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Neurologie und Poliklinik

CRITICAL CARE OF STROKE

OVERVIEW

Severe ischemic or hemorrhagic stroke is a catastrophic burden, particularly if patients need mechanical ventilation and admission to a neuro-intensive care unit (NICU). While past studies have suggested a very bad prognosis and poor outcome in most of these patients, more recent evidence clearly demonstrates the potential of dedicated, individualized and at times aggressive care to improve these patients´ mortality and morbidity. The decisive steps in the multimodal NICU treatment, however, are still not well understood.

 

Our study group is dedicated to the analysis and better understanding of critical care aspects of cerebrovascular disease. The aim is to improve the management of patients with severe ischemic and hemorrhagic stroke (large vessel occlusion ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage) in the acute and critical care setting. Our research is entirely clinical or has a strong relationship to real-life clinical situations. The overarching connection of our studies is optimal brain oxygenation after severe vascular brain damage. This affects treatment aspects as diverse as transfusion for anemia, optimal airway and ventilation setting, sedation during interventions and the NICU stay, and the monitoring of brain oxygen.

 

Our studies focus on the monitoring of cerebral oxygenation by non-invasive neuromonitoring (e.g. by near-infrared spectroscopy, COMMAND (Hametner J Cereb Blood Flow Metab  2015), the role of hemoglobin (i.e. impact of NICU anemia and transfusion on stroke outcome, STRAIGHT (Kellert Stroke 2011, Kellert Cerebrovasc Dis Ex 2012, Kellert J Crit Care 2014), oxygen- and energy-saving sedation (e.g. by volatile anesthetics, VANISH (Bösel Int Care Med 2012, Purrucker Br J Anaesth 2015) and the optimal sedation and airway management either during endovascular treatment of large vessel occlusion stroke (e.g. general anesthesia with intubation vs conscious sedation without intubation, SIESTA (Schönenberger Int J Stroke 2015, JAMA 2016), NAVIGATE (Mundiyanapurath J Stroke Cerebrovasc Dis 2015, Mundiyanapurath J Neurointerv Surg. 2016) ) or during long-term intensive care unit ventilation (e.g. early tracheostomy, SETPOINT (Bösel Int J Stroke 2012; Bösel Stroke 2013), SETscore (Schönenberger Neurocrit Care 2015)).

 

Our group has strong collaborative ties with national (Deutsche Gesellschaft für Neuro-Intensiv- und Notfallmedizin DGNI and its research network IGNITE, Deutsche Vereinigung für Interdisziplinäre Intensiv- und Notfallmedizin DIVI) and international (Neurocritical Care Society, NCS) societies and study groups. Over the last years, our group has participated successfully and been awarded in multicenter NICU stroke studies such as DESTINYII, DEPTH-SOS, CLEAR-IVH III, INCH, and ATACH II.

 

In addition to monocentric and mechanistic studies (e.g. noninvasive neuromonitoring by pupillometry, INSPIRE, Jansen, Rasch) we lead (inter)national multicenter trials directed at safety and functional outcome (e.g. volatile sedation in SAH, VANQUISH, Purrucker, Vermehren; deep vs moderate sedation in severe stroke, MODERNISE, Schönenberger). Our group leads a collaborative German-US randomized controlled trial - SETPOINT2 - comparing early with late tracheostomy in ventilated stroke patients (Schönenberger Int J Stroke 2016).

 

Future work will focus on the one hand on intensifying prospective multicenter and network research in critical care of stroke with emphasis on brain oxygenation, noninvasive neuromonitoring, airway and ventilation management of NICU stroke patients. The participation in running or upcoming multicenter trials on large hemispheric stroke, normothermia, and severe cerebral venous and sinus thrombosis is in planning. On the other hand, we will put more focus on critical care aspects of severe stroke outside the NICU, i.e. in the acute and emergency setting. One major research area here will continue to be the periinterventional management of stroke thrombectomy. We will perform several substudies following up the SIESTA trial on pathophysiological mechanisms of certain sedation modes, airway and ventilation measures, and start new studies to elucidate ways to further optimize patient care before, during and after stroke thrombectomy.

 

 

Survival benefit of early vs. late tracheostomy in mechanically ventilated patients with severe stroke. (Bösel J, Schiller P, Hook Y, Andes M, Neumann JO, Poli S, Amiri H, Schönenberger S, Peng Z, Unterberg A, Hacke W, Steiner T. Stroke-related Early Tracheostomy versus Prolonged Orotracheal Intubation in Neurocritical Care Trial (SETPOINT): a randomized pilot trial. Stroke 2013 Jan;44(1):21-8)

 

SELECTED PUBLICATIONS

Schönenberger S, Möhlenbruch M, Pfaff J, Mundiyanapurath S, Kieser M, Bendszus M, Hacke W, Bösel J. Sedation vs. Intubation for Endovascular Stroke TreAtment (SIESTA) - a randomized monocentric trial. Int J Stroke  2015;10(6):969-78

 

Hametner C, Stanarcevic P, Stampfl S, Rohde S, Veltkamp R, Bösel J. Noninvasive cerebral oximetry during endovascular therapy for acute ischemic stroke: an observational study. J Cereb Blood Flow Metab  2015;35(11):1722-8

 

Purrucker JC, Renzland J, Uhlmann L, Bruckner T, Hacke W, Steiner T,Bösel J. Volatile sedation with sevoflurane in intensive care patients with acute stroke or subarachnoid haemorrhage using AnaConDa®: an observational study. Br J Anaesth 2015;114(6):934-43

 

Bösel J, Schiller P, Hook Y, Andes M, Neumann JO, Poli S, Amiri H, Schönenberger S, Peng Z, Unterberg A, Hacke W, Steiner T. Stroke-related Early Tracheostomy versus Prolonged Orotracheal Intubation in Neurocritical Care Trial (SETPOINT): a randomized pilot trial. Stroke 2013;44(1):21-8

 

Bösel J, Purrucker JC, Nowak F, Renzland J, Schiller P, Pérez EB, Poli S, Brunn B, Hacke W, Steiner T. Volatile isoflurane sedation in cerebrovascular intensive care patients using AnaConDa(®): effects on cerebral oxygenation, circulation, and pressure. Intensive Care Med 2012;38(12):1955-64

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CONTACT

€Julian Bösel

Tel: +49 (0) 6221 – 56 39145

julian.boesel@med.uni-heidelberg.de

 

GROUP MEMBERS

Faisal Ben-Swuaidan

Juilan Bösel

Christian Hametner Jonabelle Jansen

Lars Kellert

Igor Milet

Sibu Mundiyanapurath

Jan Purrucker

Christina Rasch

Simon Schieber

Silvia Schönenberger

David Seder

Frank Stachulski

Predrag Stanarcevic

Matthias Ungerer

Philipp Vermehren