Neurosurgical Emergencies cairo 2012

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Neurosurgical Emergencies cairo 2012

  1. 1. Neurosurgical emergencies Jean Mantz, MD, PhDProfessor and Chair, Department of Anesthesia and Critical Care Paris Nord Val de Seine University Hospitals Université Paris 7 Paris Diderot INSERM U 676 France
  2. 2. Neurosurgical emergencies Cephalic and cervical emergencies (life- threatening) Spine compression or trauma (functional prognosis involved)
  3. 3. Cephalic neurosurgical emergencies (adult) Brain trauma Non-traumatic hematoma Subarachnoid hemorrhage (rupture of aneurysm) Decompressive craniectomy
  4. 4. Brain trauma
  5. 5. Prognosis of severe brain trauma • MORTALITY (overall): 25-30% •GCS < 8: 40-50% •GCS 9-13: 3.2% •GCS 14-15: 1%• SEQUELAE – 40% disabilities Mathé JF et al Ann Fr Anesth Réanim 2005; 24: 688-94
  6. 6. Prognosis of brain trauma Clinical criteria:  Age  GCS <8  Pupillar reactivity CT-scan (Marshall) Polytrauma Secondary aggravating factors Fearnside, Br J Neurosurg 1993, 7: 267-79: Chesnut J Trauma 1993, 34: 216-22 Piek J Neurosurg 1992, 77:901-7
  7. 7. Primary brain injury Secondary brain injury  Hypotension Direct result of trauma  Hypotension +++ ICH Contusions Hypoxemia Oedema Hematomas  Hypercapnia Hematomas  Hypocapnia Vasospasm  Hyperglycaemia Hydrocephaly  Hyperthermia. Epilepsy Coagulation disorders Bleeding ISCHEMIA Neuronal death
  8. 8. Normal brain regulationCBF 50 150 CPP (mmHg)
  9. 9. OPTIMAL C.P.PGuidelinesCPP = 60 -70 mm Hg Recommandations Brain Trauma Foundation 2003 Coles, Brain 2004 Steiner,JCBFM 2004
  10. 10. Autoregulation & ICP  MAP   ICPCF Vasodilatation VCMAPICPCPP
  11. 11. No autoregulation :  MAP   ICPCF 200MAP 0 40ICP 0CPP
  12. 12. Transcranial Doppler Systolic velocity (VS) Diastolic velocity (VD)Velocity Pulsatility Index PI= (VS-VD )/VM Normal < 1,2 s S D
  13. 13. OsmotherapySevere brain injury↑ ICPbolus mannitol. before afterICP 33 mmHg ICP 20 mmHgMAP 89 mmHg MAP 89 mmHgCPP 56 mmHg CPP 69 mmHg Mannitol
  14. 14. Corticosteroids ? NO!– BRAIN TRAUMA FUNDATION : J Neurotrauma 2000;14:531-35– CRASH trial, Lancet 2004;364:1321-28– Cochrane Database Syst Rev. 2005 Jan 25;(1):CD000196
  15. 15. Mechanisms of hypothermia-induced neuroprotection Reduces glutamate release Limits ca++ influx Decreases inflammatory response to ischemia Limits edema Decreases CMRO2 Suppresses ROS Decreases apoptotic cell death
  16. 16. Side effects of hypothermiaFrom Polderman KH Intensive Care Med 2004; 30: 757-69
  17. 17. Neurosurgical emergency indications in brain trauma Extradural hematoma Subdural hematoma (> 5 mm or deviation of median line > 5 mm) Acute hydrocephaly Open fracture Compressive fracture Intracerebral hematoma > 15 ml (France) or 25 ml (USA) and deviation of the median line > 5 mm
  18. 18. Neurosurgical emergencies: principles of anesthesia• Maintain cerebral oxygenation and cerebral perfusion pressure (norepinephrine)• Treat life-threatening ICH (mannitol)• Control paCO2, temperature, bleeding, coagulation, glycemia, electrolytes• Use rapid sequence for emergency induction of anesthesia• Prefer iv agents
  19. 19. Intracerebral hematomas
  20. 20. Brain imaging Mayer Stroke 2007
  21. 21. Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilot trial The Lancet Neurology - Volume 7, Issue 5 (May 2008)• Efficacy and safety study• Inclusion within 6 hours• SBP < 140 mmHg n= 203 (hematoma: 14.2 ml)• SBP = 180 mmHg, n=201 (hematoma: 12.7 ml)• % increase in hematoma at 24 Hours: – + 13.7% vs 36.3% p=0.04 – Not significant when adjustment to the size of the initial hematoma• Safety at D90: NS
  22. 22. N Engl J Med May 2008• Main goal: death/severe sequelae at day 90• Significant reduction in the size of hematoma• More arterial thrombotic events
  23. 23. Warfarin related ICHImmediately administer Kaskadil® (PPSB) 20 ml : 25-30 UI/kg PPSB (units of F IX, i.e. 1 ml/kg), infusion rate:4ml/ minute).- Vitamin K (oral or iv)- Goal: obtain INR < 1 ,5.
  24. 24. • Spontaneous ICH within 72h > 2cm, GCS > 5• randomisation: surgery within 24 hr or medical treatment• Outcome at 6 months• 1033 patients 83 centers 27 countries
  25. 25. ICH: Surgical treatment• Preferential indications – Hematomas < 1 cm from cortex (class IIb, B) – Patients with GCS 7-10 with important mass effect – EVD in case of hydrocephaly or ventricular hemorrhage• Technique: – Craniotomy, decompressive craniectomy – Aspiration – Urokinase ou rtPA
  26. 26. Nontraumatic subarachnoid hemorrhage
  27. 27. All for one One for all ! neuro-anesthetist neuro-surgeonneuro-radiologist neuro-intensivist PEASE - LINNC 2012 29
  28. 28. Clinical/TDM scoresWFNS GCS Deficit FisherI 15 0 I 0 bloodII 13-14 0 II Deposit < 1mmIII 13-14 + III Deposit > 1mmIV 7  12 +/- IV Hematoma or IVHV 36
  29. 29. Initial treatment Oxygenation MBP 100-120mmHg Analgesics, anxiolytics Mechanical ventilation if GCS ≤ 8 Anticonvulsants osmotherapy, hyperventilation if appropriate Nimodipine Discuss endovascular exclusion of aneurysm within 72 hours
  30. 30. Surgery vs endovascular procedure Molyneux, Lancet 2005 RCT 2143 patientsMortality / dependence 1 yr: 30.9% vs 23.5%, p=0.0001
  31. 31. • Indications for surgical emergency clipping of the aneurysm 1. Anatomy of the aneurysm - Not accessible to endovascular treatment - Neck 2. Intracerebral hematoma
  32. 32. Interventional neuroradiologic procedures
  33. 33. Goals for anesthesia for Interventional Neuroradiological ProceduresHemodynamic stability – Aim at optimal MAP – Hemodynamic monitoring via arterial catheter, and urine output (bladder catheter) – Euvolemia (crystalloids, colloids) via large bore IV catheters – Norephinephrine PEASE - LINNC 2012 37
  34. 34. Anticoagulation therapy•Prevention of per-procedure thrombo-embolic complications•Baseline activated clotting time (ACT).•Heparin Bolus : 70-100 UI/kg (aim at prolonged ACT x 2-3)•Heparin infusion : 35-50 UI/kg/hour (aSAH) 1000 UI/hour (AVM)•ACT and Heparin cumulative dose follow-up +++ (1q hour orwhen additional dose)•Platelet –function testing to overcoming of clopidrogelresistance: VerifyNow P2Y12® whole blood assay PEASE - LINNC 2012 38
  35. 35. Per-procedural intracranial bleeding
  36. 36. Management of per-procedural complications•Occurrence is very rapid•Consequences are devastating•management must be multidisciplinary : goodcommunication PEASE - LINNC 2012 41
  37. 37. Bleeding complications1.Immediate reversal of heparin (Protamine 1UI = 1UI)2.Decrease bleeding flow  lowering systemicarterial pressure3.Immediate neuro-protection : – Prevent cerebral tissue hypoxia  FiO2 100 %) – Preventive hypocapnia  PaCO2 30 – 37 mmHg – Barbiturate coma therapy sodium thiopental – Cerebral osmotherapy  mannitol 0,25 – 0,5 g/kg PEASE - LINNC 2012 42
  38. 38. 1.INR will stop leakage by coiling2.Seek immediate neurosurgical advice: – Cerebral decompression ? – External Ventricular Drainage ? PEASE - LINNC 2012 43
  39. 39. Occlusive complications: INR management• Enhance collateral blood flow by raising MAP• Balloon angioplasty of occluded vessel• In-situ thrombo-aspiration• In-situ intra-arterial thrombolytic therapy (r-tPA)• anti-platelet agents (abciximab) PEASE - LINNC 2012 44
  40. 40. Complications of subarachnoid hemorrhageCardiovascular NeurologicRespiratoryHydroelectrolytic Epilepsy Recurrence of hemorrhage Vasospasm +++ ICH Brain death
  41. 41. Vasospasm : diagnostic Predictors:  Severity of hemorrhage (WFNS, Fisher)+++  pre-existing hypertension, tobacco, young age, hyperglycemia Delay : [D3-D21] , Peak [D5-D15] Symptoms :  déficit,  GCS.  Fever, hyperleucocytosis Angiography Mortality ~30%
  42. 42. Vasospasm•neurological deterioration, TransCranial Dopplerexamination•confirmed by Digital Subtraction Angiography (DSA)•proximal vasospasm : balloon angioplasty•distal vasospasm : intra-arterial vasodilators (milrinone) To be discus ses PEASE - LINNC 2012 47
  43. 43. Vasospasm : PREVENTION• Statins and milrinone: unproven efficacy• Nimodipine ++ – Liposoluble (crosses BBB) po : 60mgx6/j for 21d (6 weeks if vasospasm) (Grade A) iv : 1-2mg/h with ICP monitoring
  44. 44. RCT ResultsMalignant MCA Yes (6) Not conclusive,infarction except DECIMALBrain trauma NoinjurySubarachnoid Nohemorrhage
  45. 45. Decompressivecraniectomy

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