75. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie

Prof. Dr.

Vorsitz

Prof. Dr. med.

Airway pressure release ventilation is safe to use in patients with intracranial pathologies

Trauma und Neurointensiv 

Airway Pressure Release Ventilation ist sicher bei Patienten mit intrakraniellen Pathologien

Airway Pressure Release Ventilation (APRV) is an alternate mode of ventilation in Acute Respiratory Distress Syndrome (ARDS), but there are inconsistent data to support its use over other modes of ventilation. Because of increased intrathoracic pressure for most of the respiratory cycle, a negative impact of APRV on intracranial pressure (ICP) has been hypothesized. We evaluated the impact on APRV on Horovitz index, ICP, Cerebral Perfusion Pressure (CPP), Mean Arterial Pressure (MAP), and Therapy Intensity Level (TIL).Retrospective single-center analysis from January 2021 to March 2023 of neurosurgical ICU patients with ICP probes inserted. APRV was used as a rescue mode at the physician"s discretion when the Horovitz index fell below 150 despite optimized conventional ventilation.This study enrolled 28 patients undergoing 31 episodes of APRV. Median age was 56 (IQR 44-62) years, 12 (38.7%) were female. The main diagnosis was intracerebral hemorrhage (n=11, 35.5%), subarachnoid hemorrhage (n=7, 22.6%), traumatic brain injury (n=4, 2.9%) and other (n=9, 29%). The median time between ICU admission and the first episode of APRV was 8 (IQR 4-13) days. Before conversion to APRV, compliance was 38 (IQR 23-55) ml/cmH2O, Horovitz index 144 (IQR 136-160) mmHg, ICP 12 (IQR 5-17.5) mmHg, cerebral CPP 78 (IQR 62-84) mmHg (all median). The TIL was 0 in 5 (16.1%), 1 in 12 (38.7%), 2 in 11 (35.5%) and 3 in 3 (9.7%) cases. Following conversion to APRV, there was a rise in the median Horovitz index (60min: 201,44|120min: 208,61 mmHg), indicating enhanced oxygenation. Additionally, there was a tendency towards a lower ICP (60min: 9,5|120min: 11 mmHg) with an increase in CPP (60min: 80|120min: 77 mmHg, all median). Differences, apart from CPP after 45 minutes (p=0.011), did not attain statistical significance. One-hour post-transition, TIL significantly decreased (Z=-2.464, p=0.008); yet there were no differences after two hours. No critical increases in ICP (>20 mmHg) were observed. ICP, MAP, CPP values and Horovitz Quotient are displayed in Figure 1. No instances of pneumothorax, acute renal failure or myocardial injury was observed.APRV did not increase intracranial pressure ICP or decrease CPP. TIL decreased in the first hour. APRV was safe regarding effects on ICP, MAP, and CPP. The Horovitz index showed an increase after the use of APRV. APRV appears to be a possible ventilatory strategy in this patient population.

Abstractvortrag | Abstract talk

Serum procalcitonin in the diagnosis of pneumonia in the neurosurgical intensive care unit

Serum Procalcitonin in der Diagnose einer Pneumonie auf der neurochirurgischen Intensivstation

Procalcitonin (PCT) is an inflammatory blood marker associated with lower respiratory tract infections. An optimal cutoff value and its validity in the diagnosis of Hospital-Acquired Pneumonia (HAP) is controversial. This study aims to investigate the utility of PCT in supporting the diagnosis of HAP in a neurosurgical intensive care unit (NICU).In this single-center retrospective study, we evaluated patients with clinical suspicion of HAP in our NICU from 01.01.2020 until 31.12.2022. A confirmed HAP diagnosis was based on a combination of clinical, biochemical, microbiological and radiological data. Inclusion criteria were serum PCT measurements taken for suspected HAP cases. Exclusions were patients whose PCT levels were measured >48 hours after HAP onset or for reasons unrelated to HAP. The optimal PCT cutoff value for confirmed HAP was calculated using the Youden Index. The relationship between PCT levels above this threshold, chest imaging results, and sputum culture findings with confirmed HAP was analyzed using chi-square tests.Among 2363 patients, 193 met inclusion and exclusion criteria, 45 (23.3%) of whom met our predefined criteria for confirmed HAP. The optimal cutoff procalcitonin value was 0.095ng/ml, and is highly significantly associated with confirmed HAP (p<0.001), with a sensitivity of 89.2% and specificity of 93.3% yielding a positive likelihood ratio of 13.3 and a negative likelihood ratio of 0.116. No significant association was found between confirmed HAP and signs of pneumonia on imaging or positive microbiological cultures.Contrary to previous studies, this research highlights the beneficial role of PCT in confirming HAP among patients with clinical suspicion in the NICU, establishing a cutoff value of 0.095ng/ml. Prompt and accurate identification of HAP could expedite antibiotic treatment, enhancing patient care in the NICU. Further prospective studies are needed to validate these results.

PD Dr.

PD. Dr.

Professor

The role of ICU fluid control in patients with aneurysmal subarachnoid hemorrhage

Die Rolle des Intensivstations-Flüssigkeitmanagements bei Patienten mit aneurysmatischer Subarachnoidalblutun

Rupture of intracranial aneurysm is associated with several complex primary and secondary complications where the proper intensive care unit (ICU) treatment plays an essential role. Herewith, fluid management is of eminent importance to balance between sufficient cerebral perfusion and avoiding brain swelling. This study aims to identify the significance of fluid balancing in ICU and elucidate its role as a predictor for outcome after subarachnoid hemorrhage (SAH).All consecutive cases with aneurysmal SAH treated at our institution between 01/2003 and 06/2016 were eligible for this study. Fluid balance in ICU care was analyzed in univariate and multivariate analyses. The association between positive and negative fluid balance and primary study endpoints (risk of cerebral infarction, in-hospital mortality, and unfavorable outcome at six months defined as modified Rankin scale>3) was analyzed.The final cohort (n = 904) comprised patients between 19 and 90 years old, with an in-hospital mortality rate of 17.4%. Nearly 42% had an unfavorable outcome at six months, and 48.1% had an ischemic insult. ICU fluid control ranged between -9.7 and +28.5 l in all patients. The risk of an unfavorable functional outcome increased as the fluid balance increased (OR: 1.03, CI: 1.02-1.04, p: <0.0001). Moreover, higher-balanced patients showed a higher chance of developing an ischemic insult (OR: 1.02; CI: 1.01-1.03, p: <0.0001). Further, in-hospital mortality was positively linked to higher balanced patients (OR: 1.01, CI: 1.01-1.02, p: 0.0007).The intricate balance between ensuring enough blood flow to the brain and preventing swelling highlights the importance of meticulous fluid management in the ICU. Higher balanced patients were consistently linked with higher risks of unfavorable functional outcomes at six months, ischemic insults, and in-hospital mortality. Fluid management is a critical aspect of care that significantly impacts patient outcomes and requires ongoing research for better protocols and improved results in SAH treatment.

Dr. med. univ.

Fibrinolytic subdural irrigation as an effective minimally invasive technique for acute subdural hematomas not requiring immediate evacuation

Die fibrinolytische subdurale Spülung ist eine wirksame minimal-invasive Technik für die Behandlung akuter subduraler Hämatome, die nicht sofort evakuiert werden müssen

Acute subdural hematoma (aSDH) ranks among the most prevalent conditions in neurosurgery. While craniotomy remains the gold standard for aSDH removal, its association with high perioperative complications mandates the exploration of minimally invasive techniques, particularly in non-immediate intervention cases. Here, we present a novel approach to effectively remove aSDH in patients who do not require urgent evacuation, by percutaneous subdural fibrinolytic irrigation.10 aSDH patients admitted between June to December 2023 were selected for a novel minimally invasive fibrinolytic irrigation approach. We selected patients with a GCS of 13-15, hematoma thickness of >7mm, but no need for immediate evacuation. A catheter for pressure-controlled irrigation was inserted into the aSDH via a 3.5mm twist drill burr hole under local anesthesia. Fibrinolytic irrigation was preformed using electrolyte solution containing 200,000 IU/L Urokinase at a rate of 100ml/h until radiological clearance was obtained (ca. 3-5 days). We compared perioperative complications, and neurological outcome at three-month (modified Rankin scale) with matching cases admitted before implementation of the novel approach (2020-06/2023).Near-complete hematoma resolution was attained in 9/10 cases (90%). One patient (10%) showed a decrease in the level of consciousness and was converted to an open craniotomy. There was one recurrence of a chronic subdural hematoma which resolved without sequelae after a 2nd twist drill craniostomy. No other perioperative complications or neurological deficits were observed. 8/10 patients (80%) had regained independence (mRS 0-3) at 3 months. Hematoma evacuation via craniotomy was performed in 30 matching cases (GCS 13-15, hematoma thickness of >7mm) in the preceding 2,5 years. Perioperative complications occurred in 16/30 patients (53%). We observed aphasia in 3 (10%), hemiparesis in 4 (13%), epilepsy in 8 (27%), re-hemorrhage in 2 (7%), meningitis in 1 (3%) and mortality in 2 (7%) patients. 17/30 patients (57%) had regained independence (mRS 0-3) at 3 months.Our first experience indicates that minimally invasive fibrinolytic irrigation of aSDH may represent a safe and effective alternative to open surgery in selected patients who do not require immediate evacuation.

Prospective, randomized study comparing minimal invasive burr hole craniotomy to drill hole craniotomy for the management of chronic subdural hematomas

Prospektive, randomisierte Studie zur Vergleich von minimalinvasiver Hohlschraubentrapanation und erweitertem Bohrloch zur Therapie chronischer Subduralhämatome

The chronic subdural hematoma (cSDH) is a frequently treated entity for neurosurgeons worldwide. Since the occurrence of this pathology is particularly common in elderly and multimorbid patients, the demographic shift is increasing the pressure on our healthcare systems, which are already facing major economic challenges. The high number of recurrences leads to an even greater importance of standardization of the medical approach. However, a wide spectrum of various surgical procedures is still employed.In our study, we compared bedside evacuation of the cSDH using hollow screws (HS) under local anesthesia with the commonly used evacuation via enlarged burr holes (BH) under general anesthesia in a randomized, prospective, unicentric trial. 140 patients were enrolled in the period from 2015 to 2020, 9 patients had to be excluded during the course of the study. Mean age was 77.HS trephination is not inferior to BH in terms of recurrence rate (BH 31.2% vs. HS 47.8%; p>0,05) or clinical outcome (p>0,05). Yet, this less invasive surgical approach is associated with a significantly shorter operation duration (p<0,05) and a shorter hospital stay (median BH 4.3 days vs HS 3.0 days; p<0,005).In the treatment of chronic subdural hematoma (cSDH), HS trephination should be considered as a reasonable alternative to BH trepanation, especially considering the demographic changes in modern society.

Mikrovaskuläre Perfusion bei Patienten mit aneurysmatischer Subarachnoidalblutung

Session 40
Trauma und Neurointensiv – Verschiedenes 4

Appointment

Vorsitz

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