CEREBRAL RESUSCITATION FROM ACUTE
CATASTROPHIC NEUROLOGIC INJURY:
THE BRAIN CODE / ACUTE ICP MANAGEMENT
Navaz Karanjia, MD
Director, Neurocritical Care
Assistant Professor of Neurosciences,
Anesthesiology, and Surgery
University of California-San Diego
Disclosures


No financial disclosures
Off-label use: propofol for ICP control
Objectives





To discuss the physiology of herniation and cranial
vault mechanics
To explain the specific protocols for a “brain code”
To discuss the evidence behind the specific
interventions in a “brain code”
To discuss the outcomes of patients that have been
“brain coded”
To take you through a brain code/ICP emergency
case
Cerebral Resuscitation: acute
catastrophic neurologic injury

Catastrophic neurologic injury: ICP herniation
Why do I want you to understand
acute ICP management?
Cerebral Resuscitation: herniation
Cerebral Resuscitation: herniation
Cerebral Resuscitation: herniation
Cerebral resuscitation: herniation
Subfalcine Herniation
Cerebral cortex under
falx
Leg weakness
 mental status
Tonsillar Herniation
Cerebellar tonsils in foramen
magnum
Awake, pharynx weakness,
quadriparesis
Arrhythmia/cardiac arrest
Central/Upward
Herniation
Brainstem down/up
through tentorium
 mental status
Dilated pupil, eye
“down and out” (CN3)
Weakness/posturing
Basilar stroke
Uncal Herniation
Uncus over tentorial
notch
 mental status
Sluggish -> Dilated
pupil -> eye “down and
out” (CN3)
Weakness/posturing
Cerebral Resuscitation: tonsillar
herniation
MEDULLA
-CN 9, 10—throat
sensation/muscles, vagus
-CN 11—shoulder shrug, head
turn
-CN12—tongue muscles
-Pyramids—all motor tracts
-Respiratory control, HR, BP
GAME OVER
Tonsillar Herniation
Cerebellar tonsils in foramen
magnum
Awake, pharynx weakness,
quadriparesis
Arrhythmia/cardiac arrest
Respiratory arrest
Cerebral resuscitation: tonsillar
herniation
Cerebral resuscitation: herniation
Subfalcine Herniation
Cerebral cortex under
falx
Leg weakness
 mental status
Tonsillar Herniation
Cerebellar tonsils in foramen
magnum
Awake, pharynx weakness,
quadriparesis
Arrhythmia/cardiac arrest
Central/Upward
Herniation
Brainstem down/up
through tentorium
 mental status
Dilated pupil, eye
“down and out” (CN3)
Weakness/posturing
Basilar stroke
Uncal Herniation
Uncus over tentorial
notch
 mental status
Dilated pupil, eye
“down and out” (CN3)
Weakness/posturing
PCA stroke
Cerebral Resuscitation: uncal herniation
GAME OVER
Uncal Herniation
Uncus over tentorial notch
 mental status
Dilated pupil, eye “down and out” (CN3)
Weakness/posturing
PCA stroke
Cerebral resuscitation: herniation
Subfalcine Herniation
Cerebral cortex under
falx
Leg weakness
 mental status
Tonsillar Herniation
Cerebellar tonsils in foramen
magnum
Awake, pharynx weakness,
quadriparesis
Arrhythmia/cardiac arrest
Central/Upward
Herniation
Brainstem down/up
through tentorium
 mental status
Dilated pupil, eye
“down and out” (CN3)
Weakness/posturing
Basilar stroke
Uncal Herniation
Uncus over tentorial
notch
 mental status
Dilated pupil, eye
“down and out” (CN3)
Weakness/posturing
PCA stroke
Cerebral Resuscitation: cranial vault
mechanics
Normal
Monroe Kellie Doctrine
Skull is a rigid container (1600 cc)
Cranial contents (brain, blood,
CSF) are incompressible
Additional volume (pathologic or
expansile) will lead to displacement
of normal cranial contents
8
%
12%
80%
CSF
Blood
Brain
Cerebral edema
4 4
% %
CSF Blood
92%
Brain
Tumor
20%
79%
Normal ICP = 5-20 cm H20
Blood Tumor
Brain
Saunders NR, Habgood MD, Dziegielewska KM (1999). "Barrier mechanisms in the brain, I.
Adult brain". Clin. Exp. Pharmacol. Physiol. 26 (1): 11–9.
Cerebral Resuscitation: cranial vault
mechanics
Cerebral Resuscitation: cranial vault
mechanics
No blood
== BAD
FOR
CPP
MAP
- ICPBRAIN
HV, mannitol,
23%
Brain Volume
Rosner M J, Rosner S D & Johnson A H. "Cerebral perfusion: management protocol
and clinical results." J.Neurosurgery 1985; 83: 949-962.
Cerebral Resuscitation: cranial vault
mechanics
CPP = MAP - ICP
CBF = CPP/CVR
CD02 = CBF x Ca02
Cerebral Resuscitation: cranial vault
mechanics
Healthy human subjects: normal CPP = 50-70
CPP<50 = ischemia/decreased EEG amplitude
TBI:
ICP<20, CPP>60 = mortality reduction by > 50%
HOWEVER, CPP>70 = increased mortality
AIM FOR CPP>60, ICP<20
Bratton SL et al. J Neurotrauma 24 (S1): S59-S64, 2007
Narotam P, Morrison J et al. Brain tissue oxygen monitoring in traumatic brain injury and major
trauma: outcome analysis of a brain tissue oxygen-directed therapy. JNS (2009) 111 (4): 672-682
Rosner M J, Rosner S D & Johnson A H. "Cerebral perfusion: management protocol and clinical
results." J.Neurosurgery 1985; 83: 949-962.
Cerebral Resuscitation: acute
catastrophic neurologic injury
Cerebral Resuscitation: when to brain
code

When there are clinical signs of herniation

When ICP is sustained >20cm H20 >3 minutes
Cerebral Resuscitation: herniation
Cerebral Resuscitation: compartment
approach to ICP management
Venous blood
HOB up 60 deg
Neck straight
No IJ lines, do not lay
flat for lines
Do no use venodilating
BP agents
Arterial blood
Hyperventilate
Avoid hyperemia: MAP
target 80, Pa02>50
Decrease metabolism:
sedation, cooling
CSF
Place IVC
Change popoff
Brain parenchyma
Osmotherapy (mannitol,
hypertonic saline)
Steroids only if appropriate
(tumor, HACE, some infections)
Surgery (hemicrani, SOC)
Lesion
Blood, tumor, pus -> surgery
Air-> 100% NRB, surgery
Cerebral Resuscitation: venous
compartment
Venous blood
HOB up 60 deg
Neck straight
No IJ lines, do not lay
flat for lines
Do no use venodilating
BP agents
If CVP exceeds ICP,
CPP = MAP - CVP
Ropper: n=19. 52% had ICP when HOB increased from 0->60°. 2% had ICP.
Davenport: n=8. Median ICP from 18->15 with 20° elevation, no in CPP until > 60°.
Lee: n=30. Trendelenburg positioning ICP from 20->24, but ICP in 20% of pts. (!)
Davenport A, Will EJ, Davison AM. Effect of posture on intracranial pressure and cerebral perfusion pressure.
Crit Care Med 1990; 18(3):286-289.
Lee ST. Intracranial pressure changes during positioning of patients with severe head injury. Heart Lung 1989;
18(4):411-414.
Ropper AH, O'Rourke D, Kennedy SK. Head position, intracranial pressure, and compliance. Neurology 1982;
32(11):1288-1291.
Cerebral Resuscitation: compartment
approach to ICP management
Venous blood
HOB up 60 deg
Neck straight
No IJ lines, do not lay
flat for lines
Do no use venodilating
BP agents
Arterial blood
Hyperventilate
Avoid hyperemia: MAP
target 80, Pa02>50
Decrease metabolism:
sedation, cooling
CSF
Place IVC
Change popoff
Brain parenchyma
Osmotherapy (mannitol,
hypertonic saline)
Steroids only if appropriate
(tumor, HACE, some infections)
Surgery (hemicrani, SOC)
Lesion
Blood, tumor, pus -> surgery
Air-> 100% NRB, surgery
Cerebral Resuscitation: arterial
compartment
Arterial blood
Mild
hypervent (RR
18) target pC02
30-35
Avoid
hyperemia: MAP
target 80-130
Avoid
hypoxia:
Pa02>50
Decrease
metabolism:
propofol IVP,
propofol/pentoba
rb gtt,
60
150
20
25
35
50
Kramer A, Zygun D. Anemia and red cell transfusion in neurocritical care. Critical Care 2009 13:R89
Cerebral Resuscitation: arterial
compartment
Blood gas values and hemodynamic data at different respiratory rates
10 breaths/m 13 breaths/m 16 breaths/m
PaCO2 (mmHg)
45.5 ± 9.9
39.7 ± 7.9*
35.9 ± 7.9†‡
ΔCO2 (mmHg)
4.2 ± 1.8
6.6 ± 2.8
7.6 ± 1.7†
pH
7.29 ± 0.06
7.32 ± 0.06*
7.35 ± 0.07†‡
Bicarbonate (mmol/l)
21.2 ± 2.5
20.7 ± 2.5
20 ± 2.5
ΔCO2 ≤6 mmHg, n (%)
10 (100)
4 (40)*
2 (20)†
ScvO2 (%)
77.9 ± 4.1
74.7 ± 7.4
72.6 ± 7.1†
Cardiac index (l/m2)
2.37 ± 0.5
2.36 ± 0.6
2.36 ± 0.6
Mean arterial pressure (mmHg) 71.7 ± 13.3
68 ± 14.5
71.4 ± 13.2
Temperature (°C)
36.9 ± 0.9
36.8 ± 0.9
36.9 ± 0.9
ΔCO2, venous-arterial difference in carbon dioxide tension; PaCO2, arterial partial pressure of carbon dioxide; ScvO2, central venous oxygen
saturation. *P <0.05 (respiratory rate 10 vs. 13 breaths/minute), †P <0.05 (respiratory rate 10 vs. 16 breaths/minute), ‡P <0.05 (respiratory
rate 13 vs. 16 breaths/minute).
Morel et al. Critical Care 2011 15:456 doi:10.1186/cc10528
Cerebral Resuscitation: compartment
approach to ICP management
Venous blood
HOB up 60 deg
Neck straight
No IJ lines, do not lay
flat for lines
Do no use venodilating
BP agents
Arterial blood
Hyperventilate
Avoid hyperemia: MAP
target 80, Pa02>50
Decrease metabolism:
sedation, cooling
CSF
Place IVC
Change popoff
Brain parenchyma
Osmotherapy (mannitol,
hypertonic saline)
Steroids only if appropriate
(tumor, HACE, some infections)
Surgery (hemicrani, SOC)
Lesion
Blood, tumor, pus -> surgery
Air-> 100% NRB, surgery
Cerebral Resuscitation: CSF
compartment
CSF
Place IVC
Change
popoff
Situations in which IVC
drainage is unlikely to
be helpful:
cerebral edema
with significant midline
shift and no
hydrocephalus
posterior fossa
pathology
Situations in which IVC
drainage may be
dangerous:
unsecured
aneurysm
posterior fossa
pathology
Cerebral Resuscitation: compartment
approach to ICP management
Venous blood
HOB up 60 deg
Neck straight
No IJ lines, do not lay
flat for lines
Do no use venodilating
BP agents
Arterial blood
Hyperventilate
Avoid hyperemia: MAP
target 80, Pa02>50
Decrease metabolism:
sedation, cooling
CSF
Place IVC
Change popoff
Brain parenchyma
Osmotherapy (mannitol,
hypertonic saline)
Steroids only if appropriate
(tumor, HACE, some infections)
Surgery (hemicrani, SOC)
Lesion
Blood, tumor, pus -> surgery
Air-> 100% NRB, surgery
Cerebral Resuscitation: Brain
parenchyma
Brain parenchyma
Osmotherapy
(mannitol,
hypertonic saline)
Steroids only if
appropriate (tumor,
HACE, some
infections)
Surgery
(hemicrani, SOC)
Cytotoxic
Stroke
Vasogenic
Tumor
Abscess
Cerebral Resuscitation: Brain
parenchyma
Brain parenchyma
Osmotherapy
(mannitol,
hypertonic saline)
Steroids only if
appropriate (tumor,
HACE, some
infections)
Surgery
(hemicrani, SOC)
Permeable
blood
brain
Semi-Permeable
blood
brai
n
particles
Damaged BBB
Intact BBB
Cerebral Resuscitation: Brain
parenchyma
Brain parenchyma
Osmotherapy
(mannitol,
hypertonic saline)
Steroids only if
appropriate (tumor,
HACE, some
infections)
Surgery
(hemicrani, SOC)
Reflection Coefficient
Sodium=0.97
Glycerol=0.5
Mannitol=0.9
Urea=0.6
Cerebral Resuscitation: Brain
parenchyma
Brain parenchyma
Osmotherapy
(mannitol,
hypertonic saline)
Steroids only if
appropriate (tumor,
HACE, some
infections)
Surgery
(hemicrani, SOC)
Cerebral Resuscitation: Brain
parenchyma
Brain parenchyma
Osmotherapy
(mannitol,
hypertonic saline)
Steroids only if
appropriate (tumor,
HACE, some
infections)
Surgery
(hemicrani, SOC)
 N=8. 22 episodes of elevated ICP occurred, refractory
to mannitol.
 Bolus of 75cc of 10% saline normalized ICP in all.
 ICP 10. Na 5.6 mmol/L. Serum osm 9 mmol/L.
 No unexpected side effects.
Cerebral Resuscitation: Brain
parenchyma
Brain parenchyma
Osmotherapy
(mannitol,
hypertonic saline)
Steroids only if
appropriate (tumor,
HACE, some
infections)
Surgery
(hemicrani, SOC)
Increased vascular volume-> improves
CBF up to 23%
Dehydration of erythrocytes increases
deformability through small capillaries
 Reduces inflammatory response by
reducing PMN adhesion to
microvasculature (unclear clinical
significance)
Pascual J et al. Hypertonic saline resuscitation of hemorrhagic shock diminishes neutrophil rolling and adherence
to endothelium and reduces in vivo vascular leakage. Ann Surg. 2000 Nov; 236 (5): 634-642
Tseng M, Pippa G et al. Effect of hypertonic saline on cerebral blood flow in poor grade patients with
subarachnoid hemorrhage. Stroke 2003;34:1389-1396
Cerebral Resuscitation: Brain
parenchyma
Brain parenchyma
Osmotherapy
(mannitol,
hypertonic saline)
Steroids only if
appropriate (tumor,
HACE, some
infections)
Surgery
(hemicrani, SOC)
Create a GRADIENT,
DON’T
dehydrate your patient!
Cerebral Resuscitation: compartment
approach to ICP management
Venous blood
HOB up 45 deg
Neck straight
No IJ lines, do not lay
flat for lines
Do no use venodilating
BP agents
Arterial blood
Hyperventilate
Avoid hyperemia: MAP
target 80, Pa02>50
Decrease metabolism:
sedation, cooling
CSF
Place IVC
Change popoff
Brain parenchyma
Osmotherapy (mannitol,
hypertonic saline)
Steroids only if appropriate
(tumor, HACE, some infections)
Surgery (hemicrani, SOC)
Lesion
Blood, tumor, pus -> surgery
Air-> 100% NRB, surgery
Emergency ICP management
MA Koenig, M Bryan, JL Lewin, III, MA Mirski, RG Geocadin and RD Stevens
Neurology 2008;70;1023-1029; originally published online Feb 13, 2008
 253 cases transtentorial herniation
 30cc 23.4% saline bolus reversed clinical signs of TTH in 75%
 Transient hypotension in 17%, no CPM on MRI at 17 days
Cerebral Resuscitation: outcomes
?
Cerebral Resuscitation: outcomes
Long-term outcome after medical reversal of transtentorial herniation
in patients with supratentorial mass lesions
Qureshi,,Geocadin,Suarez, Ulatowski, CRITICAL CARE MEDICINE 2000;28:1556-1564


11/28 (40%) survived to discharge
7/11 (59%) survivors functionally independent
Cerebral Resuscitation: outcomes

Hemicraniectomy for hemispheric stroke (AHA IB)
Indication: 50-66% infarction of MCA territory
 Age: <50-60 yo
 Dominance: no difference in functional outcome between L and R
(Vahedi, Lancet Neurology 2007)
 When: Early (<24-48 hrs)
 How: >12cm hemicraniectomy
 Outcomes: 43% vs 21% independent (SOC for cerebellar

decompression: 40% independent)
Cerebral Resuscitation: herniation
Cerebral Resuscitation: herniation
Brain Code Pager and Brain Code Box
 Webpage
Brain, Code (or Hillcrest pharmacy code pager 2619)
 Code pharmacist will arrive in <3 minutes with brain code box
 Contains: 100g 20% mannitol, 30 cc 23% saline, 500 cc 3%
saline, phenylephrine premixed syringes (100mcg/1mL), syringes,
filters
 Code sheet for documentation
 34
episodes of herniation treated
using BrainCodeBox at Hillcrest
in 4 months
 18 episodes herniation clinically
reversed or partially reversed
Patient TG




32M w/ colloid cyst w/ nl exam went into MRI at OSH
at 0815 -> emerged from MRI 0900 w/ BP 200/100,
pupils blown, extensor posturing, weak B corneals, +
cough/gag -> intubated/versed+vecuronium+nipride
gtt
MRI w acute obstructive hydrocephalus
JHH called at 1200; OSH instructed to stop versed/vec,
give mannitol 1g/kg bolus (no hypertonic saline
available), sedate with propofol, nicardipine only for
SBP>220, insert femoral central line in reverse
Trendelenburg if possible
None of these interventions were implemented
Patient TG


Pt arrives at JHH at 1400
Exam:
Temp 38.2, BP 220/110, HR 40-120 w/ runs of SVT, 02 sat
100%
 AC 450/12/5/5/40%
 Dilated nonreactive pupils
 +R corneal, -L corneal
 +cough/gag
 Overbreathing vent @ RR32
 Extensor posturing R, flaccid L
 No central or arterial line

Patient TG
Patient TG

1400-1410






1410-1414


30cc 23.4% saline bolus -> ? regained L corneal
1414-1417


Pt examined, pacer pads placed, labs drawn
Mannitol 1g/kg, 1L 2% saline bolus, 1L NS@100/h
Hyperventilation
Radial arterial line, femoral line placed
-> heart rate stabilized, no change in neuro exam
30cc 23.4% saline bolus -> pupils reactive, pt localizing
1443

Coags back, IVC placed and draining
Cerebral Resuscitation: outcomes


My Cell: 650-906-9521
My Email: nkaranjia@ucsd.edu
Acknowledgements
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Bill Mobley, MD
Bob Carter, MD
Alex Khalessi, MD
Jeffrey Gertsch, MD
Brian Lemkuil, MD
Bill Wilson, MD
Tom Hemmen, MD
Kim Kerr, MD
Peter Fedullo, MD
Patricia Graham RN, Laura Dibsie RN, and Cassia Chevillon RN
Romer Geocadin, MD
Marek Mirski, MD
COL Geoffrey Ling, MD