SETScore for Early Tracheostomy in Stroke


**APS acute physiology score, LIS lung injury score


  • initially an in-house screening tool for tracheostomy prediction
  • performed within 1st 24 hours after admission – use worst value in the first 24 hours
  • Dysphagia either
    • reported from a transferring neurological department or
    • observed by clinical signs on admission
      • non-successful swallowing test
      • impaired saliva handling
      • loss/reduction of gag reflex
    • if already intubated on admission, scored with “0”
  • (Neuro)surgical intervention
    • decompressive surgery, hematoma removal, non-cranial major surgery
    • NOTE EVD or probe placement, thrombectomy, angioplasty for vasospasm or coiling
  • Diffuse lesion = a multilocular or widespread affection of brain (i.e. SAH, brain edema, multiple infarcts, hematomas)
  • hydrocephalus = distension of ventricles requiring EVD
  • total sum ranges between 3 and 37

Previously used (with score of >10) to screen for eligibility to be included in pilot trial of SETPOINT study for early tracheostomy (within 3 days) to standard regimen (late tracheostomy between day7 and day14).




Schönenberger, Silvia et al. “The Setscore To Predict Tracheostomy Need In Cerebrovascular Neurocritical Care Patients”. Neurocritical Care 25.1 (2016): 94-104.


The Buffalo Score (AVM)

The Buffalo Score is a new grading system for the endovascular treatment of cerebral AVMs.  It is a 5-point system, and higher scores is associated with higher complication rates.  This new score was created because components of the Spetzler Martin Grading scale, while useful for determining suitability of surgical treatment of cerebral AVMs, may not be relevant in determining suitability for endovascular treatment.

For example, the diameter and number of arterial pedicles supplying the AVM nidus is an important factors to consider in endovascular intervention, since smaller vessels are more prone to injury with catheterization, and a greater number of arterial pedicles produces more risk with each embolization.  The actual size of the AVM nidus and venous drainage pattern is important when considering surgical resection, but is less important during endovascular embolization.

Points for Buffalo Score:

  • number of arterial pedicles
    • 1 point for 1–2 pedicles
    • 2 points for 3–4
    • 3 points greater than 5
  • arterial pedicle diameter
    • 1 point for less than 1 mm
    • 0 points for more than 1 mm
  • eloquence of the location
    • 1 point for eloquent location
    • 0 point for non-eloquent location




Buffalo System Vs. Spetzler Martin Grading System:


*arterial pedicles for Buffalo and draining veins for Spetzler Martin (black lines); nidus (black shading);  deep drainage (dashed lines)

  • Buffalo system = # arterial pedicles (N), diameter of pedicles (D), and eloquence (E)
  • Spetzler–Martin system = venous drainage (V), size (S), eloquence (E)



  1. Measurement of arterial pedicle diameter is made at a distal segment of the arterial pedicle, within 1 cm of the AVM nidus.
  2. Eloquent location is determined based on the nidus location and is defined according to the grading system of Spetzler-Martin.
  3. Any portion of AVM nidus located within motor or sensory cortex, language and vision, and deep eloquent areas (hypothalamus, thalamus, brainstem, cerebellar peduncles) is considered eloquent in location.
  4. This system has not been applied or validated yet.



Levy, EladI et al. “A Proposed Grading System For Endovascular Treatment Of Cerebral Arteriovenous Malformations: Buffalo Score”. Surgical Neurology International 6.1 (2015): 3.


Spinal Cord Injury SCI Scales


Asia impairment scale (modified from Frankel)

  • A=Complete. No sensory or motor function is preserved in the sacral segments S4-S5
  • B=Incomplete. Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5.
  • C=Incomplete. Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3.
  • D=Incomplete. Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade greater than or equal to 3.
  • E=Normal. Sensory and motor function is normal.





Key Sensory Points in SCI evaluation:

  • 0 = absent
  • 1 = impaired (partial or altered appreciation, including hyperaesthesia)
  • 2 = normal
  • NT = not testable

The testing for pin sensation is usually performed with a disposable safety pin; light touch is tested with cotton. In testing for pin appreciation, the inability to distinguish between dull and sharp sensation is graded as 0

  • C2=Occipital protuberance
  • C3=Supraclavicular fossa
  • C4=Top of the acromioclavicular joint
  • C5=Lateral side of the antecubital fossa
  • C6=Thumb
  • C7=Middle finger
  • C8=Little finger
  • T1=Medial (ulnar) side of the antecubital fossa
  • T2=Apex of the axilla
  • T3=Third intercostal space (IS)*
  • T4=Fourth IS (nipple line)*
  • T5=Fifth IS (midway between T4 and T6)*
  • T6=Sixth IS (level of xiphisternum)*
  • T7=Seventh IS (midway between T6 and T8)*
  • T8=Eighth IS (midway between T6 and T10)*
  • T9=Ninth IS (midway between T8 and T10)*
  • T10=Tenth IS (umbilicus)*
  • T11=Eleventh IS (Midway between T10 and T12)*
  • T12=Inguinal ligament at mid-point
  • L1=Half the distance between T12 and L2
  • L2=Mid-anterior thigh
  • L3=Medial femoral condyle
  • L4=Medial malleolus
  • L5=Dorsum of the foot at the third metatarsal phalangeal joint
  • S1=Lateral heel
  • S2=Popliteal fossa in the mid-line
  • S3=Ischial tuberosity
  • S4-5 = Perianal area (taken as one level)

*Asterisks indicate that the point is at the mid-clavicular line



Motor Points in SCI Evaluation:

  • C5 = Elbow flexors (biceps, brachialis)
  • C6 = Wrist extensors (extensor carpi radialis longus and brevis)
  • C7 = Elbow extensors (triceps)
  • C8 = Finger flexors (flexor digitorum profundus) to the middle finger
  • T1 = Small finger abductors (abductor digiti minimi)
  • L2 = Hip flexors (iliopsoas)
  • L3 = Knee extensors (quadriceps)
  • L4 = Ankle dorsiflexors (tibialis anterior)
  • L5 = Long toe extensors (extensor hallucis longus)
  • S1 = Ankle plantarflexors (gastrocnemius, soleus)



Jr, Frederick M Maynard et al. “International Standards For Neurological And Functional Classification Of Spinal Cord Injury”. Spinal Cord 35.5 (1997): 266-274. [pdf]

Modified Ramsay Scale

The Modified Ramsay Scale:

  • first scoring system for evaluating sedation in mechanically ventilated patients
  • four levels of sedation (3-6) and one level of agitation (1)
  • lack of scientific validation, but used in many ICUs




Marino, Paul L, Kenneth M Sutin, and Paul L Marino. The Little ICU Book Of Facts And Formulas. Philadelphia: Wolter Kluwer Health/Lippincott Williams & Wilkins, 2009. Print.

Hepatic Encephalopathy and 23.4% Hypertonic Solution (HTS)

Mechanism of Action of 23.4% HTS:  functional BBB allows an osmolar gradient to develop between blood and brain parenchyma, resulting in efflux of water from brain tissue with reduction in brain volume.  This allows displaced CSF to return from spinal subarachnoid space, and intracranial compliance improves.

Indications for 23.4% HTS in hepatic encephalopathy

  1. urgent treatment of life-threatening cerebral edema or intracranial hypertension (easily arousable or localizing excludes patient)
  2. cerebral herniation syndrome or other acute neurologic deterioration in context of existing severe hepatic encephalopathy and absence of more likely explanation (sepsis, seizure, medication toxicity)
  3. as an initial form of HTS therapy or added to ongoing infusion of 3% HTS
    • 23.4% HTS 30ml bolus over 30 minutes via central venous catheter, target acute serum sodium increase of 5 mEq/L
    • check Na 1 hour later, then serum Na q6h
    • continue 3% HTS infusion to maintain steady Na levels (acute decline may lead to rebound cerebral edema)

Displacement of CSF occurs before blood or brain displacement during pathologic processes.  Can changes in CSF volume be used to evaluate severity of cerebral edema?  See reference[1] for a retrospective study that looked into this clinical question.

Note: Change in CSF volume after 23.4% is associated with the magnitude of serum Na change but not with the total mEq of Na delivered.

Invasive ICP monitoring in hepatic encephalopathy:

  1. potential for hemorrhagic complications
  2. studies have not identified a survival benefit
  3. may be associated with worse outcomes for some patients
  4. may not accurately reflect compression of brain structures (thalami / brainstem)

West Haven Criteria

The severity of hepatic encephalopathy is graded with the West Haven Criteria.

  • Grade 1 Trivial lack of awareness; euphoria or anxiety; shortened attention span; impaired performance of addition or subtraction
  • Grade 2 Lethargy or apathy; minimal disorientation for time or place; subtle personality change; inappropriate behaviour
  • Grade 3 – Somnolence to semistupor, but responsive to verbal stimuli; confusion; gross disorientation
  • Grade 4 Coma



[1] Liotta, Eric M. et al. “23.4% Saline Decreases Brain Tissue Volume In Severe Hepatic Encephalopathy As Assessed By A Quantitative CT Marker”. Critical Care Medicine 44.1 (2016): 171-179. Web.

[2] Wikipedia,. “Hepatic Encephalopathy”. N.p., 2016. Web. 19 Feb. 2016.