Delayed Rise in Intracranial Pressure in Patients with Head Injury

Pankaj Ailawadhi , Deepak Agrawal

Department of Neurosurgery, JPN Apex Trauma centre, AIIMS, New Delhi

ICP MONITORING HI STORICAL PERSPECTIVE

- EARLIEST DESCRIPTIONS DATE BACK ALMOST 100 YEARS

- IN 1960, FIRST LARGE SERIES BY LUNDBERG ON DIRECT CONTINUOUS MONITORING

- IN 1977 , BECKER AND COLLEAGUES SUGGESTED ICP MONITORING TO BE INCLUDED AS A METHOD OF IMPROVING OUTCOME IN SEVERELY HEAD INJURED PATIENTS

ICP MONITORING

- METHODS

A. LUMBAR PUNCTURE ,FIRST DESCRIBED BY QUINCKE IN 1891 NOT PRACTICED B. CRANIAL INTRAVENTRICLAR INTRAPARENCHYMAL SUBDURAL SUBARACHNOID

- VALUES

GENERALLY ACCEPTED NORMAL RANGE IS 5 – 20 CM H2O

ICP > 20 IS SIGNIFICANT PREDICTOR OF INCREASED MORBIDITY AND WARRANTS TREATMENT

INDICATIONS OF ICP MONITORING AFTER TRAUMATIC BRAIN INJURY

1. GLASGOW COMA SCALE With A. An abnormal CT head scan Or B.. A normal CT head scan but with 2 or more high risk factors – Age >40 – Hypotension systolic BP <90mmHg – Abnormal motor posturing 2. PATIENTS WHO REQUIRE SEDATION AND VENTILATION hence making

clinical examination such as in a setting of multiple system injury.

3. POST SURGERY MONITORING

BUT THE QUESTION IS

WHEN TO MONITOR?

AND

WHEN TO DIRECTLY PROCEED WITH SURGERY ??

Diffuse Injury Grade CT appearance Mortality

I Normal CT scan 9.6%

II Cisterns present. Shift < 5mm

13.5%

III Cisterns compressed/absent.Shift < 5mm.

34%

IV Shift > 5mm 56.2%

CT BASED HEAD INJURY CLASSIFICATION BY MARSHALL

AIIMS AND OBJECTIVES

1. TO EVALUATE THE SIGNIFICANCE OF DELAYED RISE IN ICP AFTER TRAUMATIC BRAIN INJURY

2 . TO CHECK FOR ANY CORRELATION BETWEEN INITIAL CT FINDINGS AND NEUROLOGICAL OUTCOME .

MATERIAL AND METHODS

TYPE OF STUDY : PROSPECTIVE PLACE : JPNATC, AIIMS DURATION : 2 MONTHS

PATIENTS ENROLLED : - FULFILLING THE STANDARD C RITERIA OF

ICP MONITORING AS DESCRIBED

- PATIENTS WITH WELL DEFINED OPERABLE MASSES MORE THAN 1 CM IN DIAMETER

EXCLUDED FROM THE STUDY

MATERIAL AND METHODS( CONTD.)

PATIENTS ENROLLED - PATIENTS WITH DIFFUSE INJURY ,

HAEMMORHAGE , CONTUSION,

HEMISPHERICAL OEDEMA PRODUCING

MIDLINE SHIFT MORE THAN 5 MM WERE

EXCLUDED FROM STUDY

MATERIAL AND METHODS( CONTD.)

RADIOLOGY : NCCT HEAD ON PRESENTATION, DAY2 , DAY 3, AND AS PER CLINICAL STATUS

CT SCA NS EVALUATED FOR

- PRESCENCE OF EFFACEMENT OF CISTERNS (CISTERNS PRIMARILY EVALUATED

SUPRASELLLAR, PERIMESENCEPHALIC)

- MIDLINE SHIFT < OR > 5 MM

MATERIAL AND METHODS ( CONTD.)

MONITORING DEVICE : FIBREOPTIC CATHETERS

POSITION : INTRAPARENCHYMAL

MATERIAL S AND METHODS( CONTD.)

PATIENTS WERE DIVIDED IN 3 CATEGORIES:

1. INITIAL HIGH ICP (IHICP ) GROUP WITH INITIAL ICP >20 CM H2O

2. DELAYED HIGH ICP(DHICP) GROUP WITH INITIAL ICP < 20 CM H2O BUT WITH DELAYED RISE AFTER A VARIABLE PERIOD

3. NORMAL ICP( NICP )GROUP WITH ICP VALUES PERSISTENTLY<20

MATERIAL’S AND METHODS( CONTD.)

OUTCOMES ASSESSED BY USING GLASGOW OUTCOME SCALE : 1. DEAD 2. VEGETATIVE STATE unable to interact with environment, unresponsive 3. SEVERE DISABILITY able to follow commands/ Unable to live independently 4. MODERATE DISABILITY able to live independently /unable to return to work or school 5. GOOD RECOVERY able to return to work or school

RESULTS AND OUTCOMES

TOTAL PATIENTS EVALUATED :21

MALES : 21

FEMALES : O

RESULTS AND OUTCOMES

MODE OF INJURY

RTA : 15

FALL : 06

RESULTS AND OUTCOMES

AGE DISTRIBUTION

AGE RANGE : 15 - 50 YRS.

MEDIAN AGE : 30 YRS.

RESULTS AND OUTCOMES

TYPE OF INJURY

MODERATE : 3

SEVERE : 18

RESULTS AND OUTCOMES

GROUP 1 (IHICP)

TOTAL PATIENTS 5

MEAN ICP 35 cm h20

ABNORMAL CT 3

NORMAL CT 2

RESULTS AND OUTCOMES

GROUP 2 (DHICP)

TOTAL PATIENTS 6

MEAN INITIAL ICP 12 cm

ABNORMAL CT 4

NORMAL CT 2

RESULTS AND OUTCOMES

GROUP 2 (CONTD.)

PERIOD OF ICP MONITORING

RANGE 24- 92 HRS.

MEAN 66 HRS.

DELAYED ICP LEVELS

RANGE 21- 40 CM OF H2O

MEAN 30

GROUP 2

INITIAL CT WHEN ICP NORMALCT WHEN PT HAD DELAYED HICP

RESULTS AND OUTCOMES

GROUP 3 (NICP)

TOTAL PATIENTS 10

MEAN ICP 13 cm h20

ABNORMAL CT 2

NORMAL CT 8

RESULTS AND OUTCOME

CORRELATION OF INITIAL ABNORMAL CT AND FINAL SURGICAL MANAGEMENT

GROUP 1 3/3

GROUP 2 4/4 GROUP 3 0/2

TOTAL 7/9 ( 80%)

RESULTS AND OUTCOME

MORTALITY

GROUP 1 : NIL/5

GROUP 2 : 3/6

GROUP 3 : NIL /10

MORTALITY WAS SEEN ONLY IN GROUP 2 WHERE PT WERE KEPT ON INITIAL CONSERVATIVE MANAGEMENT DESPITE ABNORMAL CT BUT NORMAL INITIAL ICP VALUES

RESULTS AND OUTCOME

AS PER GOS

GROUP 1 : 3.2

GROUP 2 : 2.0

GROUP 3 : 3.2

REVIEW OF LITERATURE

Patients with either high-density or low-density lesions on computerized tomography (CT) at admission had a high incidence (53% to 63%) of intracranial hypertension (ICP persistently over 20 mm Hg).

Narayan RK, Greenberg RP, Miller JD, et al: Improved confidence of outcome prediction in severe head injury: a comparative analysis of the clinical examination, multimodality evoked potentials, CT scanning, and intracranial pressure. J Neurosurg 54:751–762, 1981

REVIEW OF LITERATURE

After traumatic brain injury (TBI), Half of the patients had their highest mean ICP during the first 3 days after injury, but many showed delayed ICP elevation, with 25% showing highest mean ICP after day 5. In these cases, HICP was significantly worse and required more intense therapies.

Nino Stocchetti, Angelo Colombo, Fabrizio Ortolano, Walter Videtta, Roberta Marchesi, Luca Longhi, Elisa R. Zanier. Time Course of Intracranial Hypertension after Traumatic Brain Injury Journal of Neurotrauma. August 2007, 24(8): 1339-1346.

REVIEW OF LITERATURE

The mortality rates were 77%, 39%, and 22% among those with absent, compressed, and normal basal cisterns Patients with GCS scores of 6 to 8, with cisterns absent or not visualized, suffered nearly a fourfold additional risk of poor outcome, compared to those with normal cisterns

Toutant S, Klauber MR, Marshall L et al. Absent or compressed basal cisterns on the first CT scan: ominous predictors of outcome in severe head injury. J Neurosurg 61:691-694, 1984

CONCLUSIONS

1. Delayed ICP rise , known phenomenon after traumatic head injury is associated with poor prognosis.

2. 80% of patients with abnormal CT developed raised ICP (initial or delayed) and required subsequent Surgery.

3.Patients of head injury with effaced cisterns on initial CT head and delayed rise in ICP in our study had the worst outcome(GOS2).