0:07 I'm James Ausman, and I'd like to introduce you to this This session on critical care in the treatment of
0:18 interest, cerebral hemorrhage and traumatic brain injury
0:23 questions and interest. Cerebral hemorrhage is A
0:27 are operating too late. Sure we operate sooner. What are the solutions people have to this question around the world and for? Traumatic brain injury. What should you do and what's the experience from around the world?
0:42 Paul Vespa is a professor of neurosurgery and neurology do Cla. He's the moderator, so just assistant dean of critical care medicine
0:53 at U. C L A medical center,
0:57 and his specialty is
1:01 critical care medicine is professor of neurosurgery and neurology. Specialty and head of that program with him are some discussions of who are known worldwide as Omar Awad, who is a professor of neurosurgery at the University of Chicago is and is known for his molecular molecular investigations into the cerebral angie almost, and is really advanced quite far along that line to understand. The biochemical pathways involved Randy Chestnut is a professor of neurosurgery and orthopedics at the University of Washington in Seattle is known for doing studies on traumatic brain injury and in developing in the developing world, comparing it to the developed world as to what things really matter,
2:00 I cheery, and many people around the world know he's He's a.
2:06 Now here's the Neurosciences Institute in the Krishna and Kerala, India, He was a formerly a director of the Institute for Neurosciences in Nepal. I brings a very interesting new approach to the surgery for acute brain injury, which his sister nice to me. I think, unfortunately, because the session went too long, we didn't have a chance. To here I have a presentation, but we're going to have him back in the next
2:43 meeting to talk about his subject, Dan Handley is a neurologist professor of neurology Neurosurgery anesthesiology, critical care at Johns Hopkins, and is a well known authority in the field.
3:01 We've also invited Samara, Whoa, Samurai is head of cerebral vascular surgery. We neurosurgery at the teaching hospital in Baghdad, Iraq, They have an incredible experience with obviously acute head injuries, and his talk is presented at the end of this session, and it is absolutely astounding in terms of what successes they have Walter Johnson is a commentator. I, also, Walter was formerly head of the world. Health Organization emergency and critical surgical care program in Switzerland, and now is a director of the Center of Global Surgery at Loma Linda University in Loma Linda California,
3:51 The session just briefly for your, so you know the first part is starts out with interest cerebral hematoma question. That's bothered me. For many years. There's room in the journal. We've received hundreds of papers on intracerebral. Tama, Tama, They're all small series are approaching and surgically from one direction or another and in the end we really don't know very much there were there Because you. You can't do much with a small series. There were some larger series done in the nineteen sixties were done by a neurologist in England, which I did surgery late only when people deteriorated and and weren't weren't very supportive of surgery as a treatment for it. And recent studies have been randomized, and by Dr. Mendel Oh, and doing fairly early surgery, up to forty eight seventy two hours,
4:49 but the question that's always bothered me is this is an acute injury, acute injury to the brain, and why are we treating of late,
4:59 We did some experiments in the laboratory with Doctor Manuel de whole night, in which we injected hematoma. The basal ganglia syria tactically and monkeys, and and either had a control, small control group or another group in which we put your Er, kinase, and the animals have your kind of set a much better and quicker functional recovery. When treated me like,
5:23 So there's a question the participants will discuss. They have a suggestion that can be used in countries around the world, basically based on C T scanning and needle Aspx. Aeration, there's a large experience in China using needle aspiration, and that would cover the subject of cerebral edema Toma, The first half hour, second half hour is devoted to traumatic brain injury, and there's a discussion of how it's treated in various places and how much technology do you need to treated Many countries in the world can't afford intracranial pressure monitoring,
6:04 and you will see in Samara hoses talk. From Baghdad, where they just have too many cases and can't do this, but the results have been outstanding in a series of seventy five patients that he'll present, that were presented to the their hospital and were triaged within a very short period of time and had a very high percentage who were able to recover, so this is an interesting targets are obviously going to have to be covered in subsequent. What meetings we hope you enjoy it. Thank you very much, Welcome everyone to room B. This session is an art critic on critical care of I, C H, and T V. I. We, I welcome all of our speakers on second,
6:56 and we have a very distinguished panel today of speakers, Dr. Awad from the University of Chicago. Dr. Chestnut from University Of Washington, Dr. Cherry, and from the Institute of Neuroscience, Krishna Institute, Dr. Handley from John Hopkins University, Dr. Hawes from Baghdad, teaching Hospital, Dr. Johnson from Loma Linda University and Dr. Zong from Loma Linda University. My name is Paul. Vespa. I'll be the moderator. My disclosures are below
7:29 today. We are going to talk about two topics that are very. Common topics, and and important topics in in a neuro critical care, and neurosurgery and neurology Ic, H, and T V I, this is just the brief outline of what we're going to discussing. We going to be having case presentations, and then discussion of topics, and we encourage and questions, and and and discussion. It's my pleasure to introduce Dr. Awad. He's going to be taking us through a A an example case, Dr. Awad. Thank you, Paul, and thank you, distinguished panel and colleagues around the world, that Rossman, thank you, so this is a case, set is a, quite often seen by by all of us At this is a thirty six year old male app,
8:25 although young has had a history of uncontrolled blood pressure and mild renal failure. It is not an anticoagulant and there was transferred from another hospital with very high blood pressure after fourteen hours of symptom onset, At at this time he had dense right, Can we please year at sorta left, emi, please, yet dense left him repletion, Gcs of eight, and then I C H volume of about fifty m L by the A B C method. And the based on the guidelines for acute management than external ventricular drain was placed, and the intracranial pressure is reasonably well -controlled as the blood pressure is being
9:20 handled and controlled by the guidelines in the range of one, sixty two, one eighty next slide so. Some of the questions that come up as as as follows it that that is not an issue of reversal of anticoagulation. The blood pressure is not an issue We're going to discuss. It's going to be handled by the guidelines. But the the question I want to focus on is should this patient have surgery for the Ic. H. Evacuation of the is being done. Is the goal to prevent mortality or to improve functional outcome. What do we know about? The that and the at a given what this looks like a, It's a time to obtain stability scans and etiology screening, or should he be rushed to surgery, and what technique should be used to open surgery, and those copic, and minimally invasive or thrombolysis, and and The how soon do we do, we proceed with that so. Before I tell you what we did with this case, this is a good way for me to segue to Dr. Hanley my partner and good colleague, Who's gonna try to tell you what we know and what we don't know about these questions
10:44 are from what do we know and what we don't know is really the single most important question and I Ch. Right now are some things that we know
10:55 we know that. In any Ic, H, I V H complicates things that makes it worse.
11:01 We know for sure that both open surgery in the stitch to trial and a minimally invasive surgery in the clear, and miss the trials of changes mortality, so we know that surgery can be helpful with mortality, and we know that there's a signal for benefit in. Functional improvement in the misty unclear trials. If you get a lot of the hematoma out, we don't know how much hematoma that he has to come out for sure, but we have good estimates of that.
11:43 We don't know whether one technique is better than another, although it looks like craniotomy causes more damage than a, than does a minimally invasive techniques and we don't have. Comparators across the minimally invasive techniques, so those are things we don't know, and one of the biggest things that that we don't know Is this timing issue is their time to stabilize the patient is their time to make sure that you don't have a vascular malformation is their time to control blood pressure. We know that controlling blood pressure helps overall outcome. Well, we know that knowing that what you're dealing with before you go into the operating room is an important neurosurgical principle that has always benefited the patient up, and we know from our own studies and from the stitch studies
12:47 that patients can benefit us in a time window that appears broad up. It appears that that time window is from twelve hours to at least forty eight, and probably seventy two hours, but we need more data on the things that we don't know.
13:09 Here's a graph that is in the supplement of our misty paper that shows that it does take a little bit of time to get the hematoma out, but that on the right hand side.
13:23 All the patients who got the procedure had a remarkable decrease in volume next slide up. This is a. N are the steps that can be done in a. As quickly as about twelve hours
13:42 in in imaging in Assam may talk about it a little bit later, but you can see in the lowest panel that you can achieve substantial reductions. In hematoma volume, and
13:56 you can mitigate edema formation next slide,
14:01 here's an a A question that we don't fully understand. On the left
14:07 are a sequence of presentation, post -op and three month scans for an endoscopic removal, whether a rather large of an suv, Hello, Malaysia, Qc, a legion of three months. And a smaller one using the the smaller tool, the the misty catheter on the right. We don't know whether the size of the lesion afterwards makes a difference or not so far, we don't have a signal on this, but it's an important question next Slide
14:44 here are some pictures of a different sized from thirty. On the left to sixty, on the right, basil, ganglionic hematomas putamen all or putamen all, and caught eight and low bar, and you can see that
15:06 the the low bars that we've selected are nucleated. They're they're essentially the ear of even density, and you can see the progression and sizes. These are the types of. Well, Pima Thomas, that are accessible with a minimally invasive surgical techniques next slide
15:29 up. Not all hematomas are ideal, of these are a so called satellite bleeds have a A. And you can see that the in the lower panel there is irregularity to some of the low bar hematomas. They often follow the The U Five, Brazil, the cortex and leave areas of subcortical white matter untouched, and are sometimes hard to access with minimally invasive techniques and and we need to consider how we handle these, or if we handle this, I think that's my last slide, so those are some of the things we know and don't know a sub. Yeah, so, let's go back. If you don't mind ball to the third slide. That, Yeah, The so so basically should. Should we have surgery at the way we approach a case like this is A already this patient is young is receiving very advanced critical care with that and with authentic alerted drain. And all the support systems of the modern. I see you, so that's not an option that this patient is going to beat be Just let go. You know, so we kind of already spend a lot of effort and money to help this patient. So and our approach we do offer the patient and family the option of mortality reduction with the level one evidence using minimally invasive evacuation and may be a shot. At helping improve outcome and facilitate neuro critical care by decreasing edema, decreasing the mass lesion, and hastening the care, and do we believe the signal's out of there with the level to be type evidence that if you remove more than seventy percent of the clock or are left with less than fifteen M. L. You will likely derive a functional benefit the approach that we have evolved. To to do is there a modification of the misty procedure that allows us to add, have the least stress on the healthcare system, so we do not go to the operating room and we do not use conventional image guidance As you know, image guidance can be a little bit problematic because you're constantly imaging. The image before you evacuate the legion, so your target the hematoma, but then if you aspirate some of it unless you re image, you have no idea where the residual hematoma is next slide, So we. What what we do if all can show is actually do this in the city scanner app. At one of the hospitals where we work, that is a city scanner in the intensive care unit. At another one it is a procedural city where people do city guided biopsies. So that our that is room for a table, and basically we take with us, the external ventricular drain a kit, and we go to the city scanner with the noodle, I see you team are typically anesthesia and the Oh, our team are not involved. Add, the patient is paralyzed and sedated with blood pressure controlled as if they are receiving April teacher, and the icy, you, and we are. We are placing the catheter at this one
19:07 and that up. I will show you the catheter We we did that via a modification of a low bar approach because of the angle of the bleed, and then we evacuate with a syringe as much as we can right there and then. And then re image the residual hematoma and put a catheter in the residual he met Alma, Go ahead and their next slide, please,
19:33 so basically, this is how it played out in this case, As so we took an approach from lateral to medial, as through the superior temporal gyrus and the Ad, and we put the catheter and. At the initial post aspiration looked like it might be a case that is not gonna do very well because of all the satellites and pseudo parts of residual, and he met Alma, but in fact with only a single those of Dp, A, A, The, The, The the scan on the right side was accomplished, and the measurement of the residual heat met Toma who was less than ten ml. At using using actual a a reading center, a measurement of the residual clause. This is very difficult clock to measured by the Aapc method, because it's all little pieces, but the that our algorithm set we have, and including artificial intelligence algorithms that allow us to know that we've reached the less than fifteen am. Also, this was a very very. Aei, positive result, using a single dose of Dp, A with this procedure. I believe a look at the mass effect on the ventricle within twelve hours of the procedure. We basically eliminated the Aicp problem. Remove the E V D, and The, and the patient was moved very very swiftly to R Q. Do they have dilatation so I want to adjust to a Ethernet Internet. Back to Dan for a for a couple more thoughts on on how this was handled and then Paul Vespa for some questions and answers,
21:26 well, that's a lovely case. Esom. I'd like to make a couple points
21:34 we have found now in four different trial datasets with independent adjudication of volume. And volume without independent adjudication is
21:50 fraught with substantial error error that can go as big as twenty or thirty milliliters in the estimate.
21:59 We have found that this fifteen milliliter threshold of looks like it's a robust threshold would like to find it again, but we founded in in the clear trial, in Misty two, in Misty three. And oh, when saw him and I and our labs looked at the stitch data. We found it in a in stitch too, as well, so that threshold of what what the surgeon needs to do seems like, it's a very robust threshold and it works in a priori statistics for mortality, and it works in per protocol statistics of four.
22:44 Functional improvement, Paul Vespa, A, in a trial called Isis showed that it works for and to Scapa. Removal. Both catheter and endoscopic removal have advantages and disadvantages, and we don't understand what they are so that would be
23:04 my scientific overview from a public health perspective and a love for Dr. Johnson to comment on this. I am a nurse. Modern European or.
25:21 Cities aren't available, but at least a third of them many more than in this country. At least a third may be as many as fifty percent are hemorrhagic. Strokes were over here. It's and twelve percent or so. So this would be
25:40 fantastic for a low resource settings if cities and people that knew how to do these procedures were available. And then the critical factor as well as there's no acute rehabilitation, because number one people can't afford it, and even if they could, it's not very much available in in any of these countries,
26:06 so those are my comments, but I have a couple of questions. If I could, could I could I say Droid, to clarifying
26:19 point, one, Esom and I. Are the conveners and hosts of the World intracranial hemorrhage conference, which is now in it's ninth iteration, I think, and we've been pleased to see that there is a a what you would call early adoption. In these have resource limited settings. We saw a wonderful presentation from the Philippines where access to their cat scan was. I paid for by a charity and have this procedure that Esom showed you can be done for under a hundred U S dollars with of have with equipment that of A was a
27:09 available in the Philippines, so we see some early adoption of this This of this capability of the. Yeah, and then I, I will add also that this is all in relative terms, right, So I think what Walter put in front of us is the is the real challenge of world epidemiology of stroke, in general, right? We're not going to have a cat scan to know whether it's a hemorrhage or scheme. Yeah, Then you know you are in a. In a. The challenges there is ought to improve more of the element that he yeah elements of care, but assuming you get to a situation such as in Karachi or Cairo and Alexandria or Nairobi, where cats kind of not The problem is it better to do it with a catheter, or is it better to do it with an endoscope that costs fifteen hundred. Scarlets, you know, and so forth, so those are the relative issues that we're trying to put on the on the table a little bit, and at, even if it is done with relatively simple terms, I just want to add that that you've got to follow the protocols extremely closely in terms of safety and effectiveness. This is not something. Where do you put the cat that that I to your turn the case loose. In that case. It's probably better not to do it right.
28:35 The rehab question just one quick point there
28:39 we've seen with clot extraction once in ischemic stroke, Once the procedure was well developed, and the safety elements defined, We've seen that there's less need for rehab because people come out of the procedure at a higher a functional level. Which is what happened here. Emma arrests of three at one month in a brain hemorrhages is unusual absolutely. Please your questions, and one of the slide said that there is irrigation without the place, and one does
29:15 one does okay, and that is done into the clock. Correct, Yes, in the past that that you see in the middle picture, Alright, and how long do you leave the drain and then so the drain is left the day after the last dose of Lt place at the places given. At until you reach that, the to Earth with less than fifteen am an evacuation. In this case, only one dog was needed. The catheter is removed. The following day. We've done kinetics. Dr. Johnson on the altar place. Twenty four hours is more than five half -lives so it's effect is no longer there, which makes the the removal of the catheter safe.
30:03 While the wonderful thing is w, a job hazard model list of essential medicines that every every country is supposed to make available, and you're a climb. A streptokinase, and Alpha place are all included on that so right, hopefully I mean that that certainly far off, but it's it's the ideal. It's far from the reality, sadly, but at least they understand the necessary nature of having these drugs available.
30:34 Encouraging, very encouraging, and I think nascent themes of neuro critical care, neurosurgeons and neurologists and it can emerge even in in in in in the setting of early developing environments with universities and medical schools that I think to this even in the poorest countries and. It just like in the Us. We have many areas that are very underserved and do not get the level of care that they that they deserve, but I think the stroke center concept of nascent themes A will start elevating the bar and showing what can be done even in local settings and the demand is going through the roof that the mattress will roof. People understand that this is much better outcomes. And and with the cell phones and everybody's becoming aware of these things and social media and the demand is growing.
31:39 There's a question from our from our attendees, What are your neurological condition and age cut offs for offering minimally invasive management, so let me take a hit that that we follow. The the standards set were that were to use the protocol set were used in the trials to answer that not to fall into false generalization, so we do not use this procedure on people who are already herniated who have a dilated pupils, who ara A in an impending herniation and instability setting at, but otherwise the G C S eligibility is very broad, so. In my practice, Gcs of five to fourteen is what gets this procedure, so the greatest benefits seemed to be in the middle range of gcs, the people between seven and eleven out of the ones where we make a huge difference on, But that is a signal benefit in all three Gcs settings then is that the your thoughts as well yog or two other more minor issues? We don't do it when the family says you know we talk this over, and my loved ones said if they had a stroke, they didn't want to have a survive, so we don't do that and the the Gcs I think one has to be careful about if the patient has been sedated of using the Gcs as a discriminator for. Procedure versus no procedure is is unwise, and so I, I would would favor of weather's doubt, are not using Gcs as a discriminator. We've used a cut off of eighty and age, Ah, but in the last two trials that we've done, we've moved to functional status rather than age as a cut off, and if someone of. Is living independently and is a rank and a zero one or perhaps two, but we've taken one as a threshold. Then we've done at if they're over over eighty,
34:02 so in countries such as China and others, neurologists have little devices for evacuating hematoma especially low bar, once yup our new training neurologists to do this in low resource settings. Well, I'm a pretty clumsy guy and disarm doesn't allow me to use sharp object.
34:27 You know Paul was probably the example leading example of neurologists at doing this procedure even at the at a high socioeconomic setting like West, L. A so, and so I think I have no trouble with well -trained neurologist. I think another important thing that we learned from this. Is that achieving the endpoint and and experience with this procedure are essential to its functional benefits? So you basically lose the ability to save life and improve function? If you put the cat that the sideways and nothing for the plot, and you know? A the brain instead of the cloth, which are things that can happen. If we loosen up the protocol too much so I don't really care in particular. Who does it as long as we are very rigorous about our our water at a technique which enormous surgery is a big deal. Right You shouldn't do bad brain surgery in
35:31 library. Let me go back to my little joke. For a second. It was with a purpose we're looking at the. The training or the number of cases it needs to train
35:43 a in our data, and we hope to do that in our next trial. It looks like somewhere between five and ten procedures with a neurosurgeon who's more skilled than I am of his enough If you go to the Chinese cranial puncture data and it looks like. The internists and and medical doctors and neurologists who do this are of doing K series of of two hundred to one thousand, and that have a good experience begins to happen. Perhaps at a larger number. I am all in favor of a aware. Your question was heading That have the skilled provider is the one who you want, and it doesn't matter what they're there. Prior training was, and I think Paul Vespa has shown us that
36:39 thinks everyone. I think we need to move on to T V, I, and for for the sake of time, thanks for excellent discussion, and Doctor and Chestnut is trying to get onto the session having some technical difficulties, but we're going to Florida. This. Thank you, Thank you so much. We're going to go on and and have a discussion. And I'm about Tb. I and Dr. Chestnut has
37:09 provided a number of slides, Dr. Oz's and so has summits as well, So
37:17 these are these are Doctor Chestnuts slides, and so I am. I'm going to start for him. Hopefully He can. He can sign on here,
37:26 but essentially this is a case in a patient with a traumatic brain injury here. It comes in to the trauma center and and has a number of other injuries as well and, and has an initial C T imaging here with, and as you can see the contusions, temporal confusion, and herbs skull fracture, as as doctor,
37:58 does, not as actually as outlined here for you. And the issue the issue is is how should touch with this patient be treated, and how what are sort of some of the decision making that goes into evaluating and and and treating a patient, such as this, and and
38:19 you know what are some options in terms of early medical management or early surgical management, and and so forth so. So there's a symmetric exam or some aphasia and and there's an initial evaluation of the patient, and I'll just back up just a second and just see what our our panel may think here and Dr. Johnson.
38:48 Perhaps you can you can give us a sort of a brief
38:52 discussion of of what you would how you would approach this kind of patient and in the early hours.
38:59 Well, there are several things of concern, first of all as being minus thirty three, so this is not a small person you're dealing with who may have blood pressure issues underlying health issues as a baseline, My primary concern, though is is the extent of this and it, it looks
39:20 majority of it in the temporal lobe and his chance impact on the upper right, I C T scan. It looks like there is very eminent herniation. If it isn't happening, then it's going to happen. I'd be very very concerned at this, This patient herniated sufficient below to cause a skull fracture, and so I'd be very concerned about them,
39:49 and I think if I think perhaps Doctor just is
39:54 on now, Yeah, Can you hear me? Yes? Yeah, Alright, Yeah, Sorry, Ran, Don't we were getting started. Please go ahead. Yeah, No, No, this guy. This guy. Actually, I think your. Your concern is quite correct. This guy came in looking like brand new zone or not. I see
40:12 Stephanie. Do you know if Dr. Chestnut is on? I can as I can hear him appall? Oh, Okay, I'm
40:20 I. I apologize for that, But The we were concerned about this guy. He looked pretty good. Clinically. He didn't look as bad as his skin. And we figured he was a phasic because of the legion, so we, we initially did not think he was directly a surgical candidate, and but we were concerned that he might be. He had no evidence of herniation based on pupil A your exam, so we actually considered not operating on him initially
40:56 Randy. This is Dan Hanley. The one thing you see on a C T, though is no Csf spaces which could suggest that Dr. Johnson's prediction might be right.
41:09 Yeah, it might be. I mean we put again. I think as we progress on the slides will come up with some.
41:17 In the E D within a very short time after he came to help us answer that question, because it's dominant temporal lobe, and and we were quite concerned that he'd be. You know that we. We were about what we were going to do about the injury itself at about whether or not he is a phasic. We were not certain that was directly surgical, but we did put an Aicp monitor and interoperable. You know which we do in the emergency department.
41:41 That's a complex set of concerns, So have you had a thought process for it, so it sounds great to me. Yeah, makes sense.
41:52 initially. His Aicp was law. We put him in. I icy you, we you know we looked at his physiologic parameters, according to the civic one tier zero approach, with the recommendation of of you know, had up an observation sedation, and and, and as indicated, physiologic resuscitation setting as initial Cpp as twenty. Initial thematic crit or hemoglobin level as seven, and and you know we set him up. Physiologically. He is a big fellow, which is a bit bit awkward, and he act. His Aicp actually stayed pretty good at, stayed in the teens and
42:35 unfortunately we did it, and then we did a routine follow up C T scan at at four hours and just go ahead and advance a couple there, Paul.
42:47 And and the lesion was worse,
42:51 so this is what we talked about about setting up and then management with him. I thought I should be. I think there's probably a lot in the audience. There's a lot of places in the world that don't have Aicp monitoring, so that would be following the crevice protocol, which is for treatment of traumatic brain injury based on suspected intracranial hypertension. This fellow would would meet the suspected integrated hypertension criteria based on his C T scan. And on several aspects of his exam, and there are, but we did put an Aicp monitor ran over four hours. You can see it drifted between about four and twenty. The like she began to react, and it gave us normal values, but we got a C T scan and follow up on next slide there,
43:34 and as you can see, the lesion was bigger,
43:37 so I think in the long run, Walter's idea was quite on track. And so we did a decompress of cardiac to me, We have kind of gone over to the campy incision at the University of Washington, because of its user -friendly It's quick, and if you have to turn it into a bilateral incision, and it can be easily done or for later by a frontal involvement, and but post operatively he, he looked pretty good. His exam was unchanged. He was decompress, but we got a C T Vina Graham. And as you can see, based on the fractures that we saw up front, he has embarrassment of his left transverse and sigmoid sinus,
44:23 Any thoughts about how that can contribute to into hypertension, Any anybody change their therapy based on net, or it's kind of a sticky wicket
44:34 and it can contribute to intracranial hypertension you?
44:39 I you know my point early on after Walter made his was the the primary. Buffer. P in globally, and locally
44:52 is the Csf but the secondary buffer is the cerebral venous blood volume system and that you've just compromised, have a significant portion of it or have it looks like from this,
45:11 Ah, Vena, Graham, particularly the upper right. That you do have a fortunately, have a contralateral dominant juggler system, so it may not have compromised at as much as a Ah. As it would have. If if the lesion all side had had been the dominant side.
45:35 Yeah, That's it. These. These certainly contributes to hypertension and it's it's a venous blood volume issue which is a bit problematic in terms of of therapy. I, but and we were concerned about that next like
45:52 you should be, because of you know, the The problem is that you have circulatory compromise, and hyper ventilation of is more likely to produce a scheme schema in the scenario like this, but as the, there's a possibility that there is a Venus in fact
46:14 in this case. Probably the rain of flabby, and so that could that could have led later on the transfer, sick mind the problem, but meant that was there from the first scan on onwards. And in the evening after surgery after decompression you can.
48:02 No, No, I wouldn't have gone with a decompression decompression. There I do, in this case, If you see that the hematoma would, If hematoma over have come out, it's the I mean, just because it's the dominant temporal lobe. You're really doesn't have to decompress. Mean that just shows that the the temporal lobe is going to herniate out more, and that's going to create more damage than if you. Take out the hematoma through a superficial incision. If it's coming out, and then after that I would have opened assistance. That's what I would have done differently. I would not have performed a decompress if you are on what he pay, a, pointed out the potential for both cortical venous thrombosis and the
48:50 and the sinus thrombosis. It's going to make any attempt at humor Toma extraction, very very difficult. You're going to have a major bleeding problem. Yes, I agree completely, I mean, since the Waynes is that this may have been a traumatic brain of flabby problem to start with, so hematoma evacuation would have been a bit messy, but I mean, rather than rather than decompression bad, the brain decompressed decompress. The hematoma could go going arenas. In fact, have gone increasing, and the old tempered local honey at the outset. I mean this case went off very well, I see, but I would rather. We with within a human drama through a small incision, opened assistance
49:35 with the with the large flap, opened assistance, and just to leave the bone back this, I mean I wouldn't do it. I wouldn't do a decompressing here. You can see here that even you can see that the brain is honey eating out here. You can see through me that I at least about twenty five ml of brain is definitely when eating out here. If you put the bone back that that damage would be much less
50:08 long ago, it didn't actually herniate out, and that was damaged as you can see. If we continue along with the case. The patient did have have some element of intracranial hypertension, and that after the the surgery, it was actually the highest was something on the order of thirty two is generally. I ran in between about twenty four, twenty six, and we followed essentially the Civic one with where we had a like auction, so we followed the Civic to protocol, which would be type B, which is
50:44 an abnormal Aicp, and normal brain tissue oxygen, and and so this would be type B, and we followed we followed that we we did treat him intermittently with
50:57 with hyper tonics and he tended. I have normal pupils. Normal oxygen are really pretty normal waveform parking. You can you go ahead and and show that, and indeed he had auto regulation when we tested that, and so The the we'd be good it basically by altering his blood pressure and looking at is his transcranial doppler flow and his Aicp response, and so what we decided after a couple of days of of hypertonic where he was. Tending to stay between twenty four and twenty six, with normal normal waveform normal
51:36 auto regulation, nope normal pupil that we eventually allowed him to run at twenty four, The total assets backed office sedation, and he was localizing without any any competent issues, so what we ended up doing was to give him a bit of of permissive into hyper. Action, because the venous side outflow problem is difficult to treat otherwise and up, and he actually ended up doing fine
52:09 sounds like you maintain Cpp. Yeah, very carefully, and we were also checking it with a brain tissue oxygen, so I think this is a case where we knew we were going to have to go hypertension and the question was as the intracranial hypertension at the low level that it existed actually harming the patient versus escalating. Treatment and and we felt it wasn't and so we we adjusted the Aicp threshold,
52:36 And is there Since you work in a great institution is Ernie role for interventional neuroradiology. They're doing Venus Angioplasties and thrombosis or Isis, Routinely, Now Any role for them.
52:55 Ah, well, we ended up. And I coagulating him an aspirin on day three and Hepburn on day five, and you know as far as doing it into eventually, we do a fair amount of that, but not necessarily in the case of trauma or intracranial hypertension. Our intervention lists are still a little reticent of taking someone to the anxious, sweet and full and relative venous system in the face of ongoing integral hypertension and we weren't sure we were going to get away with the adjusted Ocp threshold,
53:23 something to consider, I would think certainly, yes.
53:27 I as an internist, I'd be concerned with that fracture that you have a periosteal tear in the in the sinus, and that a rapid opening of of the exclusion may not be as safe as a heparin, based more slow approach.
53:51 You're concerned about air, know. I bet you had a tear. Oh, and if you, if you did have a stent, for example, or local thrombolysis, Which of the two approaches that have been used
54:09 that you might actually up, then get a a post year face of a subdural
54:18 well that the alternative anticoagulation was pretty tenuous at that early after trauma back right back. We seem to have gotten away with it On this case, All right, My point is it works more slowly. Yeah, excited that allows it allows for whatever the local thrombotic mechanisms that are keeping you from getting a subdural to perhaps continue, and and and balance out the opening of that. Did it Did it open up?
54:48 You know, actually, we don't have that locked him out. We only treated him a month ago. And we don't have a follow up city Vienna Graham, yet he seems to be doing okay. He's at rehab rehabilitation. He's doing his activities of daily living. He's got a mild right hemiparesis and he's definitely quite a phasic in. In both of his languages.
55:09 Does he have a memory? He has contralateral
55:13 medial temporal lobe injury that looks like what you often see as the bilateral temporal lobe injury of? Puppies simplex, and many of these people don't have functional memory.
55:29 I, actually, that don't know that result from his rehab.
55:34 I don't show itself in six to twelve months,
55:40 just just to finish this patient in a lot of parts of the world would have been monitored when treated without intracranial pressure monitoring. I suspect he would have been decompose.
55:51 I and but without intracranial pressure monitoring, and the, if, if the ice, if the best trip trial showed anything, it showed that you can do pretty well with just good critical care and attention to the patient in the general population of severe traumatic brain injury. I think this fellow met criteria for treatment of suspected go hypertension. He would have been put on schedule mad at all, I think, and then watched for deterioration with escalation based on clinical findings, I suspect in truth. At this fellow might have done fairly well without an Aicp monitoring treated by the crevice protocol,
56:32 I, sadly,
56:35 for many people with this kind of victory around the world. They would do whether it's a moped or falling off out of a coconut tree. There's no ic you. So
56:46 many people wouldn't survive this in. Many low resource settings.
56:53 Yeah, that's true, but if they do survive to hospital, I think that the the hopeful news is that with good critical care and attentive management, they have a reasonable shot. I don't you know? I. I don't think the lack of our fancy toys should prevent art assiduous critical care in low and middle income countries absolutely want to point out that that's the same theme that came across in the last presentation if you know what to do. If there is a way to do it, I, everybody,
57:25 Hi, Dr. Hawes. What are your thoughts
57:28 and as pleasant as discussion about the intensive care issues, For sure, right and practicing in Baghdad, Iraq, or we don't is that we have a lot of drama, and in spite of that, we don't have an icecream the monitors for any patient, so it's maybe a different pathway an era. Let yourself wish you'd kept with the standards, and I don't know if I can present to the cases. Stiffen your slide is now showing Doctor Haas
58:03 is and misled
58:06 saw an ad, and my Yeah duck will be just say, giving a maybe two slides about two different types of injury. It says a blast. Andrews traumatic brain injury. What we say. When we say, blessed a an ad -hoc Usually, it's a car bombing or suicidal attack. This is quite common. I think Iraq on his recently Baghdad. The of product is there one of the hottest spot in the word, A dealing with this shit, A terroristic attack over the last may be more than ten years, so a. In the mind, trump order in the diagram shown, you can imagine a situation that, too, that is a huge, double or suicidal bombing attack by bonding cars at the same time at the same place with a crowded population what we received in our hospital, which is then your surgery, teaching hospital on the neurosurgery at a specialized center. And as you see in the diagram will receive a seventy five patient, A to the E R. First dealing with these patient, A require a planning, require different, and many had to. I think there will be a lot of change in prioritizing the steps. Thus the main idea while receiving seventy five patient, and they are A as a first of all, for sure, that is day. And then he says Station two. After that, it's basically says Station. We have. We lost ninety impatient at the E. Are under from that that is forty or fifty six patient require treatment from those that is thirty nine. That's their main number. Here. There's thirty nine patients require surgery. All of them present at the same time. That's what what the blast induced traumatic brain injury entails Actually receiving those patients thirty nights, Let's say forty at acquiring surgery, which the patient you should do the surgery for him first, and that's how to a do the priority. I think it. At that time, we spend three or four successive days, and the earth. We have three to four, a or a. Theater's doing the surgery continuity for a few days while finishing those cases. That's him a major challenge. When you have such gush of cases. At the same time, A for sure, not all the cases that require surgery. Some require conservative treatment to a ghetto, and they are in very good condition, or they are in very bad condition, I mean. Patient with Gcs like three or four with the penetrating shell or multiple shell, this is not a priority for surgery for us, but patient with a large shell step in the head and causing midland compression. Thus will be the priority here you can find a variety of entries you can encounter and to that's why you, you must have a plant management strategy. I get is a multiple teams team working and our team working on the teams working in there at discount, because this team will take the decision was whether to send the patient directly to the or, or to prepare and the icy, or admit to the emergency department, and that's just. It gives a general idea, and that is all types of entry. You can as suspect. In these cases, maybe vascular injury. Many of it. You can expect that is a sinus injury and most of the cases, because it's at because of their waves of the blast, so that is the primary and secondary and even tertiary injury because the people are pushed through the wave of the blast and. And I think this does give a general idea about the topic, and if we go to the next and the lasts a year,
1:02:44 this said that is a and a protests, crowded protests in Baghdad near our hospital and to governmental protest, and and there is a tear gas canister the throne. Against the protestors that said, come on everywhere in the world, but what occurred in Baghdad and a two thousand and nineteen that we receive a forty cases of a head injury caused by tear gas canisters. Actually in this publication, we take only a dig at cases that they get canister. Which which should be as safe on air penetrates the scalp and fully, that is a full penetration of the kind of inside that head, and that these are ten patients. All of them died eventually, but we analyze the data because I think it's a very rare and injury and even amnesty, and advised that this type of Fred tear gas canister is not a four as civilian use. And they are all unusually used in the past for military purposes, such as a from neurosurgery perspective, that was a very challenging, and with this large penetrating object, I think it's a strange city, Scan to see it was this large object object and a, We are an pushed to do a surgery, and if you consider yourself in and. And the minute and the position of managing surgeon in such cases, and you can you leave this large object and get your expect the patient to improve, for sure, Not any patient with there any glue a gcs above five or above four, We operate them, and we tried to obstruct to their cases, and one of the cases, we we fail to extract it because it's severely adhere to their top corner. And there is a huge and bleeding with each time we are trying to moving it, and to
1:05:03 actually apart from the surgery, and and or a, there is a possibility of toxicity. As you know get is a toxic gas inside that these canisters, and what are their real effect. We don't know. It's as strange injury, but it came in a gush over two days. Will receive a forty cases at from a penetrating head injury caused by tear gas canister. I think A, in this article, we described as many as scenarios, but this one is a difficult one. A try. We are a, for sure we tried to do circumferential the Qur'anic victim well as white. As possible. For sure there is no Jura to a two and two make a joke last year. At each type, who use a direct fisher Latin instruction, and we it above the defect, after removing the tarnish that I'd make the haemostasis That's the general idea from Mike joked, and dear. I'm waiting forty or comment, Said these are very challenging situations when you have a mass of occurrence of intracranial there.
1:06:21 In injury, could you tell us a little bit about how you organized your team to tree Ash to get such a
1:06:30 positive results where only half of the individuals died and you had a substantial number who were able to be independent at discharge
1:06:45 that is how far they glisten one actually say by the frequency of? Last entry's it. I think it sometimes in two thousand and eight, and that is a daily two or three major blessed in Iraq. So with time we are, we are organized to be teams. All the team must contain a decision making, and you're a surgeon one and do are one in their city's kind, as I said, Because and and the auto a sorta one in the e r a Y have taken the decision. After his his station to send this patient data to seek, can or to go today, I see you, or sometimes director surgery. Even without the discount, you are obligated obligated to do some set. Such decisions at the second team will be at their cities, can to take it the decision about the next step. The third the team will be in the Ic. The Ic team must include a decision making. Can your decision for sure with a resident, Because in their eyes, you? You are prioritizing your patient, which patient I will send him now to the surgery, and which patient will a stay up to two or three hours later and what should I do and this time yet like using mandatory. Even sometimes you are forced to use steroids. Although you will not regret, it may be not helpful, but but if you're already using all the possible armamentarium of the O. R. We have. And in each at the theater, there is a surgeon or resident operating on each case, Because as I said, you need it, but this is not the cases for resident A. You can't face a major Venus, a bleeding or major artery, or didn't at any time getting the procedure, so decision making will not say Wait for a A just to an A surgeon. Yeah, like supervising. What he put about surgeries doing by residents? It's not the same type of situation. We need a on a surgeon with good experience at each surgery I did At the same time there is a a priority while, and said sometimes we don't close the dura. Sometimes you put it. I think most of your professor may face this, and in some cases. We put like that cut tonight's party inside the brain justice of them. Didn't leave it on the clothes. This can
1:09:24 I talk her house? I apologize. We have to go ahead and close the session. For today we appreciate all of you and your great knowledge, and we need to close the searches back your doctor hogs. That was a wonderful presentation. Thank you all. Intercept.