The Acute Neurology Survival Guide: A Practical Resource for Inpatient and ICU Neurology PDF
Preview The Acute Neurology Survival Guide: A Practical Resource for Inpatient and ICU Neurology
The Acute Neurology Survival Guide A Practical Resource for Inpatient and ICU Neurology Catherine S.W. Albin Sahar F. Zafar Editors 123 The Acute Neurology Survival Guide Catherine S. W. Albin • Sahar F. Zafar Editors The Acute Neurology Survival Guide A Practical Resource for Inpatient and ICU Neurology Editors Catherine S. W. Albin Sahar F. Zafar Department of Neurology Department of Neurology Emory University School of Medicine Massachusetts General Hospital Atlanta, GA, USA Harvard Medical School Boston, MA, USA https://doi.org/10.1007/978-3-030-75732-8 © Springer Nature Switzerland AG 2022 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Foreword For the trainee in neurology, neurosurgery, or intensive care medicine—and even for the seasoned attending physician—there is perhaps no greater challenge than the care of patients who develop a neurologic emergency. Whether encountered in the emergency room, on the neurology ward, in the medical or surgical ICU, or in a dedicated neuro-ICU, patients with acute neurologic conditions require the clinician to make rapid therapeutic deci- sions based on the interpretation of complicated neuro-diagnostics that rely on an extensive knowledge of neuroanatomy and neurophysiology. Practitioners must not only recognize neurologic syndromes and rapidly localize them but also understand the complex interactions between neuro- logic disease and concurrent systemic illness. In addition, they must stay up to date on a scientific literature that seems to evolve by the month, leading to a dizzying array of therapeutic options and constantly changing protocols that can be challenging to apply in individual patients. In just 400 pages, the reader will find rapid access to all this and more in the Acute Neurology Survival Guide by Dr. Casey Albin and Dr. Sahar Zafar. From reviews of brainstem anatomy to concisely written practical approaches to common acute neurologic conditions and medical complications in criti- cally ill neurological/neurosurgical patients to tables summarizing the major trials in stroke management to useful tables of antithrombotics, anti-seizure medications, and anticoagulation reversal agents, this book has everything the clinician needs to confidently diagnose and treat neurologic emergencies. There are many excellent textbooks on emergency neurology and neuro- critical care, but few provide access to as much information, knowledge, and wisdom presented as clearly, concisely, and practically as this one—and still fit into your “neuro bag” with room to spare for your reflex hammer, pen light, and stethoscope. I will certainly be carrying this phenomenal resource in mine. Aaron Berkowitz, MD, PhD v Preface The history of The Acute Neurology Survival Guide goes back 5 years, to 2016, when we recognized our mutual interest in improving the residents’ educational experience in the neuro-ICU. At that time, I (Sahar) had just joined my first faculty position in the neuro- ICU and saw that the many rotating residents and interns needed a struc- tured curriculum and orientation. Witnessing this need, I collaborated with the medical and nursing ICU directors and residency program director to develop a systematized orientation and ICU curriculum. Meanwhile, I (Casey) had just completed my first year of neurology resi- dency. Like residents all over the country, I had spent most of the year learning “by doing” and bouncing between various blogs, online orientations, textbooks left in resident workrooms, and various Epic “dot phrases” to ensure that I had a reasonable assessment and plan to present, but I never found a centralized resource to address, in a practical way, the many questions I had during my nights on call. Recognizing the absence of a responding-clinician-level source for guid- ance, we set out to create a centralized, check-list driven “how-to” guide which we termed the “NeuroICU Survival Guide.” The first version was printed by our neurology residency program in 2017 and in the years that followed became the core manual for trainees and advance practice provid- ers working in the neuro-ICU. Since that time, with the help and advice of pharmacists, residents, fellows, and APPs, we have dramatically expanded the content – adding chapters on common inpatient issues and routine consult questions – but the goal has always been the same: to create an incredibly easy-to-use, visually acces- sible how-to manual that covers exactly what every clinician needs to know to care for the patient in front of them. vii viii Preface Inside you will find checklists, scoring systems, pro-tips, helpful reminders, as well as concise summary of the pertinent literature. We have included over 150 images, charts, and diagrams in an effort to distill complex topics into understandable learning points that are accessible even at 4 AM or at the end of a 30-hour call. In Part I, you will find tangible guidance about how to pre-round, structure a presentation, examine neurologically ill patients, and interpret the core diagnostics obtained in many neurology patients: CT, MRI, and EEG. Parts II and III contain chief-complaint oriented chapters that delve into the care of vascular and non-vascular inpatient admissions. Part IV covers the topics central to caring for Neuro-Medicine and Neurosurgery patients in the neuro-ICU. Part V is a compilation of commonly referenced resources in a useable format: sections of the brainstem that are oriented the way you would see them in a radiology image, common drug-drug interactions to be aware of, and a comprehensive guide to anti-epileptic drugs (AEDs). As neurology and neurosurgery are rapidly evolving fields, each year there are hundreds of new studies that refine and transform the care of these complex patients. We have made every effort to include the latest guide- lines, terminology, and publications. This work would not have been possible without the dedication and collec- tive expertise of the residents, fellows, pharmacists, and APPs that contrib- uted and the guidance of experienced clinicians who made this work possible. We are deeply grateful for the time and energy that each author contributed and acknowledge that their input has made this book stronger. We would especially like to thank Dr. Aaron Berkowitz and Megan Barra, PharmD for their insightful revisions and thoughful feedback; the value of their input cannot be overstated. Whether you are a fledging clinician or an experienced provider, we hope that The Acute Neurology Survival Guide will improve your care of each patient encountered in the ICU, wards, ED, or other acute care settings. Sincerely, Atlanta, GA, USA Catherine S. W. Albin Boston, MA, USA Sahar F. Zafar Contents Part I A Comprehensive “How-To” Guide 1 Pre-rounding on and Presenting Neurology Floor Patients . . . . . . . . . . . . 3 Catherine S. W. Albin and Sahar F. Zafar 2 Pre-rounding and Presenting NeuroICU Patients . . . . . . . . . . . . . . . . . . . . 5 Catherine S. W. Albin and Sahar F. Zafar 3 The Coma Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Catherine S. W. Albin and Sahar F. Zafar 4 Cranial Nerve Testing in Acute Neurology . . . . . . . . . . . . . . . . . . . . . . . . . 13 Catherine S. W. Albin and Sahar F. Zafar 5 Stroke and Vascular Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Catherine S. W. Albin and Sahar F. Zafar 6 Basics of Computed Tomography (CT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Catherine S. W. Albin and Sahar F. Zafar 7 Basics of Magnetic Resonance Imaging (MRI) Ordering and Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Catherine S. W. Albin and Sahar F. Zafar 8 Understanding Transcranial Dopplers (TCDs) . . . . . . . . . . . . . . . . . . . . . 47 Catherine S. W. Albin and Sahar F. Zafar 9 Tips and Tricks for EEG Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Catherine S. W. Albin and Sahar F. Zafar Part II V ascular Neurology 10 Acute Ischemic Stroke – First Encounter Assessment and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Catherine S. W. Albin and Sahar F. Zafar ix x Contents 11 Perfusion Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Catherine S. W. Albin and Sahar F. Zafar 12 Ischemic Stroke: Admission Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Catherine S. W. Albin and Sahar F. Zafar 13 Stroke Workup – Beyond the Basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Catherine S. W. Albin and Sahar F. Zafar 14 Ischemic Stroke: Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Catherine S. W. Albin and Sahar F. Zafar 15 Ischemic Stroke: Symptomatic Carotid Stenosis (“Hot Carotid”) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Catherine S. W. Albin and Sahar F. Zafar 16 Ischemic Stroke – Post Stroke Management of Anticoagulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Catherine S. W. Albin and Sahar F. Zafar 17 Selected Anti-platelets and Anticoagulation in Stroke Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Catherine S. W. Albin and Megan E. Barra 18 Acute Management Strategies: tPA and Mechanical Thrombectomy Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Catherine S. W. Albin and Sahar F. Zafar 19 Venous Sinus Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Catherine S. W. Albin and Sahar F. Zafar 20 Posterior Reversible Vasoconstriction Syndrome (PRES) and Reversible Cerebral Vasoconstriction Syndrome (RCVS) . . . . . . . . 123 Catherine S. W. Albin and Sahar F. Zafar Part III N onvascular Inpatient Neurology 21 Altered Mental Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Priya Srikanth 22 Framework for Workup of Unknown Brain “Lesion” . . . . . . . . . . . . . . 133 Catherine S. W. Albin and Sahar F. Zafar 23 Approach to First-Time Seizure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Catherine S. W. Albin and Sahar F. Zafar 24 Pharmacology Tips for Commonly Used AEDS . . . . . . . . . . . . . . . . . . . . 141 Megan E. Barra Contents xi 25 Approach to Infectious Encephalitis and Meningitis . . . . . . . . . . . . . . . . 145 Catherine S. W. Albin and Megan E. Barra 26 Non-Infectious Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Catherine S. W. Albin and Sahar F. Zafar 27 Inflammatory and Autoimmune Encephalitis . . . . . . . . . . . . . . . . . . . . . 155 Catherine S. W. Albin and Sahar F. Zafar 28 Infectious Workup by Neuroanatomical Location: An Ordering Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 James Hillis and Catherine S. W. Albin 29 Autoimmune Encephalitis Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Juan Carlos Martinez Gutierrez and James Hillis 30 Approach to New Onset Weakness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Catherine S. W. Albin and Sahar F. Zafar 31 Workup of New Demyelinating Lesion . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Kathryn Holroyd and Kristin Galetta 32 Approach to the “Dizzy” Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Eric C. Lawson Part IV NeuroICU 33 Intracranial Pressure: Theory and Management Strategies . . . . . . . . . 187 Melissa Bentley and Catherine S. W. Albin 34 Management of External Ventricular Catheters . . . . . . . . . . . . . . . . . . . 197 Catherine S. W. Albin and Sahar F. Zafar 35 Malignant Middle Cerebral Artery Infarction . . . . . . . . . . . . . . . . . . . . . 199 Catherine S. W. Albin and Sahar F. Zafar 36 Intraparenchymal Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Catherine S. W. Albin and Sahar F. Zafar 37 Intracranial Hemorrhage – Landmark Trials . . . . . . . . . . . . . . . . . . . . . 211 Catherine S. W. Albin and Sahar F. Zafar 38 Reversal of Selected Antithrombotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 Catherine S. W. Albin and Megan E. Barra 39 An In-Depth Review of Reversing Direct Factor XA-Inhibitor-Related Hemorrhages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 Megan E. Barra
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