Parikh – Updates in NeuroCritical Care

Clinical Pearls (assisted by Dr. Helen Prevas)

Post arrest

• Brain injury post-arrest:
  • Caused by hypoperfusion & energy failure
    • Effects areas with high metabolism (basal ganglia, etc.)
  • Targeted Temp Management (TTM)
    • 36C is ideal x 24 hours (then 48-72 hrs normothermia)
    • Caveat: must delay neuroprognostication
• Prognostication (multimodal):
  • EEG is useful in 1st 12h, during rewarming, @ 72h and beyond
  • SSEPs is done @ 72hrs when pt lacks eye opening
    • Assesses integrity of reticular activating system by stimulating median nerve & following somatosensory pathway
  • Biomarkers
    • Trend important ones (NSE, S100 beta) – note not very specific
  • Imaging
    • MRI @ day 3 (more commonly @ 5-6)
      • Use tensor imaging to look at white matter pathways

TBI

• Changing demographic to the older, less severe pts
• Basics:
  • Monro-Kellie hypothesis: fixed cranial volume, so increase in either blood, CSF, or brain parenchymal volume must decrease others or result in elevated ICP)
  • Auto regulation of cerebral perfusion
    • Goal to prevent secondary injury
  • Elevated ICP management (low levels of evidence)
• Hypothermia→ will decrease ICP ~10 mmHg
  • NABISH II – very early hypothermia, potential harm so trial ended early
  • EuroTherm – hypothermia before osmotherapy vs osmotherapy alone (many osmo pts crossed over)
    • Failed as a therapy
  • Therefore: Used only when pt is refractory (3rd tier treatment)
• Difficult to phenotype, attempting to create a registry

ICH

• Hemorrhagic CVA
  • 10-15% all strokes; 40% 30 day mortality; ~20% independent at 6 mos
• Outcome mainly affected by ICH volume and Intraventricular hemorrhage 
  • ICH score (at baseline)
    • GCS
    • ICH volume (≥ or < 30)
    • IVH
    • Location (infratentorial?)
    • Age (≥ or < 80)
  • Clear III (unpublished)
    • Clot removal → EVD and tPA
    • Decreased mortality but no change in disability (modified Rankin 4-5)
  • MISTIE III trial (Phase 3 now enrolling)
    • Goal: reduce ICH volume (has been shown to decrease disability)
    • Again: Clot removal with EVD and prolonged tPA use
• BP management: ICH = loss of autoregulation
  • Interact II – does early intensive SBP control (<140) changed outcomes vs standard of care (<180)?
    • Borderline significance, but is safe
    • Problem: meds used weren’t standardized across trial participants
    • AHA 2015 guidelines: acute decrease in SBP to <140 safe
  • ATACH-2 – SBP <140 vs <180 with standardized tx (Nicardipine)
    • No difference in mortality
    • Increased renal failure in <140 group in 1st 7 days
      • Postulated to be due to the effect on auto regulation by chronic HTN

• Anti-platelet reversal 
  • PATCH: platelet transfusion lead to increase in death + harm
    • Problem: small study group
• Anticoagulation reversal 
  • INCH: INR (>2) reversal w 4 PCC – safe, effective (rapidly brings INR <2)
    • Decreased early hematoma expansion

Ischemic stroke

• GOALS: 4.5h to tPA or 6h to thrombectomy
• Stent retrieval: 5 RCTs on IA & stent assisted clot retriever (NNT of 5)
  • Criteria:
    1. Pre-stroke modified Rankin 0-1 (no deficits)
    2. tPA <4.5h since symptom onset
    3. ICA or prox MCA (M1) lesion
    4. Age ≥18
    5. NIHSS ≥6
    6. ASPECTS ≥ 6
       • CT rating tool (early ischemia) to estimate risk of hemorrhagic transformation (low)
    7. W/in 6 hrs of symptom onset
• MR CLEAN trial: general anesthesia negated endovascular benefit
  • Poor outcome due to hypotension on induction?
  • Goal: titrate conscious sedation to avoid movement and big BP changes

New trends in the field:

• 8-25% of CVA pts have unknown onset time
  • Imaging  (MRI) to look at tissue – i.e., MRI w DWI/FLAIR mismatch
  • tPA for these patients? Thrombectomy? more RCTs upcoming
    • MR-WITNESS – median time to tPA: 11h; safe (only 1.25% secondary ICH)
• Malignant MCA syndrome
  • Swell early and require decompression (NNT 4 for modified Rankin <=3, NNT 2 for survival)
  • SUR1-TRPM4 channel (rapid ATP depletion leads to opening of channel and increased intracellular water) blocked by Glyburide
    • GAMES-RP trial – administration of glyburide did not avoid craniectomy but did show improvement in midline shift + biomarkers