This document summarizes cardiovascular complications that can occur following traumatic brain injury (TBI). Up to 15.7% of patients with severe TBI can develop left ventricular dysfunction and wall motion abnormalities due to increased sympathetic activity and catecholamine release after brain injury. This can cause hypotension, hypertension, arrhythmias, and myocardial injury. ECG changes, echocardiogram abnormalities, and elevated biomarkers of cardiac injury have been documented following TBI. While the exact mechanisms are not fully understood, autonomic dysfunction and systemic inflammation following TBI can directly or indirectly impact cardiovascular function. Treatment involves optimizing hemodynamics and treating the underlying brain injury, as the cardiac abnormalities are often transient.
In this ppt, I am going to discuss the role of ICD in the patient with Non-ischemic cardiomyopathy. I am going to discuss all the major trials done in the patient with non-ischemic cardiomyopathy.
Moyamoya disease (MMD) is a rare and unique cerebrovascular disease. The term “moyamoya” is Japanese and refers to a hazy puff of smoke or cloud. In people with moyamoya disease, this is how the blood vessels appear in the angiogram. MMD is characterized by the progressive stenosis of the distal internal carotid artery (ICA) resulting in a hazy network of basal collaterals called moyamoya vessels. This may be a consequence of Mutations in a few genes. In addition, MMD is also associated with many genetically transmitted disorders, including neurofibromatosis, Down syndrome, Sickle cell anemia, and Collagen vascular disease. It follows bimodal age distribution. Younger populations present with ischaemic symptoms, whereas adults show hemorrhagic symptoms The exact cause remains unknown. Immune, genetic and other factors contribute to this disease. It follows complex pathophysiology resulting in neovascularization as a compensatory mechanism. Diagnosis is based on cerebral angiography using the DSA scale. Treatment involves managing symptoms with medicine or surgery, improving blood flow to the brain, and controlling seizures. Revascularization helps to rebuild the blood supply to the underside of the brain.
An overview of Decompression hemicraniectomy in patients with large hemispheric infarctions. The presentation touches upon definition, pathophysiology, medical management, rationale for surgery, mortality, functional outcomes of DHC, and complications in a nutshell.
In this ppt, I am going to discuss the role of ICD in the patient with Non-ischemic cardiomyopathy. I am going to discuss all the major trials done in the patient with non-ischemic cardiomyopathy.
Moyamoya disease (MMD) is a rare and unique cerebrovascular disease. The term “moyamoya” is Japanese and refers to a hazy puff of smoke or cloud. In people with moyamoya disease, this is how the blood vessels appear in the angiogram. MMD is characterized by the progressive stenosis of the distal internal carotid artery (ICA) resulting in a hazy network of basal collaterals called moyamoya vessels. This may be a consequence of Mutations in a few genes. In addition, MMD is also associated with many genetically transmitted disorders, including neurofibromatosis, Down syndrome, Sickle cell anemia, and Collagen vascular disease. It follows bimodal age distribution. Younger populations present with ischaemic symptoms, whereas adults show hemorrhagic symptoms The exact cause remains unknown. Immune, genetic and other factors contribute to this disease. It follows complex pathophysiology resulting in neovascularization as a compensatory mechanism. Diagnosis is based on cerebral angiography using the DSA scale. Treatment involves managing symptoms with medicine or surgery, improving blood flow to the brain, and controlling seizures. Revascularization helps to rebuild the blood supply to the underside of the brain.
An overview of Decompression hemicraniectomy in patients with large hemispheric infarctions. The presentation touches upon definition, pathophysiology, medical management, rationale for surgery, mortality, functional outcomes of DHC, and complications in a nutshell.
Resuscitation Science tips: The NYC Project Hypothermia rationale for phase IIEmergency Live
Resuscitation Science tips: The NYC Project Hypothermia
Intra-arrest induction of Therapeuitic Hypothermia via large-volume ice-cold saline infusion improves immediate outcomes for out-of-hospital cardiac arrest
The original source of this article is the AHA Journlas
http://circ.ahajournals.org/cgi/content/meeting_abstract/124/21_MeetingAbstracts/A2
Background: New York City Project Hypothermia is a collaborative effort involving the Fire Department of New York (FDNY), Greater New York Hospital Association, Health and Hospitals Corporation, the Regional Emergency Medical Advisory Committee, and the New York State Department of Health. As part of this effort, the FDNY implemented a pilot protocol in the New York City 9-1-1 System on August 1, 2010 that introduced the induction of therapeutic hypothermia during initial resuscitation efforts via large-volume ice-cold saline infusion.
Purpose: We sought to assess the effects of this protocol on immediate survival end-points following out-of-hospital cardiac arrest (OOHCA).
Methods: OOHCA data was analyzed for the following periods: August 1, 2009 - May 31, 2010 (historicalcontrol group) and August 1, 2010 - May 31, 2011 (study group). Except for the intra-arrest induction of hypothermia, no other aspect of the regional resuscitation protocols differed between the two periods. Standard Utstein definitions were utilized. Due to the large sample sizes, Chi-square analyses without Yates' correction were utilized, and a p <0.05 was considered significant.
Results: 5,582 resuscitations for nontraumatic adult cardiac arrests during the control period were compared to 4,727 resuscitations in the study period that included the intra-arrest induction of hypothermia. The groups did not differ with respect to age, response time, bystander witnessed status, or frequency of bystander CPR. Patients in the study period were less likely to be male (52.3% vs 54.6%, p = 0.019), less likely to be white (32.8% vs 35.1%, p = 0.013), and less likely to have an EMS-witnessed arrest (8.3% vs 9.5%, p=0.026). Return of spontaneous circulation (ROSC) and sustained ROSC were improved in the study group as compared to the control group: 31.7% vs 29.0% (p=0.003) and 24.1% vs 21.9% (p=0.0014), respectively.
The administration of large-volume, ice-cold saline for the intra-arrest initiation of therapeutic hypothermia improves immediate survival for out-of-hospital cardiac arrest.
Further work is required to assess the impact of this effect on long-term, neurologically intact survival and specific patient population for which this therapy may be of greatest benefit.
Special Thanks from the AHA to All of the Certified First Responder, Emergency Medical Technicians, and Paramedics of the FDNY and the New York City 9-1-1 System.
The most common cause of death in young is non other than Head injury. The modern advances not only gave human mankind a luxury but with high velocity injury there is high burden of head injury too. This slide is updated with BTF 2016 guideline
Spinal Tumors: approach and managementAmit Agrawal
The spinal cord consists of
Central canal surrounded by an H-shaped gray matter region containing neurons
Outer myelinated nerve tracts, termed white matter, surround the central gray matter
Central canal is lined with ependymal cells
Astrocytes support gray matter neurons and white matter axons
To describe which are the common pathophysiological
features ofhead injury
To define the mechanisms of head injuries
Characteristic clinical and imaging findings
To define the management and outcome
Brain tumor surgery: challenges faced in rural set upAmit Agrawal
Management of brain tumours in developing countries displays a different perspective compared to developed nations
The disease is grossly advanced before the patient seeks treatment
Diagnosis as well as management requires minimum number of diagnostic tools
70% of RTA patients have head injury(HI).
One of the most important public health problems of today.
70% of deaths in RTA are due to HI.
At Risk population
Males 15-24
Infants
Young Children
Elderly
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Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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Broken Heart Syndrome: Cardiovascular Manifestations of Traumatic Brain Injury
1. Broken Heart Syndrome:
Cardiovascular Manifestations of
Traumatic Brain Injury
Dr Amit Agrawal, MCh
Department of Neurosurgery
Narayana Medical College and Hospital
Chintareddypalem, Nellore (AP), India
3. Up to 89% patients with severe TBI can show significant organ
dysfunction*
It is shown to be independently associated with worse
outcomes*
Cardiovascular
Respiratory
Immunological
Haematological
Endocrinological systems
Introduction
*Zygun DA, Kortbeek JB, Fick GH, et al. Nonneurologic organ dysfunction in severe
traumatic brain injury. Crit Care Med 2005; 33:654660.
4. An increasing appreciation of the role of neurocardiac
interactions in TBI
Associated with increased morbidity and mortality
Although most patients succumbed to serious brain injury
15.7% of patients developed global systolic dysfunction and
regional wall motion abnormalities***
Increased sympathetic or reduced vagal activity may result in
ventricular tachyarrhythmias and sudden cardiac death**
Neurogenic cardiovascular
abnormalities
van der Bilt IAC, Hasan D, Vandertop WP et al. Impact of cardiac complications on outcome after aneurysmal
subarachnoid hemorrhage: a meta-analysis. Neurology 2009; 72: 635-42
Zygun D. Non-neurological organ dysfunction in neurocritical care: impact on outcome and etiological
considerations. Curr Opin Crit Care 2005; 11: 139-43
***Huttemann et al. Left ventricular dysfunction in lethal severe brain injury: impact of transesophageal
echocardiography on patient management. Intensive Care Medicine 2002; 28: 1084-8.
**Henden et al. Can Baroreflex Sensitivity and Heart Rate Variability Predict Late Neurological Outcome in Patients
with Traumatic Brain Injury? J. Neurosurg. Anesthesiol. 2014, 26, 50-59.
5. Hypotension
Hypertension
ECG changes
Cardiac arrhythmias
Release of biomarkers of cardiac injury
Left ventricular (LV) dysfunction
Cardiovascular complications
Gregory T, Smith M. Cardiovascular complications of brain injury. Continuing Education
in Anaesthesia Critical Care & Pain 2012;12:67-71.
6. Less well understood
Potentially a protective mechanism intend to maintain cerebral
perfusion in the presence of raised intracranial pressure (ICP)
However can have several adverse effects
Pathology
Clifton GL, Ziegler MG. Circulating catecholamines and sympathetic activity after head
injury. Neurosurgery 1981; 8: 10-4.
Clifton GL, Robertson CS, Kyper K, Taylor AA, Dhekne RD, Grossman RG. Cardiovascular
response to severe head injury. Journal of Neurosurgery 1983; 59: 447-54.
Tamsin Gregory. Cardiovascular complications of brain injury
7. Direct stimulation of specific trigger zones
Including A1, A5
Nuclei of solitary tract
Area postrema within the medulla and hypothalamus
Raised intracranial pressure
Catecholamine
excess
Autonomic
dysfunction
Systemic
inflammatory
response
The
catecholamine
surge may
cause direct
injury to the
myocardium
Intense systemic
vasoconstriction
Hyperdynamic
circulation
Tachycardia
Hypertension
Increases cardiac
afterload
Myocardial
workload
Increase
myocardial
oxygen demand
Sedy J, Kunes J, Zicha J. Pathogenetic mechanisms of neurogenic pulmonary edema. J Neurotrauma 2015; 32:1135-1145.
Elenkov IJ, Wilder RL, Chrousos GP, Vizi ES. The sympathetic nerve - an integrative interface between two supersystems: the brain and the
immune system. Pharmacol Rev 2000; 52:595-638.
Clifton GL, McCormick WF, Grossman RG. Neuropathology of early and late deaths after head injury. Neurosurgery 1981; 8: 309-14.
Nguyen H, Zaroff JG. Neurogenic stunned myocardium. Curr Neurol Neurosci Rep 2009; 9: 486-91
The degree of catecholamine release directly related to the
severity of the brain injury
8. Conventional teaching suggests that isolated head injury does
not result in hypotension in adults
Neurogenic hypotension: 13% of patients with isolated head
injury
Associated with a higher mortality than haemorrhagic
hypotension
Hypotension
Mahoney EJ, Biffl WL, Harrington DT, Cioffi WG. Isolated brain injury as a cause of
hypotension in the blunt trauma patient. Journal of Trauma 2003; 55: 1065-9.
9. Often associated with diffuse axonal injury
Disruption of brainstem centers for hemodynamic control
As the catecholamine surge subsides
The initial hyperdynamic response is often followed by significant
hypotension because of unopposed peripheral vasodilatation and
ventricular dysfunction
Injury to diencephalic region-Reduction of systematic vascular
resistance
The development of adrenal insufficiency
Neurogenic Hypotension
Chesnut et al. Neurogenic hypotension in patients with severe head injuries. Journal of Trauma 1998; 44: 958-63.
Deleu et al. “Neurogenic stunned myocardium following hemorrhagic cerebral contusion,” Saudi Medical Journal, vol. 28, no. 2, pp.
283-285, 2007.
Kocsis et al. Effects of pre-existing brain ischaemia on sympathetic nerve response to intracranial hypertension. Journal of Applied
Physiology 1991; 70: 2181-7.
10.
Cushing’s phenomenon revisited
(N=16047, Valid Records=10200)
Bhandarkar et al. On-admission blood pressure and pulse rate in trauma patients and
their correlation with mortality: Cushing's phenomenon revisited. Int J Crit Illn Inj Sci
2017;7:14-7.
11. Cushing’s phenomenon revisited
(N=16047, Valid Records=12/10200)
Bhandarkar et al. On-admission blood pressure and pulse rate in trauma patients and
their correlation with mortality: Cushing's phenomenon revisited. Int J Crit Illn Inj Sci
2017;7:14-7.
12. Cushing’s phenomenon revisited
(N=16047, Valid Records=12/10200)
Bhandarkar et al. On-admission blood pressure and pulse rate in trauma patients and
their correlation with mortality: Cushing's phenomenon revisited. Int J Crit Illn Inj Sci
2017;7:14-7.
13. In TBI, up to 73% of patients will demonstrate ECG changes*
Sinus tachycardia
Ischaemic mimics
Repolarization abnormalities (i.e. ST segment changes,
pathological T waves, QTc prolongation and U waves )**
Prolonged QTc syndrome may predispose to ventricular
arrhythmias***
ECG changes correlate with the severity of TBI and poorer
outcomes****
ECG
*Fan X, Du FH, Tian JP. The electrocardiographic changes in acute brain injury patients. Chin Med J (Engl) 2012; 125:3430-3433.
**Fan X, Du FH, Tian JP. The electrocardiographic changes in acute brain injury patients. Chin Med J (Engl) 2012; 125:3430-3433.
**Krishnamoorthy V, Prathep S, Sharma D, et al. Association between electrocardiographic findings and cardiac dysfunction in adult
isolated traumatic brain injury. Indian J Crit Care Med 2014; 18:570-574.
***Collier BR, Miller SL, Kramer GS, Balon JA, Gonzalez LS. Traumatic subarachnoid hemorrhage and QTc prolongation. Journal of
Neurosurgical Anesthesiology 2004; 16: 196200.
****Krishnamoorthy V, Prathep S, Sharma D, et al. Association between electrocardiographic findings and cardiac dysfunction in
adult isolated traumatic brain injury. Indian J Crit Care Med 2014; 18:570-574.
14. Echographic findings are often transient but are associated with
significant mortality*
Regional wall motion abnormality (RWMA)**
Echographic findings
*Prathep S, Sharma D, Hallman M, et al. Preliminary report on cardiac dysfunction after
isolated traumatic brain injury. Crit Care Med 2014; 42:142-147.
*Clifton GL, McCormick WF, Grossman RG. Neuropathology of early and late deaths after
head injury. Neurosurgery 1981; 8:309-314.
**Krishnamoorthy V, Prathep S, Sharma D, Gibbons E, Vavilala MS. Association between
electrocardiographic findings and cardiac dysfunction in adult isolated traumatic brain
injury. Indian J Crit Care Med 2014;18:570-4
15. Most of the data from SAH
Elevation of cardiac troponin I (cTnl)
Usually peaks within 24-36 h
Possibility to explore the role biomarkers of cardiac origin in TBI
Biomarkers of cardiac injury
Bruder N, Rabinstein A. Cardiovascular and pulmonary complications of aneurysmal
subarachnoid hemorrhage. Neurocrit Care 2011; 15: 257-69
16. Differentiating between neurogenic and coronary events*
No history of cardiac problems,
Temporal relationship between brain injury and cardiovascular
abnormalities
ECG changes in isolation,
Modest elevations in cTnI,
New onset LV dysfunction
Cardiac wall motion abnormalities that do not correspond with coronary
vascular territories,
Inconsistency between echocardiographic and ECG findings
Inconsistency between cTnI and LV ejection fraction
Management
*Tamsin Gregory. Cardiovascular complications of brain injury
**Diringer MN, Bleck TP, Claude Hemphill J 3rd, et al., Neurocritical Care Society. Critical care management of
patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care
Society’s Multidisciplinary Consensus Conference. Neurocrit Care 2011; 15:211240.
***Nguyen H, Zaroff JG. Neurogenic stunned myocardium. Curr Neurol Neurosci Rep 2009; 9: 486-91
17. Treatment of the underlying brain injury*
Hemodynamic optimization (Avoid hypovolemia)**
The abnormalities are usually reversible
Coronary angiography is the definitive diagnostic test to
exclude coronary artery disease but is seldom indicated in this
high-risk group of patients***
In any case, the presence of significant coronary artery disease
does not exclude co-incidental neurogenic stunned
myocardium
Management
*Tamsin Gregory. Cardiovascular complications of brain injury
**Diringer MN, Bleck TP, Claude Hemphill J 3rd, et al., Neurocritical Care Society. Critical care management of
patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care
Society’s Multidisciplinary Consensus Conference. Neurocrit Care 2011; 15:211240.
***Nguyen H, Zaroff JG. Neurogenic stunned myocardium. Curr Neurol Neurosci Rep 2009; 9: 486-91
18. Cardiac injury is common in patients with severe head trauma
It is associated with increased mortality.
Abnormal echocardiographic findings
Neurogenic hypotension needs to explored further
What is unclear is whether neurogenic cardiac injury is
independently associated with poor outcome or whether it is
an epiphenomenon reflecting the severity of the underlying
brain injury
Conclusion
19. Entire team of WACEM 2018
Dr Sagar Galwankar
Research Team, Narayana Medical College and Hospital, Nellore
Acknowledgement