Archivos de la categoría Neurotraumatología

Venous thromboembolic prophylaxis in traumatic brain injury

Venous thromboembolic prophylaxis (VTEp) is often delayed following traumatic brain injury (TBI), yet animal data suggest that it may reduce cerebral inflammation and improve cognitive recovery.

Medical charts of severe TBI patients admitted to a level 1 trauma center in 2009-2010 were queried for admission Glasgow Coma Scale (GCS), head Abbreviated Injury Scale, Injury Severity Score (ISS), osmotherapy use, emergency neurosurgery, and delay to VTEp initiation. Progression (+1 = better, 0 = no change, -1 = worse) of brain injury on head CTs and neurologic exam (by bedside MD, nurse) was collected from patient charts. Head CT Marshall classification were calculated from the initial head CT results.

A total of 22, 34, and 19 patients received VTEp at early (<3 days), intermediate (3-5 days), and late (>5 days) time intervals, respectively. Clinical and radiologic brain injury characteristics on admission were similar among the three groups (P > 0.05), but ISS was greatest in the early group (P < 0.05). Initial head CT Marshall classification were similar in early and late groups. The slowest progression of brain injury on repeated head CT scans was in the early VTEp group up to 10 days after admission.

Early initiation of prophylactic heparin in severe TBI is not associated with deterioration neurologic exam and may result in less progression of injury on brain imaging. Possible neuroprotective effects of heparin in humans need further investigation 1).

1) Kim L, Schuster J, Holena DN, Sims CA, Levine J, Pascual JL. Early initiation of prophylactic heparin in severe traumatic brain injury is associated with accelerated improvement on brain imaging. J Emerg Trauma Shock. 2014 Jul;7(3):141-148. PubMed PMID: 25114421.

Intracranial hypotension: clinical presentation, imaging findings, and imaging-guided therapy

Intracranial hypotension is a condition in which there is negative pressure within the brain cavity.

Etiology

see Spontaneous intracranial hypotension

Cerebrospinal fluid leak from the spinal canal:

A leak following a lumbar puncture (spinal tap).

A defect in the dura

Sometimes following exertion such as swinging a golf club.

A congenital weakness.

Following spinal surgery.

Following spinal trauma.

Following a shunt procedure for hydrocephalus.

Lumboperitoneal shunt.

Ventriculoperitoneal shunt with a low pressure valve.

In some cases, spinal CSF leaks can lead to a descent of the cerebellar tonsils into the spinal canal, similar to a Chiari malformation.

Large spinal dural defects can lead to herniation of the spinal cord into the defect.

Symptoms

The classic symptom is severe headache when upright, which is relieved when lying flat.

Other symptoms can include nausea, vomiting, double vision and difficulty with concentration.

The typical clinical manifestation – orthostatic headache – may be masqueraded by atypical clinical findings, including coma, frontotemporal dementia, leptomeningeal hemosiderosis-associated symptoms, and others.

Diagnosis

Diagnosis is usually suspected based on the postural dependency of the headache, although in many cases the diagnosis of intracranial hypotension is not considered for some time.

A contrast-enhanced brain magnetic response imaging (MRI) scan typically shows thickened and brightly enhancing meninges (pachymeningeal enhancement). Other findings include descent of the thalamus and cerebellar tonsils.

MRI signs are highly specific, but the imaging strategy to search for spinal cerebrospinal fluid leaks (none, computed tomography myelography, magnetic resonance myelography with gadolinium, digital subtraction myelography) is a matter of debate 1).

Continuous intracranial pressure monitoring is definitive for documenting abnormally negative intracranial pressures.

The identification of the site of CSF leak in the spinal canal can be very challenging. In some cases, the site cannot be identified. Methods include:

Dynamic myelography with fluoroscopy and computed tomography (CT).

Radioisotope cisternography.

Spinal MRI.

Treatment

If the site of the spinal CSF leak can be identified, then options include:

Epidural blood patch, performed by an anesthesiologist pain management specialist.

Surgical repair of the defect.

Over-draining CSF shunts are managed by replacing the valve with one that drains less.

Lumboperitoneal shunts may have to be removed or ligated.

Outcome

If the cause of the intracranial hypotension can be identified, the outcome following treatment is typically excellent.

1) Urbach H. Intracranial hypotension: clinical presentation, imaging findings, and imaging-guided therapy. Curr Opin Neurol. 2014 Aug;27(4):414-24. doi: 10.1097/WCO.0000000000000105. PubMed PMID: 24978633.

Standardization of practice of a routine repeat head CT

Traumatic intracranial hemorrhage

A definitive consensus on the standardization of practice of a routine repeat head CT (RHCT) scan in patients with traumatic intracranial hemorrhage is lacking.

In a 3-year prospective cohort analysis of patients aged 18 years and older, without antiplatelet or anticoagulation therapy, presenting to a level 1 trauma center with intracranial hemorrhage on initial head CT and a follow-up RHCT. Neurosurgical intervention was defined by craniotomy/craniectomy. Neurologic deterioration was defined as altered mental status, focal neurologic deficits, and/or pupillary changes.

A total of 1,129 patients were included. Routine RHCT was performed in 1,099 patients. The progression rate was 19.7% (216 of 1,099), with subsequent neurosurgical intervention in 4 patients. Four patients had an abnormal neurologic examination, with a Glasgow Coma Scale (GCS) of ≤8 requiring intubation. Thirty patients had an RHCT secondary to neurologic deterioration; 53% (16 of 30) had progression on RHCT, of which 75% (12 of 16) required neurosurgical intervention. There was an association between deterioration in neurologic examination and need for neurosurgical intervention (odds ratio 3.98; 95% CI 1.7 to 9.1). The negative predictive value of a deteriorating neurologic examination in predicting the need for neurosurgical intervention was 100% in patients with GCS > 8.

Routine repeat head CT scan is not warranted in patients with normal neurologic examination. Routine repeat head CT scan does not supplement the need for neurologic examination for determining management in patients with traumatic brain injury 1).

1) Joseph B, Aziz H, Pandit V, Kulvatunyou N, Hashmi A, Tang A, Sadoun M, O’Keeffe T, Vercruysse G, Green DJ, Friese RS, Rhee P. A three-year prospective study of repeat head computed tomography in patients with traumatic brain injury. J Am Coll Surg. 2014 Jul;219(1):45-51. doi: 10.1016/j.jamcollsurg.2013.12.062. Epub 2014 Mar 1. PubMed PMID: 24745622.

Tendencias en la lesión cerebral traumática severa

Hay una reducción del 13% en la frecuencia de TCE grave desde el primero hasta el último periodo de tiempo. Un aumento en la media de edad 35 a 43 años, mientras que la frecuencia de TCE grave según el sexo seguía siendo aproximadamente el mismo durante las últimas décadas de la vida. Se observó un cambio notable en el mecanismo de la lesión; los accidentes de tráfico se redujeron de 76% a 55%, particularmente aquellos que involucran vehículos de 4 ruedas-. Sin embargo, las caídas aumentaron significativamente, en especial en las mujeres mayores, y la contusión y hematoma subdural fueron las lesiones estructurales más frecuentes. Las puntuaciones motoras no fue posible evaluar de forma fiable durante el último período de tiempo debido a la intubación temprana y el uso de drogas sedantes1

  1. Gómez PA, Castaño-Leon AM, de-la-Cruz J, Lora D, Lagares A. Trends in epidemiological and clinical characteristics in severe traumatic brain injury: Analysis of the past 25 years of a single centre data base. Neurocirugia (Astur).
    2014 Jul 3. pii: S1130-1473(14)00072-4. doi:  0.1016/j.neucir.2014.05.001. [Epub ahead of print] PubMed PMID: 24998417. []

XVI Simposium Internacional de Neuromonitorización y Tratamiento del Paciente Neurocrítico Barcelona, 18 – 22 de noviembre de 2014

 

Fecha: 21/11/2014 al 22/11/2014 

Horario: Viernes: 09:00 – 14:00; 15:30 – 20 y sábado: 09:00 – 14:00
Sede: Hotel Alimara, Barcelona

Ponentes:
Pedro Amorim, Mercedes Arribas, Alberto Biestro, Francisco José Cambra, Victoria Cañas, José M. Domínguez-Roldan, Pedro Enríquez, Lourdes Expósito, Alfredo García, S. Ramon Leal-Noval, Francisca Munar, M. Antònia Poca, Andreea Radoi, Marilyn Riveiro, Romy Rossich, Juan Sahuquillo, Oliver W. Sakowitz, Douglas H. Smith, Francisco Javier Tercero

TEMARIO

Viernes 21 de noviembre de 2014

08:00
Últimas inscripciones y acreditación
09:00
Presentación del Simposium
Juan Sahuquillo
09:20
Conferencia inaugural: Diffuse axonal damage after traumatic brain injury
Douglas H. Smith  
10:00
Inauguración oficial del Simposium
A. Garnacho, M. Báguena
10:30
Conferencia invitada: Multimodal monitoring in neurointensive care medicine: state or the art
Oliver W. Sakowitz  
11:00
Preguntas y discusión
Moderación: Juan Sahuquillo
11:30
Descanso – café
12:00
Conferencia invitada: Integrating biomarkers in the management of traumatic brain injury. Exploring new frontiers in precision medicine
Douglas H. Smith  
12:40
Mesa redonda (expositiva): From bench to bedside. Updates on the pathophysiology and treatment of the neurocritical patient
Moderación: Pedro Amorim  

Delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: from vasospam to cortical spreading depolarizations
Oliver W. Sakowitz  

Anemia, transfusion and brain function in neurocritical care
S. Ramon Leal-Noval  

Brain energy metabolism after traumatic brain injry. What can we learn from cancer?
Juan Sahuquillo  

13:45
Preguntas y discusión
14:00
Descanso para comer
15:30
Mesa redonda (debate): Controversias en las indicaciones de la craniectomía descompresiva en el paciente neurocrítico
Moderación: Juan Sahuquillo

Craniectomía descompresiva en el paciente con traumatismo craneoencefálico grave. ¿Existe alguna indicación después del estudio DECRA?
Juan Sahuquillo

Indicaciones de la craniectomía descompresiva en el infarto maligno. Justificación del protocolo del HUVH
Marilyn Riveiro

¿Existe alguna indicación en la hemicraniectomía en pacientes mayores de 60 años? Aportaciones del estudio DESTINY-II
Pedro Enríquez

Complicaciones de las técnicas descompresivas. Reflexiones desde Medicina Intensiva
Alberto Biestro

¿Quién y cuándo debe decidir limitar el esfuerzo terapéutico en el paciente neurocrítico
José M. Domínguez-Roldan

17:00
Discusión
17:30
Descanso y café
18:00
Mesa redonda (debate): Paciente neurocrítico pediátrico. Actualizaciones y controversias
Moderación: M. Antònia Poca

Medidas terapéuticas de primer y segundo nivel en el TCE grave pediátrico. Análisis crítico de las guías de la Brain Trauma Foundation
M. Antònia Poca

Neuromonitorización no invasiva. Doppler transcraneal y saturación cerebral por espectroscopia de reflectancia (NIRS) en el paciente pediátrico
Francisco José Cambra

Monitorización contunua del EEG de superficie: ¿una herramienta útil en cuidados intensivos?
Romy Rossich

Actualizaciones en la fluidoterapia en el paciente pediátrico con lesiones cerebrales agudas
Francisca Munar

Valoración de las secuelas neurológicas y de su impacto en la calidad de vida en el paciente pediátrico
Victoria CañasAndreea Radoi

19:30
Preguntas y discusión
20:00
Fin de la sesiones del viernes

Sábado 22 de noviembre de 2014

09:00
Conferencias invitadas 
Moderación: Francisco Javier Tercero

De la medicina basada en la evidencia a la medicina de precisión en el manejo del paciente con un traumatismo craneoencefálico
Alberto Biestro

Anestesia en el paciente crítico. ¿Son los anestésicos agentes neuroprotectores o neurotóxicos?
Pedro Amorim

Diagnóstico y manejo terapéutico del delirio en el paciente neurocrítico
Francisco Javier Tercero

10:25
Discusión
10:40
Investigación básica y traslacional en el paciente neurocrítico
En esta sesión se presentarán en forma de comunicación oral de 10 minutos los tres mejores pósters seleccionados por el comité científico

Pedro EnríquezJosé M. Domínguez-Roldan
11:15
Preguntas y discusión
11:30
Descanso y café
12:00
Mesa redonda (expositiva): Hipotermia en el manejo del paciente neurocrítico
Moderación: Juan Sahuquillo

Actulaización y reflexiones históricas sobre la hipotermia inducida en el paciente con traumatismo craneoencefálico
Juan Sahuquillo

Fisiología de la termorregulación. ¿Cuál es el método óptimo para inducir hipotermia en el paciente neurocrítico?
Alberto Biestro

Aspectos prácticos en el manejo de enfermería del paciente en hipotermia
Mercedes ArribasLourdes Expósito

Hipotermia en la encefalopatía anóxica del recién nacido
Alfredo García

Hipotermia combinada con cirugía descompresiva en el infarto maligno
M. Antònia Poca

13:30
Discusión
14:00
Clausura del Simposium
M. Antònia Poca