Conflict of Interest Disclosure J. Claude Hemphill III, MD,MAS. Difficult Diagnosis and Treatment: New Onset Obtundation

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1 Difficult Diagnosis and Treatment: New Onset Obtundation J. Claude Hemphill III, MD, MAS Kenneth Rainin Chair in Neurocritical Care Professor of Neurology and Neurological Surgery University of California, San Francisco Chief, Neurology Service & Director, Neurocritical Care San Francisco General Hospital UC SF NEUROCRITICAL CARE PROGRAM Conflict of Interest Disclosure J. Claude Hemphill III, MD,MAS Salary: None Royalty: None Receipt of Intellectual Property Rights/Patent Holder: None Consulting Fees (e.g., advisory boards): None Fees for Non-CME Services Received Directly from a Commercial Interest or their Agents (e.g., speakers bureau): None Contracted Research: Cerebrotech Medical Ownership Interest (stocks, stock options or other ownership interest excluding diversified mutual funds): Ornim Other: None One Saturday Morning in the ED Physical Examination HPI 28 yo nurse with fever, headache, and URI symptoms Sore neck and some confusion Found by her mother unresponsive and with left arm flexed Was answering yes/no questions for boyfriend 3 hours earlier T 38.5 o C, BP 125/79, HR 113 ST, RR 30, O 2 sat 100% (on FM) Pus in throat (noted on suctioning) Neurological examination Opens eyes to loud voice, no other response to command Groaning but no words Pupils: OS 7 mm NR; OD 5 mm brisk Severe right hemiparesis A>F>L; withdraws left side to pain Emergency neurology consult is called Page 1

Question 1 Next Steps in order What is your first intervention? 1. Stat head CT 2. Broad-spectrum IV antibiotics 3. Lumbar puncture 4. Mannitol 100 gm IV 5.

2 Question 1 Next Steps in order What is your first intervention? 1. Stat head CT 2. Broad-spectrum IV antibiotics 3. Lumbar puncture 4. Mannitol 100 gm IV 5. EEG S t a t h e a d C T 64% B r o a d - s p e c t r u m... 27% L u m b a r p u n c t u r... 2% M a n n i t o l g... 6% E E G 1% Mannitol 100 gm IV was administered stat due to clinical exam of likely left uncal herniation Stat labs and blood cultures drawn Intubated in ED using rapid sequence induction Broad spectrum antibiotics ordered stat (cefepime/ampicillin/vancomycin) Patient sent for stat head CT Question 2 What do you see? 1. Acute ischemic stroke 2. Traumatic brain injury 3. Subdural empyema 4. Herpes encephalitis 5. Cerebral venous sinus thrombosis 19% 0% 51% 6% 24% A c u t e i s c h e m i c... T r a u m a t i c b r a i... S u b d u r a l e m p y e... H e r p e s e n c e p h a... C e r e b r a l v e n o u... Page 2

Acute intervention Patient has left subdural empyema with secondary extensive cerebral venous sinus thrombosis Seeding from untreated sinusitis Taken immediately to OR for left

for thrombectomy Occlusion of SSS & torcula, left transverse & sigmoid sinuses, left IJ Thrombectomy with Penumbra device and balloon IV systemic heparin initiated Hospital Course

3 Acute intervention Patient has left subdural empyema with secondary extensive cerebral venous sinus thrombosis Seeding from untreated sinusitis Taken immediately to OR for left decompressive craniectomy Antibiotics continued (cx Strep anginosus) Right ventriculostomy, brain tissue oxygen, jugular venous oxygen saturation monitors placed POD 1 taken to neuroangio for thrombectomy Occlusion of SSS & torcula, left transverse & sigmoid sinuses, left IJ Thrombectomy with Penumbra device and balloon IV systemic heparin initiated Hospital Course Afebrile, WBC 12,000 Comatose with withdrawal of left side to central pain HD5 ICPs increasing; brain tissue oxygen stable in mid 20s ICP remaining > 25 mm Hg despite CSF drainage, 3% NaCl for Na of 150 Page 3

4 Question 3 What do you do now? 1. Pentobarbital coma 52% 2. Tolerate ICPs up to 30 mmhg 3. Right decompressive craniectomy 4. Repeat neuroir intervention 5. Meet with patient s mother to discuss limiting care due to medical futility P e n t o b a r b i t a l... T o l e r a t e I C P s... 5% R i g h t d e c o m p r e... 23% R e p e a t n e u r o I R... 14% 7% M e e t w i t h p a t i... Hospital Course Pentobarbital coma initiated with continuous EEG monitoring to burst suppression interval of 15 seconds P bt O 2 remained adequate at 23 mmhg ICP initially below 20 mmhg, but after 2d increasing to ~28 mmhg Taken back to neuroangio on HD 10 More thrombectomy Catheter left in SSS with IV t-pa at 3 cc/hr Hospital Course HD13 ICPs remain in low 20s, no other change in condition Blood spurting from ventriculostomy site Neurosurgery stitched site Repeat head CT with no significant hemorrhage NS attending recommends withdrawal of medical support Hospital nurse manager indicates how sorry she is that things turned out this way Understanding limits of aggressive care and when to give up Decision Time What are you going to do? 1. Meet with patient s mother to discuss limiting care due to medical futility 2. Ignore NS and Critical Care attending recommendations to withdraw medical support and continue current care 3. Repeat neuroangio 4. Increase pentobarbital coma 5. Hypothermia therapy M e e t w i t h p a t i... 27% I g n o r e N S a n d... 16% R e p e a t n e u r o a n... 19% I n c r e a s e p e n t o... 6% H y p o t h e r m i a t h... 32% Page 4

$Our Decision HD 29 Continue aggressive care Discontinue SSS infusion Tolerate ICPs in 20s No escalation in care if ICP is refractory or cerebral herniation occurs 8d later, ICP begins to decline into$ replaced Lessons Diagnosis - Subdural empyema Treatment - Cerebral venous sinus thrombosis Decision making in critically ill patients Subdural Empyema Rare occurrence Usually extension or seeding

replaced Lessons Diagnosis - Subdural empyema Treatment - Cerebral venous sinus thrombosis Decision making in critically ill patients Subdural Empyema Rare occurrence Usually extension or seeding

5 Our Decision HD 29 Continue aggressive care Discontinue SSS infusion Tolerate ICPs in 20s No escalation in care if ICP is refractory or cerebral herniation occurs 8d later, ICP begins to decline into teens Pentobarbital weaned Follow Up I was called 10 weeks later by patient Asked for work excuse note She was being asked to return to her job, but she wanted to wait until her skull flap was replaced Lessons Diagnosis - Subdural empyema Treatment - Cerebral venous sinus thrombosis Decision making in critically ill patients Subdural Empyema Rare occurrence Usually extension or seeding from bacterial sinusitis Diagnosis Small subdural fluid collection Contrast enhancement Disproportionate cerebral edema Management Neurosurgical emergency» solution to pollution is dilution» Parafalcine region more difficult surgically Empiric antibiotics Sinus drainage Page 5

6 Cerebral Venous Sinus Thrombosis Evidence & Judgment in NCC Primary or secondary Range of symptoms depending on location and extent AHA CVST Guidelines 2011 Anticoagulation is primary intervention Neuroangio thrombectomy used in refractory symptomatic cases Issue is not SSS, it s the cortical veins that drain into SSS Thus, thrombectomy may not be enough (t-pa or heparin to help restore cortical venous drainage into main sinuses) Level 1 or 2 evidence for interventions in this patient Subdural empyema Rx no CVST Rx no Advanced neuromonitoring in patient with this disease no Understanding pathophysiology can drive management Keys to this case Get the pus out Restore cortical venous drainage Understand that venous ischemia is different Training Residents at UCSF/SFGH Dedicated neurocritical care rotation Collaborative approach with neurosurgery service Focus on neurotrauma Severe TBI management Exposure to mild TBI Use of advanced neuromonitoring tools Emphasis on decision-making in emergency and critically ill patients Diagnosis Treatment Bedside ethics Page 6

Introduction to Neurosurgical Subspecialties:

Introduction to Neurosurgical Subspecialties: Trauma and Critical Care Neurosurgery Brian L. Hoh, MD 1, Gregory J. Zipfel, MD 2 and Stacey Q. Wolfe, MD 3 1 University of Florida, 2 Washington University,