Cerebrovascular Disorders and Neurocritical Care Emergencies
Disorders to know
Understand pediatric ischemic stroke (sickle cell disease, congenital heart disease, arteriopathy, dissection), hemorrhagic stroke (AVM, aneurysm), cerebral venous sinus thrombosis, and hypoxic-ischemic encephalopathy after cardiac arrest. Recognize that pediatric stroke often presents with seizure or focal deficit rather than classic adult signs, and that time to recognition matters because reperfusion windows exist. Know that sickle cell stroke warrants urgent exchange transfusion.
Other emergencies
Include posterior reversible encephalopathy syndrome (PRES) with hypertension and seizures, hypertensive encephalopathy, and reversible cerebral vasoconstriction. Recognize the child with sudden severe headache and meningismus as possible subarachnoid hemorrhage. Know that anticoagulation or thrombolysis decisions are made by the team with imaging.
Nursing and monitoring
Focus on airway, blood pressure targets, glucose and temperature control, seizure prophylaxis where indicated, and serial neurologic exams. Avoid hypotension and hypoxia. For venous sinus thrombosis, anticipate anticoagulation despite hemorrhage risk. Monitor for vasospasm after subarachnoid hemorrhage.
Traps
Questions test that permissive hypertension may be appropriate acutely in ischemic stroke, that lowering blood pressure too fast in PRES or hypertensive encephalopathy can cause ischemia, and that a normal early CT does not exclude ischemia.
Rule of thumb
In suspected acute stroke, protect the penumbra: secure airway, avoid hypoxia and hypotension, check glucose, and expedite imaging.