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Background Despite serving over 10 million inhabitants, neurocritical care across the Lombardy region of Italy (from here on Lombardia) remains fragmented and insufficiently mapped, underscoring the need for a structured regional network. This study aimed to evaluate current resources and explore pathways for integration and development. Methods In 2024, along with other initiatives, a web-based survey was performed, focusing on hospitals with neurosurgical capabilities and intensive care units (ICUs) to identify variations in service delivery and adherence to evidence-based practices, guiding quality improvement across centers. Results Responses were obtained from 19 acute care hospitals with neurosurgical facilities within the regional health service. Ten hospitals (52%) host dedicated neuro-ICUs, including five (26%) that also admit pediatric patients, accounting for a total of 85 beds. In the remaining nine hospitals (47%), neurocritical care is delivered within general ICUs without dedicated beds. Continuous in-house neurosurgical coverage is available in 9 centers (47%), while the others rely on a 24/7 on-call model. All 19 centers (100%) report 24/7 availability of neurologists and neuroradiologists, either in-house or on call. However, access to advanced diagnostic and monitoring technologies remains heterogeneous across sites. Participating centers identified a clear need for standardized protocols and clinical pathways to improve care quality and support evidence-based practices. Priority areas defined by the clinicians include neuroprognostication, end-of-life care and donor management, pediatric neurocritical care, neurointerventional procedures, management of delayed cerebral ischemia following subarachnoid hemorrhage, and post-discharge follow-up. To address these gaps, several multidisciplinary working groups have been established. Conclusion Neurocritical care in Lombardia remains highly heterogeneous, with bed availability significantly below international benchmarks. The establishment of a regional network seeks to enhance the quality and equity of care for neurocritical patients, while also fostering clinical research, data sharing, and multidisciplinary collaboration across centers.

Background The ultra-low-frequency pressure reactivity index (UL-PRx) has been established as a surrogate method for bedside estimation of cerebral autoregulation (CA). Although this index has been shown to be a predictor of outcome in adult and pediatric patients with traumatic brain injury (TBI), a comprehensive evaluation of low sampling rate data collection (0.0033 Hz averaged over 5 min) on cerebrovascular reactivity has never been performed. Objective To evaluate the performance and predictive power of the UL-PRx for 12-month outcome measures, alongside all International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) models and in different age groups. To investigate the potential for optimal cerebral perfusion pressure (CPPopt). Methods Demographic data, IMPACT variables, in-hospital mortality, and Glasgow Outcome Scale Extended (GOSE) at 12 months were extracted. Filtering and processing of the time series and creation of the indices (cerebral intracranial pressure (ICP), cerebral perfusion pressure (CPP), UL-PRx, and deltaCPPopt (ΔCPPopt and CPPopt-CPP)) were performed using an in-house algorithm. Physiological parameters were assessed as follows: mean index value, % time above threshold, and mean hourly dose above threshold. Results A total of 263 TBI patients were included: pediatric (17.5% aged ≤ 16 y) and adult (60.5% aged > 16 and < 70 y and 22.0% ≥ 70 y, respectively) patients. In-hospital and 12-month mortality were 25.9% and 32.7%, respectively, and 60.0% of patients had an unfavorable outcome at 12 months (GOSE). On univariate analysis, ICP, CPP, UL-PRx, and ΔCPPopt were associated with 12-month outcomes. The cutoff of ~ 20–22 for mean ICP and of ~ 0.30 for mean UL-PRx were confirmed in all age groups, except in patients older than 70 years. Mean UL-PRx remained significantly associated with 12-month outcomes even after adjustment for IMPACT models. This association was confirmed in all age groups. UL-PRx resulted associate with CPPopt. Conclusions The study highlights UL-PRx as a tool for assessing CA and valuable outcome predictor for TBI patients. The results emphasize the potential clinical utility of the UL-PRx and its adaptability across different age groups, even after adjustment for IMPACT models. Furthermore, the correlation between UL-PRx and CPPopt suggests the potential for more targeted treatment strategies. Trial registration : ClinicalTrials.gov identifier: NCT05043545, principal investigator Paolo Gritti, date of registration 2021.08.21.

Background The duration of episodes of intracranial hypertension is related to poor outcome, hence the need for prompt diagnosis. Numerous issues can lead to delays in the implementation of invasive intracranial pressure (ICP) monitoring, thereby increasing the dose of intracranial hypertension to which the patient is exposed. The aim of this prospective, observational, multicenter study was to assess the magnitude of this delay, evaluating the time required for initiation of invasive ICP monitoring, from indication (T1) to initiation of the maneuver (T2) when performed by neurosurgeons compared to intensive care physicians. Methods We evaluated the impact of the operator performing the maneuver (neurosurgeon vs. intensivist) on the T2-T1 time interval, where T1 represents the time at which indication for invasive ICP monitoring is declared, and T2 the time at which the maneuver starts, defined as the skin incision. The effect of the operator performing the maneuver was evaluated through a parametric survival model. Both intraparenchymal catheters (IPCs) and external ventricular drains (EVDs) were considered as invasive ICP monitoring devices. Invasive monitoring could be performed in intensive care unit (ICU) or in operating room (OR). Results A total of 112 patients were included into the final analysis; 39 IPCs were placed by intensivists within the ICU, and a total of 73 IPCs and EVDs by neurosurgeons both within the ICU and OR settings. The mean difference in T2-T1 time for IPCs placement in the ICU was 69 min (CI 50.1–94.8) in the intensivist group and 145 min (CI 103.4–202.9) in neurosurgeon group. The mean difference between these groups, 76 min, was found to be statistically significant ( p-value  = 0.0021). In the group treated by neurosurgeons, no statistically significant differences were found in timing between the ICU and the OR. Conclusions Invasive ICP monitoring performed with IPCs in ICU begins earlier when performed by intensivists rather than neurosurgeons. This finding suggests the possibility to obtain a prompt diagnosis of intracranial hypertension when intensivists intervein directly at patient’s bedside. Further studies are needed to confirm these findings and investigate their effect on outcome.

Candida osteomyelitis in the current literature is an emerging infection. The factors contributing to its emergence include a growing population of immunosuppressed patients, invasive surgeries, broad-spectrum antibiotics, injection drug users, and alcohol abuse. The diagnosis requires a high degree of suspicion. The insidious progression of infection and the nonspecificity of laboratory and radiologic findings may contribute to a delay in diagnosis. The current case concerns a 27-year-old man with a spinal cord injury who, after undergoing anterior cervical fixation and fusion surgery, developed postoperative systemic bacterial infection and required long-term antibiotic therapy. After six months, a CT scan demonstrated an almost complete anterior dislocation of the implants caused by massive bone destruction and reabsorption in Candida albicans infection. The patient underwent a second intervention consisting firstly of a posterior approach with C4–C7 fixation and fusion, followed by a second anterior approach with a corpectomy of C5 and C6, a tricortical bone grafting from the iliac crest, and C4–C7 plating. The antifungal therapy with fluconazole was effective without surgical debridement of the bone graft, despite the fact that signs of the bone graft being infected were seen from the first cervical CT scans carried out after one month.