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
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Disclosures No financial disclosures Off-label use: propofol
for ICP control
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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
Why do I want you to understand acute ICP management?
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Cerebral Resuscitation: herniation
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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
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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
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Cerebral resuscitation: tonsillar herniation
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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
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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
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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
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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.
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Cerebral Resuscitation: cranial vault mechanics
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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.
Slide 19 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
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Cerebral Resuscitation: herniation
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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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!
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Cerebral Resuscitation: compartment approach to ICP management
Venous blood HOB up 45 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
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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
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Cerebral Resuscitation: outcomes ?
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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
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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
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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
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