Search Results (101)

Background and Clinical Significance: Guillain–Barré syndrome (GBS) can rarely progress to fulminant paralysis with loss of brainstem reflexes, mimicking coma or brain death despite preserved cortical function. Case Presentation: A 38-year-old man developed rapidly progressive weakness following a diarrheal illness, culminating in quadriplegia, areflexia, respiratory failure, and complete loss of brainstem reflexes within 72 h. Neuroimaging was unrevealing. EEG demonstrated preserved cerebral activity with an alpha coma pattern. Despite initial intravenous immunoglobulin therapy, neurological deterioration continued, prompting escalation to plasma exchange. Gradual recovery of brainstem reflexes and motor function ensued, followed by substantial functional improvement over nine months. This case highlights the diagnostic and prognostic challenges of fulminant GBS at the interface of peripheral and brainstem dysfunction. Neurophysiologic assessment and disciplined exclusion of central etiologies are essential. Timely immunotherapy and supportive care can lead to meaningful recovery even in extreme presentations. Conclusions: Fulminant GBS should be recognized as a potentially reversible cause of apparent coma, underscoring the importance of early diagnosis and aggressive treatment. Full article

Background: Arginase 1 deficiency (ARG1-D) is an ultra-rare urea cycle disorder characterized by hyperargininemia and progressive neurological impairment, including spasticity, loss of motor function, and reduced quality of life. Conventional management based on dietary protein restriction and ammonia scavengers rarely achieves adequate metabolic control or prevents neurological deterioration. Pegzilarginase, a recombinant human arginase 1 enzyme, is the first disease-modifying therapy for ARG1-D. Methods: We report the first Italian real-world experience with pegzilarginase in three pediatric patients with genetically confirmed ARG1-D enrolled in the phase 3 PEACE trial. Clinical, biochemical, functional, nutritional and quality-of-life data were retrospectively collected over a long-term follow-up (2003–2025). Outcomes were evaluated across three phases: treatment initiation (Start), a 13-month treatment interruption due to trial closure (Stop), and therapy re-initiation through an early access program (Restart). Results: Pegzilarginase rapidly normalized plasma arginine levels and was associated with improvements in motor function, spasticity, walking endurance, dietary protein tolerance, bone mineral density, and quality of life. During treatment interruption, all patients experienced biochemical worsening and clinical deterioration, including increased spasticity, reduced mobility, and emotional distress. Re-initiation of pegzilarginase restored metabolic control and led to progressive neurological and functional recovery, including partial reversal of long-standing motor deficits. Conclusions: This real-world experience supports pegzilarginase as a disease-modifying therapy for ARG1-D. Sustained normalization of plasma arginine, rather than subthreshold biochemical control, correlates with functional and neurological improvement and may partially reverse non-lesional metabolic brain injury. Early initiation of pegzilarginase, including in newborn-screened patients, may further modify the natural history of ARG1-D. Full article

Background/Objectives: Early neurological deterioration (END) is a frequent and clinically relevant complication in patients with a single small subcortical infarction (SSI), including lacunar infarction and branch atheromatous disease (BAD). Despite initially mild symptoms, END occurs in approximately 20–25% of cases and is strongly associated with poor functional outcomes. However, definitions, mechanisms, predictors, and therapeutic strategies remain heterogeneous. This review aims to synthesize current evidence regarding the incidence, pathophysiology, predictors, and management of END in SSI. Methods: We performed a narrative review of published studies addressing END in patients with lacunar stroke or SSI. We analyzed data on END definitions and incidence, imaging and clinical predictors, proposed pathophysiological mechanisms, and preventive and rescue therapeutic strategies. Results: END definitions vary across studies, most commonly defined as a ≥2-point increase in the National Institutes of Health Stroke Scale within 48–72 h. Hemodynamic compromise due to proximal perforator pathology, particularly in BAD, appears central to END development. Advanced imaging studies demonstrate perfusion abnormalities beyond the infarct core, supporting the concept of a “lacunar penumbra.” Lesion topology, proximal infarct patterns, parent artery plaques, larger infarct size, and vertical extension are consistent imaging predictors. Clinical factors such as diabetes mellitus, higher baseline severity, systemic inflammation, and increased arterial stiffness further modulate risk. Preventive strategies, including early dual antiplatelet therapy and intensified antithrombotic regimens, show promising signals, while induced hypertension may benefit selected patients as a rescue therapy. However, evidence remains largely observational or derived from subgroup analyses. Conclusions: END in SSI is a multifactorial and potentially modifiable process driven by interactions between proximal vascular pathology, hemodynamic failure, and tissue vulnerability. Standardized definitions, MRI-based phenotyping, and mechanism-driven trials are needed to optimize risk stratification and develop targeted preventive and rescue strategies. Full article

Neonates undergoing surgery for congenital heart disease (CHD) are at high risk for brain function impairment. Reliable early predictors of postoperative neurological complications are lacking. We examined a retrospective cohort of 55 surgically treated CHD neonates systematically monitored by concomitant conventional electroencephalography (cEEG) and amplitude-integrated EEG (aEEG). Neonates underwent cEEG/aEEG at three time points: T0 (preoperative, duration: 90–120 min); T1 (24–48 h after cardiac surgery, duration: ≥11 h); and T2 (7–10 days post-surgery, duration: 90–120 min). For each patient, aEEG background activity was evaluated and scored, and clinical and surgical data were retrieved to establish short-term post-surgical outcomes. Patients with normal T0 monitoring had significantly higher aEEG bandwidths in T1. A lower Aristotle basic score was associated with an improvement in aEEG at T1. Inversely, a narrower aEEG bandwidth in T1 was associated with post-surgical neurological deterioration. The aEEG bandwidth accurately predicted short-term neurological outcome; in particular, a minimal aEEG amplitude above 17.5 µV excluded poor neurological outcome with a negative predictive value of 81.48%. Our results demonstrated that aEEG bandwidth and trend dynamics may be associated with surgical complexity and neurological outcomes. aEEG background trend monitoring may provide relevant prognostic information on neurological outcomes in surgically treated CHD neonates. Full article

Introduction: Cardiopulmonary resuscitation (CPR) is one of the most consequential decisions in clinical medicine—a pivotal moment between life and death where science, ethics, and humanity intersect. Although advances in systems of care, technology, and training have refined technique and logistics, outcomes do not consistently result in meaningful, neurologically intact survival. In oncology—where disease trajectories are heterogeneous, treatment burdens substantial, and organ reserve often limited—these tensions are especially pronounced. Methods and approaches: This manuscript examines resuscitation as a medical, ethical, and human process, with explicit focus on patients with cancer. We review contemporary strategies for early recognition of deterioration (MEWS, NEWS, MET activation), team preparedness through Immediate Life Support (ILS), and structured decision-making at the boundaries of resuscitation. We also address communication with patients and families, the legal framework of Do-Not-Resuscitate (DNR) orders, and the distinctions among treatment forgoing, palliative sedation, and euthanasia, emphasising oncology-specific considerations such as metastatic burden, treatment intent (curative vs. palliative), performance status, and organ reserve. Results and discussion: The overall effectiveness of resuscitation remains modest (approximately 5–20% survival), highlighting the importance of prevention and early intervention. In cancer care, the limits of resuscitation are both clinical and ethical, requiring proportionality between the likely benefit and the risks of prolonging suffering, careful attention to prognosis and expected neurological outcomes, and rigorous alignment with goals of care. Early and ongoing involvement of palliative services, along with robust long-term care pathways, provides humane, value-concordant alternatives for patients with advanced disease. Psychotherapists and chaplains play integral roles in supporting families and clinical staff. Structured post-event debriefing and system-level safeguards are essential to mitigate burnout and moral distress within oncology teams. Initiating or discontinuing resuscitation in oncology requires expertise, empathy, and moral clarity. Dignity-preserving care depends on aligning interventions with patient values and realistic clinical endpoints. Acceptance of the natural course of dying represents an important component of responsible and patient-centred medical care. Full article

Caffeine is widely consumed and generally considered safe at customary doses. How-ever, high-dose preparations available online pose a risk of severe and potentially fatal intoxication. Although uncommon, lethal caffeine poisoning is associated with profound cardiovascular and neurological toxicity. A rare case of intentional acute caffeine intoxication with fatal outcome is presented. A 25-year-old woman ingested an estimated 60 tablets containing 200 mg of caffeine each, purchased online. She was admitted to hospital shortly after ingestion of the caffeine tablets with palpitations, agitation, dizziness, and repeated vomiting. On examination, she presented with arterial hypotension (90/60 mmHg) and marked sinus tachycardia (150 beats/min), accompanied by psychomotor agitation. Her blood caffeine concentration measured by means of high-performance liquid chromatography (HPLC) was 177 µg/mL. The patient’s condition rapidly deteriorated, with the development of convulsive syndrome progressing to coma, extreme ventricular tachycardia, exotoxic shock, and toxic cardiomyopathy. Despite intensive care management, including mechanical ventilation and advanced cardiopulmonary resuscitation, the patient died several hours after admission. In conclusion, this case underscores the life-threatening potential of acute high-dose caffeine ingestion and highlights the risk associated with unrestricted access to concentrated caffeine products. Early recognition and aggressive management are crucial, yet may be insufficient in cases of massive overdose. Full article

Background: Tuberculous meningitis (TBM) is the most severe manifestation of tuberculosis in children, with high mortality rates and long-term neurological sequelae. Early diagnosis is challenging due to its nonspecific symptoms and insidious onset. Case Presentation: An 8-year-old previously healthy male, fully vaccinated, presented with a two-week history of fever, headache, vomiting, and abdominal pain. Cerebrospinal fluid (CSF) analysis revealed lymphocytic pleocytosis, elevated protein, and low glucose levels, while multiplex polymerase chain reaction (PCR) testing for bacteria and viruses yielded negative results. Brain computed tomography (CT) revealed mild ventricular dilation and pansinusitis. Empirical antibacterial and antiviral therapy were initiated; however, the patient subsequently experienced neurological deterioration, including cranial nerve deficits and hemiparesis. Brain magnetic resonance imaging (MRI) demonstrated acute infarctions of the basal ganglia, raising suspicion for TBM. Repeated CSF sampling and Xpert MTB/RIF assay confirmed infection with Mycobacterium tuberculosis. Anti-tuberculosis treatment was initiated in combination with adjunctive corticosteroids, anticonvulsant and anticoagulant therapies, and supportive care, including neurosurgical intervention for hydrocephalus. After 16 months of treatment, the patient showed clinical improvement but sustained left-sided hemiparesis, visual impairment, and cognitive deficits. Conclusions: This case highlights the diagnostic challenges of pediatric TBM in immunocompetent and Bacillus Calmette–Guérin (BCG)-vaccinated children, particularly in the presence of initially negative microbiological findings. It emphasizes the importance of maintaining a high index of clinical suspicion and the crucial supportive role of neuroimaging findings, as well as the earlier initiation of empirical TB therapy especially when epidemiological plausibility exists. Early recognition and intervention remain critical to reducing morbidity and mortality associated with this devastating disease. Full article

Background/Objectives: Heart rate variability (HRV) and cerebral autoregulation (CAR) reflect physiologic processes that may influence neurological injury in children supported with extracorporeal membrane oxygenation (ECMO). Although abnormalities in both have been associated with adverse neurological outcomes, their physiologic relationship during ECMO remains unclear. Methods: This retrospective single-center study evaluated the association between HRV and CAR during the first 24 h of ECMO support and assessed their independent relationships with neurological outcome. Patients with at least two hours of simultaneous HRV and CAR monitoring within 24 h of ECMO initiation were included. HRV metrics were derived from artifact-free NN intervals across time, frequency, and nonlinear domains, while CAR was quantified using the cerebral oximetry index (COx), with impaired CAR defined as COx > 0.3. Associations between HRV indices and COx were examined using Spearman correlations at hourly and 24 h resolutions. Unfavorable outcome was defined as death or a Pediatric Cerebral Performance Category (PCPC) score ≥3 at discharge with deterioration from baseline. Results: Eighty-nine patients met inclusion criteria, and 16% demonstrated impaired CAR. HRV measures were reduced relative to age-adjusted norms in both CAR groups without significant differences between groups. Correlations between HRV indices and COx were consistently weak. Overall, 50% experienced unfavorable neurological outcomes. In adjusted logistic regression models, NN skewness and COx were independently associated with outcome, although only NN skewness remained significant in interaction analyses. Conclusions: HRV and CAR exhibited limited physiological coupling during early ECMO support, while each measure provided independent prognostic information with respect to neurological outcome. Full article

Background: Primary central nervous system tumours in pregnancy are exceptionally rare, with posterior fossa lesions presenting particular diagnostic and management challenges due to their confined anatomical location and proximity to critical neurovascular structures. Pilocytic astrocytoma (PA), typically a paediatric tumour, is uncommon in adults and exceedingly rare in pregnant patients. The physiological changes in pregnancy can obscure tumour-related symptoms, contributing to diagnostic delay and increased maternal–fetal risk. Methods: We report the case of a 24-year-old pregnant woman at 23 weeks and 5 days’ gestation who presented with progressive neurological deterioration secondary to a cystic mass in the right cerebellar hemisphere. MRI revealed significant brainstem compression and triventricular hydrocephalus. Results: A multidisciplinary team performed an urgent retrosigmoid craniotomy with gross total tumour resection under general anaesthesia and continuous intraoperative fetal monitoring. Histopathology confirmed PA (CNS WHO Grade I). Postoperative recovery was uneventful, and both maternal and fetal outcomes were favourable. Conclusions: This case highlights the importance of early neuroimaging, multidisciplinary coordination, and timely surgical intervention in managing posterior fossa tumours during pregnancy. Although PAs are considered low-grade gliomas, their behaviour in pregnancy can be unpredictable. With careful perioperative planning, neurosurgical treatment can be safely undertaken during gestation, offering optimal outcomes for both mother and fetus. Full article

Background/Objectives: Delayed cerebral ischemia (DCI) represents a major cause of morbidity and mortality after aneurysmal subarachnoid haemorrhage (aSAH). Early identification of developing cerebral ischemia is essential for timely prevention of DCI. Near-infrared spectroscopy (NIRS) provides continuous, non-invasive bedside monitoring of regional cerebral oxygen saturation (rSO₂); however, its clinical value in patients with aSAH has not yet been fully established. The primary objective of this study was to investigate whether NIRS-detected rSO₂ desaturation can serve as an early indicator of cerebral vasospasm (CV) and predict the occurrence of DCI. Secondary objectives were to examine the associations between rSO₂ changes and other cerebral deterioration events, length of intensive care unit stay, functional outcome, and in-hospital mortality. Methods: This prospective, single-centre study included 30 patients with aSAH admitted to the intensive care unit (ICU) of Riga East University Hospital between January 2019 and January 2023. Bilateral frontal near-infrared spectroscopy (NIRS) monitoring (Covidien INVOS™ 5100C-PB) was initiated within 72 h after ictus and continued for up to 7 days. Cerebral desaturation was defined as a >20% reduction from baseline (BL) or an absolute regional cerebral oxygen saturation (rSO₂) value < 50% lasting ≥30 min. CV and DCI were diagnosed according to established clinical and radiological criteria. Receiver operating characteristic (ROC) analysis was performed to evaluate the sensitivity and specificity of rSO₂ thresholds for the detection of CV, DCI, and other cerebral deterioration events. Results: CV occurred in 10 patients (33%); however, only four cases were detected during the NIRS monitoring period. NIRS demonstrated very high sensitivity (97.5%) but extremely low specificity (6%) for the early detection of CV. In contrast, diagnostic accuracy for DCI was high. An absolute rSO₂ cut-off value of 52% yielded a sensitivity of 97.5% and a specificity of 95%, whereas a decrease of ≥26% from baseline (BL) demonstrated a sensitivity of 98% and a specificity of 93%. Significant rSO₂ reductions were also observed during aneurysm re-rupture, hydrocephalus, cerebral edema, and postoperative ischemia; however, the sensitivity of NIRS for detecting these events was negligible. Patients with ≥20% desaturation tended to have longer ICU stays, and lower mean rSO₂ values as well as greater desaturation were associated with poorer functional outcomes as assessed by the modified Rankin Scale. Patients who died exhibited more pronounced rSO₂ decreases and less recovery compared with survivors. Conclusions: In this cohort, NIRS demonstrated limited specificity for the early detection of CV but showed strong associations with DCI and neurological outcome. NIRS may be useful as a non-invasive adjunct to multimodal neuromonitoring rather than as a stand-alone diagnostic tool for cerebral vasospasm. Larger, prospective studies incorporating standardized imaging protocols and optimized rSO₂ thresholds are required to more clearly define the role of NIRS in the management of aSAH. Full article

Complete or partial loss of smell (anosmia), sometimes in association with distorted olfactory perceptions (parosmia), is a common neurological symptom affecting nearly 60% of patients suffering from post-acute neurological sequelae of COronaVIrus Disease of 2019 (COVID-19) syndrome, called long COVID. Severe Acute Respiratory Syndrome CoronaVirus 2 (SARS-CoV-2) may gain access from the nasal cavity to the brain (neurotropism), and the olfactory route has been proposed as a peripheral site of virus entry. COVID-19 is a risk factor for developing Alzheimer’s Disease (AD), an age-dependent and progressive neurodegenerative disorder characterized in affected patients by early olfaction dysfunction that precedes signs of cognitive decline associated with neurodegeneration in vulnerable brain regions of their limbic system. Here, we summarize the recent literature data supporting the causal correlation between the persistent olfactory deterioration following SARS-CoV-2 infection and the long-delayed manifestation of AD-like memory impairment. SARS-CoV-2 infection of the olfactory neuroepithelium is likely to trigger a pattern of detrimental events that, directly and/or indirectly, affect the anatomically interconnected hippocampal and cortical areas, thus resulting in tardive clinical dementia. We also delineate future advancement on pharmacological and rehabilitative treatments to improve the olfactory dysfunction in patients recovering even from the acute/mild phase of COVID-19. Collectively, the present review aims at highlighting the physiopathological nexus between COVID-19 anosmia and post-pandemic mental health to favor the development of best-targeted and more effective therapeutic strategies in the fight against the long-term neurological complications associated with SARS-CoV-2 infection. Full article

Background and Clinical Significance: Cerebral candidiasis (Candida albicans meningoencephalitis) is a rare but severe central nervous system (CNS) infection, usually associated with neurosurgical procedures or indwelling devices. Diagnosis is challenging due to frequent negativity of cerebrospinal fluid (CSF) cultures, and mortality remains high despite antifungal therapy. Case Presentation: We describe a 64-year-old woman who underwent retrosigmoid resection of a left vestibular schwannoma. The early postoperative course was complicated by fever, neurological deterioration, and hydrocephalus requiring external CSF drainage. Multiple lumbar punctures revealed inflammatory CSF profiles but persistently negative cultures. One month post-surgery, intraoperative samples from mastoid repair material grew Candida albicans, prompting antifungal therapy. Despite treatment, the patient experienced fluctuating neurological status and required multiple external ventricular drains. Three months after surgery, she clinically deteriorated and died. Autopsy showed diffuse meningeal thickening and purulent exudates at the brain base and posterior fossa. Histopathology confirmed chronic lympho-histiocytic meningitis with necrotizing foci containing Candida albicans. Conclusions: This case underscores the diagnostic and therapeutic challenges of post-neurosurgical Candida CNS infections. Repeatedly negative CSF cultures delayed diagnosis, emphasizing the value of ancillary tests such as β-d-glucan and molecular assays. Even with antifungal therapy, prognosis is poor. Autopsy remains essential for uncovering fatal healthcare-associated fungal infections and informing clinical vigilance and medico-legal assessment. Full article

Background/Objectives: Aspiration pneumonia is among the most frequent medical complications after intracerebral hemorrhage (ICH), yet its role during the ultra-early emergency department (ED) phase remains poorly understood. This study aimed to identify clinical and neurological factors independently associated with radiologically confirmed aspiration pneumonia in patients presenting with acute spontaneous ICH and to evaluate its association with early clinical outcomes. Methods: A retrospective observational cohort study was conducted in the neuro-emergency department of a large tertiary university hospital. All consecutive adults with spontaneous ICH confirmed by neuroimaging between January 2020 and December 2023 were included. Univariable and multivariable logistic regression models were used to identify independent predictors of pneumonia. Results: A total of 184 patients were analyzed (median age 74 years; 46% female). Radiologically confirmed aspiration pneumonia occurred in 37 patients (22.0%). Pneumonia was significantly associated with lower GCS, higher National Institutes of Health Stroke Scale (NIHSS) and ICH scores, shorter ED stay, and more frequent endotracheal intubation (ETI). In multivariable analysis, ETI (OR 5.42, 95% CI 1.57–18.63, p = 0.007), higher NIHSS score (OR 1.09, 95% CI 1.01–1.20, p = 0.047), and shorter ED stay (OR 0.97, 95% CI 0.95–0.99, p = 0.035) were independently associated with pneumonia. Aspiration pneumonia was not independently associated with neurosurgical referral (p = 0.082) or low GCS at discharge (p = 0.650). Conclusions: In this neuro-emergency cohort, aspiration pneumonia was common and strongly associated with neurological severity, particularly with endotracheal intubation and higher NIHSS scores. Although it did not independently predict early neurological deterioration or neurosurgical transfer, it identifies a critical period in which preventive measures—such as dysphagia screening, oral hygiene, and careful airway management—should be systematically applied. Larger multicenter studies with longer follow-up are needed to better define its long-term clinical consequences after ICH. Full article

Background and Clinical Significance: Although rupture of aneurysms at the internal carotid-posterior communicating artery (ICA-PCom) junction accounts for a small percentage of all ruptured intracranial aneurysms, they are clinically relevant due to their proximity to perforator-rich cisterns, the optic-carotid-oculomotor pathways and flow-diverting zones, as well as their high likelihood for causing early neurological instability. Additionally, ruptured ICA-PCom aneurysms that have multiple lobulations are associated with increased variability in wall shear stress, local inflammatory remodeling and higher propensity for rupture at smaller sizes compared to other types of aneurysms. Due to the rapidity of early physiological destabilization in most patients with ruptured ICA-PCom aneurysms, clinical–anatomical correlations in these cases are often obscured by neurological deterioration; therefore, the presentation of this patient provides a unique opportunity to correlate the minimal early symptoms, tri-lobulation of the aneurysm and confined cisternal hemorrhage, to better understand rupture behavior, surgical decision-making in an anatomically challenging area, and postoperative recovery. Case Presentation: A 48-year-old hypertensive female experienced an acute “thunderclap” headache accompanied by intense photophobia and focal meningeal irritation, but, unexpectedly, retained a normal neurologic examination. She did exhibit some minor ocular motor micro-latencies, early cortical attentional strain and lateralized pain sensation that suggested localized cisternal involvement despite lack of generalized neurologic impairment. Digital subtraction angiography and three-dimensional CT angiography revealed a ruptured, tri-lobulated aneurysm originating from the communicating portion of the left internal carotid artery proximal to its origin from the posterior communicating artery, oriented toward the perimesencephalic cisterns. The aneurysm was surgically clipped using a standard left pterional craniotomy with direct visualization, after careful dissection through the carotid and optic windows to preserve the anterior choroidal artery, oculomotor nerve, and surrounding perforators. The neck of the aneurysm was reconstructed with a single straight clip, without compromise to the parent vessel lumen. The patient had an uneventful postoperative course without vasospasm or neurologic deficit. At both 3 and 9 months postoperatively the patient remained free of clinical neurologic deficit, and imaging demonstrated continued aneurysm exclusion, preserved ICA-PCom anatomy, and no evidence of delayed ischemic injury or hydrocephalus. Conclusions: The goal of this report is to demonstrate how a ruptured, morphologically complex ICA-PCom aneurysm may present with preserved neurologic function, thereby enabling the study of clinical–anatomical associations before secondary injury mechanisms intervene. The relationship between the configuration of the patient’s symptoms, geometry of the aneurysm and pattern of hemorrhage within the cisterns offers insight into a rare rupture pattern observed during routine clinical experience. Through complete anatomical analysis, timely microsurgical reconstruction and consistent follow-up, the authors were able to achieve long-term recovery of this particular patient. Continued advancements in vascular imaging techniques, aneurysmal wall modeling, and postoperative monitoring will likely help clarify the underlying mechanism(s) responsible for such presentations. Full article

Background: The prognostic value of preoperative deterioration in older patients with moderate-to-mild traumatic brain injury (TBI) remains unclear. Therefore, this study aimed to evaluate the impact of preoperative neurological and radiological deterioration on clinical outcomes in this population undergoing surgery. Methods: We retrospectively reviewed patients aged ≥ 65 years with moderate-to-mild TBI (Glasgow Coma Scale (GCS) ≥ 9) who underwent surgery between 2013 and 2022. Patients were grouped based on preoperative deterioration, classified as neurological (≥2-point sustained GCS drop lasting more than 1 h) or radiological (new/aggravated imaging lesions). Study outcomes included in-hospital mortality and 6-month functional status. Multivariable logistic regression was performed to identify independent predictors of outcomes. Results: Among 58 patients, preoperative deterioration was observed in 34 (58.6%), including 14 (24.1%) with neurological and 20 (34.5%) with radiological deterioration. In-hospital mortality was significantly higher in patients with neurological deterioration than in those without (57.1% vs. 13.6%; p = 0.002). Radiological deterioration alone was not associated with increased mortality or unfavorable functional outcome at 6 months. Neurological deterioration was an independent predictor of in-hospital death (adjusted odds ratio (OR), 47.9; p = 0.004) and unfavorable 6-month outcome (adjusted OR, 35.0; p = 0.014), whereas radiological deterioration was not. A lower initial GCS was also associated with unfavorable outcomes (adjusted OR, 0.5; p = 0.013). Conclusions: Preoperative neurological deterioration is an independent predictor of in-hospital mortality and unfavorable functional outcome at 6 months in older patients undergoing surgery for moderate-to-mild TBI. These findings underscore clinical neurological decline—not radiologic progression—should guide prognostication and early intervention strategies. Full article