This document provides an overview of neurologic and neurosurgical emergencies that may present in the intensive care unit (ICU). It discusses altered consciousness, increased intracranial pressure, neurogenic respiratory failure, status epilepticus, acute stroke, intracerebral hemorrhage, subarachnoid hemorrhage, head trauma, and spinal cord injury. For each topic, it describes evaluations, potential causes, and management strategies.

1. Neurologic and Neurosurgical Emergencies in the ICU Thomas P. Bleck, MD, FCCM Louise Nerancy Eminent Scholar in Neurology Professor of Neurology, Neurological Surgery, and Internal Medicine Director, Neuroscience Intensive Care Unit The University of Virginia

8. Parasympathetic control of pupil size

9. Sympathetic control of pupil size

11. Control of Horizontal Eye Movements III III VI VI VIII VIII MLF Neck stretch receptors - +

22. Herniation Ropper, 1998

23. Standard Model diencephalon midbrain pons temporal lobe uncus midline Inferred force vector causing transtentorial herniation

24. Standard Model midbrain temporal lobe uncus third cranial nerves cavernous sinuses third nerve palsy from compression cistern obliterated

25. Current Model diencephalon midbrain pons temporal lobe uncus midline Force vector displacing diencephalon laterally cistern widened

26. Current Model temporal lobe uncus third cranial nerves cavernous sinuses third nerve palsy from stretch cistern widened midline

27. brain abscess enlarged cistern Bleck et al, 2000

29. Adult and Pediatric GCS Pediatric Adult Reaction to speech 3 Reaction to speech 3 No response 1 No response 1 Reaction to pain 2 Reaction to pain 2 Spontaneous 4 Spontaneous 4 Eye opening Eye opening

30. Adult and Pediatric GCS No response 1 No response 1 Extension 2 Extension 2 Flexion 3 Flexion 3 Withdraws 4 Withdraws 4 Localizes 5 Localizes 5 Spontaneous 6 Spontaneous 6 Best motor response Best motor response Pediatric Adult

31. Adult and Pediatric GCS Best response Best verbal response Smiles, orients to sound, smiles, interacts 5 Oriented 5 Child Adult

32. Adult and Pediatric GCS No response 1 No response 1 No response 1 Irritable, restless 2 Inconsolable 2 Incomprehen-sible sounds 2 Moaning 3 Inconsistently consolable 3 Inappropriate words 3 Inappropriate 4 Consolable 4 Confused 4 Interactive Crying child Adult

33. Monitoring Sedation Status over Time in ICU Patients: Reliability and Validity of the Richmond Agitation-Sedation Scale JAMA. 2003;289:2983-91.

64. Head Trauma

69. Rosner View of Cerebral Blood Flow

70. Intact Auto-regulation Lang et al. JNNP. 2003;74:1053-1059.

71. Defective Auto-regulation

75. Marshall et al. J Neurotrauma . 1992;9 Suppl 1:S287-92. 66.7 33.3 0.0 0.4 (no brainstem reflexes by physical exam) Brainstem injury 52.8 36.1 11.1 4.8 High or mixed density lesion > 25 cm 3 not surgically evacuated Nonevacuated mass 38.8 38.4 22.8 37.0 Any lesion surgically evacuated Evacuated mass lesion 56.2 37.6 6.2 4.3 Shift > 5 mm, no high or mixed density lesion > 25 cm 3 Diffuse injury IV (shift) 34.0 49.7 16.4 20.5 Cisterns compressed or absent, shift 0 – 5 mm, no high or mixed density lesion > 25 cm 3 Diffuse injury III (swelling) 13.5 52.0 34.5 23.7 Cisterns visible, shift 0 – 5 mm, no high or mixed density lesion > 25 cm 3 Diffuse injury II 9.6 28.8 61.6 7.0 No visible pathology on CT Diffuse injury I 94.1 0.0 5.9 2.3 No CT data Dead Severe/vegetative Good/moderate % of pts Description Category

76. Rothstein: Trauma Prognosis

84. Moderate Marked

95. March 2002