Fulminant cryptococcal meningoencephalitis with adrenal involvement in an immunocompetent patient: a clinicopathologic correlation.

Invasive intracranial pressure (ICP) monitoring remains a cornerstone in the management of pediatric patients with acute brain injury, enabling early detection and treatment of intracranial hypertension []. The concept of “ICP burden,” reflecting both the magnitude and duration of elevated ICP episodes, has emerged as a key independent predictor of mortality and neurological outcomes [,]. In this context, external ventricular drains (EVDs) are considered the gold standard, providing both accurate ICP measurement and therapeutic cerebrospinal fluid drainage []. In the pediatric intensive care unit (PICU), common clinical stressors such as pain, agitation, and anxiety may significantly exacerbate intracranial hypertension. These factors can increase ICP through multiple mechanisms, including elevated intrathoracic pressure, impaired cerebral venous return, and increased cerebral metabolic demand []. Accordingly, current management strategies emphasize early administration of analgesia and sedation as first-line interventions []. However, emerging evidence suggests that commonly used agents, such as fentanyl and midazolam, may have variable and sometimes paradoxical effects on ICP dynamics [,]. Given these complexities, there is increasing interest in complementary non-invasive neuromonitoring techniques. Near-infrared spectroscopy (NIRS), which measures regional cerebral oxygen saturation (rSO), has gained attention as a bedside tool for continuous monitoring []. Although reductions in rSO have been associated with elevated ICP, this relationship appears to be heterogeneous and dependent on the underlying pathology [,]. Reductions in rSO have been associated with elevated intracranial pressure and impaired cerebral perfusion, with studies demonstrating improvements in cerebral oxygenation following cerebrospinal fluid diversion in hydrocephalus [,]. However, the relationship between rSO and intracranial dynamics remains complex and influenced by underlying pathology, cerebral blood flow, and metabolic factors. These inconsistencies, together with the limited and heterogeneous pediatric data, highlight the need for further investigation into the relationship between invasive and non-invasive neuromonitoring parameters in critically ill children [,,].