CLINICAL DECISIONS BASED ON MICRODIALYSIS DATA IN SEVERE HEAD INJURY

P.G. Papanikolaou, E.Papadopoulos, A.Markellos, K.Barkas, S.Stamatiou, A.Venetikidis, N.Papageorgiou, M.Fratzoglou, E.Chatzidakis, T.Kyriakou, T.S. Paleologos, K.Kazdaglis

Neurosurgical Department,General Hospital of Nikea - Piraeus, Athens, Greece

NOTHING TO DISCLOSE

Οur experience

Multimodal neuromonitoring in TBI patients using intraparenchymal brain catheters

Twist hand drill burr hole Single same burr hole 5.3 mm 3 – lumen cranial bolt (LICOX) ICP, PtiO2, microdialysis

Treatment strategies

CPP targeted therapy

- CPP > 60 mm Hg - ICP < 20 mm Hg - PtiO2 > 20 mm Hg

- L / P ≤ 25

Catheter’s tip

What about microdialysis?

Microdialysis only for research

•Not officially recommended as a clinical tool in TBI

Some centers favour it

and not only in

Hillered L, Vespa PM, Hovda DA. Translational neurochemical research in acute human brain injury: the current status and potential future for cerebral microdialysis. J Neurotrauma. 2005 Jan;22(1):3-41.

Our center’s opinion

Clinical decisions based on microdialysis data -Lactate to Pyruvate concetrations’ ratio (L/P) - in severe head injury: Treatment protocol of patients with peaks of

intracranial hypertension up to 30 mmHg (“group A”)

Evaluation of success and duration of thiopenthal administration (“group B”)

Decision for evacuation or not of “border-line” sized hematomas (“group C”)

GROUP A max ICP mean L/P age sex GOS

Pt 1 33 32,7 59 f 5

Pt 2 35 31 43 m 5

Pt 3 35 24 22 f 4

Pt 4 28 20 27 m 5

Pt 5 31 31 29 m 5

Pt 6 29 23,1 41 m 4

GROUP B

Pt 1 40 32 28 m 5

Pt 2 117 28,4 17 m 1

Pt 3 122 42,7 41 m 1

Pt 4 37 31,1 35 m 5

Pt 5 121 46,7 28 m 1

Pt 6 98 41,2 39 m 5

GROUP C

Pt 1 27 30,7 32 m 1

Pt 2 34 24,6 21 m 4

Pt 3 14 23,8 23 m 5

Pt 4 27 28,7 22 m 5

Pt 5 40 32 28 m 5

Pt 6 33 32,7 59 f 5

Group A

6 patients episodes of intracranial hypertension

up to 30mmHg without significant change of the L/P

ratio Decision to treat with mannitol only

or to proceed to second tier therapy with barbiturates

Group A : Sporadic ICP elevations up to 30mmHg – just sedation and mannitol or something more aggressive ?

Group B

6 patients refractory intracranial hypertension treated by barbiturates L/P ratio was the main criteria for

evaluation and duration of the treatment

Group B : Conservative treatment. Barbiturate therapy for refractory intracranial hypertension. Evaluation of continuation of barbiturate induced coma

Normalization of L/P before ICP

Discharge CT scan

GOS 5 at 6 months

Group C

6 patients intracranial hematoma initially

treated conservatively L/P ratio in association with ICP

determined the decision for a surgical evacuation

Group C : 59 yrs, female Evacuation or not?

Based on values of L/P<25 : conservative treatment

CT scan at two months (discharge)

GOS 4 at 6 months

GOS

Good

Moderate

Bad

Group AGroup BGroup C

Handicaps

Difficulty of insertion of the catheter via the 3/lumen bolt

Measurement frequency ICU personnel deficiency done by N/S residents

Lack of automatic data registration National health system structure :

patients → ICU somewhere else Hospital and social insurance managers

not so helpful

Conclusions

Multimodal neuromonitoring using brain catheters seems to be safe, reliable and useful tool

Data provided by microdialysis seems to be helpful taking appropriate clinical decisions

Especially useful in barbiturate therapy

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