Dr.Jean Mantz presentation

1. Neurosurgical emergencies
Jean Mantz, MD, PhD
Professor and Chair, Department of Anesthesia and
Critical Care
Paris Nord Val de Seine University Hospitals
Université Paris 7 Paris Diderot
INSERM U 676
France

2. Neurosurgical emergencies
 Cephalic and cervical emergencies (life-
threatening)
 Spine compression or trauma (functional
prognosis involved)

3. Cephalic neurosurgical emergencies (adult)
 Brain trauma
 Non-traumatic hematoma
 Subarachnoid hemorrhage (rupture of aneurysm)
 Decompressive craniectomy

4. Brain trauma

5. Prognosis of severe brain trauma
• MORTALITY (overall): 25-30%
•GCS < 8: 40-50%
•GCS 9-13: 3.2%
•GCS 14-15: 1%
• SEQUELAE
– 40% disabilities
Mathé JF et al Ann Fr Anesth Réanim
2005; 24: 688-94

6. Prognosis of brain trauma
 Clinical criteria:
 Age
 GCS <8
 Pupillar reactivity
 CT-scan (Marshall)
 Polytrauma
 Secondary aggravating factors
Fearnside, Br J Neurosurg 1993, 7: 267-79:
Chesnut J Trauma 1993, 34: 216-22
Piek J Neurosurg 1992, 77:901-7

7. Primary brain
injury Secondary
brain injury
 Hypotension
Direct result of trauma  Hypotension +++
 ICH Contusions Hypoxemia
 Oedema Hematomas  Hypercapnia
 Hematomas  Hypocapnia
 Vasospasm  Hyperglycaemia
 Hydrocephaly  Hyperthermia.
 Epilepsy Coagulation disorders
Bleeding
ISCHEMIA
Neuronal death

8. Normal brain regulation
CBF
50 150 CPP
(mmHg)

9. OPTIMAL C.P.P
Guidelines
CPP = 60 -70 mm Hg
Recommandations Brain Trauma Foundation 2003
Coles, Brain 2004
Steiner,JCBFM 2004

10. Autoregulation & ICP
 MAP   ICP
CF Vasodilatation VC
MAP
ICP
CPP

11. No autoregulation :
 MAP   ICP
CF
200
MAP
0
40
ICP
0
CPP

12. Transcranial Doppler
Systolic velocity (VS)
Diastolic velocity (VD)
Velocity
Pulsatility Index
PI= (VS-VD )/VM
Normal < 1,2
s
S D

13. Osmotherapy
Severe brain injury
↑ ICP
bolus mannitol.
before after
ICP 33 mmHg ICP 20 mmHg
MAP 89 mmHg MAP 89 mmHg
CPP 56 mmHg CPP 69 mmHg
Mannitol

14. Corticosteroids ?
NO!
– BRAIN TRAUMA FUNDATION : J Neurotrauma
2000;14:531-35
– CRASH trial, Lancet 2004;364:1321-28
– Cochrane Database Syst Rev. 2005 Jan 25;(1):CD000196

15. Mechanisms of hypothermia-induced
neuroprotection
 Reduces glutamate release
 Limits ca++ influx
 Decreases inflammatory response to ischemia
 Limits edema
 Decreases CMRO2
 Suppresses ROS
 Decreases apoptotic cell death

16. Side effects of hypothermia
From Polderman KH Intensive Care Med 2004; 30: 757-69

19. Neurosurgical emergency indications in brain
trauma
 Extradural hematoma
 Subdural hematoma (> 5 mm or deviation of median line >
5 mm)
 Acute hydrocephaly
 Open fracture
 Compressive fracture
 Intracerebral hematoma > 15 ml (France) or 25 ml (USA)
and deviation of the median line > 5 mm

20. Neurosurgical emergencies: principles of
anesthesia
• Maintain cerebral oxygenation and cerebral
perfusion pressure (norepinephrine)
• Treat life-threatening ICH (mannitol)
• Control paCO2, temperature, bleeding,
coagulation, glycemia, electrolytes
• Use rapid sequence for emergency induction of
anesthesia
• Prefer iv agents

21. Intracerebral hematomas

22. Brain imaging Mayer Stroke 2007

23. Intensive blood pressure reduction in acute cerebral
haemorrhage trial (INTERACT): a randomised pilot trial
The Lancet Neurology - Volume 7, Issue 5 (May 2008)
• Efficacy and safety study
• Inclusion within 6 hours
• SBP < 140 mmHg n= 203 (hematoma: 14.2 ml)
• SBP = 180 mmHg, n=201 (hematoma: 12.7 ml)
• % increase in hematoma at 24 Hours:
– + 13.7% vs 36.3% p=0.04
– Not significant when adjustment to the size of the initial
hematoma
• Safety at D90: NS

24. N Engl J Med
May 2008
• Main goal:
death/severe
sequelae at day 90
• Significant
reduction in the
size of hematoma
• More arterial
thrombotic events

25. Warfarin related ICH
Immediately administer Kaskadil® (PPSB) 20 ml :
25-30 UI/kg PPSB (units of F IX, i.e. 1 ml/kg), infusion rate:
4ml/ minute).
- Vitamin K (oral or iv)
- Goal: obtain INR < 1 ,5.

26. • Spontaneous ICH within
72h > 2cm, GCS > 5
• randomisation: surgery
within 24 hr or medical
treatment
• Outcome at 6 months
• 1033 patients 83 centers
27 countries

27. ICH: Surgical treatment
• Preferential indications
– Hematomas < 1 cm from cortex (class IIb, B)
– Patients with GCS 7-10 with important mass effect
– EVD in case of hydrocephaly or ventricular
hemorrhage
• Technique:
– Craniotomy, decompressive craniectomy
– Aspiration
– Urokinase ou rtPA

28. Nontraumatic subarachnoid hemorrhage

29. All for one
One for all !
neuro-anesthetist
neuro-surgeon
neuro-radiologist neuro-intensivist
PEASE - LINNC 2012 29

30. Clinical/TDM scores
WFNS GCS Deficit Fisher
I 15 0 I 0 blood
II 13-14 0 II Deposit < 1mm
III 13-14 + III Deposit > 1mm
IV 7  12
+/- IV Hematoma or IVH
V 36

32. Initial treatment
 Oxygenation
 MBP 100-120mmHg
 Analgesics, anxiolytics
 Mechanical ventilation if GCS ≤ 8
 Anticonvulsants
 osmotherapy, hyperventilation if appropriate
 Nimodipine
 Discuss endovascular exclusion of aneurysm within
72 hours

33. Surgery vs endovascular procedure
Molyneux, Lancet 2005
RCT 2143 patients
Mortality / dependence 1 yr: 30.9% vs 23.5%, p=0.0001

34. • Indications for surgical emergency clipping
of the aneurysm
1. Anatomy of the aneurysm
- Not accessible to endovascular treatment
- Neck
2. Intracerebral hematoma

35. Interventional neuroradiologic procedures

37. Goals for anesthesia for Interventional
Neuroradiological Procedures
Hemodynamic stability
– Aim at optimal MAP
– Hemodynamic monitoring via arterial catheter,
and urine output (bladder catheter)
– Euvolemia (crystalloids, colloids) via large bore IV
catheters
– Norephinephrine
PEASE - LINNC 2012 37

38. Anticoagulation therapy
•Prevention of per-procedure thrombo-embolic complications
•Baseline activated clotting time (ACT).
•Heparin Bolus : 70-100 UI/kg (aim at prolonged ACT x 2-3)
•Heparin infusion : 35-50 UI/kg/hour (aSAH)
1000 UI/hour (AVM)
•ACT and Heparin cumulative dose follow-up +++ (1q hour or
when additional dose)
•Platelet –function testing to overcoming of clopidrogel
resistance: VerifyNow P2Y12® whole blood assay
PEASE - LINNC 2012 38

40. Per-procedural intracranial bleeding

41. Management of per-procedural complications
•Occurrence is very rapid
•Consequences are devastating
•management must be multidisciplinary : good
communication
PEASE - LINNC 2012 41

42. Bleeding complications
1.Immediate reversal of heparin (Protamine 1UI = 1UI)
2.Decrease bleeding flow  lowering systemic
arterial pressure
3.Immediate neuro-protection :
– Prevent cerebral tissue hypoxia  FiO2 100 %)
– Preventive hypocapnia  PaCO2 30 – 37 mmHg
– Barbiturate coma therapy sodium thiopental
– Cerebral osmotherapy  mannitol 0,25 – 0,5 g/kg
PEASE - LINNC 2012 42

43. 1.INR will stop leakage by coiling
2.Seek immediate neurosurgical advice:
– Cerebral decompression ?
– External Ventricular Drainage ?
PEASE - LINNC 2012 43

44. Occlusive complications: INR management
• Enhance collateral blood flow by raising MAP
• Balloon angioplasty of occluded vessel
• In-situ thrombo-aspiration
• In-situ intra-arterial thrombolytic therapy (r-tPA)
• anti-platelet agents (abciximab)
PEASE - LINNC 2012 44

45. Complications of subarachnoid hemorrhage
Cardiovascular Neurologic
Respiratory
Hydroelectrolytic Epilepsy
Recurrence of hemorrhage
Vasospasm +++
ICH
Brain death

46. Vasospasm : diagnostic
 Predictors:
 Severity of hemorrhage (WFNS, Fisher)+++
 pre-existing hypertension, tobacco, young age, hyperglycemia
 Delay : [D3-D21] , Peak [D5-D15]
 Symptoms :
 déficit,  GCS.
 Fever, hyperleucocytosis
 Angiography
 Mortality ~30%

47. Vasospasm
•neurological deterioration, TransCranial Doppler
examination
•confirmed by Digital Subtraction Angiography (DSA)
•proximal vasospasm : balloon angioplasty
•distal vasospasm : intra-arterial vasodilators (milrinone)
To be
discus
ses
PEASE - LINNC 2012 47

48. Vasospasm : PREVENTION
• Statins and milrinone: unproven efficacy
• Nimodipine ++
– Liposoluble (crosses BBB)
po : 60mgx6/j for 21d (6 weeks if vasospasm)
(Grade A)
iv : 1-2mg/h with ICP monitoring

49. RCT Results
Malignant MCA Yes (6) Not conclusive,
infarction except DECIMAL
Brain trauma No
injury
Subarachnoid No
hemorrhage

50. Decompressive
craniectomy