Basic Concepts about Critical Care Neurology

&Stroke

Part I

Critical Care

Neurology

Coma• Definition : Aurosal , alert, aware

• Neuroanatomy : ARAS, Dienncephalon, Cerebral cortex

• Clinical approach :

• GCS

• Skull # signs

• Meningeal signs

• Respiratory pattern

• Oculocephalic

• Oculovestibular

• Pupil

• Gaze preference

• Spontaneous eye movement

• Motor response

Brain death Criterias• Done by 2 seniors

• Definitive etiology

• Metabolic profile correction

• Absent BS reflexes

• Absent motor response

• Apnea test

• Confirmation tests : EEG, 4 Vessels angio, SPECT scan, TC doppler

ICP• IC Volume ( 1.9 L : Brain vs Blood vs CSF )

• Monro Kelli concept

• Causes :

• Mass

• Edema ( cytotoxic vs vasogenic vs interstitial )

• Hydrocephalus

• ICP Monitor waves :

• A wave vs B wave

• Herniation syndromes

• Rx

• NMJ intubation indications :

• 20 / 30 / 40 : FVC / MIP / MEP

Hypoxic Ischemic Encephalopathy

• Etiology : Cardio, pulmonary, Hb

• Sensitive area : Hippocampus CA1 / BG / Cerebellum

• Clinical patterns :

• Amnesia

• Movement disorder

• Seizure

• Watershed infarction ( ACA/MCA vs MCA/PCA )

• Delayed post anoxic encephalopathy

• Bad prognosis factors :

• CLINICAL

• EEG

• SSEP

• NEURON SPECIFIC ENOLASE

Part II

Stroke

Brain Vascular Neuroanatomy & Syndromes

Definitions & Pathophysiology• Stroke

• TIA

• RIND

• Stroke in evolusion

• Penumbra

• ATH : monocytes migration to intimamacrophage engulfs lipoprotien ( Foam cells ) media smooth muscles cells proliferation plaque = stenosis vs thrombosis vs emboli

• Acute ( edema + eosinophils & monocytes ) subacute ( necrosis & astrocytes ) chronic ( cavition & gliosis )

• Neural injury mechanism :

• Anaerobic metabolism LA

• Na/K pump failure Ca influx free radicals

Etiology• I ) Ischemic ( 80 % ) :

• Cardioembolic ( 30 % )

• Large vessels extracranial ( 20 % )

• large vessels intracranial

• Lacunar Small vessels ( 20 % )

• Hematological

• Venous thrombosis

• Hereditary

• II ) Hemorrhagic ( 20 % ) :

• ICH ( 75 % )

• SAH ( 25 % )

• Special situation ( Pregnancy )

• Venous / ICH/ Shehaan/ RCVS/ PRES

Hemorrhagic stroke• ICH :

• Triad of HA, DEFECT & LOC

• MRI Pattern

• Prognostic Factors ( SITE, SIZE, GCS )

• Surgical ?

• Supratentorial ( STICH Trial ) Vs. Infratentorial

• SAH :

• Etiology

• C/P

• Dx : CT LP Angio

• Cx : General ( Cardiac, Pulm, SIADH ) Vs. Neurogenic ( Rebleed, vasospasm, seizure, hydrocephalus )

• Asymptomatic aneurysms

Acute Management• Exclude mimickers• NIHSS• General tests• CT within 30 mins ( early signs ?/ ASPECT SCORE )• IV Thrombolytic :• Indications & Contraindications• Dose ( 0.9 mg / Kg )• NINDS Trial • Precautions post tPA• IA Thrombolysis• MERCI Device• Aspirin 325 mg ( CAST Trial )• Hemicranioectomy for Malignant MCA• General measurements :• BP, Fever, BG, DVT, Depression

Secondary Prevention• Anti Platelets :

• CHARISMA & MATCH trials : Long term Plavix + aspirin = monotherapy BUT ↑ ICH > Clopidoger alone

• Carotid Stenosis :

• CREST Trial : ( 70-99 % Vs 50-69 % = ARR 17 vs 6.3 )

• Stent vs CEA

• HTN : PROGRESS Trial ACE

• DLP : SPARCL Trial Statin

• DM : Ha1c < 7

• Smocking

• AF :

• Within 2 wks

• Warfarin Vs novel anticoagulants

• CHADS2 Vs HAS-BLED Score

Thank

You