Transcript Video A Complex Brain Injured Patient Brain Injury ManagementA Complex Brain Injured Patient Presented by Professor Ha Eun Jin TC Summit 2023. From South Korea. Professor Jin is a clinical professor of neurosurgery at Seoul National University College of Medicine, South Korea. And the title of our talk is a complex brain injured patient, please. This is the pointer we can next. Uh Thank you. Thank you, Chairman. It's great Arnold to have the opportunity to share my experience uh regarding the value of temperature control for brain injured patients at this esteemed gathering. Um Today, I would like to discuss the role of temperature control in cases of refractory I IC P as well as in the part of management in poor grade sah patients. Mm As you already know lowering body temperature by just one °C can result in reduced cerebral metabolic rates of oxygen consumption, decrease intracranial pressure through the cerebral vaso constriction coupling and reduce the brain edema. Uh patients with increased IC P exhibit a traumatic um changes in IC P with even a slight decrease in intracranial volume following the monocle doc. Um while evaluating the rap index is necessary to know the brain compliance. Uh However, in situations where where like South Korea, uh a system is not available, assessing the consciousness of IC P to osmotic agents can help evaluate it. Um In cases of poor brain compliance, osmotic agents may not be sufficient for controlling brain edema. And IC P we necessary a more aggressive approach. Uh For example, uh let me see this case. Uh That is, oh I'm sorry, this is the IC P. Um and the patient with the initial IC P of 50 millim mercury who received hypertonic selling the IC P goes down dramatically but it rapidly rise up. Uh And the after that, we increase the dose of hypertonic Zyl. But the uh IC P pattern was same. In this case, we applied alternative methods to reduce intracranial volume, uh such as deeper sedation and lower body temperature. After this, you can see the uh better IC P pattern and uh more uh gradual IC P lowering and the longer effects of the osmotic agents. By this idea, uh we make our protocol and this is a bit like a civic algorithm, but we've made changes of to fit our situations in South Korea because we can not use P BT 02 at all. And we can use only IC P monitoring. Um And uh because I'm neurosurgeon, we prefer to actually decompressive craniotomy for the herniation patient suspected brain herniation. And the other cases with uh hydrocephalus, we prefer to put a EVD at the same time with IC P monitoring. In the other case, we put a IC P monitor after put the IC P monitor. We decide our next steps based on the pressure regarding the how the patients IC P reacts to osmotic agent or the controlling below the target or not. We use this information to see what if we need to lower the temperature or give deeper sedation. Always keeping in mind the patient's tolerance for IC P level. Uh It is well known that the temperature of 33 °C has more pronounced hemodynamic alterations compare compared to 36 °C. We aim to lower intracranial pressure to prevent herniation, but also we uh to uh reduce secondary brain injury. So we have to take into account factors such as CPP cardio output and odate uh CBR flow uh during the temperature lowering. That's why we uh I prefer to set the uh lower temperature. At the first. We prefer to use no demia and then stepladder method to uh titration uh coding to the patients IC P response. This is the case uh 42 patient, a 42 year old male patients initially had a moderate brain damage due to the pedestrian traffic accident. However, the problems arose after the facial fixation surgery. Uh We discovered a penetrating brain injury due to the bony fragment from the skull base after the facial fixation um to minimize the risk of infection from the uh body fragment, we removed it and we put the IC P monitor around the lesion. Uh You can see this um uh the patients also had a brain herniation through the defect in the skull base, which led to us prioritize reducing swelling and IC P, what an IC P measurement was above 20 millimeter mercury. So, uh and the preoperatively, he had a high fever such as 38 and 39 °C. We applied deep sedation and pneumo theia for these patients. Despite the pneumo theia at 30 six °C, the patients IC P remained consistently higher than a 20 millimeter mercury. So we decided to lower the patient's body temperature to 35 degree, but it's not sufficient and further lowering to the 34 degree, the IC P goes down and the response to the osmotic agent was better. And we choose to use pal therapy because the cup uh worsen the brain herniation through the skull defect. So that's why we use uh PTO coma therapy and uh 34 degree for controlling the IC P. By this combining uh method, we can uh stable the IC P of this patients. And then uh the patients uh later underwent the endoscopic score based reconstruction surgery and was successfully win from the treatment, achieving a full recovery with hemiplegia. And this is the o other case, the uh the 15 year old female suicidal attempt, uh she was presented with a subdural hematoma and diffused brain swelling. Initially, the patient had a G CS score of six and both pupils is correct and reactive. However, while waiting for admission to intensive care unit. The left pupil was dilated to five millimeters and the S DH increased. We performed an emergency cran toy and sth remover in a surgical area. The brain precision was weak but fortunately, there was minimal contusion on the brain surface postoperatively. The patient's IC P remained elevated despite the cran omy. So we lowered the body temperature to the 34.5 °C. And this lasts to longer term with the lower IC P and better response to the treatment. And these patients go back to school after this treatment. And the other case, we also applied temperature control in case of tumor bleeding. Surgical intervention is the standard approach for these kinds of onco herniation patients. But however, the neurosurgeon want to delay surgery after maximum medical treatment. Therefore, therefore, I insert a IC P monitor, uh, applying the deep sedation. And, uh, we choose to use, uh, uh, choose to set the 35.35 °C because she has already, uh, herniation. So, um, doing this, uh, as you can see the, there is a poor compliance of the brain and after the change, the deeper sedation and, uh, uh, lower temperature, I can achieve the better, uh, brain IC P measures. And she recovered her pupillary reflex on left side during this treatment. And then we went to, uh, we underwent the, uh, craniotomy and the mass remover for these patients. And she, uh, la eventually achieving uh G CS of FIF 14 and her modified Lankin scale on this uh discharge was three. And the other case is olfactory group meningoma with a large perit tumor edema. After the craniotomy, she uh still have a very tense brain and uh IC P shows going up after post operative day and we applied hypothermia like 34 degree, the IC P goes down. So these kinds of patients can uh be the examples that we can use uh temperature management for uh many uh for reduced I IC P. And the other topic is poor grade Sah uh This is Seoul National University pro grade Sah Kelburn. We focused on mostly uh on the first step. It is the most important step is uh early and aggressive control of IC P because um this is because we think that the key step to reduce mortality and morbidity in these poor grade S A patient is reduce only brain injury, only brain injury is the primary cause of only mortality of this patient. And it, if it left untreated can lead to delayed cerebral ischemia for this patient. Uh This is only cellular changes after poor grade. Uh So economic hemorrhage, when considering the mechanisms behind this uh o the brain injury, it became apparent that hypothermia may play a role in minimizing the brain injury and reducing subsequence complications. Like because the main um patho agility is I IP and circulatory arrest and cellular changes. So, the role of hypothermia in IC P control has been previously discussed on this section. And the other important mechanism is circulatory arrest and reperfusion are quite similar for uh to the cardiac arrest condition with these kinds of patients. And actually the sum of sub aid hemorrhage patients sometimes presented with cardiac arrest. So we can consider about this. So, um and in patients with a poor neuro outcome after res research station, hypothermia might be beneficial than pneumo theia. So um while mild hypothermia is not recommended in a good great aneurysmal sah patients. Uh but there is a limited discussion regarding an application and poor grade sah patients. So there's some small studies about prophylactic um targeted temperature management for poor grade sah patients. It's commerce study rigard, it decreases this uh DC I and it improves functional outcome. And this is the small study which is conducted in Korea. Uh It also shows a better functional outcome and mortality rates. Uh This is uh my case. Uh we, we had a 41 year old woman who had previously uh a com calling for sah five years ago, she came with a sudden headache and then had a collapse. She was arrived within eight minutes of CPR. So when she arrived at our hospital, her GCS was six and her pupils were fixed without dilatation and the CT scan shows diffused brain swelling in our institute before we performed the bedside EVD. Uh placement and IC P monitor insertion in the emergency room before securing the aneurysm because um the I IC P control is the most important thing for these patients. Um And we also uh do the embolization of aneurysm under the control of IC P monitor. Um considering the patient's poor grade sah compromising neurologic status and, and eight minutes of cardiac arrest, we initiated uh deep sedation and lower her body temperature to 34 degree. Um And our IC P target was set at less than 20 millimeter mercury. The patient's IC P group gradually decreased to less than 10 mill millim Mery during 48 hours. On the third day after the rupture, her CT scan showed a great improvement. We initiated rearming and tapered the sedation. She did not have better spasm and no DC I developed a mo and she recovered to no more and go back to work at last. So I think some patients may be get a benefit from the early multi moderate targeted temperature management for poor grade sah uh pro grade sah patients such as post CPR status coma to patients with diffused brain swelling and IC P doesn't go down after a VD insertion. And after some decompressive cran toy cases can be get benefit for these um early prophylactic multi moderate TT M and how deep and how long I don't know, but we just uh individualized the target. Uh We also uh we always focusing on the lowering the IC P before the peak be spasm period and uh improve the CD scans uh confirm that cerebral edema is improved and slowly rearming is also conducted under the IC P monitoring. Uh fever and IAH is very, very well known for associated with uh unfavorable outcomes. And it's really hard to control and the fever burden in saeh patients are always high. So to address these challenges, we like to use the um device controlled TT M which is better uh modulation of temperature during the veto spasm period, we have conducted study comparing the outcomes before and after these kinds of bundle, which includes the only aggressive IC P control for these patients. Um It shows the, let me show the result the favorable outcome at six months as follow up is double more than double the control and um six months mortality was a half and even for the patients presented with a fixed pupil, which is well known for the poor uh risk factor for patients. The when we applied the bundle, the fixed pupil recovered 61.5% patients and uh 23% of these patients show the favorable outcome at six months. So I think some patients can get benefit from these kinds of treatment. In conclusion, targeted temperature management proves may may be might be an effective and crucial treatment modality, particularly in patients with decreased cerebral compliance and refractory IIC. And it also holds promises in minimizing only the brain injury and its associated complications in prograde sah patients. Created by
