Traumatic Brain Injury
— Adrian Wong (@avkwong) September 28, 2019
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:
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, …
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
- 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
- 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