The Critically Ill Neurological Patient:
Why Neuro ICU Matters
Julia Durrant, MDDivision of Neurosciences Critical Care
Department of NeurologyOregon Health and Science University
Disclosures
No external sources of financial support to disclose
Outline
• The Dedicated Neuro ICU• The Art of the Neuro ICU
– Cerebral edema/ICP management– Fever control– Seizure control
• Does it work?
Neuro ICU at OHSU
• Founded in 2005• 17 bed unit• 24 hour CT/MRI access• 24 Hour access to EEG techs, Epilepsy faculty• Proximity to OR and Angio suites• 24-7 Neuro-Intensivist coverage with 8 faculty
Patient Population
• Severe ischemic stroke: at risk for cytotoxic edema
• Ischemic stroke following thrombolysis with tPA or thrombectomy
• Cerebral venous thrombosis
Who should be admitted?
• ICU admission:– Stroke complicated by respiratory failure,
myocardial decompensation or uncontrollable hypertension.
– Large mismatch between core infarction and territory
• complex hemodynamic management.
Patient Population
• Intracerebral and intraventricular hemorrhage
• Subdural and epidural hematoma
Patient Population
• Subarachnoid hemorrhage
• Cerebral aneurysms• Cerebral and spinal
vascular malformations
• Brain tumors
Patient Population
• Status epilepticus• Meningitis and
encephalitis• Neuromuscular
disorders in crisis (myasthenia gravis, Guillain-Barre syndrome) and acute myelopathies
Neuroprotection: the goal of neurocritical care
• Assessment of end organ perfusion – No direct laboratory measurements– Physical exam– MRI/CT imaging
• Interval to end-organ failure under adverse conditions can be rapid.
• Further injury to even small regions of brain can have devastating consequences.
What Can We Offer?
• Cerebral resuscitation– “The Brain Code”
• Disease-specific management
• Full complement of subspecialists
• Cutting-edge technology
Cerebral Resuscitation: acute catastrophic neurologic injury
• Catastrophic neurologic injury: ICP herniation
Cranial Vault Mechanics
• Monroe and Kellie– Skull is a rigid container– Cranial contents (brain,
blood, CSF) are viscous gel and incompressible
– Additional volume (pathologic or expansion of the 3 normal contents) will lead to the displacement of another content
87%1400 mL4%
75mL9%150mL
92%4% 4%
79%1%
20%
Saunders NR, Habgood MD, Dziegielewska KM (1999). "Barrier mechanisms in the brain, I. Adult brain". Clin. Exp. Pharmacol. Physiol. 26 (1): 11–9
csf blood brainnormal
abnormal
abnormalmass
Cranial vault mechanics
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.
CBF = CPP/CVR
CD02 = CBF x Ca02
Bratton SL et al. J Neurotrauma 24 (S1): S59-S64, 2007Narotam P, Morrison J et al. Brain tissue oxygen monitoring in traumatic brain injury and major
trauma: outcome analysis of a brain tissue oxygen-directed therapy. JNS (2009) 111 (4): 672-682
ICP<20, CPP>60 = mortality reduction by> 50% in TBI
Cerebral Resuscitation: herniation syndromesSubfalcine HerniationCerebral cortex under falx•Ipsi/contra leg weakness• mental status
Upward HerniationBrainstem up through tentorium• mental status •Dilated pupil (CNIII), ophthalmoplegia•Ipsi paresis/posturing (contra cerebral crus)
Central HerniationBrainstem down through tentorium• mental status •Dilated pupil (CNIII), ophthalmoplegia•Ipsi paresis/posturing (contra cerebral crus) •Basilar stroke
Tonsillar HerniationCerebellar tonsils in foramen magnum•Awake, quadriparesis•Arrhythmia/cardiac arrest•Respiratory arrest
Uncal Herniation mental statusUncus over tentorial notch•Dilated pupil (CNIII), ophthalmoplegia•Ipsi paresis/posturing (contra cerebral crus)• PCA stroke
Reduce Cranial Contents:Blood – vasodilation to constriction
Venous ReturnHyperventilationReduction of CMR02
Brain waterOsmolar therapy for edema
Medical Interventions
Drain CSF Surgical removal of mass
Break the rigid skull - craniectomy
Surgical Interventions
Airway: O2 sat>90%Breathing: normal CO2Circulation CPP> 60mmHg
Head of Bed: • 30 degree, midline
Hyperventilation: • pCO2 30 +/- 2 mmHg
Hyperosmolar therapy• Mannitol IV 1 gm/kg IV• Hypertonic saline (CVL)
o 3% NaCl or 23.4% NaClNormothermia/?HypothermiaPharmacologic Coma
Brain Code
Cerebral Resuscitation: compartment approach to ICP management
Venous blood-HOB up-Neck straight-No IJ lines, do not lay flat for lines-Do no use venodilating BP agents
CSF-Place IVC-Change popoff
Lesion-Blood, tumor, pus -> surgery-Air-> 100% NRB, surgery
Arterial blood-Hyperventilate-Avoid hyperemia: MAP target 60, Pa02>50-Decrease metabolism: sedation, cooling
Brain parenchyma-Osmotherapy (mannitol, hypertonic saline)-Steroids only if appropriate (Vasogenic edema)
Cerebral Resuscitation: arterial compartment
Arterial blood-Hypervent -Avoid hyperemia: MAP target 60, Pa02>50-Decrease metabolism: sedation, cooling
Kramer A, Zygun D. Anemia and red cell transfusion in neurocritical care. Critical Care 2009 13:R89
Cerebral Resuscitation: compartment approach to ICP management
Venous blood-HOB up-Neck straight-No IJ lines, do not lay flat for lines-Do no use venodilating BP agents
CSF-Place IVC-Change popoff
Lesion-Blood, tumor, pus -> surgery-Air-> 100% NRB, surgery
Arterial blood-Hyperventilate-Avoid hyperemia: MAP target 60, Pa02>50-Decrease metabolism: sedation, cooling
Brain parenchyma-Osmotherapy (mannitol, hypertonic saline)-Steroids only if appropriate (Vasogenic edema)
Cerebral Resuscitation: venous compartment
Venous blood-HOB up-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: compartment approach to ICP management
Venous blood-HOB up-Neck straight-No IJ lines, do not lay flat for lines-Do no use venodilating BP agents
CSF-Place IVC-Change popoff
Lesion-Blood, tumor, pus -> surgery-Air-> 100% NRB, surgery
Arterial blood-Hyperventilate-Avoid hyperemia: MAP target 60, Pa02>50-Decrease metabolism: sedation, cooling
Brain parenchyma-Osmotherapy (mannitol, hypertonic saline)-Steroids only if appropriate (Vasogenic edema)
Cerebral Resuscitation: CSF compartment
CSF-Place IVC-Change popoff
Cerebral Resuscitation: compartment approach to ICP management
Venous blood-HOB up-Neck straight-No IJ lines, do not lay flat for lines-Do no use venodilating BP agents
CSF-Place IVC-Change popoff
Lesion-Blood, tumor, pus -> surgery-Air-> 100% NRB, surgery
Arterial blood-Hyperventilate-Avoid hyperemia: MAP target 60, Pa02>50-Decrease metabolism: sedation, cooling
Brain parenchyma-Osmotherapy (mannitol, hypertonic saline)-Steroids only if appropriate (Vasogenic edema)
Cerebral Resuscitation: Brain parenchyma
Brain parenchyma-Osmotherapy (mannitol, hypertonic saline)-Steroids only if vasogenic edema- Surgery (hemicrani, SOC)
Cytotoxic Vasogenic Hydrostatic
Cerebral Resuscitation: Brain parenchyma
Reflection Coefficient
Osmotic Load
Hinson et al, J Intensive Care Med (2011)
Solution Concentration Sodium Concentration (mEq/L) Osmolarity (mOsm/L)
Ringer's lactate 130 2750.90% 154 3082.00% 242 6843.00% 513 1062
Mannitol 20% n/a 1098Mannitol 25% n/a 1375
7.50% 1283 256623.40% 4004 8008
P.S. 1L of NS is 3.5g of Na+ in 1 liter of free water
Cerebral Resuscitation: Brain parenchyma
• Both improve rheology of erythrocytes increases deformability through small capillaries
•Mannitol easier to give: no central line
•HS increases vascular volume improves CBF up to 23%
HS reduces inflammatory response by reducing PMN adhesion to microvasculature
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
Recent Trials
Hinson et al, J Intensive Care Med (2011)
Author/Year Type of Prospective Trial Agent
Condition(s) Treated
Number of Patients? Outcome
Ichai/2009Randomized Controlled
3% sodium lactate v. 20% mannitol TBI 34
HS>Mannitol for êICP, éGOS
Francony/2008Randomized Controlled
7.5% HS v. 20% mannitol
TBI + Stroke 20 Both êICP
similarly
Battison/2005Randomized Controlled
20mL 20% mannitol v. 100mL 7.5% HS dextran TBI + SAH 9 HS>mannitol
for êICP
Harutjunyan/2005Randomized Controlled
7.2% HS + 6% HES v. 15% mannitol
Neurosurgpatients 40 HS>mannitol
for êICP
Vialet/2003Randomized Controlled
7.5% HS v. 20% mannitol TBI 20
HS>Mannitol for reducing elevated ICP episodes
Adverse Effects
Hinson et al, J Intensive Care Med (2011)
Complication Mannitol Hypertonic Saline
Renal FailureAvoid continuous infusion, repeat high dosing
Avoid prolonged hypernatremia >160mEq/L
ReboundAllow clearance prior to repeat dosing
Allow clearance prior to repeat dosing
Metabolic Acidosis n/aReduce chloride in admixture
Hypokalemia n/a Add potassium to fluids
HypovolemiaConcurrent volume resuscitation n/a
Cerebral Resuscitation: compartment approach to ICP management
Venous blood-HOB up-Neck straight-No IJ lines, do not lay flat for lines-Do no use venodilating BP agents
CSF-Place IVC-Change popoff
Lesion-Blood, tumor, pus -> surgery-Air-> 100% NRB, surgery
Arterial blood-Hyperventilate-Avoid hyperemia: MAP target 60, Pa02>50-Decrease metabolism: sedation, cooling
Brain parenchyma-Osmotherapy (mannitol, hypertonic saline)-Steroids only if appropriate (Vasogenic edema)
Cerebral Resuscitation: Lesion
• Surgical evacuation: STICH– Subjects with ICH (≥2cm) randomized to early (<24 hours)
surgical evacuation v. medical management– No benefit to early surgery in general– Superficial lesions, large cerebellar lesions (≥3cm) may
benefit– Summary: “Except for possibly those with superficial
ICHs, craniotomy at 1 day or longer after onset is not better than initial conservative medical treatment with or without later craniotomy for patients who have deterioration.”
Mendelow AD, et. al. STICH investigators. Lancet. 2005; 365 (9457): 387–97.
Malignant Middle Cerebral Artery Stroke
• 1-10% of patients with supratentorial infarcts– life-threatening edema with
peak edema on day 2-5• Mortality of entire MCA
territory is 78%, thus “malignant MCA infarction”– Including maximal medical
intervention• Midline shift peaked after 2-4
days for those who died,– 3-7 days for survivors.
Cerebral Resuscitation: Lesion
• Hemicraniectomy in stroke: DECIMAL, DESTINY, HAMLET– All small trials showed non-significant trend
toward benefit of hemicraniectomy– Meta-analysis suggests an absolute risk reduction
of 13%– Patient selection?
• Non dominant hemisphere• Age of patient
Jüttler E. Stroke. 2007 Sep;38(9):2518-25.
Disease Specific Management: Ischemic Stroke
• Hemorrhagic Transformation• CT study shows ~1-5% hemorrhagic
transformation– ranges from minor petechial bleeding to major
mass-producing hemorrhage• Use of antithrombotics, anticoagulants,
thrombolytics increase risk – NINDS ICH: 6.4% of tPA treated patients versus
0.6% in the placebo group, and mortality was 47%
Disease Specific Management: Subarachnoid Hemorrhage
• Feared Complications:– Hydrocephalus– Aneurysm re-rupture– Seizures– Vasospasm– Stressed myocardium– Neurogenic pulmonary edema
Disease Specific Management: Subarachnoid Hemorrhage
Blood pressure management Use of intermittent labetalol boluses or continuous infusion of
nicardipine to maintain SBP less than 140 mmHg (unsecured) Vasospasm prophylaxis
Nimodipine 60 mg every 4 hours for 21 days Vasospasm monitoring
Daily transcranial doppler sonography for 14 days Hydrocephalus treatment
Extraventricular Drain (EVD) placement
Cardiac Support after SAH
• Reduced Ejection Fraction or Symptomatic Vasospasm– Fluids, vasopressors– Hemodynamic monitoring
Fever
• ~50% of stroke patients develop fever1
• Body temp > 37.5°C significantly correlates with poor outcomes2
• Fever in first 24 hours linked to infarct volume3
• Induced normothermia may reduce metabolic stress4
1. Stroke 1998;29: 2455–60. 2. Stroke 1995;26:2040–3. 3. Acta Neuropathol 1991;81:615–25. 4. Stroke 2009;40:1913–16
Fever and Hypothermia
• Fever treatment– Acetaminophen– Cooling blankets– Intravascular cooling devices
• Hypothermia– Not Standard of Care– No clinical evidence yet to support its use– National Acute Brain Injury Study: Hypothermia II
terminated early for futility1
1. GL Clifton, A Valadka, D Zygun et al. Lancet Neurol, 10 (2011), pp. 131–139
Glucose• Elevated serum glucose increases tissue necrosis and edema.
• Hyperglycemia >200mg/dl is a predictor of poor outcome in ICU patients.
• Hypoglycemia (<60mg/dl) can result in focal neurological deficits.
• The goal of care is to achieve normoglycemia (80-140 mg/dl) with insulin infusion.
Seizures after Stroke
• Seizures occur in ~ 9% of patients1
– Greater risk after hemorrhagic stroke– ~2.5% have recurrent seizures– Stroke location modifies risk
• Routine prophylaxis not recommended2
• Seizure always on differential in depressed mental status– Continuous EEG helpful in making diagnosis
1. Arch Neurol. 2000 Nov;57(11):1617-22. 2. Stroke. 2010; 41: 2108-2129
Cardiac management
• ST-T changes can be seen in large ischemic strokes
• Diffuse or confined to a cardiovascular territory• Myocardial ischemia should always be excluded• “Brain T-wave changes” do not predict cardiac
morbidity• Autonomic reciprocal innervation to the
temporal lobes may produce arrhythmias in patients without pre-existing coronary disease
Does Neurocritical Care matter?
• Improved Mortality for ICH patients
Critical Care Medicine. 29(3):635-640, March 2001.
Does Neurocritical Care matter?
• Reduced Mortality
• Shorter LOS• More
discharges to home/rehab
Journal of Neurosurgical Anesthesiology. 13(2):83-92, April 2001.
Does Neurocritical Care matter?
• Reduction in mortality after Neuro-intensivist appointed
Critical Care Medicine. 32(11):2191-2198, November 2004.
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
Does Neurocritical Care matter?
YES!
Thank you!
• Questions?