Basic Concepts about Critical Care Critical Care Neurology Neurology

& StrokeStroke

Part IPart I

Critical Care Critical Care NeurologyNeurology

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 IIPart II

StrokeStroke

Brain Vascular Neuroanatomy & Syndromes

Definitions & Pathophysiology• Stroke• TIA• RIND• Stroke in evolusion• Penumbra• ATH : monocytes migration to intima macrophage 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

Anticoagulation agent

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

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