Principles of Neurocritical Care
42-48%of exam
Diagnostic Studies & Procedural Skills
13-17%of exam
Neurocritical Care Diseases
27-33%of exam
Neurosurgical & Perioperative Complications
3-7%of exam
Ethics, Research & Practice-Based Learning
3-7%of exam
Quick Facts
- Exam
- ABIM Neurocritical Care
- Questions
- 270 (five 54-Q sections)
- Time
- 320 min + 40 min breaks
- Fee
- $2,995 initial certification
- Frequency
- Even years only (next 2028)
- Administrator
- ABPN, for all 5 boards
- Passing
- Criterion-referenced, not disclosed %
- Prerequisite
- ABIM Critical Care + fellowship
Mannitol vs Hypertonic Saline
Mannitol
- Osmotic diuresis
- Risk: hypovolemia, renal injury
Hypertonic Saline
- Raises serum sodium
- No diuresis, safer if unstable
Unstable patient favors saline
Anticoagulant Reversal Picker
- Warfarin-associated ICH→4F-PCC + vitamin K
- Dabigatran-associated bleed→Idarucizumab 5g total
- Factor Xa inhibitor bleed→4F-PCC (off-label)(COR 2b)
- Heparin-associated bleed→Protamine sulfate
Cerebral Physiology
- CPP
- MAP minus ICP
- Normal ICP
- 5-15 mmHg, adult baseline
- Cushing triad
- HTN, bradycardia, irregular respirations
- Monro-Kellie
- Fixed brain+blood+CSF volume
- Autoregulation
- CBF constant across MAP range
- Autoregulation range
- MAP ~60-150 mmHg normal
VA-ECMO vs VV-ECMO
VA-ECMO
- More ischemic stroke
- Cardiac + respiratory support
VV-ECMO
- More ICH than stroke
- Respiratory support only
Both need serial neuro exam
Sedation & Antiseizure Agents
- Propofol
- Fast wake-up, lowers ICP
- PRIS
- Acidosis, rhabdo, cardiac failure
- Dexmedetomidine
- Sedation, preserves neuro exam
- Levetiracetam
- Antiseizure, renal dosing
- Fosphenytoin
- Antiseizure, needs cardiac monitoring
Anticoagulant Reversal
- Warfarin reversal
- 4F-PCC + vitamin K
- Dabigatran reversal
- Idarucizumab, 5g total IV
- Factor Xa reversal
- 4F-PCC, off-label use
- Andexxa status
- Withdrawn from US market
- Heparin reversal
- Protamine sulfate
Airway, Vent & Hemodynamics
- Target PaCO2
- 35-40 mmHg (normocapnia)
- High PEEP
- May impede venous outflow
- Neurogenic shock
- Hypotension + bradycardia
- VA-ECMO risk
- More ischemic stroke
- VV-ECMO risk
- More intracranial hemorrhage
General ICU Care
- Enteral nutrition start
- 24-48h post-injury, if stable
- Caloric goal
- Full replacement by day 5-7
- VTE prophylaxis
- Pharmacologic after imaging stable
- Osmolar gap
- Preferred over fixed cutoff
- Fever
- Treat to normothermia
Organ-System Complications
- SIADH
- Low Na, euvolemic, concentrated urine
- Cerebral salt wasting
- Low Na, hypovolemic, high UNa
- Central DI
- High Na, dilute polyuria
- Neurogenic pulm edema
- Catecholamine surge, no cardiac cause
- Stress cardiomyopathy
- Reverse Takotsubo pattern (SAH)
- TTP
- Schistocytes + AMS = emergency
Brain Death Prerequisites
Temp≥36, SBP≥100, MAP≥75 before any testing
T ≥36°C coreSBP ≥100 mmHgMAP ≥75 mmHgExclude confounders first
EVD vs Parenchymal Monitor
EVD
- Drains CSF
- Higher infection/hemorrhage risk
- Reference standard for ICP
Parenchymal Monitor
- ICP only, no drainage
- Lower complication rate
- Easier placement
Drainage need decides choice
Neuromonitoring Picker
- Need CSF drainage→EVD
- ICP only, lower risk→Parenchymal monitor
- Suspect vasospasm (SAH)→TCD, Lindegaard ratio
- Normal ICP, concern ischemia→PbtO2 or SjvO2
- Unexplained persistent coma→Continuous EEG
Neuromonitoring & Neuroimaging
- EVD
- Drains CSF + measures ICP
- Parenchymal monitor
- ICP only, lower risk
- TCD
- MCA velocity, Lindegaard ratio
- Lindegaard >3
- Suggests vasospasm
- PbtO2
- <20 mmHg = ischemia
- SjvO2
- <50-55% = ischemia
- Continuous EEG
- Detects nonconvulsive seizures
Apnea Test Positive
No effort, pH<7.30, CO2 rise ≥20 above baseline
No respiratory effortpH below 7.30PaCO2 at least 60≥20 above baseline
Brain Death Workup Picker
- Prerequisites unmet→Correct T/BP/drugs first
- Prerequisites confirmed→Full exam + apnea test
- Apnea test unsafe or incomplete→Ancillary blood-flow study(EEG not acceptable)
- State requires 2nd exam→Repeat after interval
Brain Death Determination
- Prereq temp
- Core ≥36°C
- Prereq BP
- SBP ≥100, MAP ≥75
- Apnea test positive
- No effort, pH <7.30
- CO2 rise needed
- ≥20 mmHg above baseline
- Abort apnea test
- SpO2 <85, SBP <100, MAP <75
ICH Blood Pressure Ladder
150-220 eligible, target ~140, floor 130
SBP 150-220 eligibleTarget near 140Floor 130 = harmCOR 2b strength
Alteplase vs Tenecteplase
Alteplase
- 0.9 mg/kg, max 90
- 10% bolus + 60-min infusion
Tenecteplase
- 0.25 mg/kg, max 25
- Single IV bolus
Both Class 1, <4.5h
Stroke Reperfusion Picker
- <4.5h, eligible deficit→Alteplase or tenecteplase(Both Class 1)
- 4.5-9h, salvageable penumbra→Perfusion-selected IV lysis(COR 2a)
- Anterior LVO <24h→Mechanical thrombectomy(ASPECTS-based)
- Malignant MCA, age <60→Decompressive hemicraniectomy(<48h onset)
Acute Ischemic Stroke
- Alteplase dose
- 0.9 mg/kg, max 90
- Tenecteplase dose
- 0.25 mg/kg, max 25
- Pre-lysis BP
- <185/110 mmHg
- Post-lysis BP
- <180/105 mmHg, 24h
- Post-IVT SBP<140
- No benefit shown
- Post-EVT SBP<140
- Harmful for 72h
- EVT window
- Up to 24h, anterior LVO
Stroke Lytic Doses
Tenecteplase 0.25 max25; Alteplase 0.9 max90
TNK 0.25 mg/kgTNK max 25 mgtPA 0.9 mg/kgtPA max 90 mg
ICP & BP Target Picker
- TBI, ICP >22→Treat per BTF tiers
- Any severe TBI→CPP 60-70 mmHg
- ICH SBP 150-220→Lower toward 140(Floor 130)
- Post-EVT recanalization→Avoid SBP <140(Harm x72h)
ICH & SAH
- ICH BP target
- SBP ~140 mmHg
- ICH BP floor
- <130 potentially harmful
- Cerebellar evacuation
- ≥15 mL or deteriorating
- Nimodipine dose
- 60 mg PO q4h
- Nimodipine duration
- 21 days, all aSAH
- DCI risk window
- Days 4-14 post-bleed
Status Epilepticus Timeline
5 min benzo, 20 min ASM, 40 min anesthetic
0-5 min: ABCs + glucose5-20 min: benzodiazepine20-40 min: 2nd-line ASM40+ min: anesthetic infusion
Status Epilepticus Picker
- 0-5 min seizure→ABCs, glucose, O2
- 5-20 min, initial phase→IV/IM benzodiazepine
- 20-40 min, established SE→2nd-line IV ASM(ESETT agents)
- 40+ min, refractory SE→Anesthetic infusion + cEEG
TBI & Intracranial Hypertension
- ICP threshold
- >22 mmHg treat
- CPP target
- 60-70 mmHg
- Hyperventilation
- Avoid first 24h
- Decompressive hemicraniectomy
- <48h onset, age <60
SCI MAP Target
Floor 75-80, ceiling 90-95, for 3-7 days
Floor ~75-80 mmHgCeiling ~90-95 mmHgDuration 3-7 days2024 AO Spine/Praxis
Spinal Cord & Neuromuscular
- SCI MAP floor
- 75-80 mmHg
- SCI MAP ceiling
- 90-95 mmHg, 3-7 days
- GBS VC threshold
- <20 mL/kg
- GBS MIP threshold
- Less negative than -30
- GBS MEP threshold
- <40 cmH2O
Status Epilepticus
- SE definition
- ≥5 min continuous seizure
- IM midazolam
- 10 mg, if >40kg
- IV lorazepam
- 0.1 mg/kg, max 4mg
- IV diazepam
- 0.15-0.2 mg/kg, max 10
- Refractory SE
- Anesthetic infusion + cEEG
Post-Cardiac Arrest Care
- TTM target
- 32-37.5°C, constant
- TTM duration
- ≥36 hours total
- Prognostication delay
- ≥72h from ROSC
- Fever prevention
- At least 72h
Epidural vs Subdural Hematoma
Epidural
- Arterial, biconvex shape
- Does not cross sutures
Subdural
- Venous, crescent shape
- Can cross sutures
Shape + mechanism differ
Neurosurgical Complications
- CSF leak sign
- Clear rhinorrhea or otorrhea
- CSF confirm test
- Beta-2 transferrin assay
- Ventriculitis risk
- Rises after 5-7 days
- TBI seizure prophylaxis
- 7 days, early seizures only
- Hyperperfusion syndrome
- Headache, seizure, hemorrhage risk
DBD vs DCD
DBD
- Death by neuro criteria
- Organ support continues
DCD
- Death by circulatory arrest
- After withdrawal of support
Criteria used for death
Ethics & End-of-Life
- Self-fulfilling prophecy
- Early poor-outcome bias
- DBD
- Neuro criteria, support continues
- DCD
- Circulatory arrest after withdrawal
- Surrogate decision-maker
- Substituted judgment standard
- Futility
- No obligation for non-beneficial care
Common Traps
SIADH vs Cerebral Salt Wasting
Both cause hyponatremia ≠ Volume status distinguishes them
Neurogenic vs Spinal Shock
Neurogenic: BP+HR both drop ≠ Spinal shock: reflex loss only
Andexxa vs Current 4F-PCC Practice
Andexxa off US market ≠ 4F-PCC now main US option
Old vs New SE Definition
30-min defined old teaching ≠ 5-min now triggers treatment
TTM2 Result vs Guideline Range
Fixed 33°C not superior ≠ 32-37.5°C is current range
Post-IVT vs Post-EVT BP Harm
<140 no benefit post-IVT ≠ <140 harmful post-EVT, 72h
Osmolar Gap vs Fixed Cutoff
Fixed 320 not evidence-based ≠ Osmolar gap preferred now
Last Minute
- 1.Exam = 270 Qs, 5x54 sections
- 2.Time = 320 min + 40 min breaks
- 3.Fee = $2,995 initial certification
- 4.Offered = even years, next 2028
- 5.5 boards co-sponsor; ABPN administers
- 6.Weights: Principles 42-48%, Diseases 27-33%
- 7.Lytics: TNK 0.25, tPA 0.9
- 8.ICH target SBP 140, floor 130
- 9.Cerebellar ICH ≥15 mL = evacuate
- 10.Brain death needs T≥36, SBP≥100, MAP≥75
- 11.Apnea+ = no effort, pH<7.30
- 12.PaCO2 must rise ≥20 above baseline
- 13.TTM = 32-37.5°C for ≥36 hours
- 14.SCI MAP = 75-80 to 90-95
- 15.Status epilepticus treated at 5 min
- 16.4F-PCC: main US FXa reversal
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