Tag Archives: neurology

Blood Pressure Augmentation in DCI

HIMALAIA Study – Netherlands. The only RCT looking at efficacy of BP augmentation in DCI in increasing cerebral blood flow (via CT perfusion).  Small n, negative study.

Tey article – XeCt to measure regional CBF, at onset of DCI suspicion, 5 days of induced HTN, hypervolemia, hemodilution. Compared XeCT before and after treatment and showed increase in regional CBF in worst vascular territories from 19 to 227ml/100g/min, significant reduction of regions with CBF <20ml/100g/min from 26 to 10%.

Indications:

  1. decrease in GCS >=1
  2. new focal deficits
  3. other etiologies excluded:
    1. worsening HCP
    2. recurrent bleeding
    3. epilepsy
    4. infectious disease
    5. hypoglycemia
    6. hyponatremia
    7. metabolic enceph from renal or liver failure

 

Baseline echo:  cardiomyopathy is a contraindication

Drug of choice:  Induce HTN with norepinephrine? based on reference below (we usually use phenylephrine)

End points:

  1. improvement of neurologic deficits
  2. occurrence of complication
  3. MAP 130 mm Hg
  4. SBP 230 mm Hg

 

Risks of Induced HTN:

  1.  line placement risks
  2. vasopressor risks
  3. can induce PRES, neurologic deterioration

 

Literature does not support the use of induced HTN, but how can we ignore bedside observations of patients who clinically improve with induced HTN?

Critique:

  1. Uses surrogate physiologic endpoints (CBF / cerebral o2 delivery). Are we looking at the right endpoint?  CBF correlates with cerebral O2 delivery assuming that other factors are constant (cerebral metabolism, arterial O2 content, partial pressure of O2 and CO2).
  2. Different patients have varied responses to induced HTN.  Induced HTN increases CBF only if cerebral autoregulation is distupted.

 

Dr. Diringer’s Advice: use induced HTN in a thoughtful and individualized manner.  Trial of induced HTN at onset of DCI.  If patient improves, continue.  If no change, back off and explore alternative treatments. If patient exam is poor (no followable exam), answer less clear but prolonged extreme elevations should be avoided.

References:

Gathier, C., Dankbaar, J., van der Jagt, M., Verweij, B., Oldenbeuving, A., Rinkel, G., van den Bergh, W. and Slooter, A. (2015). Effects of Induced Hypertension on Cerebral Perfusion in Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. Stroke, 46(11), pp.3277-3281.

Diringer, M.  Editorial. Hemodynamic Therapy for Delayed Cerebral Ischemia in SAH.  Neurocritical Care Journal.  Pre-print.

 

 

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Pediatric GCS (Glasgow Coma Scale)

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References

Garvin, R. and Mangat, H. (2017). Emergency Neurological Life Support: Severe Traumatic Brain Injury. Neurocritical Care, 27(S1), pp.159-169.

TIA Management

Low-risk TIA

  • ABCD scores 0-3
  • out patient work-up in the next 1-2 days
  • alternative is to admit
  • begin ASA 81mg or plavix 75 or ASA 25/ER dipyridamole 200mg BID
  • perform carotid imaging: US, CTA, MRA
  • consider TTE (if bilateral infarcts on CT, high suspicion of cardioembolic source and TTE normal – obtain TEE)
  • consider 30d ambulatory cardiac monitor to document cryptogenic Afib
  • smoking cessation
  • Statins:
    • start high-dose statin (atorvastatin 40-80; rosuvastatin 20-40)
    • consider mod intensity statin if >75 y/o (atorvastatin 10-20, rosuvastatin 5-10, simvastatin 20-40, pravastatin 40-80)
  • consider anticoagulation if ECG (+) Afib, calculate CHADS or CHADSVASC and HAS-BLED scores
  • ? Referral to vascular neurologist or cardiologist

 

High-Risk TIA:

  • admit
  • permissive HTN
  • gradually lower BP limits over 24-48h

 

 

Reference:

Gross, H. and Grose, N. (2017). Emergency Neurological Life Support: Acute Ischemic Stroke. Neurocritical Care, 27(S1), pp.102-115.

Criteria for Thrombectomy / Endovascular Treatment of Stroke

Patients eligible for intravenous alteplase should receive intravenous alteplase even if endovascular treatments are being considered

Patients should receive endovascular therapy with a stent retriever if they meet all the following criteria:

  1. prestroke mRS score 0–1,
  2. acute ischemic stroke receiving intravenous alteplase within 4.5 h of onset
  3. causative occlusion of the internal carotid artery or proximal MCA (M1),
  4. age >18 years, (note: there is no upper age limit),
  5. NIHSS score of C6,
  6. ASPECTS of C6
  7. treatment can be initiated (groin puncture) within 6 h of symptom onset

As with intravenous alteplase, reduced time from symptom onset to reperfusion with endovascular therapies is highly associated with better clinical outcomes

When treatment is initiated beyond 6 h from symptom onset, the effectiveness of endovascular therapy is uncertain for patients with acute ischemic stroke who havecausative occlusion of the internal carotid artery or proximal MCA (M1)

In carefully selected patients with anterior circulation occlusion who have contraindications to intravenous alteplase, endovascular therapy with stent retrievers completed within 6 h of stroke onset is reasonable

Although the benefits are uncertain, use of endovascular therapy with stent retrievers may be reasonable for carefully selected patients with acute ischemic stroke in whom treatment can be initiated (groin puncture) within 6 h of symptom onset and who have causative occlusion of the M2 or M3 portion of the MCAs, anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries

Endovascular therapy with stent retrievers may be reasonable for some patients <18 years of age with acute ischemic stroke who have demonstrated large vessel occlusion in whom treatment can be initiated (groin puncture) within 6 h of symptom onset, but the benefits are not established in this age group

Observing patients after intravenous alteplase to assess for clinical response before pursuing endovascular therapy is not required to achieve beneficial outcomes and is not recommended

Endovascular therapy with stent retrievers is recommended over intra-arterial fibrinolysis as first-line therapy

It might be reasonable to favor conscious sedation over general anesthesia during endovascular therapy for acute ischemic stroke. However, the ultimate selection of anesthetic technique during endovascular therapy for acute ischemic stroke should be individualized based on patient risk factors, tolerance of the procedure, and other clinical characteristics

Reference:

Gross, H. and Grose, N. (2017). Emergency Neurological Life Support: Acute Ischemic Stroke. Neurocritical Care, 27(S1), pp.102-115.

Checklist: Bleed post TPA

img_1637

Half life of TPA is ~5 minutes and only 20% is present and active 10 mins after completion of infusion, but PT and PTT prolongation and fibrinogen levels are decreased x 24 hours or more.

Checklist:

  • STOP alteplase
  • VS q15h, GCS, pupil response, treat BP, increased ICP
  • Neurosurgery consult
  • DIAGNOSTICS: STAT CT head, PT/PTT, platelets, fibrinogen, type and cross 2-4 unit pRBC
  • THERAPEUTICS:
  1. Transfuse cryoprecipitate 6-8 units IV
    1. If fibrinogen 50-100mg/dL transfuse 10 bags
    1. If fibrinogen <50 mg/dL transfuse 20 bags
  2. Check fibrinogen level 30-60 mins post transfusion, goal fibrinogen level >100 mg/dL
  3. ALTERNATIVE: transfuse single donor platelets or 6-8 bags of random donor platelets

*each bag of cryoprecipitate contains 200-250 mg of fibrinogen, increases fibrinogen levels by 6-8 mg/dL (in a 70 Kg adult)

*half life of fibrinogen is 3-5 days

Reference:

Gross, H. and Grose, N. (2017). Emergency Neurological Life Support: Acute Ischemic Stroke. Neurocritical Care, 27(S1), pp.102-115.

Manual Inline Stabilization

img_1635

Demonstration of MILS or Manual In-Line Stabilization.

– maintain head in neutral position

– assistant to intubation stands by patient as shown above, with hand on either side of head between mastoid process and the occipital

– assistant holds head steady while opposing the applied forces of airway manipulation (gently)

This technique is used for patients with suspected cervical spine injuries. A jaw-thrust maneuver should be used instead of head-tilt/chin lift maneuver. Do not use cricoid pressure. Use of video laryngoscopes may be necessary.

 

Reference:

Rajajee, V., Riggs, B. and Seder, D. (2017). Emergency Neurological Life Support: Airway, Ventilation, and Sedation. Neurocritical Care, 27(S1), pp.4-28.

Thrombectomy Inclusion / Exclusion Criteria

Modified from MR CLEAN Trial:

  1. Criteria modified from MR CLEAN trial:
    • Clinical diagnosis of stroke, NIHSS >=2, ASPECTS >=6 on noncontrast CT
    • CT/MRI evidence rule out ICH
    • Intracranial occlusion of distal ICA or M1 M2 or A1 A2 arteries demonstrated with CTA / MRA or DSA
    • Sufficient time to initiate thrombectomy within 6 hours of onset
    • Informed consent
    • >=18y
  2. Exclusion
    • BP >185/110 mm Hg
    • Glu <2.7 or >22.2
    • s/p tPA with dose >0.9mg/Kd or 90mg
    • coagulopathy (Plt <40, INR >3)

 

References

A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. (2015). New England Journal of Medicine, 372(4), pp.394-394.

Uptodate: Reperfusion therapy for acute ischemic stroke.  Accessed 09/11/2017.