Nerazmjer između podataka za intrakranijski i cerebralni perfuzijski tlak te neuroloških nalaza u bolesnika s teškom ozljedom glave: prikaz slučaja

A 48-year-old man with relative hepatic impairment, thrombocytopenia and chronic alcoholism was admitted to intensive care unit six hours after head trauma. Computed tomography (CT) scan at admission indicated cerebral edema and subdural hematoma. Glasgow Coma Score (GCS) was 5, and his pupils were 4 mm in diameter without response. Decompression craniotomy with evacuation of hematoma was performed, and a ventricular catheter was introduced for intracranial pressure (ICP) monitoring. After the operation, there was no change in the neurologic status. ICP/CPP and jugular vein oxygen saturation (SvjO2) were continuously monitored and data were collected in hour-to-hour manner. Therapeutic goal was to optimize ICP and cerebral perfusion pressure (CPP) in accordance with the Guidelines for the Management of Severe Head Injury. Mannitol and barbiturates were not used in therapeutic procedures. Normocapnic values of PCO2 were maintained. During the first six hours postoperatively, the patient was stabilized hematologically and hemodynamically. At 24 hours postoperatively, there was no improvement in the neurologic status in spite of optimal values of ICP/CPP and SvjO2: GCS 5, pupils 4 mm with no response. The reason for this was detected on 24-hour CT scan, which revealed thalamic and pontine hemorrhage (mesencephalon lesion) with ischemia in the occipital region.Muškarac star 48 godina s relativnim oštećenjem jetre, trombocitopenijom i kroničnim alkoholizmom u anamnezi primljen je u jedinicu intenzivnog liječenja šest sati nakon ozljede glave. Nalaz kompjutorizirane tomografije (CT) kod prijma pokazao je subduralni hematom i edem mozga. Kod primitka, Glasgow Coma Score (GCS) bio je 5, zjenice 4 mm izokorične i nereaktivne. Učinjena je dekompresijska kraniotomija s evakuacijom hematoma, te je postavljen kateter za mjerenje intrakranijskog tlaka (ICP). Kontinuirano su mjereni ICP, cerebralni perfuzijski tlak (CPP), zasićenje jugularne vene kisikom (Svj O2) i CO2. Nakon 24 sata nije došlo do neurološkog poboljšanja unatoč tome što su postignute željene terapijske vrijednosti svih praćenih parametara. Kontrolni CT mozga pokazao je krvarenje u ponsu i talamusu, te ishemiju okcipitalno, zbog čega je izostalo poboljšanje neurološkog statusa. Kasna dijagnostika i nedostupnost za terapiju dubokih i infratentorijalnih ozljeda mozga problem su u svakodnevnom liječenju ovih bolesnika