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ABIM Neurocritical Care Cheat Sheet

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Principles of Neurocritical Care

  • 42-48% of exam
  • Cerebral Physiology Sedation & Antiseizure Agents Anticoagulant Reversal Airway, Vent & Hemodynamics General ICU Care Organ-System Complications

Diagnostic Studies & Procedural Skills

  • 13-17% of exam
  • Neuromonitoring & Neuroimaging Brain Death Determination Neuromonitoring Picker Brain Death Workup Picker

Neurocritical Care Diseases

  • 27-33% of exam
  • Acute Ischemic Stroke ICH & SAH TBI & Intracranial Hypertension Spinal Cord & Neuromuscular Status Epilepticus Post-Cardiac Arrest Care

Neurosurgical & Perioperative Complications

  • 3-7% of exam
  • Neurosurgical Complications Epidural vs Subdural Hematoma CSF Leak Ventriculitis Risk

Ethics, Research & Practice-Based Learning

  • 3-7% of exam
  • Ethics & End-of-Life DBD vs DCD Self-Fulfilling Prophecy Surrogate Decision-Maker

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 PR

Mannitol

  • Osmotic diuresis
  • Risk: hypovolemia, renal injury

Hypertonic Saline

  • Raises serum sodium
  • No diuresis, safer if unstable
  • Unstable patient favors saline

Anticoagulant Reversal Picker PR

  • 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 PR

  • 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 PR

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 PR

  • 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 PR

  • 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 PR

  • 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 PR

  • 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 PR

  • 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 DI

  • Temp≥36, SBP≥100, MAP≥75 before any testing
  • T ≥36°C core SBP ≥100 mmHg MAP ≥75 mmHg Exclude confounders first

EVD vs Parenchymal Monitor DI

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 DI

  • 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 DI

  • 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 DI

  • No effort, pH<7.30, CO2 rise ≥20 above baseline
  • No respiratory effort pH below 7.30 PaCO2 at least 60 ≥20 above baseline

Brain Death Workup Picker DI

  • 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 DI

  • 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 DI

  • 150-220 eligible, target ~140, floor 130
  • SBP 150-220 eligible Target near 140 Floor 130 = harm COR 2b strength

Alteplase vs Tenecteplase DI

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 DI

  • <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 DI

  • 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 DI

  • Tenecteplase 0.25 max25; Alteplase 0.9 max90
  • TNK 0.25 mg/kg TNK max 25 mg tPA 0.9 mg/kg tPA max 90 mg

ICP & BP Target Picker DI

  • 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 DI

  • 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 DI

  • 5 min benzo, 20 min ASM, 40 min anesthetic
  • 0-5 min: ABCs + glucose 5-20 min: benzodiazepine 20-40 min: 2nd-line ASM 40+ min: anesthetic infusion

Status Epilepticus Picker DI

  • 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 DI

  • ICP threshold >22 mmHg treat
  • CPP target 60-70 mmHg
  • Hyperventilation Avoid first 24h
  • Decompressive hemicraniectomy <48h onset, age <60

SCI MAP Target DI

  • Floor 75-80, ceiling 90-95, for 3-7 days
  • Floor ~75-80 mmHg Ceiling ~90-95 mmHg Duration 3-7 days 2024 AO Spine/Praxis

Spinal Cord & Neuromuscular DI

  • 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 DI

  • 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 DI

  • 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 NE

Epidural

  • Arterial, biconvex shape
  • Does not cross sutures

Subdural

  • Venous, crescent shape
  • Can cross sutures
  • Shape + mechanism differ

Neurosurgical Complications NE

  • 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 ET

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 ET

  • 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

ABIM Neurocritical Care

  • Practice Questions 198 questions Study Guide 92 topics Cheat Sheet 85 facts Flashcards 50 cards Free CE Podcast

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