Multimodality Neuromonitoring and Decompressive Hemicraniectomy After Subarachnoid Hemorrhage
Background and Methods
We report the case of a young woman with delayed cerebral infarction and intracranial hypertension following subarachnoid hemorrhage requiring hemicraniectomy, who underwent multimodality neuromonitoring of the contralateral hemisphere before and after craniectomy.
Intracranial hypertension was preceded by signs of ischemia and impaired brain metabolism diagnosed through cerebral microdialysis and PbtO2 monitoring, as well as a decrease in cerebral perfusion pressure (CPP) to <40 mmHg despite increasing vasopressor requirements. We describe how a comprehensive multimodality neuromonitoring approach was utilized to inform the decision to perform an early decompressive hemicraniectomy. Post-operatively, CPP and intracranial pressure (ICP) normalized, and the patient was weaned off all pressors within hours. The modified Rankin score at 3 and 12 months was 5.
Delayed rescue hemicraniectomy can be life-saving after poor grade SAH. The role of multimodality brain monitoring for determining the optimal timing of hemicraniectomy deserves further study.
KeywordsIntracranial monitoring Multimodality brain monitoring Decompressive craniectomy Microdialysis Brain oxygen
This work was not funded by the National Institute of Health (NIH), Wellcome Trust, Howard Hughes Medical Institute (HHMI) or any other institution requiring open access.
- 5.D’Ambrosio AL, Sughrue ME, Yorgason JG, Mocco JD, Kreiter KT, Mayer SA, et al. Decompressive hemicraniectomy for poor-grade aneurysmal subarachnoid hemorrhage patients with associated intracerebral hemorrhage: clinical outcome and quality of life assessment. Neurosurgery. 2005;56(1):12–9, discussion 9–20.PubMedGoogle Scholar
- 13.Nelson DW, Bellander BM, Maccallum RM, Axelsson J, Alm M, Wallin M, et al. Cerebral microdialysis of patients with severe traumatic brain injury exhibits highly individualistic patterns as visualized by cluster analysis with self-organizing maps. Crit Care Med. 2004;32(12):2428–36.PubMedCrossRefGoogle Scholar