Abstract
Acute brain injuries, such as traumatic brain injury and ischemic and hemorragic stroke, are a leading cause of death and disability worldwide. While characterized by clearly distict primary events—vascular damage in strokes and biomechanical damage in traumatic brain injuries—they share common secondary injury mechanisms influencing long-term outcomes. Growing evidence suggests that a more personalized approach to optimize energy substrate delivery to the injured brain and prognosticate towards families could be beneficial. In this context, continuous invasive and/or non-invasive neuromonitoring, together with clinical evaluation and neuroimaging to support strategies that optimize cerebral blood flow and metabolic delivery, as well as approaches to neuroprognostication are gaining interest. Recently, the European Society of Intensive Care Medicine organized a 2-day course focused on a practical case-based clinical approach of acute brain-injured patients in different scenarios and on future perspectives to advance the management of this population. The aim of this manuscript is to update clinicians dealing with acute brain injured patients in the intensive care unit, describing current knowledge and clinical practice based on the insights presented during this course.
Key Points
- Neuromonitoring and Secondary Injury Prevention: Advanced neuromonitoring techniques, including invasive and non-invasive modalities, help detect and mitigate secondary brain injury. Continuous assessment of cerebral blood flow, metabolism, and oxygenation is crucial for optimizing patient outcomes.
- Impact of Aging and Gender in ABI: Older patients exhibit higher vulnerability to brain injuries due to pre-existing comorbidities and reduced neuroplasticity, while sex differences influence both injury risk and recovery trajectories. Women experience higher rates of subarachnoid hemorrhage (SAH) but remain underrepresented in clinical trials.
- Neuroimaging for Diagnosis and Prognostication: Computed tomography (CT) remains the first-line imaging modality for acute brain injury evaluation, while magnetic resonance imaging (MRI) provides superior resolution for detecting microstructural damage. Diffusion-weighted imaging and functional MRI are emerging tools for assessing brain function in prolonged disorders of consciousness.
- Metabolic Management of ABI: The injured brain exhibits altered glucose metabolism, necessitating careful control of blood glucose levels. Hyperglycemia worsens outcomes, while alternative energy substrates like lactate and ketones may support brain function. Research on ketogenic diets and hypertonic lactate solutions is ongoing.
- Brain-Organ Crosstalk in Critical Illness: ABI affects multiple organ systems through neuroinflammatory responses and autonomic dysfunction. For example, increased intracranial pressure (ICP) can trigger sympathetic overactivation, leading to myocardial dysfunction and systemic inflammatory responses. Dysbiosis of the gut microbiota following ABI may contribute to long-term neuroinflammation.
- Alcohol and Neuroprotection: While chronic alcohol use exacerbates ABI-related complications, some observational studies suggest moderate alcohol levels at the time of injury may reduce inflammation and oxidative stress. However, evidence remains inconclusive, and alcohol is not recommended as a neuroprotective agent.
- Challenges in Neuroprognostication: Predicting long-term neurological outcomes in ABI remains complex, with high variability in clinical trajectories. Current guidelines emphasize delayed prognostication (≥72 hours post-injury) and multimodal assessment using clinical, neurophysiological, and biomarker data.
- Future Directions in Neuroprotection: Emerging neuroprotective strategies focus on reducing secondary brain injury and enhancing neural repair. Potential interventions include stem cell therapy, neurotrophic factors, and precision medicine approaches leveraging big data analytics. Proteomic biomarkers (e.g., S100B, GFAP, NFL) are being explored for patient stratification and therapy optimization.
- Personalized Approaches to ABI Management: Advances in artificial intelligence and machine learning may enhance real-time decision-making in neurocritical care. Tailoring therapeutic interventions to individual patient profiles could improve long-term recovery.
- Multidisciplinary Collaboration in Neurocritical Care: Effective ABI management requires close coordination among intensivists, neurologists, neurosurgeons, and rehabilitation specialists. Standardized protocols and training programs are needed to improve clinician preparedness and patient outcomes.
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