The neurocardiac axis in acute intracranial stress

Acute intracranial injuries including subarachnoid hemorrhage, traumatic brain injury, stroke, and seizures often trigger cardiovascular and pulmonary complications through the neurocardiac axis. This bidirectional connection between the brain and the heart is mediated by sympathetic overactivity, catecholamine excess, autonomic imbalance, and systemic inflammation. This narrative review synthesizes current evidence published between 1968 and 2025, identified through a comprehensive literature search. Representative studies were selected to provide an integrative overview of neurocardiac complications in acute neurologic injury, focusing on underlying mechanisms, clinical manifestations, diagnostic challenges, and management strategies. We describe the mechanisms underlying neurogenic stunned myocardium and Takotsubo syndrome, highlighting regional vulnerability based on autonomic innervation. Electrocardiographic features, cardiac biomarkers, and echocardiographic findings are discussed in the context of early recognition and risk stratification. We further examine diagnostic challenges, the importance of distinguishing neurologic from primary cardiac pathology, and therapeutic approaches including autonomic modulation and cardiopulmonary protective strategies. Understanding the unique pathogenesis of these syndromes can help guide individualized treatment strategies and anesthetic management to improve outcomes in patients with acute neurologic injury. By consolidating multidisciplinary insights, this review aims to enhance recognition and management of neurocardiac complications in this population.