Critical Care Neurology in the ICU · Glasgow, CAM-ICU, NIHSS, Fisher, Hunt & Hess and Marshall Score
Guidance tools only. Always interpret results within clinical context and according to institutional guidelines.
🧠 Glasgow Coma Scale (GCS)
Assessment of level of consciousness using eye opening, verbal response and motor response.
Eye opening (E)
Verbal response (V)
Motor response (M)
🧠 CAM-ICU · Delirium
CAM-ICU is positive if:
Step 1 + Step 2 and (Step 3 or Step 4).
If Step 1 is negative, delirium is excluded.
Step 1 · Acute onset or fluctuating course
Acute change in mental status from baseline or fluctuations during the day.
Examples: recent disorientation, alternating somnolence and agitation,
behavioral changes not explained by sedation.
🧠 NIH Stroke Scale (NIHSS)
Complete all items and press Calculate NIHSS.
🧠 Fisher Scale · SAH
| Grade | Description |
|---|---|
| 1 | No visible blood. |
| 2 | Diffuse blood < 1 mm. |
| 3 | Clot ≥ 1 mm. |
| 4 | Associated IVH or ICH. |
🧠 Hunt & Hess · SAH
| Grade | Description |
|---|---|
| I | Asymptomatic. |
| II | Moderate headache. |
| III | Confusion or mild focal deficit. |
| IV | Stupor. |
| V | Deep coma. |
🧠 Marshall Score · TBI
| Category | Description |
|---|---|
| I | Normal CT scan. |
| II | Mild diffuse injury. |
| III | Diffuse swelling. |
| IV | Midline shift ≥ 5 mm. |
| V | Evacuated mass lesion. |
| VI | Non-evacuated mass lesion. |
Clinical basis of neurological scales in the ICU
Neurological assessment in the Intensive Care Unit (ICU) is essential for early detection of deterioration, severity stratification and therapeutic decision-making. Standardized clinical scales allow objective evaluation, improve communication between teams and support longitudinal monitoring of critically ill patients.
Purpose of neurological scales
These tools help quantify neurological status, identify subtle changes over time and guide timely interventions. Their systematic use is especially important in patients with traumatic brain injury, stroke, prolonged sedation or risk of delirium.
Glasgow Coma Scale (GCS)
The Glasgow Coma Scale assesses level of consciousness using three components: eye opening, verbal response and motor response. It is widely used to evaluate the severity of neurological impairment and monitor clinical evolution.
Interpretation of Glasgow
Lower scores are associated with greater severity and worse prognosis. However, sedation, intubation and metabolic disturbances may affect the score, so it must always be interpreted within the clinical context.
CAM-ICU
CAM-ICU is a validated tool for delirium detection in critically ill patients, including those receiving mechanical ventilation. Delirium is associated with higher mortality, longer hospital stay and long-term cognitive impairment.
Importance of delirium
Early detection of delirium allows timely non-pharmacological and pharmacological interventions, improving patient outcomes. Common contributing factors include infection, sedation, hypoxia and metabolic disturbances.
NIH Stroke Scale (NIHSS)
The NIHSS quantifies stroke severity and is fundamental for therapeutic decisions such as thrombolysis or thrombectomy. It also carries prognostic value regarding patient evolution.
Scales in subarachnoid hemorrhage
The Fisher and Hunt & Hess scales help assess clinical severity and vasospasm risk in subarachnoid hemorrhage. They are key tools in initial stratification and ICU management.
Marshall Score in traumatic brain injury
The Marshall Score classifies CT findings in traumatic brain injury (TBI) and is associated with prognosis and mortality. It helps guide therapeutic strategy and monitoring intensity.
Integrated clinical interpretation
No scale should be used in isolation. Interpretation should incorporate the full neurological examination, neuroimaging findings, hemodynamic status and overall clinical course.
Factors that affect assessment
Sedation, analgesia, mechanical ventilation, metabolic abnormalities and organ dysfunction can interfere with neurological evaluation. These factors must always be considered when interpreting results.
Clinical warning
These tools are intended for educational and clinical support purposes. They do not replace medical judgment or clinical guidelines. Decisions must always be individualized according to the patient context.
References
Teasdale G, Jennett B. Assessment of coma and impaired consciousness.
Ely EW et al. Delirium in mechanically ventilated patients.
Brott T et al. NIH Stroke Scale.
Critical care neurology and intensive care guidelines.