CEREBRAL RESUSCITATION FROM ACUTE CATASTROPHIC NEUROLOGIC INJURY: THE BRAIN CODE / ACUTE ICP...

CEREBRAL RESUSCITATION FROM ACUTE CATASTROPHIC NEUROLOGIC INJURY: THE BRAIN CODE / ACUTE ICP MANAGEMENT Navaz Karanjia, MD Director, Neurocritical Care Assistant Professor of Neurosciences, Anesthesiology, and Surgery University of California-San Diego

Disclosures No financial disclosures Off-label use: propofol for ICP control

Objectives To discuss the physiology of herniation and cranial vault mechanics To explain the specific protocols for a brain code To discuss the evidence behind the specific interventions in a brain code To discuss the outcomes of patients that have been brain coded To take you through a brain code/ICP emergency case

Cerebral Resuscitation: acute catastrophic neurologic injury Catastrophic neurologic injury: ICP herniation

Why do I want you to understand acute ICP management?

Cerebral Resuscitation: herniation

Cerebral resuscitation: herniation Subfalcine Herniation Cerebral cortex under falx Leg weakness mental status Central/Upward Herniation Brainstem down/up through tentorium mental status Dilated pupil, eye down and out (CN3) Weakness/posturing Basilar stroke Tonsillar Herniation Cerebellar tonsils in foramen magnum Awake, pharynx weakness, quadriparesis Arrhythmia/cardiac arrest Respiratory arrest Uncal Herniation Uncus over tentorial notch mental status Sluggish -> Dilated pupil -> eye down and out (CN3) Weakness/posturing

Cerebral Resuscitation: tonsillar herniation MEDULLA -CN 9, 10throat sensation/muscles, vagus -CN 11shoulder shrug, head turn -CN12tongue muscles -Pyramidsall motor tracts -Respiratory control, HR, BP Tonsillar Herniation Cerebellar tonsils in foramen magnum Awake, pharynx weakness, quadriparesis Arrhythmia/cardiac arrest Respiratory arrest GAME OVER

Cerebral resuscitation: tonsillar herniation

Cerebral resuscitation: herniation Subfalcine Herniation Cerebral cortex under falx Leg weakness mental status Central/Upward Herniation Brainstem down/up through tentorium mental status Dilated pupil, eye down and out (CN3) Weakness/posturing Basilar stroke Tonsillar Herniation Cerebellar tonsils in foramen magnum Awake, pharynx weakness, quadriparesis Arrhythmia/cardiac arrest Respiratory arrest Uncal Herniation Uncus over tentorial notch mental status Dilated pupil, eye down and out (CN3) Weakness/posturing PCA stroke

Cerebral Resuscitation: uncal herniation Uncal Herniation Uncus over tentorial notch mental status Dilated pupil, eye down and out (CN3) Weakness/posturing PCA stroke GAME OVER

Cerebral resuscitation: herniation Subfalcine Herniation Cerebral cortex under falx Leg weakness mental status Central/Upward Herniation Brainstem down/up through tentorium mental status Dilated pupil, eye down and out (CN3) Weakness/posturing Basilar stroke Tonsillar Herniation Cerebellar tonsils in foramen magnum Awake, pharynx weakness, quadriparesis Arrhythmia/cardiac arrest Respiratory arrest Uncal Herniation Uncus over tentorial notch mental status Dilated pupil, eye down and out (CN3) Weakness/posturing PCA stroke

Cerebral Resuscitation: cranial vault mechanics 80% 12% 8%8% 92% 4%4% 4%4% 79%20% Monroe Kellie Doctrine Skull is a rigid container (1600 cc) Cranial contents (brain, blood, CSF) are incompressible Additional volume (pathologic or expansile) will lead to displacement of normal cranial contents Normal ICP = 5-20 cm H20 CSF Blood Brain Blood Tumor Brain Normal Cerebral edema Tumor Saunders NR, Habgood MD, Dziegielewska KM (1999). "Barrier mechanisms in the brain, I. Adult brain". Clin. Exp. Pharmacol. Physiol. 26 (1): 119.

Cerebral Resuscitation: cranial vault mechanics

HV, mannitol, 23% Brain Volume No blood = BAD FOR BRAIN CPP = MAP - ICP Rosner M J, Rosner S D & Johnson A H. "Cerebral perfusion: management protocol and clinical results." J.Neurosurgery 1985; 83: 949-962.

Cerebral Resuscitation: cranial vault mechanics CPP = MAP - ICP CBF = CPP/CVR CD02 = CBF x Ca02

50% HOWEVER, CPP>70 = increased mortality Healthy human subjects: normal CPP = 50-70 CPP60, ICP20cm H20 >3 minutes">

Cerebral Resuscitation: when to brain code When there are clinical signs of herniation When ICP is sustained >20cm H20 >3 minutes

Cerebral Resuscitation: herniation

Cerebral Resuscitation: compartment approach to ICP management Venous blood HOB up 60 deg Neck straight No IJ lines, do not lay flat for lines Do no use venodilating BP agents CSF Place IVC Change popoff Brain parenchyma Osmotherapy (mannitol, hypertonic saline) Steroids only if appropriate (tumor, HACE, some infections) Surgery (hemicrani, SOC) Lesion Blood, tumor, pus -> surgery Air-> 100% NRB, surgery Arterial blood Hyperventilate Avoid hyperemia: MAP target 80, Pa02>50 Decrease metabolism: sedation, cooling

Cerebral Resuscitation: venous compartment Venous blood HOB up 60 deg Neck straight No IJ lines, do not lay flat for lines Do no use venodilating BP agents If CVP exceeds ICP, CPP = MAP - CVP Ropper: n=19. 52% had ICP when HOB increased from 0->60. 2% had ICP. Davenport: n=8. Median ICP from 18->15 with 20 elevation, no in CPP until > 60. Lee: n=30. Trendelenburg positioning ICP from 20->24, but ICP in 20% of pts. (!) Davenport A, Will EJ, Davison AM. Effect of posture on intracranial pressure and cerebral perfusion pressure. Crit Care Med 1990; 18(3):286-289. Lee ST. Intracranial pressure changes during positioning of patients with severe head injury. Heart Lung 1989; 18(4):411-414. Ropper AH, O'Rourke D, Kennedy SK. Head position, intracranial pressure, and compliance. Neurology 1982; 32(11):1288-1291.

Cerebral Resuscitation: arterial compartment Arterial blood Mild hypervent (RR 18) target pC02 30-35 Avoid hyperemia: MAP target 80-130 Avoid hypoxia: Pa02>50 Decrease metabolism: propofol IVP, propofol/pentoba rb gtt, hypothermia 32- 34 C Kramer A, Zygun D. Anemia and red cell transfusion in neurocritical care. Critical Care 2009 13:R89 35 60150 25 20 50

Cerebral Resuscitation: arterial compartment Blood gas values and hemodynamic data at different respiratory rates 10 breaths/m13 breaths/m16 breaths/m PaCO 2 (mmHg)45.5 9.939.7 7.9*35.9 7.9 CO 2 (mmHg)4.2 1.86.6 2.87.6 1.7 pH7.29 0.067.32 0.06*7.35 0.07 Bicarbonate (mmol/l)21.2 2.520.7 2.520 2.5 CO 2 6 mmHg, n (%)10 (100)4 (40)*2 (20) ScvO 2 (%)77.9 4.174.7 7.472.6 7.1 Cardiac index (l/m 2 )2.37 0.52.36 0.62.36 0.6 Mean arterial pressure (mmHg)71.7 13.368 14.571.4 13.2 Temperature (C)36.9 0.936.9 0.936.8 0.9 CO 2, venous-arterial difference in carbon dioxide tension; PaCO 2, arterial partial pressure of carbon dioxide; ScvO 2, central venous oxygen saturation. *P

Cerebral Resuscitation: compartment approach to ICP management Venous blood HOB up 60 deg Neck straight No IJ lines, do not lay flat for lines Do no use venodilating BP agents Arterial blood Hyperventilate Avoid hyperemia: MAP target 80, Pa02>50 Decrease metabolism: sedation, cooling CSF Place IVC Change popoff Brain parenchyma Osmotherapy (mannitol, hypertonic saline) Steroids only if appropriate (tumor, HACE, some infections) Surgery (hemicrani, SOC) Lesion Blood, tumor, pus -> surgery Air-> 100% NRB, surgery

Cerebral Resuscitation: CSF compartment CSF Place IVC Change popoff Situations in which IVC drainage is unlikely to be helpful: cerebral edema with significant midline shift and no hydrocephalus posterior fossa pathology Situations in which IVC drainage may be dangerous: unsecured aneurysm posterior fossa pathology

Cerebral Resuscitation: Brain parenchyma Brain parenchyma Osmotherapy (mannitol, hypertonic saline) Steroids only if appropriate (tumor, HACE, some infections) Surgery (hemicrani, SOC) CytotoxicVasogenic Stroke Tumor Abscess

Cerebral Resuscitation: Brain parenchyma Brain parenchyma Osmotherapy (mannitol, hypertonic saline) Steroids only if appropriate (tumor, HACE, some infections) Surgery (hemicrani, SOC) Intact BBB Damaged BBB particles blood brain Permeable Semi-Permeable

Cerebral Resuscitation: Brain parenchyma Brain parenchyma Osmotherapy (mannitol, hypertonic saline) Steroids only if appropriate (tumor, HACE, some infections) Surgery (hemicrani, SOC) Sodium=1.0 Mannitol=0.9 Glycerol=0.5Sodium=0.6 Sodium=0.97 Mannitol=0.9 Glycerol=0.5Urea=0.6 Reflection Coefficient

Cerebral Resuscitation: Brain parenchyma Brain parenchyma Osmotherapy (mannitol, hypertonic saline) Steroids only if appropriate (tumor, HACE, some infections) Surgery (hemicrani, SOC) Sodium=1.0 Mannitol=0.9 Glycerol=0.5Sodium=0.6

Cerebral Resuscitation: Brain parenchyma Brain parenchyma Osmotherapy (mannitol, hypertonic saline) Steroids only if appropriate (tumor, HACE, some infections) Surgery (hemicrani, SOC) Sodium=1.0 Mannitol=0.9 Glycerol=0.5Sodium=0.6 N=8. 22 episodes of elevated ICP occurred, refractory to mannitol. Bolus of 75cc of 10% saline normalized ICP in all. ICP 10. Na 5.6 mmol/L. Serum osm 9 mmol/L. No unexpected side effects.

Cerebral Resuscitation: Brain parenchyma Brain parenchyma Osmotherapy (mannitol, hypertonic saline) Steroids only if appropriate (tumor, HACE, some infections) Surgery (hemicrani, SOC) Increased vascular volume-> improves CBF up to 23% Dehydration of erythrocytes increases deformability through small capillaries Reduces inflammatory response by reducing PMN adhesion to microvasculature (unclear clinical significance) Pascual J et al. Hypertonic saline resuscitation of hemorrhagic shock diminishes neutrophil rolling and adherence to endothelium and reduces in vivo vascular leakage. Ann Surg. 2000 Nov; 236 (5): 634-642 Tseng M, Pippa G et al. Effect of hypertonic saline on cerebral blood flow in poor grade patients with subarachnoid hemorrhage. Stroke 2003;34:1389-1396

Cerebral Resuscitation: Brain parenchyma Brain parenchyma Osmotherapy (mannitol, hypertonic saline) Steroids only if appropriate (tumor, HACE, some infections) Surgery (hemicrani, SOC) Sodium=1.0 Mannitol=0.9 Glycerol=0.5Sodium=0.6 Create a GRADIENT, DONT dehydrate your patient!

MA Koenig, M Bryan, JL Lewin, III, MA Mirski, RG Geocadin and RD Stevens Neurology 2008;70;1023-1029; originally published online Feb 13, 2008 253 cases transtentorial herniation 30cc 23.4% saline bolus reversed clinical signs of TTH in 75% Transient hypotension in 17%, no CPM on MRI at 17 days Emergency ICP management

Cerebral Resuscitation: outcomes ?

Long-term outcome after medical reversal of transtentorial herniation in patients with supratentorial mass lesions Qureshi,,Geocadin,Suarez, Ulatowski, CRITICAL CARE MEDICINE 2000;28:1556-1564 11/28 (40%) survived to discharge 7/11 (59%) survivors functionally independent

Cerebral Resuscitation: outcomes Hemicraniectomy for hemispheric stroke (AHA IB) Indication: 50-66% infarction of MCA territory Age:

Patient TG 32M w/ colloid cyst w/ nl exam went into MRI at OSH at 0815 -> emerged from MRI 0900 w/ BP 200/100, pupils blown, extensor posturing, weak B corneals, + cough/gag -> intubated/versed+vecuronium+nipride gtt MRI w acute obstructive hydrocephalus JHH called at 1200; OSH instructed to stop versed/vec, give mannitol 1g/kg bolus (no hypertonic saline available), sedate with propofol, nicardipine only for SBP>220, insert femoral central line in reverse Trendelenburg if possible None of these interventions were implemented

Patient TG Pt arrives at JHH at 1400 Exam: Temp 38.2, BP 220/110, HR 40-120 w/ runs of SVT, 02 sat 100% AC 450/12/5/5/40% Dilated nonreactive pupils +R corneal, -L corneal +cough/gag Overbreathing vent @ RR32 Extensor posturing R, flaccid L No central or arterial line

Patient TG

1400-1410 Pt examined, pacer pads placed, labs drawn Mannitol 1g/kg, 1L 2% saline bolus, 1L NS@100/h Hyperventilation Radial arterial line, femoral line placed -> heart rate stabilized, no change in neuro exam 1410-1414 30cc 23.4% saline bolus -> ? regained L corneal 1414-1417 30cc 23.4% saline bolus -> pupils reactive, pt localizing 1443 Coags back, IVC placed and draining

Cerebral Resuscitation: outcomes

My Cell: 650-906-9521 My Email: [email protected]

Acknowledgements Bill Mobley, MD Bob Carter, MD Alex Khalessi, MD Jeffrey Gertsch, MD Brian Lemkuil, MD Bill Wilson, MD Tom Hemmen, MD Kim Kerr, MD Peter Fedullo, MD Patricia Graham RN, Laura Dibsie RN, and Cassia Chevillon RN Romer Geocadin, MD Marek Mirski, MD COL Geoffrey Ling, MD

CEREBRAL RESUSCITATION FROM ACUTE CATASTROPHIC NEUROLOGIC INJURY: THE BRAIN CODE / ACUTE ICP...

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