Neurologic Assessment of the Neurocritical Care Patient

Abstract

Sedation is a ubiquitous practice in ICUs and NCCUs. It has the benefit of reducing cerebral energy demands, but also precludes an accurate neurologic assessment. Because of this, sedation is intermittently stopped for the purposes of a neurologic assessment, which is termed a neurologic wake-up test (NWT). NWTs are considered to be the gold-standard in continued assessment of brain-injured patients under sedation. NWTs also produce an acute stress response that is accompanied by elevations in blood pressure, respiratory rate, heart rate, and ICP. Utilization of cerebral microdialysis and brain tissue oxygen monitoring in small cohorts of brain-injured patients suggests that this is not mirrored by alterations in cerebral metabolism, and seldom affects oxygenation. The hard contraindications for the NWT are preexisting intracranial hypertension, barbiturate treatment, status epilepticus, and hyperthermia. However, hemodynamic instability, sedative use for primary ICP control, and sedative use for severe agitation or respiratory distress are considered significant safety concerns. Despite ubiquitous recommendation, it is not clear if additional clinically relevant information is gleaned through its use, especially with the contemporaneous utilization of multimodality monitoring. Various monitoring modalities provide unique and pertinent information about neurologic function, however, their role in improving patient outcomes and guiding treatment plans has not been fully elucidated. There is a paucity of information pertaining to the optimal frequency of NWTs, and if it differs based on type of injury. Only one concrete recommendation was found in the literature, exemplifying the uncertainty surrounding its utility. The most common sedative used and recommended is propofol because of its rapid onset, short duration, and reduction of cerebral energy requirements. Dexmedetomidine may be employed to facilitate serial NWTs, and should always be used in the non-intubated patient or if propofol infusion syndrome (PRIS) develops. Midazolam is not recommended due to tissue accumulation and residual sedation confounding a reliable NWT. Thus, NWTs are well-tolerated in selected patients and remain recommended as the gold-standard for continued neuromonitoring. Predicated upon one expert panel, they should be performed at least one time per day. Propofol or dexmedetomidine are the main sedative choices, both enabling a rapid awakening and consistent NWT.

Brain–lung interactions and mechanical ventilation in patients with isolated brain injury

“…Unfortunately, there is little evidence for neurocritical care patients, because BI patients are often excluded in these studies [ 110 , 111 ]. On the other hand, brief cessation of sedation for daily wake-up tests may be beneficial to critically ill BI patients, by allowing clinical neuromonitoring, the detection of early warning neurological signs and neuroanatomical localization of pathology, and by helping to guide appropriate therapy [ 112 , 113 ]. Daily neurological assessments may be able to reduce the duration of MV and the need for tracheostomy [ 114 ].…”

“…Daily neurological assessments may be able to reduce the duration of MV and the need for tracheostomy [ 114 ]. However, withdrawal of sedation may result in significant activation of the sympathetic autonomic system, with deterioration in cerebral haemodynamics [ 113 ], so that the benefits of daily neurological assessments must be weighed against the associated risks.…”

New-Onset Refractory Status Epilepticus Secondary to COVID-19 Infection in Adults: A Systematic Review

“…Further lack of physical movement causes vascular complications and ischemic states, leading to irregularities in cerebral blood flow. 19 , 20 , 24 , 25 …”

Less-invasive subdural electrocorticography for investigation of spreading depolarizations in patients with subarachnoid hemorrhage

“…The dilemma especially in unconscious patients is that the integrity of brain structure and function are less accessible to point-of-care diagnostics ( 3 , 4 ). While signs of secondary injury can be reliably detected via repeated neurological examinations in fully conscious patients, the assessment of secondary neurological injury in patients with reduced consciousness is very limited ( 4 , 5 ). As a result, treatment is often nonspecific and does not occur at the proper time of injury development, even if appropriate interventions were available.…”