1 MANAGEMENT OF BRAIN EDEMA AND ICP IN STROKE PATIENTS Stephan A. Mayer, MD Stephan A. Mayer, MD Director, Neuro-ICU Columbia University New York, NY Disclosures ■ NOVO NORDISK NOVO NORDISK ◆ Research funding Research funding ◆ Speaking honoraria Speaking honoraria ◆ Consulting fees Consulting fees ■ RADIANT MEDICAL RADIANT MEDICAL ◆ Stock options Stock options ■ MEDIVANCE, INC. MEDIVANCE, INC. ◆ Research grant Research grant ◆ Speaking honoraria Speaking honoraria ◆ Consulting fees Consulting fees ◆ Stock Options Stock Options ■ ESP PHARMA ESP PHARMA ◆ Speaking honoraria Speaking honoraria ■ YAMANOUCHI PHARMACEUTICALS YAMANOUCHI PHARMACEUTICALS ◆ Speaking honoraria Speaking honoraria 0 10 20 30 40 50 60 70 80 INF ICH Intubated Not intubate Overall INFARCTION ICH 30-DAY PERCENT FATALITY 57 % 6 % 9 % 74% 18 % 31% Mayer SA, et al: Cost and outcome of mechanical ventilation for life- threatening stroke. Stroke 2000;31:2346-2353.
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MANAGEMENT OF BRAIN
EDEMA AND ICP IN
STROKE PATIENTS
Stephan A. Mayer, MDStephan A. Mayer, MDDirector, Neuro-ICU
Columbia University
New York, NY
Disclosures�� NOVO NORDISKNOVO NORDISK
�� Research funding Research funding �� Speaking honorariaSpeaking honoraria�� Consulting feesConsulting fees
�� RADIANT MEDICALRADIANT MEDICAL
�� Stock optionsStock options�� MEDIVANCE, INC.MEDIVANCE, INC.
Mayer SA, et al: Cost and outcome of mechanical ventilation for life-
threatening stroke. Stroke 2000;31:2346-2353.
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What we WANT….
What we Usually GET:
�� 39 year39 year--old manold man
�� CVA day 3CVA day 3
�� R R hemiplegia hemiplegia
and neglectand neglect
�� L arm L arm extendsextends
briefly to medial briefly to medial
arm pincharm pinch
Mass Effect & Tissue Shifts are the Problem!
�� Frank JI. Frank JI. NeurologyNeurology 1995 Jul;45(7):12861995 Jul;45(7):1286--9090
�� 19 patients deteriorating to Stupor 19 patients deteriorating to Stupor from large ischemic MCA/ICA infarctsfrom large ischemic MCA/ICA infarcts
�� ICP > 15 mmHg present in only 5 ICP > 15 mmHg present in only 5 patients!patients!
�� Schwab S, et al. Schwab S, et al. NeurologyNeurology 1996 Aug; 7(2):393081996 Aug; 7(2):39308
�� 48 patients with Malignant MCA 48 patients with Malignant MCA infarctioninfarction
�� ALL patients had signs of ALL patients had signs of herniation herniation PRIOR to an increase in ICP > 20 PRIOR to an increase in ICP > 20 mmHgmmHg
�� Routine ICP Monitoring is NOT helpfulRoutine ICP Monitoring is NOT helpful
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Neurologic Deterioration in
Noncomatose Patients with ICH(Mayer et al, Neurology 1994)
�� Deterioration occurred in Deterioration occurred in 33%33%
�� Predicted primarily by Predicted primarily by large large hematoma hematoma volumevolume on initial CT scan (mean 13 h after on initial CT scan (mean 13 h after onset)onset)
�� Worsening was associated with substantial Worsening was associated with substantial mortality (47 % mortality (47 % vsvs. 3%). 3%)
�� Conclusion: Conclusion: Edema associated with Edema associated with large established hemorrhageslarge established hemorrhages is the is the most important cause of late (>12 hours) most important cause of late (>12 hours) clinical deterioration after ICHclinical deterioration after ICH
The Columbia UniversitySubarachnoidHemorrhageOutcomesProject
�� Use 50/50 chloride/acetate solutionUse 50/50 chloride/acetate solution
�� CoagulopathyCoagulopathy
�� Rebound edema with correction of NaRebound edema with correction of Na++
�� Central Central pontine myelinolsispontine myelinolsis
2% 3% 2% NS 3% NS
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Vasopressin Antagonists
in the Neuro-ICU
�� Causes a pure Causes a pure ““aquauresisaquauresis””
�� Minimal effect onMinimal effect on intravscular intravscular volume volume
�� Potential indicationsPotential indications
�� Correction of Correction of hyponatremiahyponatremia
�� ““Fine tuningFine tuning”” of sodium level while weaning of sodium level while weaning hypertonic saline hypertonic saline
�� Adjuvant to 20% mannitol or 23.4% Adjuvant to 20% mannitol or 23.4% hypertonic saline for rapid induction of hypertonic saline for rapid induction of hyperosmolar hyperosmolar state to combat ICP or state to combat ICP or herniation herniation syndromes syndromes
��ClinicalClinical�� Lower body temperature is Lower body temperature is
associated with improved outcome associated with improved outcome after strokeafter stroke
��Stroke patients with reduced body Stroke patients with reduced body temperature (<36.5temperature (<36.5°° C) on C) on admission have reduced mortality & admission have reduced mortality & better outcomes better outcomes (Reith et al)(Reith et al)
��Fever in the first 24 hours is Fever in the first 24 hours is associated with worse outcome associated with worse outcome (Castillo et al)(Castillo et al)
6 HOURS to 3-7 DAYSMaintain mild hypothermia until patient is no
longer at risk for infarct swelling
0-6 HOURSBegin moderate hypothermia for 12-24 hours
followed by controlled rewarming
ICU Temperature Management Protocol for MCA Infarction?
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Hemicraniectomy
DAY 0
DAY 2
20
DAY 3
DAY 5
DAY 8
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Surgical Decompression�� RationaleRationale
�� Reverse tissue shifts by allowing Reverse tissue shifts by allowing expansion of edematous brain tissue away expansion of edematous brain tissue away from the from the diencephalon diencephalon and and mesencephalon mesencephalon
�� Reduce ICP and increase CPPReduce ICP and increase CPP
�� Preserve CBF and minimize secondary Preserve CBF and minimize secondary ischemic injuryischemic injury
�� Similar concept as decompression of Similar concept as decompression of large large cerebellar cerebellar hemorrhage or infarctionhemorrhage or infarction
�� Technique used in head traumaTechnique used in head trauma
4 (26.7%)4 (26.7%)5 (45.5%)5 (45.5%)Dead at 21 days*Dead at 21 days*
52.352.353.553.5Age (years)Age (years)
6/96/96/56/5Hemisphere (L/R)Hemisphere (L/R)
151511 11 NN
HemicraniectomyHemicraniectomyMedicalMedical
Benefit from Surgery No Benefit
95% CI
90% CI
80% CI
Hemicraniectomy Metaanalysis
�� 138 patients with MCA infarction138 patients with MCA infarction
�� Minimum F/U of 4 monthsMinimum F/U of 4 months
�� Age was only significant predictor of survival Age was only significant predictor of survival with good recoverywith good recovery
�� Side, extra territories, timing, Side, extra territories, timing, herniation herniation signs did not matter!signs did not matter!
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
All Age <50 Age >50
Dead
Severe Dis
Mild-Mod Dis
Independent
Gupta R, Connolly ES, Mayer SA, Elkind MSV:
Hemicraniectomy for massive middle cerebral
artery territory infarction: a systematic review.
Stroke 2004;35:539-543.
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Hemicraniectomy
�� Likely reduces mortality from Likely reduces mortality from malignant MCA infarctionmalignant MCA infarction
�� Appears superior to hypothermia for Appears superior to hypothermia for treatment of spacetreatment of space--occupying cerebral occupying cerebral infarctioninfarction
�� Early Early hemicraniectomy hemicraniectomy (before signs (before signs of of herniationherniation) more effective than late ) more effective than late hemicraniectomyhemicraniectomy
�� Survival with good functional outcome Survival with good functional outcome most likely in younger patientsmost likely in younger patients