NCCEd: Neurocritical Care Education for Residents

The highest-quality data we have available is a 2021 pooled analysis of 1548 patients from 4 prospective multicenter studies; there has yet to be a high-quality RCT. (The most well-known included study was STASCIS.) In these studies and in this analysis, early surgery was defined as occurring within 24 hours of the injury. This paper found that early surgery was associated with improved motor and sensation scores and higher AIS grade at one year. The most recent 2024 Clinical Practice Guideline for the Management of Patients with Acute SCI recommends pursuing early surgical decompression be offered regardless of injury level.

You might be thinking: we must push up this patient's MAP! It's true that the most recent 2013 AANS and CNS guidelines recommend maintaining MAPs of 85-90mmHg for seven days following traumatic injury. However, the data is poor. Routine MAP augmentation as a standard of care is severely lacking in supportive evidence.

The data that inspired the AANS/CNS guidelines consisted of two low-quality observational studies from the 1990s. The duration of MAP augmentation was informed by primate models. A 2017 systematic review of studies of MAP augmentation in tSCI included 11 studies. All but one of these studies were single-arm studies that lacked a comparison group. Essentially, the patients' level of function was recorded upon their arrival and at a later time point in the study. A MAP goal wasn't actually targeted in these studies! Instead, time spent at each MAP tier was calculated. A more recent 2020 systematic review concluded that "the current literature is insufficient to make strong recommendations about interventions to support spinal cord perfusion via MAP or SCPP goals."

In considering whether to augment this patient's MAP, we also need to consider his cardiac function. Perfusion is dependent on more than just BP. This patient was noted to have NICM/HFrEF, with an LVEF of 35%. Systemic MAP can be considered to be afterload. So, if we significantly raise his afterload, we run a very real risk of decreasing his cardiac output-- and thus perfusion. Counterproductive. If you're still going to pursue this, then it's important to closely monitor their cardiac function along the way.