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Update on the Treatment of Spontaneous Intraparenchymal Hemorrhage: Medical and Interventional Management. Curr Treat Options Neurol 2018; 20:1. [PMID: 29397452 DOI: 10.1007/s11940-018-0486-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Spontaneous intraparenchymal hemorrhage (IPH) is a prominent challenge faced globally by neurosurgeons, neurologists, and intensivists. Over the past few decades, basic and clinical research efforts have been undertaken with the goal of delineating biologically and evidence-based practices aimed at decreasing mortality and optimizing the likelihood of meaningful functional outcome for patients afflicted with this devastating condition. Here, the authors review the medical and surgical approaches available for the treatment of spontaneous intraparenchymal hemorrhage, identifying areas of recent progress and ongoing research to delineate the scope and scale of IPH as it is currently understood and treated. RECENT FINDINGS The approaches to IPH have broadly focused on arresting expansion of hemorrhage using a number of approaches. Recent trials have addressed the effectiveness of rapid blood pressure lowering in hypertensive patients with IPH, with rapid lowering demonstrated to be safe and at least partially effective in preventing hematoma expansion. Hemostatic therapy with platelet transfusion in patients on anti-platelet medications has been recently demonstrated to have no benefit and may be harmful. Hemostasis with administration of clotting complexes has not been shown to be effective in reducing hematoma expansion or improving outcomes although correcting these abnormalities as soon as possible remains good practice until further data are available. Stereotactically guided drainage of IPH with intraventricular hemorrhage (IVH) has been shown to be safe and to improve outcomes. Research on new stereotactic surgical methods has begun to show promise. Patients with IPH should have rapid and accurate diagnosis with neuroimaging with computed tomography (CT) and computed tomography angiography (CTA). Early interventions should include control of hypertension to a systolic BP in the range of 140 mmHg for small hemorrhages without intracranial hypertension with beta blockers or calcium channel blockers, correction of any coagulopathy if present, and assessment of the need for surgical intervention. IPH and FUNC (Functional Outcome in Patients with Primary Intracerebral Hemorrhage) scores should be assessed. Patients should be dispositioned to a dedicated neurologic ICU if available. Patients should be monitored for seizures and intracranial pressure issues. Select patients, particularly those with intraventricular extension, may benefit from evacuation of hematoma with a ventriculostomy or stereotactically guided catheter. Once stabilized, patients should be reassessed with CT imaging and receive ongoing management of blood pressure, cerebral edema, ICP issues, and seizures as they arise. The goal of care for most patients is to regain capacity to receive multidisciplinary rehabilitation to optimize functional outcome.
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Asehnoune K, Lasocki S, Seguin P, Geeraerts T, Perrigault PF, Dahyot-Fizelier C, Paugam Burtz C, Cook F, Demeure dit latte D, Cinotti R, Mahe PJ, Fortuit C, Pirracchio R, Feuillet F, Sébille V, Roquilly A. Association between continuous hyperosmolar therapy and survival in patients with traumatic brain injury - a multicentre prospective cohort study and systematic review. Crit Care 2017; 21:328. [PMID: 29282104 PMCID: PMC5745762 DOI: 10.1186/s13054-017-1918-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 12/05/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Intracranial hypertension (ICH) is a major cause of death after traumatic brain injury (TBI). Continuous hyperosmolar therapy (CHT) has been proposed for the treatment of ICH, but its effectiveness is controversial. We compared the mortality and outcomes in patients with TBI with ICH treated or not with CHT. METHODS We included patients with TBI (Glasgow Coma Scale ≤ 12 and trauma-associated lesion on brain computed tomography (CT) scan) from the databases of the prospective multicentre trials Corti-TC, BI-VILI and ATLANREA. CHT consisted of an intravenous infusion of NaCl 20% for 24 hours or more. The primary outcome was the risk of survival at day 90, adjusted for predefined covariates and baseline differences, allowing us to reduce the bias resulting from confounding factors in observational studies. A systematic review was conducted including studies published from 1966 to December 2016. RESULTS Among the 1086 included patients, 545 (51.7%) developed ICH (143 treated and 402 not treated with CHT). In patients with ICH, the relative risk of survival at day 90 with CHT was 1.43 (95% CI, 0.99-2.06, p = 0.05). The adjusted hazard ratio for survival was 1.74 (95% CI, 1.36-2.23, p < 0.001) in propensity-score-adjusted analysis. At day 90, favourable outcomes (Glasgow Outcome Scale 4-5) occurred in 45.2% of treated patients with ICH and in 35.8% of patients with ICH not treated with CHT (p = 0.06). A review of the literature including 1304 patients from eight studies suggests that CHT is associated with a reduction of in-ICU mortality (intervention, 112/474 deaths (23.6%) vs. control, 244/781 deaths (31.2%); OR 1.42 (95% CI, 1.04-1.95), p = 0.03, I 2 = 15%). CONCLUSIONS CHT for the treatment of posttraumatic ICH was associated with improved adjusted 90-day survival. This result was strengthened by a review of the literature.
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Affiliation(s)
- Karim Asehnoune
- Intensive Care Unit, Anaesthesia and Critical Care Department, Hôtel Dieu - HME, CHU Nantes, Nantes, France
- CHU de Nantes, Service d’Anesthésie Réanimation, 1 place Alexis Ricordeau, 44093 Nantes, Cedex 1, France
| | - Sigismond Lasocki
- Department of Anaesthesiology and Critical Care Department, University Hospital of Angers, Angers, France
| | - Philippe Seguin
- Intensive Care Unit, Anaesthesia and Critical Care Department, Pontchaillou, University Hospital of Rennes, Rennes, France
| | - Thomas Geeraerts
- Anaesthesia and Critical Care Department, University Hospital of Toulouse, Toulouse, France
| | - Pierre François Perrigault
- Intensive Care Unit, Anaesthesia and Critical Care Department, Gui Chauliac University Hospital of Montpellier, Montpellier, France
| | - Claire Dahyot-Fizelier
- Neuro-Intensive Care Unit, Anaesthesia and Critical Care Department, Poitiers, University Hospital of Poitiers, Poitiers, France
| | - Catherine Paugam Burtz
- Intensive Care Unit, Anaesthesia and Critical Care Department, Beaujon, University Hospital of Beaujon (AP-HP), Beaujon, France
| | - Fabrice Cook
- Intensive Care Unit, Anaesthesia and Critical Care Department, Henri Mondor, University Hospital of Créteil (AP-HP), Créteil, France
| | | | - Raphael Cinotti
- Intensive Care Unit, Anaesthesia and Critical Care Department, Hôtel Dieu - HME, CHU Nantes, Nantes, France
| | - Pierre Joachim Mahe
- Intensive Care Unit, Anaesthesia and Critical Care Department, Hôtel Dieu - HME, CHU Nantes, Nantes, France
| | - Camille Fortuit
- Intensive Care Unit, Anaesthesia and Critical Care Department, Hôtel Dieu - HME, CHU Nantes, Nantes, France
| | - Romain Pirracchio
- Department of Anesthesia and Critical care Medicine, Hôpital Européen Georges Pompidou, Paris 5 Descartes, Sorbonne Paris Cité, Paris, France
- NSERM UMR-S1153, Team ECSTRA, Hôpital Saint Louis, Paris, France
| | - Fanny Feuillet
- UMR 1246 SPHERE “methodS in Patients-centered outcomes and HEalth ResEarch”, Nantes University, Nantes, France
| | - Véronique Sébille
- UMR 1246 SPHERE “methodS in Patients-centered outcomes and HEalth ResEarch”, Nantes University, Nantes, France
- Plateforme de Biométrie, Département Promotion de la Recherche Clinique, University Hospital of Nantes, Nantes, France
| | - Antoine Roquilly
- Intensive Care Unit, Anaesthesia and Critical Care Department, Hôtel Dieu - HME, CHU Nantes, Nantes, France
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Abstract
Head trauma is a common cause of significant morbidity and mortality in dogs and cats. Traumatic brain injury may occur after head trauma. Understanding the pathophysiology of primary and secondary injury after head trauma is essential for management. This article reviews the pathophysiology of head trauma, patient assessment and diagnostics, and treatment recommendations.
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Affiliation(s)
- Kendon W Kuo
- Emergency and Critical Care, Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, 1220 Wire Road, Auburn, AL 36849- 5540, USA.
| | - Lenore M Bacek
- Emergency and Critical Care, Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, 1220 Wire Road, Auburn, AL 36849- 5540, USA
| | - Amanda R Taylor
- Neurology/Neurosurgery, Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, 1220 Wire Road, Auburn, AL 36849- 5540, USA
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Vergouw LJM, Egal M, Bergmans B, Dippel DWJ, Lingsma HF, Vergouwen MDI, Willems PWA, Oldenbeuving AW, Bakker J, van der Jagt M. High Early Fluid Input After Aneurysmal Subarachnoid Hemorrhage: Combined Report of Association With Delayed Cerebral Ischemia and Feasibility of Cardiac Output-Guided Fluid Restriction. J Intensive Care Med 2017. [PMID: 28934895 DOI: 10.1177/0885066617732747#] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Guidelines on the management of aneurysmal subarachnoid hemorrhage (aSAH) recommend euvolemia, whereas hypervolemia may cause harm. We investigated whether high early fluid input is associated with delayed cerebral ischemia (DCI), and if fluid input can be safely decreased using transpulmonary thermodilution (TPT). METHODS We retrospectively included aSAH patients treated at an academic intensive care unit (2007-2011; cohort 1) or managed with TPT (2011-2013; cohort 2). Local guidelines recommended fluid input of 3 L daily. More fluids were administered when daily fluid balance fell below +500 mL. In cohort 2, fluid input in high-risk patients was guided by cardiac output measured by TPT per a strict protocol. Associations of fluid input and balance with DCI were analyzed with multivariable logistic regression (cohort 1), and changes in hemodynamic indices after institution of TPT assessed with linear mixed models (cohort 2). RESULTS Cumulative fluid input 0 to 72 hours after admission was associated with DCI in cohort 1 (n=223; odds ratio [OR] 1.19/L; 95% confidence interval 1.07-1.32), whereas cumulative fluid balance was not. In cohort 2 (23 patients), using TPT fluid input could be decreased from 6.0 ± 1.0 L before to 3.4 ± 0.3 L; P = .012), while preload parameters and consciousness remained stable. CONCLUSION High early fluid input was associated with DCI. Invasive hemodynamic monitoring was feasible to reduce fluid input while maintaining preload. These results indicate that fluid loading beyond a normal preload occurs, may increase DCI risk, and can be minimized with TPT.
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Affiliation(s)
- Leonie J M Vergouw
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Mohamud Egal
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Bas Bergmans
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter W A Willems
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Jan Bakker
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Bach L, Dries DJ. Management of Traumatic Intracranial Hypertension: Old Questions With New Answers. Air Med J 2017; 36:156-159. [PMID: 28739231 DOI: 10.1016/j.amj.2017.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 05/17/2017] [Indexed: 06/07/2023]
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Puntis M, Smith M. Critical care management of adult traumatic brain injury. ANAESTHESIA AND INTENSIVE CARE MEDICINE 2017. [DOI: 10.1016/j.mpaic.2017.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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García-Soler P, Amores-Torres M, Sanchiz-Cárdenas S, González-Gómez JM, Dayaldasani A, Milano-Manso G. Thiopental and false hypernatremia: Check your analyzer. Med Intensiva 2017; 41:573-574. [PMID: 28318672 DOI: 10.1016/j.medin.2017.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 01/13/2017] [Accepted: 01/21/2017] [Indexed: 11/29/2022]
Affiliation(s)
- P García-Soler
- Unidad de Cuidados Intensivos Pediátricos, Hospital Regional Universitario de Málaga, Málaga, España.
| | - M Amores-Torres
- Unidad de Cuidados Intensivos Pediátricos, Hospital Regional Universitario de Málaga, Málaga, España
| | - S Sanchiz-Cárdenas
- Unidad de Cuidados Intensivos Pediátricos, Hospital Regional Universitario de Málaga, Málaga, España
| | - J M González-Gómez
- Unidad de Cuidados Intensivos Pediátricos, Hospital Regional Universitario de Málaga, Málaga, España
| | - A Dayaldasani
- Unidad de Análisis Clínicos, Hospital Regional Universitario de Málaga, Málaga, España
| | - G Milano-Manso
- Unidad de Cuidados Intensivos Pediátricos, Hospital Regional Universitario de Málaga, Málaga, España
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Increased Perioperative Crystalloid Transfusion Is Associated with Better Outcomes After Spontaneous Hypertensive Putamen Hemorrhage: A Retrospective Study. World Neurosurg 2017; 98:140-145. [DOI: 10.1016/j.wneu.2016.10.115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 10/23/2016] [Accepted: 10/24/2016] [Indexed: 11/23/2022]
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Vigué B, Leblanc PE, Moati F, Pussard E, Foufa H, Rodrigues A, Figueiredo S, Harrois A, Mazoit JX, Rafi H, Duranteau J. Mid-regional pro-adrenomedullin (MR-proADM), a marker of positive fluid balance in critically ill patients: results of the ENVOL study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:363. [PMID: 27825364 PMCID: PMC5101658 DOI: 10.1186/s13054-016-1540-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 10/20/2016] [Indexed: 12/14/2022]
Abstract
Background The optimal control of blood volume without fluid overload is a main challenge in the daily care of intensive care unit (ICU) patients. Accordingly this study focused on the identification of biomarkers to help characterize fluid overload status. Methods Sixty-seven patients were studied from ICU admission to day 7 (D7). Blood and urine samples were taken daily and sodium and water balance strictly calculated resulting in a total cumulative assessment of ∆Na+ and ∆H2O. Furthermore, plasmatic biomarkers (cortisol, epinephrine, norepinephrine, renin, angiotensin II, aldosterone, pro-endothelin, copeptine, atrial natriuretic peptide, erythropoietin, mid-regional pro-adrenomedullin (MR-proADM)) and Sequential Organ Failure Assessment (SOFA) scores were measured at D2, D5 and D7. Blood volumes were measured with 51Cr fixed on red blood cells at D2 and D7. Results The ∆Na+ or ∆H2O were increased in all patients but never related to blood volumes at D2 nor D7. Total blood volumes were at normal values with constantly low red blood cell volumes and normal or decreased plasmatic volume. Weight, plasmatic proteins, and hemoglobin were weakly related to ∆Na+ or ∆H2O. Amongst all tested biomarkers, only MR-proADM was related to sodium and fluid overload. This biomarker was also a predictor of SOFA scores. Conclusions Plasmatic concentration in MR-proADM seems to be a good surrogate for evaluation of ∆Na+ or ∆H2O and predicts sodium and extracellular fluid overload. Trial registration ClinicalTrials.gov: NCT01858675 in May 13, 2013. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1540-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bernard Vigué
- Département d'Anesthésie-Réanimation, Hôpital de Bicêtre, Université Paris-Sud, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, Paris, France.
| | - Pierre-Etienne Leblanc
- Département d'Anesthésie-Réanimation, Hôpital de Bicêtre, Université Paris-Sud, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, Paris, France
| | - Frédérique Moati
- Service de biophysique et de médecine nucléaire, Centre Hospitalier Universitaire de Bicêtre, Assistance publique - Hôpitaux de Paris, Paris, France
| | - Eric Pussard
- Service de Génétique Moléculaire, Pharmacogénétique et Hormonologie, Inserm U1185, Centre Hospitalier Universitaire de Bicêtre, Assistance publique - Hôpitaux de Paris, Paris, France
| | - Hussam Foufa
- Département d'Anesthésie-Réanimation, Hôpital de Bicêtre, Université Paris-Sud, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, Paris, France
| | - Aurore Rodrigues
- Département d'Anesthésie-Réanimation, Hôpital de Bicêtre, Université Paris-Sud, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, Paris, France
| | - Samy Figueiredo
- Département d'Anesthésie-Réanimation, Hôpital de Bicêtre, Université Paris-Sud, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, Paris, France
| | - Anatole Harrois
- Département d'Anesthésie-Réanimation, Hôpital de Bicêtre, Université Paris-Sud, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, Paris, France
| | - Jean-Xavier Mazoit
- Département d'Anesthésie-Réanimation, Hôpital de Bicêtre, Université Paris-Sud, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, Paris, France
| | - Homa Rafi
- Thermo Fisher Scientific, Asnières sur Seine, France
| | - Jacques Duranteau
- Département d'Anesthésie-Réanimation, Hôpital de Bicêtre, Université Paris-Sud, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, Paris, France
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