1. The document discusses various neurosurgical emergencies including brain trauma, subarachnoid hemorrhage, and intracerebral hematomas. 2. It outlines key factors that influence prognosis in brain trauma such as age, Glasgow Coma Scale score, pupillary reactivity, and CT scan findings. Secondary factors like hypotension can also worsen outcomes. 3. Management principles for neurosurgical emergencies focus on maintaining cerebral oxygenation and perfusion while controlling factors like intracranial pressure, temperature, blood pressure, and glucose.

1. Neurosurgical emergencies
Jean Mantz, MD, PhD
Professor 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. Neurosurgical emergencies
 Cephalic and cervical emergencies (life-
threatening)
 Spine compression or trauma (functional
prognosis involved)

3. Cephalic neurosurgical emergencies (adult)
 Brain trauma
 Non-traumatic hematoma
 Subarachnoid hemorrhage (rupture of aneurysm)
 Decompressive craniectomy

4. Brain trauma

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. 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. 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. Normal brain regulation
CBF
50 150 CPP
(mmHg)

9. OPTIMAL C.P.P
Guidelines
CPP = 60 -70 mm Hg
Recommandations Brain Trauma Foundation 2003
Coles, Brain 2004
Steiner,JCBFM 2004

10. Autoregulation & ICP
 MAP   ICP
CF Vasodilatation VC
MAP
ICP
CPP

11. No autoregulation :
 MAP   ICP
CF
200
MAP
0
40
ICP
0
CPP

12. Transcranial Doppler
Systolic velocity (VS)
Diastolic velocity (VD)
Velocity
Pulsatility Index
PI= (VS-VD )/VM
Normal < 1,2
s
S D

13. Osmotherapy
Severe brain injury
↑ ICP
bolus mannitol.
before after
ICP 33 mmHg ICP 20 mmHg
MAP 89 mmHg MAP 89 mmHg
CPP 56 mmHg CPP 69 mmHg
Mannitol

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. 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. Side effects of hypothermia
From Polderman KH Intensive Care Med 2004; 30: 757-69

19. 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

20. 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

21. Intracerebral hematomas

22. Brain imaging Mayer Stroke 2007

23. 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

24. 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

25. 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.

26. • 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

27. 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

28. Nontraumatic subarachnoid hemorrhage

29. All for one
One for all !
neuro-anesthetist
neuro-surgeon
neuro-radiologist neuro-intensivist
PEASE - LINNC 2012 29

30. Clinical/TDM scores
WFNS GCS Deficit Fisher
I 15 0 I 0 blood
II 13-14 0 II Deposit < 1mm
III 13-14 + III Deposit > 1mm
IV 7  12
+/- IV Hematoma or IVH
V 36

32. 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

33. Surgery vs endovascular procedure
Molyneux, Lancet 2005
RCT 2143 patients
Mortality / dependence 1 yr: 30.9% vs 23.5%, p=0.0001

34. • Indications for surgical emergency clipping
of the aneurysm
1. Anatomy of the aneurysm
- Not accessible to endovascular treatment
- Neck
2. Intracerebral hematoma

35. Interventional neuroradiologic procedures

37. Goals for anesthesia for Interventional
Neuroradiological Procedures
Hemodynamic stability
– Aim at optimal MAP
– Hemodynamic monitoring via arterial catheter,
and urine output (bladder catheter)
– Euvolemia (crystalloids, colloids) via large bore IV
catheters
– Norephinephrine
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38. 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 or
when additional dose)
•Platelet –function testing to overcoming of clopidrogel
resistance: VerifyNow P2Y12® whole blood assay
PEASE - LINNC 2012 38

40. Per-procedural intracranial bleeding

41. Management of per-procedural complications
•Occurrence is very rapid
•Consequences are devastating
•management must be multidisciplinary : good
communication
PEASE - LINNC 2012 41

42. Bleeding complications
1.Immediate reversal of heparin (Protamine 1UI = 1UI)
2.Decrease bleeding flow  lowering systemic
arterial pressure
3.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
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43. 1.INR will stop leakage by coiling
2.Seek immediate neurosurgical advice:
– Cerebral decompression ?
– External Ventricular Drainage ?
PEASE - LINNC 2012 43

44. 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

45. Complications of subarachnoid hemorrhage
Cardiovascular Neurologic
Respiratory
Hydroelectrolytic Epilepsy
Recurrence of hemorrhage
Vasospasm +++
ICH
Brain death

46. 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%

47. Vasospasm
•neurological deterioration, TransCranial Doppler
examination
•confirmed by Digital Subtraction Angiography (DSA)
•proximal vasospasm : balloon angioplasty
•distal vasospasm : intra-arterial vasodilators (milrinone)
To be
discus
ses
PEASE - LINNC 2012 47

48. 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

49. RCT Results
Malignant MCA Yes (6) Not conclusive,
infarction except DECIMAL
Brain trauma No
injury
Subarachnoid No
hemorrhage

50. Decompressive
craniectomy