1. DISCLOSURES BASED ON EARLY CONSULTATION WITH COMPANY ON DESIGN OF TECHNOLOGY RECEIVED A MINOR STOCK POSITION WITH NEUROLOGICA INC, MAKER OF CERETOM. XENON/CT CBF NOT FDA APPROVED.. XENON/CT CBF INTEGRATED WITHIN CERETM SCANNER BUT AVAILABLE ONLY UNDER AN INVESTIGATIVE PROTOCOL… REAPPROACHING FDA IN 2011…

2. WHAT IS THE ICU STAFF ASKING THEMSELVES?? WHAT DID WE DO WITHOUT A PORTABLE SCANNER?

3. MULTIPLE TRAUMA WITH SEVERE TBI PHYSIOLOGICALLY UNSTABLE WITH ALL THE MONITORS WE KNOW HOW TO PLACE. VENTILATION STATUS MARGINAL…. THIS IS SOMEONE WE DO NOT WANT TO SEE TAKING A “ROAD TRIP”.. WE WERE FORCED TO PROVIDE CARE WITHOUT VITAL ANATOMIC AND PHYSIOLOGICAL DATA

4. BRING HE TECHNOLOGY TO THE PATIENT… DO NOT HAVE TO BE A “ROCKET SCIENTIST ” TO FIGURE THIS OUT….

5. PAST BARRIERS TOMO M (PHILLIPS) -- 1990’S TOO LARGE, TOO HEAVY, TOO UNRELIABLE, TOO DIFFICULT TO USE. CERETOM (NEUROLOGICA)-- 2004+ SMALLER, LIGHTER, MORE RELIABLE, USER FRIENDLY

6. WHY DO WE NEED A PORTABLE SCANNER? BECAUSE MOVEMENT OF MARGINALLY STABLE ICU PATIENTS OUT OF THE UNIT IS DANGEROUS 25% OF HIGH RISK PATIENTS HAVE A COMPLICATION DUE TO TRANSPORT.. COMPROMISES CARE OF PATIENTS REMAINING IN UNIT REDUCES PRODUCTIVITY OF LARGER FIXED SCANNERS

7. WHY A PORTABLE SCANNER BETTER FOR THE PATIENT BETTER FOR OTHER PATIENTS BETTER FOR STAFF (NURSING, INHALATION THERAPY AND MEDICAL) BETTER FOR HOSPITAL LOW COST OF ACQUISITION (1/3 COST OF FIXED SCANNER)

8. WHY NOT IMAGING NOT EQUAL TO FIXED BASED SCANNERS IF NOT EQUAL….VERY CLOSE NOT ENOUGH TECHNICAL SUPPORT MAY NEED MORE CT TECH SUPPORT PERCEIVED LOSS OF CONTROL OF IMAGING TECHNOLOGY BY RADIOLOGY UNIQUE TO EACH HOSPITAL

9. Head Computed Tomography Scanner Technology and Applications: Experience with 3421 Scans Andrew P. Carlson, MD, Howard Yonas, MD From the Department of Neurosurgery, University of New Mexico, Albuquerque, NM. METHODS We describe the clinical use of a portable head CT scanner (CereTom: NeuroLogica: Danvers, MA) that can be brought to the patient’s bedside or to other locations such as the operating room or angiography suite.

10. RESULTS Between June of 2006 and December of 2009, a total of 3421 portable CTs were performed. A total of 3278 (95.8%) were performed in the neuroscience intensive care unit (ICU) for an average of 2.6 neuroscience ICU CT scans per day. Other locations where CTs were performed included other ICUs (n = 97), the operating room (n = 53), the emergency department (n = 1), and the angiography suite (n = 2). Most studies were non-contrasted head CT, though other modalities including xenon/CT, contrasted CT, and CT angiography were performed. CONCLUSION Portable head CT can reliably and consistently be performed at the patient’s bedside. This should lead to decreased transportation-related morbidity and improved rapid decision making in the ICU, OR, and other locations.

11. -STORED IN HALL -BATTERY POWERED -CHARGE MAINTAINED WITH 120 V WALL PLUG -ONE AVERAGE TECH CAN ROLE TO PATIENT -PATIENT HEAD IS STILL AND SCANNER MOVES

12. 2.5 FEET

14. Scattered Radiation Diagram

15. CERETOM CT (Non Enhanced) Acquisition method Axial Acquired in 1.25mm slices Reconstruction On the scanner In real time 1.25mm, 2.5mm, 5mm & 10mm DICOM SOFT WARE IMPROVEMENTS HAVE STEADILY IMPROVED IMAGE QUALITY..

16. Image Comparison Portable CT image Fixed CT image Same patient scanned 24 hours apart on the CereTom and fixed scanner

17. Comparison: Coronal Sinus Images 4 months apart, Same Patient, Same Dose, Same recon settings CereTom GE Lightspeed

18. Various CERETOM Scans

19. CERETOM GOES ELSEWHERE OPERATING ROOM PLACEMENT OF VENTRICULAR CATHETERS EXTENT OF TUMOR REMOVAL– MOST TUMORS ARE EVIDENT WITH CONTRAST PEDIATRIC ICU ANGIO SUITE EVALUATE HEMORRHAGE CBF

20. REMOVE RETRACTOR SYSTEM AND ALL METAL OVER HEAD. 10-15 MINUTES FROM START TO REVIEW OF IMAGES. Intra Operative Scanning

21. DESPITE NAVIGATION TARGETS CAN MOVE DUE TO FIRM CAPSULE

22. TUMORS CAN HIDE

23. REMAINING AVM CAN HIDE --- (DIFFICULT TO DO INTRA OPERATIVE ANGIO IN PRONE POSITION)

24. PEDIATRIC ICU SINGLE ROTATION OF SCANNER CAN IMAGE WITH VERY LOW RADIATION EXPOSURE

25. XENON/CT CBF INTEGRATED WITHIN CERETOM WHY HAVE WE CONTINUED TO PURSUE? ONLY MEANS OF OBTAINING QUANTITATIVE CBF AT BEDSIDE. 24,000 CALCULATIONS PER CT IMAGE X 4 IMAGES SAFEST CONTRAST AGENT WITH VERY RAPID WASHIN AND WASHOUT STUDIES REPEATABLE WITHIN 10 MINUTES

26. BEEN AT THIS FOR A LONG TIME (1978---) ⏎ -REBREATHER- 8 LITERS XE/STUDY -CALCULATION IN 10 SECONDS SEPARATE COMPUTER ---------I HAD SOME HAIR -33% XENON FILLED BAG 20 LITERS/STUDY -GE SCANNER INTEGRATION -CALCULALTION 1 HOUR PER LEVEL ------I HAD LOTS OF HAIR

27. 2009 A NEW XE/CT CBF -INTEGRATED WITH CERETOM -CALCULATION 10 SECONDS IMMEDIATE DISPLAY -REBREATHER (8 LITERS 23% XENON/STUDY) ---- I HAVE MUCH LESS HAIR FINALLY: -RIGHT PLACE -RIGHT TIMING -WITH THE RIGHT STUFF

28. WHY PERSIST?? BECAUSE REAL TOMOGRPAHIC HIGH RESOLUTION CBF IS IMPORTANT! PROBABILITY OF INFARCTION 20 40 cc/100gms/min JOVIN, STROKE 03

30. ENDOVASCULAR REPERFUSION ASSOCIATED WITH HEMORRHAGIC COMPLICATION. GUPTA, 2006 HERNIATION IF INVOLVES MOST OF MCA. FIRLIK, 1999 FAILED REPERFUSION HOUR 48 HOUR 2 HOUR 24

31. NEED REAL NUMBERS TO DECIDE ON VESSEL SACIFICEALL QUALITATIVE METHODS FAIL 50% OF TIME..

32. BASELINE BTO CAROTID OCCLUSION+ BYPASS

33. WHY TOMOGRAPHIC DATA BECAUSE INJURY IS RARELY HOMOGENEOUS, ESPECIALLY IN THE WORLD OF HEAD TRAUMA.. CT DAY 1

34. WHY TOMOGRAPHIC DATA BECAUSE INJURY IS RARELY HOMOGENEOUS, ESPECIALLY IN THE WORLD OF HEAD TRAUMA.. CT DAY 1 CBF

35. WHY TOMOGRAPHIC DATA BECAUSE INJURY IS RARELY HOMOGENEOUS, ESPECIALLY IN THE WORLD OF HEAD TRAUMA. CBF DATA CAN TELL YOU WHERE TO PLACE PROBE AND IMPORTANTLY, HOW TO INTERPRET .. CT DAY ONE CBF CT DAY 2 LICOX PROBE

36. TEST RE TEST XE/CT CBF ALLOWS FOR A RAPID AND DIRECT MEASUREMENT OF RESULT OF PHYSIOLOGICAL CHANGE. SHOULD WE RAISE OR LOWER THE BLOOD PRESSURE??

37. 5 DAYS POST ICA ANEURYSM RUPTURE, NEW LEFT HEMIPARESIS DESPITE BLOOD PRESSURE ELEVATION TO 170 MMHG SYSTOLIC STILL HEMIPARETIC, APHASIC AND ISCHEMIC MCA FLOW 18 CC/100GMS/MIN 170/110 on Dopamine SHOULD BP BE HIGHER AND IF SO HOW HIGH??

38. RAISING PRESSURE FURTHER ELEVATED CBF AND CLEARED DEFICITS. NO LONGER ISCHEMIC. NOW WHAT? ANGIOPLASTY 220/125 on more Dopamine 170/110 on Dopamine QUANTITATIVE INFORMATION PROVIDES NEEDED GUIDANCE

39. DAY 10 POST SAH FROM MCA ANEURYSM WITH SYMPTOMATIC VASOSPASM, ON PRESSORS. WHEN TO WITHDRAW PRESSORS? 168/90 ON NEO 145/80 OFF NEO ?

40. DAY 10 POST SAH FROM MCA ANEURYSM WITH SYMPTOMATIC VASOSPASM, ON PRESSORS. WHEN TO WITHDRAW PRESSORS? 168/90 ON NEO 145/80 OFF NEO TOO SOON!!!!!

41. INTRACEREBRAL BLEED 24 YEAR OLD WOMAN POST PARTUM 170 MMHG WE THINK WE KNOW: BP TOO HIGH, MUST LOWER BLUE < 20 CC/100GMS/MIN LAVENDER <8 CC/100GMS/MIN LEVEL BELOW

42. TOO LOW? 175 mm Hg 140 mm Hg 1 CM ABOVE L Basal Ganglia ICH LEVEL 4 GLOBAL REDUCTION OF FLOW WITH FOCAL INCREASE OF CORE AND PENUMBRA 1 CM BELOW

43. WHAT ABOUTLOWERING CO2 TO IMPROVE ICP??IS THERE A FLOOR??

44. GSW- 18 YEAR OLD, GCS 8 PCO2 38MMHG AND ICP 35 MMGG. Level 4 Level 1 Level 2 Level 3 BASELINE CT pCO2 = 38

45. GSW- 18 YEAR OLD, ICP 35 MMGG. HOW LOW CAN YOU GO WITH CO2? Level 4 Level 1 Level 2 Level 3 BASELINE CT pCO2 = 38 FLOW LOOKS “NORMAL” DESPITE HIGH ICP

46. GSW- 18 YEAR OLD , ICP25 MMHG WITH PCO2 OF 27 MMHG, Level 4 Level 1 Level 2 Level 3 pCO2 = 38 pCO2 = 27 IMPROVED ICP BUT MADE BRAIN ISCHEMIC, WHAT IS THE GOAL?

47. HEAD TRAUMA 12 YEAR OLD, GCS 7 ICP 35 MMHG.PCO2 36 MMHG. LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 BASELINE pCO2 = 36

48. HEAD TRAUMA 12 YEAR OLD, GCS 7 ICP 35 MMHG, PCO2 36 MMGH LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 BASELINE pCO2 = 36 CBF 70 CC/100GMS/MIN WITH LOW GCS, CLEARLY HYPEREMIC. HOW LOW SHOULD PCO2 GO??

49. HEAD TRAUMA 12 YEAR OLD, GCS 7 CO2 24 AND ICP 18 MMGH. WHAT IS OUR GOAL, ICP, CPP, PCO2 OR CBF??? LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 BASELINE pCO2 = 36 pCO2 = 24 mmHg NEED PATIENT SPECIFIC INFORMATION. LUMPING IS EASIER BUT UNDERSTANDING EACH PATIENT HAS TO BE THE GOAL.

50. CAN AN INITIAL XENON/CT CBF STUDY OBTAINED EARLY AFTER SEVERE TBI PREDICT OUTCOME? NIH GRANT PI: CLAUDIA ROBERTSON DAY ONEXENON/CT CBF STUDIES OBTAINED AND OUTCOMES ASSESSED AS PART OF A PROSPECTIVE TBI DRUG TRIAL.. RE ANALYSIS BY ED NEMOTO

51. TN= VOLUME CORTICAL MANTLE WITH FLOW > 30 CC/100GMS/MIN TC+P= VOLUME CORTICAL MANTLE < 30 CC/100GMS/MIN DAY ONE FLOW VALUES PREDICT OUT COME AT ONE AND 6 MONTHS I MO GOS 6 MO GOS

52. THE GOAL HAS TO BE BRINGING THE TECHNOLOGY TO THE PATIENT WITH BOTH FOCAL AND GLOBAL, EPISODIC AND CONTINUOUS MONITORS OF VITAL VARIABLES. QUANTITATIVE TOMOGRAPHIC CBF SHOULD BE PART OF THE GOAL… THANK YOU FOR ALLOWING ME TO SHARE SOME OF OUR EXPERIENCE AT THE UNIVERSITY OF NEW MEXICO..