# Clinical Cases: Neurocritical Care

## Case 1: Severe Traumatic Brain Injury

### Patient Demographics
- **Age:** 23 years old
- **Sex:** Male
- **Mechanism:** Motorcycle accident, not wearing helmet

### Prehospital Information
EMS called to scene of motorcycle vs. car collision. Patient found unresponsive with obvious head trauma. GCS at scene: Eye 1, Verbal 1 (intubated), Motor 3 = GCS 5T. Right pupil 5mm and sluggish; left pupil 3mm and reactive. Intubated in field. Transported as trauma code.

### Emergency Department Assessment

**Primary Survey:**
- **Airway:** Secured (intubated in field)
- **Breathing:** Bilateral breath sounds, SpO2 99% on ventilator
- **Circulation:** HR 58, BP 168/92 (Cushing response)
- **Disability:** GCS 5T (E1V1TM3)

**Secondary Survey - Neuro:**
- **GCS Breakdown:**
  - Eyes: 1 (no opening)
  - Verbal: 1T (intubated)
  - Motor: 3 (abnormal flexion to pain)
- **Pupils:**
  - Right: 6mm, fixed
  - Left: 3mm, sluggish
- **Motor Response:** Abnormal flexion (decorticate posturing) bilaterally

**Other Injuries:**
- Scalp laceration, right temporal
- Right clavicle fracture
- No other significant injuries

### Clinical Image
![Subdural Hematoma CT](case_01_image.jpg)

*Image: CT head showing acute subdural hematoma with midline shift, demonstrating the crescent-shaped hyperdense collection conforming to the brain surface with mass effect.*

**Image Source:** Wikimedia Commons
**Attribution:** Radiology case, CC BY-SA 3.0
**URL:** https://commons.wikimedia.org/wiki/File:Subdural_hematoma.jpg

### CT Head (Non-contrast)

**Findings:**
- **Right acute subdural hematoma** - crescent-shaped, 12mm maximal thickness
- **Midline shift:** 10mm to the left
- **Right uncal herniation:** Effacement of ipsilateral ambient cistern
- **Diffuse cerebral edema:** Loss of gray-white differentiation
- **No epidural hematoma**
- **No skull fracture**

### Assessment

1. **Severe traumatic brain injury** (GCS ≤8)
2. **Acute subdural hematoma** requiring emergent evacuation
3. **Right uncal herniation** - dilated right pupil from CN III compression
4. **Elevated intracranial pressure**

### Signs of Herniation

| Finding | Present |
|---------|---------|
| Dilated pupil ipsilateral to lesion | YES (right pupil 6mm fixed) |
| Contralateral hemiparesis | Unable to assess (bilateral posturing) |
| Declining GCS | YES |
| Cushing's triad (HTN, bradycardia, irregular respirations) | Partial (HTN, bradycardia) |

### Immediate Management (ED)

**Airway/Ventilation:**
- Confirm ETT placement
- Target: PCO2 35-40 mmHg (avoid hypocapnia unless herniating)
- Target: SpO2 >94%

**Blood Pressure:**
- SBP target: >100 mmHg (age 50-69) or >110 mmHg (age 15-49)
- Avoid hypotension - single episode of SBP <90 associated with worse outcomes
- This patient hypertensive (Cushing response) - no treatment of HTN (reflects ICP elevation)

**ICP Management - Emergent:**
- **Head of bed elevated 30 degrees**
- **Midline head positioning** (avoid jugular compression)
- **Hypertonic saline 23.4% - 30mL bolus** (or mannitol 1g/kg if HTS unavailable)
- **Brief hyperventilation** to PCO2 30-35 (temporary bridge to OR)
- **Sedation** with propofol

**Seizure Prophylaxis:**
- **Levetiracetam 1000mg IV** (reduces early post-traumatic seizures)

**Other:**
- Normothermia (avoid fever)
- Glucose control (avoid hypoglycemia and severe hyperglycemia)

### Neurosurgical Intervention

**Decision:** Emergent surgical evacuation

**Indications for SDH evacuation met:**
- Thickness >10mm: YES (12mm)
- Midline shift >5mm: YES (10mm)
- GCS drop: N/A (already severe)
- Neurological deterioration: YES (herniation)

**Procedure:** Right frontotemporoparietal decompressive craniectomy with SDH evacuation

**Operative Findings:**
- Large acute subdural hematoma evacuated
- Brain swollen, not replaced bone flap (decompressive craniectomy)
- ICP monitor placed

### ICU Management Post-Operatively

**Neuroprotective Targets:**

| Parameter | Target |
|-----------|--------|
| ICP | <22 mmHg |
| CPP (MAP - ICP) | 60-70 mmHg |
| SBP | >110 mmHg (age 15-49) |
| PaO2 | >60 mmHg; SpO2 >94% |
| PaCO2 | 35-45 mmHg |
| Temperature | 36-37.5°C (normothermia) |
| Glucose | 140-180 mg/dL |
| Sodium | 140-155 mEq/L |
| Hemoglobin | >7 g/dL |

**ICP Monitoring:**
- Initial ICP post-op: 18 mmHg (improved)
- CPP maintained at 65 mmHg

**Tiered ICP Management Protocol:**

**Tier 1 (General measures):**
- Head of bed 30 degrees
- Avoid fever, pain, agitation
- Sedation with propofol/fentanyl
- Maintain euvolemia

**Tier 2 (If ICP remains elevated):**
- CSF drainage (if EVD in place)
- Osmotic therapy:
  - Hypertonic saline (3% continuous or 23.4% bolus)
  - OR Mannitol 0.25-1 g/kg boluses
- Brief hyperventilation (if acutely herniating)

**Tier 3 (Refractory ICP elevation):**
- Barbiturate coma (pentobarbital)
- Decompressive craniectomy (already done)
- Hypothermia (controversial)

### Clinical Course

**Day 1-3:**
- ICP controlled 15-20 mmHg on tier 1 measures
- Sedation weaned on day 3
- Opened eyes to voice, localized to pain
- Right pupil improved to 4mm, sluggishly reactive

**Day 7:**
- Off sedation
- Following simple commands
- Moving all extremities (left weaker than right)
- Tracheostomy and PEG placed

**Day 14:**
- Transferred to acute rehabilitation
- GCS 11T (E4VTM6)
- Cranioplasty planned in 6-8 weeks

### Teaching Points

1. **GCS ≤8 defines severe TBI** and mandates airway protection (intubation)

2. **Avoid secondary brain injury:**
   - Hypotension (SBP <90) dramatically worsens outcomes
   - Hypoxia (SpO2 <90%) worsens outcomes
   - Fever increases metabolic demand
   - Hyperglycemia and hypoglycemia are harmful

3. **Subdural hematoma surgical indications:**
   - Thickness >10mm
   - Midline shift >5mm
   - GCS drop of ≥2 points
   - ICP >20 mmHg

4. **Signs of uncal herniation:**
   - Ipsilateral pupil dilation (CN III compression)
   - Contralateral hemiparesis (or ipsilateral - Kernohan's notch)
   - Declining consciousness

5. **ICP management is tiered** - start with basic measures, escalate as needed

6. **Target ICP <22 mmHg and CPP 60-70 mmHg**

---

## Case 2: Aneurysmal Subarachnoid Hemorrhage

### Patient Demographics
- **Age:** 48 years old
- **Sex:** Female
- **Occupation:** Attorney

### Chief Complaint
"Worst headache of my life."

### History of Present Illness
Ms. Katherine Ross is a 48-year-old woman who developed sudden onset of severe headache while at work. She describes it as the "worst headache of my life" that came on like a "thunderclap" and reached maximum intensity within seconds. She experienced nausea and vomiting. Coworkers noted she seemed confused. EMS was called and she was transported to the emergency department.

### Past Medical History
- Hypertension (inconsistently treated)
- Smoker

### Emergency Department

**Initial Assessment:**
- **Vital Signs:** BP 178/102, HR 88, Temp 37.2C
- **GCS:** 14 (E4V4M6) - confused
- **Neuro Exam:**
  - Alert but confused, disoriented to date
  - Photophobia
  - Nuchal rigidity (meningismus)
  - No focal motor deficits
  - No pupil abnormalities

### Clinical Image
![Subarachnoid Hemorrhage CT](case_02_image.jpg)

*Image: Non-contrast CT head showing diffuse subarachnoid hemorrhage in the basal cisterns and sylvian fissures, appearing as hyperdense (white) blood in the CSF spaces.*

**Image Source:** Wikimedia Commons
**Attribution:** Radiology case, Public Domain
**URL:** https://commons.wikimedia.org/wiki/File:Subarachnoid_hemorrhage_CT.jpg

### CT Head (Non-contrast)

**Findings:**
- **Diffuse subarachnoid hemorrhage** in basal cisterns, sylvian fissures, and interhemispheric fissure
- **Modified Fisher Grade 3** - thick SAH without IVH
- No hydrocephalus
- No parenchymal hematoma

### CTA Head

**Findings:**
- **6mm saccular aneurysm at the anterior communicating artery (AComm) bifurcation**
- No other aneurysms identified
- Patent cerebral vasculature, no vasospasm

### Hunt and Hess Grading

| Grade | Clinical Features | Patient |
|-------|-------------------|---------|
| 1 | Asymptomatic or mild headache | No |
| **2** | **Moderate-severe headache, nuchal rigidity, no deficit** | **YES** |
| 3 | Drowsiness, confusion, mild focal deficit | No |
| 4 | Stupor, moderate-severe hemiparesis | No |
| 5 | Coma, decerebrate posturing | No |

**Patient is Hunt and Hess Grade 2** - relatively good prognosis with treatment

### Management Plan

**Immediate Priorities:**

1. **Prevent Rebleeding (highest early risk):**
   - Blood pressure control: Target SBP <160 mmHg until aneurysm secured
   - Nicardipine drip started
   - Strict bed rest
   - Minimize stimulation
   - Stool softeners (avoid Valsalva)

2. **Secure the Aneurysm (within 24 hours):**
   - Neurosurgical and neurointerventional consultation
   - Decision: **Endovascular coiling** (AComm aneurysm favorable anatomy)
   - Performed within 12 hours of admission

3. **Prevent Vasospasm:**
   - **Nimodipine 60mg PO/NG every 4 hours x 21 days** - improves outcomes
   - Note: Nimodipine does NOT prevent vasospasm on imaging but improves clinical outcomes

4. **Maintain Cerebral Perfusion:**
   - After aneurysm secured: Allow higher BP (no longer need SBP <160)
   - Euvolemia - avoid hypovolemia
   - Maintain hemoglobin >8 g/dL

5. **Monitoring:**
   - Neurological examination every 1-2 hours
   - Daily transcranial Doppler (TCD) starting day 3 to monitor for vasospasm
   - Repeat imaging if clinical change

### Post-Coiling Course

**Day 1-3:**
- Aneurysm coiled successfully
- Neurologically stable
- No hydrocephalus on repeat CT

**Day 5-14 (Vasospasm Window):**
- Day 7: TCD shows elevated velocities in bilateral MCAs (150 cm/s)
- Day 8: New confusion, mild left arm weakness
- Clinical vasospasm suspected

**Management of Vasospasm:**
- Permissive hypertension (SBP 180-200 mmHg)
- Euvolemia confirmed
- Emergent cerebral angiogram: Moderate right MCA vasospasm
- Intra-arterial verapamil and balloon angioplasty performed
- Clinical improvement within hours

**Other Complications Monitored:**

| Complication | Status |
|--------------|--------|
| Rebleeding | No (aneurysm secured) |
| Vasospasm | Day 7-8 (treated) |
| Hydrocephalus | Mild ventriculomegaly day 10, no EVD needed |
| Hyponatremia | Na 132 day 6, SIADH, fluid restriction |
| Seizures | None |

### Day 14:
- Neurologically at baseline
- Transferred to rehabilitation
- Modified Rankin Scale: 1 (no significant disability)

### Teaching Points

1. **"Worst headache of my life" = SAH until proven otherwise**
   - CT head (95% sensitive if <6 hours)
   - LP if CT negative but clinical suspicion high

2. **Secure the aneurysm within 24 hours** to prevent rebleeding (highest risk in first 24 hours)

3. **Vasospasm is the major delayed complication:**
   - Occurs days 3-14 (peak days 7-10)
   - Monitor with serial neuro exams and TCD
   - Treat with induced hypertension and endovascular intervention

4. **Nimodipine 60mg q4h x 21 days** is standard of care - improves outcomes despite not preventing angiographic vasospasm

5. **Hunt and Hess grade correlates with prognosis:**
   - Grade 1-2: Good outcomes expected
   - Grade 4-5: Poor prognosis

6. **Hyponatremia is common** - usually SIADH; can also be cerebral salt wasting

---

## Case 3: Status Epilepticus

### Patient Demographics
- **Age:** 34 years old
- **Sex:** Male
- **History:** Known epilepsy

### Prehospital

EMS called for witnessed seizure at home. Per wife, patient has known epilepsy (on levetiracetam) but ran out of medication 3 days ago. Seizure activity began approximately 10 minutes before EMS arrival. Generalized tonic-clonic seizure ongoing when paramedics arrived.

**EMS Treatment:**
- Midazolam 10mg IM given
- Seizure continued
- Transported to ED (estimated seizure duration now 15 minutes)

### Emergency Department

**Arrival Assessment:**
- Ongoing generalized tonic-clonic seizure
- **Total seizure duration: ~18 minutes**
- **Vital Signs:** HR 130, BP 180/100, SpO2 91% on non-rebreather, Temp 38.2C
- Cyanosis present
- Incontinent of urine

### Clinical Image
![Status Epilepticus EEG](case_03_image.jpg)

*Image: EEG recording showing continuous generalized seizure activity with rhythmic spike-wave discharges, characteristic of generalized convulsive status epilepticus.*

**Image Source:** Wikimedia Commons
**Attribution:** EEG case, Educational use
**URL:** https://commons.wikimedia.org/wiki/File:Status_epilepticus_EEG.png

### Definition of Status Epilepticus

| Type | Definition |
|------|------------|
| **Convulsive SE** | ≥5 minutes of continuous seizure OR ≥2 seizures without return to baseline |
| **Non-convulsive SE** | EEG seizure activity without overt convulsions |
| **Refractory SE** | Continues despite 2 appropriate medications |
| **Super-refractory SE** | Continues ≥24 hours despite anesthesia |

**This patient has convulsive status epilepticus (>5 minutes)**

### Treatment Protocol

**Time 0-5 min (Stabilization):**
- ABCs: Supplemental O2, position patient
- Midazolam 10mg IM (already given by EMS) ✓
- IV access obtained

**Time 5-20 min (First-line benzodiazepine given, need second-line):**
- Seizure continues despite midazolam
- **Fosphenytoin 20 mg PE/kg IV** at 150 mg PE/min
- (Alternatives: Valproic acid 40 mg/kg IV or Levetiracetam 60 mg/kg IV)

**Time 20 min:**
- Seizure continues after fosphenytoin loading complete
- Now meets criteria for **REFRACTORY STATUS EPILEPTICUS**

**Time 20-40 min (Refractory SE):**
- **Intubation** for airway protection
- **Propofol bolus 2 mg/kg** then infusion 50-100 mcg/kg/min
- (Alternative: Midazolam infusion or pentobarbital)
- **Continuous EEG monitoring** initiated

**Time 30 min:**
- Clinical seizure activity stopped
- EEG shows burst suppression (goal achieved)

### Workup for Status Epilepticus

**Immediate Labs:**
- Glucose: 95 mg/dL (normal)
- BMP: Na 136, others normal
- Antiepileptic drug level: Levetiracetam <5 mcg/mL (subtherapeutic - confirms non-compliance)
- Urine toxicology: Negative
- CBC: WBC 12,000 (stress response)

**Imaging:**
- CT head: No acute intracranial abnormality

### Etiology

**Most likely: Antiepileptic medication non-compliance**
- Confirmed by subtherapeutic levetiracetam level
- Patient ran out of medication 3 days ago

### ICU Course

**Day 1:**
- Maintained on propofol infusion
- Continuous EEG: Burst suppression achieved
- Loaded with levetiracetam 2000 mg IV
- Target: Maintain burst suppression for 24 hours

**Day 2:**
- Propofol weaned slowly
- Continuous EEG shows no seizure activity
- Extubated successfully
- Neurologically at baseline - alert, following commands, no deficits

**Assessment:**
- Status epilepticus secondary to antiepileptic medication non-compliance
- No structural brain abnormality
- Resolved with treatment

### Discharge Plan

- Continue levetiracetam 1500 mg twice daily
- Neurology follow-up in 2 weeks
- Counseled extensively on importance of medication adherence
- Discussed driving restrictions (state-specific, typically 3-6 months seizure-free)
- Social work consultation for medication access/financial issues
- Provided 90-day prescription to ensure medication supply

### Non-Convulsive Status Epilepticus (NCSE)

**Important concept:** If a patient with convulsive SE has convulsions controlled but does not wake up:
- MUST obtain continuous EEG
- Up to 20-40% of patients have ongoing non-convulsive seizures
- NCSE presents as persistent altered mental status without overt convulsions
- Requires aggressive treatment

**Risk factors for NCSE:**
- Prior convulsive SE
- Critical illness
- CNS infection or injury
- Hypoxic brain injury

### Teaching Points

1. **Status epilepticus is a medical emergency** - mortality increases with duration

2. **Treatment timeline:**
   - 0-5 min: Benzodiazepine (lorazepam IV or midazolam IM)
   - 5-20 min: Second-line AED (fosphenytoin, valproate, or levetiracetam)
   - 20+ min (refractory): Anesthetic infusion (propofol, midazolam, or pentobarbital)

3. **Continuous EEG monitoring is essential** in refractory SE and when consciousness does not recover

4. **Non-convulsive SE is common** and easily missed - always consider in unexplained altered mental status

5. **Most common cause of SE in known epileptics: medication non-compliance**

6. **Goal of anesthetic treatment: burst suppression** for 24-48 hours before weaning

---

## Key Teaching Points Summary

### Severe TBI
- GCS ≤8 = severe TBI, requires intubation
- Avoid secondary injury: hypotension (SBP <90) and hypoxia (SpO2 <90)
- ICP target <22 mmHg, CPP 60-70 mmHg
- Subdural evacuation if >10mm thick or >5mm midline shift

### Subarachnoid Hemorrhage
- "Worst headache of my life" = SAH until proven otherwise
- Secure aneurysm within 24 hours (coiling or clipping)
- Vasospasm occurs days 3-14; monitor with TCD and serial exams
- Nimodipine 60mg q4h x 21 days is standard of care

### Status Epilepticus
- ≥5 minutes of continuous seizure = status epilepticus
- Treatment escalation: benzodiazepine → second-line AED → anesthetic infusion
- Continuous EEG for refractory SE and to detect NCSE
- NCSE is common and easily missed in ICU patients