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Prognostication After Brain Injury Prognostication After Brain Injury

Prognostication After Brain Injury - PowerPoint Presentation

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Prognostication After Brain Injury - PPT Presentation

Organ Donation Midland Collaborative 7 th May 2015 Birmingham Maria Cartmill Are we able to prognosticate No or not accurately for an individual patient Hippocratic aphorism ID: 619032

poor outcome gcs gos outcome poor gos gcs age patients resuscitation arrest prognosticate blood subarachnoid care specific pupils 2013 bilateral increased hypothermia

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Slide1

Prognostication After Brain Injury

Organ Donation Midland Collaborative

7

th

May 2015 Birmingham

Maria CartmillSlide2

Are

we able

to prognosticate

?

Slide3

NoSlide4

..or not accurately for an individual patient…Slide5

Hippocratic aphorism

“No head injury is so serious that it

should be despaired of nor so

trivial that it

can be ignored”Slide6

Just about rightSlide7

Experienced neurosurgeon

assessed 100 patients;

56% correct prognosis

(Kaufman)

If the initial GCS is reliable,

20% with the worst initial score

will survive; 8-10% with GOS 4-5Slide8

Probabilities not prophecies!Slide9

Glasgow Outcome Scale (GOS)

Unfavourable

1 Death

2 Persistent vegetative state

3 Severe disability (dependent on daily support)

------------------------------------------

Favourable

4 Moderate disability (disabled, independent)

5 Good recovery (resumption of normal life)Slide10

Glasgow Coma Scale (GCS)Slide11

Brain Injuries

Traumatic

Aneurysmal subarachnoid

h

aemorrhage

HypoxiaSlide12

Traumatic

IMPACT/CRASH/TRISS/APACHE 2

Early prognostic indicators

Age

Motor part of GCS

Pupils

Imaging findingsSlide13

Age

P

oor outcome increases with increasing age

Poor outcome increases significantly in patients aged > 60y

Independent of the increased frequency of complications in elderlySlide14

Age vs

outcome

Age (y)

GOS 1 (%)

GOS 5

(%)

1-4

17

17

5-9

22

61

10-14

20

40

15-19

25

40

21-40

35

33

41-60

55

15

61-80

80

5

(

Alberico

. Class

II)Slide15

Age vs

mortality

Age (y)

GOS 1 (%)

11-20

35

21-30

39

31-40

45

41-50

55

51-60

66

61-70

77

71-80

85

81-90

95

(Teasdale. Class I)Slide16

Recent studies

No age threshold

40-50% increase in poor outcome each additional 10y

(

Mukkelhoven

2003, 5600pts)Slide17

Pupils

Post resuscitation responses

“> 4mm is a dilated pupil”

Bilateral absent pupil response > 70% PPV of poor outcomeSlide18

Pupils vs

GOS 1-2 outcome

No of patients in study

Bilat

reactive

%

Unilateral fixed

%

Bilat

fixed

%

600

42

-

95

305

29

54

90

213

36

-

91

746

32

34

74

Ave

35

44

88

(

www.braintrauma.org

)Slide19

GCS (Motor)

The motor component of GCS provides the best predictive value

GCS (M)

GOS 1 (%)

1

88.9

2-4

56.2

5

12.5

6

0.4

(

Colohan

. Class

II)Slide20

Imaging findings

Multiple lesions worse than single

Midline shift > 15 mm worse than < 5 mm

Basal cisterns compressed

Traumatic subarachnoid

haemorrhage

Slide21

Basal cisterns

Compressed basal cisterns x 3 increased

risk of raised ICP

x

2-3 increased risk of mortality

Direct relationship with pupils

Slide22

HerniationSlide23

GOS vs

basal cisterns

Basal cisterns

GOS

%

1

2

3

4

5

Normal

22

6

16

21

35

Compressed

39

7

18

17

19

Absent

77

2

6

4

11

(218

pts

with GCS <8)Slide24

Traumatic subarachnoid haemorrhage

(

TrSAH

)

Present in severe TBI (26-53%)

Mortality increased x2

Extent of

TrSAH

related to outcome

TrSAH

is significant independent prognostic indicatorSlide25

SAH grade

Fisher Grade

Unfavourable

(GOS 1-3)

Favourable

(GOS 4-5)

1

(no blood)

0

14

2

(diffuse/ <1mm)

6

13

3

(clot/ >1mm)

15

6

4

(ICH or IVH)

7

0

(

Harders

. Class II)Slide26

ICP monitoring

Helps manage ICP

Does it alter outcome

?

Useful if ICP > MAP

Pressures can be very high in children with good outcomeSlide27

MRI

Using

conventional imaging, presence of bilateral lesions in the dorsolateral upper brainstem appears to be the factor of greatest adverse prognostic significance.

With MRS, low

NAA/

creatine

ratio in the hemispheres and in the pons predicts a poor outcome

.

(Weiss

et

al,

Crit Care

2007

; 11(5):

230

)Slide28

Neurosurgery registrars’ 3am hopelessness chartSlide29

Aneurysmal subarachnoid h

aemorrhageSlide30

Natural history

Peak incidence 55-60y

10-20% die before reaching medical care

30 day mortality 45%

Overall mortality 51%

1/3 survivors remain dependent

Of the other 2/3 – only 30% patients achieve their previous quality of lifeSlide31

Outcome

Related to grade on admission

Age >70y fare worse for each neurological grade

Amount of blood on CT head (Fisher)

(Drake et al. Report

of World Federation of Neurological Surgeons Committee on a

Universal

Subarachnoid Hemorrhage Grading Scale.

J

Neurosurg

. Jun 1988;68(6):985-

6

)

WFNS grade

GCS score

Major

deficit

1

15

-

2

13-14

-

3

13-14

+

4

7-12

+ or -

5

3-6

+ or -Slide32

Physiology

Average blood loss < 10mls

Rapid increase in ICP to > blood pressure

Cerebral

stand

still

Lose consciousness/ vomit/ severe headache

Possible seizure

Permanent

vs

transient effect upon brain

Cerebral Stunning

- “TIA of the midbrain”Slide33

When to prognosticate?

Recommendation is to wait 6 hours to test

If diabetes

insipidus

/ hypothermia then likely permanent

Keep assessing

Support

in the

interim

Allows for re-perfusion of central structuresSlide34

HypoxiaSlide35

Pre-hospital

Poor outcome associated with:

Type of

arrhythmia:

shockable

>> non-

shockable

Age > 70 years

Anoxia / no-flow time (witnessed) >25

mins

Duration of CPR

Co-morbidities

Variable, with poor sensitivity / specificity

Cannot be used to reliably prognosticateSlide36

Clinical

Affected by therapeutic hypothermia (sedation)

GCS

Motor response to pain

Corneal reflexes

Unaffected

Pupillary reflexes

Seizures / early myoclonus

(

Cronberg

et al. Recommendations

from the Swedish Resuscitation Council.

Resuscitation

. 2013; 84(7): 867–

72)Slide37

Imaging

MRI

4 stages

MRI sensitive but non-specific

as single prognosticator

Grey-white-matter ratio (GWR)

Recent data suggests GWR <1.16 predicts poor outcome (100% specific / 38% sensitive)

(

Scheel

et al.

Scandinavian

Journal of Trauma, Resuscitation and Emergency Medicine

. 2013; 21(1):

23)Slide38

Biomarkers

S-100B: calcium-binding

astroglial

protein

Neuron-specific

enolase

(NSE): isomer of

enolase

, located in neurones

Ammonia & lactate

References

Intensive

Care Society.

Standards for the management of patients

a

fter

ca

rdiac

a

rrest.

2008 Oct.

http

://www.ics.ac.uk/ics-homepage/guidelines-standards/ (accessed 12/09/2013)

Huntgeburth

et al. Changes in

neuron-specific

e

nola

se

are

more suitable

t

han

i

ts

a

bsolute

s

erum

l

evels

for

the

p

rediction

of

neurologic

o

utcome

in

hypothermia-treated

p

atients

with

out

-of

-hospital

c

ardiac

a

rrest

. Neurocritical Care. 2014;20(3):358-366 Shinozaki et al. Blood ammonia and lactate levels on hospital arrival as a predictive biomarker in patients with out-of-hospitalcardiac arrest. Resuscitation. 2011; 82(4): 404–9. Slide39

Neurophysiology

SSEPs

Bilateral median nerve stimulation

Measure cortical (N20) or shoulder (N9) potentials

Reliable specific test of neurological outcome (even with hypothermia)

EEG

Burst suppression / generalised

epileptiform

discharge predict poor outcome

Issues of accuracy (not recommended)Slide40
Slide41

Seizures

Seizures / myoclonus post-arrest + during cooling associated with poor outcome

Myoclonic

jerks on day 3, or after warming, do not

predict poor outcome

Lance-Adams, action-induced myoclonus without LOC

(

Yadavmali

et al

.

The Lance-Adams syndrome: helpful or just hopeful, after cardiopulmonary arrest.

Journal

of the Intensive Care Society. 2011; 12(4): 324 –

328

)Slide42

Can we prognosticate?

Good

Bad

Early

Reaction to pain (GCS M ≥ 5)

Normal CT

Reactive

EEG

Myoclonic status (+/- EEG)

Reduced GWR

Increase

in biomarkers

Late

Reaction

to pain

(GCS M ≥ 5)

Normal CT

Low biomarkers

Reactive EEG

GCS

M 1 – 2

Pupils / cornea unreactive

SSEP: bilateral lack of N20

Abnormal CT / MRI

High levels of biomarker

(Recommendations

from the Swedish Resuscitation Council.

Resuscitation

. 2013; 84(7): 867–

72)Slide43

When to prognosticate?

Traditional guidance

72 hours after

arrest

/event

If cooled

72 hours

after

reaching

normothermia

(

Wijdickset

al.

Neurology

. 2006; 67(2): 203–

10)Slide44

Are we able to prognosticate in patients with brain injury

?Slide45

Conclusion

Not early

We can give an early probability

MDT approach recommended

Time