Since the early second century, the pupillary light response (PLR) has been utilized in neurological examinations to gain insight into patient conditions and neuroprognostication. Traditionally, manual pupillometry has been employed to evaluate PLRs. However, this method is subjective and exhibits low interexaminer consistency and reliability. The advent of quantitative pupillometry (QP) has provided clinicians with an objective and reliable method to evaluate and standardize pupillary metrics, most notably, the Neurological Pupil index (NPi). QP protocols have been instituted in many neuro intensive care units (ICUs) as a tool for quickly assessing patients and informing clinical decision-making. A literature review was conducted to understand the use of QP in neuro ICUs and document the relationships between pupillary measurements and clinical consequences. The databases PubMed, Embase, and Scopus were systematically searched for original research articles from 1995 to 2025 in which QP was used for adult patients in the neuro ICU. Using 21 search terms, a total of 52 articles were identified and analyzed. The findings demonstrated the widespread use of QP in patients with acute brain injuries, such as traumatic brain injury, aneurysmal subarachnoid hemorrhage, intracerebral hemorrhage, and stroke. Many studies have established NPi as a non-invasive surrogate measure of intracranial pressure (ICP), which is particularly useful in screening for elevated ICP owing to its high negative predictive value. Correlations were noted between abnormal NPi, poor neurological outcomes, and a greater risk of mortality in many types of brain injury. The identification of the relationship between NPi and clinical events in specific patient populations may aid clinicians in tailoring QP usage to patients.

Background: Traumatic brain injury (TBI) presents specific challenges for sedation management, especially in intensive care units (ICUs) in resource-limited or conflict-affected settings. Nurses play a central role in sedation; however, standardized tools such as the Richmond Agitation-Sedation Scale (RASS) are frequently underutilized. Evidence of the effectiveness of nurse-led sedation protocols in such contexts remains limited. This randomized controlled trial aimed to evaluate the influence of a nurse-led RASS-guided sedation protocol on sedation quality and care practices among patients with TBI. Methods: This study employed a randomized controlled design using block randomization and included 80 adult patients with TBI recruited from three general ICUs. Data were collected using four tools: a patient demographic and clinical data form, multiple clinical assessment scales, a pharmacological and non-pharmacological intervention checklist, and the nurse-led sedation protocol. The control group received standard sedation, whereas the intervention group underwent the RASS-guided protocol. Results: Patients in the intervention group remained within the target sedation range (−2 to +1) significantly longer (61.6% vs. 30.1%, P<0.001), showed fewer episodes of over- and undersedation, achieved superior pain control, had a lower mean Behavioral Pain Scale score (5.51 vs. 7.88, P<0.001), and received more non-pharmacological interventions with fewer sedative infusion hours (P<0.001). Conclusion The nurse-led sedation protocol enhanced sedation quality, improved pain management, and minimized sedative exposure in patients with TBI.

Background: In acute ischemic stroke (AIS), the treatment window for thrombolytics is 4.5 hours from symptom onset. Tenecteplase, a modified tissue plasminogen activator, may be effective over an extended treatment window (4.5–24 hours). Hence, a meta-analysis was performed to evaluate tenecteplase use within an extended treatment window. Methods: Databases were searched for articles published before July 3, 2024. Randomized controlled trials (RCTs) that compared tenecteplase treatment in an extended treatment window with the current standard of care were included. The endpoints were excellent functional outcomes (modified Rankin Scale [mRS] 0–1) at 90 days, National Institutes of Health Stroke Scale (NIHSS) score change at 24 hours and 7 days, and symptomatic intracranial hemorrhage (sICH) at 90 days. The pooled risk ratio (RR) and mean difference (MD) were calculated for categorical and continuous outcomes, respectively. Results: Four RCTs involving 1,629 patients with AIS were included. High-quality evidence indicated that tenecteplase achieved a higher likelihood of mRS 0–1 at 90 days (RR, 1.21; 95% confidence interval [CI], 1.06 to 1.38; P=0.004) and a lower NIHSS score change at 24 hours (MD, −0.84; 95% CI, −1.40 to −0.27; P=0.003) than that of the placebo. Low-quality evidence showed that tenecteplase reduced the NIHSS score change at 7 days (MD, −0.79; 95% CI, −1.56 to −0.03; P=0.04). No differences in sICH or mortality were observed. Conclusion Tenecteplase compared favorably with non-thrombolytic therapy in an extended treatment window. Future RCTs may establish tenecteplase as the standard of care for up to 24 hours.

Background: Hemorrhagic transformation (HT) is a major complication of intravenous thrombolysis in acute ischemic stroke (AIS). While an elevated heart rate (HR) at admission is linked to poor outcomes, the heart rate trajectory (HRT) may offer a better prognostic value. This study investigated the association between 24-hour HRT patterns and HT in patients treated with intravenous thrombolysis for AIS. Methods: This retrospective cohort study included patients with AIS who received intravenous recombinant tissue plasminogen activator between January 2015 and February 2025. Patients aged ≥18 years with AIS, complete 24-hour HR data, and follow-up neuroimaging data were analyzed. Latent mixture modeling was applied to classify the HRT patterns using hourly HR measurements. The primary outcome was HT, and the secondary outcomes were in-hospital mortality and modified Rankin Scale (mRS) score at discharge. Results: Among the 164 patients with AIS, 38 (23.2%) developed HT. Four distinct HRT patterns were identified: low-early decline (7.3%), moderate-gradual decline (37.8%), moderate-stable (40.9%), and high-gradual rise (14.0%). Compared with the low-early decline HR group, the high-gradual rise HR group showed a significantly increased risk of HT (adjusted odds ratio, 11.1; 95% CI, 1.0–122.6; P=0.049). In-hospital mortality did not differ significantly, but the discharge mRS scores were significantly higher in the moderate-stable group than in the low-early decline group (P=0.010). Conclusion Distinct 24-hour HRT patterns were associated with HT and discharge outcomes. A persistently high HR may serve as an early risk marker and therapeutic target.

Background: Cerebral malaria (CM) is the most severe complication of Plasmodium falciparum infection, associated with cerebral edema, seizures, and high mortality. Optimizing cerebral hemodynamics is essential to improve outcomes.Case Report: We describe a 28-year-old man returning from Côte d’Ivoire who presented with a 4% parasitemia. Rapid deterioration required intensive care admission, mechanical ventilation, and intravenous artesunate. Multimodal neuromonitoring included continuous electroencephalography, intracranial pressure (ICP) monitoring, and cerebral autoregulation assessment using the long-pressure reactivity index (L-PRx). Despite parasite clearance, cerebral edema developed with radiological signs of intracranial hypertension and ischemic lesions on magnetic resonance imaging. L-PRx demonstrated impaired cerebral autoregulation, whereas ICP remained within noncritical ranges. Continuous electroencephalography excluded epileptiform activity. Gradual neurological improvement allowed extubation after 14 days and hospital discharge after 65 days. Conclusion This is the first report demonstrating cerebral autoregulatory dysfunction in CM using L-PRx and supports multimodal neuromonitoring to guide individualized hemodynamic strategies to prevent secondary brain injury.

Background: Neuroleptic Malignant Syndrome (NMS) is a rare but life-threatening potentially fatal adverse condition most commonly associated with dopamine receptor antagonists. It is characterized by hyperthermia, generalized muscular rigidity, autonomic dysregulation, and elevated serum creatine kinase levels. Prompt recognition and intervention are critical for reducing morbidity and mortality. Case Report: A 61-year-old female with multiple comorbidities developed atypical NMS following abrupt discontinuation of long-acting depot antipsychotic therapy. The patient presented with fever, altered mental status, autonomic dysfunction, and progressive respiratory failure without marked rigidity or significant elevation in creatine kinase levels. Her condition was further complicated by sepsis and hemodynamic instability, necessitating admission to the intensive care unit (ICU) and mechanical ventilation. The diagnosis was established based on the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders and clinical judgment. The patient responded favorably to bromocriptine and other supportive interventions. Conclusion This case highlights the diagnostic complexity of atypical NMS, particularly in elderly patients undergoing depot antipsychotic therapy. A high index of clinical suspicion and prompt multidisciplinary intervention are essential to improve outcomes in such challenging presentations.

Background: Aneurysmal subarachnoid hemorrhage (aSAH) accounts for only 5% of strokes in the United States but imposes substantial economic burdens on healthcare systems, with hospitalization costs exceeding $90,000 per patient. This study evaluated the economic implications of incorporating transcutaneous auricular vagus nerve stimulation (taVNS) into standard aSAH management. Methods: This was a secondary analysis of the Non-invasive Auricular Vagus nerve stimulation for Subarachnoid Hemorrhage (NAVSaH) trial, a single-center trial enrolling adult patients with spontaneous SAH, randomized 1:1 to receive either taVNS or sham stimulation. Cost data were sourced from institutional accounting databases. The primary economic outcomes included total hospitalization costs, resource utilization across service lines, and 30-day readmission rates. Cost and utilization analyses were stratified by Hunt and Hess grades and compared between the treatment arms. Results: The taVNS group (n=13) had lower 30-day hospitalization costs than the sham group (n=14) ($82,632 vs. $103,998, P=0.003), representing a 20.54% reduction. Resource utilization was lower in the taVNS than the sham group for multiple service areas, including respiratory (17.00 vs. 64.60 charges per patient, P=0.003), laboratory (112.23 vs. 140.36 charges per patient, P<0.001), and pharmacy services (266.54 vs 313.29 charges per patient, P=0.004). Additionally, the taVNS group had lower 30-day readmission rates (7.7% vs. 28.6%) and readmission costs ($2,716 vs. $13,085). Conclusion This study provides preliminary evidence that taVNS reduces hospital costs and service utilization in patients with aSAH. Multicenter validation is warranted; however, these findings suggest that taVNS offers a novel strategy for improving resource utilization and costs in critical care settings.

Background: Elevated intraspinal pressure (ISP) driven by cord swelling is hypothesized to cause secondary injuries following trauma. We previously observed comparable ISP elevations in pigs undergoing traumatic spinal cord injury (TSCI) and sham operations (standalone laminectomy), suggesting the presence of other drivers. Methods: Using a porcine model, we assessed whether ISP elevation was compartment specific, related to cerebrospinal fluid (CSF) restoration, or driven by epidural pressure. In three corresponding sub-studies, the ISP was measured in the spinal cord, subdural, and epidural compartments after TSCI (n=5), and the effects of CSF drainage (n=3) and leaving the surgical wound open were tested (n=6). Results: The spinal cord and subdural ISP increased comparably, validating subdural ISP as a proxy for spinal cord pressure. CSF drainage attempts yielded no fluid and did not affect the subdural ISP. Correspondingly, magnetic resonance imaging revealed that the CSF was displaced by a higher degree of epidural compression than by spinal cord swelling. Leaving the wound open reduced ISP 2.5-fold more than the TSCI itself, further implicating epidural pressure from post-laminectomy swelling as a major driver of elevated ISP. Conclusion Epidural pressure influences elevated ISP following TSCI and laminectomy, rather than spinal cord swelling alone or CSF reconstitution. These findings suggest caution against external compression after laminectomy and call for further investigation of elevated ISP in patients with TSCI.

Background: Myasthenic crisis (MC) and systemic lupus erythematosus (SLE) are distinct autoimmune conditions, each capable of leading to severe life-threatening complications. Their coexistence is rare, and their management becomes particularly difficult when they are triggered by infection and respiratory failure. This case report highlights the critical role of plasma exchange (PLEX) as a primary intervention for overlapping autoimmune crises.Case Report: We describe the case of a 57-year-old woman with a 15-year history of myasthenia gravis (MG) and a recent diagnosis of SLE who presented with progressive dyspnea and pneumonia. The patient’s condition rapidly deteriorated, requiring intubation and mechanical ventilation. She was categorized as having Myasthenia Gravis Foundation of America Class V MG with concurrent lupus flare. Early initiation of PLEX resulted in marked clinical improvement and successful extubation on day 5. Conclusion PLEX can play a pivotal role in the management of dual autoimmune crises. Prompt condition recognition and timely use of PLEX can significantly improve the outcomes of patients with MC complicated by SLE.

Background: Paraneoplastic cerebellar degeneration (PCD) is a rare immune-mediated disorder often linked to gynecologic or breast tumors, with anti-Yo antibodies being a key marker. Appendiceal adenocarcinoma-associated PCD has not been previously reported.Case Report: A 64-year-old woman presented with agitation, ataxia, and disinhibition. Magnetic resonance imaging and cerebrospinal fluid were unremarkable, but serum testing revealed anti-Yo antibodies. She received high-dose corticosteroids without full neurological recovery. Positron emission tomography-computed tomography later revealed a hypermetabolic lesion in the appendix. Histopathology confirmed early-stage appendiceal adenocarcinoma. After surgical resection, both autonomic and neuropsychiatric symptoms resolved, with sustained remission at 2.5 years. Conclusion This is the first reported case of anti-Yo–associated PCD linked to appendiceal adenocarcinoma. Early recognition of PCD in atypical presentations can guide oncological investigation even when initial screening is negative. Early treatment with high-dose corticosteroid therapy in combination with early surgical resection may be curative.