Neurology indications CC

Question 1

Indications for immediate continuous video electroencephalographic monitoring in the critical care setting

Answer 1

• Altered mental status following convulsive status epilepticus or clinical seizures
• Altered mental status with acute brain injury (such as hemorrhage, trauma, infection, stroke, hypoxia, cardiac arrest)
• Unexplained altered mental status with subacute or chronic brain injury (tumor, history of epilepsy)
• Unexplained altered mental status (or mental fluctuation) without acute brain injury (as in sepsis)
• Unexplained altered mental status following a CNS procedure or CNS instrumentation
• Pharmacologic coma and paralysis that limit the ability to perform a neurologic examination (as is used with therapeutic hypothermia, ECMO)
• Clinical episodes concerning for seizures (such as unexplained muscle or eye movements)

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Question 2

Prerequisites for performing the apnea test

Answer 2

• Core body temperature >36.5°C
• Systolic blood pressure ≥90 mm Hg (may use intravenous fluids or dopamine to achieve)
• Eucapnia (PaCO2 approximately 40 mm Hg) if possible
• Normoxemia (PaO2 ≥200 mm Hg) if possible (typically 10 min at an FiO2 of 1.0 will achieve)

Question 3

Indications for ICP and CPP monitoring

Answer 3

• Patients with GCS <8 and an abnormal CT scan (i.e., hematoma, contusion, swelling, herniation, or compressed basal cisterns)
• Patients with GCS <8 and normal CT scan and at least two of the following on admission:
  
  • Age >40
  • Unilateral or bilateral motor posturing
  • Systolic BP <90 mm Hg

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Question 4

Indications for decompressive hemicraniectomy in acute stroke

Answer 4

• Clinical signs of MCA infarction, NIHSS score > 15
• Decreased level of consciousness, score ≥1 on item 1a on NIHSS
• CT infarct ≥50% MCA territory
  ** ± additional infarction of anterior/posterior cerebral artery on same side or
  ** Infarct volume > 145 cm3 on diffusion-weighted MRI

Question 5

Indication of ancillary testing

Answer 5

• After the first test to confirm indeterminate apnea test
• If significant doses of CNS depressants have been administered recently
• Toxic level of sedative drugs
• Severe facial trauma
• Pupillary abnormalities
• Severe chronic CO2 retention

Question 6

Surgical Intervention in ICH

Answer 6

• Cerebellar ICH that is ≥3 cm or causing brainstem compression
• ICH causing obstructive hydrocephalus leading to clinical/neurologic deterioration
• Posterior fossa hemorrhage >3 cm
• IVH causing hydrocephalus and necessitating EVD
• Complicated cases requiring ICP monitoring

Question 7

Relative Contraindications of Surgical Intervention in ICH

Answer 7

• Advanced age
• Serious medical comorbidities
• Stable clinical condition
• Hemorrhage in the dominant cerebral hemisphere

Question 8

Refer for carotid endarterectomy if

Answer 8

• Symptomatic stenosis (TIA or stroke within the last 6 months):
  
  • Stenosis 70-99% with a life expectancy of >5 years
  • Stenosis 50-69% in men with a life expectancy of >5 years (CEA may not be beneficial in women in this category, and they are usually medically managed)

MCQs