Acta Neurochirurgica

, Volume 159, Issue 4, pp 615–622 | Cite as

Intracranial pressure monitoring after primary decompressive craniectomy in traumatic brain injury: a clinical study

  • Edoardo Picetti
  • Maria Luisa Caspani
  • Corrado Iaccarino
  • Giulia Pastorello
  • Pierpaolo Salsi
  • Edoardo Viaroli
  • Franco Servadei
Original Article - Brain Injury

Abstract

Background

Intracranial pressure (ICP) monitoring represents an important tool in the management of traumatic brain injury (TBI). Although current information exists regarding ICP monitoring in secondary decompressive craniectomy (DC), little is known after primary DC following emergency hematoma evacuation.

Methods

Retrospective analysis of prospectively collected data. Inclusion criteria were age ≥18 years and admission to the intensive care unit (ICU) for TBI and ICP monitoring after primary DC. Exclusion criteria were ICU length of stay (LOS) <1 day and pregnancy. Major objectives were: (1) to analyze changes in ICP/cerebral perfusion pressure (CPP) after primary DC, (2) to evaluate the relationship between ICP/CPP and neurological outcome and (3) to characterize and evaluate ICP-driven therapies after DC.

Results

A total of 34 patients were enrolled. Over 308 days of ICP/CPP monitoring, 130 days with at least one episode of intracranial hypertension (26 patients, 76.5%) and 57 days with at least one episode of CPP <60 mmHg (22 patients, 64.7%) were recorded. A statistically significant relationship was discovered between the Glasgow Outcome Scale (GOS) scores and mean post-decompression ICP (p < 0.04) and between GOS and CPP minimum (CPPmin) (p < 0.04). After DC, persisting intracranial hypertension was treated with: barbiturate coma (n = 7, 20.6%), external ventricular drain (EVD) (n = 4, 11.8%), DC diameter widening (n = 1, 2.9%) and removal of newly formed hematomas (n = 3, 8.8%).

Conclusion

Intracranial hypertension and/or low CPP occurs frequently after primary DC; their occurence is associated with an unfavorable neurological outcome. ICP monitoring appears useful in guiding therapy after primary DC.

Keywords

Intracranial pressure Cerebral perfusion pressure Monitoring Primary decompressive craniectomy Traumatic brain injury Outcome 

References

  1. 1.
    Aarabi B, Hesdorffer DC, Ahn ES, Aresco C, Scalea TM, Eisenberg HM (2006) Outcome following decompressive craniectomy for malignant swelling due to severe head injury. J Neurosurg 104(4):469–479CrossRefPubMedGoogle Scholar
  2. 2.
    Baker SP, O’Neill B, Haddon W Jr, Long WB (1974) The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 14(3):187–196CrossRefPubMedGoogle Scholar
  3. 3.
    Brain Trauma Foundation, American Association of Neurological Surgeons (AANS), Congress of Neurological Surgeons (CNS), AANS/CNS Join Section on Neurotrauma and Critical Care (2007) Guidelines for the management of severe traumatic brain injury, 3rd edition. J Neurotrauma 24(suppl 1):S1–S106Google Scholar
  4. 4.
    Carney N, Totten AM, OʼReilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N, Rubiano AM, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Ghajar J (2016) Guidelines for the management of severe traumatic brain injury, Fourth Edition. Neurosurgery. doi:10.1227/NEU.0000000000001432 PubMedGoogle Scholar
  5. 5.
    Chesnut RM (2015) A conceptual approach to managing severe traumatic brain injury in a time of uncertainty. Ann N Y Acad Sci 1345:99–107CrossRefPubMedGoogle Scholar
  6. 6.
    Chesnut RM (2015) What is wrong with the tenets underpinning current management of severe traumatic brain injury? Ann N Y Acad Sci 1345:74–82CrossRefPubMedGoogle Scholar
  7. 7.
    Chesnut RM, Bleck TP, Citerio G, Classen J, Cooper DJ, Coplin WM, Diringer MN, Grände PO, Hemphill JC 3rd, Hutchinson PJ, Le Roux P, Mayer SA, Menon DK, Myburgh JA, Okonkwo DO, Robertson CS, Sahuquillo J, Stocchetti N, Sung G, Temkin N, Vespa PM, Videtta W, Yonas H (2015) A consensus-based interpretation of the benchmark evidence from South American trials: treatment of intracranial pressure trial. J Neurotrauma 32(22):1722–1724CrossRefPubMedGoogle Scholar
  8. 8.
    Chesnut RM, Temkin N, Carney N, Dikmen S, Rondina C, Videtta W, Petroni G, Lujan S, Pridgeon J, Barber J, Machamer J, Chaddock K, Celix JM, Cherner M, Hendrix T, Global Neurotrauma Research Group (2012) A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med 367(26):2471–2481CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Chesnut R, Videtta W, Vespa P, Le Roux P, Participants in the International Multidisciplinary Consensus Conference on Multimodality Monitoring (2014) Intracranial pressure monitoring: fundamental considerations and rationale for monitoring. Neurocrit Care 21(Suppl 2):S64–S84CrossRefPubMedGoogle Scholar
  10. 10.
    Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D’Urso P, Kossmann T, Ponsford J, Seppelt I, Reilly P, Wolfe R, DECRA Trial Investigators; Australian and New Zealand Intensive Care Society Clinical Trials Group (2011) Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 364(16):1493–1502CrossRefPubMedGoogle Scholar
  11. 11.
    Cremer OL, van Dijk GW, van Wensen E, Brekelmans GJ, Moons KG, Leenen LP, Kalkman CJ (2005) Effect of intracranial pressure monitoring and targeted intensive care on functional outcome after severe head injury. Crit Care Med 33(10):2207–2213CrossRefPubMedGoogle Scholar
  12. 12.
    Flint AC, Manley GT, Gean AD, Hemphill JC 3rd, Rosenthal G (2008) Post-operative expansion of hemorrhagic contusions after unilateral decompressive hemicraniectomy in severe traumatic brain injury. J Neurotrauma 25:503–512CrossRefPubMedGoogle Scholar
  13. 13.
    Güiza F, Depreitere B, Piper I, Citerio G, Chambers I, Jones PA, Lo TY, Enblad P, Nillson P, Feyen B, Jorens P, Maas A, Schuhmann MU, Donald R, Moss L, Van den Berghe G, Meyfroidt G (2015) Visualizing the pressure and time burden of intracranial hypertension in adult and paediatric traumatic brain injury. Intensive Care Med 41(6):1067–1076CrossRefPubMedGoogle Scholar
  14. 14.
    Hamilton R, Xu P, Asgari S, Kasprowicz M, Vespa P, Bergsneider M, Hu X (2009) Forecasting intracranial pressure elevation using pulse waveform morphology. Conf Proc IEEE Eng Med Biol Soc 2009:4331–4334PubMedGoogle Scholar
  15. 15.
    Hu X, Xu P, Scalzo F, Vespa P, Bergsneider M (2009) Morphological clustering and analysis of continuous intracranial pressure. IEEE Trans Biomed Eng 56(3):696–705CrossRefPubMedGoogle Scholar
  16. 16.
    Huang YH, Lee TC, Lee TH, Yang KY, Liao CC (2013) Remote epidural hemorrhage after unilateral decompressive hemicraniectomy in brain-injured patients. J Neurotrauma 30:96–101CrossRefPubMedGoogle Scholar
  17. 17.
    Huang YH, Ou CY (2016) Prognostic impact of intracranial pressure monitoring after primary decompressive craniectomy for traumatic brain injury. World Neurosurg 88:59–63CrossRefPubMedGoogle Scholar
  18. 18.
    Jennett B, Bond M (1975) Assessment of outcome after severe brain damage. Lancet 1(7905):480–484CrossRefPubMedGoogle Scholar
  19. 19.
    Kolias AG, Kirkpatrick PJ, Hutchinson PJ (2013) Decompressive craniectomy: past, present and future. Nat Rev Neurol 9(7):405–415CrossRefPubMedGoogle Scholar
  20. 20.
    Le Gall JR, Lemeshow S, Saulnier F (1993) A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 270(24):2957–2963CrossRefPubMedGoogle Scholar
  21. 21.
    Maas AI, Hukkelhoven CW, Marshall LF, Steyerberg EW (2005) Prediction of outcome in traumatic brain injury with computed tomographic characteristics: a comparison between the computed tomographic classification and combinations of computed tomographic predictors. Neurosurgery 57(6):1173–1182CrossRefPubMedGoogle Scholar
  22. 22.
    Maas AI, Stocchetti N, Bullock R (2008) Moderate and severe traumatic brain injury in adults. Lancet Neurol 7(8):728–741CrossRefPubMedGoogle Scholar
  23. 23.
    Marmarou A, Eisenberg HM, Foulkes MA, Marshall LF, Jane JA (1991) Impact of ICP instability and hypotension on outcome in patients with severe head trauma. J Neurosurg 75(1S):S59–S66Google Scholar
  24. 24.
    Olivecrona M, Rodling-Wahlström M, Naredi S, Koskinen LO (2007) Effective ICP reduction by decompressive craniectomy in patients with severe traumatic brain injury treated by an ICP-targeted therapy. J Neurotrauma 24(6):927–935CrossRefPubMedGoogle Scholar
  25. 25.
    Rangel-Castilla L, Gasco J, Nauta HJ, Okonkwo DO, Robertson CS (2008) Cerebral pressure autoregulation in traumatic brain injury. Neurosurg Focus 25(4):E7CrossRefPubMedGoogle Scholar
  26. 26.
    Roozenbeek B, Maas AI, Menon DK (2013) Changing patterns in the epidemiology of traumatic brain injury. Nat Rev Neurol 9(4):231–236CrossRefPubMedGoogle Scholar
  27. 27.
    Servadei F, Compagnone C, Sahuquillo J (2007) The role of surgery in traumatic brain injury. Curr Opin Crit Care 13(2):163–168CrossRefPubMedGoogle Scholar
  28. 28.
    Shafi S, Diaz-Arrastia R, Madden C, Gentilello L (2008) Intracranial pressure monitoring in brain-injured patients is associated with worsening of survival. J Trauma 64(2):335–340CrossRefPubMedGoogle Scholar
  29. 29.
    Stiver SI (2009) Complications of decompressive craniectomy for traumatic brain injury. Neurosurg Focus 26(6):E7CrossRefPubMedGoogle Scholar
  30. 30.
    Stocchetti N, Maas AI (2014) Traumatic intracranial hypertension. N Engl J Med 370(22):2121–2130CrossRefPubMedGoogle Scholar
  31. 31.
    Stocchetti N, Picetti E, Berardino M, Buki A, Chesnut RM, Fountas KN, Horn P, Hutchinson PJ, Iaccarino C, Kolias AG, Koskinen LO, Latronico N, Maas AI, Payen JF, Rosenthal G, Sahuquillo J, Signoretti S, Soustiel JF, Servadei F (2014) Clinical applications of intracranial pressure monitoring in traumatic brain injury: report of the Milan Consensus Conference. Acta Neurochir (Wien) 156(8):1615–1622CrossRefGoogle Scholar
  32. 32.
    Stocchetti N, Zanaboni C, Colombo A, Citerio G, Beretta L, Ghisoni L, Zanier ER, Canavesi K (2008) Refractory intracranial hypertension and “second-tier” therapies in traumatic brain injury. Intensive Care Med 34(3):461–467CrossRefPubMedGoogle Scholar
  33. 33.
    Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet 2(7872):81–84CrossRefPubMedGoogle Scholar
  34. 34.
    Vik A, Nag T, Fredriksli OA, Skandsen T, Moen KG, Schirmer-Mikalsen K, Manley GT (2008) Relationship of “dose” of intracranial hypertension to outcome in severe traumatic brain injury. J Neurosurg 109(4):678–684CrossRefPubMedGoogle Scholar
  35. 35.
    Zeng J, Tong W, Zheng P (2013) Decreased risk of acute kidney injury with intracranial pressure monitoring in patients with moderate or severe brain injury. J Neurosurg 119(5):1228–1232CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Wien 2017

Authors and Affiliations

  1. 1.I Servizio Anestesia RianimazioneAzienda Ospedaliero Universitaria di ParmaParmaItaly
  2. 2.Neurochirugia e NeurotraumatologiaAzienda Ospedaliero Universitaria di Parma and Arcispedale Santa Maria Nuova di Reggio EmiliaParma and Reggio EmiliaItaly
  3. 3.Servizio di Anestesia e RianimazioneArcispedale Santa Maria Nuova di Reggio EmiliaReggio EmiliaItaly

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