NCCEd: Neurocritical Care Education for Residents

Objectives: Teach the elements of the coma exam and brain death exam

Objective: Appraise the available clinical data in making a diagnosis of brain death

Rationale: The coma and brain death exams are more focused than the comprehensive neurologic exam—which cannot be performed in many neurocritically ill patients—and require application of brainstem functional anatomy. Brain death is often misunderstood, and misdiagnosis has grave ramifications for the patient and for the medical field in general.

Objective: Interpret neuroimaging (both CT and MRI) to recognize common critical pathologies and the compartment(s) affected

Objective: Hypothesize what impending clinicoradiographic progression may be at risk of occurring (e.g. stroke types, herniations, hydrocephalus) based on imaging interpretation

Rationale: Localization of the compartment in which a pathology lies informs the etiology and risk profile. Providing clinical correlation and anticipating what progression could entail helps to inform the clinical team of the early signs/symptoms to monitor, which may help improve outcomes.

Objective: Identify the different modalities and strengths/weaknesses of ICP monitoring

Objective: Interpret abnormal ICP waveforms (e.g. plateau waves)

Objective: Recognize the signs/symptoms of elevated ICP in the absence of invasive monitoring (i.e. plateau waves)

Rationale: Abnormal waveforms may provide clues to impending decline despite normal quantitative ICP measurements. However, when invasive monitoring is not available, patients may exhibit non-specific signs and symptoms that, in the clinical context, require swift recognition and intervention to prevent morbidity and mortality.

Objective: Select a management strategy for managing elevated ICPs, whether known via invasive monitoring or by clinical signs/symptoms

Rationale: Elevated ICP can result from a variety of neurologic pathologies, and medical management—as well as indication for surgical management such as CSF diversion or decompressive craniectomy—is needed to appropriately manage patients.

Objective: Give examples of available rapid-response EEG devices (e.g. Ceribell)

Objective: Discuss the inherent limitations of these devices

Rationale: Use of rapid-response devices is increasing nationwide as availability increases and the benefits are appreciated. However, clinical practice is influenced by the limitations inherent to the modality, as this modality does not remove the need for full-array continuous EEG.

Objective: Explain the indications for continuous EEG

Objective: Recommend the duration of continuous EEG monitoring based on the clinical scenario

Objective: Recognize the ACNS Critical Care EEG terminology

Rationale: Continuous EEG is a ubiquitous diagnostic test in neurocritical care, but its use and application are nuanced. Knowledge of the indications and determination of monitoring duration will optimize its clinical utility. Recognition of ACNS’ terminology in formal reports influences the decision-making process for further monitoring and/or treatment.

Objectives: Describe the pathophysiology of ischemic stroke, IPH, SAH, SDH, EDH, IVH, status epilepticus, neuromuscular respiratory failure, TBI, and tSCI

Objectives: Summarize the diagnostic and therapeutic management of ischemic stroke, IPH, SAH, SDH, EDH, IVH, status epilepticus, neuromuscular respiratory failure, TBI, and tSCI

Rationale: These are the most common neurologic emergencies that neurologists will either primarily manage or on which they’ll be consulted. Selection and prioritization of diagnostic and therapeutic options follow from an understanding of the applicable pathophysiology, and may reduce the chances of leaving out any key task. Discussion of the characteristics (e.g. sensitivity, specificity) inherent to the diagnostic tests allows for more informed, accurate diagnosis and management beyond the first level.

Objectives: Integrate clinical, radiographic, and electrophysiologic data while adhering to the latest guidelines and evidence base to provide post-cardiac arrest neuroprognostication and post-TBI neuroprognostication

Rationale: Cardiac arrest and TBI are the two most common conditions for which neurologists may be called upon to provide neuroprognostication. Much uncertainty can be present, but it is the neurologist’s responsibility to try to utilize multimodal testing where indicated to prognosticate as best possible. There is a relatively mature yet constantly evolving literature for this topic in these conditions, with recent NCS guidelines published after extensive literature reviews. The general trend has been an increase in understanding that several various markers used to predict poor outcomes, such as myoclonus or the presence of DAI, are not reliable and may lead to falsely pessimistic assessments.