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Verticalization for Refractory Intracranial Hypertension: A Case Series

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Abstract

Background

Severe intracranial hypertension is strongly associated with mortality. Guidelines recommend medical management involving sedation, hyperosmotic agents, barbiturates, hypothermia, and surgical intervention. When these interventions are maximized or are contraindicated, refractory intracranial hypertension poses risk for herniation and death. We describe a novel intervention of verticalization for treating intracranial hypertension refractory to aggressive medical treatment.

Methods

This study was a single-center retrospective review of six cases of refractory intracranial hypertension in a tertiary care center. All patients were treated with a standard-of-care algorithm for lowering intracranial pressure (ICP) yet maintained an ICP greater than 20 mmHg. They were then treated with verticalization for at least 24 h. We compared the median ICP, the number of ICP spikes greater than 20 mmHg, and the percentage of ICP values greater than 20 mmHg in the 24 h before verticalization vs. after verticalization. We assessed the use of hyperosmotic therapies and any changes in the mean arterial pressure and cerebral perfusion pressure related with the intervention.

Results

Five patients were admitted with subarachnoid hemorrhage and one with intracerebral hemorrhage. All patients had ICP monitoring by external ventricular drain. The median opening pressure was 30 mmHg (25th–75th interquartile range 22.5–30 mmHg). All patients demonstrated a reduction in ICP after verticalization, with a significant decrease in the median ICP (12 vs. 8 mmHg; p < 0.001), the number of ICP spikes (12 vs. 2; p < 0.01), and the percentage of ICP values greater than 20 mmHg (50% vs. 8.3%; p < 0.01). There was a decrease in total medical interventions after verticalization (79 vs. 41; p = 0.05) and a lower total therapy intensity level score after verticalization. The most common adverse effects included asymptomatic bradycardia (n = 3) and pressure wounds (n = 4).

Conclusions

Verticalization is an effective noninvasive intervention for lowering ICP in intracranial hypertension that is refractory to aggressive standard management and warrants further study.

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Funding

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Authors and Affiliations

  1. Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA

    Brittany Bolduc Lachance, WanTsu Chang, Melissa Motta, Gunjan Parikh, Jamie Podell, Neeraj Badjatia & Nicholas A. Morris

  2. Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, 21201, USA

    WanTsu Chang

  3. Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, 21201, USA

    J. Marc Simard & Gary T. Schwartzbauer

Authors
  1. Brittany Bolduc Lachance
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  2. WanTsu Chang
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  9. Nicholas A. Morris
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Contributions

All authors made substantial contributions to the conception and design, acquisition of data, and/or analysis and interpretation of data. All authors provided critical revision of the manuscript content, and all authors approved the final version of the manuscript for publication.

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Correspondence to Brittany Bolduc Lachance.

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12028_2021_1323_MOESM1_ESM.docx

LR: Lindegaard Ratio; MCA: Middle Cerebral Artery; MV: Mean Velocity; PBD: Post-Bleed Day; PI: Pulsatility Index; SAH: Subarachnoid Hemorrhage; TCD: Transcranial Doppler. (DOCX 18 kb)

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Lachance, B.B., Chang, W., Motta, M. et al. Verticalization for Refractory Intracranial Hypertension: A Case Series. Neurocrit Care 36, 463–470 (2022). https://doi.org/10.1007/s12028-021-01323-z

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  • DOI: https://doi.org/10.1007/s12028-021-01323-z

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