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Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage
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Subarachnoid Hemorrhage

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  • 1. Multimodality Monitoring in SAH Paul Vespa, MD, FCCM Associate Professor of Neurosurgery and Neurology Director of Neurocritical Care Geffen School of Medicine at UCLA New York Neurologic Emergencies and Neurocritical Care Symposium
  • 2. What do we use at UCLA for SAH pt who is comatose? • ICP • cEEG • Cerebral microdialysis • Brain Tissue Oxygen • TCD (intermittent) • Xenon CBF (intermittent)
  • 3. What are we looking for • Seizures – 30% of SAH pts have seizures on cEEG • Brain Ischemia – 50% of SAH pts will have some form of vasospasm with variable amounts of ischemia • Elevated ICP • Brain Glucopenia
  • 4. Multimodality Case 1 - SAH • 74 yo with acomm aneurysm SAH • Confused with poor attention • Intubated due to respiratory distress • Not obeying, but some sedation given • Mild left hemiparesis on exam; leg worse than arm • cEEG and PbtO2
  • 5. SAH # 1 vital signs • SBP 160/80 • ICP 12-15 mm Hg • HR 84 • SaO2 99% • Temp 37.9 C • Na 139 • Hb 31
  • 6. EEG PAV in SAH early before deterioration 1 – 9 - 06
  • 7. SAH and EEG PAV • PAV is an indicator of brain ischemia from vasospasm – Also Alpha/delta ratio is an indicator of brain ischemia • PAV goes down (becomes flat) with vasospasm
  • 8. EEG PAV is worse Possibilities: 1. Vasospasm 2. Deep sedation 3. Sepsis due to pneumonia 4. Hydrocephalus
  • 9. Get a CT, shows no hydrocephalus PbrO2 is dropping to low values PbtO2 PbrO2 0 5 10 15 20 25 30 35 40 45 18:00 19:00 20:00 21:00 22:00 23:00 0:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 mmHg
  • 10. Angiogram shows vasospasm
  • 11. Treatment of vasospasm • Treatment options – HHH Rx – Intraarterial vasodilators – Angioplasty – Hypothermia/ Normothermia – Hyperoxia – Metabolic Suppression
  • 12. HHH Rx is selected Improvement in PAV
  • 13. Improvement in PbtO2 with HHH Rx PbrO2 0 5 10 15 20 25 30 35 40 45 18:00 19:00 20:00 21:00 22:00 23:00 0:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 12:00 13:00 mmHg
  • 14. SAH case # 3 • 46 yo man with SAH with basilar aneurysm • GCS 7, HH 4, GCS motor = 4-5 • Coiled on PBD # 2 • ICP, MD, and EEG placed • ICP becomes elevated requiring frequent CSF drainage
  • 15. SAH # 3, clipping, edema, elevated ICP
  • 16. Elevated ICP persistent after SAH #3
  • 17. Microdialysis during metabolic suppression with high dose propofol treatment for ICP LPR during early period of elevated ICP 0 5 10 15 20 25 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 hour LPR Glutamate during early period 0 2 4 6 8 10 12 14 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 hour uM
  • 18. Then, Vasospasm despite continued elevated ICP
  • 19. LPR response to IAnicardipine 0 5 10 15 20 25 30 35 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 hour LPR Glutamate response to IAnicardipine 0 0.5 1 1.5 2 2.5 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 hour glutamateuM Glucose response to IAnicardipine 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 hour glucosemM vasospasm Microdialysis response to vasospasm and subsequent treatment
  • 20. Case 4 • 58 yo woman with SAH due to Acomm • Clipped on day 2 • Comatose with slight Right Leg weakness post operatively • EEG PAV becomes poor on day 6 • MD monitoring started on day 3
  • 21. SAH Microdialysis Monitoring of Vasospasm MD 1 MD 2
  • 22. Microdialysis shows normal LPR, glutamate, glucose LPR 20-25 range
  • 23. Uncertainty and Action • The TCD and angio show vasospasm • Microdialysis does not show ischemic changes • HH therapy and intraarterial verapamil Tx done once, but persistent angio and TCD findings • Do we return to angio? Be more aggressive?
  • 24. DWI while MD LPR is 25 2 1 MD probe locations 1 and 2
  • 25. What we did • We continued with HH therapy and returned to angio for IA treatment • The MD did not change from that point on • We watched clinical exam, and EEG PAV
  • 26. What did we learn? • LPR reflected the region of interest well • The ischemia occurred in the distal ACA territory due to distal effects of spasm • We may need to place multiple probes in locations that are quite different than the frontal location • We need imaging or other adjunct monitoring
  • 27. Summary • Multimodality monitoring with PbrO2, MD, and cEEG detected the ischemic response that occurred with vasospasm after SAH • Monitoring in the ACA-MCA borderzone is good but very regional changes may occur in remote locations. • It is unclear which method is best: PBrO2, EEG PAV, TCD, MD. • Response to treatment can be seen

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