Hourly Neurological Examinations After Nontraumatic, Vascular Acute Brain Injury Associated With Delirium: A...

Hourly neurological examinations are commonly performed in neurocritical care units after acute brain injury to detect clinical deterioration. However, their clinical yield and impact on patient outcomes, particularly delirium, remain unclear. Our objective is to evaluate the diagnostic utility of hourly neurological examinations and their association with delirium in patients with nontraumatic, vascular acute brain injury.

We conducted a retrospective observational study of patients admitted to the neuro-ICU between January 2022 and December 2024 with nontraumatic, vascular acute brain injury (large vessel occlusion stroke, subarachnoid hemorrhage, or spontaneous intracerebral hemorrhage). We analyzed the duration and frequency of hourly neurological examinations, the incidence of neurological decline, the use of radiographic imaging or electrophysiological testing, and the occurrence of delirium. Statistical comparisons were made using the unpaired Student t-tests, Mann-Whitney U tests, and multivariate logistic regression.

Of 191 patients (mean age 63.3 ± 15.0 years; 53.0% female), 51.0% developed delirium. Across 34 767 total hours of hourly examinations, 600 neurological declines (1.7%) were detected. Most declines (73.1%) required no further imaging, electrophysiological testing, or neurosurgical intervention; only 6.0% led to neurosurgical intervention. No neurosurgical procedures or changes in clinical management were triggered by examinations between 84 and 108 hours postadmission. Delirium was significantly associated with longer duration of hourly examinations across the total cohort (P < .001) and spontaneous intracerebral hemorrhage subgroup (P < .001) and approached significance in aneurysmal subarachnoid hemorrhage group (P = .056) but not in large vessel occlusion strokes (P = .176).

Hourly neurological examinations after acute brain injury detect few actionable events after 48 hours of admission and are associated with increased delirium, particularly in intracerebral hemorrhage patients. These findings suggest a need for prospective studies to assess the utility and duration of routine hourly examinations in acutely brain-injured patients.