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Neurosurgical Emergencies cairo 2012
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
16. Side effects of hypothermia
From Polderman KH Intensive Care Med 2004; 30: 757-69
17.
18.
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
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
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 36
31.
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
41. Management of per-procedural complications
•Occurrence is very rapid
•Consequences are devastating
•management must be multidisciplinary : good
communication
PEASE - LINNC 2012 41
45. Complications of subarachnoid hemorrhage
Cardiovascular Neurologic
Respiratory
Hydroelectrolytic Epilepsy
Recurrence of hemorrhage
Vasospasm +++
ICH
Brain death
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