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ICARUS —  case #1: reviewer OLD

Setting
57-year-old female patient with a past medical history of ischemic cardiomyopathy, non-stentable coronary stenosis and a myocardial infarction at age 41. Chronic treatment: Asaflow, bisoprolol, a lipid-lowering agent, and isosorbide as needed.
The patient suffered a witnessed cardiac arrest in the presence of a physician friend who immediately initiated resuscitation (no no-flow time). Advanced emergency services arrived within 6 minutes. ROSC was achieved after three electrical cardioversions. No adrenaline was administered. She was admitted to the nearest regional hospital.
ICU
On admission: Blood pressure: 200/120 mmHg, Heart rate: 90 bpm, Respiratory rate: 15 (volume-controlled ventilation), Core temperature: 35.4°C, SpO₂: 100%, Pupils isochoric and isoreactive, GCS: E1VTM4 under continuous midazolam infusion (5 mg/h), No signs of shock.
Examinations
ECG was normal, with no arrhythmias or ST changes to explain the cardiac arrest. Bedside echocardiography was reassuring.
Lab results showed a D-dimer of 12,261 and a troponin of 28.9.
CT pulmonary angiography ruled out pulmonary embolism.
Coronary angiography revealed no significant coronary lesions.
Neurological fluctuations were noted during neurological assessment windows. A CT scan performed 48 hours later showed hemorrhage in the basal cisterns, along with a fine subarachnoid hemorrhage in the peri-encephalic region, without a clear epicenter. The bleeding was particularly abundant in the peribulbar and pontine regions, extending to the perimedullary space, and was associated with hydrocephalus. No vascular source was identified on the CT angiography sequences.
Clinical evolution
An external ventricular drain was urgently placed. MRI revealed a perimedullary hematoma from C1 to D3, which was surgically drained via decompressive laminectomy. The patient was transferred on Day 3 to a specialized neuro-ICU under sedation, with a diagnosis of subarachnoid hemorrhage with modified Fisher grade III, WFNS grade 4, sine materia.
She continued with EVD drainage for hydrocephalus.
Tetraplegia was observed, with sensory loss up to T4. Extubation attempt failed due to absent airway protective reflexes. Consciousness was preserved throughout.
GCS E4VtM6, with communication via eye movements.
The patient was able to express her refusal to accept a state of severe disability.
Therapy included standard care with norepinephrine (0.1 mcg/kg/min), sedation until Day 4, levetiracetam until Day 5, nimodipine.
Sudden change of the clinical status
On Day 11: The patient experienced a sudden loss of consciousness. GCS dropped to E1VTM1.
Dear expert,
You are being asked to validate the scoring criteria for a neurocritical care case-based assessment.
Your task is to review each clinical case and confirm the proposed +1 responses for each of the four questions (differential diagnosis, most probable diagnosis, next diagnostic test, and immediate management).
These +1 responses will serve as the "gold standard" answers during live assessment. Responses receiving +0.5, 0, or -1 point will be determined by individual reviewer discretion during the actual assessment phase.
For each proposed +1 response, please indicate: Approve (appropriate as +1) or Modify (suggest changes).
Please provide brief rationale for any Modify.

Q1: List up to five important differential diagnoses.

Feedback needed from Michele's team

Scoring criteria: clinical probability & significance

+1: High-probability diagnosis AND/OR critical/life-threatening diagnosis that must be considered

+0.5: Plausible diagnosis with moderate probability OR significant diagnosis with lower probability

0: Possible diagnosis, but low probability and low clinical impact in this context

-1: Implausible diagnosis, misleading, or potentially dangerous to consider

Q2: What is the single most likely diagnosis?

=> DCI due to vasospasm, possibly worsened by EVD dysfunction or rebleeding

Scoring criteria: probability focus

+1: Correct most likely diagnosis based on clinical evidence
+0.5: Highly plausible but not the most likely diagnosis
0: Plausible diagnosis
-1: Implausible diagnosis

Q3: What is the single most informative diagnostic test or examination that should be performed next?

Feedback needed from Michele's team

Scoring criteria: diagnostic contribution

+1: Most informative test for this specific clinical scenario; highest diagnostic yield
+0.5: Appropriate and useful test, but not the most contributive; moderate diagnostic yield
0: Unnecessary test or redundant with available information; low diagnostic yield
-1: Inappropriate test, potentially harmful, or contraindicated

Q4: What is the single most important therapeutic intervention that should be initiated immediately?

Feedback needed from Michele's team

Scoring criteria: therapeutic priority

+1: Most appropriate immediate intervention; highest therapeutic priority
+0.5: Appropriate intervention but not highest priority; beneficial but less urgent
0: Unnecessary intervention or not immediately indicated
-1: Inappropriate intervention, potentially harmful, or contraindicated