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Multimodality Monitoring in SAH. Paul Vespa, MD, FCCM Associate Professor of Neurosurgery and Neurology Director of Neurocritical Care Geffen School of Medicine at UCLA. New York Neurologic Emergencies and Neurocritical Care Symposium. What do we use at UCLA for SAH pt who is comatose? .
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Multimodality Monitoring in SAH Paul Vespa, MD, FCCM Associate Professor of Neurosurgery and Neurology Director of Neurocritical Care Geffen School of Medicine at UCLA New York Neurologic Emergencies and Neurocritical Care Symposium
What do we use at UCLA for SAH pt who is comatose? • ICP • cEEG • Cerebral microdialysis • Brain Tissue Oxygen • TCD (intermittent) • Xenon CBF (intermittent)
What are we looking for • Seizures • 30% of SAH pts have seizures on cEEG • Brain Ischemia • 50% of SAH pts will have some form of vasospasm with variable amounts of ischemia • Elevated ICP • Brain Glucopenia
Multimodality Case 1 - SAH • 74 yo with acomm aneurysm SAH • Confused with poor attention • Intubated due to respiratory distress • Not obeying, but some sedation given • Mild left hemiparesis on exam; leg worse than arm • cEEG and PbtO2
SAH # 1 vital signs • SBP 160/80 • ICP 12-15 mm Hg • HR 84 • SaO2 99% • Temp 37.9 C • Na 139 • Hb 31
EEG PAV in SAH early before deterioration 1 – 9 - 06
PAV is an indicator of brain ischemia from vasospasm Also Alpha/delta ratio is an indicator of brain ischemia PAV goes down (becomes flat) with vasospasm SAH and EEG PAV
EEG PAV is worse • Possibilities: • Vasospasm • Deep sedation • Sepsis due to pneumonia • Hydrocephalus
Get a CT, shows no hydrocephalus PbrO2 is dropping to low values PbtO2
Treatment of vasospasm • Treatment options • HHH Rx • Intraarterial vasodilators • Angioplasty • Hypothermia/ Normothermia • Hyperoxia • Metabolic Suppression
SAH case # 3 • 46 yo man with SAH with basilar aneurysm • GCS 7, HH 4, GCS motor = 4-5 • Coiled on PBD # 2 • ICP, MD, and EEG placed • ICP becomes elevated requiring frequent CSF drainage
Microdialysis during metabolic suppression with high dose propofol treatment for ICP
Microdialysis response to vasospasm and subsequent treatment vasospasm
Case 4 • 58 yo woman with SAH due to Acomm • Clipped on day 2 • Comatose with slight Right Leg weakness post operatively • EEG PAV becomes poor on day 6 • MD monitoring started on day 3
Microdialysis shows normal LPR, glutamate, glucose LPR 20-25 range
Uncertainty and Action • The TCD and angio show vasospasm • Microdialysis does not show ischemic changes • HH therapy and intraarterial verapamil Tx done once, but persistent angio and TCD findings • Do we return to angio? Be more aggressive?
DWI while MD LPR is 25 MD probe locations 1 and 2 2 1
What we did • We continued with HH therapy and returned to angio for IA treatment • The MD did not change from that point on • We watched clinical exam, and EEG PAV
What did we learn? • LPR reflected the region of interest well • The ischemia occurred in the distal ACA territory due to distal effects of spasm • We may need to place multiple probes in locations that are quite different than the frontal location • We need imaging or other adjunct monitoring
Summary • Multimodality monitoring with PbrO2, MD, and cEEG detected the ischemic response that occurred with vasospasm after SAH • Monitoring in the ACA-MCA borderzone is good but very regional changes may occur in remote locations. • It is unclear which method is best: PBrO2, EEG PAV, TCD, MD. • Response to treatment can be seen