Background:
Lightning injuries (LI) can affect multiple organs, including the peripheral and central nervous system (CNS). Neuroimaging studies in LI are scarce, and it is unknown whether off-target changes in the CNS occur.

Methods:
Retrospective review of patients who were treated in two neurology tertiary referral centers for sequelae of LI between 2004-2024 and had magnetic resonance imaging (MRI) or computed tomography (CT) of the CNS. A narrative literature search was performed to identify other studies on neuroimaging after LI.

Results:
Of 31 patients (39% female, median age 38 years), 30 had cranial neuroimaging (28 had cranial MRI, five cranial CT), and 14 spinal MRI. The median delay between LI and first neuroimaging was 67 days. Cranial MRI or CT showed two cases of brain edema, one accompanied by subarachnoid bleeding, one case of laminar cortical necrosis after resuscitation, and one case with hyperintensities in the hippocampi. 14 patients with cranial MRI had unspecific white matter lesions. In six of 14 patients who received a spinal MRI, intramedullary spinal cord lesions were found. A review of 54 published patients revealed pathological neuroimaging in 24 (44%) cases. Main findings were hypoxic encephalopathy after cardiac arrest, intracerebral bleeding, cerebral ischemia, brain edema and subarachnoid bleeding.

Interpretation:
Typical neuroimaging findings after LI include brain edema, intracerebral or subarachnoid bleeding, ischemia, hypoxic encephalopathy, and intramedullary spinal cord lesions. Moreover, brain white matter lesions are common, which are of unknown significance, since clinical correlates are rare and pre-existing pathologies often cannot be ruled out.