Lessons from Clinical Challenges in Neuro-Critical Care

Traumatic Brain Injury

Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research

Trajectories of early secondary insults correlate to outcomes of traumatic brain injury: results from a large, single centre, observational study

Clinical applications of intracranial pressure monitoring in traumatic brain injury : report of the Milan consensus conference.

 

Intracranial Haemorrhage

Definition: non-traumatic bleeding into the brain parenchyma

2nd most common type of stroke (10-30%)

5.3 million cases worldwide, 3 million deaths (2010 Global Report on Diseases)

Less than 40% of patients regain functional independence

Most important risk factors:

  • hypertension
  • anticoagulation

The critical care management of spontaneous intracranial hemorrhage: a contemporary review

Blood pressure management: BPsys < 140 -160 mmHg

  • Higher systolic pressures may lead to hematoma expansion and increased edema.
  • Prospective trials: INTERACT II, ATACH II

Correction of coagulopathy, if possible… or not?

  • Vitamin-K-antagonists (Phenprocoumon, Marcumar): Yes. Use PCC (prothrombin complex concentrate)
    •  INR-goal: < 1.3
  • DOACs: if specific antidote available and within 2-3 half lifes of substance, probably yes.
  • Heparin: use protamine.
  • Aspirin / Clopidogrel: may depend on hemorrhage size

Summary: intracranial hemorrhage

  • Data: meanwhile useful prospective works available
  • Difficult to estimate who will decompensate
  • Prognosis difficult to estimate, likely to be worse after large ICH.
    No application of score systems for single patients
  • Superficial, cortical hemorrhage: open surgery
  • Large Basal ganglia hemorrhage (> 30 ml): minimally invasive surgery
  • Intraventriular hemorrhage: EVD + Lysis (+ lumbale Drainage)
  • Decompressive surgery: trial ongoing.
  • Massive hemorrhage (> 100 ml): conservative approach
  • ICP monitoring standard in ventilated patients, optionally pbtO2, EEG, eCox, …

Subarachnoid hemorrhage

Transcranial Doppler ultrasound goal-directed therapy for the early management of severe traumatic brain injury.

Calcium antagonists for aneurysmal subarachnoid haemorrhage – Cochrane Review

Transcranial Doppler versus angiography in patients with vasospasm due to a ruptured cerebral aneurysm: A systematic review.

Hyponatraemia: Practical Management

  • Monitor volemia and Natremia after SAH
  • Fluid restriction is not recommended
  • Isotonic saline (0.9%) for drug dilution and fluids (1-3L)
  • We rarely use 3% saline (1 ml/Kg of 3% NaCl increases the PNa by 1mmol/L)
  • Consider hydrocortisone in case of vasopressor use
  • Vaptans are not useful
  • Consider urea (0.5 -1g/Kg/Day) for HypoNa + euvolemia

Summary

  • Late risk: vasospasm
  • Monitoring: depends on severity and risk of vasospasm
  • At least: TCD and ICP, PbtO2 and CMD in tissue at risk
  • HypoNa is frequent: no fluid restriction! NaCl, Steroids, Urea

Acute Management of Status Epilepticus

International League Against Epilepsy (ILAE) task force on classification

SE = Status Epilepticus

◦ condition resulting

  • from the failure of the mechanisms responsible for seizure termination
  • from the initiation of mechanisms which lead to abnormally prolonged seizures

◦Long-term consequences

  • neuronal death, neuronal injury, alteration of neuronal networks, depending on the type and duration of seizures

RSE = Refractory Status Epilepticus

  • SE that persists despite adequate administration of benzodiazepines and at least one antiepileptic drug

SRSE = Super Refractory Status Epilepticus

  • SE that continues or recurs ≥24h after onset of anaesthetic therapy, including recurrence on the reduction or withdrawal of anaesthesia.

Convulsive status epilepticus (CSE)

  • SE with convulsions / seizures / myoclonus

Non-Convulsive Status Epilepticus (NCSE)

  • SE without clinical signs à EEG diagnosis