Daily Archives: March 7, 2022

March 2 Conference Notes

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  • Venous sinus thrombosis- Dr. Hill-Norby
    • 89% present with headache but can also present with altered mental status, focal neuro deficits, seizures, nuchal rigidity
    • Cavernous sinus
      • Ocular signs dominate d/t cranial enerve dysfunction
      • Cortical vein occlusions can present with motor and sensory dysfunction
    • Physical exam
      • Papilledema on fundoscopic or ultrasound
        • Ultrasound measurement is measured 3 mm posterior to the retina
    • Dx
      • CT/CTV
      • MRI/MRV
      • LP with opening pressure can be suggestive of Dx
    • Tx
      • Recanalize occlusion
      • Prevent propagation
      • Treat underlying cause
      • Standard care for elevated icp (HOB elevation to 30 degrees, etc.)
      • Seizure prophylaxis
  • PRES- Dr. McMurray
    • Sx usually will have posterior cortical deficits
    • 25% of people with PRES will not have HTN on presentation
    • Risk factors include renal disease, autoimmune conditions and immunosuppressive Tx
    • Pathogenesis
      • Autoregulatory failure, endothelial dysfunction, cortical dysfunction 
    • Tx
      • Target maximal reduction in MAP by 20-25% in the first hour
      • Reduce to 160/100 over next 2-6 hours
      • Then to normal over the next 24-48 hours
      • Medications
        • Labetalol, cardene, hydralazine, nitro
        • Seizure medications for seizures, if suspect eclampsia give Mg
  • Emergency management of individuals with brain tumors, a focus on steroids- Dr. Mistry
    • Focus of ER management
      • Control ICP (nonsurgically)
        • locally high ICP can progress to a generalized ICP problem
          • generalized will eventually involve the brainstem, also concerning is focal ICP that can compress the brain stem
        • signs of brain stem compression
          • imaging showing posterior fossa or supratentorial lesion/hydro
          • decreased mental status
          • bradycardia
          • hypertension (especially the diastolic pressure)
        • control
          • Delay MRI until after addressing ICP
          • Position
            • HOB > 30 degrees
              • Works by increasing venous return
            • Neck in anatomically free position
              • Want the jugular veins to actually be able to return blood
          • Vital interventions
            • Intubation
            • Hyperventilate (ETCO2 ~ 25 mmHg)
          • Drugs
            • Mannitol +/- furosemide
              • Will break down the blood brain barrier and will only work once
            • Hypertonic NaCl (>3%)
              • Preferred, can be given more than once and help control ICP
      • Control of tumor-related hemorrhage (ICP)
      • Control of neuroendocrine related shock
      • Control of seizures
        • Especially vulnerable are patients with temporal lobe lesions
    • Dexamethasone- “ a big problem”
      • Evidence for dex was initially based on case series work
      • However, there is NO evidence for dexamethasone, there is not even 1 study on dex that shows benefit
      • Dexamethasone is a very potent and long acting anti-inflammatory
        • Can be bad for people needing a stem-cell transplant 
        • Kills lymphocytes by apoptosis
          • *Pre-operative dexamethasone decreases diagnostic yield from surgical samples of primary CNS lymphoma*
      • Study in Brain 2016 showed that corticosteroids decreased survival in glioblastoma 
      • Pre-op dexamethasone in 2021 Hopkins study showed greatly decreased survival on Kaplan-Meyer survival curve
      • Dexamethasone thwarts immunotherapy
        • Combined corticosteroids plus immunotherapy has a higher hazard ratio than immunotherapy alone
      • Dexamethasone is standard of care and now we are in a battle with reversing this narrative
        • **dexamethasone does not decrease ICP emergently, it can take a week to see the ICP effects, use mannitol, Lasix, or hypertonic saline**
  • **there is one type of tumor to give steroids**
    • Pituitary apoplexy- a special hemorrhage
      • ER treatment is counter adrenal crisis (hydrocortisone 100 or 200 mg) and give fluids
        • Need to draw all endocrine labs before giving the hydrocortisone
      • Need a CTA immediately because there is an aneurysm that will mimic pituitary apoplexy, r/o aneurysm first before they can take to the OR
      • Consult
        • NES, ENT, optho, and endocrinology