Critical Care after Neurologic Surgery
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1 Critical Care after Neurologic Surgery Seung-Ki Kim, Ji Hoon Phi, Ji Yeoun Lee, Kyu-Chang Wang Division of Pediatric Neurosurgery Seoul National University Children s Hospital, College of Medicine Seoul, Korea
2 Illustrative Case F/10 Transient ischemic attacks (TIA) right side motor TIA onset: 1 month ago frequency: weekly recent TIA: 2 wks ago before surgery Past medical history: precocious puberty (decapeptyl)
3 1st Operation: Left EDAS Rt facial palsy Rt U/E weakness gr. III Postoperative CT POD #4 Diffusion MRI
4 Second Admission Right motor power: nearly full recovery Right TIA: none after 1 st operation Newly developed left motor TIA: 2 months ago, daily Visited ER due to aggravating left TIAs
5 2nd Op: Right EDAS & BiF Multiple Burr EGS Lt U/E weakness gr. II Postoperative CT POD #1 day CT (11 hrs after 1 st CT)
6 Clinical Course Craniectomy and duroplasty Progressive decreased level of consciousness Thiopental coma therapy Dilated rt pupil Extended craniectomy and lobectomy Progressive infarction involving rt ACA/PCA territory Current Status - left hemiplegic gait - receptive language: good - speech output: none - writing: good
7 V/S ICP monitoring Infusion pump EEG Ventilator I/O Hypothermia EVD
8 Contents Concepts of ICP and CPP ICP monitoring Multimodality monitoring
9 Intracranial Pressure (ICP) Precondition Expandable and soft brain Closed and hard skull Definition Pressure resulting from intracranial components (parenchyme, blood, CSF) Influencing factors Age, posture, activity, blood pressure
10 Components of Central Nervous System Parenchyme (80%; 1400cc) Cerebrum, cerebellum, spinal cord Blood (10%; 150cc) Cerebrospinal Fluid (10%; 150cc) Ventricle Subarachnoid space: cortical & spinal
11 Monro-Kellie Hypothesis Intracranial volume is constant, and it consists of brain, blood, and CSF V = V brain + V blood + V CSF Constant ICP
12 Cerebral Perfusion CPP = MAP ICP Normal range = mmhg CBF regulation Autoregulation CPP = 50 ~ 150 mmhg Metabolic control: e, adenosine Neurogenic regulation: ANS Blood gas regulation: Hypoxia: PaO2 < 60 mmhg Hypercapnia: PaCO2 > 45 mmhg (Most powerful effecter)
13 Increased ICP ICP 20 mmhg Increase in volume Intracranial components: Brain swelling Venous congestion Hydrocephalus New mass: brain tumor, ICH Effect Decrease in cerebral perfusion: Ischemia Compression or herniation of brain
14 Conditions Related to ICP 1. Space occupying mass SDH, EDH, ICH, brain tumor, abscess 2. Increase in brain volume Cerebral infarction, hypoxia-ischemia, acute hyponatremia 3. Increase in brain and blood volume Traumatic brain injury, meningitis, encephalitis, hypertensive encephalopathy, eclampsia, SAH, sinus thrombosis 4. Increase in CSF volume Hydrocephalus, choroid plexus papilloma
15 IICP Symptoms and Signs Symptoms Headache: dura, vessel Nausea, vomiting: area postrema Diplopia Decrease of mental status: decreased CPP Signs Papilledema: venous congestion CN VI (abducens nerve) palsy Open suture line, fontanelle bulging, increase of HC Cushing s reflex (hypertension, bradycardia, irregular respiration) Change of respiration pattern Herniation signs
16 Herniation Subfalcine H Uncal H Transtentorial H Tonsilar H Upward H Vessel compromise Parenchymal injury Cranial nerve compromise Blockage of CSF circulation
17 Uncal Herniation CN III palsy: ptosis, mydriasis, medial gaze limitation PCA territory infarction: Contralateral homonymous hemianopsia Non-communicating HCP: Aqueductal stenosis Duret hemorrhage: Stem injury
18 Central Dogma in Neurointensive Care Maintenance of ICP < 20 mmhg CPP = mmhg ICP monitoring Hyperventilation Head elevation BP control Hyperosmolar or hypertonic saline Management of Nutrition Complications DVT/PE, infection, sore Rehabilitation CSF diversion Decompressive craniectomy Barbiturate coma therapy
19 2007 Guidelines for Traumatic Brain Injury Standard Level 1 (class I) from RCT Guideline Level 2 (class II) prospective, retrospective (reliable data) Option Level 3 (class III) prospective (observational), retrospective
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24 Are they (ICP, CPP, MAP) sufficient for saving brain? Are the thresholds of them really absolute for all patients? Are ICP values measured really exact ones?
25 CBV Brain swelling CBV Vasoconstriction Brain swelling MAP ICP MAP ICP CPP CPP
26 The Pearson s correlation coefficient between ICP and MAP
27 Cerebral Blood Flow (CBF) Perfusion CT/MRI, PET, SPECT, Xenon CT Snapshot Doppler flowmetry Noninvasive, but inaccurate Bowman Perfusion Monitor (BPM) Use of thermal difference Vasospasm in asah Relationship between CBF and CPP Brain water conductivity Water content and edema: brain swelling
28 Microdialysis Minimally-invasive sampling technique Insertion of a microdialysis catheter into the tissue of interest Small solutes can cross the semipermeable membrane by passive diffusion Continuous monitoring of tissue metabolism Theoretically, any molecules Actually, glucose, pyruvate, lactate, glutamate, glycerol
29 Aerobic condition Glucose pyruvate acetyl-coa citric acid cycle LPR (lactate pyruvate ratio): around 15 Anaerobic condition Glucose pyruvate lactate LPR surge (> 25): early metabolic distress LPR and CPP Negative correlation Anaerobic condition Aerobic condition
30 Brain Tissue Oxygen Monitoring Licox, Integra Lifesciences Normal PbtO 2 in the white matter = mmhg At least, more than 15 mmhg
31 MMM in Comatose ICH Patients Ko SB, Stroke 2011
32 Ko et al, JOS 2013
33 Multimodality Monitoring (MMM) Early detection of parametric changes ICP, CPP, CBF, MAP, bto2 Brain metabolism (glucose, lactate, pyruvate) EEG, EKG Identification of causes Brain swelling Tissue hypoxia Seizure Minimization of secondary brain injury
34 Thank you for your attention!
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