Multimodality Monitoring in
SAH
Paul Vespa, MD, FCCM
Associate Professor of Neurosurgery and Neurology
Director of Neurocr...
What do we use at UCLA for SAH
pt who is comatose?
• ICP
• cEEG
• Cerebral microdialysis
• Brain Tissue Oxygen
• TCD (inte...
What are we looking for
• Seizures
– 30% of SAH pts have seizures on cEEG
• Brain Ischemia
– 50% of SAH pts will have some...
Multimodality Case 1 - SAH
• 74 yo with acomm aneurysm SAH
• Confused with poor attention
• Intubated due to respiratory d...
SAH # 1 vital signs
• SBP 160/80
• ICP 12-15 mm Hg
• HR 84
• SaO2 99%
• Temp 37.9 C
• Na 139
• Hb 31
EEG PAV in
SAH
early before
deterioration
1 – 9 - 06
SAH and EEG PAV
• PAV is an indicator of brain ischemia
from vasospasm
– Also Alpha/delta ratio is an indicator of
brain i...
EEG PAV is
worse
Possibilities:
1. Vasospasm
2. Deep sedation
3. Sepsis due to pneumonia
4. Hydrocephalus
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...
Angiogram shows vasospasm
Treatment of vasospasm
• Treatment options
– HHH Rx
– Intraarterial vasodilators
– Angioplasty
– Hypothermia/ Normothermia...
HHH Rx is
selected
Improvement in
PAV
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...
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 ...
SAH # 3, clipping, edema, elevated
ICP
Elevated ICP persistent after SAH
#3
Microdialysis during metabolic suppression with
high dose propofol treatment for ICP
LPR during early period of elevated I...
Then, Vasospasm despite continued
elevated ICP
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...
Case 4
• 58 yo woman with SAH due to Acomm
• Clipped on day 2
• Comatose with slight Right Leg weakness
post operatively
•...
SAH Microdialysis Monitoring of
Vasospasm
MD 1
MD 2
Microdialysis shows normal LPR,
glutamate, glucose
LPR 20-25 range
Uncertainty and Action
• The TCD and angio show vasospasm
• Microdialysis does not show ischemic
changes
• HH therapy and ...
DWI while MD LPR is 25
2
1
MD probe locations 1 and 2
What we did
• We continued with HH therapy and
returned to angio for IA treatment
• The MD did not change from that point ...
What did we learn?
• LPR reflected the region of interest well
• The ischemia occurred in the distal ACA
territory due to ...
Summary
• Multimodality monitoring with PbrO2, MD,
and cEEG detected the ischemic
response that occurred with vasospasm
af...
Subarachnoid Hemorrhage
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Subarachnoid Hemorrhage

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Subarachnoid Hemorrhage

  1. 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. 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. 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. 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. 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. 6. EEG PAV in SAH early before deterioration 1 – 9 - 06
  7. 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. 8. EEG PAV is worse Possibilities: 1. Vasospasm 2. Deep sedation 3. Sepsis due to pneumonia 4. Hydrocephalus
  9. 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. 10. Angiogram shows vasospasm
  11. 11. Treatment of vasospasm • Treatment options – HHH Rx – Intraarterial vasodilators – Angioplasty – Hypothermia/ Normothermia – Hyperoxia – Metabolic Suppression
  12. 12. HHH Rx is selected Improvement in PAV
  13. 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. 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. 15. SAH # 3, clipping, edema, elevated ICP
  16. 16. Elevated ICP persistent after SAH #3
  17. 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. 18. Then, Vasospasm despite continued elevated ICP
  19. 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. 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. 21. SAH Microdialysis Monitoring of Vasospasm MD 1 MD 2
  22. 22. Microdialysis shows normal LPR, glutamate, glucose LPR 20-25 range
  23. 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. 24. DWI while MD LPR is 25 2 1 MD probe locations 1 and 2
  25. 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. 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. 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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