December 2018, Volume 24, Issue 6
BROWSE ISSUE

December 2018, Vol.24, No.6

Editor-in-Chief:

STEVEN L. LEWIS, MD, FAAN

ISSN: 1080-2371

Online ISSN: 1538-6899

REVIEW ARTICLES
Cerebral Edema and Elevated Intracranial Pressure
Koenig, Matthew A.
CONTINUUM: Lifelong Learning in Neurology
December 2018 - Volume 24 - Issue 6 - p 1588-1602
doi: 10.1212/CON.0000000000000665
Intracerebral Hemorrhage
Ziai, Wendy C.; Carhuapoma, J. Ricardo
CONTINUUM: Lifelong Learning in Neurology
December 2018 - Volume 24 - Issue 6 - p 1603-1622
doi: 10.1212/CON.0000000000000672
Subarachnoid Hemorrhage
Muehlschlegel, Susanne
CONTINUUM: Lifelong Learning in Neurology
December 2018 - Volume 24 - Issue 6 - p 1623-1657
doi: 10.1212/CON.0000000000000679
Management of Stroke in the Neurocritical Care Unit
Venkatasubba Rao, Chethan P.; Suarez, Jose I.
CONTINUUM: Lifelong Learning in Neurology
December 2018 - Volume 24 - Issue 6 - p 1658-1682
doi: 10.1212/CON.0000000000000670
Status Epilepticus, Refractory Status Epilepticus, and Super-refractory Status Epilepticus
Nelson, Sarah E.; Varelas, Panayiotis N.
CONTINUUM: Lifelong Learning in Neurology
December 2018 - Volume 24 - Issue 6 - p 1683-1707
doi: 10.1212/CON.0000000000000668
Coma and Brain Death
Rabinstein, Alejandro A.
CONTINUUM: Lifelong Learning in Neurology
December 2018 - Volume 24 - Issue 6 - p 1708-1731
doi: 10.1212/CON.0000000000000666
Management of Comatose Survivors of Cardiac Arrest
Seder, David B.
CONTINUUM: Lifelong Learning in Neurology
December 2018 - Volume 24 - Issue 6 - p 1732-1752
doi: 10.1212/CON.0000000000000669
Critical Care of Neuromuscular Disorders
Greene-Chandos, Diana; Torbey, Michel
CONTINUUM: Lifelong Learning in Neurology
December 2018 - Volume 24 - Issue 6 - p 1753-1775
doi: 10.1212/CON.0000000000000682
Multimodality Monitoring in the Neurocritical Care Unit
Lara, Lucia Rivera; Püttgen, Hans Adrian
CONTINUUM: Lifelong Learning in Neurology
December 2018 - Volume 24 - Issue 6 - p 1776-1788
doi: 10.1212/CON.0000000000000671
Editor's Preface
Articles
Key Points
Abbreviations
Appendix
Issue Overview

Issue Overview

CONTINUUM: Lifelong Learning in Neurology December 2018 - Volume 24 - Issue 6 - [no page #] doi: 10.1212/01.CON.0000550314.81465.8a

Issue Overview

Neurocritical Care, Volume 24, Issue 6, December 2018

Continuum: Lifelong Learning in Neurology® is designed to help practicing neurologists stay abreast of advances in the field while simultaneously developing lifelong self-directed learning skills.

Learning Objectives

Upon completion of this Continuum: Lifelong Learning in Neurology Neurocritical Care issue, participants will be able to:

  • Implement the distinct treatment strategies and protocols for cerebral edema, elevated intracranial pressure, and cerebral herniation syndromes
  • Discuss the current best practices for the management of intracerebral hemorrhage and review the results of recent major intracerebral hemorrhage clinical trials
  • Discuss the epidemiology, diagnosis, management, and medical and neurologic complications of aneurysmal subarachnoid hemorrhage
  • Discuss the management of acute ischemic stroke including its management in the neurocritical care unit
  • Define status epilepticus and discuss the etiologies, diagnostic tools, the urgency for aborting it, and implement the currently available treatment options, including escalation algorithms
  • Describe the diagnostic and therapeutic approach to acute coma and the principles of brain death determination
  • Discuss the assessment and management of patients who are comatose following cardiac arrest
  • Review the management options and intensive care needs and evaluate respiratory failure in patients with neuromuscular disorders
  • Discuss the approaches to multimodality neuromonitoring, the neuromonitoring devices currently available, and their strengths and limitations
  • Navigate discussions about advanced care planning and end-of-life care
  • Recognize caveats that may undermine the aims of shared decision making in the neurocritical care setting

Core Competencies

This Continuum: Lifelong Learning in Neurology Neurocritical Care issue covers the following core competencies:

Patient Care

Medical Knowledge

Practice-Based Learning and Improvement

Interpersonal and Communication Skills

Professionalism

Systems-Based Practice

Contributors

Jose I. Suarez, MD, FNCS, FANA, Guest Editor

Professor, Director of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland

Relationship Disclosure: Dr Suarez has received research/grant support from the National Institute of Neurological Disorders and Stroke and as co-investigator in the SETPOINT2 (Stroke-related Early Tracheostomy Versus Prolonged Orotracheal Intubation in Neurocritical Care Trial) study from the Patient-Centered Outcomes Research Institute. Dr Suarez is the current president and a member of the board of directors of the Neurocritical Care Society.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Suarez reports no disclosure.

J. Ricardo Carhuapoma, MD, FAHA

Associate Professor, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland

Relationship Disclosure: Dr Carhuapoma reports no disclosure.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Carhuapoma discusses the unlabeled/investigational use of alteplase for the treatment of intracerebral hemorrhage and discusses the use of several devices, including ultrasound microcatheters, sonothrombolysis for minimally invasive subcortical parafascicular transsulcal access for clot evacuation (MiSPACE), and the stereotactic mechanical (suction/vibration/aspiration) thrombolytic technique for minimally invasive evacuation of intracerebral hemorrhage.

Diana Greene-Chandos, MD, FNCS

Director of Neuroscience Critical Care for Education; Program Director, Neuroscience Critical Care Fellowship, Wexner Medical Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute; Assistant Professor, Departments of Neurology and Neurosurgery, The Ohio State University College of Medicine, Columbus, Ohio

Relationship Disclosure: Dr Greene-Chandos has received personal compensation as a speaker for the Ecuador Neurocritical Care Society Annual Meeting and the Neurocritical Care Society Annual Meeting and has received research/grant support from Biogen, the Neuroemergency Treatment Trials Grant from the National Institutes of Health, and the Stroke Network Grant from the National Institute of Neurological Disorders and Stroke. Dr Greene-Chandos has worked as a consultant for court cases.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Greene-Chandos reports no disclosure.

Joseph S. Kass, MD, JD, FAAN

Associate Dean, Office of Student Affairs; Professor of Neurology, Psychiatry, and Medical Ethics; Director, Alzheimer’s Disease and Memory Disorders Center, Baylor College of Medicine; Chief of Neurology, Ben Taub General Hospital, Houston, Texas

Relationship Disclosure: Dr Kass serves as associate editor of ethical and medicolegal issues for Continuum, as an associate editor for Continuum Audio, as a neurology section editor of Ferri’s Clinical Advisor for Elsevier, and as co-editor of Neurology Secrets, Sixth Edition. Dr Kass has received personal compensation for CME lectures from Pri-Med Medical Group and has received personal compensation as a medicolegal consultant in legal cases involving criminal cases, malpractice, and personal injury.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Kass reports no disclosure.

Matthew A. Koenig, MD, FNCS

Medical Director of Telemedicine, The Queen’s Health Systems; Associate Professor of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii

Relationship Disclosure: Dr Koenig has received research/grant support as principal investigator of a study for the Hawaii Department of Health Neurotrauma Special Fund and receives publishing royalties from Rutgers University Press.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Koenig reports no disclosure.

Christos Lazaridis, MD, EDIC

Associate Professor, Division of Neurocritical Care, Departments of Neurology and Neurosurgery, University of Chicago, Chicago, Illinois

Relationship Disclosure: Dr Lazaridis serves on the editorial board of Neurocritical Care and has received research/grant support from Cheetah Medical, Inc.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Lazaridis reports no disclosure.

Ariane Lewis, MD

Associate Professor, Departments of Neurology and Neurosurgery, New York University Langone Medical Center, New York, New York

Relationship Disclosure: Dr Lewis has received personal compensation as a workshop lecturer for the American Academy of Neurology and for grand rounds lectures from Mount Sinai Hospital, Mount Sinai Beth Israel Hospital, and Newark Beth Israel Medical Center, and for work as a legal consultant for David A. Axelrod & Associates, PC.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Lewis reports no disclosure.

Susanne Muehlschlegel, MD, MPH, FNCS, FCCM

Associate Professor, Director of Neurocritical Care Research, Departments of Neurology, Anesthesiology, and Surgery, University of Massachusetts Medical School, Worcester, Massachusetts

Relationship Disclosure: Dr Muehlschlegel has received research/grant support from the National Institutes of Health/National Institute of Child Health and Human Development and the Prize for Academic Collaboration and Excellence (PACE) from the University of Massachusetts Memorial Medical Group. Dr Muehlschlegel receives partial research salary support as the site principal investigator for the INTREPID (Impact of Fever Prevention in Brain Injured Patients) trial sponsored by C. R. Bard Inc. Dr Muehlschlegel has received compensation for serving as a course director for the American Academy of Neurology.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Muehlschlegel discusses the unlabeled/investigational short-term use of antifibrinolytics (ε-aminocaproic acid and tranexamic acid) for the treatment of early aneurysm bleeding, the use of fludrocortisone for the treatment of cerebral salt wasting syndrome after subarachnoid hemorrhage, the use of levetiracetam for seizure prophylaxis, and the use of milrinone, nicardipine, and verapamil as endovascular therapy using intraarterial vasodilators for the treatment of subarachnoid hemorrhage.

Sarah E. Nelson, MD

Assistant Professor, Departments of Neurology and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland

Relationship Disclosure: Dr Nelson receives grant support from the Johns Hopkins Anesthesiology and Critical Care Medicine (ACCM) Stimulating and Advancing ACCM Research (StAAR) program.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Nelson discusses the unlabeled/investigational use of allopregnanolone, deep brain stimulation, desflurane, diazepam, electroconvulsive therapy, fosphenytoin, gabapentin, isoflurane, IV immunoglobulin, ketamine, ketogenic diet, lacosamide, levetiracetam, lidocaine, lorazepam, methylprednisolone, midazolam, pentobarbital, phenobarbital, phenytoin, plasma exchange, propofol, pyridoxine, thiopental, topiramate, vagal nerve stimulation, and valproic acid for the treatment of refractory status epilepticus.

Marc R. Nuwer, MD, PhD, FAAN

Professor, Vice Chair, Department of Neurology, David Geffen School of Medicine; Department Head, Department of Clinical Neurophysiology, Ronald Reagan University of California Los Angeles Medical Center, University of California Los Angeles, Los Angeles, California

Relationship Disclosure: Dr Nuwer has received personal compensation for serving as an honorary editor for Clinical Neurophysiology; for serving on the board of directors of CortiCare, Inc; and for serving on the editorial boards of the Journal of Clinical Neurophysiology and Neurology Clinical Practice. Dr Nuwer receives royalties from Cambridge University Press and has received research/grant funding from the National Institutes of Health, Second Sight, and the United States Army. Dr Nuwer has given expert medicolegal testimony in a court deposition and a court hearing.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Nuwer reports no disclosure.

Hans Adrian Püttgen, MD

Assistant Professor, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland

Relationship Disclosure: Dr Püttgen reports no disclosure.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Püttgen discusses the unlabeled/investigational use of near-infrared spectroscopy as a surrogate of cerebral blood flow to measure cerebral autoregulation.

Alejandro A. Rabinstein, MD, FAAN

Professor of Neurology, Mayo Clinic, Rochester, Minnesota

Relationship Disclosure: Dr Rabinstein receives royalties from Elsevier and Oxford University Press and has received research support from DJO Global, Inc.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Rabinstein reports no disclosure.

Lucia Rivera Lara, MD, MPH

Assistant Professor, Departments of Neurology and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland

Relationship Disclosure: Dr Rivera Lara has received research/grant support from Covidien Ltd/Medtronic; the Johns Hopkins Anesthesiology and Critical Care Medicine (ACCM) Stimulating and Advancing ACCM Research (StAAR) award; and Ornim, Inc.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Rivera Lara discusses the unlabeled/investigational use of near-infrared spectroscopy as a surrogate of cerebral blood flow to measure cerebral autoregulation.

Michael A. Rubin, MD, MA

Assistant Professor, Departments of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas

Relationship Disclosure: Dr Rubin reports no disclosure.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Rubin reports no disclosure.

David B. Seder, MD, FCCP, FCCM, FNCS

Chairman, Department of Critical Care Services, Maine Medical Center, Portland, Maine; Associate Professor of Medicine, Tufts University School of Medicine, Boston, Massachusetts

Relationship Disclosure: Dr Seder receives grant support from the Patient-Centered Outcomes Research Institute (CER-1602-34137).

Unlabeled Use of Products/Investigational Use Disclosure: Dr Seder discusses the unlabeled/investigational use of the bispectral index in determining the severity of brain injury after cardiac arrest.

Michel Torbey, MD, MPH, FCCM, FAHA, FNCS, FAAN

Professor and Chairman, Department of Neurology; University of New Mexico, Albuquerque, New Mexico

Relationship Disclosure: Dr Torbey has received personal compensation as the past president of the Neurocritical Care Society and has received grant support from the National Institute of Neurological Disorders and Stroke.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Torbey reports no disclosure.

Panayiotis N. Varelas, MD, PhD, FNCS, FAAN

Professor of Neurology, Wayne State University; Division Head, Neurosciences Critical Care Services, Director Neuro-Intensive Care Unit, Henry Ford Hospital, Detroit, Michigan

Relationship Disclosure: Dr Varelas serves on the board of directors of the Neurocritical Care Society, on the editorial board of Neurocritical Care, and on an advisory board of Portola Pharmaceuticals, Inc. Dr Varelas has received personal compensation for speaking engagements for Portola Pharmaceuticals, Inc and UCB SA and receives publishing royalties from Springer. Dr Varelas receives research/grant support from Bard Pharmaceuticals Limited; Edge Therapeutics, Inc; Marinus Pharmaceuticals, Inc; the National Institutes of Health; the Patient-Centered Outcomes Research Institute; and Portola Pharmaceuticals, Inc.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Varelas discusses the unlabeled/investigational use of allopregnanolone, deep brain stimulation, desflurane, diazepam, electroconvulsive therapy, fosphenytoin, gabapentin, isoflurane, IV immunoglobulin, ketamine, ketogenic diet, lacosamide, levetiracetam, lidocaine, lorazepam, methylprednisolone, midazolam, pentobarbital, phenobarbital, phenytoin, plasma exchange, propofol, pyridoxine, thiopental, topiramate, vagal nerve stimulation, and valproic acid for the treatment of refractory status epilepticus.

Chethan P. Venkatasubba Rao, MD, FNCS

Section Head, Vascular Neurology and Neurocritical Care; Program Director, Neurocritical Care Fellowship; Assistant Professor, Baylor College of Medicine; Medical Director, Neurocritical Care, Baylor St. Luke’s Medical Center, Houston, Texas

Relationship Disclosure: Dr Venkatasubba Rao has received personal compensation as an editorial board member of Brain Disorders & Therapy.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Venkatasubba Rao reports no disclosure.

Paul M. Vespa, MD, FAAN

Assistant Dean of Critical Care Medicine, Gary L. Brinderson Family Chair in Neurocritical Care, Neurology Director of Neurocritical Care, Professor of Neurosurgery and Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California

Relationship Disclosure: Dr Vespa has received personal compensation as an editor for Critical Care Medicine and Neurocritical Care. Dr Vespa has received personal compensation as a consultant for Sage Therapeutics, has received research/grant support from the National Institutes of Health, and holds stock options in InTouch Health.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Vespa reports no disclosure.

Wendy C. Ziai, MD, MPH, FAHA, FNCS, FESO

Associate Professor, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland

Relationship Disclosure: Dr Ziai serves as an associate editor for Neurocritical Care, on an advisory board for C.R. Bard Inc, and has received personal compensation as a consultant for and research/grant support from HeadSense Medical Ltd. Dr Ziai has received grant support from the Johns Hopkins Anesthesiology and Critical Care Medicine (ACCM) Stimulating and Advancing ACCM Research (StAAR) program and from the National Institutes of Health (5U01NS062851, 1U01NS08082).

Unlabeled Use of Products/Investigational Use Disclosure: Dr Ziai discusses the unlabeled/investigational use of alteplase for the treatment of intracerebral hemorrhage and discusses the use of several devices, including ultrasound microcatheters, sonothrombolysis for minimally invasive subcortical parafascicular transsulcal access for clot evacuation (MiSPACE), and the stereotactic mechanical (suction/vibration/aspiration) thrombolytic technique for minimally invasive evacuation of intracerebral hemorrhage.

Self-Assessment and CME Test Writers

Adam G. Kelly, MD

Associate Professor of Neurology; Chief, Neurovascular Division, University of Florida, Gainesville, Florida

Relationship Disclosure: Dr Kelly has received personal compensation as CME editor of Neurology.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Kelly reports no disclosure.

James W. M. Owens Jr, MD, PhD

Associate Professor of Neurology, Adjunct Associate Professor of Pediatrics, University of Washington School of Medicine, Seattle, Washington

Relationship Disclosure: Dr Owens serves as CME co-editor for Neurology and receives publishing royalties from UpToDate, Inc.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Owens reports no disclosure.

Methods of Participation and Instructions for Use

Continuum: Lifelong Learning in Neurology® is designed to help practicing neurologists stay abreast of advances in the field while simultaneously developing lifelong self-directed learning skills. In Continuum, the process of absorbing, integrating, and applying the material presented is as important as, if not more important than, the material itself.

The goals of Continuum include disseminating up-to-date information to the practicing neurologist in a lively, interactive format; fostering self-assessment and lifelong study skills; encouraging critical thinking; and, in the final analysis, strengthening and improving patient care.

Each Continuum issue is prepared by distinguished authors who are acknowledged leaders in their respective fields. Six issues are published annually and are composed of review articles, case-based discussions on ethical and practice issues related to the issue topic, coding information, and comprehensive continuing medical education (CME) and self-assessment offerings. For detailed instructions regarding Continuum CME and self-assessment activities, visit continpub.com/CME.

The review articles emphasize clinical issues emerging in the field in recent years. Case reports and vignettes are used liberally, as are tables and illustrations. Audio interviews with the authors of Continuum articles are published alongside each article, and video material relating to the issue topic accompanies issues when applicable.

The text can be reviewed and digested most effectively by establishing a regular schedule of study in the office or at home, either alone or in an interactive group. If subscribers use such regular and perhaps new study habits, Continuum’s goal of establishing lifelong learning patterns can be met.

© 2018 American Academy of Neurology