Free ABIM Neurocritical Care Exam Prep

IV thrombolysis (alteplase 0-4.5 hrs per NINDS; tenecteplase 0.25 mg/kg single bolus per AHA 2024 update + AcT 2022), inclusion/exclusion, post-tPA BP <180/105, hemorrhagic transformation; mechanical thrombectomy 0-6 hrs (HERMES NNT ~3, MR CLEAN), extended 6-24 hrs with imaging selection (DAWN clinical/core mismatch, DEFUSE 3 perfusion mismatch); NIHSS 0-42 cutoffs; ASPECTS ≥6 for thrombectomy.

ICH BP control SBP <140 (INTERACT-2, ATACH-2), anticoagulant reversal (4F-PCC for warfarin, idarucizumab for dabigatran, andexanet alfa per ANNEXA-I 2023 for FXa inhibitors), surgical evacuation (cerebellar >3 cm); SAH Hunt-Hess/WFNS/Modified Fisher grading, aneurysm clipping vs coiling (ISAT favored coiling), nimodipine 60 mg q4h x 21 days for vasospasm prevention, modern euvolemic-induced HTN; EVD for hydrocephalus.

Convulsive SE = ≥5 min continuous seizure or ≥2 seizures without recovery; benzodiazepine first-line; ESETT (2019) showed fosphenytoin = levetiracetam = valproate equivalent for benzo-refractory; refractory and super-refractory definitions; continuous EEG ≥24-48 hrs for non-convulsive SE detection; ictal-interictal continuum patterns.

Glasgow Coma Scale 3-15 (severe ≤8); Brain Trauma Foundation 4th ed. (2017): ICP threshold >22 mmHg, CPP target 60-70 mmHg, hyperventilation only as bridge (PaCO2 30-35 short term, avoid <25); hyperosmolar therapy (3% saline bolus, mannitol 0.25-1 g/kg); decompressive craniectomy per DECRA + RESCUE-ICP; cytotoxic vs vasogenic vs interstitial edema; dexamethasone for vasogenic (tumor) — NOT cytotoxic stroke.

Neurogenic shock (hypotension + bradycardia from sympathetic disruption) vs spinal shock (transient areflexia/flaccid paralysis); high-dose methylprednisolone (NASCIS II/III) controversial — most centers no longer use; MAP goal ≥85 mmHg x 7 days; GBS (ascending paralysis, areflexia, albuminocytologic dissociation, AIDP, IVIG 0.4 g/kg/day x 5 or PLEX, watch FVC <20 mL/kg or NIF >-30); MG crisis (cholinergic vs myasthenic, IVIG/PLEX, intubate before failure).

AAN 2023 update (with pediatric guideline 2023): prerequisites (cause known, exclude reversible, T ≥36°C, SBP ≥100); clinical exam (coma + brainstem reflex absence: pupillary, corneal, oculocephalic, vestibulo-ocular cold caloric, pharyngeal, tracheal cough); apnea test (PaCO2 ≥60 or 20+ above baseline); ancillary studies (EEG, cerebral angiography, TCD, nuclear scan) only if clinical exam unreliable; pediatric requires 2 exams + observation; UNOS allocation; DBD vs DCD.

Anticoagulant reversal (vitamin K + 4F-PCC for warfarin; idarucizumab/Praxbind for dabigatran; andexanet alfa/Andexxa for apixaban/rivaroxaban per ANNEXA-I 2023 + ANNEXA-A/R; PCC off-label for FXa inhibitors); ICU sedation (propofol, dexmedetomidine, midazolam, ketamine); vasoactives in neuro-ICU; antiseizure medications; osmotic therapy.

Targeted Temperature Management (TTM2 2021 showed 33°C = 36°C; ERC 2021 + AHA 2023 recommend TTM 32-36°C for ≥24 hrs with active fever avoidance); multimodal neuro-prognostication delayed to ≥72 hours after ROSC (clinical exam, EEG, SSEP N20 absence, NSE ≥60 ng/mL, neuroimaging); avoidance of single-modality decisions.

ICP monitoring (parenchymal vs EVD), CPP = MAP - ICP, PbtO2 brain tissue oxygen ≥20 mmHg, jugular bulb saturation SjvO2 55-75%, NIRS, microdialysis (lactate/pyruvate >40 anaerobic), TCD (vasospasm Lindegaard ratio MCA/ICA >3 mild, >6 severe); CT for acute hemorrhage, MRI DWI for hyperacute ischemia, CTA/MRA for vessels, CT/MR perfusion (penumbra vs core), DSA gold standard for aneurysm/AVM.