2012 the NeuroICU book 1st edition

Editor Kiwon Lee, MD, FACP, FAHA, FCCM Assistant Professor of Neurology and Neurological Surgery Columbia University College of Physicians and Surgeons Department of Neurology, Division

Aung Kyaw Oo

NeuroICU T H E B O O K

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Medicine is an ever-changing science As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required The authors and the publisher of this work have checked with sources believed to be reli-able in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication However, in view of the pos-sibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publica-tion of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions

or for the results obtained from use of the information contained in this work ers are encouraged to confirm the information contained herein with other sources For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration This recommendation is of particular importance in connection with new or infrequently used drugs

Editor

Kiwon Lee, MD, FACP, FAHA, FCCM

Assistant Professor of Neurology and Neurological Surgery Columbia University College of Physicians and Surgeons Department of Neurology, Division of Critical Care

Neurological Intensive Care Unit New York Presbyterian Hospital Columbia University Medical Center

New York, New York

New York Chicago San Francisco Lisbon London Madrid Mexico City

Milan New Delhi San Juan Seoul Singapore Sydney Toronto

T H E

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diligence and hard working; to my mother, Younghee Lee, who has taught me how

to lead and trained me to become tough; to my one and only sister, Katelyn Jongmee Lee; to my dearest daughters, Sophia Koen and Charin Lee, who constantly bring

me happiness; and to my wife without whose support I would not be at where I am.

Kiwon Lee, MD

ection editor: Neera Bad atia, MD, M c, FCCM

Santiago Ortega-Gutierrez, MD, Naman Desai, BA,

and Jan Claassen, MD, PhD

Mithil Gajera, MD, Quinn A Czosnowski, PharmD, BCPS,

and Fred Rincon, MD, MSc, FACP

Simon Hanft, MD and Michael B Sisti, MD

H Alex Choi, MD, Sang-Bae Ko, MD, PhD,

and Kiwon Lee, MD, FACP, FAHA, FCCM

Cardiac arrest and anoxic Brain n ury 188

Rishi Malhotra, MD and Kiwon Lee, MD, FACP, FAHA, FCCM

H Alex Choi, MD, Rebecca Bauer, MD,

and Kiwon Lee, MD, FACP, FAHA, FCCM

ection editor: an Claassen, MD, phD

Kiwon Lee, MD and Stephan A Mayer, MD

Continuous electroencephalo gram Monitoring in the

Santiago Ortega-Gutierrez, MD, Emily Gilmore, MD, and Jan Claassen, MD, PhD

Raimund Helbok, MD, Pedro Kurtz, MD, and Jan Claassen, MD, PhD

Pedro Kurtz, MD and Kiwon Lee, MD

Errol Gordon, MD and Jan Claassen, MD

Michael J Schmidt, PhD

Section 3 neurocritical care Intervention 325

ection editor: tephan a Mayer, MD, FCCM

Amy L Dzierba, PharmD, BCPS, Vivek K Moitra, MD, and

Robert N Sladen, MBChB, MRCP(UK), FRCP(C), FCCM

Neeraj Badjatia, MD, MSc, FCCM

Raqeeb Haque, MD, Celina Crisman, BS, Brian Hwang, MD,

E Sander Connolly, MD, and Philip M Meyers, MD

Section 4 Perioperative Surgical care 385

ection editor: e ander Connolly, MD

Raqeeb Haque, MD, Ivan S Kotchetkov, BA, Brian Y Hwang, MD, and

E Sander Connolly, MD

external entricular Drain Management and

Paul R Gigante, MD, Brian Y Hwang, MD, and E Sander Connolly, MD

Christopher Kellner, MD, Matthew Piazza, BA, Geoffrey Appelboom, MD,

and E Sander Connolly, MD

Raqeeb Haque, MD, Teresa J Wojtasiewicz, BA, Brian Y Hwang, MD, and

E Sander Connolly, MD

Section 5 trauma and Surgical Intensive care 455

ection editors: oseph Meltzer, MD and ivek Moitra, MD

Steven Miller, MD and Vivek K Moitra, MD

Brian Woods, MD

Shahzad Shaefi, MD and Joseph Meltzer, MD

ection editor: oseph e parrillo, MD, FCCp

Joanne Mazzarelli, MD and Steven Werns, MD

arrhythmias: rhythm Disturbances in Critically ll patients 587

Tracy Walker, MD and Andrea M Russo, MD

Fredric Ginsberg, MD and Joseph E Parrillo, MD

Simon K Topalian, MD and Joseph E Parrillo, MD

ection editor: r phillip Dellinger, MD, FCCp

Laura McPhee, DO and David B Seder, MD

Brian M Fuller, MD

Maher Dahdel, MD and R Phillip Dellinger, MD

Ramya Lotano, MD and Hiren Shingala, MD

Section Renal and Electrolyte Disorders 751

ection editor: La rence eisberg, MD

Jean-Sebastien Rachoin, MD and Lawrence S Weisberg, MD

Andrew Davenport, MD

Lawrence S Weisberg, MD

Samia Mian, MD, Thilagavathi Venkatachalam, MD, and

Christopher B McFadden, MD

Section 9 Hematology 807

ection editor: Louis aledort, MD

Caroline Cromwell, MD and Louis M Aledort, MD, MACP

Caroline Cromwell, MD and Louis M Aledort, MD, MACP

ection editor: Fred rincon, MD, M c, FaCp

Sergio L Zanotti-Cavazoni, MD, FCCM

Quinn A Czosnowski, PharmD, BCPS and Jomy M George, PharmD, BCPS

Rose Kim, MD, Daniel K Meyer, MD, and Annette C Reboli, MD

Constantine Tsigrelis, MD and Annette C Reboli, MD

ection editor: Neera Bad atia, MD, M c, FCCM

Dongwook Kim, MD and David S Seres, MD

Kiwon Lee, MD, FACP, FAHA, FCCM

ection editor: i on Lee, MD, FaCp, Faha, FCCM

Guillermo Linares, MD, Mireia Anglada, MD, and

Kiwon Lee, MD, FACP, FAHA, FCCM

Index 931

Sparks Health System

Fort Smith, Arkansas

Chapter 40

Louis M Aledort, MD, MAcP

The Mary Weinfeld Professor of

Clinical Research in Hemophilia

Division of Hematology and

Medical Oncology

Department of Medicine

The Mount Sinai School of Medicine

New York, New York

Chapters 45, 46

Mireia Anglada, MD

Germans Trias i Pujol Hospital

Intensive Care Unit

Columbia University College of

Physicians and Surgeons

Medical Director, Neurological

Intensive Care Unit

Director, Neurocritical Care

Training Program

NewYork-Presbyterian/Columbia

University Medical Center

New York, New York

Chapters 4, 19, 50

thaddeus artter, MD

Professor of Medicine Director, Interventional Pulmonary Division of Pulmonary and Critical Care Medicine

University of Arkansas for the Medical Sciences

Little Rock, Arkansas

Chapter 11

H Alex choi, MD

Fellow, Division of Critical Care Department of Neurology Columbia University College of Physicians and Surgeons NewYork-Presbyterian/Columbia University Medical Center New York, New York

Chapters 9, 11

an claassen, MD, PhD

Assistant Professor of Neurology and

Neurological Surgery

Columbia University College of

Physicians and Surgeons

Department of Neurology, Division of

Critical Care

NewYork-Presbyterian/Columbia

University Medical Center

New York, New York

Chapters 3, 13, 14, 16

carlee clark, MD

Assistant Professor of Anesthesia and

Perioperative Medicine

Medical University of South Carolina

Charleston, South Carolina

Chapter 28

E Sander connolly, r, MD, FAcS

Bennett M Stein Professor of

Neurological Surgery

Vice Chairman of Neurosurgery

Director, Cerebrovascular Research

Laboratory

Surgical Director, Neuro-Intensive

Care Unit

Columbia University College of

Physicians and Surgeons

NewYork-Presbyterian/Columbia

University Medical Center

New York, New York

R Phillip Dellinger, MD, FccP

Professor of Medicine

Robert Wood Johnson Medical School

University of Medicine and

Dentistry of New Jersey

Head, Division of Critical Care

Medicine

Cooper University Hospital

Camden, New Jersey

Chapter 37

Amy L Dzierba, PharmD, cPS

Clinical Pharmacist, Medical

Intensive Care Unit

Department of Pharmacy

NewYork-Presbyterian/Columbia

University Medical Center

New York, New York

Chapter 18

ennifer Frontera, MD

Assistant Professor of Neurosurgery

and Neurology

The Mount Sinai School of Medicine

Division of Neuro-Critical Care

Mount Sinai Hospital

New York, New York

Chapter 6

rian M Fuller, MD

Assistant Professor of Anesthesiology

and Emergency Medicine

Department of Anesthesiology

Division of Critical Care

Division of Emergency Medicine

Washington University School of

of New Jersey Division of Pulmonary & Critical Care Medicine

Cooper University Hospital Camden, NJ

Chapter 7

omy M George, PharmD, cPS

Assistant Professor of Clinical Pharmacy

Department of Pharmacy Practice & Pharmacy Administration Philadelphia College of Pharmacy University of the Sciences Philadelphia, Pennsylvania

Chapter 48

Paul Gigante, MD

House staff, Department of Neurological Surgery Columbia University College of Physicians and Surgeons NewYork-Presbyterian/Columbia University Medical Center New York, New York

Chapter 22

Emily Gilmore, MD

Fellow, Division of Critical Care

Department of Neurology

Columbia University College of

Physicians and Surgeons

NewYork-Presbyterian/Columbia

University Medical Center

New York, New York

Chapter 13

Fredric Ginsberg, MD

Assistant Professor of Medicine

Robert Wood Johnson Medical School

University of Medicine and

Dentistry of New Jersey

Director, Nuclear Cardiology

Director, Heart Failure Program

Cooper University Hospital

Camden, New Jersey

Chapter 33

Errol Gordon, MD

Assistant Professor of Neurosurgery

and Neurology

The Mount Sinai School of Medicine

Division of Neuro-Critical Care

Mount Sinai Hospital

New York, New York

Chapter 16

Simon Hanft, MD, M Phil

House staff, Department of

Neurological Surgery

Columbia University College of

Physicians and Surgeons

NewYork-Presbyterian/Columbia

University Medical Center

New York, New York

Chapter 8

Ra eeb Ha ue, MD

House staff, Department of Neurological Surgery Columbia University College of Physicians and Surgeons NewYork-Presbyterian/Columbia University Medical Center New York, New York

Chapters 20, 21, and 24

Raimund Helbok, MD

Department of Neurology, Neurocritical Care Unit Innsbruck Medical University Innsbruck, Austria

Chapter 14

rian Hwang, MD

Neurosurgical Resident Department of Neurosurgery Johns Hopkins University Hospital Baltimore, MD

Chapters 20, 21, 22, 24

christopher ellner, MD

House staff, Department of Neurological Surgery Columbia University College of Physicians and Surgeons NewYork-Presbyterian/Columbia University Medical Center New York, New York

Chapter 23

Sang- ae o, MD, PhD

Postdoctoral Research Fellow

Division of Critical Care

Department of Neurology

Columbia University College of

Physicians and Surgeons

NewYork-Presbyterian/Columbia

University Medical Center

New York, New York

Assistant Professor of Medicine

Cooper Medical School of Rowan

University

Division of Infectious Diseases

Cooper University Hospital

Camden, New Jersey

Chapter 49

Dongwook im, MD

Clinical Nutrition and Obesity Fellow

Endocrinology, Diabetes & Nutrition

Boston University School of Medicine

Boston Medical Center

Casa de Saúde São José

Rio de Janeiro, Brasil

New York-Presbyterian/Columbia University Medical Center New York, New York

Chapters 1, 9, 10, 11, 12, 15, 52, and 53

Guillermo Linares, MD

Fellow, Division of Critical Care Department of Neurology Columbia University College of Physicians and Surgeons NewYork-Presbyterian/Columbia University Medical Center New York, New York

Chapter 53

Ramya Lotano, MD

Assistant Professor of Medicine Director, Pulmonary & Critical Care fellowship

Robert Wood Johnson Medical School University of Medicine and

Dentistry of New Jersey Division of Pulmonary & Critical Care Medicine

Cooper University Hospital Camden, New Jersey

Chapter 38

Frank Macchio, MD

Fellow, Division of Anesthesia and

Critical Care

Department of Anesthesiology

Columbia University College of

Physicians and Surgeons

NewYork-Presbyterian/Columbia

University Medical Center

New York, New York

Chapter 29

Rishi Malhotra, MD

Neurointensivist

Department of Neurosurgery, North

Shore University Hospital and

Long Island Jewish Medical Center

Cushing Neuroscience Institute

Manhasset, New York

Chapter 10

Stephan A Mayer, MD, FccM

Professor of Neurology and

Neurological Surgery

Columbia University College of

Physicians & Surgeons

Director, Division of Critical Care,

Department of Neurology

NewYork-Presbyterian/Columbia

University Medical Center

New York, New York

Chapters 2 and 12

oanne Mazzarelli, MD

Postdoctoral Fellow, Cardiology

Robert Wood Johnson Medical School

University of Medicine and

Dentistry of New Jersey

Department of Medicine

Division of Cardiovascular Diseases

Cooper University Hospital

Camden, New Jersey

Chapter 31

christopher McFadden, MD

Assistant Professor of Medicine Robert Wood Johnson Medical School University of Medicine and Dentistry of New Jersey

Division of Nephrology Cooper University Hospital Camden, New Jersey

David Geffen Medical School Ronald Reagan UCLA Medical Center Los Angeles, California

Chapter 27

Daniel Meyer, MD

Assistant Professor of Medicine Robert Wood Johnson Medical School University of Medicine and

Dentistry of New Jersey Division of Infectious Diseases Cooper University Hospital Camden, New Jersey

Chapter 49

Philip M Meyers, MD, FAHA

Associate Professor of Radiology and

Neurological Surgery

Clinical Co-Director,

Neuroendovascular Services

Columbia University College of

Physicians and Surgeons

NewYork-Presbyterian/Columbia

University Medical Center

New York, New York

Chapter 20

Samia Mian, MD

Postdoctoral Fellow, Nephrology

Robert Wood Johnson Medical School

University of Medicine and

Dentistry of New Jersey

Division of Nephrology

Cooper University Hospital

Camden, New Jersey

Chapter 44

Steven Miller, MD

Assistant Professor of Anesthesiology

Department of Anesthesiology

Columbia University College of

Physicians and Surgeons

NewYork-Presbyterian/Columbia

University Medical Center

New York, New York

Chapter 25

ivek Moitra, MD

Assistant Professor of Anesthesiology

Assistant Medical Director, Surgical

Intensive Care Unit

Columbia University College of

Physicians and Surgeons

NewYork-Presbyterian/Columbia

University Medical Center

New York, New York

Chapter 18 and 25

oliver Panzer, MD

Assistant Professor of Anesthesiology Columbia University College of Physicians and Surgeons NewYork-Presbyterian/Columbia University Medical Center New York, New York

Chapter 30

Santiago ortega-Gutierrez, MD

Fellow, Division of Critical Care Department of Neurology Columbia University College of Physicians and Surgeons NewYork-Presbyterian/Columbia University Medical Center New York, New York

Chapters 3 and 13

oseph E Parrillo, MD, FccP

Professor of Medicine Robert Wood Johnson Medical School University of Medicine and

Dentistry of New Jersey Chief, Department of Medicine Edward D Viner MD Chair, Department of Medicine Director, Cooper Heart Institute Cooper University Hospital Camden, New Jersey

Chapters 33 and 34

Melvin R Pratter, MD

Professor of Medicine Robert Wood Johnson Medical School University of Medicine and Dentistry

of New Jersey Head, Division of Pulmonary Diseases and Critical Care Medicine

Cooper University Hospital Camden, New Jersey

Chapter 40

ean-Sebastien Rachoin, MD, FASn

Assistant Professor of Medicine

Robert Wood Johnson Medical School

University of Medicine and Dentistry

of New Jersey

Department of Medicine, Division of

Hospital Medicine

Cooper University Hospital

Camden, New Jersey

Division of Infectious Diseases

Cooper University Hospital

Camden, New Jersey

Chapters 49 and 50

Fred Rincon, MD, MSc, FAcP

Assistant Professor of Neurology and

Neurological Surgery

Department of Neurological Surgery

Thomas Jefferson University Jefferson

Robert Wood Johnson Medical School

University of Medicine and Dentistry

of New Jersey

Department of Medicine

Division of Cardiovascular Diseases

Director of Cardiac Electrophysiology

Cooper University Hospital

Camden, New Jersey

Chapter 32

David Seder, MD

Assistant Professor of Medicine Tufts University School of Medicine Director of Neurocritical Care Maine Medical Center Portland, Maine

Chapters 35 and 39

David S Seres, MD, ScM, PnS

Director of Medical Nutrition Assistant Professor of Clinical Medicine Department of Medicine

Columbia University College of Physicians and Surgeons New York-Presbyterian/Columbia University Medical Center New York, New York

Chapter 51

Michael Schmidt, PhD

Assistant Professor of Clinical Neuropsychology in Neurology Director of Clinical Neuromonitoring and Informatics

Neurological Intensive Care Unit Columbia University College of Physicians and Surgeons New York, New York

Chapter 27

Cooper University Hospital

Camden, New Jersey

Department of Internal Medicine

University of Arkansas for Medical

Associate Professor of Clinical

Neurosurgery, Radiation Oncology

& Otolaryngology

Co-Director, The Center for

Radiosurgery

Department of Neurological Surgery

Columbia University College of

Physicians and Surgeons

New York-Presbyterian/Columbia

University Medical Center

New York, New York

Chapter 8

Robert n Sladen, M ch (cape town), MRcP ( ), FRcP (c),FccM

Professor and Executive Vice-Chair of Anesthesiology

Chief, Division of Critical Care Department of Anesthesiology Columbia University College of Physicians and Surgeons New York-Presbyterian/Columbia University Medical Center New York, New York

Chapter 18

Simon topalian, MD, FAcc

Assistant Professor of Medicine Robert Wood Johnson Medical School University of Medicine and Dentistry

of New Jersey Cooper University Hospital Camden, New Jersey

Chapter 34

constantine tsigrelis, MD

Assistant Professor of Medicine Cooper Medical School of Rowan University

Division of Infectious Diseases Cooper University Hospital Camden, New Jersey

Chapter 50

thilagavathi enkatachalam, MD

Postdoctoral Fellow, Nephrology Robert Wood Johnson Medical School University of Medicine and Dentistry

of New Jersey Division of Nephrology Cooper University Hospital Camden, New Jersey

Chapter 44

tracy Walker, MD

Postdoctoral Fellow, Cardiology

Robert Wood Johnson Medical School

University of Medicine and Dentistry

of New Jersey

Department of Medicine

Division of Cardiovascular Diseases

Cooper University Hospital

Camden, New Jersey

Robert Wood Johnson Medical School

University of Medicine and Dentistry

of New Jersey

Director, Invasive Cardiovascular

Services

Cooper University Hospital

Camden, New Jersey

Robert Wood Johnson Medical School

University of Medicine and Dentistry

of New Jersey

Head, Division of Nephrology

Deputy Chief, Department of

Medicine

Cooper University Hospital

Camden, New Jersey

Chapters 41 and 43

oshua Willey, MD, MS

Assistant Professor of Neurology Columbia University College of Physicians and Surgeons Department of Neurology, Division of Stroke

New York-Presbyterian/Columbia University Medical Center New York, New York

Chapter 26

ason A ahwak, MD

Clinical Instructor in Medicine Tufts University School of Medicine Division of Pulmonary and Critical Care Medicine

Maine Medical Center Portland, Maine

Chapter 39

Moussa F azbeck, MD

Postdoctoral Fellow

Robert Wood Johnson Medical School

University of Medicine and Dentistry

of New Jersey

Division of Critical Care Medicine

Cooper University Hospital

Camden, New Jersey

Chapter 2

Sergio L anotti-cavazzoni, MD

Assistant Professor of Medicine Robert Wood Johnson Medical School University of Medicine and Dentistry

of New Jersey Department of Medicine Division of Critical Care Medicine Cooper University Hospital Camden, New Jersey

Chapter 47

Foreword

This work is a dialogue It could be between two colleagues from different plines, between a resident or fellow with a mentor, or between two neurointensiv- ists trying to work through a challenging patient care dilemma But, in any event,

disci-it is a dialogue.

Each chapter considers a case vignette or small number of vignettes The patients presented illustrate the typical, common problems encountered in a NeuroICU The vignettes are broken up and interspersed with the sort of discussions that occur every day in such a unit In all cases, the discussion begins by establishing

priority What’s the goal at this stage? What must we do now, to get to the next

stage? The answers are as clear as the questions Then, what else should we be thinking about? Question after question, answer after answer, the same straight- forward dialogue occurs What next? What is happening to the patient? What should we do about it? Why? Each question elicits a clear, practical response The answer is supported by selected, pertinent evidence Evidence is not presented as

a mere list of data but rather as integrated information The key data are explicitly stated but then there is also commentary based on subsequent studies and the subsequent collective experience of its accomplished authors In other words, this

is a dialogue And finally, at the end of each section, as if asking “Still unsure how

to proceed?”, the answer comes back “Well let me tell you how we do it” and a by-step protocol follows.

step-This occurs over and over again, subject after subject and organ after organ For this, work is not just about intensive care of the nervous system, it acknowl- edges and addresses all of the multiorgan problems that attend the complex dis- eases that can produce catastrophic injury of the nervous system.

This book is sure to be a favorite for many years to come It is not a volume that will sit on an office shelf; it will live out in the ICU or the ED One can only hope that the binding and pages are sturdy enough to handle the usage.

George C Newman, MD, PhD

Preface

The field of medicine has always been in the state of constant evolution ers have been relentlessly investigating challenging problems that appeared con- fusing and difficult to address both at the bedside as well as in the laboratories

Research-As a result, clinicians have benefitted from learning new findings and ing previously equivocal and debatable issues Along with remarkable advances

elucidat-in the recent years, particularly elucidat-in the therapeutic aspect, the field of neurology is

no longer considered merely a field of phenomenology and simply admiring the localization and neuronal circuits around it Today, there are numerous acute and long-term therapies that are supported by scientific evidence of improving condi- tions of patients with illnesses in both central and peripheral nervous systems The idea of neurologic critical care is to provide acute medical therapies and appropriate interventions in a prompt fashion by monitoring the patients in one area by specially trained neurointensivists and nurses It is by no means surprising

to observe dedicated units with adequate staffing producing improved outcomes

in both medical-surgical as well as neurologic intensive care units as people in critical condition require constant monitoring As with many critical illnesses in general, acute brain injuries and other neurologic emergencies are complicated with time-sensitive matters In order to provide adequate assessment and thera- pies without any delays, competency in being able to recognize acute changes in neurologic function cannot be overemphasized By the same argument, other end organs in critical condition also require the same degree of close monitoring and rapid treatment Patients with acute, severe brain injuries are often accompanied

by other organ failures at the time of presentation and/or during the ICU stay Priorities may differ between each case, but it is of paramount importance that all organs must be treated successfully in order to achieve favorable outcomes For instance, it is physiologically impossible to improve brain oxygenation without addressing ARDS for a patient with both problems It is true that as long as pa-

tients receive adequate care, it may not matter as to who is providing it However,

providing critical care medicine for a number of different injured organs by a tem that requires consultants, who are not staffing the unit constantly, may possi- bly lead to delay in both diagnosis as well as providing therapy Multiorgan failure needs a multidisciplinary team approach and adequate staffing This text is written for that very reason Readers will find that this book is not just about the brain

sys-It is about all organ insufficiencies and failures along with neurologic illnesses in

an effort to reflect the real-life challenges in a modern NeuroICU where care goes beyond the scope of classic neurology The overall content is synthesized with another main concept: practicality When an intensivist is faced with life-threatening

neurologic and medical emergencies, pathophysiology and epidemiology are not

as essential as step-by-step management plan The flow of content is written with case-based, question-and-answer format in order to simulate the real life of mak- ing ICU rounds, which makes it easier and more interesting to read By having

50 percent neuro and 50 percent critical care, this text may serve as a helpful tool

in preparation for neurocritical care board certification examination, as well as for daily clinical work for anyone who provides critical care medicine for patients with acute brain injury and other organ failures.

Kiwon Lee, MD New York City

Acknowledgments

This book is a proud product of many leading academic physicians at multiple medical institutions including Columbia University College of Physicians and Surgeons, UMDNJ Robert Wood Johnson Medical School, Mount Sinai School of Medicine, Thomas Jefferson University Jefferson Medical College, and University

of California at Los Angeles David Geffen Medical School First I would like to express my grateful heart to Anne Sydor, Executive Editor at McGraw-Hill, who has been supportive of the idea from the beginning and to the production staff Christine Diedrich, Karen Edmonson, and Catherine Saggese who worked diligently to bring the book to fruition I would like to sincerely thank every contributing author especially those who served kindly as the section editors: Neeraj Badjatia,

MD, Jan Claassen, MD, PhD, Stephan A Mayer, MD, E Sander Connolly, MD, Joseph Meltzer, MD, Joseph Parrillo, MD, R Phillip Dellinger, MD, Lawrence S Weisberg, MD, Louis Aledort, MD, and especially Fred Rincon, MD, who has been incredibly helpful to me throughout the entire process Without the efforts from all the authors and section editors, it would not have been possible to successfully produce this textbook I would like to also thank George C Newman, MD, PhD who has kindly offered the Foreword.

of the initial symptoms, he progressed to stuporous mental status with minimal but intact drawal responses to painful stimulation Brainstem reflexes were intact Stat head computed tomography (CT) (Figure 1-1) revealed acute subarachnoid hemorrhage (SAH) filling the basal cistern, bilateral sylvian fissures with thick hemorrhages along with early radiographic evi-dence for hydrocephalus, and intraventricular hemorrhage (IVH) mainly in the fourth ventricle The local ED physicians decided to transfer the patient immediately to the nearest tertiary medical center During the emergent transfer, patient stopped responding to any painful stimuli and had only intact brainstem reflexes.

with-On arrival at the neurologic intensive care unit, the following is the clinical observation: Patient

is intubated with endotracheal tube, in coma, decerebrate posturing on painful stimulation, intact corneal reflexes, pupils 5 mm in diameter briskly constricting to 3 mm bilaterally to the light stimulation, intact oculocephalic reflexes, and positive bilateral Babinski signs

Vital signs: HR 110 bpm in sinus tachycardia, RR 20 breaths/min on the set rate of 14 breaths/min on assist control–volume control mechanical ventilation, temperature: 99.3°F, BP: 190/100 mm Hg by cuff pressure on arrival to the NeuroICU

neurocritical care

Diseases

Section Editor: Neeraj Badjatia, MD, MSc

Figure 1-1 Axial CT images of the brain without contrast.

is high at this time The very first step in managing this patient is ventricular drain, the second step

is ventricular drain, and the third step is ensuring that the ventricular drain you have just placed is working (ie, draining the hemorrhagic cerebrospinal fluid [CSF] adequately when the drain is kept open, and maintaining good waveforms when the drain is clamped) After ABC, placing external ventricular drain (EVD) is the most crucial, lifesaving, important early step for managing the patients

with high-grade acute SAH with poor mental status and IVH The presence of IVH complicates the

natural course of both intracerebral hemorrhage (ICH) as well as SAH cases IVH is often associated with development of an acute obstructive hydrocephalus, which may lead to vertical eye movement impairment and depressed level of arousal by its mass effect on the thalamus and midbrain IVH is also associated with elevated intracranial pressure (ICP), which lowers the cerebral perfusion pres-sure (CPP) (by the principle of the equation, CPP = MAP ICP) if the mean arterial pressure (MAP) remains constant IVH has also been reported to be an independent risk factor for increased risk of developing symptomatic vasospasm The mass effect and cerebral edema may rapidly progress to her-niation syndrome and death As such, the presence of IVH has been recognized as a significant risk factor of poor outcome for both ICH and SAH.1-3 Placing an EVD provides twofold benefits: (1) reli-able (as long as the catheter tip is in the right location providing appropriate ICP waveforms without obstructing the ventricular catheter by any blood clot) measurements of the ICP, and (2) therapeutic drainage of the CSF in order to alleviate the intracranial hypertension (Figure 1-2)

It is important to note that the presence of IVH does not necessarily mean the ICP is abnormally elevated, and the placement of an EVD alone may not always lead to improved outcome even if the high ICP responds favorably to opening and lowering of the drain.4 In the past, there were concerns regarding the potential harmful effect of EVD placement in treating the acute hydrocephalus in SAH cases These concerns were mainly focused on the theoretical impact of suddenly lowering the ICP

P1

P2

P3

by EVD placement and eliminating the tamponade effect on ruptured aneurysmal wall, leading to

an increased risk of rebleed in the acute phase However, the clinical studies have failed to prove such a hypothesis and there is not sufficient evidence to believe that the CSF diversion by an EVD in treating acute hydrocephalus after SAH leads to a higher incidence of rerupturing of the unsecured aneurysms.5,6 It is wise, however, to avoid aggressively lowering the drain level immediately after placement In managing SAH cases, whether to place an EVD or not is occasionally debatable For instance, a patient with good-grade (eg, HH I or II) SAH who is awake, following commands with normal strength with no IVH, no acute hydrocephalus, and either absent or minimal volume of SAH

(eg, classic Fisher groups 1 to 2) is not a candidate for EVD placement On the other hand, a patient

with a high HH grade, Fisher group 3 SAH, plus the radiographic evidence of severe IVH and acute

hydrocephalus who is progressively getting worse in the level of arousal needs emergent placement

of an EVD These are extreme ends of the clinical spectrum of SAH, and the timing and indication for EVD could be debated for the cases that are somewhere in between these two extreme case sce-narios Acute hydrocephalus with IVH and clinical signs and symptoms of intracranial hypertension are all good indications for placing EVDs It is also important to remember that even if the patient does not have any of the indications mentioned above, if the treating physician believes that there is

a reasonable probability of developing these signs and symptoms in the near future, EVD ment should be considered (Technical details and further management strategies are discussed

place-in Chapter 22.) Despite the lack of “level 1” evidence of randomized data for improved outcomes, the use of an EVD is important as it can be helpful in managing ICP and CPP and is often lifesaving in certain SAH patients

this patient’s level of arousal improves a few minutes after placing the E D (opening pressure 35 mm Hg) He is now able to localize to painful stimula- tions Does the prognosis change with improved neuroexamination after

E D placement?

changing neurologic Status After E D Placement

Placement of an EVD frequently results in a significant improvement in neurologic status Comatose patients may start to localize to painful stimulation and may even open their eyes Although this is not always seen, when it happens, it may possibly indicate a favorable outlook (eg, a patient, who presents with HH grade V after aneurysmal SAH, wakes up after EVD placement and begins to follow verbalcommands: if such patient remains awake and continues to follow commands throughout the course of his/her illness, then the patient is behaving like a low-grade HH [ie, grades I to III], not like a grade V who presents and remains in coma)

Patients with HH grade V have extremely poor prognosis Many physicians and surgeons disclose such a poor prognosis to the patient’s family and this often leads to withdrawal of life-sustainingcare prior to any treatment While the decision of treating versus not treating should be made based

on the prognosis and for the best interest of the patient, the initial prognosis is mostly based on the bedside neurologic assessment, and physicians should be aware that the patient’s clinical status may dramatically change after placing an EVD, which has significant implications for the prognosis.7There are several SAH grading systems worth mentioning here In 1967, Hunt and Hess have reported 275 consecutive patients who were treated at the Ohio State University over a 12-year period They believed that the intensity of the meningeal inflammatory reaction and the severity of neuro-logic deficit and the presence or absence of significant systemic disease should be taken into account when classifying SAH patients From the original manuscript, their grading system (which is now known and widely used as the Hunt and Hess Grade) was a classification of patients with intracranial aneurysms according to surgical risk (Table 1-1).8

Higher grades are associated with increased surgical risk for the repair of ruptured intracranial aneurysms The Hunt and Hess original report included the presence of significant systemic disease

vasos-This criticism has been actually predicted, and the original authors have mentioned it in their journal article: “It is recognized that such classifications are arbitrary and that the margins between categories may be ill-defined.”8 For this reason, it has been pointed out that the HH system has poor interobserver reliability and reproducibility.9 Nevertheless, the HH grading system is widely used and numerous studies have shown that the higher grade (or sometimes called poor grade, which usually refers to HH grades IV and V) is associated with a poor outcome.10-13

Another grading system to consider is the one that is the most universally accepted system for patients presenting with altered level of consciousness, the Glasgow Coma Scale (GCS) In 1975, Jennet and Bond, from the University of Glasgow, reported a scale called Assessment of Outcome After Severe Brain Damage, a Practical Scale (Table 1-2).14

The GCS is a more general grading system and was not developed specifically for SAH patients However, studies show that for patients with aneurysmal SAH, the initial GCS score has positively correlated with long-term outcome.15

In 1988, the World Federation of Neurosurgical Societies (WFNS) developed a grading system that incorporated both the GCS and bedside neurologic assessment focusing on any focal deficit (Table 1-3).16

The HH and WFNS grading systems are by far the two most commonly used systems for grading patients with acute aneurysmal SAH Despite the frequently raised criticisms regarding the inter-observer variability, the HH grade is used even more commonly than the WFNS scale (71% of reported studies from 1985 to 1992 used the HH grade compared to 19% that used the WFNS scale),17,18 and both grading systems have been shown to correlate reasonably well with the long-term outcome.19

In 1980, Fisher and colleagues reported the relationship between the amount of SAH and risk of developing severe vasospasm (defined as delayed clinical symptoms and signs, Table 1-4).20

The Fisher group’s grading system is based on the description of CT findings mainly focusing

on the actual volume of blood in the subarachnoid space There is a linear relationship between the amount of hemorrhage and the rate of developing symptomatic vasospasm.20 This grading system has

table 1-1. hunt and hess rade for aha

a Classification of patients with intracranial aneurysms according to surgical risk.

(From Hunt W, Hess R Surgical risk as related to time of intervention in the repair of intracranial aneurysms J Neurosurg 1968;28:14-20.)

table 1-4. Fisher cale of ah

roup Ct finding description

de e e

Abbreviation: SAH, subarachnoid hemorrhage (From Fisher CM, Kistler JP, Davis JM Relation of cerebral vasospasm to subarachnoid

hemorrhage visualized by computerized tomographic scanning Neurosurgery 1980;6:1-9.)

table 1-3. orld Federation of Neurosurgical ocieties cale for ah

a Focal deficit is defined as either aphasia and/or motor deficit.

(From Drake C Report of World Federation of Neurological Surgeons Committee on a Universal Subarachnoid Hemorrhage Grading Scale J Neurosurg 1988;68:985-986.)

mul-et al does describe the low risk of vasospasm, and ymul-et there is a clearly observed risk of vasospasm even for patients with minimal blood in the subarachnoid space and for those with intraparenchymal

or intraventricular hemorrhage.20

It is important to understand that the Fisher scale actually did report some incidence of spasm in groups 1, 2, and 4 The group 3 had the highest incidence of vasospasm, but other groups also had vasospasms, just much lower in frequency.20 Like all other grading systems, the Fisher scale

vaso-is not without limitations There have been concerns in the literature reporting a low correlation between the Fisher grade and the incidence of symptomatic vasospasm (one of the recent studies showed about 50% correlation between the Fisher grade and vasospasm).26 Another criticism about the Fisher scale is its inevitable interpresonal variability in assessing the estimated blood volume Also, according to the scale, all cases of CT head showing SAH with greater than 1 mm of vertical thickness is categorized as grade III, but this includes vast majority of patients with SAH who may not

in fact have the same risk of developing vasospasm.26,27

In light of these concerns, Claassen et al’s group, from Columbia University, proposed another grading system (Table 1-5), the modified Fisher scale (mFS).28,29

Note that the mFS incorporates the presence or absence of IVH, and if a patient has IVH, even

if there is no blood in the subarachnoid space, the scale is 2 (as opposed to 1 [no blood seen] or 4 [minimal SAH and the presence of intraparenchymal hemorrhage or IVH] in the original Fisher scale) This scale emphasizes that the presence of IVH increases the risk of developing symptomatic vasospasm This emphasis is stronger but not completely different from that of the Fisher scale as the original Fisher scale does report some incidence (although low) of vasospasm in those with IVH and absent or minimal SAH Furthermore, the mFS uses a subjective description and coding of the hem-orrhage by the use of “thick” or “thin” clots in the subarachnoid space, and the description of IVH did not take the exact amount of IVH into account (this scale takes the “presence” versus the “absence” of IVH into account, not how much IVH there is) The mFS emphasizes the importance of IVH as well

as it highlights how the amount of hemorrhage once again plays an important role Its grading system

is easy and intuitive (unlike the classic Fisher scale in which group 4 actually has a lower incidence of

table 1-5. the Modified Fisher cale

Ct finding description h Modified Fisher cale

(From Claassen J, Bernardini GL, Kreiter KT, et al Effect of cisternal and ventricular blood on risk of delayed cerebral ischemia after subarachnoid hemorrhage: The Fisher Scale revisited Stroke 2001; 32:2012-2020.)

vasospasm than lower grades), as the scale goes from 0 to 4, and the higher grade is the higher risk of developing delayed cerebral ischemia (DCI).

In order to minimize the interobserver variability in assessing the estimated volume of blood in the subarachnoid space, a volumetric quantification of Fisher grade 3 has been proposed and studied

by Friedman and colleagues from the Mayo Clinic.30 However, while quantification of SAH may

pro-vide a more accurate assessment of the volume of blood in the subarachnoid space, it requires manual

outlining of the hemorrhage volume, which can be time consuming and less reliable

In 2011, Ko and colleagues, from Columbia University, reported a study of volumetric analysis

of SAH using a MIPAV (Medical Image Processing, Analysis, and Visualization; version 4.3; National

Institutes of Heath, NIH) software package that automatically outlines the hemorrhage on CT at the

click of a button.31 This quantification analysis showed that patients with a higher volume of cisternal

plus IVH clot burden developed a greater risk of developing DCI and poor outcome at 3 months

(Figure 1-3) It also validated the modified Fisher scale as a reasonable grading system in predicting DCI that can be done easily at the bedside However, it is important to note that although both the Fisher scale and the mFS have demonstrated the association between blood burden and DCI, a question still remained: Does the location and exact thresholds of blood volume matter? Ko and colleagues have reported:

Our data show that the quantitative blood volume in contact with the cisternal space, whether directly in

the cisternal subarachnoid space or intraventricular space, acts as cumulative blood burden and is associated

0.000.60.70.80.91.0

based on cisternal plus intraventricular hemorrhage volume criteria, patients with higher blood burden (≥16.5 mL, dotted line) had earlier development of delayed cerebral ischemia compared to the less blood burden group

( 16.5 mL, solid line; Cox regression analysis, P < 024) (From Ko SB, Choi HA, Carpenter AM, et al Quantitative analysis of hemorrhage volume for predicting delayed cerebral ischemia after subarachnoid hemorrhage Stroke 2011;42:669-674 Epub ahead of print Jan 21.)

Klimo and Schmidt have eloquently summarized a historical review of the literature on the tionship between the CT findings and the rate of developing cerebral vasospasm after aneurysmal SAH using different scales32:

rela-The elucidation of predictive factors of cerebral vasospasm following aneurysmal subarachnoid rhage is a major area of both clinical and basic science research It is becoming clear that many factors

hemor-contribute to this phenomenon The most consistent predictor of vasospasm has been the amount of SAH

seen on the postictal computed tomography scan Over the last 30 years, it has become clear that the greater the amount of blood within the basal cisterns, the greater the risk of vasospasm To evaluate this risk, various grading schemes have been proposed, from simple to elaborate, the most widely known being the Fisher scale Most recently, volumetric quantification and clearance models have provided the most detailed analysis Intraventricular hemorrhage, although not supported as strongly as cisternal SAH, has also been shown to be a risk factor for vasospasm

Angiography shows an anterior communicating (A-comm) artery aneurysm and coiling was performed to secure the ruptured aneurysm Patient returns

to the Ic but now has elevated intracranial pressure (IcP) of 5 to 55 mm

What is the stepwise approach for treating high IcP for SAH patients?

The early phase of high-grade SAH is often complicated by the presence of ICP crisis An ICP value out of the normal range (0 to 20 mm Hg) is considered abnormal, but the ICP alone as an absolute value may not always signify the need for an urgent treatment A good example would be people with pseudotumor cere-bri and high ICP but having normal daily activities ICP also rises when patients cough or get suctioned Such a rise, if it is induced and transient, does not necessarily need any treatment In the setting of acute,

high-grade SAH, however, abnormally elevated ICP is a major concern owing to its direct, negative impact

on the cerebral perfusion pressure (CPP) With persistently low or decreasing CPP, a certain degree of ischemic insult is inevitable A step-by-step algorithm for managing refractory ICP crisis is outlined below This is a recommendation that reflects the latest medical treatment available in the literature

A Step-by-Step Algorithm for Intracranial Hypertension

ICP > 20 mm Hg for >10 min (EVD is functional and draining bloody CSF, and patient is not coughing, getting suctioned, or being agitated)

Surgical Decompression

1 Consider placing the second EVD on the opposite side.

2 Decompressive craniectomy/craniotomy is the most effective way of reducing intracranial hypertension If surgery is

not an option, proceed to the following medical steps