const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.author = "MD Anesthesia";
pres.title = "Hydrocephalus & Raised ICP – Anesthesia Management";

// ── Palette ──────────────────────────────────────────────────────────────
const DARK   = "0A1628";   // deep midnight navy
const MID    = "163A5F";   // rich steel blue
const PANEL  = "1E4D78";   // panel blue
const LIGHT  = "E8F4FD";   // ice blue text
const ACCENT = "E8A020";   // amber gold
const GREEN  = "1A7A4A";   // success green
const RED    = "8B1A1A";   // danger red
const TEAL   = "0D6E6E";   // teal accent
const WHITE  = "FFFFFF";
const GRAY   = "B0BEC5";
const LIME   = "2ECC71";

// ── Helpers ──────────────────────────────────────────────────────────────
function bg(s) {
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:10, h:5.625, fill:{color:DARK}, line:{color:DARK} });
}

function tag(s, txt, color=ACCENT) {
  s.addShape(pres.ShapeType.roundRect, { x:0.28, y:0.18, w:3.0, h:0.36, fill:{color:color}, line:{color:color}, rectRadius:0.09 });
  s.addText(txt.toUpperCase(), { x:0.28, y:0.18, w:3.0, h:0.36, fontSize:8.5, bold:true, color:DARK, align:"center", valign:"middle", margin:0 });
}

function heading(s, txt) {
  s.addText(txt, { x:0.35, y:0.65, w:9.3, h:0.58, fontSize:23, bold:true, color:WHITE, fontFace:"Calibri" });
}

function rule(s, y=1.3) {
  s.addShape(pres.ShapeType.line, { x:0.35, y:y, w:9.3, h:0, line:{color:ACCENT, width:1.6} });
}

function bullets(s, items, opts={}) {
  const {x=0.38, y=1.48, w=9.25, h=3.8, fs=13} = opts;
  const rt = items.map((it, i) => {
    const last = i===items.length-1;
    if (typeof it==="string") return { text:it, options:{bullet:{type:"bullet"}, color:LIGHT, fontSize:fs, fontFace:"Calibri", breakLine:!last} };
    return { text:it.t, options:{bullet:it.sub?{indent:20}:{type:"bullet"}, color:it.c||LIGHT, fontSize:it.fs||fs, bold:!!it.b, italic:!!it.i, fontFace:"Calibri", breakLine:!last} };
  });
  s.addText(rt, { x, y, w, h, valign:"top", margin:3 });
}

function card(s, x, y, w, h, title, body, opts={}) {
  const {bg:bgc=PANEL, border=ACCENT, titleColor=ACCENT, bodyColor=LIGHT, fs=11} = opts;
  s.addShape(pres.ShapeType.roundRect, { x, y, w, h, fill:{color:bgc}, line:{color:border, width:0.8}, rectRadius:0.1 });
  if(title) s.addText(title, { x:x+0.1, y:y+0.08, w:w-0.2, h:0.38, fontSize:11.5, bold:true, color:titleColor, fontFace:"Calibri" });
  if(body) {
    const bodyY = title ? y+0.48 : y+0.08;
    const bodyH = title ? h-0.56 : h-0.16;
    if(Array.isArray(body)) {
      const rt = body.map((it,i)=>({ text:it, options:{bullet:{type:"bullet"}, color:bodyColor, fontSize:fs, fontFace:"Calibri", breakLine:i<body.length-1} }));
      s.addText(rt, { x:x+0.12, y:bodyY, w:w-0.24, h:bodyH, valign:"top", margin:2 });
    } else {
      s.addText(body, { x:x+0.12, y:bodyY, w:w-0.24, h:bodyH, fontSize:fs, color:bodyColor, fontFace:"Calibri", valign:"top" });
    }
  }
}

function twoCol(s, lTitle, lItems, rTitle, rItems, opts={}) {
  const {lbg=MID, rbg=MID} = opts;
  card(s, 0.28, 1.48, 4.55, 3.75, lTitle, lItems, {bg:lbg});
  card(s, 5.17, 1.48, 4.55, 3.75, rTitle, rItems, {bg:rbg});
}

function threeCol(s, items) {
  // items: [{title, body}] x3
  items.forEach((it, i) => {
    card(s, 0.28 + i*3.22, 1.48, 3.1, 3.75, it.title, it.body);
  });
}

// ════════════════════════════════════════════════════════════════════
// SLIDE 1 – Title
// ════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  // Gradient strip top
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:10, h:1.1, fill:{color:MID}, line:{color:MID} });
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:3.8, h:1.1, fill:{color:"0D3B6E"}, line:{color:"0D3B6E"} });
  // Bottom strip
  s.addShape(pres.ShapeType.rect, { x:0, y:5.15, w:10, h:0.475, fill:{color:MID}, line:{color:MID} });
  s.addShape(pres.ShapeType.rect, { x:0, y:5.15, w:4.2, h:0.475, fill:{color:ACCENT}, line:{color:ACCENT} });
  // Brain icon text
  s.addText("🧠", { x:0.3, y:0.15, w:0.9, h:0.8, fontSize:30, align:"center" });
  s.addText("MD ANESTHESIA", { x:1.1, y:0.2, w:8, h:0.35, fontSize:10, color:GRAY, charSpacing:4, fontFace:"Calibri" });
  s.addText("NEUROSURGICAL ANAESTHESIA", { x:1.1, y:0.55, w:8, h:0.38, fontSize:13, bold:true, color:ACCENT, fontFace:"Calibri", charSpacing:1 });
  // Divider
  s.addShape(pres.ShapeType.line, { x:0.35, y:1.25, w:9.3, h:0, line:{color:ACCENT, width:2} });
  // Main title
  s.addText("HYDROCEPHALUS &", { x:0.35, y:1.35, w:9.3, h:0.8, fontSize:40, bold:true, color:WHITE, fontFace:"Calibri", charSpacing:1 });
  s.addText("RAISED INTRACRANIAL PRESSURE", { x:0.35, y:2.15, w:9.3, h:0.7, fontSize:28, bold:true, color:ACCENT, fontFace:"Calibri", charSpacing:0.5 });
  s.addText("Pathophysiology · Classification · Anesthetic Management", {
    x:0.35, y:2.95, w:9.3, h:0.45, fontSize:15, color:LIGHT, fontFace:"Calibri", italic:true
  });
  // Key icons row
  const icons = [
    { icon:"🔬", label:"Etiology" },
    { icon:"📊", label:"Monroe-Kellie" },
    { icon:"💊", label:"Pharmacology" },
    { icon:"🏥", label:"Perioperative Care" },
    { icon:"⚕", label:"Surgical Mx" },
  ];
  icons.forEach((ic, i) => {
    s.addText(ic.icon, { x:0.5+i*1.85, y:3.6, w:1.2, h:0.5, fontSize:22, align:"center" });
    s.addText(ic.label, { x:0.3+i*1.85, y:4.1, w:1.6, h:0.35, fontSize:9.5, color:GRAY, align:"center", fontFace:"Calibri" });
  });
  s.addText("Miller's Anesthesia 10e  |  Adams & Victor's Neurology 12e  |  Rev Chil Neuro-Psiquiat 2024", {
    x:4.3, y:5.2, w:5.5, h:0.35, fontSize:8.5, color:WHITE, align:"right", fontFace:"Calibri"
  });
}

// ════════════════════════════════════════════════════════════════════
// SLIDE 2 – Monroe-Kellie Doctrine & Normal ICP
// ════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  tag(s, "Pathophysiology");
  heading(s, "Monroe-Kellie Doctrine & Normal ICP");
  rule(s);

  // Left: Doctrine box
  card(s, 0.28, 1.42, 4.55, 2.5, "Monroe-Kellie Doctrine",
    ["Cranial vault is a rigid closed box", "Fixed total volume = Brain (80%) + CSF (10%) + Blood (10%)", "Increase in any one component → compensated by ↓ in others", "Compensation fails → exponential ↑ in ICP", "Compensatory mechanisms: CSF displacement to thecal sac; Venous blood outflow"],
    {fs:11.5});

  // Right: Normal values box
  card(s, 5.17, 1.42, 4.55, 2.5, "Normal ICP Values",
    ["Adults: 7–15 mmHg", "Children: 3–7 mmHg", "Neonates: 1.5–6 mmHg", "Raised ICP: > 20 mmHg (treatment threshold)", "Critical ICP: > 40 mmHg (herniation risk)"],
    {fs:11.5, bg:TEAL});

  // Bottom: CPP formula
  s.addShape(pres.ShapeType.roundRect, { x:0.28, y:4.02, w:9.44, h:1.22, fill:{color:"1A1A2E"}, line:{color:ACCENT, width:1.2}, rectRadius:0.12 });
  s.addText([
    { text: "CPP = MAP − ICP", options:{ bold:true, fontSize:20, color:ACCENT, fontFace:"Calibri" } },
    { text: "     |     Target CPP: 60–70 mmHg     |     Minimum acceptable: 50 mmHg", options:{ fontSize:14, color:LIGHT, fontFace:"Calibri" } }
  ], { x:0.4, y:4.08, w:9.2, h:0.5, align:"center", valign:"middle" });
  s.addText("Low CPP = Cerebral ischaemia     |     High ICP + Low MAP = Lethal", {
    x:0.4, y:4.62, w:9.2, h:0.5, fontSize:12, color:GRAY, align:"center", fontFace:"Calibri", italic:true
  });
}

// ════════════════════════════════════════════════════════════════════
// SLIDE 3 – Hydrocephalus: Definition & Classification
// ════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  tag(s, "Hydrocephalus");
  heading(s, "Hydrocephalus – Definition & Classification");
  rule(s);

  // Definition banner
  s.addShape(pres.ShapeType.roundRect, { x:0.28, y:1.42, w:9.44, h:0.55, fill:{color:MID}, line:{color:ACCENT, width:0.8}, rectRadius:0.08 });
  s.addText("Definition: Abnormal accumulation of CSF → ↑ ventricular size → ↑ ICP and brain damage", {
    x:0.38, y:1.45, w:9.2, h:0.48, fontSize:12.5, bold:true, color:ACCENT, fontFace:"Calibri", valign:"middle"
  });

  // Three classification cards
  threeCol(s, [
    {
      title:"🔵 Obstructive (Non-Communicating)",
      body:["Block within ventricular system", "Aqueductal stenosis (most common)", "Posterior fossa tumors", "Intraventricular hemorrhage", "Pineal/tectal lesions", "Colloid cyst of 3rd ventricle"]
    },
    {
      title:"🟢 Communicating",
      body:["Obstruction outside ventricles", "Post-meningitis adhesions", "Post-SAH arachnoid granulation failure", "Choroid plexus papilloma (↑ CSF prod)", "Dural venous sinus thrombosis", "Normal Pressure Hydrocephalus (NPH)"]
    },
    {
      title:"🟡 Special Types",
      body:["Ex-vacuo: brain atrophy → CSF fills space", "Normal Pressure Hydrocephalus: Adams triad: dementia, gait, incontinence", "Congenital: Dandy-Walker, Arnold-Chiari", "Hydrocephalus ex-vacuo: not true ↑ ICP"]
    }
  ]);
}

// ════════════════════════════════════════════════════════════════════
// SLIDE 4 – Causes of Raised ICP
// ════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  tag(s, "Aetiology");
  heading(s, "Causes of Raised Intracranial Pressure");
  rule(s);

  twoCol(s,
    "🔴 Space-Occupying / Mass Lesions",
    ["Brain tumor (primary/secondary)", "Intracranial hematoma (EDH, SDH, ICH)", "Brain abscess / empyema", "Cerebral contusion (TBI)", "Hypertensive encephalopathy"],
    "🟡 CSF / Vascular Causes",
    ["Hydrocephalus (obstructive/communicating)", "Cerebral edema (vasogenic/cytotoxic)", "Cerebral venous sinus thrombosis", "Idiopathic intracranial HTN (pseudotumor cerebri)", "Hepatic encephalopathy, CO₂ retention"]
  );
}

// ════════════════════════════════════════════════════════════════════
// SLIDE 5 – Clinical Features of Raised ICP
// ════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  tag(s, "Clinical Features");
  heading(s, "Clinical Features of Raised ICP");
  rule(s);

  bullets(s, [
    { t:"EARLY FEATURES", b:true, c:ACCENT },
    { t:"Headache – worse in morning, worse lying down (↑ venous pressure)", sub:false },
    { t:"Vomiting – often projectile, without preceding nausea", sub:false },
    { t:"Visual disturbances – diplopia (CN VI palsy), blurring, obscurations", sub:false },
    { t:"Papilledema on fundoscopy (classical but may be absent acutely)", sub:false },
    { t:"LATE / PROGRESSIVE FEATURES", b:true, c:ACCENT },
    { t:"Altered consciousness → GCS deterioration", sub:false },
    { t:"Cushing's Triad: Hypertension + Bradycardia + Irregular breathing (brainstem compression)", sub:false },
    { t:"Herniation syndromes: Uncal (CN III palsy, ipsilateral fixed dilated pupil), Central, Tonsillar", sub:false },
    { t:"Decorticate / Decerebrate posturing", sub:false },
    { t:"Anesthesia relevance: Treat as full stomach (↑ vomiting risk); avoid drugs that ↑ ICP", b:true, c:LIME },
  ], { fs:12.5 });
}

// ════════════════════════════════════════════════════════════════════
// SLIDE 6 – Herniation Syndromes
// ════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  tag(s, "Herniation", RED);
  heading(s, "Herniation Syndromes – Recognise & Act");
  rule(s);

  const herniations = [
    { name:"Subfalcine (Cingulate)", signs:"Contralateral leg weakness; ACA compression; ipsilateral → contralateral shift", action:"Urgent imaging; osmotherapy; consider surgery" },
    { name:"Transtentorial (Uncal)", signs:"Ipsilateral CN III palsy → fixed dilated pupil; contralateral hemiplegia; LOC", action:"Emergency! Intubate, hyperventilate, mannitol/HTS" },
    { name:"Central Transtentorial", signs:"Bilateral pupil changes, Cheyne-Stokes → central hyperventilation → apnoea", action:"Immediate airway + ICP reduction" },
    { name:"Tonsillar (Cerebellar)", signs:"Bradycardia, HTN, apnoea — Cushing response; sudden death risk", action:"Emergency decompression; suboccipital craniectomy" },
    { name:"Upward Cerebellar", signs:"Pinpoint pupils, coma; seen after LP in posterior fossa lesions", action:"Avoid LP if raised ICP suspected!" },
  ];

  herniations.forEach((h, i) => {
    const yy = 1.48 + i*0.74;
    const bgc = i%2===0 ? MID : "0D2840";
    s.addShape(pres.ShapeType.roundRect, { x:0.28, y:yy, w:9.44, h:0.65, fill:{color:bgc}, line:{color:RED, width:0.5}, rectRadius:0.07 });
    s.addText(h.name, { x:0.38, y:yy+0.08, w:2.3, h:0.48, fontSize:11, bold:true, color:ACCENT, fontFace:"Calibri" });
    s.addText(h.signs, { x:2.75, y:yy+0.06, w:4.4, h:0.52, fontSize:10.5, color:LIGHT, fontFace:"Calibri" });
    s.addText(h.action, { x:7.2, y:yy+0.06, w:2.4, h:0.52, fontSize:10, color:LIME, fontFace:"Calibri", italic:true });
  });

  s.addText("TYPE  →  SIGNS  →  ACTION", { x:0.28, y:5.2, w:9.44, h:0.28, fontSize:9, color:GRAY, align:"center", fontFace:"Calibri" });
}

// ════════════════════════════════════════════════════════════════════
// SLIDE 7 – ICP Monitoring
// ════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  tag(s, "Monitoring");
  heading(s, "ICP Monitoring – Methods & Indications");
  rule(s);

  twoCol(s,
    "📡 Methods of ICP Monitoring",
    [
      "Intraventricular catheter (EVD) — GOLD STANDARD",
      "Directly coupled to CSF; allows therapeutic CSF drainage",
      "Infection risk <3%; limit use to 3–5 days",
      "Intraparenchymal fiber-optic monitor (Camino)",
      "Less risk of infection; no CSF drainage",
      "Subdural/epidural transducers (less accurate)",
      "Non-invasive: TCD, optic nerve sheath US, pupillometry",
    ],
    "📋 Indications for ICP Monitoring",
    [
      "GCS 3–8 with abnormal CT scan",
      "GCS 3–8 with normal CT + any 2 of: age >40, posturing, SBP <90",
      "Clinical concern for herniation",
      "Need for ICP-guided pharmacotherapy",
      "Perioperative in high-risk neurosurgery",
      "Target ICP < 20 mmHg",
      "BEST:TRIP trial: clinical ± CT approach non-inferior in low-resource settings",
    ],
    {lbg:MID, rbg:TEAL}
  );
}

// ════════════════════════════════════════════════════════════════════
// SLIDE 8 – Tiered ICP Management
// ════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  tag(s, "ICP Management", TEAL);
  heading(s, "Tiered Approach to ICP Management");
  rule(s);

  const tiers = [
    { tier:"Tier 0 (Always)", color:GREEN, items:"HOB 30°; head midline (no neck flexion/rotation); avoid hyperthermia; treat pain/agitation; normoglycaemia; normoxia (SpO₂ >94%); avoid hypotension (SBP >90)" },
    { tier:"Tier 1 (First Line)", color:ACCENT, items:"Sedation/analgesia (propofol ± fentanyl); Mannitol 20% 0.25–1 g/kg IV (q4–6h, serum osmol <320); OR Hypertonic saline 3% 150mL / 7.5% 75mL / 23.4% 30mL bolus; Controlled ventilation: PaCO₂ 35–40 mmHg (normocapnia)" },
    { tier:"Tier 2 (Second Line)", color:"E8821A", items:"Mild hyperventilation: PaCO₂ 30–35 mmHg (temporary bridge — effective 20–40 min only); CSF drainage via EVD (1–2 mL/min, 2–3 min at a time, target ICP <20 mmHg); Neuromuscular blockade to prevent ICP spikes (coughing, straining)" },
    { tier:"Tier 3 (Refractory)", color:RED, items:"Decompressive craniectomy (DECRA / RESCUEicp trials); Barbiturate coma: pentobarbital 5–20 mg/kg load, 1–4 mg/kg/hr infusion (EEG burst suppression monitoring required); Therapeutic hypothermia (33°C) — limited evidence; Lumbar CSF drainage (communicating hydrocephalus)" },
  ];

  tiers.forEach((t, i) => {
    const yy = 1.45 + i*0.98;
    s.addShape(pres.ShapeType.roundRect, { x:0.28, y:yy, w:9.44, h:0.87, fill:{color:MID}, line:{color:t.color, width:1.2}, rectRadius:0.09 });
    s.addShape(pres.ShapeType.roundRect, { x:0.28, y:yy, w:1.8, h:0.87, fill:{color:t.color}, line:{color:t.color}, rectRadius:0.09 });
    s.addText(t.tier, { x:0.28, y:yy, w:1.8, h:0.87, fontSize:10.5, bold:true, color:DARK, align:"center", valign:"middle", fontFace:"Calibri", margin:0 });
    s.addText(t.items, { x:2.15, y:yy+0.06, w:7.5, h:0.74, fontSize:10.5, color:LIGHT, fontFace:"Calibri", valign:"middle" });
  });
}

// ════════════════════════════════════════════════════════════════════
// SLIDE 9 – Osmotherapy: Mannitol vs HTS
// ════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  tag(s, "Osmotherapy");
  heading(s, "Osmotherapy: Mannitol vs Hypertonic Saline");
  rule(s);

  twoCol(s,
    "💊 Mannitol 20%",
    [
      "Dose: 0.25–1.0 g/kg IV over 15–20 min",
      "Mechanism: Osmotic gradient → brain dehydration; viscosity ↓ → CBF ↑ → autoregulatory vasoconstriction → ↓CBV",
      "Onset: 15–30 min; Duration: 2–6 hr",
      "Monitor: Serum osmolality (keep <320 mOsm/L)",
      "Repeat q4–6h; avoid >200 g/day (renal failure risk)",
      "Caution: Hypovolemia, hypotension, rebound edema",
      "Avoid: Renal failure, CHF, pulmonary edema",
    ],
    "🧪 Hypertonic Saline (HTS)",
    [
      "3%: 150 mL bolus; 7.5%: 75 mL; 23.4%: 30 mL (central line for ≥3%)",
      "Mechanism: ↑ serum Na → osmotic gradient → ↓ brain water; also ↑ intravascular volume",
      "Target serum Na: 145–155 mEq/L",
      "Advantages over mannitol: No diuresis; volume expansion (better for hypovolemic patients)",
      "Disadvantages: Hypernatraemia, CHF risk, central pontine myelinolysis (rapid correction)",
      "Both agents: No long-term outcome difference (Miller's 10e)",
    ],
    {lbg:MID, rbg:TEAL}
  );
}

// ════════════════════════════════════════════════════════════════════
// SLIDE 10 – Preoperative Assessment
// ════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  tag(s, "Preoperative");
  heading(s, "Preoperative Assessment – Hydrocephalus / Raised ICP");
  rule(s);

  bullets(s, [
    { t:"HISTORY & CLINICAL ASSESSMENT", b:true, c:ACCENT },
    { t:"Duration & progression of symptoms (headache, vomiting, visual changes, GCS)" },
    { t:"Existing VP/VA shunt: function, last revision, type of valve" },
    { t:"Current medications: steroids, anticonvulsants, anticoagulants" },
    { t:"Assess for full stomach (vomiting + ↑ ICP → aspiration risk)" },
    { t:"INVESTIGATIONS", b:true, c:ACCENT },
    { t:"CT/MRI brain: ventricular size, midline shift, herniation, cause of hydrocephalus" },
    { t:"Electrolytes, renal function (if on diuretics/mannitol), serum osmolality" },
    { t:"Coagulation (pre-surgical), blood glucose, FBC" },
    { t:"OPTIMIZATION", b:true, c:ACCENT },
    { t:"Defer elective surgery if ICP uncontrolled; emergencies proceed with concurrent ICP management" },
    { t:"Avoid sedatives/opioids pre-op unless ICP controlled (risk of hypoventilation → ↑ ICP)" },
  ], { fs:12.5 });
}

// ════════════════════════════════════════════════════════════════════
// SLIDE 11 – Anesthetic Drugs & ICP Effects
// ════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  tag(s, "Pharmacology");
  heading(s, "Anesthetic Drugs & Effects on ICP / CBF");
  rule(s);

  const drugs = [
    { drug:"Propofol", effect:"↓↓ ICP, ↓ CBF, ↓ CMRO₂", use:"PREFERRED induction & TIVA maintenance", color:GREEN },
    { drug:"Thiopentone", effect:"↓↓ ICP, ↓ CBF, ↓ CMRO₂", use:"Preferred if propofol unavailable; good for ICP crisis", color:GREEN },
    { drug:"Etomidate", effect:"↓ CBF, ↓ CMRO₂, minimal ICP change", use:"Haemodynamically unstable patients; caution: myoclonus may ↑ ICP", color:ACCENT },
    { drug:"Ketamine", effect:"↑↑ ICP, ↑ CBF, ↑ CMRO₂", use:"AVOID in raised ICP (ICP spike from 13→63 mmHg documented)", color:RED },
    { drug:"Sevo/Isoflurane", effect:"↑ CBF at >1 MAC (vasodilation); ↓ CMRO₂", use:"Use ≤1 MAC; sevoflurane preserves autoregulation better; avoid N₂O", color:ACCENT },
    { drug:"Opioids (fentanyl)", effect:"Minimal effect on ICP if ventilation controlled", use:"Preferred analgesia; remifentanil ideal for responsive neuromon.", color:GREEN },
    { drug:"Succinylcholine", effect:"Transient ↑ ICP (fasciculation)", use:"Acceptable for RSI if airway emergency; pretreat with defasciculating dose", color:ACCENT },
    { drug:"Rocuronium", effect:"No effect on ICP", use:"PREFERRED NMBA for modified RSI (sugammadex available)", color:GREEN },
    { drug:"Dexmedetomidine", effect:"↓ CBF, no significant ↑ ICP", use:"Useful sedation adjunct; minimal respiratory depression", color:GREEN },
  ];

  const hdrY = 1.43;
  ["Drug/Agent", "ICP/CBF Effect", "Anesthetic Use", "Preferred?"].forEach((h,i)=>{
    const xArr=[0.28,2.2,4.4,8.0]; const wArr=[1.85,2.1,3.5,1.7];
    s.addShape(pres.ShapeType.rect, { x:xArr[i], y:hdrY, w:wArr[i], h:0.35, fill:{color:ACCENT}, line:{color:ACCENT} });
    s.addText(h, { x:xArr[i], y:hdrY, w:wArr[i], h:0.35, fontSize:10.5, bold:true, color:DARK, align:"center", valign:"middle", margin:0 });
  });

  drugs.forEach((d,i)=>{
    const yy = 1.8 + i*0.405;
    const rowBg = i%2===0 ? MID : "0D2840";
    [[0.28,1.85,d.drug,true],[2.2,2.1,d.effect,false],[4.4,3.5,d.use,false],[8.0,1.7,"",false]].forEach(([x,w,txt,bold])=>{
      s.addShape(pres.ShapeType.rect, { x, y:yy, w, h:0.39, fill:{color:rowBg}, line:{color:"1A4060", width:0.3} });
      if(txt) s.addText(txt, { x:x+0.05, y:yy+0.03, w:w-0.1, h:0.33, fontSize:10, color:bold?ACCENT:LIGHT, bold, fontFace:"Calibri", valign:"middle" });
    });
    // color dot in last col
    s.addShape(pres.ShapeType.ellipse, { x:8.7, y:yy+0.1, w:0.22, h:0.22, fill:{color:d.color}, line:{color:d.color} });
  });

  s.addText("🟢 Preferred   🟡 Use with caution   🔴 Avoid", { x:0.3, y:5.28, w:9.4, h:0.28, fontSize:9.5, color:GRAY, fontFace:"Calibri", italic:true });
}

// ════════════════════════════════════════════════════════════════════
// SLIDE 12 – Induction & Airway Management
// ════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  tag(s, "Induction");
  heading(s, "Induction & Airway Management in Raised ICP");
  rule(s);

  bullets(s, [
    { t:"GOALS OF INDUCTION", b:true, c:ACCENT },
    { t:"Smooth, rapid loss of consciousness — avoid coughing, straining, Valsalva → spike in ICP" },
    { t:"Maintain CPP: avoid hypotension (MAP drop) and hypertension (↑ CBV)" },
    { t:"Prevent aspiration: raised ICP patients are full stomach (vomiting)" },
    { t:"MODIFIED RSI PROTOCOL", b:true, c:ACCENT },
    { t:"Pre-oxygenate 3–5 min; avoid bag-mask ventilation if possible (↑ gastric pressure)", c:LIGHT },
    { t:"Lidocaine 1.5 mg/kg IV 90 sec before laryngoscopy → attenuates ICP spike" },
    { t:"Induction: Propofol 1.5–2 mg/kg IV (preferred) OR Thiopentone 3–5 mg/kg" },
    { t:"NMBA: Rocuronium 1.2 mg/kg (modified RSI) with sugammadex available" },
    { t:"Fentanyl 1–2 μg/kg blunts intubation response" },
    { t:"AIRWAY TRICKS", b:true, c:ACCENT },
    { t:"HOB 20–30° during induction; avoid neck flexion/rotation (impairs venous drainage)" },
    { t:"Avoid prolonged laryngoscopy; videolaryngoscope recommended for difficult airway" },
    { t:"Confirm ETT with ETCO₂; target PaCO₂ 35–40 mmHg immediately post-intubation" },
  ], { fs:12 });
}

// ════════════════════════════════════════════════════════════════════
// SLIDE 13 – Intraoperative Maintenance
// ════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  tag(s, "Intraoperative");
  heading(s, "Intraoperative Anesthetic Maintenance");
  rule(s);

  twoCol(s,
    "🫁 Ventilation Strategy",
    [
      "PaCO₂: 35–40 mmHg (normocapnia) — standard",
      "Mild hyperventilation (PaCO₂ 30–35) only as bridge (lasts <20–40 min)",
      "Avoid PaCO₂ <25 → cerebral ischaemia",
      "PEEP: Keep ≤5 cmH₂O (↑ PEEP → ↑ CVP → ↓ venous drainage → ↑ ICP)",
      "SpO₂ >94%; avoid hypoxia absolutely",
      "ETCO₂ monitoring mandatory; correlate with PaCO₂",
    ],
    "💉 Pharmacological Maintenance",
    [
      "TIVA with propofol + remifentanil: IDEAL (no cerebral vasodilation)",
      "Volatile agents (sevo ≤1 MAC): acceptable; isoflurane alternative",
      "AVOID: N₂O (vasodilation, ↑ ICP, air space expansion), ketamine",
      "NMB: Rocuronium/vecuronium (prevent ICP spikes from coughing)",
      "Dexamethasone 0.1 mg/kg for vasogenic edema (tumors/abscesses)",
      "Mannitol or HTS intraoperatively if ICP ↑",
    ],
    {lbg:MID, rbg:TEAL}
  );
}

// ════════════════════════════════════════════════════════════════════
// SLIDE 14 – Positioning & Monitoring
// ════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  tag(s, "Monitoring & Positioning");
  heading(s, "Intraoperative Monitoring & Patient Positioning");
  rule(s);

  // 3-column
  threeCol(s, [
    {
      title:"📍 Positioning",
      body:[
        "HOB 30° (↑ venous drainage, ↓ ICP)",
        "Head midline — avoid flexion/rotation",
        "Avoid Trendelenburg (↑ ICP)",
        "Supine with slight reverse Trendelenburg for VP shunt",
        "Head turned to contralateral shunt side",
        "Shoulder roll to align ear-neck-abdomen",
        "Avoid tight neck ties/tape",
      ]
    },
    {
      title:"📊 Standard Monitoring",
      body:[
        "Invasive arterial line (IBP) — MANDATORY",
        "ECG, SpO₂, ETCO₂",
        "Temperature (normothermia target)",
        "Urine output (diuresis from mannitol)",
        "Central venous access (HTS, vasoactive drugs)",
        "BIS/EEG neuromonitoring if available",
        "ICP monitor (EVD/intraparenchymal)",
      ]
    },
    {
      title:"🎯 Target Parameters",
      body:[
        "ICP < 20 mmHg",
        "CPP 60–70 mmHg",
        "MAP 80–100 mmHg",
        "PaCO₂ 35–40 mmHg",
        "SpO₂ > 94%",
        "Temp 36–37.5°C",
        "Serum Na 140–155 mEq/L",
        "Glucose 6–10 mmol/L",
      ]
    }
  ]);
}

// ════════════════════════════════════════════════════════════════════
// SLIDE 15 – Surgical Management: VP Shunt
// ════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  tag(s, "Surgical Management");
  heading(s, "Surgical Management of Hydrocephalus");
  rule(s);

  bullets(s, [
    { t:"VENTRICULOPERITONEAL (VP) SHUNT — Most Common", b:true, c:ACCENT },
    { t:"Burr hole in frontal/occipital region → catheter into ventricle → subcutaneous tunnel → peritoneum" },
    { t:"Valve types: Fixed pressure / Programmable / Flow-regulated / Anti-siphon devices" },
    { t:"Anesthesia consideration: GA with ETT; lateral/supine position; tunneling causes brief stimulation" },
    { t:"OTHER SHUNTS", b:true, c:ACCENT },
    { t:"Ventriculoatrial (VA): catheter into right atrium — used if peritoneum not suitable; cardiac dysrhythmia risk" },
    { t:"Ventriculopleural: into pleural cavity (third choice); hydrothorax risk" },
    { t:"Lumboperitoneal: for communicating hydrocephalus only" },
    { t:"ENDOSCOPIC PROCEDURES", b:true, c:ACCENT },
    { t:"Endoscopic Third Ventriculostomy (ETV): stoma in floor of 3rd ventricle → CSF bypasses obstruction; NO hardware required" },
    { t:"Endoscopic Choroid Plexus Cauterization (ECC): reduces CSF production; used in infants" },
    { t:"VP shunt revision: commonest neurosurgical emergency; treat shunt malfunction as raised ICP" },
  ], { fs:12 });
}

// ════════════════════════════════════════════════════════════════════
// SLIDE 16 – Emergence & Postoperative Care
// ════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  tag(s, "Post-operative");
  heading(s, "Emergence, Recovery & Postoperative Care");
  rule(s);

  twoCol(s,
    "🌅 Emergence Strategy",
    [
      "SMOOTH emergence: avoid coughing, bucking on ETT (↑ ICP)",
      "Remifentanil/short-acting opioids aid smooth extubation",
      "Lidocaine 1 mg/kg IV at end of surgery → attenuates cough reflex",
      "Extubate ONLY if: GCS adequate, no herniation risk, controlled ICP",
      "If ICP control uncertain → elective post-op ventilation in ICU",
      "Check ETT position before extubation (migration during positioning)",
    ],
    "🏥 Postoperative Concerns",
    [
      "Neurological assessment: GCS, pupils q1h",
      "SIADH (24–48h post-op): ↑ ADH → free water retention → ↓ Na → cerebral edema",
      "Central DI: after suprasellar surgery → massive diuresis → ↑ osmolality",
      "Triphasic response: SIADH → DI → SIADH (classic post-pituitary surgery)",
      "Shunt over-drainage: subdural collections, slit-ventricle syndrome",
      "Pneumocephalus: air in cranial vault → headache, confusion",
      "Analgesia: paracetamol ± NSAIDs; avoid opioids if risk of respiratory depression",
      "DVT prophylaxis: early mobilization, TEDS",
    ],
    {lbg:MID, rbg:TEAL}
  );
}

// ════════════════════════════════════════════════════════════════════
// SLIDE 17 – Paediatric Considerations
// ════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  tag(s, "Paediatric");
  heading(s, "Hydrocephalus in Children – Special Considerations");
  rule(s);

  bullets(s, [
    { t:"EPIDEMIOLOGY & CAUSES", b:true, c:ACCENT },
    { t:"Most common cause: post-hemorrhagic (IVH in premature neonates), myelomeningocele, congenital malformations (Dandy-Walker, Arnold-Chiari), infections" },
    { t:"UNIQUE ANATOMY", b:true, c:ACCENT },
    { t:"Open fontanelle in neonates/infants: buffer against ICP rise → symptoms may appear late; tense bulging fontanelle = raised ICP" },
    { t:"Head circumference tracking: macrocephaly, 'sunset sign' (downward gaze preference = tectal plate pressure)" },
    { t:"ANESTHETIC DIFFERENCES", b:true, c:ACCENT },
    { t:"Higher risk of desaturation; smaller airway diameter; awake vs. gas induction depends on clinical state" },
    { t:"NMBA: succinylcholine acceptable in emergency; rocuronium 1.2 mg/kg for modified RSI" },
    { t:"ICP-lowering drugs: same drugs, weight-based dosing; mannitol 0.5–1 g/kg; HTS as in adults" },
    { t:"Brain tumors in children: 70% posterior fossa (astrocytoma most common); obstructive hydrocephalus common" },
    { t:"Post-op: higher SIADH / DI risk after posterior fossa surgery; close endocrine monitoring" },
  ], { fs:12.5 });
}

// ════════════════════════════════════════════════════════════════════
// SLIDE 18 – Key Mnemonics & Exam Points
// ════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  tag(s, "Exam Points", GREEN);
  heading(s, "Key Mnemonics & MD Anesthesia Exam Points");
  rule(s);

  threeCol(s, [
    {
      title:"⚡ AVOID in Raised ICP",
      body:[
        "Ketamine (↑ CBF, ↑ ICP)",
        "Nitrous oxide (cerebral vasodilator)",
        "Volatile >1 MAC (dose-dependent vasodilation)",
        "Hypotension (↓ CPP)",
        "Hypoxia & Hypercarbia",
        "Neck flexion/rotation",
        "High PEEP (>5 cmH₂O)",
        "Hypotonic fluids (5% dextrose, 0.45% saline)",
        "LP before CT in suspected raised ICP",
      ]
    },
    {
      title:"✅ TARGETS to REMEMBER",
      body:[
        "Normal ICP: 7–15 mmHg (adult)",
        "Treat ICP: > 20 mmHg",
        "CPP target: 60–70 mmHg",
        "CPP = MAP − ICP",
        "PaCO₂: 35–40 mmHg (normal)",
        "Hypervent limit: >30 mmHg PaCO₂",
        "Mannitol: 0.25–1 g/kg (max 1g/kg)",
        "Serum osmol: <320 mOsm/L",
        "Serum Na target with HTS: 145–155",
      ]
    },
    {
      title:"🧠 MNEMONICS",
      body:[
        "Cushing TRIAD: HTN + Bradycardia + Irregular breathing",
        "ICP SPIKE TRIGGERS: COPS — Coughing, O2 desat, Posturing, Suction",
        "TIVA = Preferred technique (propofol + remifentanil)",
        "FOUR Score for coma (Eyes, Motor, Brainstem, Respiration)",
        "Adams Triad (NPH): Wet-Wobbly-Wacky (incontinence-ataxia-dementia)",
        "ETV: Endoscopic Third Ventriculostomy — no hardware!",
      ]
    }
  ]);
}

// ════════════════════════════════════════════════════════════════════
// SLIDE 19 – Summary Flowchart
// ════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  tag(s, "Summary");
  heading(s, "Anesthetic Management Algorithm – Raised ICP");
  rule(s);

  const steps = [
    { step:"1. Preop", color:MID, txt:"CT/MRI + GCS + Electrolytes + Full stomach assessment + Optimize ICP before elective surgery" },
    { step:"2. Induction", color:TEAL, txt:"HOB 30° | Preoxygenate | Lidocaine 1.5 mg/kg | Propofol + Fentanyl + Rocuronium 1.2 mg/kg (modified RSI)" },
    { step:"3. Airway", color:"1A6B4A", txt:"Videolaryngoscopy preferred | Avoid prolonged attempt | Confirm ETCO₂ | Target PaCO₂ 35–40 mmHg immediately" },
    { step:"4. Maintenance", color:"2E5E8E", txt:"TIVA (propofol+remifentanil) preferred | If volatile: ≤1 MAC Sevo | No N₂O | Continuous IBP + ETCO₂ + ICP monitoring" },
    { step:"5. ICP Crisis", color:"8B4513", txt:"Hyperventilate briefly → Mannitol/HTS → CSF drainage (EVD) → Deepen sedation → Surgeon informed" },
    { step:"6. Emergence", color:"4A235A", txt:"Smooth extubation | Lidocaine 1 mg/kg | Neurological assessment | ICU if any concern" },
  ];

  steps.forEach((st, i) => {
    const col = i<3 ? 0 : 1;
    const row = i%3;
    const xx = 0.28 + col*4.9;
    const yy = 1.47 + row*1.32;
    s.addShape(pres.ShapeType.roundRect, { x:xx, y:yy, w:4.65, h:1.15, fill:{color:st.color}, line:{color:ACCENT, width:0.8}, rectRadius:0.1 });
    s.addText(st.step, { x:xx+0.1, y:yy+0.08, w:4.4, h:0.32, fontSize:12, bold:true, color:ACCENT, fontFace:"Calibri" });
    s.addText(st.txt, { x:xx+0.12, y:yy+0.42, w:4.4, h:0.65, fontSize:10, color:WHITE, fontFace:"Calibri", valign:"top" });
  });
}

// ════════════════════════════════════════════════════════════════════
// SLIDE 20 – Thank You / References
// ════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  bg(s);
  s.addShape(pres.ShapeType.rect, { x:0, y:2.1, w:10, h:1.1, fill:{color:MID}, line:{color:MID} });
  s.addShape(pres.ShapeType.line, { x:0.4, y:2.1, w:9.2, h:0, line:{color:ACCENT, width:2} });
  s.addShape(pres.ShapeType.line, { x:0.4, y:3.2, w:9.2, h:0, line:{color:ACCENT, width:2} });

  s.addText("🧠", { x:4.5, y:0.4, w:1, h:0.85, fontSize:36, align:"center" });
  s.addText("Thank You", { x:0, y:2.15, w:10, h:0.95, fontSize:40, bold:true, color:WHITE, align:"center", valign:"middle", fontFace:"Calibri", charSpacing:3 });

  s.addText("References", { x:0.4, y:3.35, w:9.2, h:0.3, fontSize:11.5, bold:true, color:ACCENT, fontFace:"Calibri" });
  const refs = [
    "Miller's Anesthesia, 10th Edition – Chapter on Neuroanesthesia & TBI (p. 9444)",
    "Adams & Victor's Principles of Neurology, 12th Ed – Management of Raised ICP (p. 913–914)",
    "Rev Chil Neuro-Psiquiat 2024; 62(4) – Anesthetic Considerations in Hydrocephalus requiring VP Shunt",
    "Anesthesia Considerations for Elevated ICP – Kansas Anesthesia Associates, 2024",
    "Deranged Physiology – Tiered Approach to Management of Raised ICP",
  ];
  const refRt = refs.map((r, i)=>({ text:"• "+r, options:{ color:LIGHT, fontSize:10, fontFace:"Calibri", breakLine:i<refs.length-1 } }));
  s.addText(refRt, { x:0.4, y:3.68, w:9.2, h:1.7, valign:"top" });
}

// ─── Write ───────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/hydrocephalus-ppt/Hydrocephalus_Raised_ICP_MD_Anaesthesia.pptx" })
  .then(() => console.log("DONE"))
  .catch(e => { console.error(e); process.exit(1); });