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1、Wengui Yu,MD,PhDDivision of Neurological Critical CareDepartments of Neurological Surgery and Neurology,Neurocritical Care of Acute Stroke,The Primary Diagnoses In Neuro-ICU,Intracerebral hemorrhage(ICH)Subarachnoid hemorrhage(SAH)Ischemic stroke/TIAsStatus post craniotomy for tumor resectionTraumat
2、ic brain injury(SDH,EDH)Status post coil embolization,angioplasty,or stenting.,Thrombolysis for Ischemic Stroke Intravenous t-PAIntraarterial t-PAEndovascular therapyAngioplasty/StentingMERCI RetrievalPenumbra Clot RetrievalCoil embolization of aneurysmSurgical treatmentHemicraniectomy for MCA strok
3、e,Advances in Stroke Management,S/p IA tPA,1.Neuro-monitoring,1).Neuro Exam Simple and effectiveNeurologic changes that need immediate attentionMental status changeDecreased levels of consciousness:lethargy,stupor,coma.Disorientation:name,place,time,and event.Speech difficulty:expressive or receptiv
4、e aphasia Cranial nerve palsy:dilated and fixed pupil(s)New weakness/numbness,2).Neuroimagings,a).CTTo follow hematoma expansion,cerebral edema,mass effect,herniation,or hydrocephalus.Indicated inFirst few days after stroke,Deterioration on neuro exam,Sedated and paralyzed patient.,b).CTA Contrast e
5、xtravasation predicts hematoma expansion,CT demonstrates a left putaminal hematoma(A).A small focus of enhancement isseen on CTA(B),consistent with extravasation on postcontrast CT(C).UnenhancedCT image 1 day after presentation reveals hematoma enlargement and IVH(D).-Wada et al.Stroke.2007;38:1257-
6、Golstein et al.Neurology.2007;20;68(12):889-94.,Contrast extravasation predicts mortality in ICH,A 69-yo man underwent imaging 2 hrs following onset of right-sided paralysis.Admission NCCT demonstrates a left thalamic hematoma with extension into the thirdVentricle(A).CTA(B)and CECT(C),respectively,
7、show 2 foci of active extravasation(arrows).Follow-up NCCT 12 hrs later shows marked hematoma growth with hemorrhagein both lateral ventricles and severe hydrocephalus(D).The patient had a fatal outcome.Becker et al.Stroke 1999;30:2025-2032 Kim et al.American Journal of Neuroradiology 2008;29:520-52
8、5.,The DWI map demonstrates a small area of diffusion restriction in the right MCA territory consistent with acute infarction.The MTT map demonstrates the infarct penumbra which is larger than the infarct,indicating the presence of salvageable tissue.,C).MRI:vasospasm/delayed ischemic deficit,Intrav
9、entricular catheterIntraparenchymal catheterEpidural DeviceSubdural catheter,3).ICP Monitoring,4).Transcranial Doppler(TCD),Non-invasive.Measure the velocity of flow in the intracranial circulation.The Doppler shift measured is inversely proportional to the diameter of the vessel.,Figs show the posi
10、tion of TCD probes and a sample tracing of normal MCA waveform.,TCD Criteria of vasospasm,5).Electroencephalograph(EEG)Monitoring,EEG of a comatose patient showed generalized sharp theta rhythm consistent with non-convulsive seizure activity.,Continuous vEEG monitoring:status epilepticus,2.Cardiac-R
11、espiratory Monitoring,Cardiac arrhythmia,stunned myocardium,and ACS are common complications of stroke.Right hemisphere infarct(insula)increases the risk of cardiac complications(autonomic dysfunction).ECG changes include ST-segment depression,QT dispersion,inverted T waves,and prominent U waves.Ele
12、vated levels of cardiac enzymes are common in patients with SAH.Stroke may also cause respiratory distress,impaired oropharyngeal mobility,airway obstruction,and aspiration pneumonia.,3.Critical Care of Patient with Acute Stroke,Initiate Neuro-Cardiac-Respiratory monitoring,Intubate for airway prote
13、ction if comatose or GCS 8,Manage hypertensive crisis or hypotension,Treat headache,agitation,hyperglycemia,and aspiration,Evaluate electrolyte imbalance,seizure,fever,and infection,GI and DVT prophylaxis.,4.Management of Blood Pressure(BP),Both elevated and low BP are associated with poor outcome a
14、fter stroke.The common causes of elevated BP:Stress of the stroke(large infarct,ICH,SAH).Increased intracranial pressure.Hypoxia,a full bladder,nausea/vomiting,pain/headache.preexisting hypertension.Blood pressure reductionTo prevent hemorrhagic conversion or rehemorrhage.To prevent hyperperfusion s
15、yndrome.Blood pressure augmentationHypotension.Vasospasm.,Management of Hypertensive Crisis,Initial therapyLabetalol 10-20 mg iv q30 min prnHydralazine 10-20 mg iv q30 min prnFor persistent hypertensionNicardipine 2-15 mg/hr iv infusion orNipride 0.3-10 mcg/kg/min iv infusionStart and titrate oral m
16、edicationsBB,CCB,ACEI,hydralazine,or clonidine.In case of hypotensionReduce anti-hypertensive and IV fluid bolus.,Indications:Prevention of hemorrhage or hematoma expansion Urgent neurosurgical interventionCoagulopathy from warfarin or hepatic failure Factor VIIa 40-80 g/kg iv+Vitamin K 10 mg iv dai
17、ly x 3.Prothrombin complex concentrate(PCC):25-50 units/kg iv.Fresh frozen plasma(FFP)10-20 ml/kgHeparin-induced coagulopathy Protamine sulfate 1mg for each 100 U heparin received in the last 3ht-PA induced thrombolysisCryoprecipitates 6-8 unitsThrombocytopenia or platelet dysfunctionSingle donor pl
18、atelets 2-6 units,5.Urgent Reversal of Coagulopathy,6.Management of Elevated ICP/Hydrocephalus,External ventricular drainage(EVD):open at 0-20 cm H2O.Osmolar therapy:Mannitol 0.5-1 gm/kg iv q4hHypertonic saline:3%or 23.4%NaClHyperventilation(short term use prior to emergent surgery):-Hypocarbia(pCO2
19、 30-35)reduction of CBFSedatives/paralytic agentsPentobarbital coma,7.Decompressive Craniectomy,Large cerebellar infarct or hemorrhage.Hemisphere infarct with edema and potential herniation.,Jauss et al.J Neurol 1999;246:257-64Raco et al.Neurosurgery.2003;53(5):1061.Robertson et al.Neurosurgery.2004
20、;55(1):55.,Hemicraniectomy for MCA Stroke,3 clinical trials:DECIMAL,HAMLET,and DESTINY.93 patients randomized to surgical or medical therapy.Patients 60 years of age.The timing of surgery 48 hrs after stroke onset.Outcome with mRS at 1 yr.,2007;6(3):215-22,1033 patients with supertentorial ICH enrol
21、led in 87 centersRandomized within 72 hr of ICH onsetEarly surgeryNo surgery early(but 20%had later surgery)Showed no benefit inMortalityGood outcome,Surgical Treatment of ICH(STICH Trial)Mendel AD,et al.Lancet 2005,365:387,8.Intra-ventricular t-PA for IVH,Intraventricular hemorrhage(IVH)Occurs in 1
22、5-40%of patients with ICH or SAH.Severe IVH causes hydrocephalus,increased ICP or herniation.Death occurs in all patients with GCS less than 8 and severe IVH.Intra-ventricular t-PA Facilitate the clearance of IVH Improve outcome.Findlay et al.Neurosurgery 74:803807,1991Rohde et al,J Neurol Neurosurg
23、 Psychiatry 1995;58:447451Naff et al.Neurosurgery 2004;54:57783,9.Vasospasm and Delayed Ischemic Deficit,DiagnosisOccur at day 3-10,Neuorologic deterioration.TCD,CTA or cerebral angiography.Prevention and treatment Nimodipine 60 mg q4h,Triple H(hypervolemia,hypertension,and hemodilution)Keep CVP 8-1
24、2,Raise MAP by 15-20%to improve cerebral perfusion.Endovascular therapy:balloon angioplasty or IA nicardipine.,L-VA,Basilar Artery,Vasospasm,10.Cerebral Salt Wasting Syndrome,Hyponatremia,hypovolemia,and elevated serum BNP.Associated with brain edema,vasospasm and poor outcome.Aggressive treatment w
25、ith 3%NaCl infusionSalt tabletsFlorinef 0.1-0.2 mg/day,11.Therapeutic Hypothermia,Hypothermia in global ischemiaModerate hypothermia(32-34 oC)for 12-24 hrs increases favorable neurologic outcome at 6 months in comatose survivors of out-of-hospital cardiac arrest.Bernard SA,et al.NEJM 2002;346:557-56
26、3.Michael Holzer et al.NEJM 2002;346:549-556.Hypothermia in ischemic stroke.Safe and feasible.Effective in controlling ICP due to the mass effect of large infarct.Reduce MCA stroke mortality.Schwab et al.Stroke 2001;32:2033-5.Schwab et al.Stroke 1998;29:2461-6.Schwab et al.Stroke 1998;29:1988-93.Gum
27、ula et al.Acad Emerg Med.2006;13(8):820-7.,Favorable outcome,Survival Home/Rehab,12.Management of Seizure,12.Management of Seizure,Treatment of Status Epilepticus1).Lorazepam 2 mg iv q 2 min,up to 0.1 mg/kg.2).Fosphenytoin 20 mg/kg iv,150 mg/min.3).Fosphenytoin 10 mg/kg 4).Intubate patient if not do
28、ne yet.5).Phenobarbital 20 mg/kg 50 mg/min 6).Phenobarbital 10 mg/kgMidazolam 7).Anesthesia:Pentobarbital burst suppression Propofol or Midazolam,Treatment of Nonconvulsive Status Epilepticus,Treatment of Nonconvulsive Status Epilepticus1).Lorazepam 2 mg iv q 2 min,up to 0.1 mg/kg.2).Valproate 25 mg
29、/kg over 4-8 min.3).Phenobarbital 20 mg/kg 50 mg/min.4).Intubate patient if not done yet.5).Phenobarbital 10 mg/kg.6).Propofol or Midazolam.,13.Recombinant Factor VIIa for Acute ICHMayer et al.2005;352:777-85,Phase 2B trial399 patients were randomized to receive placebo,or 40,80,and 160 g/kg of rFVI
30、Ia within 4 h symptom onset.Primary outcome:ICH volume at 24 hClinical outcome at 90 days,Effects of rFVIIa on ICH volumes,rFVIIa limits the growth of hematoma and reduces mortalityby approximately 35%.,Mayer et al.2005;352:777-85,Factor Seven for Acute Hemorrhagic Stroke(FAST),Phase 3 trial841 pati
31、ents with ICH were randomized to receive Placebo 20 g/kg of rFVIIa80 g/kg of rFVIIaPrimary end point:Poor outcome,defined as severe disability or death 90 days after the stroke,Mayer et al.2008;358:2127-37,Figure 3.Clinical outcome at 90 days according to the Modified Rankin Scale.rFVIIa does not re
32、duce the rate of death or severe disability after ICH.,Clinical Centers(with numbers of patients in parentheses),Wang YJ,Beijing Tiantan Hospital,Beijing(73);Selchen,Trillium Health Centre,Mississauga,ON,Canada(25);lvarez Sabin,Hospital Vall dHebron,Barcelona(24);Steiner,Universittsklinikum und Medi
33、zinische Fakultt Heidelberg,Germany(22);Hill,Foothills Medical Centre,Calgary,AB,Canada(21);Hennerici,Univ of Heidelberg,Mannheim,Germany(16);Ng Hua,National Neuroscience Institute,Singapore(16);Toni,Universit La Sapienza,Rome(10);Woolfenden,Vancouver General Hospital,Canada(10)Flaherty,University o
34、f Cincinnati,Cincinnati(9)Hall,Medical College of Georgia,Augusta(9);Gladstone,Sunnybrook and Womens College,Toronto(9)Washington University,St.Louis(9);Rosand,Massachusetts General Hospital,Boston(5);Parra,Columbia University,New York(2)Grotta,University of Texas,Houston(2)Hemphill,University of Ca
35、lifornia,San Francisco,(1),14.Prognosticate Outcome of Coma,Depends on cause rather than the depth of the coma.Coma from drug intoxication and metabolic causes carries the best prognosis.Coma from global hypoxia-ischemia carries the least favorable prognosis.,A 51 year old woman was comatose for 8 w
36、eeks after cardiac bypass surgery.The follow-up CT 13 years later are shown below.,Functional Outcome:mRS 1,Case Study#1,A 44 yo man with h/o HTN and prior R-MCA stroke was last seen normal 7:30 AM.Found unresponsive with R-sided weakness and 911 activation to ED at 11:30 AM.Initial NIH stroke scale
37、 21.Intubated to CT scan.,CT head at 11:46 AM,Prior to IA thrombolysisS/P IA t-PA/Reopro,Repeat CT 24h after IA t-PA showed a small MCA stroke.He was extubated with mild expressive aphasia.Treated with anticoagulation for LV thrombus.Recovered with mild cognitive problem at 3 month-f/u.,Who is the l
38、ucky patient?,Case Study#2,A 67 yo man with h/o CAD and DM presented with sudden onset HA,vertigo,slurred speech and right sided weakness.,MRI/MRA:pontine infarct,L-ICA stenosis,R-VA occlusion and L-distal VA stenosis.,Developed incomplete locked-in syndrome while on medical therapy.,Vertebral arter
39、y stenting,ICA Stenosis:Stenting,After weeks ICU care and rehabilitation,the patient recovered with moderate R-sided weakness/dysarthria in two months.,Case#3,50 y/o man with h/o HTN presented with neck pain and loss of consciousness,CT shows diffuse subarachnoid hemorrhage and hydrocephalus.*CTA an
40、d cerebral angio showed no aneurysm,MRA showed L-distal VA irregularities.Fat-saturated T1 MRI revealed intramural thrombus,indicative of VA dissection.,Coil embolization of distal L-VA dissection,Despite comatose and ventilator-dependence for more than 2 weeks,he recovered fully in 2 months.,SUMMAR
41、Y,Neurocritical care provides comprehensiveAirway and hemodynamic management,Neuro-monitoring and brain resuscitation,Periprocedural monitoring and management.Neurocritical care is associated withReduce mortality,Improved outcome,Reduced ventilator days and ICU length of stay.,Diringeret al.Critical care medicine 2001,29:635-640.Juarez et al.Crit Care Med 2004;32:2311-2317.Varelas et al.Crit Care Med 2004;32:2191-2198.,
