Management of Neurological Complications in CVICU

Neurological Monitoring and Management

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
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%) 2, 3
Non-contrast head CT should be performed to rule out intracranial hemorrhage (ICH) when acute neurological changes are suspected, particularly in patients on anticoagulation 4, 5

For patients with ICH and intraventricular extension causing hydrocephalus, external ventricular drainage may be considered in selected patients at risk of imminent death 4, 5
In ECMO patients with ICH, early cessation without reversal and judicious resumption of anticoagulation with repeated neuroimaging is recommended 4
Neurosurgical evaluation is indicated for patients with moderate to severe supratentorial ICH (volume ≥30 mL or GCS score <8) 6
Tissue plasminogen activator (tPA) is NOT recommended for acute ischemic stroke in ECMO patients due to high risk of bleeding 5
Mechanical thrombectomy should be considered for acute large vessel ischemic stroke in ECMO patients 5
For patients with hemispheric infarction with malignant edema, decompressive craniectomy may be indicated 4, 5
Stepwise management of acute intracranial hypertension includes raising the head of the bed, hyperosmolar therapy, and sedation/analgesia 5
Hyperosmolar therapy is indicated for cerebral edema 4
In severe cerebral venous sinus thrombosis (CVST) with hemispheric cerebral edema, decompressive craniectomy may be considered 5

Specialized neurological care in the CVICU should include neurological consultation for any acute neurological change 5
Multidisciplinary collaboration between intensivists, neurologists, neurosurgeons, and specialized nursing staff is essential 4, 6
Hemodynamic monitoring to establish goals that take into account cerebral blood flow and oxygenation is crucial 7

Neurological prognostication is essential, particularly in patients supported by extracorporeal cardiopulmonary resuscitation (ECPR), where severe hypoxic-ischemic brain injury may occur 5
A comprehensive approach to prognostication should include clinical examination, electrophysiological tests, biomarkers of acute brain injury, and neuroimaging 5
Daily clinical/neurological assessments for patients undergoing targeted temperature management, with crucial evaluation after rewarming, are necessary 5

Avoid the "self-fulfilling prophecy" bias in prognostication, where test results indicating poor outcomes inappropriately influence treatment decisions 5
Clinical diagnosis of neurological issues can be challenging due to varying manifestations, including non-specific symptoms such as headache, seizure, or encephalopathy 5
In ECMO patients, the risk of thromboembolism must be balanced against the risk of bleeding when managing anticoagulation 4, 5
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 4