Come valutare il potenziale recupero dello stato di coscienza in ICU

Dr. A. Amadori Neuroanestesia e Rianimazione CTO

Careggi-Firenze

Ricoveri in ICU

• Infezioni (Shock settico)

• Traumi cranici

• Emorragie-ischemie endocraniche e non

• Politraumi

• Patologia cardiaca (shock cardiogeno ecc. )

• Patologie respiratorie (Insuffic.Respiratorie)

DANNO

CEREBRALE

ACUTO

COMA

MCS

“CRONICO”

RECUPERO

COSCIENZA

STATO

VEGATIVO

“CRONICO”

STATO DI

MINIMA

COSCIENZA

(MCS)

STATO

VEGETATIVO

MORTE

ENCEFALICA

RECUPERO

SINDROME

LOCKED-IN

COMA

cronico

Fase acuta Fase subacuta Fase protratta FASE Iperacuta /acuta

Durata media: 7-8 gg (min 3 – max 15)

indicatori di danno neurologico in

evoluzione Instabilità del danno cerebrale

primario e/o instabilità, emodinamica e

respiratoria

Indicatori prognostici precoci Importanza della collaborazione

interprofessionale per l’inquadramento

diagnostico e prognostico e per definire il

percorso terapeutico assistenziale

FASE Acuta-Subacuta

Durata 10-15 gg (non>3 gg dopo

lo svezzamento)

Persiste necessità di monitoraggio dei

parametri vitali

primi indirizzi prognostici specifici

(indagini neurofisiologiche e di

neuroimaging)

È indispensabile e non prorogabile la

valutazione a scopo riabilitativo

A. Amantini; A. Piccioli

Monitoraggio

Sistemico

Clinico Strumentale

Invasivo Non

invasivo

Di organo

Clinico Strumentale

Invasivo Non

invasivo

Monitoraggio Sistemico

• Ecg

• Pressione arteriosa invasiva ed emogasanalisi

• Pulsiossimetria

• Emodinamica: PVC, cateterismo arteria polmonare,

gittata cardiaca in continuo, ecc.

• Diuresi

• Capnografia

• Temperatura

• Esami ematochimici

Monitoraggio

Sistemico

Clinico Strumentale

Invasivo Non

invasivo

Di organo

Clinico Strumentale

Invasivo Non

invasivo

NON INVASIVO

• Doppler Transcranico

• EEG

• Potenziali Evocati

• Immagini: TC, RMN

INVASIVO

• Pressione Intracranica (PIC)

• Sat. Venosa Giugulare (SjO2)

• Pressione tissutale O2 (PtO2)

• Temperatura (T°c)

• Microdialisi

• Flusso

Monitoraggio strumentale

della funzione cerebrale

Monitoraggio

Sistemico

Clinico Strumentale

Invasivo Non

invasivo

Di organo

Clinico Strumentale

Invasivo Non

invasivo

Valutazione del paziente in coma Clinical (and Radiological) Etiology, age, time from onset GCS, FOUR scale, AIS, IMPACT, CRASH ( pupillary reactivity, Marshall scale) for TBI HH , WFNS ( Fisher e mFisher scale) for SAH

Neurophysiology: EEG ( amplitude, dominant frequency, reactivity) Short latency EP SEP ( A, N, P) Long latency ERP ( A, P)

BIOMARKERS

NEUROIMAGING

Neurophysiology

Which is the real incidence of NCS e NCSE ?

0/8 - 48% ?

11-55% NCS in pazienti in ICU (Scheuer, 2002)

34% NCS (di cui 3/4 NCSE) in ABI (Jordan,1993)

12% NCS o NCSE in grave ABI (Vespa et al., 1999)

22% - 8% - 28% NCS rispettivamente in TBI – ischemic stroke – ICH (Claassen et al., 2004)

7% NCSE in ICH (Claassen et al., 2007)

8% NCSE in pazienti in coma senza manifestazioni critiche cliniche (Towne et al., 2000)

12-53% NCSE dopo trattamento del GCSE (Jaitly et al., 1997; Treiman et al.,1998)

Revisioni: 8-55% (Olivecrona et al., 2009) e almeno 20%

secondo Young and Claassen (2010)

28% di tutti gli NCSE sono stati riscontrati in ICU cardiologica o

cardiochirurgica (Drislane et al., 2008)

Early and persistent impaired percent alpha variability on continuous electroencephalography monitoring as predictive of

poor outcome after traumatic brain injury Paul M. Vespa, W. John Boscardin, David A. Hovda, David L. McArthur, Marc R. Nuwer, Neil A. Martin, Valeriy Nenov, Thomas C. Glenn, Marvin Bergsneider, Daniel F. Kelly, Donald P. Becker,

Journal of Neurosurgery, July 2002, 1 : Pages 84-92

Abstract Object. Early prediction of outcomes in patients after they suffer traumatic brain injury (TBI) is often nonspecific and based on initial imaging and clinical findings alone, without direct physiological testing. Improved outcome prediction is desirable for ethical, social, and financial reasons. The goal of this study was to determine the usefulness of continuous electroencephalography (EEG) monitoring in determining prognosis early after TBI, while the patient is in the intensive care unit. Methods. The authors hypothesized that the reduced percentage of alpha variability (PAV) in continuous EEG tracings indicates a poor prognosis. Prospective continuous EEG monitoring was performed in 89 consecutive patients with moderate to severe TBI (Glasgow Coma Scale [GCS] Scores 3–12) from 0 to 10 days after injury. The PAV was calculated daily, and the time course and trends of the PAV were analyzed in comparison with the patient's Glasgow Outcome Scale (GOS) score at the time of discharge. In patients with GCS scores of 8 or lower, a PAV value of 0.1 or lower is highly predictive of a poor outcome or death (positive predictive value 86%). The determinant PAV value was obtained by Day 3 after injury. Persistent PAV values of 0.1 or lower over several days or worsening of the PAV to a value of 0.1 or lower indicated a high likelihood of poor outcome (GOS Scores 1 and 2). In comparison with the combination of traditional initial clinical indicators of outcome (GCS score, pupillary response to light, patient age, results of computerized tomography scanning, and early hypotension or hypoxemia), the early PAV value during the initial 3 days after injury independently improved prognostic ability (p < 0.01). Conclusions. Continuous EEG monitoring performed with particular attention paid to the PAV is a sensitive and specific method of prognosis that can indicate outcomes in patients with moderate to severe TBI within 3 days post injury.

Rispetto a:

EEG

TC

GCS

risp. motorie

fotomotore

(Robinson et al. 2003)

Valore prognostico PES:

Casistica gennaio 2004- agosto 2008

Pattern Assente AA :

42/165 pz (88ESA,77EIP)

25% di tutte le emorragie: 26% delle ESA

25% delle EIP

Specificità 100% esito sfavorevole

100% decessi in T.I. o SV

010203040506070

PIC

mm

Hg

Pazienti

PIC Max/Die Pazienti stabili

PES, PIC & evoluzione clinica

Pazienti deter

Nell’arresto cardiaco?

Bilateral absent N20 response strongly correlated with poor outcome

During TH ( FPR 0% [95% CI0-2]) After TH 0.5% CI [0-2]

The results of this pilot study show that bilaterally absent cortical N20 responses of median nerve somatosensory evoked potentials performed during mild hypothermia after resuscitation can predict a poor neurologic outcome.

Background activity - continuous background activity 12 h correlated with a normal voltage background at 24 h . An exception to the good prognosis related to background activity is an EEG profile indicative of α coma;:associated with poor prognosis in up to 100% of patients.

Background activity - low-voltage (<20 μV) isoelectric (suppressed) background at 24 h -burst suppression at any time (0% [0–11]); -burst suppression with identical bursts ; -spontaneously discontinuous background during TTM

Absence of reactivity if assessed after TTM (FPR 7% [95% CI 1–15]);this correlation is stronger if an absence of reactivity is seen during TTM (2% ) Reproducible reactivity recorded during TTM (positive predictive value 86% ) and thereafter (78%

Lancet Neurol 2016; 15: 597–609

Epileptiform features Sharp waves, spikes, poly-spikes, and waves, collectively referred to as epileptiform features, are rarely recorded in isolation, as they typically occur in repetitive (periodic or rhythmic) patterns.

Occurrence of these features after TTM is associated with poor outcome (FPR 9% [95% CI 2–21]);the association is stronger when epileptiform discharges are recorded during TTM, when the patient is sedated with a drug with antiepileptic properties (0% [0–30])

In conditions capable of causing neuronal death, especially hypoxic-ischemic encephalopathy after cardiac arrest, marked suppression or a burst suppression pattern with generalized epileptiform activity within the bursts is most often associated with an outcome of no better than a minimally conscious or vegetative state

a b s t r a c t Objective: To evaluate the prognostic value of single EEG patterns recorded at various time-frames in postanoxic comatose patients. Methods: This retrospective study included 30-min EEGs, classified according to the definitions of continuity of background activity given by the American Clinical Neurophysiology Society. Isoelectric pattern was distinguished from other suppressed activities. Epileptiform patterns were considered separately. Outcome was dichotomised based on recovery of consciousness as good (Glasgow Outcome Scale [GOS] 3–5) or poor (GOS 1–2). Results: We analysed 211 EEGs, categorised according to time since cardiac arrest (within 12 h and around 24, 48 and 72 h). In each time-frame we observed at least one EEG pattern which was 100% specific to poor or good outcome: at 12 h continuous and nearly continuous patterns predicted good outcome and isoelectric pattern poor outcome; at 24 h isoelectric and burst-suppression predicted poor outcome; at 48 and 72 h isoelectric, burst-suppression and suppression (2–10 lV) patterns predicted poor outcome. Conclusions: The prognostic value of single EEG patterns, defined according to continuity and voltage of background activity, changes until 48–72 h after cardiac arrest and in each time-frame there is at least one pattern which accurately predicts good or poor outcome. Significance: Standard EEG can provide time-dependent reliable indicators of good and poor

outcome throughout the first 48–72 h after cardiac arrest.

H I G H L I G H T S Based on standardised definitions of continuity of background activity we identified single EEG patterns with 100% specificity for good or poor outcome. Good outcome was predicted by continuous pattern at 12 h. Poor outcome was predicted by isoelectric pattern since 12 h, by burst-suppression pattern since 24 h and by suppression pattern since 48 h.

EEG Grades Grade 1: continuous and nearly continuous patterns Grade 2 isoelectric, suppression,burst suppression and dicontinuous patterns

Results: Within 12 h after CA, grade 1 EEG predicted good outcome and bilaterally absent (BA) SEPs predicted poor outcome. Because grade 1 EEG and BA-SEPs were never found in the same patient, the recording of both EEG and SEPs allows us to correctly prognosticate a greater number of patients with respect to the use of a single test within 12 h after CA. At 48–72 h after CA, both grade 2 EEG and BA-SEPs predicted poor outcome with FPR=0.0%. When these neurophysiological patterns are both present in the same patient, they confirm and strengthen their prognostic value, but because they also occurred independently in eight patients, poor outcome is predictable in a greater number of patients. Significance: The combination of EEG/SEP findings allows prediction of good and poor outcome (within 12 h after CA) and of poor outcome (after 48–72 h). Recording of EEG and SEPs in the same patients allows always an increase in the number of cases correctly classified, and an increase of the reliability of prognostication in a single patient due to concordance of patterns

Still much work to be done

Grazie