BACKGROUND: X-ray, computed tomography (CT), and digital subtraction angiography (DSA) techniques are indispensable in managing critically ill neurosurgical patients. However, repeated diagnostic imaging leads to cumulative radiation exposure, raising concerns about long-term risks such as malignancies. This study evaluates the frequency, dosage, and implications of radiation exposure in a neurosurgical intensive care unit (NICU) patient cohort. METHODS: A retrospective analysis was conducted on 589 patients admitted to the NICU between 2013 and 2018 with the diagnosis of traumatic brain injury (TBI), intracerebral hemorrhage (ICH), subarachnoidal hemorrhage (SAH), and stroke with >
24 h of mechanical ventilation time. The cumulative radiation dose per patient from X-ray, CT, and DSA imaging was calculated and stratified by diagnostic indication, patient condition, and clinical course. To contextualize the findings, international benchmarks were compared. RESULTS: The cohort's median cumulative effective dose (ED) was 17.8 mSv (range: 1.7-194.3 mSv). CT scans accounted for 81.95 % of the total radiation exposure, with head and thorax imaging being the most frequently performed studies. Younger age and a shorter ventilation time revealed a significant increase in the calculated lifetime attributable risk (LAR) of radiation-induced cancer in multivariate testing. Comparisons with international data revealed a comparable level of radiation exposure in this cohort. Despite the high radiation burden, imaging was deemed clinically essential, with direct implications for patient outcomes. CONCLUSION: While radiation exposure in NICU patients is substantial, the benefits of timely and accurate diagnostic information outweigh the potential long-term risks. In critical care settings, where patients face life-threatening conditions, the judicious use of diagnostic imaging is essential. Future efforts should focus on optimizing imaging protocols to minimize radiation exposure without compromising diagnostic quality.