3 - Neurological Emergencies Flashcards
What is a bulbar palsy and how does it present?
LMN lesion of CN 9, 10 and 12 causing issues with speech and swallowing
- Flaccid fasiculating tongue
- Absent or normal jaw jerk reflex
- Absent gag reflex
- Nasal quiet speech
What are the cause of an acute bulbar palsy
(Image important)
- GBS
- Myasthenia Gravis
- Stroke (Lateral Medullary Syndrome)
- MND
- Syringobulbia
What is a pseudobulbar palsy?
A bilateral lesion of the corticobulbar tracts so affects CN 9, 10 and 12
UMN lesion of speech and swallow
Has to be bilateral lesion as CN nuclei have bilateral input
How does pseudobulbar palsy present?
Presentation
- Spastic tongue
- Increased jaw jerk reflex
- Slow deliberate speech
- Increased gag reflex
- Emotional lability
What are some causes of pseudobulbar palsy?
- Vascular: bilateral internal capsule stroke
- Degenerative: MND, progressive supranuclear palsy
- Autoimmune: MS
- Upper brain stem tumours
- Trauma
How is the pseudobulbar affect treated?
Dextromethorphan and Quinidine
Why is temporal arteritis an emergency?
Bilaterally sight threatening vasculitis!!!!!
Also a stroke risk
What symptoms should make you consider temporal arteritis?
- Headache
- Scalp tenderness
- Jaw claudication
- Sudden unilateral blindness
- Amaurosis Fugax
- History of PMR
- >55
What investigations should you do if you suspect GCA?
- CRP and ESR: raised
- FBC: normocytic anaemia, raised platelets
- LFTs: raised ALP
- Temporal artery biopsy: within 14 days of starting steroids, take around 3-5cm due to skip lesions, if nothing then biopsy asymptomatic side too
What is the management for a suspected case of GCA?
- Immediate high dose steroids: before TAB (60mg PO prednisolone) to prevent blindness and stroke
- Low dose aspirin
- PPI: Gastric protection
- Bisphosphonate and Adcal: Bone protection
What is the prognosis with GCA?
Usually a 2 year course then full remission if tapered slowly
Wean down prednisolone as symptoms improve and ESR declines
What are some signs of respiratory distress?
- Tachypnoea
- Nasal Flaring
- Tracheal tug
- Use of accessory muscles
- Intercostal, subcostal and sternal recession
- Pulsus paradoxus
- Abnormal sounds
How do you manage a respiratory arrest?
- Call for help
- Check pulse every 2 minutes
- Head-tilt-Chin-lift (if C-Spine injury do jaw thrust)
- Bag Valve Mask every 5-6 seconds
- Consider oral or nasopharyngeal adjunct
- Prepare for advanced airway e.g laryngeal mask
- 15L supplemental oxygen through BVM
What are some neurological causes of respiratory distress/arrest?
- Drive Failure: centrally acting drugs, tonsillar herniation due to raised ICP, Stroke
- Transmission Failure: GBS, MG, Spinal Cord Lesion, MND
- Action Failure: Muscular dystrophies, myopathies
How can you manage respiratory distress?
Ix:
- CXR
- ABG
- Review drug chart e.g opioids
- U+Es
Mx:
- Oxygen
- CPAP
- Consider need for invasive ventilation
Head trauma patients are treated with an ABCDE approach. What are some alterations made in the A to E process when there is head trauma?
- Do not use nasopharyngeal airway as can cause damage if skull fracture
- Do not do Head-tilt-Chin-lift if C-Spine injury, do Jaw Thrust
What is the immediate management for a patient with a head injury?
- Stabilise C-spine, Airway, Breathing and Circulation
- Assess GCS: If 8 or less need urgent ICU involvement to manage airway
- Assess antegrade/retrograde amnesia
- Neurological examination: start neuro obs
- Consider need for imaging
Whay is the criteria for performing a CT head scan within 1 hour of head injury? (immediately)
- GCS <13 on initial assessment
- GCS <15 at 2 hours after the injury on assessment in ED
- Suspected open or depressed skull fracture
- Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, CSF from the ear or nose, Battle’s sign)
- Post-traumatic seizure
- Focal neurological deficit.
- More than 1 episode of vomiting.
What parameters are included in neuro obs and how often should they be taken?
What is the criteria for performing a CT head scan within 8 hours following head injury?
Any loss of consciousness or amnesia since the injury AND ONE OF:
- Aged 65 or more
- History of bleeding or clotting disorders (inc taking warfarin)
- High-impact injury (e.g fall>1m or >5 stairs or struck by moving vehicle)
- Retrograde amnesia >30 minutes
For suspected cervical spine injuries, when should you perfor a CT cervical spine within an hour?
- GCS <13 on initial assessment
- Patient has been intubated
- Definitive diagnosis of cevical spine injury is needed urgently e.g beforre surgery
- Patient is having other body areas scanned e.g multitrauma
- See image
When should you discuss a patient with a headinjury with the neurosurgeons?
- Significant abnormalities on CT
- Persistent GCS of 8 or less
- Deteriorating GCS
- Focal neurology
- Seizure without full recovery
- CSF LEAK
What are some complications of a head injury?
Early
- Extradural/subdural haemorraghe
- Seizures
Late
- Subdural
- Seizures
- Diabetes Insipidus
- Parkinsonism
- Dementia
What are some causes of impaired conscious level/coma?
Metabolic: drugs, alcohol, CO, hypoglycaemia, hypothermia, sepsis, hypoxia
Neurological: trauma, meningitis, tumour, stroke, haemorraghe, epilepsy
How do you manage a patient that has arrived in ED comatosed?
A to E:
- Consider intubation if GCS<8
- Give O2 and treat any seizures
- Protect cervical spine
- Checl BM
- IV naloxone if opioid intoxication, IV flumazenil if benzodiazepine intoxication and airway compromise
Full Body Exam
Collalteral History:
- How they were found
- Recent complaints and PMHx inc DHx
- Drug or Alcohol Exposure
Arrange Urgent CT head
How do you calculate GCS?
Best response
How may spinal cord compression present?
- Bilateral leg weakness (arms if C-spine)
- Sensory level
- Preceding back pain
- Bladder and anal sphincter (involved late, hesitancy/frequency/retention)
- LMN sign at level of lesion, UMN below: remember acute cord compression may show LMN signs e.g reduced reflexes but actually be UMN
What are some causes of spinal cord compression?
- Trauma
- Metastases from BLTKP
- Infection (especially TB in at-risk patients)
- Disc prolapse
- Epidural haematoma (on warfarin)
- Myeloma
How is suspected spinal cord compression investigated and managed? (same as CES)
Ix
- Urgent whole spine MRI
- PR Exam
- CXR: metastases, TB
- Bloods: FBC, ESR, B12, U+Es, LFTs, PSA, serum electrophoresis
Mx
- Urgent dexamethasone if malignancy given daily with PPI cover
- Surgical decompression (laminectomy) within 48 hours as otherwise permanent neurological deficits
What are some differential diagnoses for spinal cord compression?
- Transverse myelitis
- MS
- GBS
- Spinal artery thrombosis or aneurysm
What is the difference in presentation between spinal cord compression and cauda equina syndrome?
How can metastases cause spinal cord compression?
- Collapse of vertebrae
- Extension of tumour into cord
What is the difference in presentaion between cauda equina and conus medullaris syndrome?
CES
- Back and radicular leg pain
- Asymmetrical atrophic areflexic paralysis of legs (LMN)
- Sensory loss in root distribution
- Decreased sphincter tone
Conus Medullaris
- Mixed UMN/LMN
- Leg weakness
- Early urinary retention and constipation
- Back pain
- Sacral sensory disturbance
What is the definition of a stroke?
Cerebrovascular event that is caused by abnormal perfusion of cerebral tissue
Sudden onset of rapidly developing focal or global neurological disturbance, which lasts more than 24 hours
Ischaemic or Haemorraghic
How are strokes classified?
-
Ischaemic (85%): Oxford/Bamford Classification
- Haemorraghic (15%): Intracerebral or SAH
What are some causes of stroke?
- Ischaemic: Thrombosis, Emboli, Dissection
- Haemorraghic: HTN, AV malformation, Trauma, Bleeding disorders, Vasculitis
What are some risk factors for a stroke?
- Smoking
- Diabetes mellitus
- Hypertension
- Hypercholesterolaemia
- Obesity
- Atrial fibrillation
- Carotid artery disease
- Age
- Thrombophilic disorders (e.g. antiphospholipid syndrome)
- Sickle cell disease
What is the blood supply to each part of the brain?
Anterior Circulation: From ICA
Posterior Circulation: From Vertebrobasilar circulation
What are the different classifications of stroke in the Bamford/Oxford classification?
Remember criteria at bottom of table
What are some of the signs and symptoms of the following types of strokes:
- Haemorraghic
- Anterior Ischaemic
- Posterior Ischaemic
Haemorraghic
- Headache
- Altered mental status
- Nausea & Vomiting
- Hypertension
- Seizures
- Focal neurological deficits
Anterior Ischaemic
- Unilateral contralateral weakness and/or sensory deficit: face and/or arms and/or legs
- Homonymous hemianopia
- Higher cerebral dysfunction: dysphasia, visuospatial dysfunction (e.g. neglect, agnosia)
Posterior Ischaemic
- Dizziness
- Diplopia
- Dysarthria & Dysphagia
- Ataxia
- Visual Field defects
- Brainstem syndromes (ipsilateral cranial nerve lesions with contralateral sensory and motor limb deficits)
What is Wallenburg and Locked-In Syndrome?
Wallenburg/Lateral Medullary syndrome
- Posterior inferior cerebellar artery occlusion
- Nystagmus, Vertigo, Ipsilateral Horner’s syndrome, Ipsilateral facial sensory loss, Dysarthria & dysphagia
- Diplopia
- Contralateral pain and temperature loss
What are two scoring systems used for an acute stroke?
FAST
- Used in the community to decide whether a patient needs transfer to a hyper acute stroke unit
- Any new arm weakness, facial weakness, new speech difficulty
NIHSS
- In hospital to decide whether to do thrombolysis and the clinical outcome
- Score <4 is good clinical outcome
- Score >22 is high and risk of haemorraghe with thrombolysis as larger proportion of ischaemia
- Score of 26 or more is contraindication for thrombolysis
What are some examples of ‘stroke mimics’?
What investigations are done when an acute stroke is suspected?
CT HEAD TO SEE IF ISCHAEMIC OR HAEMORRAGHIC
- Bedside: observations, blood glucose, ECG (AF)
- Bloods: FBC, U&Es, Bone profile, LFT, ESR, coagulation, lipid profile, HbA1c
-
Imaging: CT head +/- CT angiography +/- MRI head
- Special: Echo, carotid dopplers, 24 hour tape, young stroke screen
What is the acute management for a stroke?
- Protect airway
- Maintain homeostasis: Blood glucose (4-11) and BP
- Screen swallow: NBM until screen
- CT/MRI within 1hr
- Aspirin 300mg if haemorraghic stroke ruled out
- Thrombolysis (Alteplase) if haemorraghic stroke ruled out and <4.5 hours since onset. Also consider thrombectomy
- If haemorraghic stroke consider need for decompressive hemicraniectomy
What is the secondary management for a stroke after initial management has taken place?
Secondary Prevention:
- Clopidogrel 75mg once daily
- Atorvastatin 80mg should be started but not immediately
- Carotid endarterectomy or stenting in patients with carotid artery disease
- Treat modifiable risk factors such as hypertension and diabetes
What are some complications with a stroke?
What is a malignant MCA infarction?
- Rapid neurological deterioration due to cerebral oedema following an MCA infarct
- Need urgent decompressive hemicraniectomy
What advice should you give somebody on driving following a stroke?
- Cars and motorcycles: stop driving one month. Inform DVLA if ongoing symptoms after one month
- Larger vehicles (e.g. buses, lorries): stop driving, inform the DVLA
What is the gold standard imaging following a stroke?
Diffusion-Weighted MRI
Often do CT as faster and can exclude haemorraghic. Can also do Carotid Doppler US to see if need to do endartectomy
What is a TIA and how may it present?
Ischaemic neurological event with symptoms lasting <24h, patient’s often go on to have a full stroke within a week of a TIA
- Amaurosis Fugax
- Unilateral weakness or paraesthesia
- Rare to have global events e.g dizzy, syncope
- Crescendo TIA: more than 2 in a week suggests critical stenosis in superior division MCA
What investigations are done when a patient has a TIA?
- FBC
- U+Es
- Glucose
- Lipids
- CXR
- ECG
- Carotid Doppler and Angiograph
- CT or Diffusion Weighted MRI
- Echo
How is a TIA treated?
- Control risk factors: Optimise BP, DM, stop smoking
- Aspirin 300mg: for 2 weeks then switch to Clopidogrel 75mg
- Anticoagulate if AF
- Carotid Endarctectomy within 2 weeks if critical stenosis
- Do not drive for a month
- Calculate ABCD2 score
What is the ABCD2 score?
Stratifies which patients are at higher risk of having a stroke following a TIA
Score of 4 or more patient is at high risk of early stroke so see within 24h
Score of 6 or more predicts stroke in next 2 days
What is status epilepticus?
- Seizure lasting > 5 minutes
- Repeated seizures without regaining full consciousness/recovery between episodes
- High risk of permanent brain damage so assume status when seizure at 5 minute mark
What are the different stages of status epileptics and what happens in each stage?
(important image)
1st Stage - Early Status (0-10 minutes)
- Check for safety and call for help
- ABCDE
- Protect airway and provide oxygen therapy 100%
- Protect patient, but do not restrain
- Establish IV access and take bloods
2nd Stage (0-30 minutes)
- Regular monitoring (e.g. cycling observations, ECG monitoring if possible, temperature)
- Emergency AED therapy
- Emergency investigations (bloods, CXR, toxicology screen)
- Consider alcohol intoxication: consider Parbinex
- Blood glucose level: consider intravenous glucose (e.g. 100 mls 20%)
3rd Stage - Established Status (0-60 minutes)
- Determine aetiology (collateral history, hospital records)
- Further emergency AEDs
- Alert anaesthetic team and ITU
- Treat any co-morbidities (i.e. sepsis)
- Consider urgent CT head (e.g. exclude intracerebral bleed, structural abnormalities)
4th Stage - Refractory Status (30-90 minutes)
- Transfer to ITU: requires general anaesthesia with intubation and ventilation
- EEG monitoring
What is some basic seizure first aid?
What are the emergency drugs used for status epilepticus?
- Benzodiazepine (IV Lorazepam 4mg/0.1mg per Kg, Diazepam 10mg PR, Midazolam 10mg Buccal): At 5 minutes
- Benzodiazepine: Another dose 10-20 minutes later
- IV Phenytoin Loading: 15-18mg/kg IVI at a rate of 100mg/minute, needs ECG monitoring as risk of hypotension, bradycardia and heart block.
Can also use phenobarbital
- Seek ICU Help: put under general anaesthesia for 12-24 hours guided by EEG monitoring, use Propofol, Midazolam, Thiopental sodium
If a patient is in status epilepticus and you suspect the patient has alcoholism or malnourishment, what other pharmacological treatment should you give them?
- Thiamine 250mg IV over 30 minutes before glucose as risk of making Wernicke’s worse
- Glucose 50ml 50% IV
What investigations are important in status epilepticus?
- O2 sats and BMs (reversible seizure causes)
- ABG
- Bloods: FBC, U&E, LFT, CRP, Ca, Mg, clotting. Take when gaining IV access
- Serum and Urine: toxicology, AED levels
What are some of the acute and chronic complications of Status Epilepticus?
- Acute: hyperthermia, cardiac arrhythmias, severe hypoxaemia, shock, cerebral oedema, death
- Chronic: long-term neurological damage (epilepsy, focal neurological deficits, encephalopathy)
What organisms are most common in meningitis?
- Meningococcus
- Pneumococcus
- H.Influenzae
- Listeria Monocytogenes
- HSV
- VSV
- CMV
- TB
- Cryptococcus neoformans
What are the features of meningitis?
Early
Headache, fever, cold hands and feet, abnormal skin colour
Late
- Meningism: neck stiffness, photophobia, Kernig’s signs
- Reduced GCS
- Seizures
- Petechial rash
- Shock
What is the management of suspected meningitis?
Do Ix and Mx in parallel
- Signs of raised ICP contact ICU immediately
- Isolate for 24h and inform public health
- SEPSIS 6 if necessary
- Blood Cultures and LP: if no signs of raised ICP, shock or petechial rash
- IV abx: Ceftriaxone. Add Amoxicillin if >60 years old to cover Listeria, IV acyclovir if Viral
- IV dexamethasone: 10mg/6h if signs of meningism
- Ix: U+E, FBC, LFT, Glucose, Coagulation, Bacterial and Viral Throat swab
- Prophylaxis
If a patient is suspected to have meningitis in primary care, what should the GP do?
Give benzylpenicillin 1.2g IM before admitting
When should you do a CT head in the work up for meningitis?
Urgent CT Head scan before LP if signs suggestive of a shift of brain compartments
- GCS ≤12
- Focal neurological signs
- Papilloedema
- Continuous or uncontrolled seizures
What is the second line empirical antibiotic for meningitis?
Viral meningitis is supportive with rest, hydration, analgesia and antipyretic
What will a LP show in bacterial, viral and TB meningitis?
(IMPORTANT IMAGE)
- Opening pressure
- Cell count and differential
- Protein
- Glucose (paired with serum glucose)
- Microscopy, cultures & sensitivity (MC&S)
- Viral PCR
- Save sample (can subsequently be used to run other tests)
- Others (if indicated): cryptococcal antigen (paired with serum), TB PCR
After notifying PHE about a case of meningitis, what other public health measures do you need to take?
- Isolate patient in side room for 24h
- Contact trace (household and kissed on mouth)
- Give contacts Ciprofloxacin 500mg PO or Rifampicin regardless of vaccination status
- Check MenB and MenACWY status
What are some complications with meningitis?
What is encephalitis and how may it present?
Inflammation of the brain parenchyma, suspect in anyone with odd behaviour
- Altered mental status or confusion
- Fever
- Flu-like prodrome
- Early seizures
Should you CT after a head injury and if so, when?
What are some causes of encephalitis?
(most common cause is underlined)
- Viral: HSV-1 or 2 (fatal if not treated), CMV, EBV, VSV, HIV
- Non-Viral Infectious: Mycoplasma, Tuberculosis, Rickettsial infections, Histoplasmosis and parasites (e.g. Echinococcus)
- Paraneoplastic
- Autoimmune
What is post infectious encephalitis?
- Acute disseminated encephalomyelitis (ADEM)
- Demyelinating condition affecting CNS
- Development of encephalopathy (e.g. confusion, altered mental status, irritability) and other neurological signs (e.g. hemiparesis, cranial nerve palsy, myelopathy)
- 4-13 days following an infection or vaccination.
What is autoimmune encephalitis?
- Antibody against antigen in the CNS. Cause inflammation of the CNS
- NMDA Encephalitis: psychiatric manifestations (e.g. agitation, bizarre behaviour, hallucinations, delusions), memory deficits, sleep deficits, seizures, altered mental status and autonomic instability (e.g. hyperthermia, fluctuations in blood pressure).
What are the different types of autoimmune encephalitis?
How can you tell the difference between encephalitis and meningitis?
Altered mental status in encephalitis!!!
What investigations should you do if you suspect encephalitis?
- Bedside: observations, urinalysis, ECG, sputum cultures
- Bloods: full blood count, urea & electrolytes, bone profile, liver function tests, CRP, blood cultures, coagulation
- Imaging: chest x-ray, CT head
- Neuroimaging: MRI, CT
- EEG
- LP for CSF
- Serology: autoantibodies
Where do you often see HSV damage on neuroimaging?
- Temporal lobes
- Bilateral multifocal haemorrhage
How is encephalitis managed?
- IV acyclovir within 30 minutes (10mg/kg/8h) for 14 days
- 2g IV Ceftriaxone BD to cover for meningitis
- HDU or ICU transfer
- Symptomatic treatment e.g Phenytoin for seizures
70% mortality if left untreated
When should you suspect a cerebral abscess?
Suspect in any patient with raised ICP especially if fever and raised WCC
- Seizures
- Fever
- Localising signs
- Signs of raised ICP
What investigations and management should you do for a cerebral abscess?
Ix:
- CT/MRI (Ring-Enhancing Lesion)
- FBC and ESR (raised WCC and ESR)
- Biopsy
Mx:
- Urgent neurosurgical referral
What are the signs and symptoms of a SAH (bleed between arachnoid and pia mater)?
Symptoms
- Thunderclap sudden onset headache
- Sentinel headache
- Vomiting
- Seizures
- Coma
Signs
- Neck stiffness/Meningism
- Kernig’s sign (after 6h)
- Focal neurology e.g pupil changes
SAH are often caused by AV malformations or a burst of a berry aneurysm.
What are some risk factors for a SAH?
- Hypertension
- Smoking
- Excessive alcohol consumption
- Cocaine use
- Family history
- EDS
- Polycystic Kidney disease
- Marfan’s
- Sickle Cell Disease
What investigations do you do if you suspect a SAH?
- Urgent Non-Contrast CT head: hyperattenuation
- LP: if -ve CT, do >12h after headache onset to look for xanthochromia (bilirubin from breakdown of RBCs, differentiates from traumatic tap)
- Cerebral angiography: gold standard for detection, demonstration and localisation of ruptured aneurysms
How is a SAH managed?
IMMEDIATE REFFERAL TO NEUROSURGERY
Supportive: Analgesia, Antiemetic, Fluid resus (Keep SBP<160)
Medical:
Nimodipine to reduce cerebral vasospasm and consequent cerebral ischaemia.
Can also give Levetiracetam if seizures or risk of
Surgical: Coiling or Clipping of aneurysm
Monitoring: for complications
What are the complications with a SAH?
- Rebleeding: common in first few days
- Cerebral Ischaemia: due to vasospasm, can cause permanent neurological deficit
- Hydrocephalus: due to blockage of arachnoid granulations, needs ventricular or lumbar drain
- Hyponatraemia: do not fluid restrict
How may a posterior communicating artery aneurysm present?
CNIII palsy
How may a posterior communicating artery aneurysm present?
CNIII palsy
What is a subdural haemorrhage and how does it appear on CT?
Collection of venous blood between dura and arachnoid due to damage to bridging veins
Presentation: Headache, nausea or vomiting, confusion, and diminished GCS
CT: Crescent shape not limited by sutures. Check if bilateral
Risks: Elderly due to atrophy, Trauma, Alcohol, Anticoagulants
How is a subdural haematoma managed?
- Urgent reversal of any clotting abnormalities
- >10MM OR with midline shift>5mm then need craniotomy or burr hole
What is the pathophysiology of an extradural haemorrhage and how does it appear on CT?
Rupture of the middle meningeal artery after a blow to temporoparietal region. Blood between skull and dura
CT: Biconvex limited to sutures
LP is contraindicated
How may an extradural haemorrhage present?
- Traumatic head injury
- Transient LOC
- Lucid interval for few hours then rapid decline in GCS
- Headache
- Vomiting
- Ipsilateral pupil dilates
- Can lead to death if left as respiratory arrest from brainstem compression
How is an extradural haemorrhage managed?
- Urgent transfer to neurosurgical unit
- Clot evacuation and ligation of bleeding vessel
- Consider need for intubation
What are the principles of management for any intracranial bleed?
What is classed as a raised ICP and what are some causes of this?
- <15mmHg is normal
- 20-25mmHg needs treatment
- >40mmHg is severe life threatening
Could be mass effect, oedema or obstruction to fluid outflow
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What are some of the features of a raised ICP?
Early
- Morning headache: worse on coughing, leaning forward
- Vomiting
- Altered GCS
Late
- Cushing’s Triad
- Opthalmoplegia
- Coma
- Death
- Seizures
What signs on examination may you see with raised ICP?
- Papilloedema with loss of venous pulsation
- Occular palsies
- Pupillary constriction then dilation
What investigations should you do if you suspect a raised ICP?
How is a raised ICP managed?
(image important!!!)
Need to lower ICP and avert secondary injury
- Urgent Craniotomy or Burr Holes if focal causes
- ICP monitor or bolt to monitor pressure
What are the different types of herniation that can occur with raised ICP and how do they present?
Uncal: Lateral Supratentorial mass. Temporal lobe herniates to midbrain, CNIII compressed so ipsilateral dilated pupil and diplopia. Can lead to coma as compressing reticular activating system
Cerebellar Tonsil: Posterior fossa mass. Cerebellar tonsils through F.Magnum causing ataxia, upping plantar reflexes, LOC, Cushing’s triad, irregular breathing
Subfalcine (Cingulate): Frontal mass. Medial Frontal Lobe forced under rigid Falx Cerebri. Can compress ACA so stroke (contralateral leg weakness)
What are some red flags for raised ICP?
What are some red flags for raised ICP?
