Acute Neurological Injury and Neurosurgical Care
Ischemic stroke
Time is brain. IV alteplase is considered within 3–4.5 hours of last known well; thrombectomy is offered in selected large-vessel occlusions up to 6 hours, and up to 24 hours when imaging/clinical mismatch criteria are met. Before thrombolysis, lower BP below 185/110 mmHg; after, keep below 180/105 for 24 hours. Hold antiplatelets and anticoagulants for 24 hours post-alteplase. Monitor neuro status every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly.
Hemorrhage
Subarachnoid hemorrhage presents as a thunderclap headache; early rebleeding is a major killer. Nimodipine 60 mg PO/NG every 4 hours for 21 days reduces delayed cerebral ischemia - watch for hypotension. Vasospasm peaks days 3–14; new confusion, focal deficit, or rising transcranial Doppler velocities are red flags.
TBI and postoperative care
Avoid hypoxia and hypotension, keep the head midline with HOB about 30 degrees, avoid neck compression, maintain CPP, and treat elevated ICP. Hyperventilation to a PaCO2 of 30–35 is a short bridge only, because prolonged use causes ischemia. Hypertonic saline and mannitol are osmotic therapies; steroids are contraindicated in TBI. Epidural hematoma is typically middle meningeal artery with a lucid interval; subdural is bridging veins. After craniotomy, position per surgeon and watch for hemorrhage, seizure, and edema.
Spinal cord injury
Neurogenic shock (T6 or above) = hypotension with bradycardia; give fluids cautiously, then vasopressors, and atropine for symptomatic bradycardia. Spinal shock is the transient loss of reflexes. Autonomic dysreflexia: acute hypertension, pounding headache, bradycardia, flushing - sit the patient up, remove constriction, check bladder and bowel, then treat BP.
Traps: confusing spinal with neurogenic shock, assuming steroids are standard for acute SCI, and treating hyperventilation as definitive ICP therapy.