World Neurosurgical Congress (WFNS), Boston, 2009

1. Clinical decisions based on microdialysisdatA in severe head injury P.G.Papanikolaou, E.Papadopoulos, A.Markellos, K.Barkas, S.Stamatiou, A.Venetikidis, N.Papageorgiou, M.Fratzoglou, E.Chatzidakis, T.Kyriakou, T.S. Paleologos, K.Kazdaglis Neurosurgical Department, General Hospital of Nikea - Piraeus, Athens, Greece

2. NOTHING TO DISCLOSE

3. Οur experience Multimodal neuromonitoring in TBI patients using intraparenchymal brain catheters Twist hand drill burr hole Single same burr hole 5.3 mm 3 – lumen cranial bolt (LICOX) ICP, PtiO2, microdialysis

4. Treatment strategies CPP targeted therapy - CPP > 60 mm Hg - ICP < 20 mm Hg - PtiO2 > 20 mm Hg - L / P ≤ 25

5. Catheter’s tip

7. Some centers favour it and not only in Hillered L, Vespa PM, Hovda DA.Translational neurochemical research in acute human brain injury: the current status and potential future for cerebral microdialysis.J Neurotrauma. 2005 Jan;22(1):3-41.

8. Our center’s opinion Clinical decisions based on microdialysisdata -Lactate to Pyruvateconcetrations’ ratio (L/P) - in severe head injury: Treatment protocol of patients with peaks of intracranial hypertension up to 30 mmHg (“group A”) Evaluation of success and duration of thiopenthaladministration (“group B”) Decision for evacuation or not of “border-line” sized hematomas (“group C”)

11. Group A 6 patients episodes of intracranial hypertension up to 30mmHg without significant change of the L/P ratio Decision to treat with mannitol only or to proceed to second tier therapy with barbiturates

12. Group A : Sporadic ICP elevations up to 30mmHg – just sedation and mannitol or something more aggressive ?

13. Group B 6 patients refractory intracranial hypertension treated by barbiturates L/P ratio was the main criteria for evaluation and duration of the treatment

14. Group B : Conservative treatment. Barbiturate therapy for refractory intracranial hypertension. Evaluation of continuation of barbiturate induced coma

15. Normalization of L/P before ICP

16. Discharge CT scan GOS 5 at 6 months

17. Group C 6 patients intracranial hematoma initially treated conservatively L/P ratio in association with ICP determined the decision for a surgical evacuation

18. Group C : 59 yrs, female Evacuation or not?

19. Based on values of L/P<25 : conservative treatment

20. CT scan at two months (discharge) GOS 4 at 6 months

21. GOS

22. Handicaps Difficulty of insertion of the catheter via the 3/lumen bolt Measurement frequency ICU personnel deficiency done by N/S residents Lack of automatic data registration National health system structure : patients -> ICU somewhere else Hospital and social insurance managers not so helpful

23. Conclusions Multimodal neuromonitoring using brain catheters seems to be safe, reliable and useful tool Data provided by microdialysis seems to be helpful taking appropriate clinical decisions Especially useful in barbiturate therapy

24. References 1.Poca MA et al. Percutaneous implantation of cerebral microdialysis catheters by twist-drill craniostomy in neurocritical patients: description of the technique and results of a feasibility study in 97 patients. J Neurotrauma. 2006 Oct;23(10):1510-7. 2. Tisdall MM et al Cerebral microdialysis: research technique or clinical tool. Br J Anaesth. 2006 Jul;97(1):18-25. Epub 2006 May 12 3. Hutchinson PJ. Microdialysis in traumatic brain injury--methodology and pathophysiology. ActaNeurochir Suppl. 2005;95:441-5 4. Martins RS et al. Prognostic factors and treatment of penetrating gunshot wounds to the head. Surg Neurol. 2003 Aug;60(2):98-104 5. Sarrafzadeh AS et al. Detection of secondary insults by brain tissue pO2 and bedside microdialysis in severe head injury. Acta Neurochir Suppl. 2002;81:319-21. 6. Stahl N et al. Intracerebral microdialysis and bedside biochemical analysis in patients with fatal traumatic brain lesions. ActaAnaesthesiol Scand. 2001 Sep;45(8):977-85. 7. Hecimovic I et al. Intracranial infection after missile brain wound: 15 war cases. Zentralbl Neurochir. 2000;61(2):95-102. 8. Goodman JC et al. Lactate and excitatory amino acids measured by microdialysis are decreased by pentobarbital coma in head-injured patients. J Neurotrauma. 1996 Oct;13(10):549-56. 9. Brain Trauma Foundation Guidelines 2007. J Neurotrauma2007;24 Suppl1:S91-5 10. Bhatia A., Gupta A.K. Neuromonitoring in the intensive care unit. I. Intracranial pressure and cerebral blood flowMonitoring.Intensive Care Med (2007) 33:1263–1271 11. Bhatia A., Gupta A.K. Neuromonitoring in the intensive care unit. II. Cerebral oxygenation monitoring and microdialysis. Intensive Care Med (2007) 33:1322–1328