u Brain Death

u Encephalopathy (anoxic, hypoxicischemic)

u Hemorrhage (ICH, IVH,

Subarachnoid)

u Ischemic stroke

u Neuro Infectious Disease

u Neurosurgery

u Seizure Disorders

u Frontal

u Personality, motor function,

motor speech, morals,

emotions, judgment

u Parietal

u Sensation, pain

interpretation, temperature,

pressure

u Temporal

u Auditory & speech

u Occipital

u Visual

u Cerebellum

u Coordination of muscle

movement & tone,

coordination, equilibrium

u Brain Stem

u 4 ventricles

u Lateral ventricles

u Foramen of Monro

u Conduit of CSF flow from the

lateral ventricles to the Third

ventricle

u Third & Fourth Ventricles

u Cerebral Spinal Fluid (CSF)

u Clear, colorless, large amount of

NaCl, some protein & glucose

u Cushions and protects the brain

& spinal cord

u 500 ml produced per day

u Brain compartment

u 80% tissue

u 10% CSF

u 10% Blood

u Monro-Kellie Doctrine

u Balance of tissue, CSF & blood to

create an equilibrium

u Increase in one area must result in

a decrease in another

u If not, the ICP will increase

uCompression of venous blood

uDisplacement of CSF

uBlood flow is maintained by

cerebral auto-regulation

u Trauma - TBI

u Intracranial Hemorrhage

u Hydrocephalus

u Cerebral edema

u Stroke

u Brain tumors

u Hypoxic-ischemic brain

injury (cardiac arrest)

u Brain infections/abscess

External Causes of Intracranial

Hypertension

u Suctioning

u Position changes

u Positive End-Expiratory Pressure (PEEP)

u Fever

u Seizures

u Increased stimuli

u Level of consciousness

u Mentation

u Changes?

u Pupillary response

u Equal & reactive?

u Signs of increased ICP

u Motor skills

u Equal on both sides?

u Sensory deficits

u Vision or speech deficits?

u Test with light touch/pinprick

u Cranial Nerve Assessment

GCS ≤ 8

u Airway

u Breathing

u Maintain PaCO2 ~ 35 mmHg

u Circulation

u Headache

u Nausea/vomiting

uCan progress to

projectile

u Change in LOC

u Lethargy

u Irritability

u Slow decision making

Late changes:

u Pupillary changes

uDilation in one eye

u Seizures

u Posturing

u Can progress to coma

Who should be monitored?

u Early recognition of

changes in ICP

u Head injuries – GCS < 8

uCerebral edema

u Ischemic stroke

u Hydrocephalus

Parameters

u Normal ICP 0 – 15 mmHg

u Treatment indicated if

sustained > 20 – 25 mmHg

u Cerebral Perfusion Pressure

(CPP)

uMAP – ICP = CPP

uGoal > 60 (Usually 70 –

90)

What’s in an ICP waveform?

P1 – Percussion wave

P2 – Tidal Wave

P3 – Dicrotic notch

What’s in an ICP waveform?

P1 – Percussion wave

P2 – Tidal Wave

P3 – Dicrotic notch

First Tier Interventions

u Patient positioning

u Manage venous drainage

u Prevent compression of jugular

veins

u HOB 30 – 45 degrees

u Good head alignment

u Straight legs

u Decrease stimuli

u Analgesics

u Sedation

u Propofol (if intubated)

u Normothermia

u Mannitol 20% - Osmotic diuretic

u 0.25 to 1 gram/kg IV bolus

u ICP decrease within 5 – 10 min

u Maximum effect in 1 hour

u Use filter!

u May repeat q 1 – 4 hours

u Hypertonic Saline

u Continuous infusion

u Loop Diuretics

u Decrease intracranial volume

u Monitoring

u Serum osmo & fluid status

u No higher than 320 mOsm/L (or

as decided by provider)

u Rebound increase in ICPs

u Potassium levels

u Keep CPP > 60 mmHg

Second Tier Interventions

u Neuromuscular Blockade

u Mild hyperventilation

u Cautious!

u Decreased PaCO2 is a

potent vasoconstrictor

u Low normal 35 – 40 mmHg

Second Tier Interventions

u Mild hypothermia

u Fever is bad!!!

u Barbiturate coma

u Pentobarbital

uClosely monitor for hypotension

uUse continuous EEG

u Thiopental

u Decompressive Craniectomy

u Used for refractory intracranial

hypertension

u Used when other approaches

have failed

u Must ALWAYS be intubated & used with continuous IV sedation

u Assess peripheral nerve stimulation

u Goal 1 – 2 twitches out of 4

u Protect the corneas with lubricant

u What is the significance of having:

u 0 / 4 twitches?

u 4 / 4 twitches?

Types:

u Blunt

u Penetrating

u Blast

u Focal

uCoup-countrecoup

uContusions

uLacerations

uArterial or venous tears

Causes:

u Motor Vehicle Crash

u Assault

u Falls

u Diffuse

uTwist & turn/shearing

injury

uMild – concussion

u< 15 min alteration

in LOC

uSevere – Diffuse

Axonal Injury

uAcceleration injury

Mild

Concussion

u Stretch injury of the axons

u Attention span & memory

affected (cortical function)

u Confusion & disorientation

after injury

u Symptoms usually cease

after 15 – 30 min

u Nausea, vomiting,

dizziness, headache

 u Can last for a few days

Severe

Diffuse Axonal Injury (DAI)

u Damage to axons

u Disconnects the cerebral

hemisphere from the reticular

activating system (RAS)

u Mild – loss of consciousness for < 24

hours

u Severe – coma, many times

involves the brainstem

u Increased ICP

u Cerebral edema

u Fever

u Poor prognosis

Types

u Linear

u No treatment required

u Dura usually intact

u Depressed

u If less than thickness of the skull,

no intervention

u If > thickness of skull (~6 mm),

will need decompression

u Basilar

u Fracture in the floor of the skull

u Eyes, ears, nose, spine

u Risk of injury to cranial nerves

 Headache

 Nausea

 Vomiting

 Blurred vision

 Restlessness

 Irritability

 Disequilibrium

 Stiff neck

 Pupils not reacting to light

 Confusion

 Drowsiness

 Key assessment: Is the dura torn?

 CT Scan (most common) or MRI

 Yes  surgery to remove bone

fragments

 ?Leaking CSF

 High risk of infection

Avoid NASOGASTRIC or ORAL

TUBES!!

u Avoid oral suctioning

u Rhinorrhea

u Torn blood vessels in the

nose

u CSF indicates rupture of the

meninges

u C/O salty taste

u Otorrhea

u Test for glucose

u + glucose = CSF

u “halo” sign

u Pneumocephalus

u Also look for other injuries (Subdural

hematoma, contusions)

u Prevent infections!

X bruising around mastoid bone (ear)

X racoon eyes (bruised eyes)

u Neuro emergency!!!!

u Usually temporal or parietal

region

u Laceration of meningeal

artery &/or vein

u Loss of consciousness à

Lucid à Coma

u Nausea, vomiting, agitation,

confusion

u Uncal (lateral) herniation

Subdural

Hematoma

Bleeding between the

dura mater

& the arachnoid space

u Acute

u Symptoms hours to days

u Decreased LOC

u Signs of Increased ICP

u Ipsilateral occulomotor paralysis

u Contralateral hemiparesis

u Sub-acute

u Hematoma can form 2 days - 2 weeks

after initial injury

u Chronic

uWeeks following injury

u Elderly

u Headaches

u Confusion

*All types can develop spontaneously r/t

anticoagulation therapy

u Diagnosis:

u*CT Scan – Gold standard

uMRI – If stable

uAngiography – if arterial

dissection suspected

uLumbar puncture –

contraindicated with

increased ICP

u Arterial Blood Gas – Hypoxia or

ineffective ventilation

u Hyponatremia

u SIADH

u Cerebral Salt Wasting

u Hypernatremia

u Diabetes Insipidus

u Pulmonary complications

u Seizures

u Immobility

u DVT

u Know how to monitor

for each of these!

Supratentorial (Uncal)

u Uncus pressure

on the tentorial

notch

u Compression of

the midbrain

u Change in LOC

u Unilateral pupil

dilation

u Lateral

displacement

Infratentoria

2

u Downward pressure toward

brainstem & medulla

u *Bradycardia

u *Systolic Hypertension

u *Wide pulse pressure

u Small pupils

u Nuchal rigidity

u Ataxic respirations

u Coma

*Cushing’s response

Decorticate (Flexion)

u Flexion of the arms,

wrist & fingers

u Internal rotation of

the lower

extremities

Decerebrate (Extension)

u Arch the back

u Arms extended

and pronated

u Normothermic

u Narcotics/Sedatives cleared from system

u EEG

u Assess cerebral blood flow

• uICP > MAP
• uMRI, TCDs, EEG, SSEP

u Pupillary response

• uSympathetic & Parasympathetic control
• uAbsent

 Cranial Nerves III, VI, VIII

 Absent – Brain death

Normal

Eyes move with head movement

 “Cold Calorics”

 Cranial Nerves III, VI, VIII

Absent

Normal – look toward

the stimulus

Cold Calorics testing 

This test stimulates your acoustic nerve by delivering cold or warm water or air into your ear canal. When cold water or air enters your ear and the inner ear changes temperature, it should cause fast, side-to-side eye movements called nystagmus. The test is done in the following way:

Cold : Away then back

Warm : Towards then away

ü Absence of cough

ü Absence of gag

ü Absence of pupillary response

ü Absence of corneal reflex

ü Absence of Oculocephalic Reflex

ü Absence of Oculovestibular Reflex

ü Positive Apnea Test

ü Absence of cerebral blood flow

ü Absence of EEG activity

ü Absence of Somatosensory Evoked

Response

2 Types:

• Ischemic
• Hemorrhagic

Previously was the 3rd

leading cause of death

Dropped to 4th leading

cause

Improved prevention

Improved care within the

first few hours

 Stroke Centers

•  Radiology capabilities
•  CT Scan & MRI
•  Tele Radiology
•  Trained staff – Team activation
•  EMS
•  Quality Improvement

 1 hour goals:

•  Complete assessment
•  NIHSS
•  Treat with fibrinolytic therapy (if
• appropriate)

Facial

drooping

 Arm weakness

 Speech

difficulty

 Call 911

NIHSS assesses:

 LOC

 Eye deviation (CN III, VI, VIII)

 Visual field loss (hemianopia)

 Facial palsy

 Motor arms (drift)

 Motor legs

 Limb ataxia

 Sensory

 Language

 Dysarthria

 Extinction & inattention

Stroke – Ischemic (AHA Guidelines)

• CT Scan without contrast

• R/O hemorrhage

• Should be interpreted within 45 min

• Hypodensity in ischemic area

• CT perfusion or MRI perfusion

• Measures infarct core or penumbra

• Non-invasive intra-cranial vascular

• study if plan to do intra-arterial

• fibrinolysis or mechanical

• thrombectomy

NIHSS assesses:

 LOC

 Eye deviation (CN III, VI, VIII)

 Visual field loss (hemianopia)

 Facial palsy

 Motor arms (drift)

 Motor legs

 Limb ataxia

 Sensory

 Language

 Dysarthria

 Extinction & inattention

Stroke – Ischemic (AHA Guidelines)

CT Scan without contrast

 R/O hemorrhage

 Should be interpreted within 45 min

 Hypodensity in ischemic area

CT perfusion or MRI perfusion

 Measures infarct core or penumbra

 Non-invasive intra-cranial vascular

study if plan to do intra-arterial

fibrinolysis or mechanical

thrombectomy

rtPA Considerations

 Treatment: rtPA

 Administer within 3 hours or

 Extended 4.5 hour window

 Excludes:

•  Age >80,
•  Taking oral anticoagulation,
•  Hx of stroke or DM,
•  baseline NIHSS score >25,
•  Imaging reveals ischemic injury
• > 1/3 of the MCA territory

 Baseline labs/tests:

CBC

Coags

Chemistry with glucose

Troponin

Chest x-ray

ECG

rtPA – Ischemic Stroke

**Control BP prior to administration!!**

• SBP < 185, DBP < 110

0.9 mg/kg IV, maximum of 90 mg

“Door to needle” time within 60 min

of hospital arrival

Other medication tips:

Aspirin 325 mg should be given within

24-48 hours of stroke onset

Do not provide other anticoagulation

therapy within 24 hours of rtPA

Restart statins if they were previously

taking them

Cooling – needs more evidence

Risk vs. benefit:

Mild symptoms

• Rapidly improving
•  
• symptoms
•  
• Major surgery within
•  
• the last 3 months
•  
• Recent MI
•  
• Taking thrombin
•  
• inhibitors or direct
•  
• factor Xa inhibitor
•  
•  

Endovascular Therapies for Ischemic Stroke

Should receive rtPA regardless

Many treatments not well

established in the literature

May be reasonable in patients

with a contraindication to IV

fibrinolysis

Intra-arterial treatments

Mechanical thrombectomy

Intra-cranial angioplasty &

stenting should be used only in

the setting of clinical trials

Stroke care components

Cardiac monitoring

• Atrial fibrillation
•  
• Cardiac arrhythmias

Airway support

• Ventilatory assistance if
•  
• needed
•  
• Apply O2 if O2 sats are < 94%

Avoid fever!!! (temp > 38°C)

• Antipyretic therapy

Treat hypovolemia

Treat hypoglycemia (< 60 mg/dL)

• Goal: normoglycemia
•  
• BS 140 – 180
•  
• Worse outcomes if hyperglycemic

Restart anti-hypertensives after 24

hours

NPO until swallow evaluation

Stroke care components

Standardized Stroke Orders

DVT prophylaxis

• SCDs

Swallow screen

• If unable to take solids, consider placing a feeding
•  
• tube
•  
• If > 2 weeks, consider PEG

Early mobilization

Avoid in-dwelling urinary catheters

• 
  
• High risk of UTIs

 Frequent neuro checks

 Monitor for bleeding

 Monitor for signs of increased ICP

Decompressive surgical evacuation if sustained

Corticosteroids are not recommended

 Monitor for seizures

Prophylactic anti-convulsants are not recommended

 Placement of a Ventriculostomy drain if develop

hydrocephalus

 Clinical presentation:

TIAs, visual Δ’s, memory

loss, vertigo, syncope

 Bruit or thrill

 Treatment: antiplatelet

aggregation (ASA, plavix)

 BP control

 Balloon angioplasty

Carotid Endarterectomy

 Post-op: Monitor for

bleeding/hematoma

Neuro assessment

Cranial nerve assessment:

 VII: Smile

 IX/X: Swallow, gag, speech

 XI: Shrug shoulders

 XII: Stick out tongue

Hemorrhagic Stroke

Causes:

 Spontaneous rupture of a blood

vessel

 Brain tumor bleed

 Uncontrolled anticoagulation

 Who’s at risk?

 HTN

 Diabetes

 Atrial fibrillation

 Smokers

 Prior TIAs

 Geriatric population

 Trauma

Symptoms:

 Abrupt & rapid onset

 Severe headache

 Nuchal rigidity

 Hemiparesis

 Posturing

 Stupor

 Coma

**Severity depends on the size of the

bleed

Symptoms – all stroke

Right cerebral hemisphere

 Left sided motor symptoms

 Respond well to verbal cues

 Can understand language

 Assists with cognition (thinking)

 Difficulty starting a

conversation

 Rambling speech

 Issues with problem solving

Left hemisphere

 Right sided motor symptoms

 Aphasia

 Expressive aphasia

 Inability to express verbally in an

understandable manner

 Receptive aphasia

 Inability to understand spoken

words

 Dyslexia

 Acalcia

 Right & left disorientation

 May respond well to pictures

 Memory loss

 Emotionally labile

Left brain

 Analysis

 Writing

 Reading

 Speech

 Calculation

 Logic

Right brain

 Personality

 Creativity

 Art

 Intuition

 Implementation

 Performance

Hemorrhagic Stroke

 Consider BP reduction if:

 SBP > 200 or

 MAP > 150

 More aggressive if

increased ICPs & SBP > 180

 Airway support

 Monitor for seizures

 Nursing care same as

ischemic stroke

 Supportive treatment

Aneurysms

 Muscle layer of the vessel

 Most occur in the anterior arteries of

the Circle of Willis

 Rupture most likely when > 8 – 10 mm

 Congenital weakness or unknown

 Other risk factors:

HTN

Smokers

Polycystic kidney disease

Aneurysms cont.

 Many are asymptomatic

until they bleed/rupture

 Sudden headache

 “Worst headache of my life”

 Nausea/vomiting

 Photophobia

 Diplopia

 Nuchal rigidity

 Kernig’s sign

 Brudzinski’s sign

Indicates meningeal

irritation

 Seizures

 Decreased LOC, may

progress to coma

Hunt & Hess Scale

Aneurysms con’t

 Symptoms & prognosis depend on the

area & size of bleed

 Treatment:

•  BP control – SBP < 160 mmHg
•  
•  Surgical or endovascular

 Monitor for re-bleed

 Days 4 – 14 monitor for vasospasm

 Calcium Channel Blocker (Nimodipine)

 Transcranial Doppler

 Monitor for signs of:

 Increased ICP

 Cerebral edema

 Hydrocephalus

Arterial-Venous Malformation (AVM)

 Congenital

 Entanglement of blood

vessels

 Concern with bleed or

rupture

 Surgical and/or

endovascular treatment

Hydrocephalus

 Accumulation of CSF in

the ventricles

 Signs of increased ICP

 Headache

 Decreased LOC

 Confusion

 Seizures

 Emergent treatment:

 Ventriculostomy

 Long term: VP Shunt

Seizures

 Abnormal electrical discharges in the

brain

 Causes:

 Genetic

 Congenital

 Exposure to drugs

Withdrawal from drugs or alcohol

 Low sodium or glucose

 Infection

 Trauma

 Tumors

 Can last a few seconds to

continuous without

intervention

 > 5 minutes is considered

a medical emergency

 Epilepsy – transient &

recurrent

Tonic-clonic (Grand mal)

Tonic

 Lose consciousness

 Many times

experience a fall

 Rigid extremities

 Bite tongue

 Pupils dilate

Clonic

 Tachycardia

 Diaphoretic

 Frothing at mouth

 Violent, rhythmic shaking

 Alternating contraction &

relaxation

Status Epilepticus

 Seizure lasts more than 30 min

 20 – 30% mortality

 All seizures:

 Safety is a priority!!!

Patent airway

Don’t ever stick anything into the mouth

 Figure out the underlying cause

Consider toxicology screen

Assess electrolytes & glucose

Medications - Seizures

 Phenytoin (Dilantin)

 Load 10-15 mg/kg or 15-20 mg/kg

 Give slowly! 50 mg/min

 Peaks in 15 – 20 min

 Monitor for bradycardia &

hypotension

 Assess levels

10 – 20 mcg/L therapeutic

 Use a filter

 Monitor IV site for infiltration

 Fosphenytoin

 150 mg/min

 Valproic Acid

 Benzodiazepines

 Lorazepam

 Diazepam

Guillain-Barre

 Autoimmune disorder

 Immune system attacks the peripheral nervous system

 Many times follows when recovering from an illness or

virus

Usually 1 – 3 weeks after

 Damage to the myelin sheath

 Impulses travel slow causing slow movements or

paralysis

Guillain-Barre Symptoms

 Symptoms:

 Paresthesia (numbness & tingling)

 Pins & needles hands, feet & face

 Uncoordinated movements

 Blurred vision

 Unilateral or bilateral

 Loss of DTRs/areflexia

 Difficulty breathing

 Muscle weakness usually starts in legs, then arms, face &

respiratory

 Ascending paralysis

Guillain-Barre

 ***Albuminocytologic

dissociation in the CSF

 High protein level, few cells

 Recovery weeks to months

 Peak incidence age 30-40

Treatment options:

 Plasmapheresis

 IVIG (immunoglobulin)

Nursing:

 Airway, monitor for respiratory

failure

 ~ 30% require mechanical

ventilation

 Supportive treatment:

 DVT Prophylaxis

 Nutritional support

 Physical Therapy

 Neurogenic bowel & bladder

 Prevent infections!!!

 Psychosocial support

Meningitis

• Inflammation of the meninges

• S/S: Headache, nuchal rigidity, fever, altered LOC,

photophobia, phonophobia, + Brudzinski's & Kernig’s signs

• Lumbar puncture for diagnosis

• Antibiotics or antivirals

Viral

 + Protein in CSF

 Normal glucose in CSF

 Lymphocytes

 Enteroviruses, herpes simplex

virus, varicella zoster virus, HIV

Bacterial

 +++ Protein in CSF

 Low glucose in CSF

 Neutrophils, WBCs

 Rash may indicate meningococcal

infection

 Neisseria meningitidis & Streptococcus

pneumoniae 80% of cases

Lumbar puncture

 Usually L4 – L5 interspace

 Assess “opening pressure” normal: 6 – 18 mmHg

 CSF sample

WBC, RBC, Protein, glucose, gram stain

 CSF glucose is usually 40% higher than serum

 Bacterial meningitis – divide CSF glucose by serum

glucose

 Index ≤ 0.4

 Assess for lactate (Increased level = Bacterial)

 Supine position post LP

Treatment: Cool to 32 – 34 degrees

To minimize reperfusion injury!

• Depleted stores of O2 & glucose

• Intracellular calcium influx

• Formation of O2 free radicals

• Release of glutamate

• Intracellular acidosis

• Disruption in blood brain barrier

• Mitochondrial injury

• Apoptosis

Targeted Temperature

Management PERLS

 32 – 34 degrees C for

12 – 24 hours

 Only in patients

remaining comatose

post cardiac arrest

 Neuro protective

 Side effects of

cooling:

 Bradycardia

 Vasoconstriction

induced hypertension

 Diuresis

 Hypokalemia

 Elevated lactate