Disease | What is important | What is new |
---|---|---|
Hypoxic-ischaemic brain injury | In-hospital targeted temperature management (TTM) Optimize blood pressure and ventilatory management (SaO2, CO2) Multimodal neuro-prognostication | Pre-hospital TTM not effective Use automated devices for TTM Precise temperature target undefined Quantitative tools (pupillometry, MRI) improve neuro-prognostication |
Immune-mediated encephalitis | ≈ 30% of encephalitis are of non-infectious origin Anti-NMDAR encephalitis most common form | Two main patterns in the ICU: (1) anti-NMDA-R encephalitis (psychiatric symptoms, seizures and abnormal movements) (2), anti-NMDA, GABA-A or LGI-1-R (refractory status epilepticus) |
CNS vasculitis | Two main forms: Primary (primary CNS angitis, PACNS) or Secondary to systemic diseases (infections, autoimmune vasculitis with or without anti-cytoplasmic antibodies (ANCA), connective tissue diseases, malignancies, lymphoma) MRI is essential to diagnosis | Treatment of CNS vasculitis requires high-dose of steroids; cyclophosphamide and rituximab may be added (no consensus) |
Refractory status epilepticus | Maintain general anaesthesia for at least 24 h Continuous EEG monitoring | Ketamine is an alternative to barbiturates Novel anti-epileptic drugs available (levetiracetam, brivaracetam, lacosamide, perampanel, etc.) |
Ischaemic stroke | Mechanical recanalization and alteplase Therapeutic time window can be extended beyond 12 h | Tenecteplase as alternative to alteplase |
Anticoagulation-associated intracerebral haemorrhage | Rapid reversal with the use of PCC | Idarucizumab for dabigatran reversal Andexanet-alpha for reversal of other direct oral anticoagulants (available in the US only) |
Cerebral venous thrombosis | Early anticoagulation with heparin | Endovascular therapy and/or decompressive craniectomy for severe forms Favourable prognosis in the majority of cases if early intervention is applied |
Delayed ischaemia after subarachnoid haemorrhage | Additional mechanisms other than vasospasm play a role Diagnosis based on the combination of clinical, and neuroimaging data Nimodipine prophylaxis Management based on the combination of medical (BP augmentation) and endovascular (local vasodilatory drugs ± angioplasty) therapies | MMM may help in the diagnosis in comatose patients |
TBI surgical management | Secondary decompressive craniectomy may increase dependency in survivors | Individualized multidisciplinary decisions are recommended |
TBI prognosis | IMPACT and CRASH scores | Advanced MRI diffusion at least 1 week after injury (DWI and DTI) |