Intracerebral hemorrhage in the pons can, on rare occasions, present with acute coronary syndrome-like symptoms via neurogenic cardiac findings, such as electrocardiographic changes and increased cardiac biomarkers. The challenge in this condition is that the treatment for acute coronary syndrome can potentially exacerbate the neurological outcome in hemorrhagic stroke. Neurogenic stress-induced cardiomyopathy in pontine hemorrhage is a result of autonomic dysfunction and excess catecholamine, which cause reversible myocardial dysfunction in the absence of obstructive coronary artery disease. The key to this condition is the proper differentiation between true myocardial ischemia and neurogenic cardiac injury to avoid the risks of antithrombotic therapy and invasive cardiac procedures. This review aims to highlight the neurocardiac mechanisms, challenges, and implications of pontine hemorrhage presenting with acute coronary syndrome-like symptoms.
Mannitol, an osmotically active and commonly employed agent in neurocritical care which is well tolerated. However, isolated case reports of IgE-mediated anaphylaxis impose a potential immunological risk, pertaining to CCD-sensitized or atopically predisposed subjects. This review summarizes recent studies of hypersensitivity to mannitol included with emphasis on immunopathogenesis, case reports, diagnostic possibilities, and clinical issues. A comprehensive literature search was conducted in PubMed, Web of Science, and EMBASE from inception through December 2025. Search terms included “mannitol,” “anaphylaxis,” “hypersensitivity,” “cross-reactive carbohydrate determinants,” and “neurocritical care,” using Boolean operators and Medical Subject Headings where applicable. The review followed PRISMA guidelines for study identification, screening, eligibility, and inclusion. Reference lists of relevant articles were manually screened to identify additional publications. Only English-language human studies were included. While uncommon, anaphylaxis from mannitol has been documented, especially in cross-reactive carbohydrate determinant (CCD)-sensitized patients. IgE-CCD interaction facilitated by the molecular structure of mannitol can result in mast cell degranulation and systemic hypersensitivity. Several reports of intraoperative deaths highlight the need for increased awareness. Alternatives such as hypertonic saline should be considered in high-risk cases. Allergic history screening in mannitol-dependent individuals should be performed by medical practitioners. Tests for CCD sensitization are not used appropriately but can reduce risk. Hypertonic saline provides a safer option in appropriately chosen cases.
The Monro-Kellie doctrine, first articulated in 1783, established that intracranial volume remains constant within the rigid cranium. However, this static three-compartment model has proven inadequate to explain the full complexity of intracranial pathophysiology. Sequential paradigm shifts—designated Monro-Kellie (MK) 1.0 through 4.0—have progressively transformed this foundational framework. MK 2.0 (Wilson, 2016) demonstrated that cerebral venous outflow dynamics, rather than static volume compensation, are the dominant determinant of acute intracranial pressure (ICP) fluctuations, with arterial inflow of approximately 700 mL/min dwarfing CSF production of 0.35 mL/min. MK 3.0 (Mangalore et al., 2019; Benson et al., 2022) revealed that brain tissue viscoelastic remodeling and calvarial structural adaptation constitute previously unrecognized compensatory mechanisms in chronic pressure dysregulation. MK 4.0 (Brasil et al., 2025) integrates cerebrovascular autoregulation assessment, glymphatic system physiology, and the novel concept of Intracranial Compartment Syndrome into a multimodal dynamic framework that challenges threshold-based ICP management. The Brussels International Consensus (B-ICONIC, 2025) has provided 34 evidence-based recommendations for noninvasive ICP monitoring implementation. This evolution necessitates a transition from threshold-driven management to individualized, physiology-guided neurocritical care incorporating continuous assessment of intracranial compliance, cerebrovascular reactivity, and glymphatic function.
The shock index (SI) is a rapid and practical physiological parameter used to identify decompensated shock and assess severity in cases of progressive hemodynamic decline. This study aims to determine an optimal SI cutoff for adult trauma patients (18 years or older). The research was conducted in accordance with MOOSE checklist for systematic reviews and a comprehensive search for observational studies through December 2023 in various databases. Search terms included “Shock index” AND “Trauma”. Statistical analysis encompassed the extraction of data on mortality, shock index, ROC for mortality, and cutoff point calculations from individual studies. A pooled ROC analysis was performed using a random-effects analysis model. Heterogeneity was assessed via Chi-square and I-squared calculations. Following rigorous search and assessment procedures, 6 studies comprising 292,171 participants were considered eligible for the meta-analysis. These studies predominantly featured retrospective observational cohorts. An optimal SI cut-off of greater than 0.75 was identified (Youden Index J = 0.5673). The combined ROC area value was found to be 0.779 (95 percent confidence interval: 0.707 to 0.852), indicating a statistically significant predictive value for shock index in trauma patient outcomes. The moderate inconsistency level (I-squared = 38.55 percent) highlights the need to account for methodological variations among the studies. The statistically significant aggregated ROC area value supports the utility of shock index as a diagnostic tool at a threshold of greater than 0.75, provided that neurological confounders are considered in neuro-trauma cases.
Background External ventricular drain (EVD) placement is one of the most commonly used interventions in life-saving neurosurgical care. EVDs are often used to treat traumatic brain injuries, infection, primary and secondary hydrocephalus, and intracranial space occupying lesions, such as tumors, cysts, and ischemic/hemorrhagic strokes. EVDs have been proven to reduce mortality but are often associated with complications that can affect patient outcomes. Our study investigates the patient outcomes associated with emergent EVD placement in a patient population with no prior history of neurosurgery.MethodsA retrospective chart review was performed on all patients 18+ requiring emergent EVD placement from January 2016 to December 2022 at Allegheny General Hospital in Pittsburgh, PA. Exclusion criteria included intra-operative EVD placements and patients with any prior neurosurgical history. 223 patient charts were analyzed for outcomes of independent ambulation capability, length of hospital stay, subsequent neurosurgical intervention, and final patient disposition. Subsequent neurosurgical interventions were stratified into six subcategories: EVD removal only, subsequent EVD placement, ventriculoperitoneal shunt (VPS) placement, endoscopic third ventriculostomy (ETV), craniotomy, and other. Patient disposition included home, inpatient rehab, skilled nursing facility, long-term acute care, hospice, and expiration.ResultsOur study demonstrated that only 10% of patients were able to ambulate independently at discharge, 24% of patients required shunt placement, 20% of patients expired in hospital and the average length of hospital stay was 20 days. ConclusionsDespite there being immense research demonstrating the efficacy and safety of EVDs, there is limited literature for clinicians and patients together to demonstrate the clinical gravity of EVD placement. Our study accurately delineates the clinical patient outcomes associated with EVD placement on neuro-surgically naive patients.
Hemorrhagic moyamoya disease (MMD) often manifests with pure intraventricular hemorrhage (IVH) or intracerebral hemorrhage (ICH) with IVH, causing increased intracranial pressure (ICP) and neurological decline. Although intraventricular injection of recombinant tissue plasminogen activator (rt-PA) has been proven safe, its safety in MMD is uncertain. We introduce a case of rescue intraventricular rt-PA injection for an ICP crisis caused by IVH in MMD. A patient with MMD presented with acute ICH with IVH. Bilateral external ventricular drains (EVD) were placed, but the both EVD lost patency immediately due to an intraventricular clot. The next day, due to increased ICP, we injected rt-PA into the right EVD catheter to facilitate intraventricular drainage and reduce clot burden. After injection, IVH volume and ICP decreased significantly without rebleeding, leading to gradual neurological improvement. Intraventricular rt-PA effectively reduced ICP and IVH burden without rebleeding in hemorrhagic MMD, warranting further safety studies.
Studies have suggested that patients with severe head injury, in addition to Glasgow Coma Scale (GCS), reveal high D-dimer levels which are independently associated with increased mortality. In the present review, we analyzed the literature where studies have reported the role of D-dimers as a potential biomarker in stratification and early identification of patients with TBI who are at risk of clinical deterioration, where early intervention can improve overall outcomes. After scrutinizing 246 articles, which were narrowed down to 38 (16 prospective, 9 retrospective, 2 RCTs, 2 case-control, 1 cross-sectional study). All these studies included 7,589 patients, in whom D-dimer was measured at different timings and in different ways. Most studies demonstrated significant changes that could be utilized for prognostication. However, we also observed instances where no significant changes were found. Unfortunately, direct comparisons were hindered by variations in the methods used to measure D-dimer across different outcomes. Limitations included the lack of a substantial number of RCTs, heterogeneity of available data, and the difficulty in summarization of specific cutoff points for D-dimer. Future studies, especially RCTs, should measure D-dimer levels at different times from injury for an accurate assessment of its correlation with outcomes.
Angiogram-negative subarachnoid hemorrhage (SAH) represents a diagnostic challenge because rebleeding risk persists despite negative initial angiography. We report a rare case of a 65-year-old man presenting with diffuse SAH on initial CT but with negative CTA and transfemoral cerebral angiography (TFCA). Serial follow-up CT scans demonstrated gradual resolution of subarachnoid blood except for persistent prepontine cisternal hemorrhage. On hospital day 7, repeat TFCA revealed a bilobulated pseudoaneurysm arising from a midbasilar perforator artery. The lesion was treated using a modified stent-assisted coiling technique involving partial coil deployment, achieving complete angiographic obliteration with parent artery preservation. Post-procedural diffusion-weighted MRI demonstrated a left pontine infarction, but the patient achieved meaningful functional recovery and returned to work at the 3-month follow-up. This case underscores the necessity of repeat angiography in diffuse angiogram-negative SAH and highlights tailored endovascular strategies for fragile basilar perforator pseudoaneurysm.
Streptococcus gordonii is an oral commensal viridans streptococcus that rarely causes invasive infections such as lung abscess or intracranial empyema. The sequential presentation of concomitant pulmonary and cranial abscesses by this organism is extremely uncommon. A 70-year-old man presented with progressive dyspnea and fever. Chest CT demonstrated a 14.4 × 6.8cm mass like lung lesion consistent with a lung abscess. Percutaneous drainage yielded Streptococcus gordoniii. On hospital day 5 following drainage, patient presented with scalp swelling and headache. Brain MRI revealed a subgaleal abscess with an epidural empyema. Emergent craniectomy and debridement were performed, and cultures again grew Streptococcus gordonii. This case is a rare but clinically significant pattern of sequential presentation of concomitant pulmonary and cranial abscesses caused by Streptococcus gordonii, emphasizing the need for dental evaluation, meticulous inpatient monitoring, and early neuroimaging when viridans streptococci are revealed from deep infections.
Cerebral blood flow (CBF) is the percentage of blood that supplies brain tissue and is essential for maintaining cerebral homeostasis due to the brain's significant metabolic demands. CBF is primarily regulated through cerebral autoregulation, which encompasses neurovascular mechanisms interrelated with levels of arterial gases. However, its dynamics are subject to constant changes, influenced by both physiological processes—such as aging and exercise—and pathological conditions, including neurodegenerative diseases and chronic illnesses. We introduce the new concept of "Cerebral Pressure Dynamics Reactions," which elucidates the interplay between the central nervous system's ischemic response and Cushing's triad. We propose that these responses represent a crucial adaptive mechanism to fluctuations in cerebral perfusion, highlighting their significance in the pathobiology of cerebral blood flow in neurocritical patients. Understanding these interactions may offer novel insights into therapeutic strategies to optimize CBF and improve outcomes in this vulnerable population.
Background: The role of glycopyrrolate and other pharmacological drying agents is well established for secretion management in specific populations such as patients living with cerebral palsy or requiring palliative care. Whilst drying agents are used for weaning tracheostomised patients with an acute neurological condition, clinical decision–making pathways have not been well described. To examine the clinical practice of tracheostomy weaning and use of pharmacological drying agents in an acute neurological population admitted to a tertiary hospital.Methods: A retrospective cohort analysis between 2014 to 2019 of all patients tracheostomised after a neurological event. Data were extracted from medical records to obtain patient demographic details, history of presenting condition and weaning plans.Results: A total of 116 patients with a neurological diagnosis required a tracheostomy, of whom 20 patients were using at least one pharmacological drying agent during tracheostomy weaning process. Nine patients still required drying agents on discharge from hospital.Conclusion: Patients who required drying agents in their tracheostomy wean demonstrated a trend towards a longer duration of tracheostomy and a longer length of stay than those who did not. Clinicians need to complete patient–centred objective measures regarding swallowing function and saliva management when considering if a drying agent will be required.
Hydrocephalus, characterized by abnormal cerebrospinal fluid (CSF) accumulation, is commonly treated with ventriculoperitoneal shunting (VPS). Despite its efficacy, VPS is prone to complications, with distal catheter occlusion being a frequent cause of shunt malfunction. This study presents our experience using laparoscopy to manage distal catheter malfunctions in two VPS patients. Postoperative outcomes demonstrated symptom resolution and normalization of imaging parameters without complications. Our findings suggest that laparoscopy is a minimally invasive, effective, and cost-efficient alternative for addressing distal shunt malfunctions, complementing current neurosurgical practices. Additionally, we review the literature on the use of endoscopy and laparoscopy in VPS management and propose an applicable protocol.
Excessive use of antibiotics is a significant public health concern with several severe implications for the development of Antibiotic Resistance and its impact on Gut Microbiota. C-reactive Protein (CRP) is non-specific, acute-phase reactant whose levels increase in response to infection or inflammation due bacterial and viral etiologies. Many studies have explored the role of CRP as a point-of-care tool to assist in decision-making and improve the efficiency of antibiotic prescribing practices among healthcare professionals in primary care settings. The main benefit of POC CRP testing is its ease of use, providing results within 2 to 3 minutes from a simple finger prick, which is optimal for an outpatient clinic. While several studies demonstrate reductions in antibiotic use with POC CRP testing, there are many controversies around those need to be resolved, including the cutoff values of CRP for antibiotic prescription, whether CRP can differentiate bacterial and viral etiologies, and whether a single CRP level can reflect the disease state. Future research needs to focus on developing uniform guidelines for interpreting CRP levels and evaluating whether serial CRP measurements, physician training, especially in primary care and rural settings, to reduce overprescribing. Ultimately, while POC CRP testing can support antibiotic stewardship, its utility must be carefully balanced with sound clinical judgment.
Malignant hyperthermia (MH) is a rare, potentially fatal genetic disorder characterized by an unexplained elevation of expired carbon dioxide despite increased minute ventilation, muscle rigidity, and rhabdomyolysis, hyperthermia, tachycardia, acidosis, and hyperkalemia. It can be triggered by many pharmacological agents such as potent inhalation agents (halothane/ isoflurane/ sevoflurane/ desflurane), the depolarizing muscle relaxant (succinylcholine), and extreme physiological conditions such as vigorous exercise and working excessively in a hot and dry environment. Prompt and early recognition of the condition and rapid initiation of treatment measures are necessary to salvage the patient. Since MH is commonly encountered in the operating room or early postoperative period, anesthetists and surgeons need to keep themselves updated regarding the same. This review article aims to summarize our understanding of MH's pathophysiology, current diagnostics, management, and treatment strategies, along with a brief review of literature of published cases in Indian Subcontinent.
Background: We investigated the distribution of tumor-infiltrating lymphocytes (TILs) and the expression of programmed cell death-ligand 1 (PD-L1) in patients with brain metastasis (BM) from small cell lung cancer (SCLC). Methods: A retrospective analysis was performed on 12 surgical specimens of BMs from SCLC at our institute for 5 years. The Immunofluorescence-based Tissue Microenvironment Analysis Panel (MAP) was utilized for the detection of TILs, including CD3, CD8, PD-1, and PD-L1, in pathological archival specimens of BMs. The correlation between the overall survival (OS) and the above-mentioned markers was analyzed in the patients.Results: Positive rates of CD3+ TILs in the tumor parenchyma versus tumor stroma were 0.60±0.94% versus 1.76±2.72% (p=0.010), respectively; positive rates of CD8+ TILs in the tumor parenchyma versus tumor stroma were 0.80±0.78% versus 2.46±3.72% (p=0.016), respectively. There was no co-expression of CD8+ and PD-1+ TILs in the tumor parenchyma of 11 cases, and the infiltration density of co-expressed CD3+ and PD-1+ TILs was more than 10/mm2 in only 1 case. There was no co-expression of CD3+ and PD-1+ TIL in the stroma of 10 cases, and the infiltration density of CD8+ and PD-1+ TILs was more than 10/mm2 in 2 cases. Immunohistochemistry was used to detect the expression of PD-L1 in 12 cases of BMs, and 3 cases (25%) were positive. Survival analysis showed that patients with positive CD3+ TILs had significantly longer OS (p=0.040). Conclusions: The distribution of TILs in BM of SCLC is low and mainly distributed in the stroma, with the low expression of PD-L1 in the tumor tissues.
Background: There is a shortage of data on brain tumor patients admitted in to intensive care unit (ICU) from developing countries. We aimed to assess the clinical course and 30-day mortality with factors affecting the mortality of brain tumor patients who were admitted to medical ICU.Methods: This study was a single-centre retrospective observational cohort study and was conducted in a medical ICU of a tertiary care center in India. We included 42 patients admitted in to the medical oncology ICU over 3 years. Data regarding demographics, baseline characteristics, clinical and laboratory data, need for organ support, and 30-day mortality were collected. Factors associated with increased mortality in these patients were determined.Results: Overall 30-day mortality was 30.95%. The most common indication for ICU admission was altered sensorium (57.1%) followed by sepsis (23.8%). Age [odds ratio, OR: 0.843 (95% confidence interval, CI: 0.721–0.986)], and need for invasive mechanical ventilator (IMV) support [OR: 484.62 (95% CI: 2.707–8676.02)] or vasopressor support [OR: 523.83 (95% CI: 2.12– 3,023.13)] were directly associated with 30-day mortality. Severity indices such as Sequential Organ Failure Assessment (SOFA) score, SAPS II (Simplified Acute Physiology Score II), and Acute physiology and chronic health evaluation II (APACHE II), APACHE III and APACHE IV scores were higher in non-survivors than survivors.Conclusion: Advancing age and need for IMV or vasopressor support may be associated with worse prognosis in brain tumor patients admitted in to ICU. A scoring system could be used along with clinical judgement to triage brain tumor patients for ICU admission.
Background: The objective of this study is to summarize the evidence in Cochrane and non-Cochrane systematic reviews, the effects, and the benefits of monitoring intracranial pressure (ICP) in patients with head trauma with an indication of ICP monitoringMethods: The process of preparing this overview followed the guidelines established by the Joanna Briggs Institute (JBI) for umbrella reviews. Two independent reviewers evaluated the quality of reporting, bias risk, methodologies, and evidence using three different tools: the Risk of Bias in Systematic Reviews (ROBIS) instrument, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and A Measurement Tool to Assess Systematic Reviews (AMSTAR 2). Results: A total of five papers met the criteria for inclusion in the study. These papers consisted of 49 primary research studies and 19 unique primary research studies. One of the SRs indicated that using intracranial pressure (ICP) monitoring led to a reduction in mortality. Two of the SRs had mixed results with temporal variation, while two found no significant difference in mortality with ICP monitoring. It is important to note that the quality of the SRs varied, with some being of higher quality than others.Conclusion: There was no conclusive evidence that ICP monitoring reduces mortality in TBI patients. There was high heterogeneity in included primary research studies. Future research should aim to address the limitations of these studies and provide more conclusive evidence regarding the effectiveness of ICP monitoring in reducing mortality in patients with traumatic brain injury.
