Neurocritical Care

, Volume 15, Issue 1, pp 146–150 | Cite as

Multimodality Neuromonitoring and Decompressive Hemicraniectomy After Subarachnoid Hemorrhage

  • Robert Morgan Stuart
  • Jan Claassen
  • Michael Schmidt
  • Raimund Helbok
  • Pedro Kurtz
  • Luis Fernandez
  • Kiwon Lee
  • Neeraj Badjatia
  • Stephan A. Mayer
  • Sean Lavine
  • E. Sander Connolly
Practical Pearl

Abstract

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.

Results

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.

Conclusions

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.

Keywords

Intracranial monitoring Multimodality brain monitoring Decompressive craniectomy Microdialysis Brain oxygen 

References

  1. 1.
    Vahedi K, Hofmeijer J, Juettler E, Vicaut E, George B, Algra A, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol. 2007;6(3):215–22.PubMedCrossRefGoogle Scholar
  2. 2.
    Kim KT, Park JK, Kang SG, Cho KS, Yoo DS, Jang DK, et al. Comparison of the effect of decompressive craniectomy on different neurosurgical diseases. Acta Neurochir (Wien). 2009;151(1):21–30.CrossRefGoogle Scholar
  3. 3.
    Vahedi K, Vicaut E, Mateo J, Kurtz A, Orabi M, Guichard JP, et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke. 2007;38(9):2506–17.PubMedCrossRefGoogle Scholar
  4. 4.
    Buschmann U, Yonekawa Y, Fortunati M, Cesnulis E, Keller E. Decompressive hemicraniectomy in patients with subarachnoid hemorrhage and intractable intracranial hypertension. Acta Neurochir (Wien). 2007;149(1):59–65.CrossRefGoogle Scholar
  5. 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
  6. 6.
    Schirmer CM, Hoit DA, Malek AM. Decompressive hemicraniectomy for the treatment of intractable intracranial hypertension after aneurysmal subarachnoid hemorrhage. Stroke. 2007;38(3):987–92.PubMedCrossRefGoogle Scholar
  7. 7.
    Smith ER, Carter BS, Ogilvy CS. Proposed use of prophylactic decompressive craniectomy in poor-grade aneurysmal subarachnoid hemorrhage patients presenting with associated large sylvian hematomas. Neurosurgery. 2002;51(1):117–24, discussion 24.PubMedCrossRefGoogle Scholar
  8. 8.
    Coplin WM, Cullen NK, Policherla PN, Vinas FC, Wilseck JM, Zafonte RD, et al. Safety and feasibility of craniectomy with duraplasty as the initial surgical intervention for severe traumatic brain injury. J Trauma. 2001;50(6):1050–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Guerra WK, Gaab MR, Dietz H, Mueller JU, Piek J, Fritsch MJ. Surgical decompression for traumatic brain swelling: indications and results. J Neurosurg. 1999;90(2):187–96.PubMedCrossRefGoogle Scholar
  10. 10.
    Munch E, Horn P, Schurer L, Piepgras A, Paul T, Schmiedek P. Management of severe traumatic brain injury by decompressive craniectomy. Neurosurgery. 2000;47(2):315–22, discussion 22–3.PubMedCrossRefGoogle Scholar
  11. 11.
    Strege RJ, Lang EW, Stark AM, Scheffner H, Fritsch MJ, Barth H, et al. Cerebral edema leading to decompressive craniectomy: an assessment of the preceding clinical and neuromonitoring trends. Neurol Res. 2003;25(5):510–5.PubMedCrossRefGoogle Scholar
  12. 12.
    Nordstrom CH, Reinstrup P, Xu W, Gardenfors A, Ungerstedt U. Assessment of the lower limit for cerebral perfusion pressure in severe head injuries by bedside monitoring of regional energy metabolism. Anesthesiology. 2003;98(4):809–14.PubMedCrossRefGoogle Scholar
  13. 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
  14. 14.
    Dohmen C, Bosche B, Graf R, Staub F, Kracht L, Sobesky J, et al. Prediction of malignant course in MCA infarction by PET and microdialysis. Stroke. 2003;34(9):2152–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Bardt TF, Unterberg AW, Hartl R, Kiening KL, Schneider GH, Lanksch WR. Monitoring of brain tissue PO2 in traumatic brain injury: effect of cerebral hypoxia on outcome. Acta Neurochir Suppl. 1998;71:153–6.PubMedGoogle Scholar
  16. 16.
    Kirkness CJ, Thompson HJ. Brain tissue oxygen monitoring in traumatic brain injury: cornerstone of care or another brick in the wall? Crit Care Med. 2009;37(1):371–2.PubMedCrossRefGoogle Scholar
  17. 17.
    Belli A, Sen J, Petzold A, Russo S, Kitchen N, Smith M. Metabolic failure precedes intracranial pressure rises in traumatic brain injury: a microdialysis study. Acta Neurochir (Wien). 2008;150(5):461–9, discussion 70.CrossRefGoogle Scholar
  18. 18.
    Unterberg AW, Sakowitz OW, Sarrafzadeh AS, Benndorf G, Lanksch WR. Role of bedside microdialysis in the diagnosis of cerebral vasospasm following aneurysmal subarachnoid hemorrhage. J Neurosurg. 2001;94(5):740–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Mayberg MR. Cerebral vasospasm. Neurosurg Clin N Am. 1998;9(3):615–27.PubMedGoogle Scholar
  20. 20.
    Shimoda M, Takeuchi M, Tominaga J, Oda S, Kumasaka A, Tsugane R. Asymptomatic versus symptomatic infarcts from vasospasm in patients with subarachnoid hemorrhage: serial magnetic resonance imaging. Neurosurgery. 2001;49(6):1341–8, discussion 8–50.PubMedCrossRefGoogle Scholar
  21. 21.
    Engstrom M, Polito A, Reinstrup P, Romner B, Ryding E, Ungerstedt U, et al. Intracerebral microdialysis in severe brain trauma: the importance of catheter location. J Neurosurg. 2005;102(3):460–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Berger C, Annecke A, Aschoff A, Spranger M, Schwab S. Neurochemical monitoring of fatal middle cerebral artery infarction. Stroke. 1999;30(2):460–3.PubMedCrossRefGoogle Scholar
  23. 23.
    Ushewokunze S, Sgouros S. Brain tissue oxygenation changes in children during the first 24 h following head injury. Childs Nerv Syst. 2009;25(3):341–5.PubMedCrossRefGoogle Scholar

Copyright information

© Humana Press Inc. 2009

Authors and Affiliations

  • Robert Morgan Stuart
    • 1
    • 3
  • Jan Claassen
    • 2
  • Michael Schmidt
    • 2
  • Raimund Helbok
    • 2
  • Pedro Kurtz
    • 2
  • Luis Fernandez
    • 2
  • Kiwon Lee
    • 2
  • Neeraj Badjatia
    • 2
  • Stephan A. Mayer
    • 2
  • Sean Lavine
    • 1
  • E. Sander Connolly
    • 1
  1. 1.Department of Neurological SurgeryColumbia University College of Physicians and SurgeonsNew YorkUSA
  2. 2.Division of Critical Care Neurology, Department of NeurologyColumbia University College of Physicians and SurgeonsNew YorkUSA
  3. 3.Department of Neurosurgery, Columbia-Presbyterian HospitalThe Neurological Institute of New YorkNew YorkUSA

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