by Casey & Neha
Back in May, we had the opportunity to present about Neurologic Emergencies at the Hospitalist and Rescuscitationist Conference (H&R22). For those not familiar, H&R is a conference led by Philippe Rola that brings together passionate educators and clinicians to explore strategies to take caring for sick patients to the next level. It is an awesome conference and we are grateful that Phil is allowing us to share our talk on this platform!
Part 1 of the talk is posted here.
Let's dive back in with Part 2!
Case 4: Subarachnoid Hemorrhage
Does your pulse quicken if you get a radiology report that states “subarachnoid hemorrhage”? Probably, right? But, this is a case to emphasize that not all SAH is aneurysmal.
(Case reveals a cortical frontal subarachnoid hemorrhage)
- Pearl: The most common cause of SAH is trauma. It is crucial to ask about falls and to evaluate for other evidence of trauma. (our patient had none)
- Other important history and workup include: headache quality, pregnancy status, medication exposure (especially vasoactive medications and calcineurin inhibitors). CBC and coags will be helpful to assess for thrombocytopenia or coagulopathy (spontaneous or drug induced).
- Pearl: The pattern of blood gives you a big clue into the etiology of SAH
- We plan to do a whole post about the different patterns and management of SAH; however, for now, the main take away is that not all SAH are due to aneurysm rupture. We should think of cortical SAH as a separate entity.
- Pearl: Reversible Cerebral Vasoconstriction Syndrome (RCVS) should be on the differential for any patient presenting with cortical SAH. However, note that 30-70% of patients ultimately diagnosed with RCVS will have a normal MRI (PMID 24715501) and up to a 3rd of patients may have no evidence of angiographic spasm within the 1st week following initial headache. As such, this is often a clinical diagnosis. The pathognomonic feature is recurrent thunderclap headaches. Josh has a nice post about RCVS here.
- Pearl: What do do about RCVS?
- Cutting Edge: Any way we can improved confidence in our diagnosis? The RCVS2 score has good sensitivity and specificity and is easy to calculate from factors gleaned from the chart and CTA.
- It is important to remember that RCVS is not the only etiology of cerebral vasospasm. Furthermore, a CTA is a static image and so what is called vasospasm may be intracranial atherosclerosis, another etiology of vasculopathy, or even vasculitis. The clinical history (recurrent thunderclap headaches) with a likely precipitating factor is crucial in making this diagnosis accurately. If the patient does not have the typical headache story or has no precipitating factor, be very thorough in assessing for an alternative etiology.
Case 5: Hypoxic Ischemic Encephalopathy
(Patient has a OHCA with ROSC achieved in the field. On arrival the patient is unresponsive, but has reactive pupils, intact corneal, cough and is spontaneously breathing. There is abnormal flexure posturing in the uppers and triple flexion in the lowers.)
- Pearl: We cannot change the degree of primary injury from the hypoxic ischemic brain injury (HIBI), but we can prevent secondary neurologic injuries. This includes management of cerebral edema and cerebral infarcts, treatment of seizures/ status epilepticus, interventions to restore homeostasis (treatment of shock, hypoxia, sepsis) and fever prevention.
- Pearl: Fever can result in secondary injury by a variety of mechanisms:
- Pearl: Our focus should be on high quality TTM. Meaning there is a specified body temperature (typically 33-37.5 degree C) with rapid induction, continuous temperature monitoring, slow rewarming, and shivering monitoring and management.
- Cutting Edge: As has been explored on EMCrit (here, here, and here to name a few), hypothermia may have been an overly aggressive mechanism to prevent fever. BUT, it is very important to realize that all studies to date have been high quality TTM vs high quality TTM… the only difference has been the target temperature.
- Cutting Edge: It's also important that we consider the patient population when thinking about how to apply the different temperature targets with TTM. It may be that patients with more severe injuries will be the ones that most benefit from lower temperatures. Not all patients enrolled in trials of temperature control have had the same level of injury. As emphasized, the patients in TTM2 had less severity of injury than the patients we may admit.
- Cutting edge: We delved a little into how to think about patients with periodic EEG patterns, seizures and status after arrest. Yikes!
- Getting into this requires a whole different post, but important to remember that TELSTAR does not give us answers about differences in outcome in patients with seizures or status epilepticus who are treated with anti seizure medication. The enrolled population in the TELSTAR trial was patients with any rhythmic pattern. Perhaps treatment of generalized periodic discharges does not make a difference in outcome, but we also reflect in how this trial was biased by a very high of withdrawal of life sustaining treatment (75% of patients), so even for the patient population that was enrolled, it is hard to draw firm conclusion.
- Finally our talk concludes with an application of a frame work for family meetings and goals of care conversation as well as the cutting edge coma science that's moving neurocritical care forward.
- Perhaps nothing is more important than the time we take with families to establish the most goal-concordant path towards recovery or comfort. We like this framework by Fischer et al:
- As we have these conversations though, we must remain humble. We have so much to learn about the science of coma and recovery. Curing Coma (R) is an initiative through the Neurocritical Care Society which takes a multi-modal approach to understand disorders of consciousness and healthcare delivery. Follow along at #curingcoma and #awakeninghope on Twitter.
For now — our final take-aways: #timeisbrain and connect matters!
Thank you again H&R for having us, and to the EMCrit team for letting us share the talk here!
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Now on to the Podcast
- EMCrit 336 – Team NeuroEMCrit's Critical Neuro Cases – Part 2 - November 3, 2022
- NeuroEMCrit – Team NeuroEMCrit's H&R Conference Talk, Part 1 - October 3, 2022
- NeuroEMCrit – The Perils of the ICH Score - August 1, 2022