ABSTRACT Introduction This study aimed to evaluate the use of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score as a proactive clinical tool to enhance Quality of Care (QoC), providing empirical evidence for critical nursing practice in detecting patient deterioration. Methods This prospective cohort study analyzed 76 neurosurgery ICU patients at a tertiary referral hospital. The first 24-hour APACHE II score was calculated to determine its association with clinical deterioration within the first 48 hours. An APACHE II score of ≥16 was established as the cutoff point to stratify patients into high-risk and low-risk groups. Results The APACHE II score demonstrated strong prognostic accuracy in predicting mortality (AUC 0.779, p < 0.001). Furthermore, a high-risk APACHE II score (≥16) was significantly associated with the incidence of early clinical deterioration within the first 48 hours (27.3% vs. 4.7%; p = 0.008). Conclusions This study provides empirical validation of APACHE II in this neurosurgery cohort, demonstrating good prognostic accuracy. The significant association established between high initial scores and early clinical deterioration suggests its potential utility as an objective trigger for enhanced monitoring. These findings support a shift toward using the score proactively, although validation in larger multi-center cohorts is required.

ABSTRACT Objective The regulation of mitochondrial bioenergetics – as one of the endogenous defense mechanisms against ischemia-reperfusion (IR) injury – has been considered promising. This study aimed to determine which mitophagy-related signaling pathways (parkin, Bnip3, or FUNDC1) mediate the protective effects of postconditioning (PostC) and melatonin, both of which enhance the intrinsic defense capacity of cerebral tissue. In addition, microRNA-137 and microRNA-145, as well as serum asprosin, a novel glucogenic adipokine, levels were analyzed in cerebral IR injury. Method Rats were divided into four groups: control (sham), IR, IR+PostC and IR+Mel(n:10). After 90 minutes of occlusion, PostC was performed at the onset of reperfusion in three cycles of 30-sec reperfusion, followed by 10-sec ischemia. Results: All parameters involved in mitophagy pathways increased with IR in cerebral cortex, and serum asprosin level decreased. Parkin and PINK1 levels did not change due to the treatments, while the FUNDC1 and Bnip3 levels decreased and serum asprosin levels increased significantly compared to IR. MicroRNA-137 and microRNA-145 decreased, although treatment partially restored the levels of these microRNAs. Conclusion Increased expressions of parkin/PINK1, FUNDC1 and Bnip3 may suggest that all mitophagy pathways are activated by cerebral IR. Melatonin PostC may protect the cerebral tissue by inhibiting BNİP3- and FUNDC1-mediated mitophagy.

ABSTRACT Objective Ventilator-associated pneumonia (VAP) is a frequent complication in patients with traumatic brain injury (TBI) requiring mechanical ventilation. This study aimed to evaluate the incidence, microbiological characteristics, and clinical impact of VAP in mechanically ventilated patients with TBI. Methods During the 5-year study period, 565 patients with traumatic brain injury were screened; 340 met inclusion criteria and were included in the final analysis, divided into VAP (n = 170) and non-VAP (n = 170) groups. This retrospective observational study included adult patients with TBI who required invasive mechanical ventilation for ≥48 hours between January 2020 and December 2024. Patients with pneumonia at admission were excluded. VAP was diagnosed according to international guideline criteria using clinical, radiological, and microbiological findings. Demographic data, injury severity, microbiological results, and clinical outcomes were analyzed. Independent predictors of VAP and mortality were assessed using multivariate logistic regression and Cox proportional hazards models. Results Among 340 mechanically ventilated patients with TBI, 170 (50%) developed VAP, with a median onset of 5 days. Gram-negative pathogens predominated, mainly Acinetobacter baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae, with multidrug-resistant organisms accounting for 61% of isolates. VAP was associated with longer mechanical ventilation, prolonged intensive care unit stay, and higher mortality. Lower admission Glasgow Coma Scale scores, prolonged sedation exposure, and longer ventilation duration were independently associated with VAP. VAP remained an independent predictor of mortality. Conclusions VAP is highly prevalent in mechanically ventilated patients with TBI and is associated with adverse clinical outcomes, underscoring the importance of effective prevention strategies.

ABSTRACT Introduction Mild traumatic brain injury (mTBI) is common, and up to half of patients experience persistent symptoms, but conventional neuroimaging typically appears normal. Divided Subtracted Inversion Recovery (dSIR) is a new sequence with high sensitivity to white matter changes that may appear normal on standard imaging. Case presentation We present a case series of three adolescent males with acute mTBI scanned with both T2-FLAIR and dSIR. In all cases, T2-FLAIR images were normal. In two symptomatic cases, dSIR demonstrated a ‘whiteout sign,’ with bilateral, symmetrical high signal in cerebral and cerebellar white matter. In one case, the whiteout sign was present at 21 hours post-injury and had largely resolved by 64 hours. The third patient showed no abnormality on dSIR, consistent with their asymptomatic clinical presentation. Across all three cases, dSIR findings corresponded to clinical symptom status at the time of scanning. Conclusion These early observations suggest dSIR may provide a useful imaging marker of secondary brain responses to injury. Further studies are needed to determine the sensitivity, specificity, and clinical value of dSIR in the assessment of mTBI.

ABSTRACT Introduction Posttraumatic hydrocephalus (PTH) is an uncommon but serious complication of traumatic brain injury (TBI). Although extensively studied in adults, important developmental differences in the pediatric central nervous system contribute to differing PTH pathophysiology, with important differences in diagnosis, clinical course, and treatment. Objective This review synthesizes current evidence regarding pediatric PTH, with specific attention to the influence of pediatric developmental pathophysiology on disease susceptibility, diagnosis, and outcomes. Key takeaways Pediatric-specific data on PTH remain limited; however, recent studies suggest that younger age – particularly under five years at injury – as well as injury severity are the two strongest predictors of PTH development. Clinically, PTH may present acutely with neurological deterioration or chronically with delayed recovery and neurodevelopmental regression. Early recognition is critical, as untreated PTH can lead to lifelong neurological dysfunction and even death, yet diagnosis is often delayed by symptom overlap with other posttraumatic conditions and difficulties in distinguishing true hydrocephalus from ventriculomegaly. Management is primarily surgical and centers on cerebrospinal fluid (CSF) diversion, most commonly with external ventricular drainage (EVD) in the acute phase and permanent shunting or ventriculostomy in select cases. Despite timely intervention, long-term morbidity remains substantial, underscoring the importance of prevention, early detection, and multidisciplinary follow-up.

ABSTRACT Introduction Acquired brain injury (ABI) can lead to difficulties in activities of daily living and reduced participation. Few interventions have explored the treatment impact of peer mentoring for people with ABI. This study explored the feasibility and acceptability of a peer mentoring intervention (PAIRS). Methods Mixed-methods feasibility study with post-intervention interviews. Feasibility was assessed regarding recruitment, retention, and intervention adherence. Acceptability was assessed through post-intervention interviews with mentors, mentees, carers, and healthcare professionals. Effectiveness was assessed using descriptive statistics on quality of life, mood, and goal attainment. Interviews were analyzed using the framework method. Results Four mentor-mentee pairs completed an introductory meeting, and between one and six further meetings. Three carers and five healthcare providers were recruited. More resources, such as improved staffing levels, would have improved recruitment rates. Carers showed reductions in carer burden. Interviews showed that participants valued the social contact provided by mentoring and reported some benefits to quality of life and adaptations to the effects of brain injury. However, they experienced difficulties arranging meetings. Conclusion Peer mentoring was challenging and resource-intensive, suggesting a larger effectiveness study using the methods employed here is not feasible. Future studies should address matching procedures, implementation barriers, and consider alternative outcomes.

ABSTRACT Aim This systematic review and meta-analysis critically evaluates preclinical evidence on leptin’s efficacy and mechanistic actions in rodent models of focal cerebral ischemia. Method Comprehensive searches of PubMed, EMBASE, Scopus, and Google Scholar (1995–2024) identified 17 eligible studies (n = 1,383 animals), following PRISMA 2020 guidelines and PROSPERO registration (CRD42023461569). Data extraction and risk of bias assessment (SYRCLE tool) were conducted independently by dual reviewers. Pooled standardized mean differences (SMD) were calculated using a random-effects model. Results Leptin administration significantly reduced infarct volume (SMD = -2.76; 95% CI: −3.65 to −1.86; p < 0.001) and ameliorated neurological deficits (SMD = -4.37; 95% CI: −5.80 to −2.95; p < 0.001), with pronounced effects in murine models. Mechanistically, leptin mitigated apoptosis – indicated by lowered cleaved Caspase-3 and TUNEL-positive cells – and promoted the upregulation of proteins involved in neuroprotection, including BCL-2, p-STAT, TRPV1, and the leptin receptor. Conclusion Although this meta-analysis demonstrates the promising neuroprotective properties of leptin, the substantial heterogeneity among studies and the resulting lower certainty of evidence highlight the critical need for future research employing standardized methodologies, rigorous study designs, and sufficient statistical power to validate these findings and support their translation into clinical settings.

ABSTRACT Background Veterans experiencing homelessness are clinically complex, often requiring myriad Department of Veterans Affairs (VA) services to manage their health and social service needs. Conditions common among these Veterans, including traumatic brain injury (TBI), may impact their VA service use; nonetheless, examination of the intersection of TBI and service use among Veterans experiencing homelessness remains understudied. Method Electronic medical record data for 1,088,328 Veterans identified as experiencing homelessness who were accessing Veterans Health Administration (VHA) services from 2005 to 2024 were examined. Crude and adjusted models were conducted to examine VA service use based on documented TBI diagnosis. Results In total, 12.7% of Veterans experiencing homelessness had a documented TBI diagnosis. TBI diagnosis was associated with increased frequency across all VHA service use settings. Associations appeared most robust in VA rehabilitative, mental health, and emergency service settings. Conclusions Veterans experiencing homelessness with TBI histories appear to access several VHA services to manage their health and social service needs. Given this, interdisciplinary approaches (e.g. VA Homeless Patient Aligned Care Teams) are likely pragmatic for these Veterans. Further dissemination and evaluation of the utility of brain health-informed care within novel VHA service settings (e.g. justice programs, emergency services) may hold merit.

ABSTRACT Background Traumatic brain injury (TBI) represents a significant cause of morbidity and mortality in children, with secondary injuries such as elevated intracranial pressure (ICP) significantly impacting outcomes. Hyperosmolar therapy is a cornerstone of acute management, with hypertonic saline (HTS) and mannitol as principal agents; however, comparative evidence regarding their efficacy and safety in pediatric populations remains inconclusive. Methods Comprehensive searches of PubMed, Embase, and CENTRAL were performed up to June 2025. Primary outcomes were ICP reduction and all-cause mortality; secondary outcomes included neurological outcomes, adverse events, ICU/hospital stay, and physiological parameters. Meta-analyses employed random-effects models to pool risk ratios (RR), mean differences (MD), and proportions with 95% confidence intervals (CI). Results A total of 14 studies, including 680 pediatric patients with TBI, were analyzed. HTS was associated with an increase in serum sodium (mean change 5.47 mEq/L; 95% CI: 1.30–9.64), severe hypernatremia (37%; on resolving heterogeneity rose to 53%), acute kidney injury (2.1%), and acute respiratory distress syndrome (4.5%). Comparative meta-analysis revealed no significant difference in mortality between HTS and mannitol (RR = 0.78; 95% CI: 0.50–1.23) and similar survival rates (RR = 1.05; 95% CI: 0.96–1.14), with high certainty. The pooled mortality rate for HTS was 17% (95% CI: 11%–24%), and survival was 83% (95% CI: 76%–89%). Pooled HTS analyses demonstrated a time-dependent decrease in ICP: 17.35 mmHg at 30 minutes, 9.72 mmHg at 60 minutes, and 8.45 mmHg at 24 hours. No significant differences were found for cerebral perfusion pressure (CPP) at 24 hours, ICU stay, hospital stay, or mechanical ventilation duration. Conclusion In pediatric TBI, hypertonic saline and mannitol provide comparable efficacy for ICP reduction and mortality, with HTS demonstrating rapid ICP lowering and manageable safety signals. While HTS is generally well tolerated, further high-quality multicenter RCTs with standardized protocols and long-term outcomes are needed to clarify its clinical advantages over mannitol.

ABSTRACT Background Hyponatremia is a frequently encountered electrolyte disorder in neurocritical care patients, often associated with various types of brain injuries such as hemorrhages, ischemic events, tumors, infections, surgical procedures, and traumatic brain injury (TBI), among others. Case presentation Herein, we present a case study of a patient with severe TBI who underwent decompressive craniectomy and subsequently developed persistent hyponatremia during the Intensive Care Unit (ICU) stay. Recognizing the crucial distinction between the Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) and Cerebral Salt Wasting (CSW) syndrome is imperative, given the distinct treatment approaches required for each condition. The patient underwent ultra-early cranioplasty, which resulted in the subsequent resolution of hyponatremia and improvement in clinical status. Conclusion We provide a comprehensive review of the management of hyponatremia in neurocritical patients, underscoring the efficacy of early cranioplasty as a therapeutic intervention.