What are the management strategies for neurological issues in the Cardiovascular Intensive Care Unit (CVICU)?

Management Strategies for Neurological Issues in the Cardiovascular Intensive Care Unit (CVICU)

Effective management of neurological issues in the CVICU requires a multidisciplinary approach with specialized neurological monitoring and targeted interventions to improve mortality and quality of life outcomes.

Neurological Monitoring

• A comprehensive neurological examination should be performed on all patients admitted to the CVICU, including assessment of consciousness, cognition, brainstem function, and motor function 1, 2
• Sedation should be managed to maximize clinical detection of neurological dysfunction, except in patients with reduced intracranial compliance where withdrawal of sedation may be harmful 2
• For patients on extracorporeal membrane oxygenation (ECMO), regular neurological assessments are essential as acute brain injury (ABI) occurs in approximately 16% of cases, with higher rates (19%) in VA-ECMO compared to VV-ECMO (10%) 1
• Non-contrast head CT should be performed to rule out intracranial hemorrhage (ICH) when acute neurological changes are suspected, particularly in patients on anticoagulation 1

Management of Specific Neurological Complications

Intracranial Hemorrhage (ICH)

• For patients with ICH and intraventricular extension causing hydrocephalus, external ventricular drainage may be considered in selected patients at risk of imminent death 1
• In ECMO patients with ICH, early cessation without reversal and judicious resumption of anticoagulation with repeated neuroimaging is recommended 1
• Neurosurgical evaluation is indicated for patients with moderate to severe supratentorial ICH (volume ≥30 mL or GCS score <8) 1
• Surgical or minimally invasive hematoma evacuation may be considered after multidisciplinary discussion involving neurosurgeons and neurologists 1

Ischemic Stroke

• Tissue plasminogen activator (tPA) is NOT recommended for acute ischemic stroke in ECMO patients due to high risk of bleeding 1
• Mechanical thrombectomy should be considered for acute large vessel ischemic stroke in ECMO patients 1
• For patients with hemispheric infarction with malignant edema, decompressive craniectomy may be indicated 1

Intracranial Hypertension

• Stepwise management of acute intracranial hypertension includes:
  • Raising the head of the bed, hyperosmolar therapy, and sedation/analgesia 1
  • Hyperosmolar therapy is indicated for cerebral edema 1
  • In severe cerebral venous sinus thrombosis (CVST) with hemispheric cerebral edema, decompressive craniectomy may be considered 1
  • For patients at high risk of intracranial pressure (ICP) elevation, monitoring ICP may be used, though invasive monitoring carries risk of parenchymal hemorrhage in anticoagulated patients 1

Sedation and Pharmacological Management

• Propofol is effective for sedation in neurocritical care and can decrease intracranial pressure independent of changes in arterial pressure when given by infusion or slow bolus in combination with hypocarbia 3
• In hemodynamically stable head trauma patients, adequate sedation can be maintained with propofol or morphine 3
• For patients with intracranial hypertension, propofol infusion and hyperventilation, both with and without diuretics, can control intracranial pressure while maintaining cerebral perfusion pressure 3
• Caution is needed with bolus doses of propofol as they may decrease blood pressure and compromise cerebral perfusion pressure 3

Organizational Aspects of Neurological Care in CVICU

• Patients with neurological disorders have lower mortality and better outcomes when cared for in specialized neurointensive care units compared to general ICUs 4
• Specialized neurological care in the CVICU should include:
  • Neurological consultation for any acute neurological change 1
  • Multidisciplinary collaboration between intensivists, neurologists, neurosurgeons, and specialized nursing staff 1
  • Protocol-directed consistent care using physiological measures to protect brain function 5
  • Hemodynamic monitoring to establish goals that take into account cerebral blood flow and oxygenation 1

Prognostication and Follow-up

• Neurological prognostication is essential, particularly in patients supported by extracorporeal cardiopulmonary resuscitation (ECPR), where severe hypoxic-ischemic brain injury may occur 1
• A comprehensive approach to prognostication should include:
  • Clinical examination (after ruling out confounding factors like sedatives, electrolyte disturbances, and hypothermia) 1
  • Electrophysiological tests, biomarkers of acute brain injury, and neuroimaging 1
  • Daily clinical/neurological assessments for patients undergoing targeted temperature management, with crucial evaluation after rewarming 1

Common Pitfalls and Caveats

• Avoid the "self-fulfilling prophecy" bias in prognostication, where test results indicating poor outcomes inappropriately influence treatment decisions 1
• Clinical diagnosis of neurological issues can be challenging due to varying manifestations, including non-specific symptoms such as headache, seizure, or encephalopathy 1
• In ECMO patients, the risk of thromboembolism must be balanced against the risk of bleeding when managing anticoagulation 1
• Invasive monitoring (ICP, brain tissue oxygenation) carries increased risk of parenchymal hemorrhage in ECMO patients and has not been shown to improve long-term outcomes 1