1. Basic Concepts about
Critical Care
Neurology
&
Stroke

2. Part I
Critical Care
Neurology

3. 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

4. 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

5. 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

6. 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

7. Part II
Stroke

8. Brain Vascular Neuroanatomy &
Syndromes

9. 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

10. 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

11. 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

12. 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

13. 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

14. Thank
You