Multimodality Monitoring in SAH

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Multimodality Monitoring in SAH

• Paul Vespa, MD, FCCM
• Associate Professor of Neurosurgery and Neurology
• Director of Neurocritical Care
• Geffen School of Medicine at UCLA

New York Neurologic Emergencies and Neurocritical
Care Symposium
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What do we use at UCLA for SAH pt who is
comatose?

• ICP
• cEEG
• Cerebral microdialysis
• Brain Tissue Oxygen
• TCD (intermittent)
• Xenon CBF (intermittent)

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What are we looking for

• Seizures
• 30 of SAH pts have seizures on cEEG
• Brain Ischemia
• 50 of SAH pts will have some form of vasospasm
  with variable amounts of ischemia
• Elevated ICP
• Brain Glucopenia

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Multimodality Case 1 - SAH

• 74 yo with acomm aneurysm SAH
• Confused with poor attention
• Intubated due to respiratory distress
• Not obeying, but some sedation given
• Mild left hemiparesis on exam leg worse than arm
• cEEG and PbtO2

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SAH 1 vital signs

• SBP 160/80
• ICP 12-15 mm Hg
• HR 84
• SaO2 99
• Temp 37.9 C
• Na 139
• Hb 31

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EEG PAV in SAH early before deterioration
1 9 - 06
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SAH and EEG PAV

• PAV is an indicator of brain ischemia from
  vasospasm
• Also Alpha/delta ratio is an indicator of brain
  ischemia
• PAV goes down (becomes flat) with vasospasm

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EEG PAV is worse

• Possibilities
• Vasospasm
• Deep sedation
• Sepsis due to pneumonia
• Hydrocephalus

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Get a CT, shows no hydrocephalus PbrO2 is
dropping to low values
PbtO2
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Angiogram shows vasospasm
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Treatment of vasospasm

• Treatment options
• HHH Rx
• Intraarterial vasodilators
• Angioplasty
• Hypothermia/ Normothermia
• Hyperoxia
• Metabolic Suppression

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HHH Rx is selectedImprovement in PAV
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Improvement in PbtO2 with HHH Rx
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SAH case 3

• 46 yo man with SAH with basilar aneurysm
• GCS 7, HH 4, GCS motor 4-5
• Coiled on PBD 2
• ICP, MD, and EEG placed
• ICP becomes elevated requiring frequent CSF
  drainage

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SAH 3, clipping, edema, elevated ICP
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Elevated ICP persistent after SAH 3
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Microdialysis during metabolic suppression with
high dose propofol treatment for ICP
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Then, Vasospasm despite continued elevated ICP
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Microdialysis response to vasospasm and
subsequent treatment
vasospasm
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Case 4

• 58 yo woman with SAH due to Acomm
• Clipped on day 2
• Comatose with slight Right Leg weakness post
  operatively
• EEG PAV becomes poor on day 6
• MD monitoring started on day 3

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SAH Microdialysis Monitoring of Vasospasm
MD 1
MD 2
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Microdialysis shows normal LPR, glutamate, glucose
LPR 20-25 range
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Uncertainty and Action

• The TCD and angio show vasospasm
• Microdialysis does not show ischemic changes
• HH therapy and intraarterial verapamil Tx done
  once, but persistent angio and TCD findings
• Do we return to angio? Be more aggressive?

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DWI while MD LPR is 25
MD probe locations 1 and 2
2
1
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What we did

• We continued with HH therapy and returned to
  angio for IA treatment
• The MD did not change from that point on
• We watched clinical exam, and EEG PAV

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What did we learn?

• LPR reflected the region of interest well
• The ischemia occurred in the distal ACA territory
  due to distal effects of spasm
• We may need to place multiple probes in locations
  that are quite different than the frontal
  location
• We need imaging or other adjunct monitoring

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Summary

• Multimodality monitoring with PbrO2, MD, and cEEG
  detected the ischemic response that occurred with
  vasospasm after SAH
• Monitoring in the ACA-MCA borderzone is good but
  very regional changes may occur in remote
  locations.
• It is unclear which method is best PBrO2, EEG
  PAV, TCD, MD.
• Response to treatment can be seen