Cerebral Edema

Cerebral Edema A Review and Management PJ Papadakos MD FCCP FCCM Professor Anesthesiology, Surgery and Neurosurgery Director Critical Care Medicine University of Rochester

HOW DO PATIENTS PRESENT ? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

CAVEATS IN BRAIN INJURY ,[object Object],[object Object],[object Object],[object Object]

CEREBRAL RESUSCITATION ,[object Object],[object Object],[object Object],[object Object],[object Object]

MECHANISMS OF INJURY-PRIMARY ,[object Object],[object Object],[object Object]

MECHANISMS OF 2 nd INJURY ,[object Object],[object Object],[object Object],[object Object],[object Object]

PATHOPHYSIOLOGY ,[object Object],[object Object]

Brain trauma BBB disruption diffuse axonal injury edema formation Eicosanoids endocannabinoids necrosis energy failure cytokines SOME of the SECONDARY EVENTS IN TRAUMATIC BRAIN INJURY apoptosis inflammation ROS polyamines Calcium Acetyl Choline ischemia Shohami, 2000 Green – pathophysiological processes; Yellow – various mediators

[object Object],Dynamic Changes Following Stroke/Trauma Days Weeks / Months Weeks/Months Ca , Na + Glut, ROS 8 hrs 7 Necrosis Apoptosis Repair Remodeling Plasticity Functional Recovery I N J U R Y 14 2 Inflammation Barone &Feuerstein JCBF, 1999

MONRO-KELLIE DOCTRINE ,[object Object]

BRAIN: CEREBRAL EDEMA-VASOGENIC (Caused mainly by activation of NMDA receptors by glutamate)

BRAIN: CEREBRAL EDEMA-CYTOTOXIC (Caused mainly by activation of cytokines, ROS and other pro-inflammatory mediators)

[object Object],[object Object],BLOOD: CEREBRAL BLOOD FLOW

BLOOD: CEREBRAL BLOOD FLOW (VOLUME) ,[object Object],[object Object],[object Object],[object Object]

CSF: CEREBROSPINAL FLUID ,[object Object],[object Object],[object Object]

Intracranial Compliance ,[object Object]

GUIDELINES – GENERAL ASPECTS ,[object Object],[object Object],[object Object]

PREHOSPITAL AIRWAY MANAGEMENT ,[object Object],[object Object],[object Object],[object Object]

RESUSCITATION OF BP AND O 2 AND PREHOSPITAL BRAIN-SPECIFIC TX’S FOR SPTBI PATIENTS ,[object Object],[object Object],[object Object],[object Object]

PREHOSPITAL TREATMENTS ,[object Object],[object Object],[object Object]

PREHOSPITAL TREATMENTS ,[object Object],[object Object],[object Object],[object Object],[object Object]

Coup-Contrecoup ,[object Object]

Reversible high T2 signal abnormalities in pre-eclampsia

INDICATIONS FOR ICP MONITORING IN PATIENTS WITH SEVERE TBI ,[object Object],[object Object],[object Object]

INTRACRANIAL PRESSURE MONITORING ,[object Object],[object Object],[object Object],[object Object],[object Object]

THRESHOLD FOR TREATMENT OF INTRA-CRANIAL HYPERTENSION ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

INTRACRANIAL PRESSURE MONITORING TECHNOLOGY ,[object Object],[object Object],[object Object]

CEREBRAL PERFUSION PRESSURE (CPP) ,[object Object]

THE ROLE OF CSF DRAINAGE ,[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],USE OF HYPEROSMOLAR THERAPY

HYPEROSMOLAR THERAPY ,[object Object],[object Object],[object Object],[object Object]

USE OF HYPERVENTILATION in the ACUTE MANAGEMENT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

HYPERVENTILATION ,[object Object],[object Object],[object Object]

THE USE of BARBITURATES in the CONTROL of INTRA-CRANIAL HYPERTENSION ,[object Object],[object Object]

THE USE of BARBITURATES in the CONTROL of INTRA-CRANIAL HYPERTENSION ,[object Object],[object Object],[object Object]

THE ROLE OF TEMPERATURE CONTROL ,[object Object],[object Object]

Ca2+ inf lux Voltag e- Operated Ca2+ specific Receptor- O perated Ca2+ / Cation Ligand-Operated Ca2+/Cation Plasma membrane channels Ca2+ Mitochondrial Ca Uptake Sarco-/Endo-plasmic reticulum Ca Uptake Ca/Mg pump Na-Ca exchg.

Calcium Channel blockers ,[object Object],[object Object]

Coronary/Cerebral Steal The detrimental redistribution of blood flow in patients with atherosclerotic disease from underperfused areas toward better perfused areas Before Vasodilator Stenosis After Vasodilator

DECOMPRESSIVE CRANIECTOMY ,[object Object],[object Object],[object Object],[object Object]

THE USE OF CORTICOSTEROIDS IN THE TREATMENT TBI ,[object Object]

NUTRITIONAL SUPPORT ,[object Object],[object Object],[object Object],[object Object]

THE ROLE of ANTI-SEIZURE PROPHYLAXIS FOLLOWING STBI ,[object Object]

Cerebral Edema

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Cerebral Edema