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: Explain the indications for continuous EEG

Rationale: Continuous EEG is a ubiquitous diagnostic test in neurocritical care, but its use and application are nuanced. Knowledge of the indications will guide appropriate utilization.

Objectives: Describe the pathophysiology of ischemic stroke, IPH, SAH, SDH, EDH, IVH, TBI, and tSCI

Objectives: Summarize the diagnostic and therapeutic management of ischemic stroke, IPH, SAH, SDH, EDH, IVH, TBI, and tSCI

Rationale: These are the most common neurologic emergencies that neurosurgeons will either primarily manage or on which they’ll be consulted. Selection and prioritization of diagnostic and therapeutic options (particularly guideline-recommended surgical indications) follow from an understanding of the applicable pathophysiology, and may reduce the chances of leaving out any key task. There are several guideline recommendations for indications for operative intervention (e.g. early decompression of malignant MCA infarcts, size and/or other clinical characteristics for EDH or SDH, ICP monitoring for severe TBI).