1. Traumatisme cranien J. Duranteau Hôpital de Bicêtre - Université Paris-Sud XI

2. Mortalité (%) 75 70% 50 35% 27% 25 13% 4% 0 3 4-8 9-12 13-14 15 Score de Glasgow Riou et al., Anesthesiology 2001

3. Amélioration spectaculaire Mortalité : de 52%(1977) à 26%(1998) Bons résultats : de 35%(1977) à 58%(1998) Physiopathologie des premières heures post-traumatique Lésions primairesLésions secondaires

4. 90% de lésions ischémiques (Graham 1989) Bas DSC chez 30 à 50% des patients (Bouma 1992) Hypotension préhospitalière : mortalité x 2 (Chesnut, 1993) Influence hypotension, hypoxie, hyperthermie (Jones 1994) Ischémie et traumatisme crânien

5. Relation pression - volume Pression Volume

6. Balance apports versus besoins Apports : Débit et Hb Besoins : CMRO2 Température PAM

7. Autorégulation cérébrale DSC 50 150 PPC (mmHg)

8. 70 Autorégulation cérébrale et traumatisme crânien DSC 50 PPC (mmHg)

9. Le monitorage minimal • PAM • SaO2 • Température • EtCO2

10. Early SjvO2 monitoring in patients with severe brain trauma Availability of invasive cerebral monitoring Severe TBI (GCS ≤ 8) (n = 27) Delay from admission (min) MAP (mmHg) ICP (mmHg) CPP (mmHg) SjvO2 (%) CPP < 60 mmHg or SjvO2 < 55 % (n, %) Trauma toor SjvO2<55% n=17 (63%) 205 ± 96 79 ± 9 25 ± 11 53 ± 15 56 ± 12 17 (63 %) Vigue B. et al. Intensive Care Med, 25: 445-451, 1999

11. Transcranial Doppler Middle Cerebral Artery (MCA) Transtemporal window Above the zygomatic arch 2-MHz pulsed Doppler probe

12. Transcranial Doppler Middle cerebral artery Systolic Velocity Diastolic Velocity Pulsatility index 50 mm Peak systolic velocity (Vs) End-diastolic velocity (Vd) Time-averaged mean velocity (Vm) Pulsatility index: PI = (Vs – Vd)/Vm (0.6 to 1.1)

13. Beam direction Flow Vessel Doppler frequency (fd) = (2.ft.V.cos)/c fd - doppler shift ft - transmitted beam V - velocity of the blood - angle of incidence between the US beam and the direction of the flow c - speed of sound in tissue pulsatility index (PI) is independant of the angle of incidence

14. V (cm/s) 150 - 100 - 50 - 0 - -50 - Normal decreasing diastole systolic peaks biphasic flow Cerebral circulatory arrest Time-course of flow velocities in MCA from normal condition Up to cerebral circulatory arrest Increasing ICP Decreasing CPP Ducrocq X et al., J Neurological Science 1998 (Consensus opinion TCD/brain death)

15. Transcranial Doppler Middle cerebral artery Systolic Velocity Diastolic Velocity Pulsatility index 50 mm Vm < 30 cm/s Vd < 20 cm/s PI > 1.3  Intracranial hypertension

16. Transcranial Doppler ultrasound goal-directed therapy for the early management of severe traumatic brain injury Severe TBI (GCS ≤ 8) Group 1 - admission TCD abnormal Group 2 - admission TCD normal Usefulness of early TCD goal-directed therapy after severe traumatic brain injury initiated before invasive cerebral monitoring is available Ract C. et al. Intensive Care Med, 33:645–651 2007

17. Transcranial Doppler ultrasound goal-directed therapy for the early management of severe traumatic brain injury Ract C. et al. Intensive Care Med 33:645–651 2007  Group 1 - admission TCD abnormal  Group 2 - admission TCD normal PI Vd (cm/s)

18. Management of traumatic brain injury Early TCD identifies high-risk patients with impaired cerebral perfusion, intracranial hypertension and poor outcome TCD goal-directed therapy improves cerebral perfusion and reduces the duration of secondary brain injuries before availability of invasive cerebral monitoring Ract C. et al. Intensive Care Med, 33:645–651 2007

19. TCD in emergency department Transcranial Doppler to detecton admission patients at risk for neurological deterioration following mild and moderate brain trauma Jaffres P. et al. Intensive Care Med, 31:785-790 2005 Group 1 (absence of secondary neurological deterioration) Group 2 (presence of secondary neurological deterioration) Neurological deterioration (7 days after trauma) (a) decrease in GCS score of 2 points or more or (b) medical (mechanical ventilation, sedation, osmotherapy, barbiturates) or neurosurgical intervention n = 42 patients with mild (GCS 14-15) brain injury n = 36 patients with moderate (GCS 9-13) brain injury

20. Transcranial Doppler - Multiple trauma patient Vd < 20 cm/s PI > 1.3 Increase MAP (fluid loading/Norepinephrine) Mannitol / hypertonic saline CT scan / neurosurgeons

21. Choc hémorragique PAS < 90 mmHg, PAM < 60 mmHg Traumatisme cranien CGS ≤ 8 Remplissage vasculaire 1000 - 1500 mL PAS < 120; PAM < 90 mmHg PA Vasopresseur - Norepinephrine Débute 0.5 mg/h ou 0.1 g/kg/min PAS 120 mmHg PAM ≥ 90 mmHg ∆PP VES Transfusion produits dérivés du sang Vélocité diastolique < 25 cm/s IP = (V Syst- V Diast)/ V moyenne > 1.3  Hypertension intracranienne Hb 10 g.dL-1 TP > 50% Plaquettes ≥ 80-100.109 L-1 Hémostase chirugicale ou artérioembolisation

22. Detection of vasospasm

23. Osmothérapie • jamais de solutés hypotoniques • à la prise en charge ou en urgence • correction d'une hypernatrémie extrêmement prudente et avec surveillance (clinique, PIC)

24. Traitement de l'urgence = engagement = sous-utilisé effet prédominant du coté sain (Videen, 2001) effet "rebond" (expérimental) surtout variations osmotiques, diurèse osmotique et ses complications Osmothérapie

25. 229 patients with TBI GCS < 9 And hypotensive PAS < 100 mmHg Cooper J et al. JAMA 2004

26. Cooper J et al. JAMA 2004

27. ICP, mmHg CPP, mmHg Duration of ICP > 20 mmHg Duration of CPP < 70 mmHg Inotropic support, d Cooper J et al. JAMA 2004

28. Hypocapnie Modifications de la PIC et de la SvjO2 à 20 min 4 2 0 - 2 - 4 - 6 - 8 - 1 0 Hyperventilation Drainage ventriculaire Mannitol

29. Conclusion Contrôle du temps de la PAM, Hb, PaO2 de l’osmolarité, de la température et PCO2

30. Conclusion Il n’y a pas plus de fatalité en neurochirurgie que dans les autres spécialités médicales