thank you everybody Thank You Stefan for
asking me to put the Sun in a lightbulb
in essence so he we've got to focus on
three topics blood pest control glucose
management and connect Tommy and first
before we go to that let's talk about
who's gonna be in the neuro ICU compared
to let's say the floor so these are the
guidelines and as you can see here first
in your critical care units an essential
important part integral part of
comprehensive stroke centers and you're
going to put patients who have large
hemispheric strokes or patients flying
to beta dope patients are having a
stable and more dynamic profile or
patients who up you know on the watch
for can yet to me you know because the
can deteriorate so these are the
patients and the same thing for the
recommendations by a doctor which Dix
paper also about Sybil edema so large
territorial stroke need more close
monitoring and these are the patients
that will end up in the in the neuro ICU
does it improve the outcome having an ER
intensive a neuro ICU well that's a bit
more controversial and as you can see
the data does not show any decrease in
mortality except for one study but
clearly they decrease the length of stay
in the ICU make the administrators happy
and maybe some of them actually may end
up going home you know when they are in
the neuro ICU compared to any other unit
so there are some data about that well
let's talk a little odd blood pressure
control after a neuro ICU admission you
would expect obviously that you know
been in a very highly monitor unit you
will be able to control the blood
pressure very well not exactly that the
data do not show that so this is a nice
study that shows in in the middle
actually that the blood pressure in
these patients with with strokes on the
average we're outside the recommended
range almost one third of the time so
even under the best circumstances who
may not be able to control the blood
pressure beautifully exactly 99% 100%
and what's the right blood pressure
well again the recommendations before we
go to that we know now that you know
very high blood pressure or very low
blood pressure actually may lead to
worse outcomes
there is a sweet spot in the middle so
there is a you type of curve there as
you can see on the left and on the right
about mortality in these patients and we
need to find this sweet spot so it's
very difficult and we go to guidelines
because that's the best thing to have
the most condensated information in
these patients and if you don't give TPA
in these patients they're outside the
window then the guidelines support a
blood pressure don't treat the blood
patient unless developers goes above to
220 systolic and 120 diastolic if you
want to try to treat it then don't go
below 15% from from the baseline again
you know one size doesn't fit all
you know because you could have somebody
who has let's say he lives with a blood
pressure of 220 every day that's okay to
have the purpose rascai as that but if
you have somebody who lives with a blood
pressure of 100 young patient probably
we shouldn't allow this patient to go so
high up also you need to think about the
rest of the body because you know if you
have let's say a big MI or a CHF patient
are you going to allow this patient with
an ejection fraction of I don't know 15%
to go all the way up to 220 absolutely
not
so again nobody knows what would be the
sweet sweet spot in these patients but
in essence if you don't know just lower
the blockage by 15% so again what about
if you have patients who get the PA IV
thrombolysis so this goes back to the
initial NIH study and you can see that
even before that pilot studies show that
the diastolic blood pressure actually
was associated with him watch conversion
these patients and even in the NIH study
one out of five patients did not have
blood pressure below the goal as I'm
gonna show you at that time and 2/3 of
them actually even after giving TPA were
not within the range that we want it to
be so what are the current guidelines
the current guidelines support to have
application below 185 over 110 diastolic
before you give TPA you can use
labetalol you can use my car deep in you
can use hydrolyze and you can use an
elaborate lot doesn't work so fast after
you give TPA the blood pressure should
be five points lower you know it would
be 180 over 105
if the blockage who despite all these
measures is very high so it's above
let's say diastolic above 140 on the
very bottom then you can use nipride I
haven't used up my pride for the last 10
years I don't know if Stefan has used we
don't use it in the ICU but we have new
drugs right now so what about home
antihypertensives what are going to do
for these patients who obviously many of
them are happy happy times are on a
decapitation treatment either you
discontinue them or you read use the
doors so don't discontinue beta blockers
try to have the dose if you want and
then when are you gonna give them back
to them again you know nobody knows but
probably the best would be to to
initiate to the anti hypertensive
treatment 24 hours after the stroke so
this just came out it's from Memphis and
in essence this talks about patients
with large vessel occlusion the first
during the first 24 hours and they look
at the blood patient what they show here
actually is that for having independence
independent living after three months
the blood pressure in this patient was
higher than the patients who had lower
blood pressure and the same thing for
mortality the blood pressure of those
patients who died actually was higher
than the patients who survived and if
you look at the bottom on the right then
you can see that there is an inverse
relationship between three month
independent living with ranking a zero
to two and then the mortality also so
the higher the blood pressure the more
the mortality and the the higher the
blood pressure the last independent
living doctor my actual right wrote a
very nice editorial about that so which
one is the sweet spot in these patients
so comparing to blood pressure o of 220
and compared to blood pressure of 140
it looks like blood pressure below 160
over 90 is the sweet spot so that
improved a little bit the mortality a
little bit the mortality in these
patients but again when our gonna you
know start again treating these patients
you know how long after so this is an
older study it's interesting because
there is a correlation between the blood
pressure and the TCD velocities if you
do that it
there's kind of Doppler velocities
monitoring in this patient so normally
when the blood pressure goes up the TCD
velocity does not necessarily go up
immediately the same spot it goes down
so there is a phase reverse phase
difference between the two the two
curves as you can see on the bottom so
normally this phase difference is around
65 degrees and if it is less than 30
then we don't have auto regulation in
this patient so they did a study and
they look at patients at one day four
days and almost 10 days later and as you
can see on the left on day 1 and day 4
that was not a regulation because the
angle was very low and then anywhere
between 4.1 days and nine point seven
five days actually this changed so if
you want to to say well we're going to
start treating these patients probably
should treat them after the first four
days maybe up to ten days
what about glucose changing gears here
yeah there are many reasons actually to
try to control the glucose in these
patients and you sit on the top and
actually they are data that show that
the outcomes if you have a admission
hyperglycemia in these patients is worse
so you have a worse functional outcomes
you have increased risk for symptomatic
izh and you have decreased reckon
analyzation so it looks like you know
this is an easy target for us but you
know the argument there is isn't an
epiphenomenon or it is a real problem so
all the other studies as you can see on
the right show that actually the
outcomes were worse if the if the
admission glucose was high so for every
100 grams per deciliter actually
increased glucose in these patients
the outcome was worse the favorable
outcome at 3 months for instance of the
white side was worse so again you know
they are good data about that so what
are the guidelines tell you well they
asked you to keep the blood glucose
between 140 and 180 both of them and
actually even the hae guidelines for
ischemic stroke the same thing 140 over
180 just out of the oven just recently
actually there was a paper in stroke
that look at patients who had
thrombectomy so large vessel occlusion
with Rebecca me and they tried to see if
the glucose played any role in this in
these patients and as you can see there
was either the admission of glucose or
the hyperglycemia in these patients did
not show any difference in the outcome
after from Beck to me and again these
are the the the plots and again
obviously the from backcombing shows
much better outcome in these patients
but the effect of hyperglycemia or
normal glycaemia did not change that and
the same thing there was no difference
in regularization rates in this very
recent study from mr. clean actually so
one of the five studies so the
conclusion was that they didn't find any
evidence of effect modification of in
territorial treatment but missions in
glucose in patients with acute ischemic
stroke nice statement so what I'm gonna
do is it over no it's not because we
have a study in Henry Ford is one of the
sides of the study and actually it's
called a shine and I think Chris is the
API if I'm not mistaken and we'll we'll
see we'll see what happens so we don't
know yet and I'll finish a bit talking
about the compressive can react on me
this is bilateral as you can see and the
timing because that that's a major
question when are you gonna do the
connectome we all gonna do it
immediately or you can do it after five
days when so I can't do it when you have
this oval pupil this is an oval pupil
one of our patients actually so this is
the first step for for herniation so
this is if you pick it up if the nurses
pick it up at that stage that's the
first step and then the next step would
be to have a blown pupil in these
patients so I'm gonna do it when the
patient has an oval pupil are you gonna
do it when the patient has a blown pupil
when so if you look at all their studies
and actually the the first study is from
Germany this is Stefan swap study from
1998 he divided the patients in to
connect to me less than 24 hours and
patients with connect on me after 24
hours and you cannot see it very well
but just to magnify and you can see that
the ones that had connectome in less
than 24 hours then the more the the
science of creation before surgery was
only 13 percent versus the other ones
that late ones 75% so if you wait then
you have many more chances
for having herniation and then the
mortality rate was half in the early
group than in the late group in the late
group was half of the ones that did not
get any kind decompressive craniectomy
so these are pretty good data actually
convincing data that we need to do it
early on and these are the guidelines
and I put all three papers the one that
there is no question about that is
obviously if you have a posterior fossa
big stroke compressing the the fourth
ventricle or compressing the brain stem
in these patients
then you need to decompress the
posterior fossa now super dent oh really
when are you gonna do it again what they
are saying here the guidelines that we
had with Michele Torbay again try to do
it if you do it during the first 24-48
hours if you want to wait how are you
gonna look at these patients you know
look at the clinical exam if the
patient's clinical exam deteriorates and
there is no other reason for that that
would be a strong reason to do the
connectome II before you blow a pupil
what about ICP I didn't put any slide
here you know there are convincing data
that the ICP goes up after you you
herniate so don't wait and don't base
your judgment based on the on the ICP
when when you herniate you compress the
midbrain you compress the aqueduct you
develop a hydrocephalus and the ICP goes
up it's too late you need to do it
before that happens all right that's all
folks thank you very much
[Applause]