Stroke & Neurovascular Center of New Jersey. Jawad F. Kirmani, MD Director, Stroke and Neurovascular Center

Size: px
Start display at page:

Download "Stroke & Neurovascular Center of New Jersey. Jawad F. Kirmani, MD Director, Stroke and Neurovascular Center"

Transcription

1 Stroke & Neurovascular Center of New Jersey Jawad F. Kirmani, MD Director, Stroke and Neurovascular Center

2 Past, present and future

3 Past, present and future Cerebral Blood Flow

4 Past, present and future Cerebral Blood Flow ICP monitoring

5 Past, present and future Cerebral Blood Flow ICP monitoring Cerebral oxygen monitoring

6 Past, present and future Cerebral Blood Flow ICP monitoring Cerebral oxygen monitoring Cerebral Metabolism

7 Past, present and future Cerebral Blood Flow ICP monitoring Cerebral oxygen monitoring Cerebral Metabolism

8 1940 s:polio Epidemic

9 Iron Lung Wards

10 Neurologists were making decisions regarding mechanical ventilation and various aspects of management of polio patients with respiratory failure.

11 Manual inflation of lungs

12 Manual inflation of lungs Prototype lung inflation device (Boston).

13 Manual inflation of lungs Prototype lung inflation device (Boston). Invention of PPV= Birth of Intensive care unit.

14 Generally applied for patient with respiratory failure in general medical and surgical ICUs.

15 Generally applied for patient with respiratory failure in general medical and surgical ICUs. Neurological patients with coma were often seen as non salvageable.

16 Generally applied for patient with respiratory failure in general medical and surgical ICUs. Neurological patients with coma were often seen as non salvageable. Neurologists gradually withdrew from critical care.

17 Focused exclusively on the care of postoperative patients. Monitoring = neuro checks to detect clinical deterioration as soon as possible

18 Often does not reveal changes in cerebral function until they are irreversible.

19 Our understanding about pathophysiology of outcome from severe TBI improves.

20 Primary Insult Local Immediate Cell bodies Axons Blood vessels Delayed Free radicals Ca+ influx K+ efflux

21 Primary Insult Local Immediate Cell bodies Axons Blood vessels Delayed Free radicals Ca+ influx K+ efflux Hematoma Inflammation Edema Ischemia Increased ICP

22 Primary Insult Local Systemic Stunned Myocardium Immediate Delayed Autonomic dysfunction Cell bodies Free radicals Hypovolumia Axons Ca+ influx Acute lung injury Blood vessels K+ efflux Hematoma Inflammation Edema Ischemia Increased ICP

23 Primary Insult Local Systemic Stunned Myocardium Immediate Delayed Autonomic dysfunction Cell bodies Free radicals Hypovolumia Axons Ca+ influx Acute lung injury Blood vessels K+ efflux Hematoma Inflammation Edema Ischemia Increased ICP Hypoxia Hypotension Hyperthermia Hyperglycemia Acidosis

24 ICP monitoring became more widespread

25 ICP monitoring became more widespread Advanced neuroimaging - Detection of structural lesion, mass effect, shift - CBF measurement with Xe-CT/PET scans

26 Transportation Expertise Static nature

27 Continuous and real time rather than static information. - Brain tissue O2 tension - Neurochemical analysis (microdialysis) - Continuous EEG monitoring - Ultrasound

28 Traditional Alarm the clinician when clinical deterioration has occurred. Reacting to harmful pyhysiologic events

29 Traditional Alarm the clinician when clinical deterioration has occurred. Reacting to harmful pyhysiologic events Multimodality Real time physiologic end points to detect secondary injury in its earliest phase Prevent harmful physiologic events altogether.

30 Past, present and future Cerebral Blood Flow ICP monitoring Cerebral oxygen monitoring Cerebral Metabolism

31 O2 contents of blood=1.34 x Hbx SaO2

32 O2 contents of blood=1.34 x Hbx SaO2 O2 delivery to any tissue=o2 contents x C.O.(flow)

33 Adequate oxygenation requires adequate flow.

34 Adequate oxygenation requires adequate flow. Normal CBF=50ml/100gm/min (20% of total C.O.)

35 Adequate oxygenation requires adequate flow. Normal CBF=50ml/100gm/min (20% of total C.O.) Amount + Duration

36 Adequate oxygenation requires adequate flow. Normal CBF=50ml/100gm/min (20% of total C.O.) Amount + Duration Ischemia=Low CBF Infarction=Neuronal death

37 CPP is driving force of CBF

38 CPP is driving force of CBF CBF = CPP/CVR

39 CBF = CPP/CVR

40

41

42 If volume of one compartment increases, other compartment must decrease, otherwise ICP will increase.

43

44 Compensatory Mechanisms Shift of CSF into spinal compartment. Reduction CBV

45 Compliance

46 Compliance

47 Kety-Schimdt Technique Thermodilution Xenon-CT SPECT/PET Perfusion Weighted MRI

48 Laser Flowmetry Thermal Diffusion (Bowman s Perfusion Monitor)

49

50

51

52

53 Past, present and future Cerebral Blood Flow ICP monitoring Cerebral oxygen monitoring Cerebral Metabolism

54 Headache, nausea, and vomiting, are impossible to elicit in comatose patients. Papilloedema is unreliable marker in acute settings. (Selhorst JB et al: Papilledema after acute head injury. Neurosurgery 1985;16: )

55 Headache, nausea, and vomiting, are impossible to elicit in comatose patients. Papilloedema is unreliable marker in acute settings. (Selhorst JB et al: Papilledema after acute head injury. Neurosurgery 1985;16: ) Pupillary dilatation and decerebrate posturing, can occur in the absence of intracranial hypertension.

56 Signs of brain swelling, such as midline shift and compressed basal cisterns, are predictive of raised ICP, but intracranial hypertension can occur without these findings. (Kishore PRS et al AJNR Am J Neuroradiol 1981;2: )

57 GCS of < 8 and Abnormal CT Scan OR

58 GCS of < 8 and Abnormal CT Scan GCS of < 8 and Normal CT Scan and One of following OR

59 GCS of < 8 and Abnormal CT Scan GCS of < 8 and Normal CT Scan and One of following 1) Age > 40 yrs. 2) Motor posturing 3) SBP < 90 mm Hg OR

60 ICP elevations after SAH result from - CSF outflow obstruction and. - Cerebral edema. (Rordorf G., Acta Neurochir (Wien) 139. (12): ;)

61 ICP control is essential before treatment of the aneurysm and is associated with more favorable outcome by - protection against cortical injury and - facilitation of surgical exposure of the aneurysm. (Rordorf G., Acta Neurochir (Wien) 139. (12): ;)

62 Microtransducers (Subdural/Epidural/Parenchymal) Intraventricular drains

63 Advantages Disadvantages Microtranducers Low infection rate Low risk of hemorrhage Considerable zero drift Cannot be rezeroed after insertion

64 Advantages Disadvantages Microtranducers Low infection rate Low risk of hemorrhage Conciderable zero drift Cannot be rezeroed after insertion Intraventricular Catheters More accurate Allow ICP control by CSF drainage Re-zeroed externally Higher complication rate

65

66 Risk of infection = 10%, which increase with longer duration of monitoring (Czosnyka M., Neurol Neurosurg Psychiatry 75. (6): ;)

67 Antibiotic coating of intraventricular drains may prevent or delay the onset of ventriculitis (Hamilton A.J Neurosurgery 40. (5): ;)

68

69

70 Plateau A Wave

71 Past, present and future Cerebral Hemodynamics ICP monitoring Cerebral oxygen monitoring Cerebral Metabolism

72 D Jugular Venous Oxygen saturation (SjvO2) Brain Tissue Oxygen Pressure (PBO2)

73 Retrograde placement of a catheter equipped with an oximeter. Dominant internal jugular vein Positioned in bulb

74 Indications Severe TBI with GCS < 8. High grade aneurysmal SAH. During neurosurgical procedures.

75 Absolute value in percentage. A-V difference in O2 supply. Hb x SaO2 x 1.34 Hb x SvO2 x 1.34

76 AVDO2 = CMRO2/CBF

77 Adequacy of balance between supply (Cerebral O2 delivery) & demand (Cerebral metabolic rate)

78 Real-time monitoring in NCCU can give immediate insight in the physiologic and metabolic state of brain regions at risk for ischemia and injury. NCCU enhances the potential of early effective interventions to reverse pathologic states in stroke patients.

79

PRACTICE GUIDELINE. DEFINITIONS: Mild head injury: Glasgow Coma Scale* (GCS) score Moderate head injury: GCS 9-12 Severe head injury: GCS 3-8

PRACTICE GUIDELINE. DEFINITIONS: Mild head injury: Glasgow Coma Scale* (GCS) score Moderate head injury: GCS 9-12 Severe head injury: GCS 3-8 PRACTICE GUIDELINE Effective Date: 9-1-2012 Manual Reference: Deaconess Trauma Services TITLE: TRAUMATIC BRAIN INJURY GUIDELINE OBJECTIVE: To provide practice management guidelines for traumatic brain

More information

Lisa T. Hannegan, MS, CNS, ACNP. Department of Neurological Surgery University of California, San Francisco

Lisa T. Hannegan, MS, CNS, ACNP. Department of Neurological Surgery University of California, San Francisco Lisa T. Hannegan, MS, CNS, ACNP Department of Neurological Surgery University of California, San Francisco Era of Clinical Neuro Monitoring Clinical Examination Heart rate Blood Pressure Body temperature

More information

Neurocritical Care Monitoring. Academic Half Day Critical Care Fellows

Neurocritical Care Monitoring. Academic Half Day Critical Care Fellows Neurocritical Care Monitoring Academic Half Day Critical Care Fellows Clinical Scenarios for CNS monitoring No Universally accepted Guidelines Traumatic Brain Injury Intracerebral Hemorrhage Subarachnoid

More information

Standardize comprehensive care of the patient with severe traumatic brain injury

Standardize comprehensive care of the patient with severe traumatic brain injury Trauma Center Practice Management Guideline Iowa Methodist Medical Center Des Moines Management of Patients with Severe Traumatic Brain Injury (GCS < 9) ADULT Practice Management Guideline Contact: Trauma

More information

Perioperative Management Of Extra-Ventricular Drains (EVD)

Perioperative Management Of Extra-Ventricular Drains (EVD) Perioperative Management Of Extra-Ventricular Drains (EVD) Dr. Vijay Tarnal MBBS, FRCA Clinical Assistant Professor Division of Neuroanesthesiology Division of Head & Neck Anesthesiology Michigan Medicine

More information

Medical Management of Intracranial Hypertension. Joao A. Gomes, MD FAHA Head, Neurointensive Care Unit Cerebrovascular Center

Medical Management of Intracranial Hypertension. Joao A. Gomes, MD FAHA Head, Neurointensive Care Unit Cerebrovascular Center Medical Management of Intracranial Hypertension Joao A. Gomes, MD FAHA Head, Neurointensive Care Unit Cerebrovascular Center Anatomic and Physiologic Principles Intracranial compartments Brain 80% (1,400

More information

Current bedside monitors of brain blood flow and oxygen delivery

Current bedside monitors of brain blood flow and oxygen delivery 24. Brain Chemistry Current bedside monitors of brain blood flow and oxygen delivery Global monitors Cannot detect regional abnormalities Local monitors Sample only a small region of the brain and highly

More information

Traumatic Brain Injuries

Traumatic Brain Injuries Traumatic Brain Injuries Scott P. Sherry, MS, PA-C, FCCM Assistant Professor Department of Surgery Division of Trauma, Critical Care and Acute Care Surgery DISCLOSURES Nothing to disclose Discussion of

More information

Multimodal monitoring to individualize care in TBI

Multimodal monitoring to individualize care in TBI Multimodal monitoring to individualize care in TBI Critical Care Canada Forum 2017 October 4 th, 2017 Donald Griesdale MD MPH Associate Professor Department of Anesthesiology, Pharmacology & Therapeutics

More information

Update on Guidelines for Traumatic Brain Injury

Update on Guidelines for Traumatic Brain Injury Update on Guidelines for Traumatic Brain Injury Current TBI Guidelines Shirley I. Stiver MD, PhD Department of Neurosurgery Guidelines for the management of traumatic brain injury Journal of Neurotrauma

More information

9/19/2011. Damien Beilman, RRT Adult Clinical Specialist Wesley Medical Center. Epidural Hematoma: Lens Shaped.

9/19/2011. Damien Beilman, RRT Adult Clinical Specialist Wesley Medical Center. Epidural Hematoma: Lens Shaped. Damien Beilman, RRT Adult Clinical Specialist Wesley Medical Center Epidural Hematoma: Lens Shaped. 1 Epidural Hematoma Subdural Hematoma: Crescent-shaped Subdural Hematoma 2 Cerebral Contusion Cause of

More information

Case 1. Case 5/30/2013. Traumatic Brain Injury : Review, Update, and Controversies

Case 1. Case 5/30/2013. Traumatic Brain Injury : Review, Update, and Controversies Case 1 Traumatic Brain Injury : Review, Update, and Controversies Shirley I. Stiver MD, PhD 32 year old male s/p high speed MVA Difficult extrication Intubated at scene Case BP 75 systolic / palp GCS 3

More information

Traumatic Brain Injury:

Traumatic Brain Injury: Traumatic Brain Injury: Changes in Management Across the Spectrum of Age and Time Omaha 2018 Trauma Symposium June 15, 2018 Gail T. Tominaga, M.D., F.A.C.S. Scripps Memorial Hospital La Jolla Outline Background

More information

8/29/2011. Brain Injury Incidence: 200/100,000. Prehospital Brain Injury Mortality Incidence: 20/100,000

8/29/2011. Brain Injury Incidence: 200/100,000. Prehospital Brain Injury Mortality Incidence: 20/100,000 Traumatic Brain Injury Almario G. Jabson MD Section Of Neurosurgery Asian Hospital And Medical Center Brain Injury Incidence: 200/100,000 Prehospital Brain Injury Mortality Incidence: 20/100,000 Hospital

More information

State of the Art Multimodal Monitoring

State of the Art Multimodal Monitoring State of the Art Multimodal Monitoring Baptist Neurological Institute Mohamad Chmayssani, MD Disclosures I have no financial relationships to disclose with makers of the products here discussed. Outline

More information

INCREASED INTRACRANIAL PRESSURE

INCREASED INTRACRANIAL PRESSURE INCREASED INTRACRANIAL PRESSURE Sheba Medical Center, Acute Medicine Department Irene Frantzis P-Year student SGUL 2013 Normal Values Normal intracranial volume: 1700 ml Volume of brain: 1200-1400 ml CSF:

More information

Perioperative Management of Traumatic Brain Injury. C. Werner

Perioperative Management of Traumatic Brain Injury. C. Werner Perioperative Management of Traumatic Brain Injury C. Werner Perioperative Management of TBI Pathophysiology Monitoring Oxygenation CPP Fluid Management Glycemic Control Temperature Management Surgical

More information

Traumatic brain Injury- An open eye approach

Traumatic brain Injury- An open eye approach Traumatic brain Injury- An open eye approach Dr. Sunit Dr Sunit, Apollo children's hospital Blah blah Lots of head injury Lot of ill children Various methods of injury Various mechanisms of brain damage

More information

INTRACRANIAL PRESSURE -!!

INTRACRANIAL PRESSURE -!! INTRACRANIAL PRESSURE - Significance raised ICP main cause of death in severe head injury main cause of morbidity in moderate and mild head injury main target and prognostic indicator in the ITU setting

More information

Continuous cerebral autoregulation monitoring

Continuous cerebral autoregulation monitoring Continuous cerebral autoregulation monitoring Dr Peter Smielewski ps10011@cam.ac.uk 20/10/2017 Division of Neurosurgery, Department of Clinical Neurosciences Determinants of cerebral blood flow Thanks

More information

Pediatric Head Trauma August 2016

Pediatric Head Trauma August 2016 PEDIATRIC HEAD TRAUMA AUGUST 2016 Pediatric Head Trauma August 2016 EDUCATION COMMITTEE PEER EDUCATION Quick Review of Pathophysiology of TBI Nuggets of knowledge to keep in mind with TBI Intracranial

More information

Severe traumatic brain injury. Fellowship Training Intensive Care Radboud University Nijmegen Medical Centre

Severe traumatic brain injury. Fellowship Training Intensive Care Radboud University Nijmegen Medical Centre Severe traumatic brain injury Fellowship Training Intensive Care Radboud University Nijmegen Medical Centre Primary focus of care Prevent ischemia, hypoxia and hypoglycemia Nutrient & oxygen supply Limited

More information

UPSTATE Comprehensive Stroke Center. Neurosurgical Interventions Satish Krishnamurthy MD, MCh

UPSTATE Comprehensive Stroke Center. Neurosurgical Interventions Satish Krishnamurthy MD, MCh UPSTATE Comprehensive Stroke Center Neurosurgical Interventions Satish Krishnamurthy MD, MCh Regional cerebral blood flow is important Some essential facts Neurons are obligatory glucose users Under anerobic

More information

Positron Emission Tomography Imaging in Brain Injured Patients

Positron Emission Tomography Imaging in Brain Injured Patients Positron Emission Tomography Imaging in Brain Injured Patients Paul Vespa, MD Professor Director of Neurocritical Care UCLA Brain Injury Research Center Outline Clinical Context of imaging Practical issues

More information

Head injuries. Severity of head injuries

Head injuries. Severity of head injuries Head injuries ED Teaching day 23 rd October Severity of head injuries Minor GCS 14-15 Must not have any of the following: Amnesia 10min Neurological sign or symptom Skull fracture (clinically or radiologically)

More information

11/23/2015. Disclosures. Stroke Management in the Neurocritical Care Unit. Karel Fuentes MD Medical Director of Neurocritical Care.

11/23/2015. Disclosures. Stroke Management in the Neurocritical Care Unit. Karel Fuentes MD Medical Director of Neurocritical Care. Stroke Management in the Neurocritical Care Unit Karel Fuentes MD Medical Director of Neurocritical Care Disclosures I have no relevant commercial relationships to disclose, and my presentations will not

More information

Role of Invasive ICP Monitoring in Patients with Traumatic Brain Injury: An Experience of 98 Cases

Role of Invasive ICP Monitoring in Patients with Traumatic Brain Injury: An Experience of 98 Cases 31 Original Article Indian Journal of Neurotrauma (IJNT) 2006, Vol. 3, No. 1, pp. 31-36 Role of Invasive ICP Monitoring in Patients with Traumatic Brain Injury: An Experience of 98 Cases Deepak Kumar Gupta

More information

Evaluation & Management of Elevated Intracranial Pressure in Adults. Dr. Tawfiq Almezeiny

Evaluation & Management of Elevated Intracranial Pressure in Adults. Dr. Tawfiq Almezeiny Evaluation & Management of Elevated Intracranial Pressure in Adults Dr. Tawfiq Almezeiny Objectives Pathophsiology of elevated intracranial pressure. Clinical features and sequences. Management : Investigations

More information

Neurointensive Care of Aneurysmal Subarachnoid Hemorrhage. Alejandro A. Rabinstein Department of Neurology Mayo Clinic, Rochester, USA

Neurointensive Care of Aneurysmal Subarachnoid Hemorrhage. Alejandro A. Rabinstein Department of Neurology Mayo Clinic, Rochester, USA Neurointensive Care of Aneurysmal Subarachnoid Hemorrhage Alejandro A. Rabinstein Department of Neurology Mayo Clinic, Rochester, USA The traditional view: asah is a bad disease Pre-hospital mortality

More information

HEAD INJURY. Dept Neurosurgery

HEAD INJURY. Dept Neurosurgery HEAD INJURY Dept Neurosurgery INTRODUCTION PATHOPHYSIOLOGY CLINICAL CLASSIFICATION MANAGEMENT - INVESTIGATIONS - TREATMENT INTRODUCTION Most head injuries are due to an impact between the head and another

More information

A few Neurosurgical Emergencies. Cathrin Parsch Lyell Mc Ewin Hospital SA Ambulance Service SAAS medstar Spring Seminar on Emergency Medicine 2015

A few Neurosurgical Emergencies. Cathrin Parsch Lyell Mc Ewin Hospital SA Ambulance Service SAAS medstar Spring Seminar on Emergency Medicine 2015 A few Neurosurgical Emergencies Cathrin Parsch Lyell Mc Ewin Hospital SA Ambulance Service SAAS medstar Spring Seminar on Emergency Medicine 2015 Outline Neuroanatomy and physiology (85 slides ) Raised

More information

Any closer to evidence based practice? Asma Salloo Chris Hani Baragwantah Academic Hospital University of Witwatersrand

Any closer to evidence based practice? Asma Salloo Chris Hani Baragwantah Academic Hospital University of Witwatersrand Any closer to evidence based practice? Asma Salloo Chris Hani Baragwantah Academic Hospital University of Witwatersrand Evidence Pathophysiology Why? Management Non-degenerative, Non-congenital insult

More information

ICP (Intracranial Pressure) Monitoring Brain Tissue Oxygen Monitoring Jugular Venous Bulb Oximetry

ICP (Intracranial Pressure) Monitoring Brain Tissue Oxygen Monitoring Jugular Venous Bulb Oximetry ICP (Intracranial Pressure) Monitoring Secondary brain injury may be a direct consequence of intracranial hypertension. Therefore monitoring of ICP and cerebral perfusion pressure (CPP) are immediate priority

More information

TBI are twice as common in males High potential for poor outcome Deaths occur at three points in time after injury

TBI are twice as common in males High potential for poor outcome Deaths occur at three points in time after injury Head Injury Any trauma to (closed vs. open) Skull Scalp Brain Traumatic brain injury (TBI) High incidence Most common causes Falls Motor vehicle accidents Other causes Firearm- related injuries Assaults

More information

DISCLOSURES. Specific TCD clinical applications for patients with traumatic brain injury 1/10/2015. FTE, Private Practice for profit TBI TBI: SCOPE

DISCLOSURES. Specific TCD clinical applications for patients with traumatic brain injury 1/10/2015. FTE, Private Practice for profit TBI TBI: SCOPE DISCLOSURES Specific TCD clinical applications for patients with traumatic brain injury FTE, Private Practice for profit Alexander Razumovsky, PhD, FAHA 38 35 th Annual Meeting 38 35 th Annual Meeting

More information

11/27/2017. Stroke Management in the Neurocritical Care Unit. Conflict of interest. Karel Fuentes MD Medical Director of Neurocritical Care

11/27/2017. Stroke Management in the Neurocritical Care Unit. Conflict of interest. Karel Fuentes MD Medical Director of Neurocritical Care Stroke Management in the Neurocritical Care Unit Karel Fuentes MD Medical Director of Neurocritical Care Conflict of interest None Introduction Reperfusion therapy remains the mainstay in the treatment

More information

perfusion pressure: Definitions. Implication on management protocols. What happens when CPP is too low, and when it is too high? Non-invasive CPP?

perfusion pressure: Definitions. Implication on management protocols. What happens when CPP is too low, and when it is too high? Non-invasive CPP? 7. Cerebral perfusion pressure: Definitions. Implication on management protocols. What happens when CPP is too low, and when it is too high? Non-invasive CPP? Douglas J. Miller Miller JD, Stanek A, Langfitt

More information

Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury*

Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury* J Neurosurg 92:1 6, 2000, Click here to return to Table of Contents Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury*

More information

Clinical Outcome of Borderline Subdural Hematoma with 5-9 mm Thickness and/or Midline Shift 2-5 mm

Clinical Outcome of Borderline Subdural Hematoma with 5-9 mm Thickness and/or Midline Shift 2-5 mm Original Article Print ISSN: 2321-6379 Online ISSN: 2321-595X DOI: 10.17354/ijss/2017/300 Clinical Outcome of Borderline Subdural Hematoma with 5-9 mm Thickness and/or Midline Shift 2-5 mm Raja S Vignesh

More information

Disclosure Statement. Dr. Kadish has no relevant financial relationships with any commercial interests mentioned in this talk.

Disclosure Statement. Dr. Kadish has no relevant financial relationships with any commercial interests mentioned in this talk. Disclosure Statement Dr. Kadish has no relevant financial relationships with any commercial interests mentioned in this talk. Head Trauma Evaluation Primary and secondary injury Disposition Sports related

More information

Trauma is the leading cause of death in the first four decades of life, with head injury being

Trauma is the leading cause of death in the first four decades of life, with head injury being Correspondence to: Mr PJ Hutchinson, Academic Department of Neurosurgery, University of Cambridge, Box 167, Addenbrooke s Hospital, Cambridge CB2 2QQ, UK: p.hutch@which.net ACUTE HEAD INJURY FOR THE NEUROLOGIST

More information

Traumatic Brain Injury

Traumatic Brain Injury Traumatic Brain Injury Mark J. Harris M.D. Associate Professor University of Utah Salt Lake City USA Overview In US HI responsible for 33% trauma deaths. Closed HI 80% Missile / Penetrating HI 20% Glasgow

More information

Recent trends in the management of head injury

Recent trends in the management of head injury Recent trends in the management of head injury Contents: Current concepts of management in TBI Blood pressure and oxygenation Intracranial pressure monitoring Cerebral perfusion pressure Body temperature

More information

Do Prognostic Models Matter in Neurocritical Care?

Do Prognostic Models Matter in Neurocritical Care? Do Prognostic Models Matter in Neurocritical Care? Alexis F. Turgeon MD MSc FRCPC Associate Professor and Director of Research Department of Anesthesiology and Critical Care Medicine Division of Critical

More information

Introduction to Neurosurgical Subspecialties:

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,

More information

Cosa chiedo alla PtO 2

Cosa chiedo alla PtO 2 Cosa chiedo alla PtO 2 Pr Mauro Oddo Department of Medical-Surgical Intensive Care Medicine CHUV-Lausanne University Hospital Faculty of Biology and Medicine, University of Lausanne, Switzerland NEURO

More information

Quiz 43. This quiz is being published on behalf of the Education Committee of the SNACC. Start. Traumatic Brain Injury 101

Quiz 43. This quiz is being published on behalf of the Education Committee of the SNACC. Start. Traumatic Brain Injury 101 Quiz 43 Traumatic Brain Injury 101 SUNEETA GOLLAPUDY, M.D ASSOCIATE PROFESSOR, DIVISION DIRECTOR - NEUROANESTHESIA, MEDICAL COLLEGE OF WISCONSIN, MILWAUKEE, WI QUIZ TEAM: SHOBANA RAJAN, M.D; SUNEETA GOLLAPUDY,

More information

National Hospital for Neurology and Neurosurgery

National Hospital for Neurology and Neurosurgery National Hospital for Neurology and Neurosurgery Venous sinus stents (for the treatment of venous sinus stenosis and idiopathic intracranial hypertension) Lysholm Department of Neuroradiology If you would

More information

Written 01/09/17 Rewritten 3/29/17 for Interior Regional EMS Symposium

Written 01/09/17 Rewritten 3/29/17 for Interior Regional EMS Symposium Written 01/09/17 Rewritten 3/29/17 for Interior Regional EMS Symposium MARIA E. MANDICH MD Fairbanks Memorial Hospital Emergency Department Attending Physician Interior Region EMS Council Medical Director

More information

Moron General Hospital Ciego de Avila Cuba. Department of Neurological Surgery

Moron General Hospital Ciego de Avila Cuba. Department of Neurological Surgery Moron General Hospital Ciego de Avila Cuba Department of Neurological Surgery Early decompressive craniectomy in severe head injury with intracranial hypertension Angel J. Lacerda MD PhD, Daisy Abreu MD,

More information

PACT module. Traumatic Brain Injury. Intensive Care Training Program Radboud University Medical Centre Nijmegen

PACT module. Traumatic Brain Injury. Intensive Care Training Program Radboud University Medical Centre Nijmegen PACT module Traumatic Brain Injury Intensive Care Training Program Radboud University Medical Centre Nijmegen Severe traumatic brain injury Leading cause of morbidity/mortality among young individuals

More information

9/16/2018. Recognizing & Managing Seizures in Pediatric TBI. Objectives. Definitions and Epidemiology

9/16/2018. Recognizing & Managing Seizures in Pediatric TBI. Objectives. Definitions and Epidemiology Recognizing & Managing Seizures in Pediatric TBI UW Medicine EMS & Trauma 2018 Conference September 17 and 18, 2018 Mark Wainwright MD PhD Herman and Faye Sarkowsky Professor of Neurology Division Head,

More information

MCHENRY WESTERN LAKE COUNTY EMS SYSTEM Paramedic, EMT-B and PHRN Optional Continuing Education 2019 #7 Strokes

MCHENRY WESTERN LAKE COUNTY EMS SYSTEM Paramedic, EMT-B and PHRN Optional Continuing Education 2019 #7 Strokes MCHENRY WESTERN LAKE COUNTY EMS SYSTEM Paramedic, EMT-B and PHRN Optional Continuing Education 2019 #7 Strokes Stroke is the third leading cause of death and the leading cause of adult disability in the

More information

ICP. A Stepwise Approach. Stephan A. Mayer, MD Professor, Neurology & Neurosurgery Director, Neurocritical Care, Mount Sinai Health System

ICP. A Stepwise Approach. Stephan A. Mayer, MD Professor, Neurology & Neurosurgery Director, Neurocritical Care, Mount Sinai Health System ICP A Stepwise Approach Stephan A. Mayer, MD Professor, Neurology & Neurosurgery Director, Neurocritical Care, Mount Sinai Health System ICP: Basic Concepts Monroe-Kellie doctrine: skull = fixed volume

More information

Cerebral Oxygen Desaturation with Normal ICP and CPP in Severe TBI

Cerebral Oxygen Desaturation with Normal ICP and CPP in Severe TBI The Open Critical Care Medicine Journal,, 1, -3 Open Access Cerebral Oxygen Desaturation with Normal ICP and CPP in Severe TBI Sylvain Palmer *,1 and Mary Kay Bader 1 Orange County Neurological Associates,

More information

CNS pathology Third year medical students. Dr Heyam Awad 2018 Lecture 5: disturbed fluid balance and increased intracranial pressure

CNS pathology Third year medical students. Dr Heyam Awad 2018 Lecture 5: disturbed fluid balance and increased intracranial pressure CNS pathology Third year medical students Dr Heyam Awad 2018 Lecture 5: disturbed fluid balance and increased intracranial pressure ILOs Understand causes and symptoms of increased intracranial pressure.

More information

Treatment of Acute Hydrocephalus After Subarachnoid Hemorrhage With Serial Lumbar Puncture

Treatment of Acute Hydrocephalus After Subarachnoid Hemorrhage With Serial Lumbar Puncture 19 Treatment of Acute After Subarachnoid Hemorrhage With Serial Lumbar Puncture Djo Hasan, MD; Kenneth W. Lindsay, PhD, FRCS; and Marinus Vermeulen, MD Downloaded from http://ahajournals.org by on vember,

More information

with susceptibility-weighted imaging and computed tomography perfusion abnormalities in diagnosis of classic migraine

with susceptibility-weighted imaging and computed tomography perfusion abnormalities in diagnosis of classic migraine Emerg Radiol (2012) 19:565 569 DOI 10.1007/s10140-012-1051-2 CASE REPORT Susceptibility-weighted imaging and computed tomography perfusion abnormalities in diagnosis of classic migraine Christopher Miller

More information

Dynamic autoregulatory response after severe head injury

Dynamic autoregulatory response after severe head injury J Neurosurg 97:1054 1061, 2002 Dynamic autoregulatory response after severe head injury ROMAN HLATKY, M.D., YU FURUYA, M.D., PH.D., ALEX B. VALADKA, M.D., JORGE GONZALEZ, M.D., ARI CHACKO, M.D., YASU MIZUTANI,

More information

Chapter 57: Nursing Management: Acute Intracranial Problems

Chapter 57: Nursing Management: Acute Intracranial Problems Chapter 57: Nursing Management: Acute Intracranial Problems NORMAL INTRACRANIAL PRESSURE Intracranial pressure (ICP) is the hydrostatic force measured in the brain CSF compartment. Normal ICP is the total

More information

PEDIATRIC BRAIN CARE

PEDIATRIC BRAIN CARE PEDIATRIC BRAIN CARE The brain matters most! OVERVIEW OF NEURO ASSESSMENT 1. Overall responsiveness/activity 2. The eyes 3.? Increased ICP 4. Movements 5.? Seizures 6. Other OVERALL RESPONSIVENESS/ ACTIVITY

More information

Traumatic brain injuries are caused by external mechanical forces such as: - Falls - Transport-related accidents - Assault

Traumatic brain injuries are caused by external mechanical forces such as: - Falls - Transport-related accidents - Assault PP2231 Brain injury Cerebrum consists of frontal, parietal, occipital and temporal lobes Diencephalon consists of thalamus, hypothalamus Cerbellum Brain stem consists of midbrain, pons, medulla Central

More information

GLYCEMIC CONTROL IN NEUROCRITICAL CARE PATIENTS

GLYCEMIC CONTROL IN NEUROCRITICAL CARE PATIENTS GLYCEMIC CONTROL IN NEUROCRITICAL CARE PATIENTS David Zygun MD MSc FRCPC Professor and Director Division of Critical Care Medicine University of Alberta Zone Clinical Department Head Critical Care Medicine,

More information

Pediatric Subdural Hematoma and Traumatic Brain Injury J. Charles Mace MD FACS Springfield Neurological Institute CoxHealth. Objectives 11/7/2017

Pediatric Subdural Hematoma and Traumatic Brain Injury J. Charles Mace MD FACS Springfield Neurological Institute CoxHealth. Objectives 11/7/2017 Pediatric Subdural Hematoma and Traumatic Brain Injury J. Charles Mace MD FACS Springfield Neurological Institute CoxHealth Objectives 1. Be able to discuss brain anatomy and physiology as it applies to

More information

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

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

More information

10. Severe traumatic brain injury also see flow chart Appendix 5

10. Severe traumatic brain injury also see flow chart Appendix 5 10. Severe traumatic brain injury also see flow chart Appendix 5 Introduction Severe traumatic brain injury (TBI) is the leading cause of death in children in the UK, accounting for 15% of deaths in 1-15

More information

Blood transfusions in sepsis, the elderly and patients with TBI

Blood transfusions in sepsis, the elderly and patients with TBI Blood transfusions in sepsis, the elderly and patients with TBI Shabbir Alekar MICU, CH Baragwanath Academic Hospital & The University of the Witwatersrand CCSSA Congress 11 June 2015 Packed RBC - complications

More information

New Frontiers in Intracerebral Hemorrhage

New Frontiers in Intracerebral Hemorrhage New Frontiers in Intracerebral Hemorrhage Ryan Hakimi, DO, MS Director, Neuro ICU Director, Inpatient Neurology Services Greenville Health System Clinical Associate Professor Department of Medicine (Neurology)

More information

11/1/2018. Disclosure. Imaging in Acute Ischemic Stroke 2018 Neuro Symposium. Is NCCT good enough? Keystone Heart Consultant, Stock Options

11/1/2018. Disclosure. Imaging in Acute Ischemic Stroke 2018 Neuro Symposium. Is NCCT good enough? Keystone Heart Consultant, Stock Options Disclosure Imaging in Acute Ischemic Stroke 2018 Neuro Symposium Keystone Heart Consultant, Stock Options Kevin Abrams, M.D. Chief of Radiology Medical Director of Neuroradiology Baptist Hospital, Miami,

More information

SHOCK. Emergency pediatric PICU division Pediatric Department Medical Faculty, University of Sumatera Utara H. Adam Malik Hospital

SHOCK. Emergency pediatric PICU division Pediatric Department Medical Faculty, University of Sumatera Utara H. Adam Malik Hospital SHOCK Emergency pediatric PICU division Pediatric Department Medical Faculty, University of Sumatera Utara H. Adam Malik Hospital 1 Definition Shock is an acute, complex state of circulatory dysfunction

More information

Surgical Management of Stroke Brandon Evans, MD Department of Neurosurgery

Surgical Management of Stroke Brandon Evans, MD Department of Neurosurgery Surgical Management of Stroke Brandon Evans, MD Department of Neurosurgery 2 Stroke Stroke kills almost 130,000 Americans each year. - Third cause of all deaths in Arkansas. - Death Rate is highest in

More information

Elevated jugular venous oxygen saturation after severe head injury

Elevated jugular venous oxygen saturation after severe head injury J Neurosurg 90:9 15, 1999, Click here to return to Table of Contents Elevated jugular venous oxygen saturation after severe head injury MANUELA CORMIO, M.D., ALEX B. VALADKA, M.D., AND CLAUDIA S. ROBERTSON,

More information

Mannitol for Resuscitation in Acute Head Injury: Effects on Cerebral Perfusion and Osmolality

Mannitol for Resuscitation in Acute Head Injury: Effects on Cerebral Perfusion and Osmolality Original articles Mannitol for Resuscitation in Acute Head Injury: Effects on Cerebral Perfusion and Osmolality J. A. MYBURGH*, S. B. LEWIS *Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SOUTH

More information

LOSS OF CONSCIOUSNESS & ASSESSMENT. Sheba Medical Center Acute Medicine Department MATTHEW WRIGHT

LOSS OF CONSCIOUSNESS & ASSESSMENT. Sheba Medical Center Acute Medicine Department MATTHEW WRIGHT LOSS OF CONSCIOUSNESS & ASSESSMENT Sheba Medical Center Acute Medicine Department MATTHEW WRIGHT OUTLINE Causes Head Injury Clinical Features Complications Rapid Assessment Glasgow Coma Scale Classification

More information

Monitoring of Regional Cerebral Blood Flow Using an Implanted Cerebral Thermal Perfusion Probe Archived Medical Policy

Monitoring of Regional Cerebral Blood Flow Using an Implanted Cerebral Thermal Perfusion Probe Archived Medical Policy Applies to all products administered or underwritten by Blue Cross and Blue Shield of Louisiana and its subsidiary, HMO Louisiana, Inc.(collectively referred to as the Company ), unless otherwise provided

More information

Increased Intracranial Pressure 2.0 Contact Hours Presented by: CEU Professor

Increased Intracranial Pressure 2.0 Contact Hours Presented by: CEU Professor Increased Intracranial Pressure 2.0 Contact Hours Presented by: CEU Professor 7 www.ceuprofessoronline.com Copyright 8 2007 The Magellan Group, LLC All Rights Reserved. Reproduction and distribution of

More information

CrackCast Episode 8 Brain Resuscitation

CrackCast Episode 8 Brain Resuscitation CrackCast Episode 8 Brain Resuscitation Episode Overview: 1) Describe 6 therapeutic interventions for the post-arrest brain 2) List 5 techniques for initiating therapeutic hypothermia 3) List 4 mechanisms

More information

CEREBRAL DECONGESTANTS. Dr. Dwarakanath Srinivas Additional Professor Neurosurgery, NIMHANS

CEREBRAL DECONGESTANTS. Dr. Dwarakanath Srinivas Additional Professor Neurosurgery, NIMHANS CEREBRAL DECONGESTANTS Dr. Dwarakanath Srinivas Additional Professor Neurosurgery, NIMHANS Cerebral Oedema Increase in brain water content above normal (80%) in response to primary brain insult. Intracranial

More information

Example Clinician Educational Material for Providers of Immune Effector Cellular Therapy

Example Clinician Educational Material for Providers of Immune Effector Cellular Therapy Example Clinician Educational Material for Providers of Immune Effector Cellular Therapy Disclaimer: This example is just one of many potential examples of clinician education material that can be provided

More information

Extracorporeal Life Support Organization (ELSO) Guidelines for Pediatric Respiratory Failure

Extracorporeal Life Support Organization (ELSO) Guidelines for Pediatric Respiratory Failure Extracorporeal Life Support Organization (ELSO) Guidelines for Pediatric Respiratory Failure Introduction This pediatric respiratory failure guideline is a supplement to ELSO s General Guidelines for all

More information

PSEUDO-SUBARACHNOID HEMORRHAGE AFTER INADVERTENT DURAL PUNCTURE DURING CERVICAL EPIDURAL STEROID INJECTION

PSEUDO-SUBARACHNOID HEMORRHAGE AFTER INADVERTENT DURAL PUNCTURE DURING CERVICAL EPIDURAL STEROID INJECTION PSEUDO-SUBARACHNOID HEMORRHAGE AFTER INADVERTENT DURAL PUNCTURE DURING CERVICAL EPIDURAL STEROID INJECTION HAI NGUYEN, DO, MPH Anesthesiology Resident (University of Kansas Wichita) JOEL CAVAZOS, MD Pain

More information

WHITE PAPER: A GUIDE TO UNDERSTANDING SUBARACHNOID HEMORRHAGE

WHITE PAPER: A GUIDE TO UNDERSTANDING SUBARACHNOID HEMORRHAGE WHITE PAPER: A GUIDE TO UNDERSTANDING SUBARACHNOID HEMORRHAGE Subarachnoid Hemorrhage is a serious, life-threatening type of hemorrhagic stroke caused by bleeding into the space surrounding the brain,

More information

Pre-hospital Response to Trauma and Brain Injury. Hans Notenboom, M.D. Asst. Medical Director Sacred Heart Medical Center

Pre-hospital Response to Trauma and Brain Injury. Hans Notenboom, M.D. Asst. Medical Director Sacred Heart Medical Center Pre-hospital Response to Trauma and Brain Injury Hans Notenboom, M.D. Asst. Medical Director Sacred Heart Medical Center Traumatic Brain Injury is Common 235,000 Americans hospitalized for non-fatal TBI

More information

SUBJECT: Clinical Practice Guideline for the Management of Severe Traumatic Brain Injury

SUBJECT: Clinical Practice Guideline for the Management of Severe Traumatic Brain Injury ASPIRUS WAUSAU HOSPITAL, INC. Passion for excellence. Compassion for people. Effective Date: December 1, 2005 Proposed By: Samuel Picone III, MD, Trauma Medical Director Approval and Dates: Dr. Bunch,

More information

R Adams Cowley Founder of the R Adams Cowley Shock Trauma Center and Maryland EMS System in Baltimore, Maryland.

R Adams Cowley Founder of the R Adams Cowley Shock Trauma Center and Maryland EMS System in Baltimore, Maryland. R Adams Cowley 1917 -- 1991 Founder of the R Adams Cowley Shock Trauma Center and Maryland EMS System in Baltimore, Maryland. ...That the primary purpose of medicine was to save lives, that every critically

More information

Effect of stable xenon inhalation on intracranial pressure during measurement of cerebral blood flow in head injury

Effect of stable xenon inhalation on intracranial pressure during measurement of cerebral blood flow in head injury J Neurosurg 81:822 828, 1994 Effect of stable xenon inhalation on intracranial pressure during measurement of cerebral blood flow in head injury JAN PLOUGMANN, M.D., JENS ASTRUP, M.D., JENS PEDERSEN, M.D.,

More information

Acute cerebral MCA ischemia with secondary severe head injury and acute intracerebral and subdural haematoma. Case report

Acute cerebral MCA ischemia with secondary severe head injury and acute intracerebral and subdural haematoma. Case report 214 Balasa et al - Acute cerebral MCA ischemia Acute cerebral MCA ischemia with secondary severe head injury and acute intracerebral and subdural haematoma. Case report D. Balasa 1, A. Tunas 1, I. Rusu

More information

Cerebral Blood Flow and Metabolism during Mild Hypothermia in Patients with Severe Traumatic Brain Injury

Cerebral Blood Flow and Metabolism during Mild Hypothermia in Patients with Severe Traumatic Brain Injury J Med Dent Sci 2010; 57: 133-138 Original Article Cerebral Blood Flow and Metabolism during Mild Hypothermia in Patients with Severe Traumatic Brain Injury Hiroyuki Masaoka Department of Neurosurgery,

More information

Subarachnoid Hemorrhage (SAH) Disclosures/Relationships. Click to edit Master title style. Click to edit Master title style.

Subarachnoid Hemorrhage (SAH) Disclosures/Relationships. Click to edit Master title style. Click to edit Master title style. Subarachnoid Hemorrhage (SAH) William J. Jones, M.D. Assistant Professor of Neurology Co-Director, UCH Stroke Program Click to edit Master title style Disclosures/Relationships No conflicts of interest

More information

SAH READMISSIONS TO NCCU

SAH READMISSIONS TO NCCU SAH READMISSIONS TO NCCU Are they preventable? João Amaral Rebecca Gorf Critical Care Outreach Team - NHNN 2015 Total admissions to NCCU =862 Total SAH admitted to NCCU= 104 (93e) (12.0%) Total SAH readmissions=

More information

Aneurysmal Subarachnoid Hemorrhage Presentation and Complications

Aneurysmal Subarachnoid Hemorrhage Presentation and Complications Aneurysmal Subarachnoid Hemorrhage Presentation and Complications Sherry H-Y. Chou MD MMSc FNCS Department of Critical Care Medicine, Neurology and Neurosurgery University of Pittsburgh School of Medicine

More information

Virtual Mentor American Medical Association Journal of Ethics August 2008, Volume 10, Number 8:

Virtual Mentor American Medical Association Journal of Ethics August 2008, Volume 10, Number 8: Virtual Mentor American Medical Association Journal of Ethics August 2008, Volume 10, Number 8: 516-520. CLINICAL PEARL The Hazards of Stopping a Brain in Motion: Evaluation and Classification of Traumatic

More information

NEUROMONITORING AND ANESTHESIA CONSIDERATIONS. Martha Richter, MSN, CRNA

NEUROMONITORING AND ANESTHESIA CONSIDERATIONS. Martha Richter, MSN, CRNA NEUROMONITORING AND ANESTHESIA CONSIDERATIONS Martha Richter, MSN, CRNA OBJECTIVES The student will 1. Review the types of neuromonitoring currently in use 2. Identify possible procedural applications

More information

Pediatric emergencies (SHOCK & COMA) Dr Mubarak Abdelrahman Assistant Professor Jazan University

Pediatric emergencies (SHOCK & COMA) Dr Mubarak Abdelrahman Assistant Professor Jazan University Pediatric emergencies (SHOCK & COMA) Dr Mubarak Abdelrahman Assistant Professor Jazan University SHOCK Definition: Shock is a syndrome = inability to provide sufficient oxygenated blood to tissues. Oxygen

More information

Bedside microdialysis for early detection of cerebral hypoxia in traumatic brain injury

Bedside microdialysis for early detection of cerebral hypoxia in traumatic brain injury Neurosurg Focus 9 (5):E2, 2000 Bedside microdialysis for early detection of cerebral hypoxia in traumatic brain injury ASITA S. SARRAFZADEH, M.D., OLIVER W. SAKOWITZ, M.D., TIM A. CALLSEN, M.D., WOLFGANG

More information

SCCEP 2013 LLSA Course Article 10 AHA/ASA Guidelines for the Management of Spontaneous ICH

SCCEP 2013 LLSA Course Article 10 AHA/ASA Guidelines for the Management of Spontaneous ICH SCCEP 2013 LLSA Course Article 10 AHA/ASA Guidelines for the Management of Spontaneous ICH Morgenstern LB, Hemphill JC. Stroke July 2010;41:2108-2129. Article: This article presents guidelines whose "aim

More information

Anesthetic Management of a Patient with Traumatic Brain Injury

Anesthetic Management of a Patient with Traumatic Brain Injury Anesthetic Management of a Patient with Traumatic Brain Injury Arne O. Budde, MD, DEAA Associate Professor of Anesthesiology Director, Division of Neuroanesthesia Department of Anesthesiology Milton S

More information

Neurosurgical Management of Stroke

Neurosurgical Management of Stroke Overview Hemorrhagic Stroke Ischemic Stroke Aneurysmal Subarachnoid hemorrhage Neurosurgical Management of Stroke Jesse Liu, MD Instructor, Neurological Surgery Initial management In hospital management

More information

Regulation of Cerebral Blood Flow. Myogenic- pressure autoregulation Chemical: PaCO2, PaO2 Metabolic Neuronal

Regulation of Cerebral Blood Flow. Myogenic- pressure autoregulation Chemical: PaCO2, PaO2 Metabolic Neuronal Regulation of Cerebral Blood Flow Myogenic- pressure autoregulation Chemical: PaCO2, PaO2 Metabolic Neuronal The Autoregulation, Stupid! Drawing of her daughter (age 7) Flow through rigid tube Mogens Fog

More information