulnerability associated with delirium occurrence. Further multicenter studies are warranted to improve delirium risk stratification and clarify the mechanisms underlying postoperative cognitive dysfunction.