Acute brain injury (ABI), including traumatic brain injury, ischemic and hemorrhagic stroke, is associated with high morbidity and mortality, which is driven not only by the primary brain injury, but also by the development of secondary cerebral insults. Among these, raised intracranial pressure (ICP) plays a central pathophysiological role, acting both as a consequence and a driver of ongoing brain injury through mechanical deformation and cerebral ischemia. Although invasive intracranial pressure (ICP) monitoring has a longstanding and ongoing role in neurocritical care management, the interpretation and clinical use of ICP remain controversial. Traditional management strategies rely on fixed ICP thresholds (e.g., > 22 mmHg) to trigger a standardized stepwise escalation of therapy; however, growing clinical evidence indicates that tolerance to ICP elevation varies widely across patients, disease entities, and physiological contexts. This review summarizes the physiological determinants of ICP, including intracranial compliance, cerebrospinal fluid dynamics, cerebral blood volume, and systemic factors, and describes the mechanisms underlying intracranial hypertension. We discuss limitations of using fixed ICP thresholds and highlight emerging concepts, such as ICP burden, waveform morphology, cerebral autoregulation, and functional brain monitoring, as tools to individualize ICP interpretation. The role of invasive and noninvasive ICP monitoring (nICP) modalities is reviewed, emphasizing the complementary value of nICP in guiding decision-making when invasive monitoring is unavailable or contraindicated. Particular attention is given to the integration of ICP within multimodal neuromonitoring frameworks assessing cerebral perfusion, oxygenation, and metabolism. Finally, we explore future perspectives, including the potential of artificial intelligence–based approaches to analyse complex neuromonitoring data, predict secondary insults, and move toward actionable, patientspecific therapeutic strategies. Collectively, these advances support a shift from a uniform, threshold-driven approach toward individualized, physiology-informed management of intracranial hypertension.

STUDY DESIGN:Retrospective cohort study. OBJECTIVES:To examine whether early chemoprophylaxis, compared with no chemoprophylaxis, is associated with a reduced risk of venous thromboembolism (VTE) and bleeding complications after spine surgery for acute central cord syndrome (CCS). SETTING:Multi-site academic centers. METHODS:This pre-registered study using the TriNetX database included adults who underwent primary cervical spine surgery the same day they sustained a CCS. After excluding those with very high VTE risk or prior VTE, we divided participants into cohorts depending on the administration of chemoprophylaxis (heparin or enoxaparin; chemoprophylaxis cohort) versus no chemoprophylaxis (no chemoprophylaxis cohort) within the first three days after surgery. Outcomes through three months included the incidence and risk ratio (RR) of VTE (primary), pulmonary embolism (PE), deep venous thrombosis (DVT), and deceased status. Cohorts were propensity matched according to key risk factors. RESULTS:There were 2417 participants per matched cohort with high follow-up retention (98%). Between cohorts, there was no statistically significant or clinically meaningful difference in the risk of VTE (p = 0.375) over three months' follow-up. Furthermore, there was no statistically significant difference in the risk of PE (p = 0.762) or DVT (p = 0.384). We were unable to assess the risk of epidural hematoma or severe postoperative bleeding as both outcomes were rare. CONCLUSION:Early postoperative chemoprophylaxis was not associated with reduced VTE risk compared with no chemoprophylaxis after spine surgery for acute CCS in adults. These findings do not provide evidence supporting routine chemoprophylaxis use in CCS participants after surgery. However, clinical decisions should remain individualized, particularly for higher-risk participants.

BACKGROUND AND OBJECTIVES:The priority for measuring and optimizing physiological metrics in brain injury care remains to be determined. Calculating and targeting optimal cerebral perfusion pressure (CPP opt ) is an emerging treatment paradigm, but its association with other parameters is uncertain. A previous analysis of 22 patients found that brain tissue oxygenation (P bt O 2 ) peaked when CPP values were near CPP opt . This study sought to validate those findings using a distinct, larger cohort. It also studied the relationship between CPP opt and physiological parameters related to intracranial dynamics and with neurological outcome. METHODS:P bt O 2 , intracranial pressure (ICP), and arterial blood pressure data were collected during a 15-year period from 432 brain injury patients at 4 cooperating trauma centers. CPP opt was retrospectively computed. RESULTS:The median age was 36 years ( n = 316), the median admission Glasgow coma score was 6 ( n = 323), and 75% of the patients were men ( n = 324). In aggregate data, P bt O 2 peaked at CPP values near CPP opt (+/- 2 mm Hg). Proportion of out-of-range ICP measurements (>22 mm Hg) and positive pressure reactivity index were higher in dying and unfavorable outcome groups, and increased with worsening outcome. Time spent near CPP opt was significantly lower in dying patients but not in patients with unfavorable outcome. Time near CPP opt was, however, correlated with better outcome. Proportion of out-of-range P bt O 2 (<20 mm Hg) was not associated with outcome or mortality. CONCLUSION:The results verify CPP opt as physiologically significant and that in aggregate data achievement of CPP opt is associated with maximized P bt O 2 . Compliance with the ICP treatment threshold was, though, the only modifiable physiological variable associated with both functional outcome and mortality. Our results support optimization of ICP with highest priority. Further study is required in patients in whom CPP opt is specifically targeted.

BACKGROUND AND OBJECTIVES:There has been renewed interest in the use of external lumbar drainage (ELD) of cerebrospinal fluid (CSF) to reduce intracranial pressure after traumatic brain injury (TBI). Although the evidence is retrospective and thus confounded by selection bias, it is critical that a phase 1 trial systematically identify "select" patients who would gain benefit of intracranial pressure (ICP) reduction from lumbar drainage. The aim of this study is to evaluate safety and feasibility of controlled CSF ELD in reducing ICP burden and improving outcomes of select severe TBI patients. METHODS:The study will include 30 severe TBI patients with a Glasgow Coma Scale score ≤9 who will be randomized to usual treatment, usual treatment plus early ELD placement if initial ICP ≤20 mm Hg, or late ELD if ICP ≥20 mm Hg as first intervention in tier 2 of Seattle International Brain Injury Consensus Consortium protocol. EXPECTED OUTCOMES:It is expected that the incidence of severe neurological worsening events as per Seattle International Brain Injury Consensus Consortium will not be different between the control and intervention groups. DISCUSSION:A multitude of clinical trials to advance or discover new treatments of severe TBI have remained unfruitful. Recent understanding of the glymphatic system in the brain is suggestive that extraventricular CSF drainage may be very useful in reducing ICP. The natural avenue for this is through ELD. To avoid past mistakes by jumping into an advanced stage trial, we intend to conduct a phase 1 safety and feasibility trial to identify 'select' patients in whom ELD may be performed safely and may serve as a significant change of therapeutic approach to such patients with traumatic intracranial hypertension.

BACKGROUND:Neuroworsening (NW) refers to a state of deterioration of neurological status that occurs as a consequence of the progression of primary lesions or due to intracranial or systemic complications. NW has been associated with worse functional outcomes, and therefore its avoidance may improve prognosis. The objective of this scoping review was to analyze the definitions, prevalence, predisposing factors, and impact on the outcome of NW during all spectra of traumatic brain injury (TBI). METHODS:We performed a scoping review following Joanna Briggs Institute guidelines. RESULTS:A total of 92 studies were identified after the systematic review of the literature using four databases. After applying Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 19 studies were included in the final analysis. Criteria used to define NW were not specified in ten studies, two studies used clinical criteria, two used radiological criteria, and five used a combination of clinical and radiological criteria. The mean prevalence of NW of the total population was 17%; whereas the mean prevalence was 28.2% for severe TBI, 23.4% for moderate TBI, and 6.42% for mild TBI. The predictors of NW were multiple, with a predominance of neuroimaging findings. CONCLUSIONS:NW is common after TBI, occurring in one in every five patients, and it is associated with high mortality and worse functional outcomes. The criteria to define NW has varied across studies; most used definitions based on clinical and neuroimaging criteria, but some included neuromonitoring parameters. Thus, lack of uniformity in the definition of NW remains a major limitation for the study of this major complication. A consensus to standardize the definition of NW and large-scale studies to determine its prevalence and risk factors are urgently needed.

Despite advances in the management of traumatic brain injury (TBI) in the intensive care unit (ICU), and the implementation of new diagnostic techniques and monitoring modalities, the rate of poor neurological outcomes remains high. Specialized neurocritical care units have been shown to improve outcomes. Guidelines have been developed, but most recommendations are based on low levels of evidence. This has led to substantial heterogeneity in clinical practice for many aspects of TBI management, including multimodal neuromonitoring indications, treatment of intra- and extra-cranial complications, and use of prognostic tools. New tools have recently emerged, such as biomarkers and the use of artificial intelligence, but further research is needed to establish their application in clinical practice. This narrative review aims to describe standards of practice for the management of TBI in the ICU, highlighting current evidence and knowledge gaps, to provide a pragmatic approach for clinicians caring for this population.

Background The early management of polytrauma patients with traumatic spinal cord injury (tSCI) is a major challenge. Sparse data is available to provide optimal care in this scenario and worldwide variability in clinical practice has been documented in recent studies. Methods A multidisciplinary consensus panel of physicians selected for their established clinical and scientific expertise in the acute management of tSCI polytrauma patients with different specializations was established. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) endorsed the consensus, and a modified Delphi approach was adopted. Results A total of 17 statements were proposed and discussed. A consensus was reached generating 17 recommendations (16 strong and 1 weak). Conclusions This consensus provides practical recommendations to support a clinician’s decision making in the management of tSCI polytrauma patients.

Care for the patient with traumatic brain injury (TBI) in austere or combat environments is challenging because resources are substantially limited as compared with care for these patients in a tertiary medical facility. Significant research has been and will continue to be performed on TBI care in these settings. This includes high-quality, evidence-based guidelines that are routinely updated to help guide the treating team as to best practices for a wide range of TBI presentations, complications, and outcomes. Much less is known regarding best practices for TBI care in a resource-limited environment, such as a facility in an austere environment without advanced imaging, dedicated neurointensive care, or definitive neurosurgical capabilities. The aim of this study was to identify the methodology that will be used for an upcoming in-person guideline conference, focusing on the care of patients with TBI in resource-limited austere and/or combat zones.

AIM:To discuss adherence to guidelines for the management of traumatic brain injury (TBI) in Türkiye and physicians' attitudes toward standardized, evidence-based medical practice. MATERIAL AND METHODS:Survey questions were uploaded on the website www.surveymonkey.com and sent to the participants via e-mail or social media applications. The first 10 questions were about the participants' profiles, and the rest were purposed on presenting the physicians' viewpoint on and barriers against CPG adherence. SPSS version 17.0 for Windows was used for statistical analysis. RESULTS:A total of 404 physicians (neurosurgeons, 59.5%; anesthesiologists, 16.7%; and emergency medicine practitioners, 23.9%) who were involved in TBI management were included in this study. Of them, 61.7% stated that they frequently adhere to the CPG recommendations for TBI. In their own experience, most of the respondents agreed that CPGs frequently improve outcomes. They stated that they would occasionally or never adopt recommendations with weak evidence. Physicians reached a consensus on individualizing the decision-making along with the CPG recommendations. CONCLUSION:Of the participants, 61% adopted the CPG recommendations. The main barriers to the implementation of the CPGs are the strength of evidence levels and the affordability of the recommendations.

Study Design Clinical practice guideline development. Objectives Acute spinal cord injury (SCI) can result in devastating motor, sensory, and autonomic impairment; loss of independence; and reduced quality of life. Preclinical evidence suggests that early decompression of the spinal cord may help to limit secondary injury, reduce damage to the neural tissue, and improve functional outcomes. Emerging evidence indicates that “early” surgical decompression completed within 24 hours of injury also improves neurological recovery in patients with acute SCI. The objective of this clinical practice guideline (CPG) is to update the 2017 recommendations on the timing of surgical decompression and to evaluate the evidence with respect to ultra-early surgery (in particular, but not limited to, <12 hours after acute SCI). Methods A multidisciplinary, international, guideline development group (GDG) was formed that consisted of spine surgeons, neurologists, critical care specialists, emergency medicine doctors, physical medicine and rehabilitation professionals, as well as individuals living with SCI. A systematic review was conducted based on accepted methodological standards to evaluate the impact of early (within 24 hours of acute SCI) or ultra-early (in particular, but not limited to, within 12 hours of acute SCI) surgery on neurological recovery, functional outcomes, administrative outcomes, safety, and cost-effectiveness. The GRADE approach was used to rate the overall strength of evidence across studies for each primary outcome. Using the “evidence-to-recommendation” framework, recommendations were then developed that considered the balance of benefits and harms, financial impact, patient values, acceptability, and feasibility. The guideline was internally appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. Results The GDG recommended that early surgery (≤24 hours after injury) be offered as the preferred option for adult patients with acute SCI regardless of level. This recommendation was based on moderate evidence suggesting that patients were 2 times more likely to recover by ≥ 2 ASIA Impairment Score (AIS) grades at 6 months (RR: 2.76, 95% CI 1.60 to 4.98) and 12 months (RR: 1.95, 95% CI 1.26 to 3.18) if they were decompressed within 24 hours compared to after 24 hours. Furthermore, patients undergoing early surgery improved by an additional 4.50 (95% 1.70 to 7.29) points on the ASIA Motor Score compared to patients undergoing surgery after 24 hours post-injury. The GDG also agreed that a recommendation for ultra-early surgery could not be made on the basis of the current evidence because of the small sample sizes, variable definitions of what constituted ultra-early in the literature, and the inconsistency of the evidence. Conclusions It is recommended that patients with an acute SCI, regardless of level, undergo surgery within 24 hours after injury when medically feasible. Future research is required to determine the differential effectiveness of early surgery in different subpopulations and the impact of ultra-early surgery on neurological recovery. Moreover, further work is required to define what constitutes effective spinal cord decompression and to individualize care. It is also recognized that a concerted international effort will be required to translate these recommendations into policy.

Background: Traumatic brain injury (TBI) is a major cause of morbidity and mortality worldwide. Intracranial pressure (ICP) monitoring forms the cornerstone of most severe TBI (sTBI) management guidelines, yet treatment practices vary between high income countries (HIC) and low/middle-income countries (LMICs). We sought to find the reasons for variation in ICP monitoring and treatment practices between neurosurgeons in low- and high-income countries. Methods: We developed a 34-item anonymous survey questionnaire on ICP monitoring and treatments, which was emailed to neurosurgeons of various neurosurgical societies (Africa, Asia, Europe, and North America) who manage TBI. Results: One hundred and six respondents from 23 countries completed the questionnaire. Sixty-nine were from Africa, 16 were from North America, 12 were from Western Europe, and 8 were from Asia. About 48.72% of respondents from LMICs versus 96.43% from HICs have had training on ICP use. Among practitioners who monitor ICP invasively in <50% of patients that need it, 41.6% and 37.5% from LMIC cited availability and cost as the major constraints, versus 3.3% and 6.67%, respectively, in HIC. Only 7 (8.97%) from LMIC follow Brain Trauma Foundation guidelines all the time compared to 17.86% from HIC. When asked about their knowledge of randomized controlled trial(RCT), 78.57% of respondents from HIC versus 11.54% from LMIC knew about RCTs that tested the role of ICP monitoring in sTBI. Conclusion: Significant differences exist in ICP monitoring and treatment in patients with sTBI between high and LMICs. Cost and availability are the main determinants of ICP monitor usage. Practice pattern among the respondents was not completely supported by evidence.

Traumatic Brain Injury (TBI) remains a leading cause of morbidity and mortality among all ages; despite the advances, understanding pathophysiological responses after TBI is still complex, involving multiple mechanisms. Previous reviews have focused on potential targets; however, the research on potential targets has continuously grown in the last five years, bringing even more alternatives and elucidating previous mechanisms. Knowing the key and updated pathophysiology concepts is vital for adequate management and better outcomes. This article reviews the underlying molecular mechanisms, the latest updates, and future directions for pathophysiology-based TBI management.

Intracranial pressure monitoring enables the detection and treatment of intracranial hypertension, a potentially lethal insult after traumatic brain injury. Despite its widespread use, robust evidence supporting intracranial pressure monitoring and treatment remains sparse. International studies have shown large variations between centres regarding the indications for intracranial pressure monitoring and treatment of intracranial hypertension. Experts have reviewed these two aspects and, by consensus, provided practical approaches for monitoring and treatment. Advances have occurred in methods for non-invasive estimation of intracranial pressure although, for now, a reliable way to non-invasively and continuously measure intracranial pressure remains aspirational. Analysis of the intracranial pressure signal can provide information on brain compliance (ie, the ability of the cranium to tolerate volume changes) and on cerebral autoregulation (ie, the ability of cerebral blood vessels to react to changes in blood pressure). The information derived from the intracranial pressure signal might allow for more individualised patient management. Machine learning and artificial intelligence approaches are being increasingly applied to intracranial pressure monitoring, but many obstacles need to be overcome before their use in clinical practice could be attempted. Robust clinical trials are needed to support indications for intracranial pressure monitoring and treatment. Progress in non-invasive assessment of intracranial pressure and in signal analysis (for targeted treatment) will also be crucial.

OBJECTIVE Different paradigms for neurocritical care of traumatic brain injury (TBI) have emerged in conjunction with advanced neuromonitoring technologies and derived metrics. The priority for optimizing these metrics is not currently clear. The goal of this study was to determine whether achieving cerebral perfusion pressure (CPPopt) also improves other metrics like brain oxygenation and brain blood flow. METHODS The authors performed a retrospective analysis of high-frequency data from patients with TBI who were treated at a single center and who had partial pressure of brain oxygen (PbtO2) measurements and/or brain blood flow measurements, while also undergoing intracranial pressure (ICP) monitoring. CPPopt was not calculated or targeted during patient care, but was retrospectively computed, as was the difference between the observed CPP and CPPopt. RESULTS A total of 22 patients with ICP, PbtO2, and/or brain blood flow monitoring were included in the analysis, and 245.7 days of measurements obtained every second were analyzed including 6,748,866 PbtO2 measurements, 3,296,405 blood flow measurements, and 10,264,770 ICP measurements. The data obtained every second were averaged by minute for analysis. In summative data, PbtO2 measurements peaked near CPPopt and were not improved above CPPopt. Blood flow measurements remained stable near CPPopt, decreased below it, and increased when CPP exceeded CPPopt. ICP decreased linearly with CPP without a specific relationship with CPPopt. In an inverse analysis, the percentage of CPP values at CPPopt, although significantly higher on the favorable side of contemporary treatment thresholds of PbtO2, ICP, and blood flow, was not found to be strongly correlated with the mean values of the physiological measurements obtained every minute (r = 0.27, r = 0.11, and r = 0.47 for ICP, PbtO2, and blood flow, respectively; p < 0.0001). CONCLUSIONS Although CPPopt was not targeted in the patients in this study, CPPopt was a physiologically significant value based on concurrent measurements of PbtO2 and blood flow. In summative data, achievement of CPPopt was associated with optimized PbtO2 and blood flow. Conversely, the correlation between achievement of CPPopt and the mean measurement value was not strong, strengthening the significance of CPPopt. In individual patients, achieving CPPopt is not always associated with optimal PbtO2 or blood flow. Further research should explore these relationships in treatment paradigms that specifically target CPPopt. These data do not support the premise that targeting and achieving CPPopt obviates the need for concurrent PbtO2 and blood flow monitoring. Although these data suggest that targeting CPPopt may be an appropriate initial treatment strategy, they do not provide evidence that CPPopt should be targeted with highest priority.

Study Design Development of a clinical practice guideline following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process. Objective The objectives of this study were to develop guidelines that outline the utility of intraoperative neuromonitoring (IONM) to detect intraoperative spinal cord injury (ISCI) among patients undergoing spine surgery, to define a subset of patients undergoing spine surgery at higher risk for ISCI and to develop protocols to prevent, diagnose, and manage ISCI. Methods All systematic reviews were performed according to PRISMA standards and registered on PROSPERO. A multidisciplinary, international Guidelines Development Group (GDG) reviewed and discussed the evidence using GRADE protocols. Consensus was defined by 80% agreement among GDG members. A systematic review and diagnostic test accuracy (DTA) meta-analysis was performed to synthesize pooled evidence on the diagnostic accuracy of IONM to detect ISCI among patients undergoing spinal surgery. The IONM modalities evaluated included somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), electromyography (EMG), and multimodal neuromonitoring. Utilizing this knowledge and their clinical experience, the multidisciplinary GDG created recommendations for the use of IONM to identify ISCI in patients undergoing spine surgery. The evidence related to existing care pathways to manage ISCI was summarized and based on this a novel AO Spine-PRAXIS care pathway was created. Results Our recommendations are as follows: (1) We recommend that intraoperative neurophysiological monitoring be employed for high risk patients undergoing spine surgery, and (2) We suggest that patients at “high risk” for ISCI during spine surgery be proactively identified, that after identification of such patients, multi-disciplinary team discussions be undertaken to manage patients, and that an intraoperative protocol including the use of IONM be implemented. A care pathway for the prevention, diagnosis, and management of ISCI has been developed by the GDG. Conclusion We anticipate that these guidelines will promote the use of IONM to detect and manage ISCI, and promote the use of preoperative and intraoperative checklists by surgeons and other team members for high risk patients undergoing spine surgery. We welcome teams to implement and evaluate the care pathway created by our GDG.

Intracranial pressure (ICP) monitoring is now viewed as integral to the clinical care of many life-threatening brain insults, such as severe traumatic brain injury, subarachnoid hemorrhage, and malignant stroke. It serves to warn of expanding intracranial mass lesions, to prevent or treat herniation events as well as pressure elevation which impedes nutrient delivery to the brain. It facilitates the calculation of cerebral perfusion pressure (CPP) and the estimation of cerebrovascular autoregulatory status. Despite advancements in our knowledge emanating from a half century of experience with this technology, important controversies remain related even to fundamental aspects of ICP measurements, including indications for monitoring, ICP treatment thresholds, and management of intracranial hypertension. Here, we review the history of ICP monitoring, the underlying pathophysiology as well as current perspectives on why, when and how ICP monitoring is best used. ICP is typically assessed invasively but a number of emerging, non-invasive technologies with inherently lower risk are showing promise. In selected cases, additional neuromonitoring can be used to assist in the interpretation of ICP monitoring information and adapt directed treatment accordingly. Additional efforts to expand the evidence base relevant to ICP monitoring, related technologies and management remain a high priority in neurosurgery and neurocritical care.