Kaitlin J. Reilly, MD, opens up this session by discussing the recognition and initial management of status epilepticus. Then, new faculty members Spyridoula Tsetsou, MD, and Sarah Nelson, MD, respectively, discuss specialized monitoring systems for brain injuries and the benefits of using magnetic resonance imaging to detect subarachnoid hemorrhages. S O. I think this is the first Euro critical care cases and pearls that we've had in a little while. But hopefully for the next couple of months, we should have them at the beginning of the month every month. On the kind of the purpose of this Siri's is kind of go through some cases and talk about some major issues in the big neural critical care topic. So today I'm gonna be talking about status. Epileptic Assis. Um, I have no financial disclosures to report, but I will be discussing some material from the Sarah Bell Inc company. Um, and our objective here is just kind of go through some of the basics of the initial management, says the politicus, which is a potentially life threatening complication of neurosurgery and for end of neurosurgical disorders. So our, for our first case, is a 48 year old, unjust, undamaged wild man with an unknown past medical history who presents the emergent emergency department, um, in a prolonged generalized on the comic seizure. According to CMS, the patient seizure onset was witnessed and began 14 minutes ago. Thus far, he's received at the van. 4 mg i v and an exam. He's having rhythmic movements of his right arm. Okay, so what is his next best step? So, um Alex Shipper, What would you Which one of these you would you like to dio Alex? There. Sorry was made. Um, sorry. Do you mind just going back to sleep? Sure. We have. A 48 year old man is having a very long, generalized tonic tonic seizure on seizing so far for 14 minutes and he's already received advance 4 mg, got it? Que and then casting answers. Okay, Um, so I would then give another dose of four of at a van and loaded with phosphate. I agree. Um, so under the new definition of status epileptics, which was made by the International League against Epilepsy in 2015, they define two separate time points. The first one is the T one time point, which is which is a way of defining, um, what is an abnormal prolonged seizure that deserves and merits treatment? Um, and then in the second time point, the t two time point. What? At what time? The seizure is expected to have long term long term consequences such as neuronal death and injury. Um, the prior seizure, uh, definition that we had used is a seizure lasting for more than 30 minutes. But this is no longer used, but I do. I did see it in a couple of Europe neurosurgical ordered new books, just something to keep in mind. Eso for a patient, for example, who is in generalized convulsive status. The T one time point is five minutes or the time at which you should initiate a treatment. Eyes on the T two time points is 30 minutes For different seizure types, the T one and T two time points are different. Eso I'm sure all of you have seen the patients who is not necessarily in a general like having a generalized tonic Kalanick seizure. But it's in fact having focal seizures with impaired awareness. It used to be called the complex partial seizure, but the definition changed a couple of years ago, and that situation the seizure still merit treatment, but the time points are a little bit different, so they t one time points the time point at which you should initiate a therapy for vocal sets. Epileptic, it's with impaired awareness is 10 minutes on we actually don't know exactly how long it takes for the brain to suffer long term consequences as a result of that prolong seizure, we suspect it's longer than 60 minutes, Absalon says. Epileptic asses that these process that we typically see in Children. Andi. It's a generalized seizure type, and the T one time point has been defined as 10 to 15 minutes. But we actually don't know how long the patients will have to seize before they suffer long term consequences. Um, the initial and mainstay of initial says epileptic. Its management are ivy, benzodiazepines or I am benzodiazepines. Here in our hospital descends epileptics protocol calls for the administration of lorazepam up thio 0.1 mg per hour. If I would define a mistake that young physicians make when they're first starting to manage stuff. So this epileptic asses they tend not to give enough out of an in order to try to control the seizures before moving on to something else. Um, and then with your sex particular with your second dose of at oven, it is indicated thio load with another second line. A D. Um, there was a trial last year called the set, which defined thes doses, and that these three doses of these three medications were roughly equivalent in terms of their efficacy in this setting. And that's false monotone. A 20 mg per kilogram evaporated 40 mg per kilogram and love interest him at 60 mg per kilogram, which is Capra. And it's quite a lot of pepper, actually up to 4.5 g. Um, I like to think of this is the 2040 60 rule, but it's important if you're going to remember that rule to remember which medication is which. Okay, so Alex is patient, received 4 mg of Ativan and Foster to win 20,000,020 mg per kilogram. Justus, he said, Um, and the abnormal movements of Stop So he's successfully controlled the convulsion on exam. However, the patient is stuporous with sonar respirations, his opening his eyes to deep tactile stimuli only and making incomprehensible sounds. His vital signs are as above, and I think notably his 02 saturation is 82% on six liters by a nasal cannula. So what should you do next? So, Bobby, what do you think we should dio uh, given the vitals and the exam next day would be to integrate the patient as soon as possible. I agree completely. Um so the important part, like we said it's epileptic is is a life threatening emergency and the most important part of the initial management of any life threatening emergency eyes focusing on the ABC s. So that's airway breathing circulation, and particularly in set us up ellipticals, where you're expected to give a high dose of a benzodiazepine. Many patients will fail, will hyperventilate and failed check their airway, particularly after they get the full dose of 0.1 mg per kilogram of, uh, lorazepam. Um, So I agree. I think the most important thing to do next is integrating the patient before proceeding with some other other treatments. Um, in unless they specify a couple of other things. Thio checklist. That includes checking a finger stick glucose because hypoglycemia is actually quite a common cause, common very reversible cause of Seth's epileptic assis. Making sure that we obtain some ivy access your patients stop shaking. It will be a little bit easier getting a full set of vitals sitting. A full set of labs head C t will be appropriate for most cases unless you know what the cause is really clearly. And ultimately continuous EEG monitoring eyes very important, because after generalized convulsion, ongoing non convulsive seizures are quite common. Okay, so the patients close friend arrives with patients, home medicine, medications and is able to drive the history on based on the history you're able to determine what with his most likely cause of sets. Epileptic. This is what is the most common cause of sets Epileptic Assis. So see who's here, Trevor, Hard again. What do you think? Maybe I'm here. Um, my, uh I thought would be that the patient hasn't known seizure disorder and just became sub therapeutic on their A e ds. Um, I agree. And in fact, that is the most common cause of Cetus Epileptic ASUs throughout our country and throughout the world. A couple of these other ones are quite likely as well, particularly alcohol withdrawal and type of leukemia. It's totally right. So the leading cause of set up Leviticus are unknown seizure disorder with sub therapeutic at levels. The number two actually is alcohol withdrawal, which presents is generalized convulsive status. Number three is a drug toxicity, and number four is a CNS infection. Um, less commonly seen our new structural lesions, acute stroke, anoxic injuries and metabolic abnormalities, particularly hyperglycemia and hyponatremia. But I feel like we in our practice, we tend to Seymour of those, including new structural lesions. Okay, so the patient gets intubated. Hey, received some additional Capra and a surge in the low dose propofol drip gets connected to E G. Which shows this following pattern. Now, this is a little tricky. Eso I'm going to say that I'm gonna let you guys know that these air, these air g pds generalized periodic discharges and they go up to four hertz in fluctuate. So let's see. Ernest, what do you think we should do next? Okay, um g pds. So I think this is an interrupt April pattern, so I wouldn't I wouldn't treat this. Okay, I think that's quite close. Eso the a C n s, uh, defines non convulsive status, as in this context as a GPS, more than three hurts. So I think in this in this situation, and it's a little tricky. Um, I would I would go ahead and start him on aversive drip for this pattern, which is the point to mix for kick ivy, followed by a point to mixed per kid per hour drip. Um, and what I would highlight about that is that this dough subversive is actually quite a lot. It's much, much more than you would use, typically for sedation in the medicalized to you. Another mistake I feel like early status epileptic ASUs managers make is that they don't give enough data midazolam. Eso. We frequently get calls on the hotline for patients who are continued to be in status despite 4 mg an hour of a versus verse, said Theme. The starting dose here is for like, 100 kg individual would be about 20 mg per hour. Okay, so this patient isn't generalized. Periodic sharp waves up to four hertz, which are consistent with not convulsive status. Um, and in fact, he's in refractory status, which is a which is find as a patient who persists in status despite inadequate dose of events. Dia spin plus a second line anti epileptic drugs at an appropriate dose. So the treatments that we use for factory status epileptic is here. Um, I think I would say our first line agents at Mount Sinai is typically midazolam, which just started that point to mix for kick and goes up to 2.9 mix for kick per hour, which for 100 kg individual will be 290 mg an hour. So quite a lot A. To those Joseph you'd expect to see worst thing hypertension and acidosis. Our second line agent that we typically use here is academy. We started that typically about 1.2 mics per kid per hour with a Bullis, and our max does Here is 7.56 per kid per hour. Um, ketamine acts in a different way. The midazolam. It's an NMDA antagonists, so it can be helpful for patients who are no longer responding well to bend with diocese Peens, Um, and also has a as a side effect. Hypertension, which means it can act very well, is the second agent when paired with the first step, which causes Hypo tension, um, the other two agents you'll see a little bit less frequently on. That's propofol, which is probably the most common, uh, treatment for status of Leviticus that's used in the community. Um, my issues with propofol is an excellent agent. It's a gap in ergic agent on but Max in a similar way to midazolam by that comparable anti status doses, it causes a lot more hypertension on some other end organ injury. My, uh, my experience. So it tends to use a little bit less were else not able to use it for us long because it can cause a propofol infusion syndrome. Um, and probably the last. Our last line agents that we use here in Mt. Sinai is pentobarbital, which used to be the agent of choice for factory status, probably 20 or 30 years ago. Um, it has It's an incredibly effective agent. It will control status, my experience that can't be controlled on these other drugs. But it has an enormous number of complications associated with it, including cardiac suppression, hypertension, amino suppression and hypothermia. Eso it's you know, I would say we would only use this if everything else was ineffective. So our second case eyes a 72 year old woman who is now post update for following resection of the left temporal mass frozen pathology is consistent with a high grade glioma. Her surgery was initially uncomplicated, but since then she has been periodically confused, often speaking and interacting with her deceased husband as if he's still there. Um, the CT scan shows expected post surgical changes on Lee. What did you do next? See who's here. Eso Travis, are you here? Yeah, I'm here. Okay. What do you think we should do next? Can you go back to the previous slide, please? S. So we have a woman who's having probably some visual hallucinations after a surgery of the left reception of the left temporal mass. Okay, you can go forward. Okay. So we could give her some empirical evidence. Next T e d. We can treat her for postoperative delirium. You could get a memory of the brain sleeping. It's more detail. That way we can start to run subtraction for treatment of the ordinary tract infection. So she's already had head imaging. I wouldn't get other Mariah would put on e g. I agree. Um, in this context, visual hallucinations can represent focal seizures. And so I think it's important. Thio rule that out before proceeding further. Now, it is possible that these visual hallucinations were just part of a delirium syndrome. But I think once you need really need the G in this context, nor to rule out seizures that could potentially be treatable before describing this is delirium eso. If the egg would only say that Gigi was negative, that further work up would be indicated in order to determine what the underlying causes the delirium wants. Okay, so our third case is a 69 year old woman with the history of coronary artery disease who fell in her bathroom on it, comes into mounts on a Brooklyn with lethargy and confusion and is found to have a large left side of the cute subdural hematoma. 10 millimeters. A midline shift. Um, she's brought to Emma. Stage Andan underwent emergent craniotomy with evacuation. Um, Post op. She's awake. Alert oriented. Onda has just a left right crony through drift. It's a mild word, finding difficulties post up Day two, however, she begins having episodes where she stopped speaking on starts, smacking her lips over the course of that day. The episodes increasing frequency, and they're now occurring once every two minutes without returned to baseline in between. So you connect her to E. G. And it shows this pattern and just to kind of highlight some of the features that I'm seeing here. Um, I'm starting to see some increasing rhythmic activity that's right over the left front of front of central area. And over time, it seems to increase in rhythm a city it's associated with Cem Spike waves as well on Ben. And as time goes on, it spreads progress of the Left Hemisphere and also seems to appear toe involved the right hemisphere, which is a little bit hard to see because it's it's obscured by artifact. Um, and then it increases in amplitude and decreases in frequency over time and then breaks up, and it's followed by a period of slowing. Okay, So if you assume that by the time of connection, this patient has been having this for two hours, what would this pattern be called? So is it complex? Partial status, epileptic? Its focal status. Epilepsy. Ghost wood compared awareness epilepsy. A partial is continuing one or absence status. Epileptic Assis. So let's see. Um, right. Are you there? Yes. Um, so which of these do you think this is to complex partial status? Apple Leviticus s O, I would say. Generally speaking, I would agree because I don't like it when they changed the names of things. But a couple of years ago, the A C N s redefined the definition of or reclassified how complex, partial status epileptic is called. That's now the official name that you're supposed to use is focal status up politicus with impaired awareness. So that's what you saw people here now, But you're right. That that this is what we've classically always called complex partial status epileptic, Us. Okay, eso according to the new definition by the International League against Epilepsy. At what point should we initiate, uh, into the course of the status? Should we initiate the treatment of patients? See, um, is Matt car there? Maybe not. Okay, s So what do you think? 5, 10, 15 or 16 minutes? I think this would still be, um, be 10 minutes. That's exactly right. Um, u t one time point for focal status with impaired awareness is 10 minutes. Okay. Eso In our fourth case, we have a 72 year old man with a large left anterior fossa meningioma scheduled for surgery later this week, three days prior to surgery date. He presents the e. D. After having an episode on episode of rights of the shaking at home in the e. D. The episode Rikers. That's followed by a generalized tonic clinic convulsion seizures stopped on its own. He hasn't given any medication. His head, C t. Shows a stable appearing tumor with associative based agenda Kadima that seems stable from its prior imaging. 20 minutes later, you are consulted as the junior neurosurgery resident on exam. You notice the patient is withdrawing minimally to pain. Eso. You become concerned that he may be having on ongoing non convulsive seizures. Um, and as the e g be connected, unfortunately, is 3 a.m. and e e g tec is not available? Eso what should be done? I have to say that I find this to be one of the most challenging things, one of the most challenging part of a need evaluation of a patient with a seizure, which is a patient who has had a seizure for some period of time. The seizure has stopped, but the patient hasn't returned yet to baseline, and I think it's tricky to try to determine. Is this patient just in the Pacific Coast eight, or is the patient having ongoing seizures ongoing in this case. Non convulsive seizures. Um, So, um, it's Lima there, you know, because she's neither side. He's on vacation this week. Needs me here. Mm hmm. So, Bobby, what do you think should be done instead? So we could treat empirically with Adam and 4 mg. We could just put the patient on the other side to you and observe them. We can just start a maintenance does Pepe? Or we could connect the patient to Sara Bell. Rapid response to you, Jay. Uh, to be honest, I don't really see Ah, downside off. I would just give the patient adam and former programs if the patient breaks. Um, you know, and if needed, the patient detours further. We can always obviously intubate and then send the patient that I see you. But I think that would be the first step. Um, e think that's a really good thought. Um, because I think you know, the concern that the patient may be having ongoing noncommercial seizures is really significant. And you should be able to make that determination clinically giving out of an however, giving a patient who is already a little bit stuporous at the van. 4 mg was likely to cause problems. Um, hits, he may hyperventilate. As a result, he may lose his airway. As a result, they may need to be intubated, so it's not. It's on an intervention with that risk eso in this situation, and this is a little tricky. I would connect the patients of Sarah Bell Rapper Response E G. Eso Sara Bell is a relatively new system that we haven't Mount Sinai. It's coming online in since March. Um, it's a new company on Do. What they do is they create thes headbands. Um, that could be applied pretty easily at the bedside s. So far, all of our attendings fellows, a PPS and nurses and the annus I see you have been trained to put them on. You basically just attach this headbands around, and then you screw in each of the leads with a little that has a little bit of gel on the end and then connect it to this receiver, um, which has a direct up linked to WiFi and transmits the E G data directly into the cloud. So it only takes about 5 to 6 minutes to set up cerebro um e g tec is not required on deacon. Use it to make an immediate triage decision about whether or not the patient is in non convulsive status and would merit administration of the benzodiazepines. Um, you can there a couple of different ways in order to determine whether or not the patient is seizing by using Sara Bell for the first is that there is a screen on the device itself so you can look to see if the patients having rhythmic activity if you're not necessarily used to seeing rhythmic activity on this on syrup on E G. You can hit this blue button on the side, which has a, um, this audio function where if it detects rhythmic activity, it makes this kind of bizarre, laughing sound andan The third way is that because the data is transmitted directly in the cloud, you could call me and I could interpret the data for you. Um, at any hour on Ben, we should be able Teoh make a decision about whether or not they has. The pins are indicated based on that. So this patient gets connected to Sara Bell on it shows this pattern here, So there's some increasing rhythmic activity that begins in the area just over where the brain tumor is aan den kind of evolves over time. We're only seeing the first couple of seconds of what's likely a seizure here. Eso this is recognized and the patient gets 4 mg of Avalon, after which the seizure activity stops. Curiously, in this case, the patient's mental says improved significantly on we were able to just give sort of maintenance dose of Capra without having Thio give load another a d andan. This exam proved slowly over time, and he didn't experience any further seizures. Okay, so this is just a little bit of ah um a pitch for this new system that we just, uh we just acquired. Um, it's a quick and reliable way to get e g data Could help make a rule. Ins not could also set us up Leviticus because it only gives you the temporal chains. It doesn't necessarily rule out the possibly that the patient still having very small seizures and their parasitical chains. Um, it's now available on the other side. So you just unfortunately, amount signing mean campus hospital. Um, if you have a patient that you think you're trying to make a decision about whether or not they're still in non convulsive status. Um, you can ask that this be applied. In fact, you can even learn how to apply. It really only takes a few minutes to learn. Um, and the data is available within five minutes online or on the device. Or you can use this brain stethoscope, which has a very characteristic sound. E would say that the sound it makes during seizures is kind of Ah, I don't know, haunted. So I would only I would press that. Keep in mind if you press the button. Um okay, so I think overall the kind of take away points are that status epileptic asses a life threatening condition that should be treated properly in order. Thio prevent neural injury. The mainstay of initial treatment is benzodiazepines. When giving a benzodiazepine, you should love the second line agent. Um, use the 2040 60 rule on Duffy's measures failed to control seizures. You can I would rapidly move to intubate and initiating aesthetic trip for the treatment. Refractory says what guests? Um, And if you're not sure, if the patient is ongoing status, you can use Sarah Bell or other egg technology in order to do that. You guys have any questions? That was really awesome. Thank you. When you apply Sarah, when we if somebody applies Sara Bell, are you able to see the recording from off site by by signing on the website? Yes, I am, in fact, so I have been able to review EEG data from Sarah Bell within five minutes, both at home when I was baby sitting my nieces on my iPhone. Um, it's ah, it's actually it goes directly into the cloud continued anywhere on the web. Um, do they have somebody who reviews that? If you want that to happen, um or is there an automatic algorithm and if so, how accurate is it? Eso They have an automatic algorithm called clarity, which will indicate your overall seizure burden on, but which is also a parent on the device itself. Eso you can. It has a predictive algorithm that will indicate how likely it is the patients having a seizure at any given point. It's they have some data to support it. It's there. They're still testing it. To a degree. I would say that it is pretty good but probably not as accurate as a human reviewer. Okay, Has this been published on yes, eso They have evidence demonstrating that it is almost equally effective, e g. In terms of really in non convulsive status epileptic, ASUs, and that the data that it gets for the two chains that that it records on the temporal chains are accurate. Do you use it for a continuous monitoring I have. I think there are some limitations in terms of continuous monitoring. The first is that it's only FDA approved to be used for up to 10 hours, after which the contacts with the headband tend to degrade a little bit. And there are some concerns about skin issues at that point. Um, the issue that I've had is that there is no associative video eso. Sometimes it can be really challenging to detect the difference between certain artifacts. Andi Actual seizures eso, for example, like rhythmic artifacts like we have when patients get chess PT in the I c u. They, um, tend to get shook and arrhythmic rhythmic fashion that can kind of look like a like a seizure on the E G. And it's nice to be able to have that video, um, to try to detect what's an artifact and what's a seizure. Eso, without it so terrible doesn't have video. So sometimes that that could be tricky and that the patients were doing other things. It's hard to tell exactly what's going on during this during the event, but it can be used for up to 10 hours. In fact, during, um, co vid because we wanted to try to decrease our utilization of conventional E G because of the risk of potential infection to the e g tec, we use a lot more Sarah belt and use it for our periods of I think we used. We had one on the patient for almost 48 48 hours without the complications were and we were able to get good data up to that point, she was having cyclic cities cyclic seizures. How many do we have? S. So we have to weigh, have two devices. They're both house in the N S I. C. U mounts on a main campus hospital on den. In order to make it work, you have to get a disposable headband and just connected to the receiver. It seems great. I really like it. Do any residents have any questions? Yeah. Actions. Kurt, Um, how about monitoring like this for things like they continue to monitor visa spasm or stroke like that? Is that in use it all nice U S. O. So I would say that for Sarah Bell, but for conventional e g, there have been some, uh, published data on the use of quantitative e g Ortio monitor for basis, spasm after supper. Factoring Cambridge. Um, there's a lot of there's been a a lot of retrospective analyses of this where you can kind of do things like out the delta ratio, which is to look at, um, is there an increase in slowing during similar periods that might indicate that there's, uh, that there's ongoing basis spasm. It's easier to do retrospectively. I haven't seen a way that has been done prospectively in order to detect the onset of Bezos as, um and and operationalized way. But that's definitely an open research question. Andi, I think one that has real promise. Thanks. Kate, This is Saudi. Gaetan, can you hear me? I can. Great job. But I didn't hear anything in there about the surgical management of status epileptic asses. And I've been troubled on occasion by patients that have come to our attention that have been in status for months sometimes, and we have applied vagus nerve stimulation to those patients with somewhat promising results. And there's multiple reports and literature about this. And we've also thought about applying R N s to epilepsy. Partials continue of patients in in the ICU setting. Yeah, any comments there or reasons why you left it out? Eso I left to that because I think that's kind of my status to point out talk where I talk a little bit more about super factory status. So if I'm asked to come back in a couple of months to give more cases and pearls, I'm definitely gonna go into some of the cool treatments that we use for super refractory status, which is defined as status that continues despite 24 hours from the Pacific drip on. I think there are some really promising potential surgical options that case like you mentioned we used, we put it, I think we put in to vagal nerve stimulators in patients with super factory status, one with really fantastic results. Um a patient who has had nuance, that refractory said a couple of tickets north. We've been in status on Max. Does midazolam, ketamine and pentobarbital for that. As you said months who responded really well to make a nerve stimulation, um, stand out of the hospital in back, living a functional life. Um, so in another case, where e think it was helpful, but it wasn't as dramatically helpful. Eso I think initiation of early potential surgical evaluation stations in super factory status is really, really helpful. Andi, I agree with you that r N s. It seems like a really promising potential potential therapy. Um, for both epilepsy, a partials continue and potentially for refractory status of other deal, uh, of other types is Well, yeah, there's a third case to add. Uh, that did not occur at main, as you call it, Which was the West recently. And a patient recognized by Yakov Gula Gorski are famous alumnus out at, uh, um okay, in New Jersey, understand? To us. So it's I think it is effective, and I also I think that it's important that we make sure that we get our epileptic ologists involved in this management as well. You know, uh, I couldn't agree more. Thank you. Yeah, way. Have another question there. Just wondering for patients who present with a first time seizure. You know, oftentimes these patients were loaded with a D is treated empirically and discharged to follow up. Is there any role for using cerebellum The outpatient setting to continue monitoring patients more or less like a holter monitor for the brain eso. In that context, I don't think Sarah Bell would be quite as good. It's a little bit harder to stay on and you don't necessarily get is much detail as you do with conventional e g eso. In those contexts, we use what's called ambulatory EEG, which similar laid does not have video but is essentially like more of a conventional array of E G leads. Patients get hooked up here and usually in the in the outpatient clinic, get a big head wrap like they just had neurosurgery and go home with it for three days. Onda. That's a pretty common, uh, pretty common modality for assessing patients who have potentially suspected seizures or suspected epilepsy. Thanks, Thanks. It seems like this might be a better option for a patient who has just had surgery and might have an incision on the top of the head on this could just go around this. I haven't seen it applied. Does it require gel? And do you think that might be an advantage to it? I think there. I think that is a real possibility, especially if the surgical site is like high up in the Paris agile area. Although if the patient if the reason why the surgery was there is because the lesion is up there, then maybe you're gonna miss the Paris agile chains where you might be able to text seizures a little bit better. But in my experience, there is less skin injury with Sara Bell. I haven't put it directly onto a fresh, fresh post op yet, but wait did put it on someone who is post op day to from a craniotomy. Um, and it did seem to protect the wound a little bit better than conventional egg. So I agree that that's promising. Mhm. Really cool. Um, okay, let's move on to our speakers. Um, is Sarah Nelson on the line? I don't see you signed on here. Um, so let's start with spirit doula right now. Spiritual. Are you ready already? Let me just share my screen second, So Sure. Mm mm. Share. Do you see what I'm sharing? Okay. So thank you for having me here today with you. And we're gonna discuss about the multi model you're monitoring. Uh, nice you. So first to tell you that I have no disclosures on guard to give you a background start. So you know, everyone knows that primary brain injury. Um, it's gonna be followed by a secondary brain injury, mainly through a big cascade off biochemical events. I mainly glutamate made it damage. Oxidative damage, Consummated damage and inflammation. So the tools that we have up to now the traditional tools that we use in the I c u to timely detect secondary brain injury eyes, the neurological exam, the brain imaging and the isolated. I see p monitor however, uh, sedation interruption for a neurological exam. Although it's safe, and we should do it sometimes it's not on. It's even a not advice toe. Transferring the patient out of the EU for emerging can be harmful or even doing them emerging in the I. C. U. Positioning the patient can be very hard for and also I keep monitoring isolation. I see monitoring. Um, the data are debatable. There was a because that the child in 2012, the best your child had showed that there was no difference in outcome if we treat base and based on the I C P monitor or based on our exam and emerging. So the data that we have up to now the traditional tools are very, um, not very robust. And we need to do something to improve the outcome and timely monitor and find out the secondary brain injury in this population. And in that setting, your critical care society, um introduced and recommended the multi model you're monitoring, plus the specialized I see you like taking care of the spaces and specialized, setting off your critical I see you the goal of these two things eyes mainly to be able to detect in a timely fashion. The brain damage the secondary brain damage in the kid brain injury patients to offer an individualized treatment and very importantly, to be able to understand the path of physiology off the kid brain injury and second of brain injury in order to develop a more specific treatments. Eso the monitoring classically can be divided and invasive. Non invasive, original versus global. I prefer the invasive, non invasive separation, and we're gonna talk about the most commonly used part in the invasive and noninvasive modalities. So first we can start talking about the invasive monitor. The most common modalities include the DVD on ice, a pinch of our animal book, the brain oxygenation monitoring through the brain tissue oxygenation, tension or the jugular jugular Venice oxygenation saturation. Something that's very common all days is the macro dialysis for bring metabolites monitoring and last but not least, the peacock the electoral cartography for social detection and stables spreading popularization. We will discuss it between tale for, uh, for this modalities so classically David D or the SP Bolt, we use it for I, C, P and C p p monitor. The goal for this, uh, measurements is mainly to understand the other regulation and have a personalized numbers for each basin. So, using correlation off, I see P and Ma. We can have the plot off regulation. A positive plot means that there is an impairment of regulation on def. We plot the curve off the pier X. With the CPP care, we can find the optimal CPP. Actually, where the point off the minimal PR exes, We can identify the optimal CPP. This concept it's debatable, but still 6% of the patient, uh, in 6% of the patient, we can identify the optimal see PP. The second part second tool off the invasive monitor, as we said, was at the cerebral oxygenation monitor that we can do it. Look, using the brain tissue of oxygen tension by placing a catheter through the ice speedboat. Actually, we can use the multi channel, multi port icy bolt. We can have one with four ports looking place different coverage for different measurements. Um, the advantage off the original option monitor is it's very safe. It's the balance between oxygen supply, diffusion and demand. The only carrier, it's mainly do not place it in a diligent area. If you want to have a global assessment off the oxygenation, we can do it invisibly by placing junior jugular venues about OC symmetry. Uh, calculating the venous oxygen content. It's a balance between oxygen supply, and demand doesn't take into account the diffusion. Um, even though it's easier to do and we can do it. Uh, everyone can do it. Um, in the i c u. The quality data, our food. And even though it is safe, the complications can happen. Many the ventral bosses can be deleterious, especially in patients with intracranial hypertension. Um, preliminary data have shown that brain hypoxia is a predictor for poor outcome. Independently off the icy p and c p p. A prospective study in Switzerland with 103 patients showed that the longer the longer the brain hypoxia is the highest the risk of having unfavorable outcome. Andi that was confirmed also with a Multivariate analysis excluding for CPP on uh, I speak things. Data are now trying to be confirmed in a large, uh, clinical trial randomized pastry that is currently ongoing. The bowsprit eso We're waiting for the results. Another tool off the invasive border is the cerebral maker dialysis. We do that in order to monitor the metabolic state, to understand the brain pathology and also to get therapy and prognostication less frequently how it's done again by using a catheter through the boat. So the character from the outside part is connected to pump where we can infuse the purpose It which is artificial CSF. The tip of the catheter, um, consists off a semi permeable dies like membrane dialysis membrane askew can see. And then there is an equilibrium between the division of molecules And at the end we collect the diocese, which reflects the 70% off the molecules off the interstitial off the brains. Interstitial tissue, Uh, when the catheters placed has been confirmed by emerging off course. And what we measure, uh, every hour is the glucose elevated lactate blue team in the classroom, and we can calculate the index the LPR ratio elected pyramid ratio. Classically, what we're looking for for detecting, uh, secondary brain injury is the increase off the LPR with decrease of glucose and decrease off pirouette that reflects sweets. Toe anaerobic metabolism commonly seen in Vegas for some high box ischemia. Fever inflammation. A big large trial published in brain in 2011 confirmed that Theis metabolic markers are independently associated with, uh, the outcome fallen to be I. They had 223 patients that had micro dialysis for four days. Three average situation methodologies was four days, and it was found that the increased total of glutamate and the LPR predict mortality and off course by drinking. Motivate analysis. Confront that low glucose and high LPR are independent positive predictors for mortality, whereas hi pervade was an independent predictor off. Good outcome, at least, but not last, but not least on very important tool off. The basic monitor is the electro cartography. Or it could, as you say, that can be done with either the eight. Contact the electron again, place through the boat or the six contact subdural strip placed strategically. I bought a reality safe, mainly data from epilepsy surgery so that they have kind of equal safety. Death a little tends to be a little safer with this complication. However. The rate of infection and main add residents are the same. Um, it is mainly used for two things, has higher sensitivity for social detections detection and then, like multiple smaller studies that they have showed that I showed you here two of them one in 14 patients, they found 10 patients had seizures with the tax collector and only four off them had seizures in the skull. PG, Another bigger, larger trial. I showed that 48 common spaces suffering from separate. 38% had seizures. Uh, intra cortical e detectable seizures, where it's only 8% off the space and had seizures detected on stop e G. The big The advantage off the ICO is the detection off, cerebral spreading de polarization, which is a new term in the neurophysiology world. I feel not that new. It was first described in cortex in rabbit cortex, 1944 then from 77 were correlated with cortical ischemia and classically inhuman and more, uh, constantly. It started since 2002 cereals spreading the polarization. Actually, we're talking about the waves off mass urinal and associate deplore ization starting and propagating from the cerebral cortex on the The rate of propagation is between 129 millimeter per minute, usually 3 to 5, and they actually most forms off. Keep brain injury just to have an idea how you can see them in the unfiltered ICO. Strict data. You see the polarization that they start and spread, and then if we do it in the candidate of e g monitor with a filter, you can see the spreading de polarization that starts here and goes up. It can go with whatever direction it can go from up to down or whatever. But it has to spread and typically start with a deep polarization. Why this term is important is because in the beginning, actually, we believed that they were the result off the primary brain injury. However, it has been shown that they appear independently off what happening with primary brain injury. This believed to be a part of the secondary brain injury there associated with this injury preservation with increased lactate increase Sylvia and Tommy without having an anaerobic metabolism or ischemia. And when they appear in clusters, it has been shown that, uh, they are correlated. They are associated with waas outcome. The big the goal. Actually, the bet is to find out, um, skull PG features that detect, uh, see a space and that because not every patient has invested wander and not every facility can, uh, support this kind off monitoring. We conducted thesis past year study, attend gits with 35 patients, um, suffering either from Sabra or T B. I. We found 124 since this event. Unfortunately, we found or fortunately, we found no significant association between sees this and continue e d. However, it's a small study and we need a larger population. Uh, thio started. Look into that. So now we're gonna talk about the non invasive, uh, part of the monitoring. Uh, the more commonly tools used for noninvasive monitoring is the transcranial doctor, the opioid per sound and the big, less frequently the book potentials and mainly the smaller sensory once, so to talk a little bit about them. Also, separately, they have much less lower accuracy for predicting ICMP or secondary brain injury. So many groups tend to combine them in orderto check on there predictor character. We did here at Mount Sinai, uh, one year ago, a small perspective pilot study with 14 patients, all of them having a DVD. And we had a total of 21 measurements and we found that the presence off two or more off optic nurses diameter more than five millimeter. Uh, unilateral or bilateral presence off optic nerve. This elevation and mean, uh m c a p I more than one. If you have two or more of this, uh, parameters. It's very sensitive and specific for predicting Isobe more than 15 with an area under the rope off 0.97 This is very important, especially in patients, that they cannot have a nice be monitoring and also in orderto understand the importance of the non invasive monitoring assessment. Um classically Neuro Critical Care Society and Brain Trauma Foundation recommends e g for every basis with a brain injury and other mental status continues G or routine e g classically using the setting for several detection and starts politics treatment as also mentioned earlier, a very important part of the G in the i c u for this population, especially the ones with ultra mental status of have no seizures s. So that's the activity. All the most of the data tohave is from Boston knocks population after characteristic. We have shown in different studies that produce the reactivity during, uh, temperature targeted temperature management or after it's a very good, uh, prognostic prognosticator tool for good outcome and again for common circulation. This is less established, though can be extrapolated and testing the activity in all these patients with ultimate established sort of thing is know how to test the reactivity because many times we say it's a reactive, whereas it is So we have conducted, um, back in 2015 study comparing different nooks of stimulus for sorry. Stimulate to test the Egypt background activity. Uh, in 77 patients of the I c u. We found that bilateral nipple pinching is the most, uh, create for, um, testing the Egypt account activity with a very good P value adjusting for the other, uh, come founders last part off the non investment other we're gonna discuss today is the evoked potentials. Again, the data that we have, the more robust data that we have for the potentials, uh, come from the characteristic pasta Mexican population class city is the stomach of sensory evoked potentials. We know that bilateral absence off 20 was here. That's a normal Uh uh, on here we have the peripheral, uh, ways, but we don't have the cortical 1 20 both sides and we know that bilateral absence it's ah, very robust prognosticator for poor outcome. Uh, in Poznan population Also, smaller studies have shown that can be extrapolating, comma. Unfortunately, other evoked potentials, like brings them auditory evoked potentials or transcranial motor ones, though classically used in the O. R or even a south facing they don't like. They're not very frequently used in the I C U setting, though we should start trying the more so to sum up. Ah, we. What we discussed up to now is that the traditional wandering failed to timely detect secondary brain injury and newest ways of assessing secondary brain injury involved a big variety off invasive and noninvasive techniques, even much more than what I mentioned. Um, it's technique separate, have moderate accuracy. Some are more accurate, something less I create. But alone. It's technique, uh, cannot be used. Unfortunately, up to now we have no randomized trials for assessing that the benefit off multi model you're monitoring and for assessing the combination. Which combination will be the more effective both for outcome, both for cost effectiveness part and for better understanding the brain physiology. So what? We definitely need this data in large population places, And the hypothesis behind that is that combining invasive and noninvasive techniques with the molecular biomarkers will help us understand and underlying the bottom astrology off a kid brain injury, timely detect, secondary brain injury and, of course, develop treatments in the future. And to do that, we need to have standardized protocols for the multi model in your monitoring, including against the tools that the test that we just discussed and also develop cystic Burbank's that it's a trend that started happening in a many institutions in orderto develop also standardized techniques for more molecular biomarkers. And that's it. I hope it wasn't too much. Any questions? Hey, spirituality, uh, this Alex more of the nursery residents. Thanks so much. This was awesome. I totally agree with you that we need more standardization with our intracranial monitoring. I'm just curious, you know? Now, on service just for context, we have a patient, but high grades. I recommend hemorrhage. Thio Romantic has actually been very helpful. Um, in treating predicted, entering vase a spasm, I'm just curious from your perspective, what you see is far a standardization for high grades of bracket hemorrhage. And you know how we can use dramatic because I've seen that we don't really have great standardization, knows faras use and just kind of what you first see the role of some of these intracranial pressure monitoring and romantic with P b t o to monitoring and what the potential implications are a sfar standardization. Well, I think that it would be very important to for every person with high grade separate toe have like like almost all of them had DVD, but to place also romantic or other I C. P Both the important thing. The we need four points because I really believe that we should put also the depth electrodes, the peacock eso I think romantic has three ports, whatever a company, that doesn't matter. But I think it's very important to have both the invasive like the bull and the video, because if it is very important for the CSF biomarkers other than a treatment, of course, but for developing new tools, it's very important to collect CSF for I have in bear markets. But in order to have the oxygenation, uh, to have them, the cook and the macro dialysis, we need the bolt and it's very safe. It doesn't increase the adverse effect, and I think that off course it's extra work for neurosurgery perspective. But I think it would be very useful to do it standardized every hydrate, Sabra basin, or even like every other acute brain injury pathology with comodo speculation. A process with my name is Ernest on the chief resident. Um, that was an outstanding talk. I wanna first, uh, point out doctored Evaldo cameras question in the chat about whether there's any role for Sarah Bell egg and severe TBI patients as a quick seizure assessment. So that's one question then my own question is, with regard to cortical spreading the polarization. Are you familiar with any of the literature about ketamine for treatment of those threatening polarization? And what's the current state? Uh oh. Is there a role for ketamine in the clinical setting? Eso first for the kid? I mean, I'm not aware of a military treating the sixties. Uh, there's some trend now that they started treating, but there is no big large trial for treatment, especially ticket. I mean, I will look into that, but I'm not aware for ketamine Uh, treating in theory. Yes, it could be a good treatment because it's Andy, and not only so it should, uh, be effective. But I am not aware of any child for that. But happy to take a look into it. Um, the other question for the terrible. It's not apart off the multi model, you know, monitoring because something very new so guidelines in your critical care. Also, they're like very old. Published 2014 haven't been updated since, but also cerebral concept. It's very new. So yes, we can do it as an institution of guidelines part and see if it's useful for a quick assessment. Knowing that if it's negative, doesn't mean that you don't have seizures, even Skull PG. It's much less, uh, create for seizure detection. That's why we need also the depth electrode. But it would be a very interesting point to correlate those with Jeff Electric special in case that we don't have scalp e g two cerebral and that elected Thank you so much brutal, You think? Comment? Alright, guys, thank you so much for a wonderful talk. And that again shows why grand rounds are so important were such a big center. And unfortunately, you know what? We did not realize that the epilepsy center your interest in this and we would love to continue. This work could stop when Meg Pain left is one of our residents. But we have safety data on depth. Electrodes were 2500 depth electrodes in the past five years, and we must certainly would love to collaborate on patients that are critically ill. We know the safety data is there, and I think we could get this done fairly expeditiously since we have the technology to do it both East and West. Perfect. Thank you very much in 20 cents. Well, that actually is a good separated my question. Thanks a lot for your talk. Um, but I was wondering spiritual if you had any information on the risk between a single lumen versus a quad, Lumen, Um, depth electrodes versus just intra prank implies piemonte. Or is there any data distinction that distinguishes the two different types of thoughts? There are no data comparing the two types of balls, classically like I know that the in the beginning, we're doing two balls before the four port appears. But now there's a very good paper off. Dr. Foreman was a very, uh, guru of the neuro monitor. Multiple on your monitor advocating for the four port. Uh, Lumen. Um but there is no direct comparison between the two ports or the two bolts. There's a scrambled with four ports. Logically, the one bolt with four ports should be better because you have won their home than to, but again, even the two balls. Uh, there were data from Columbia, actually, doctor class, and have published thing 2015 or 16 showing that it's very safe, even with the two balls. So whatever everyone has on availability off course, if I get to choose, I would prefer that four ports. Hello. Uh, any other questions? That was fantastic. Spiritually. Thank you. I think there's really a lot of interest in getting this going among the residents and attendings, so thank you very much. Um, Sara Nelson. So the station, if you stop sharing. Yeah, Mhm. Fantastic. First, um, sorry. We can't hear you. Are you? Yeah. Sorry. Yeah. Just trying to figure out the share screen thing again. S. Oh, sorry for the delay on logging on today. I'm actually on service right now with my current institution. We have a couple of sick patients in the unit, Um, and even thank you so much for the opportunity to present today. So today I'll be talking a little bit about, um, some of the work that's been done in the field of, um, Orion subarachnoid hemorrhage and some of the work that I've also contributed Thio Aziz. Well, and then on the right there Just because we can't travel anymore. Ah, it seems is just a picture from Amsterdam in June 2019, when I was there. So good. Thio, think about good times. There are some disclosures that I have. Some of this research is based on internal grant. They got a couple years ago, um, at Hopkins and also some funding from the Brain Aneurysm Foundation as well. So, um, memory in sub Reckon, um, an aneurysm is a wreck on a hemorrhage. It can be potentially useful tool. It obviously provides. Ah, lot more details. You know, um, about structure and function and physiology past the physiology of these pretty highly complex patients. Um, but you know, some higher soft tissue contrast and C t is, well, lack of radiation risk as opposed to, uh, things like cat scans. But there are some notable drawbacks. As I'm sure many of us are aware from practice and including the fact that, you know, there could be the risk of artifacts. A lot of our patients are stable enough unit dynamically. Or um, I see P wise or other reasons why they can't undergo, Uh, memory, and particularly in a timely fashion, is we may want them to go. Um, but it seems like there still could be some utility for this fidelity. And that's what I'm gonna show briefly today. Um, So what can it do for us? Well, to start off with, we know that it can help in diagnosing summarecon. Hemorrhage were cts ambiguous both early on just after rupture. And in the sub acute phase, it does a better job. Typically, then cat scan can, Uh um, there's some nice studies out there, primarily case reports that show that, um, particularly when you add contrast, it may help identify rupture aneurysms, and it also can help identify, um, aneurysm occlusion. Um, and I already discussed previously that there are some reasons why this modality isn't used a bit more. So, um, this is just one example where C t may not do as good of a job is showing. Um shh. And why this is important. Well, we know that the risk of re bleeding us particularly high after initial, uh, aneurysm rupture. And so making sure that we have the right diagnosis is critical. So on the left, there we have ah, cat scan that, Aziz. We can see there's a dot of hemorrhage there that is described Thio. Anybody tracked related injury. Um, but as we progress towards the flare in the SW I sequences and the, um, right side and the middle panel is there, you could see from the arrows that there is not only evidence of, um, flare suppression, which is indicative of the presence of blood in the middle panel. But on the S W Y, um, a Z I know a lot of very familiar with you could see the evidence and many of the soul society of human citrine. Um, and then this was just some nice examples of when you add Gunnell idiom. You can actually, um, get a pretty good idea if there's been rupture of an aneurysm. And they show this both in this panel down here pre and Post grad. And unfortunately, the zoom is right over me where I'm looking at this panel on the right here, where they basically used cattle any, um, to try to differentiate which aneurysm was considered the culprit of the aneurysm a bleed. And in this case, we see that um I believe it was the a con that they showed here. That is, uh, highlighted. In contrast, after get Illini, um, administration and was therefore deemed to be the culprit lesion. There's some data out there, and I won't get into this in depth. But there has some been some literature in the past few years that have attempted Thio document a little bit about some of the findings off, um, diffusion, weighted images, um, ischemia and some of these patients. This was a review from stroke in 2017 that, um, try Thio showcases and and a few different ways, and I just only show a couple of it here. But what was kind of interesting is pre treatment. So that means prior thio aneurysm secrete mint and post There was actually a fairly significant amount of D w violations that were documented. And what was a fair number of patients? Eso This was just the forest plot that showed that pre treatment D w Y lesions. The, um, prevalence there is hovering around 50%. So, um, this could be relatively common occurrence in these patients, and there can be some potential relationships with how old you are and the number of lesions. So you typically have, ah, fume. Or if you're older, there may be some, uh, sex related differences, too, in this relationship. So some, um, interesting things that have come out of this, but this review kind of just basically showcase some of these findings without giving a little bit more detail on why some of these things might actually be, uh um, And there might be, which is not too surprising relationship with clinical condition as well as, uh, d w violations. And that's shown here with about 47% between 72. I'm sorry. This is ah, different forest plot. This that was looking at between 72 hours and 21 days showing the d W I lesions appear on almost 50% of folks who were scanned during that time. Um, so we also Ah, a couple of years ago, we did a bit of ah review toe use, um, kind of pull together their some of some more of the data, including some of the studies that were discussed. The previous review also, um, discuss other, um sequences and findings as well, too. Get an idea of the relationship of memory, Uh, findings a variety of Emory findings, Um, and things like neurologic severity outcomes. And even if there is a differential, that they're differential findings between people who are clipped versus coiled on dso. Basically, we found and this was this was a review to be clear. So it wasn't in a meta analysis. And so given the variety of findings that we found and the fairly little data per sequence, we did find, um but to ah, general degree, it seemed as if the presence and or size of the Emory lesions were associated with more severe general logic examined. This was also measured in a variety of ways, which also would make men analysis complicated On dso we attempted toe show this here in a few different, uh, tables where I've just highlighted a few, But D w i lesions being, um, noted in mawr poor grade than, um good grade hunting has patients, is you could see here and then, um even there is even come up in the literature flare lesions, which isn't too surprising. Onda volume being greater than 25 fold and worse off aneurysms. Several kind of patients that better off patients, at least in this particular, um, study, which actually had a fair number of patients. Actually, Onda then this, uh, same glimpse that again, still looking at neuro exams during the cute hospitalization showed that, um, you could see some differences in a Magdala and hippocampal volumes down the line that were correlated to the patient's exam when they were in the hospital. So, typically, smaller volumes, which eyes? Probably not. Um, that's surprising. A swell Asimo sarin. Um, deposition also being correlative to the patient's exams. Well, and then just provide, um, a few examples. Uh, this was just a patient here who obviously has a variety of, um, uh, lesions both on a diffusion and flair. And this hunting has four, uh, introduce. We'll see Barack, Uh, patient s o not, uh, kind of. You're seeing the coalition kind of on at least a small scale here with just this one patient. Um, And then there's some additional things that we can, um, look at as well. So, um, this is an example, for instance, of looking at a patient with hunt Has five on the top is compared to hunt. Has three of the bottom and it's fairly clear that on the DT, which is the panels on the left, there's more rare ification of the white Matter tracks. Um, is you could see there, which juxtaposed to the, um, lateral ventricles. And there is the hunt has three patient, um, and similarly, there's definitely more abnormalities seen on the flare, and the hunt has five is compared to the hunt has three patients. So these are just some examples. Obviously, there's more examples that we see every day of this, but we can see kind of the contrast here. Um, and then generally speaking in the same review, um, is mentioned. We also looked a bit at, uh, correlations that have been seen in the literature between ah variety of memory findings and outcomes. And similarly, given the variety of findings that we saw in the literature, it didn't seem prudent to conduct a meta analysis. Um, but, um, Thio Ah, rough degree. We saw basically changes such as an increases in flare volume, correlating with increases on the modified rank and scale, which is recalls a scale from zero toe, six higher being worse. Um, a functional outcome. Basically six, you're dead. Um and then even findings. Um, this time around, um, this this paper specifically was looking at functional connectivity in the context of bold using bold FMR I, um And seeing that there was, um, mortgage w I lesions in impaired patients than not. And they also looked at some functional stuff, too. But I don't include that, um, here in this example, um, and then some differentiation and karnowski score with relationship to a number of human certain regions. So that was another, um, interesting finding. From from this review, we have started by, um we've done a little bit of preliminary work on a, um ah. On a project that is utilizing some of this. So basically, the overlying thing is, um is part of some of these, um, grants that you saw front. We've we've scanned, actually, um, around 50 or so patients that, um, Hopkins, either, um, for clinical reasons or with the grant funny that you saw on basically, the thrust was to help with the idea of outcome prediction and in helping in this disease since eight years with subarachnoid hemorrhage, still doesn't have great prediction models. We know already that, you know, based on clinical exam is our best predictor. As at the present moment, kind of other things help us in, um, in prediction. Um, and so one of the, um uh you know, one of the things whose could, uh, could different types of, uh, memory, um, findings. Could that help us with that? And so this slide here is unpublished work that we're starting to look at where we drill down a little bit more into, um, in our own, uh, work that we've collected ourselves or diffusion and flair related, um, changes and whether or not this might be different, such as compared to controls and then also versus outcome. So this particular table here and again this is unpublished. And so it's still a little bit raw data, but, um, taken as a whole, we have the controls in the middle column and the patients in the left hand column and these scores down at the bottom is kind of what I wanted. Thio, focus on here, and this is taken from a, um a paper that, um in 2015 attempted thio categorize, um, diffusion and flair related findings based on the number and severity. It was a paper published by Karen Hirsch, who was at Stanford. Um, and we decided to use that because, frankly, there aren't a lot of scales that look at Emory and attempt to categorize lesions and then also attempt to correlate with outcome. Um, in that paper that Karen Hirsch wrote what the idea was to correlate the lesions and in cardiac arrest patients. So maybe not the best measure in us for Subbarao, but frankly, it's one of the best scores that we have. So when we just look at this table here, some of these choristers so higher is worse. Meaning greater severity of diffusion and flair related, um, lesions. Where D g n, by the way, stands for deep gray nuclei. Um, in general, you can see that there is seems to be a correlation between, um a greater number of lesions that were found, um, in the patient's versus the controls. And again the patients or this column right here. So it didn't correlate for all of the, um, uh, components of this particular score. And then this is Table is again looking at outcome at six months of which we have some data from, uh, several of the patients that we looked at and again if we just kind of focused in on, um, the scores here, I'll do that in a second slide and the next slide rather eso again m r s greater than two years on the left. So those patients, they're worse off. And so if we look at those also there seems to be, um, some correlation where generally higher scores are seen in the, um, in the patients who are worse off at six months. Eso again, This is all unadjusted unit variant analysis and so unpublished and still a little preliminary. But, um, perhaps there might be some potential if we added thio some of these findings multi variable analysis that there could be some, um, possible augmentation of prognosis of these patients. That's at least our hope. Um, And then, as I mentioned earlier, um, you know, there's some what we have found in doing the review that I was discussing earlier is, um, you know, there could be some differences potentially in, uh, memory lesion burden and people who undergo clipping versus coiling. And so it seemed like a general. There seemed to be a greater incidence of lesions and those who underwent surgical clipping. Um, but, uh, once again, this was a review. It wasn't designed thio be definitive. And, uh, we don't actually have all of the definitive numbers on this. Um, and just quickly at the end here, I just wanted to go over some of the newer sequences that have been part of the thrust of the project I was discussing earlier. We we've been Emory in these patients. A lot of what we've been trying to do is multimodal stuff. So not just diffusion and flair that I have previously talked about, adding on stuff such as there, Carol spin labeling, which looks at the blood volume, Uh, diffusion tensor imaging, which looks at White Matter tracks and bold infirmary, which looks at functional connectivity. And we've started a little bit some preliminary data analysis based on the patients that we've gotten to date, so s O A S l and Brief. As I mentioned, it's basically three ideas toe look, a sort of blood flow. And the nice part about CSL is that it doesn't require an exogenous tracer. It's all endogenous, so it relies on arterial blood to make this happen on DSO is the consequences of that. It can be a nice thing. Uh, that, you know, we we don't have to worry about kidney function or that sorts of things are worsening kidney dysfunction. And so there have been some initial data that suggests that decreases of CBF on a cell can court with clinical symptoms and that also that there could be a good degree of inter rater reliability with the sequence. I mean, this is just David that I presented the N. C s last year when it was still in person. Um, which which was, um, some data. And this is only at the time of the course of my study. This is only about 34 patients, and again, the 10 control patients. And, um, what we're trying to show here is that in areas of the brain that are critical to consciousness and some of these networks, such as the the default Mode network, the salience network, that there seems to be a decrease in a cerebral blood flow. And some of these patients in these critical areas is compared to controls eso again, we still are looking at some of these data. I just got my last outcome data for this project yesterday for six months. So hopefully will be more data on the way d t I has been, As I mentioned, another focus of this multimodal emery project that we've been doing on dso d t I. The means for us is that it uses diffuse Yvette defectors of water molecules, attract the integrity of the white matter tracks. And, um, there have been some, um, anecdotal studies. There was one that was published in stroke that showed maybe fractional Anna Satrapi values, um, that were taken from, uh, d t i or lower in the cerebellum. Um, that, uh, this increase the odds of of noting district lace, triple ischemia and non traumatic not traumatic. Shh. Patients not quite the same patient population. They weren't definitively aneurysm all. And we've done a little bit of primitive research, and this is also still a little bit kind of raw data. But this just kind of gives you an idea of some of the work that we've been trying to do to try toe analyze, Um uh, this work and actually think I mixed up a couple of slides, so let me just go quickly. Thio This, um which is one of the other ideas that we were trying to One of the other sequences that we try Thio analyzes Well, eso bold sequencing using FM awry. So basically, it confers. I mentioned regional functional activation andan some studies. There has been some suggestion that, um, bold activity can correlate with strip of last year. Reserve that also that increase bold activity, many cortical areas concurrent with the associated with the pyramid working memory performance is listed there, and, um, on basically, we, um we've done some work on this. This this here is an example. We've been looking at adjacency matrices. Um, and again, this is still very preliminary as well. Um, you could see kind of the brain regions there on both sides. And again. Then the no line here is the one that's kind of at this 45 degree angle here on this brain here on the left here, which is an attempt to look at some of these networks as well. So again, very pre preliminary and looking at some of these networks and their connectivity. Um, but hopefully, um, we'll continue to have more, more data Um, And again, this this project generated a ton of data from these FM arise. Uh um, you know, I'm taking a course now. It's for my mph courses. And it turns out that medical imaging is comprises the largest proportion of basically Elektronik storage space in the world. And I don't think that's any surprise, because we certainly generated a lot of data from this from this project. So, um, just a brief, because I'm going over time, I think, perhaps, but there's a couple other sequences that are still somewhat experimental that we haven't yet added to our protocol. Trust is a sequence that hasn't been used in sub brecko and hemorrhage, but the ideas that could be combined with with other types of measures such a struggle blood flow to estimate auction extraction fraction and circle metabolic rate of auction nation. So it could be a potentially useful, um, sequence that could be used on summarecon hemorrhage. But still pretty experimental to my knowledge has only been done in control people so far, um and then magnetic resonance spectroscopy, which I understand it is no longer reimbursed by, um, some insurance companies. But in any event, uh, the idea being to analyze regional metabolite concentrations. And there's some studies that, you know, maybe it helps detect a scheme in Shh. Maybe it doesn't. It seems like the jury is a little bit still out regarding that, but has the potential perhaps to be useful, but again not used as much? Probably because it's not well reimbursed. So conclusions, uh, that I have here. So, uh, Amerian, Shh. Um, it seems as I mentioned at the top, uh, it's it is potentially hard to do. There are some obstacles to try to get it done and some artifacts that could get in our way. But, um, it seems that at least from the preliminary data that we have, that could be, uh, somewhat promising, though there's still a lot of data out there that, um, you know, needs to be done. And even in the project that I've been doing, this still needs to be analyzed. So could multimodal Amory B, um added is an addition to prognostic models in this in this disease? Well, that that is a little uncertain, too, but, um, there it seems like there could be some potential there, and then some uniformity against studies might be useful to, um, getting more patients doing, um, or uniformed type study where it's, uh, it's possible to actually do a lot more rigorous. Um, quantitative analysis Thio kind of drill down and see if this is actually useful, um, modality that can be used in prognostication in this, um, in this condition. Um and so I just wanted to thank some of the folks I've been working with at Hopkins on this project, the top to being the main mentors are working with. But a good deal of these folks have been, um, either undergrads have really stepped up to the plate or some image ing folks here who have really done some fantastic work and have helped me out a lot. And then the pictures on the right, if we're being nostalgic again and thinking about times when we used to travel is from Honolulu in 2013, when I was there for the SC, and that's all I had. Thank you. Thank you very much. I know they're a few questions day, Dr Nelson. Thanks so much. Is Alex again one of the nurses residence? E Think it's awesome. Some of these emery sequencing with bold and trust. I just had a quick question about the actual utility of them. You know, Are we able to do on our regular 1.5 t scan or do some of these sequences require, like, a three or 70? Because I know in the past, we've had trouble, um, gang, some of these, you know, critical impatient patients to an outpatient scanner. So I just question come utility of some of these sequences and you know, the usability of them in the Yeah, it's a great point. I should have brought that up a swell because it's, um, not always feasible to get these patients to the scanner that you want them to to get the scan done for variety of reasons. Most of the sequences that I mentioned are, uh, kind of more designed for three T, particularly the bold and the D. T I and things of that nature. So it is more designed for that, Um, for for three t um, and I will also say that towards your point about or how you brought up out patients there, it turns out that, um one drawback to our study has been the fact that the outpatients were actually scanned in a different three T scanner than the ones that were impatient. And that is strictly because of the practicability of and the safety of kind of transporting these patients to a scanner where they'd be safer than going to like an outpatient center. Scanners say, Um so but, uh, you're right, and then the other, the other issue to that sometimes arises to sometimes these patients some of the instrumentation that they get for, um, aneurysm. Secure mint isn't always compatible with with three t but is for 1.5 t. So that's sometimes an issue that has come up a swell. So it's a good point. Great. Thank you so much. Are you using DT clinically or do you know anybody doing that? Where the radiologist is analyzing the DT, I'm making comments with D T I and the interpretation. Yeah, that's a good question. So, um, it turns out that I don't I don't think a lot of people are using it clinically. A lot of the times, Frankly, when I've run this protocol with the sequences that I discussed, including D t. I, um, the radiologist almost seemed to kind of breeze right over that and the findings at the bottom that, you know, in the discuss the pressure of the porter generally related to the diffusion and flair and S O B I and all the, you know, the typical sequences and so and definitely less so on the on the on the d t I. But our hope is and and this is what we've been trying toe do through this project is try to come up with a way that these diffusion the D t I, the bowl, those types of sequences that could be, uh, run and a relatively quick manner, like an hour or so that so that we actually do get useful data that can be actually helpful to the clinician in real time. And that's been kind of one of the hopes from this project. Great. There are. There is some software that we use in operating room that will give you a quick and dirty d t. I assessment. Then you're able to incorporate that into your trajectory planning on and it doesn't give you, at this point quantified measurements, but it does let you at least see Andi and estimate What tracks you're gonna go through with different trajectories? There's kind of some preliminary automatic processing available, um, through brain lab. And I think a few other companies have that. Okay, that's awesome. Yeah, I'd love to learn more about that, too, so that sounds really cool. Really interesting. Any other questions? Okay, Sarah, thank you so much. All right. Thank you. Fantastic. Thanks for taking time while you're in service. We appreciate it. Look forward to seeing you here. Yeah. Thank you. You too. All right. Thanks, Everybody. Have a great day.