Delayed Cerebral Ischemia (Definition)

DEFINITION:

 

Delayed Cerebral Ischemia:

Focal (hemiparesis, aphasia, hemianopia, or neglect) or global (2 points decrease on GCS) neurological impairment lasting for at least 1 hour and/or cerebral infarction, which:
▪ Is not apparent immediately after aneurysm occlusion
▪ Is attributable to ischemia
▪ Is not attributed to other causes (i.e. surgical complication, metabolic derangements) after appropriate clinical, imaging, and laboratory evaluation

 

Cerebral infarction:

Presence of cerebral infarction on CT or MR scan of the brain within 6 weeks after SAH, or on the latest CT or MR scan made before death within 6 weeks, or proven at autopsy; that is:
▪ Not present on the CT or MR scan between 24 and 48 hours after early aneurysm occlusion
▪ Not attributable to other causes such as surgical clipping or endovascular treatment
▪ Not due to a nonischemic lucency related to a ventricular catheter, intraparenchymal hematoma, or brain retraction injury

 

Reference:

Francoeur, Charles L. and Stephan A. Mayer. “Management Of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage”. Critical Care 20.1 (2016): n. pag. Web.

DCI Prevention (Failed Interventions)

Here is a list of failed interventions (so far) for DCI prevention in subarachnoid hemorrhage.

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Table was taken from first reference listed below.  The other references listed are the source articles (RCTs) where the table was based from.

Reference

Francoeur, Charles L. and Stephan A. Mayer. “Management Of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage”. Critical Care 20.1 (2016): n. pag. Web.

van den Bergh WM, Algra A, Dorhout Mees SM, van Kooten F, Dirven CMF, van Gijn J, Vermeulen M, Rinkel GJE. Randomized controlled trial of acetylsalicylic acid in aneurysmal subarachnoid hemorrhage: the MASH Study. Stroke. 2006;37:2326–30.

Petruck KC, West M, Mohr G, Weir BK, Benoit BG, Gentilli F, Disney LB, Khan MI, Grace M, Holness RO, Karwon MS, Ford RM, Cameron S, Tucker WS, Purves GB, Miller JDR, Hunter KM, Richard MT, Durity FA, Chan R, Cleain LJ, Maroun FB, Godon A. Nimodipine treatment in poor-grade aneurysm patients. J Neurosurg. 1988;68:505–17.

Siironen J, Juvela S, Varis J, Porras M, Poussa K, Ilveskero S, Hernesniemi J, Lassila R. No effect of enoxaparin on outcome of aneurysmal subarachnoid hemorrhage: a randomized, double-blind, placebo-controlled clinical trial. J Neurosurg. 2003;99:953–9.

Tseng M-Y, Hutchinson PJ, Richards HK, Czosnyka M, Pickard JD, Erber WN, Brown S, Kirkpatrick PJ. Acute systemic erythropoietin therapy to reduce delayed ischemic deficits following aneurysmal subarachnoid hemorrhage: a Phase II randomized, double-blind, placebo-controlled trial. Clinical article. J Neurosurg. 2009;111(1):171–80.

Hasan D, Lindsay KW, Wijdicks EF, Murray GD, Brouwers PJ, Bakker WH, van Gijn J, Vermeulen M. Effect of fludrocortisone acetate in patients with subarachnoid hemorrhage. Stroke. 1989;20(9):1156–61.

Mees SMD, Rinkel GJE, Vandertop WP, Pablo AA, Lavados M, van Kooten F, Kuijsten HAJM, Boiten J, van Oostenbrugge RJ, Salman RA-S, van den Bergh WM. Magnesium for aneurysmal subarachnoid haemorrhage (MASH-2): a randomised placebo-controlled trial. Lancet. 2012;380(9836):44–9.

Gomis P, Graftieaux JP, Sercombe R, Hettler D, Scherpereel B, Rousseaux P. Randomized, double-blind, placebo-controlled, pilot trial of high-dose methylprednisolone in aneurysmal subarachnoid hemorrhage. J Neurosurg. 2010;112(3):681–8.

Haley EC, Kassell NF, Torner JC. A randomized controlled trial of high-dose intravenous nicardipine in aneurysmal subarachnoid hemorrhage. A report of the Cooperative Aneurysm Study. J Neurosurg. 1993;78(4):537–47.

Zwienenberg-Lee M, Hartman J, Rudisill N, Madden LK, Smith K, Eskridge J, Newell D, Verweij B, Bullock MR, Baker A, Coplin W, Mericle R, Dai J, Rocke D, Muizelaar JP. Effect of prophylactic transluminal balloon angioplasty on cerebral vasospasm and outcome in patients with fisher grade IIi subarachnoid hemorrhage: Results of a phase II multicenter, randomized, clinical trial. Stroke. 2008;39:1759–65.

Lennihan L, Mayer SA, Fink ME, Beckford A, Paik MC, Zhang H, Wu YC, Klebanoff LM, Raps EC, Solomon RA. Effect of hypervolemic therapy on cerebral blood flow after subarachnoid hemorrhage: a randomized controlled trial. Stroke. 2000;31:383–91.

Kirkpatrick PJ, Turner CL, Smith C, Hutchinson PJ, Murray GD. Simvastatin in aneurysmal subarachnoid haemorrhage (STASH): a multicentre randomised phase 3 trial. Lancet Neurol. 2014;13(7):666–75.

Stepwise Treatment of DCI

Management of DCI is presented here as a three-stage algorithm.  Tier One therapy should be initiated for new DCI which can manifest as neurological deterioration, characteristic imaging findings or MMM abnormalities indicating ischemia.  Tier Two therapy hsould be started in cases of refractory DCI(inadequate reversal of ischemia after first-line therapy.)

 

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Reference:

Francoeur, Charles L. and Stephan A. Mayer. “Management Of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage”. Critical Care 20.1 (2016).

 

tPA Dosing Chart + Flowsheets post-tPA

Total Dose = 0.9 mg/kg (maximum dose =90 mg): give 10% of dose as IV bolus over 1minute; infuse remainder over 1 hour
(Reconstitute Activase 100 mg vial with 100 ml sterile water = 1mg/ml)

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IV-tPA-Dosing-Chart

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tPA Dosing Chart

References:

“Acute Stroke Protocol”. Boston Medical Center. N.p., 2017. Web. 16 Jan. 2017.

Strokecarenow.com. (2017). [online] Available at: http://www.strokecarenow.com/wp-content/uploads/IV-tPA-Dosing-Chart.pdf [Accessed 18 Nov. 2017].

Post-operative Orders for Transphenoidal Surgery

Complications after TSP surgery:

  • post-operative hematomas
  • epistaxis
  • ischemic events
  • hydrocephalus
  • CSF leaks
  • meningitis
  • diabetes insipidus

 

Nasal packing

  • for intraoperative leaks requiring sellar floor reconstruction, Cushing’s Disease and acromegaly
  • typically removed POD#1

 

Post-op Epistaxis

  • common occurrence, routine nasal packing x 2-3days
  • if refractory, reoperation or endovascular embolization of arterial bleeder

 

Electrolyte disturbances / DI / hyponatremia

  • strict measurement of Is and Os, daily weight
  • frequent sodium levels
  • UO >250 cc/hr x 2-3 hours – check serum Na and USG
  • DI is usually transient phenomenon
  • DDAVP at bedtime (even if patient can drink to satiety) in clear-cut DI to allow patients to sleep comfortably
  • SIADH and delayed hyponatremia 1 week after – check serum labs on POD#7
    • mild hyponatremia, asymptomatic – manage at home with fluid restriction and f/u labs
    • moderate to severe hyponatremia or symptomatic – admit for fluid restriction, Na checks and hypertonic saline

 

Hypopituitarism

  • preoperative evidence of hypopituitarism
    • stress dose steroids perioperatively ad keep on physiological maintenance doses until appropriate to assess pituitary function in controlled manner
  • evidence of hormonal excess
    • lab testing during first few days after surgery to assess for endocrinological remission
    • if Cushing’s – no steroids during operation unless necessary, check serum cortisol level post-op q6h until nadir, if <5ug/dL, esp if symptomatic hypocortisolemia, immediate glucocorticorticoid therapy IV then transition to physiologic oral maintenance doses until function can be reassessed in delayed and controlled setting
  • normal cortisol function prior to surgery
    • no intraoperative  glucocorticoids
    • assess post-op with AM fasting cortisol on POD#1 and POD#2
    • if new hypocortisolemia (cortisol <10 ug/dL) – start glucocorticoid replacement until reassessed by endocrinologist in delayed fashion
  • Acromegaly
    • POD#1 serum GH level may predict early remission
    • gold standard test is delayed IGF-1 level 6 weeks after surgery
    • successful tumor resection – brisk fluid diuresis of third-spaced fluid, mimics DI – check serum Na and USG
  • Prolactinomas
    • POD1 or POD#2 am prolactin, typically normalizes in cases of remission
  • Check cortisol POD#7 to rule out delayed hypocortisolemia

 

Discharge

  • routine follow-up 1 week after surgery then 6 weeks post-op (for routine endocrine and post-op evaluation) [equilibration of PA axis and longer half-life of thyroid hormone]
  • MRI 3 months after OR to allow resolution of post-op changes and assess extent of tumor resection
  • routine imaging annually or more often as indicated (WOF delayed tumor recurrence up to several years) – continued endocrinological and imagnig surveillance even beyond a decade

 

REFERENCE:

Zada, G. et al.  Asian J Neurosurg. 2010 Jan-Jun; 5(1): 1–6. PMCID: PMC3198670 Perioperative Management of Patients Undergoing Transsphenoidal Pituitary Surgery

 

Reflection Coefficient

Movement of solutes across the blood brain barrier depends on the reflection coefficient of the solute.  Reflection coefficient is defined as the selectivity of the blood brain barrier to a particular substance.  Molecules with a reflection coefficient of 1 are excluded by the blood brain barrier.  As shown in the table below, sodium chloride is effectively “reflected back” or excluded by the blood brain barrier compared to the other osmotic compounds listed.

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Reference:

Qureshi, Adnan I. and Jose I. Suarez. “Use Of Hypertonic Saline Solutions In Treatment Of Cerebral Edema And Intracranial Hypertension”. Critical Care Medicine 28.9 (2000): 3301-3313.

Empiric Antibiotics for Brain Abscess

Base empiric therapy on presumed source of abscess and Gram stain results

Source: mouth, ear, sinus

  • [Penicillin (mouth) OR cefotaxime (ear/sinus)] + [metronidazole]

Source:  neurosurgery / post-op

  • [ceftazidime OR cefepime OR meropenem OR imipenem] + [vancomycin]

Source: penetrating trauma

  • [ceftriaxone or cefotaxime] + [vancomycin] +/- [metronidazole  (sinus involvement)]

Source:  hematogenous spread (IE, multiple abscess)

  • [ceftriaxone or cefotaxime] + [vancomycin] + [metronidazole]

Source: unknown

  • [ceftriaxone or cefotaxime] + [vancomycin] + [metronidazole]

 

Dosages:

  • Cefepime 2g IV q8h
  • Cefotaxime 2g IV q4-6h
  • Ceftriaxone 2g IV q12h
  • Ceftazidime 2g IV q8h
  • Imipenem 500-1000mg q6h
  • Meropenem 2g IV q8h
  • Metronidazole 15mg/kg IV load then 7.5mg/kg IV q8h;  usually 1G load & 500mg q8h
  • Nafcililn 2g IV q4h
  • Oxacillin 2g IV q4h
  • Penicillin G 20-24 M units / day IV in 6 divided doses
  • Vancomycin 15-20mg/Kg IV q8-12h

 

Reference:

Uptodate: Treatment and prognosis of bacterial brain abscess, accessed 01/10/2017.

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Definitions for ICU Infections

Bloodstream infections – (+) blood cultures without evidence of a separate primary source

UTI

  • ≥10,000 CFUs, or
  • (+) urinalysis (i.e. (+) leukocyte esterase or nitrate or >5 WBC/mL) and ≥1000 CFU.

Pneumonia

  • new infiltrate on CXR and (+) sputum culture or change in respiratory status (increased ventilator support or oxygen requirements)

Sinusitis – purulent nasal discharge with corresponding CT imaging

Ventriculitis – (+) CSF culture

CDAD – diarrhea with (+) C. difficile toxin PCR

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Reference:

Halvorson, Karin et al. “Procalcitonin Is A Poor Predictor Of Non-Infectious Fever In The Neurocritical Care Unit”. Neurocritical Care (2017).  Epublished.