Nuances of interventional neurosurgery: Brain hemorrhages

ACVLS 2019

Aashish Anand, MD

Interventional Neurosurgery and Critical Care Neurology

50-year-old M with h/o of HTN and HLD presents with bifrontal worst headache of his life and nausea. He becomes obtunded in the ambulance and is immediately intubated on arrival to the ER.

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What is the next step after ABC?

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SAH/Aneurysm Workflow

• SAH Workflow Activate Stroke Team if ACH or SBH ED

Contact Regional Call Center (RCC) X 54166 to initiate communication with Summa

SAH/Aneurysm on call physician from ALL Summa ED’s

Summa NeuroIntervention determines treatment and contacts Neurosurgery if indicated

RCC contacts Critical Care, who contacts Neuro Critical Care (if not already involved)

If transfer to UH, contact UH transfer center

Critical Care air transport preferred

• ED to SAH/Aneurysm On Call Physician Communication Clinical presentation, LOC, motor exam, pupils, GCS, Hunt & Hess grading scale, VS

CT results, including fisher Grading scale done by radiology, and presence of

hydrocephalus

Airway status

Sedation meds given

Other acute medical issues

Home meds Mode of Transport

ED Subarachnoid Hemorrhage Protocolo CTA head & neck if not already done

o CXR if difficulty breathing, low sat or suspicion of aspiration

o PT/PTT/INR, CBC, BMP, troponin, tox screen if not done

o 12 lead EKG if not already done

o O2, keep sats > 94%

o Bedrest, HOB 30 degrees

o NS at 50 cc/hr

o Intubate if GCS < 8

o EVD at 20 cm H20, prior to transfer if symptomatic hydrocephalus

o SBP goal < 140, titratable agent preferred

o Cardene gtt .1mg/ml, start at 5mg/hr. Titrate by 2.5 mg/hr every 5 min. Max dose 15 mg.

o Labetalol 10 mg IVP every 10 min. times 3 doses. Hold HR < 60. Max 40 mg over 1 hour.

o Hydralazine 10 mg IVP every 15 min. Hold HR > 100. Max dose 40 mg total.

o AED Prophylaxis:

o Levetiracetam (Keppra) loading dose 1000mg IVPB STAT

o OR Phenytoin 20mg/kg IVPB STAT

o Active Seizure:

o Levetiracetam (Keppra) loading dose 1000mg IVPB STAT

o Valproate Injection loading dose 20mg/kg IVPB STAT

o Phenytoin 20mg/kg IVPB STAT

o Comfort: Decadron 4mg IV X1 for ha

o Ondansetron (Zofran) 4mg IVP X1 for nausea

o Anticoagulation Reversal

o Vit K, PCC’s,Non warfarin reversal agents

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Main reasons for further neuro worsening/poor outcome in the first 24-48 hours

1 early hydrocephalus and intracranial hypertension 2 rebleeding 3 seizures

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Management in the first 24-48 hours until the aneurysm is secured 1 early hydrocephalus and intracranial hypertension • Emergent neurosurgical consult and external

ventricular drain where appropriate. Craniectomy and decompression in selected cases

• Medical treatment for intracranial hypertension including mannitol, hypertonic saline

• Head of bed elevation to 30-45°• Adequate sedation and analgesia • Therapeutic temperature management • PCO2 35–45• CPP 55-65

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2 Re-bleeding

• Blood pressure goals to be followed strictly

• Adequate sedation and analgesia. RAAS -1 to 1

• Reversal and correction of coagulopathy Tranexamic acid/EACA. Level 1 evidence lacking

• Identification and securing the ruptured aneurysm

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Coiling vs. Surgical ClippingCase by case selection.While coiling is the favored option for ruptured aneurysm, surgical clipping has important indications and may be the only option in some patients.

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3 seizures Seizure prophylaxis until the aneurysm is secure and/or physical exam to follow

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Main reasons for neuroworsening/poor outcome after 72-96 hours until post-bleed day 21

1 Vasospasm 2 Delayed cerebral ischemia 3 SIADH /cerebral salt wasting 4 Late hydrocephalus

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Management after post-bleed day 2-3 until post-bleed day 14-21

1 vasospasm Start Nimodipine as soon as the patient gets admitted with SAH. RCT shows reduced incidence of neurological deficits from vasospasm.It is important to remember that randomized controlled trial did not find reduced incidence of vasospasm with Nimodipine.

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Most common time for vasospasm is from post-bleed day 4-14

Transcranial Dopplers Frequent neurological exams

Predictors for vasospasm: Modified fissure grade 3 and 4, young age, female gender

Rx vasospasm Triple H therapy Endovascular treatment with intra-arterial vasodilators and in rare cases angioplasty Hypothermia, deep sedation, paralytics in severe cases

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2 delayed cerebral ischemia

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3 SIADH /cerebral salt wasting Intraventricular bleed, severity of bleed predictors of SIADH/cerebral salt wasting . Often found in close association with vasospasm.

SIADH and CWS are not separate disorders but in the same spectrum. The main differentiation is volume status.

Euvolemia or hypervolemia with hyponatremia suggests SIADH. The treatment is water restriction, salt tablets and occasionally cautious use of hyperosmotic solution. Hypovolemia with hyponatremia suggests cerebral salt wasting and the treatment is isotonic/hypertonic saline.

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4 Late hydrocephalus Change in mentation, Sunset eyes, incontinenceVentriculostomy/ definite Sx : VP sunt

50-year-old AAF with abrupt onset right hemiparesis and aphasia. Initially she is alert but becomes increasingly obtunded and is intubated in the ER. Her BP is 220/110 mm Hg.

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ICHPathogenesis of Intracerebral Hemorrhage

Hypertension

Vascular MalformationsSaccular Aneurysms

Arteriovenous Malformations

Dural AVF

Venous Angiomas

Cavernous Angiomas

Bleeding Disorders

Oral anticoagulants

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• CT angiogram

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SPOT SIGN

Deadliest Form of Stroke→Accounts for 10 – 15% of all stroke cases (1)

→Approx. 120K annually in the United States (2)

→ICH early mortality (within 30 days) = 32 – 50% (3)

− 80% of patients are physically disabled (4)

− At 6 months, only 20% of individuals who survive are

functionally independent (5)

Costliest form of Stroke →Impact of ICH

o ICH accounts for ≈ $12.7 billion of the $74 billion

in direct costs related to stroke care annually (6)

o Emergent cases that cost on average $32K per patient (7)

ICH Statistics: Deadliest, Costliest

MASS EFFECTHEMATOTOXICITY

C = 8 x (5mm)

Slice#1

Slice# 8

A

B

Vol = AxBxC/2Vol = 40x25x40/2

Vol = 52.5 cc

Estimation of ICH Volume

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ICH Management

AcuteAVOID HEMATOMA EXTENSION

Treating HYDROCEPHALUS

OPTIMIZE FLOW TO THE AREA OF TAMPONADE

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ICH Management

Acute

AVOID HEMATOMA EXTENSION

Correction of HTN.

SBP < 140 or <160 ( based on new data)

CPP 55-65

Correction of coagulopathy

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ICH Management

AcuteOPTIMIZE FLOW TO THE AREA OF TAMPONADE

HOB 30 %

CPP control / ICP monitor

Optimization of CPP = CO

What about seizures ?

What about temperature ?

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ICH Management

Acute

Ventriculostomy

Sx. Limited role:

Cerebellar ICH: stat neurosurg consult

Poor mental status, >3cm, compression signs, obs hydrocephalus

Decompressive suboccipital craniectomy

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ICH Management

Sx: lobar hemorrhages

DHC was studied in the STITCH trial

Deeper hemorrhages: no benefit

Superficial <2cm from surface hemorrhage: trend towards benefit

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Minimally Invasive surgeries

MISTIE II : ICH volume >20 ccTpa via drainage cath for 72 hours

CLEAR II: tPA with EVD for large IVH

Trend towards benefitComplication rate as well

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APOLLO ASPIRATION. INVEST TRIAL

•MRI brain with and without contrast

•4 vessel angiogram in select cases

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AVM

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REFRACTORY EPISTAXIS AND HEAD AND NECK BLEEDSEndovascular embolization