ICU Map
neurologic

New Focal Neurologic Deficit in the ICU

Rapid code-stroke protocol in critical illness: emergent non-contrast CT and CTA, distinguishing acute ischemic stroke (LVO candidate) from intracranial hemorrhage, and managing post-procedural neurological loss.

The acute development of a new focal neurologic deficit (unilateral hemiparesis, facial droop, acute aphasia, visual field cut, gaze preference, or pupillary asymmetry) in an ICU patient mandates an immediate 'Code Stroke' response. In critically ill patients, acute deficits can result from large vessel ischemic stroke (embolic or hypoperfusion), acute intracranial hemorrhage, intracranial mass effect/herniation, or metabolic mimics.

Caution

Dangerous Diagnosis Not to Miss: Acute Large Vessel Occlusion (LVO) Ischemic Stroke (treatable with endovascular thrombectomy up to 24 hours), Acute Intracerebral Hemorrhage / Hematoma Expansion (requiring urgent anticoagulant reversal and SBP control), and Expanding Mass / Uncal Herniation (unilateral dilated pupil).

1

IMMEDIATE 5-MINUTE BEDSIDE TRIAGE

  • Fingerstick Blood Glucose: Rule out hypoglycemia (mimics acute focal hemiparesis/aphasia; treat with D50W).

  • Focused Neurologic Exam (NIHSS / BE-FAST):

    • Cranial Nerves: Pupil reactivity and symmetry, visual fields, facial symmetry, gaze deviation (eyes look toward cortical stroke, away from seizure focus).
    • Motor & Sensory: Hemiparesis, pronator drift, localization to noxious stimuli.
    • Language: Expressive or receptive aphasia, dysarthria.

  • Establish 'Last Known Well' (LKW) Time: Review nursing records, sedation holds, and physician notes.

2

DIFFERENTIAL DIAGNOSIS

  • Acute Ischemic Stroke (AIS):

    • Cardioembolic: New-onset AF, mural thrombus, infective endocarditis.
    • Large Vessel Atherothrombosis / Carotid Dissection.
    • Watershed / Low-Flow Infarction: Severe hypoperfusion during shock/cardiac arrest.

  • Acute Intracranial Hemorrhage (ICH):

    • Spontaneous hypertensive ICH, anticoagulation-related hemorrhage, hemorrhagic transformation of ischemic stroke, ruptured cerebral aneurysm (SAH).

  • Structural Non-Vascular: Acute subdural/epidural hematoma, expanding brain tumor/abscess with uncal herniation.

  • Stroke Mimics: Todd's postictal paresis (following unwitnessed seizure), severe hypoglycemia, complex migraine, severe septic encephalopathy with unmasking of old stroke deficits.

3

EMERGENCY NEUROIMAGING WORKUP

  • Emergent Non-Contrast Head CT (NCCT): Rapidly excludes intracranial hemorrhage and assesses early ischemic change.

  • Vascular Imaging (CTA/MRA): Obtain rapidly when large-vessel occlusion is suspected or thrombectomy eligibility is being assessed; do not delay otherwise-eligible IV thrombolysis solely to obtain additional multimodal imaging.

  • CT Perfusion / MRI: Use selectively in extended-window or uncertain-onset presentations according to current reperfusion criteria and local stroke pathways.

4

TIME-CRITICAL ACUTE INTERVENTIONS

5

REASSESSMENT & NEURO-INTENSIVE MONITORING

Caution

Common Diagnostic Trap: Assuming a patient outside the 4.5-hour IV-thrombolysis window cannot receive reperfusion therapy. Selected anterior-circulation LVO patients and selected basilar-artery occlusions may benefit from EVT up to 24 hours. Obtain rapid vascular imaging when LVO is clinically suspected or EVT eligibility is plausible, while avoiding unnecessary delay of IV thrombolysis in eligible early-window patients.

Destination Topics

  • Ischemic Stroke: Reperfusion eligibility, thrombectomy trials (DAWN/DEFUSE-3), and permissive hypertension.

  • Intracranial Hemorrhage: Hematoma expansion kinetics, reversal agents, and surgical decompression.

  • Intracranial Hypertension: ICP monitoring, hyperosmolar therapy (mannitol/hypertonic saline), and CPP targets.

  • Anticoagulation: Coagulation assay interpretation and reversal protocols.

  • Arrhythmias: Cardioembolic risk stratification and new-onset atrial fibrillation.

Evidence status

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Actionable Clinical Workflows (8)

Step-by-step ICU Processes
Initial Hemodynamic Resuscitation & Shock Bundling

From recognizing hypoperfusion and initial crystalloid bolus to dynamic fluid responsiveness assessment and vasopressor targets.

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Vasopressor & Inotrope Initiation & Titration

From first-line norepinephrine titration to multi-agent vasopressor escalation and inotrope selection.

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Massive Hemorrhage & Hemostatic Resuscitation

From emergent massive-hemorrhage protocol activation and early balanced component resuscitation to physiologic correction, targeted factor/anticoagulant reversal, and definitive source control.

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Bleeding

From assessing hemodynamic stability to correcting reversible contributors to coagulopathy.

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Deep-Dive Topic Destinations (6)

Reference Knowledge
Acute Ischemic Strokeneurology

Core vs penumbra dynamics, ASPECTS & CT perfusion, Tenecteplase/Alteplase thrombolysis, DAWN/DEFUSE 3 extended thrombectomy, BP targets, and malignant MCA hemicraniectomy.

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Intracranial Hemorrhage: ICH & SAHneurology

Spontaneous ICH vs Aneurysmal SAH, INTERACT-2/ATACH-2 blood pressure targets, emergency anticoagulant reversal, ENRICH minimally invasive evacuation, ISAT coiling, and Nimodipine for delayed cerebral ischemia.

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Intracranial Hypertension & Cerebral Edemaneurology

Monro-Kellie doctrine, ICP waveforms (P2>P1, Lundberg A-waves), CPP targets (60–70 mmHg), herniation syndromes, and the 4-tier BTF management protocol.

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Altered Consciousness, Coma, & Delirium in the ICUneurology

ARAS neuroanatomy, structural vs toxic-metabolic coma, the comprehensive Coma Exam (pupils, cold calorics, posturing), FOUR score, and CAM-ICU delirium.

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Therapeutic Anticoagulation & Emergency Reversal in the ICUhematology

UFH vs LMWH vs DTIs (Argatroban/Bivalirudin), anti-Xa vs aPTT monitoring, and emergency reversal (Protamine, 4F-PCC, Idarucizumab; historical andexanet evidence with current availability caveats).

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Arrhythmias in Critical Illnesscardiovascular

Algorithmic tachy- and bradyarrhythmia management, new-onset ICU atrial fibrillation, wide-complex tachycardia differentiation, and refractory Torsades overdrive pacing protocols.

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