Background: Stroke significantly increases morbidity and mortality in patients receiving extracorporeal membrane oxygenation (ECMO). This study evaluates the prognostic impact of stroke subtypes, acute ischemic stroke (AIS) and hemorrhagic stroke (HS), and neurologic injury severity in a contemporary adult population. Methods: We conducted a retrospective cohort study using the TriNetX federated electronic health record network, including adult patients who underwent ECMO between 1 October 2015 and 31 December 2025. Stroke was defined as a first-instance diagnosis of AIS, HS, or unspecified cerebrovascular event occurring within 24 h of ECMO cannulation during the index hospitalization. Propensity score matching (1:1 nearest neighbor) was performed to balance baseline demographics, comorbidities, anticoagulant use, and ECMO modality between the stroke and non-stroke cohorts. Primary outcomes included all-cause mortality at 30 days, 90 days, and 1 year. Secondary outcomes included cardiac arrest, seizures, palliative care utilization, and hospital readmission. Kaplan–Meier survival analysis and multivariable Cox proportional hazards modeling were performed. Results: Among 18,981 ECMO patients, 1481 (7.8%) developed a stroke within 24 h of ECMO cannulation, including 814 AIS (54.9%), 454 HS (30.6%), and 213 unspecified cerebrovascular events (14.4%). After propensity score matching, stroke was associated with significantly higher all-cause mortality at 30 days (RR 1.16), 90 days (RR 1.18), and 1 year (RR 1.18), all p < 0.05. Stroke was also associated with higher rates of cardiac arrest, seizures, hospital readmission, and palliative care utilization (all p < 0.001). AIS was associated with significantly lower mortality than HS at 30 days, 90 days, and 1 year (all p < 0.0001). In multivariable Cox regression, only HS was independently associated with increased 30-day mortality compared with no stroke. Markers of neurologic injury severity, including cerebral edema, brain compression, and coma, were among the strongest independent predictors of mortality. Conclusions: Stroke occurring early after ECMO cannulation is associated with substantially worse short- and long-term survival, with hemorrhagic subtype and markers of neurologic injury severity driving the strongest prognostic signals. These findings support early stroke recognition and subtype-informed prognostic discussions in ECMO patients.

BACKGROUND AND OBJECTIVES: Penetrating brain injury (PBI) is a highly lethal form of traumatic brain injury, with substantial mortality and marked differences across high-income countries and low- to middle-income countries. The aim of the Comparative Effectiveness Research in the Americas on Penetrating Brain Injury (COMPAS-PBI) study was to evaluate management variability, compare outcomes across resource settings, and assess the feasibility of real-time multinational neurocritical care data collection. METHODS: COMPAS-PBI is a multinational, multicenter observational comparative effectiveness study. It includes a retrospective cohort (2021-2025) and a prospective cohort (2026-2028) of adults aged 18 years or older with confirmed PBI, defined by radiographic evidence of dural penetration on head computed tomography, presenting within 24 hours of injury. Eleven trauma centers across 8 countries in the Americas will participate, with the University of Oklahoma Health Sciences Campus serving as the coordinating center. The principal management strategies compared are intracranial pressure monitoring vs no monitoring and neurosurgical intervention, primarily early decompressive craniectomy, vs medical management alone. Comparative analyses will use propensity score–based methods to address baseline confounding. EXPECTED OUTCOMES: The primary outcome is in-hospital mortality. Secondary outcomes include disposition at discharge, Glasgow Outcome Scale-Extended score (at discharge, 6, and 12 months), and timing of intracranial pressure monitoring and decompressive craniectomy. Feasibility outcomes will assess completeness, timeliness, and quality of prospective real-time data capture, particularly in resource-limited settings. DISCUSSION: COMPAS-PBI will generate the first multinational comparative effectiveness data sets focused on civilian PBI within the Americas. The study is expected to provide pragmatic evidence to inform context-sensitive care strategies, reduce practice differences, and support future collaborative neurotrauma research.

Background: Early cardiovascular complications after non-traumatic intracerebral hemorrhage (ICH) contribute to short-term morbidity and mortality, yet reliable prognostic markers remain limited. We examined the association between admission serum albumin and 30-day cardiovascular complications after ICH, including dose–response patterns and consistency across subgroups. Methods: In this retrospective cohort study using the TriNetX US Collaborative Network, adults hospitalized with ICH (ICD-10-CM I61) and serum albumin measured within 24 h of admission were stratified into reduced (≤3.4 g/dL) and normal (≥3.5 g/dL) groups and balanced by 1:1 propensity score matching on demographics, cardiovascular comorbidities, ICH severity, neurosurgical procedures, and medications. The primary outcome was a 30-day composite of all-cause death, acute myocardial infarction, heart failure, atrial fibrillation or flutter, ventricular arrhythmias, and Takotsubo cardiomyopathy. Sensitivity analyses addressed age, sex, comorbidity burden, and chronic hypoalbuminemia. Results: Of 241,228 patients, 94,925 (39%) had reduced albumin; 79,751 were retained per group after matching. The composite outcome occurred in 40.4% versus 33.3% (HR 1.28, 95% CI 1.26–1.30; p < 0.0001). Reduced albumin was associated with higher all-cause mortality (HR 1.50), myocardial infarction (HR 1.36), heart failure (HR 1.22), ventricular arrhythmias (HR 1.41), and Takotsubo cardiomyopathy (HR 1.41; all p < 0.005). Atrial fibrillation or flutter did not differ (HR 1.02; p = 0.779). A dose–response was observed, with severe hypoalbuminemia conferring greater composite risk (HR 1.49) than mild (HR 1.16). Findings were consistent across all sensitivity analyses. Conclusions: Reduced admission serum albumin is independently associated with higher short-term mortality and cardiovascular complications after ICH and may aid early risk stratification. Prospective studies are needed to clarify its utility.