Intrcranial pressure (ICP) monitoring was carried out in 100 patients with severe acute brain trauma, primarily by means of a subarachnoid catheter. Statistical associations were evaluated between maximum ICP values and: 1) Glasgow Coma Scale (GCS) scores; 2) findings on computed tomography (CT) scans of the head; and 3) mortality. A significant association was found between low GCS scores (3 to 5) and high ICP levels, as well as between focal lesions on CT scans and elevated ICP. Mortality was significantly higher in patients with ICP > 40 mm Hg than in those;vith ICP less than or equal to 20 mm Hg.533A39039

ARAUJO, S

DANTAS, VP

DRAGOSAVAC, D

FALCAO, ALE

QUAGLIATO, EMAB

SARDINHA, LAC

TERZI, RGG

Arquivos de Neuro-Psiquiatria

Repositorio da Producao Cientifica e Intelectual da Unicamp

HIGHLIGHTING INTRACRANIAL PRESSURE MONITORING IN PATIENTS WITH SEVERE ACUTE BRAIN TRAUMA 
ANTONIO L. E FALCÃO*, VENÂNCIO P. DANTAS FILHO*, LUIZ A. C. SARDINHA*, ELIZABETH M. A. B. QUAGLIATO**, DESANKA DRAGOSAVAC*, SEBASTIÃO ARAÚJO*, RENATO G. G. TERZI* 
SUMMARY - Intracranial pressure (ICP) monitoring was carried out in 100 patients with severe acute brain 
trauma, primarily by means of a subarachnoid catheter. Statistical associations were evaluated between maximum 
ICP values and: 1) Glasgow Coma Scale (GCS) scores; 2) findings on computed tomography (CT) scans of the 
head; and 3) mortality. A significant association was found between low GCS scores (3 to 5) and high ICP 
levels, as well as between focal lesions on CT scans and elevated ICP. Mortality was significantly higher in 
patients with ICP > 40 mm Hg than in those with ICP < 20 mm Hg. 
KEY WORDS: head injury, intracranial pressure, coma. 
Ressaltando a monitorização da pressão intracraniana em pacientes com traumatismo cerebral agudo 
grave 
RESUMO - Monitorização da pressão intracraniana (PIC) foi adotada em 100 pacientes com traumatismo 
cerebral agudo grave, usando-se preferencialmente um catéter subaracnóide. Associações estatísticas foram 
avaliadas entre valores máximos de PIC e : 1) número de pontos na Escala de Coma de Glasgow (ECG); 2) 
achados na tomografia computadorizada (TC) da cabeça; e 3) mortalidade. Encontrou-se associação significante 
entre baixo número de pontos (3 a 5) na ECG e PIC elevada, assim como entre lesões focais na TC e hipertensão 
intracraniana. A mortalidade foi significantemente maior em pacientes com PIC > 40 mm Hg do que naqueles 
com PIC < 20 mm Hg. 
PALAVRAS-CHAVE: traumatismo cerebral, pressão intracraniana, coma. 
Continuous monitoring of intracranial pressure (ICP) in humans was first proposed by 
Guillaume and Janny10. This landmark contribution was followed by extensive work of Lundberg on 
the same subject11, where ICP patterns were more thoroughly established. Post-traumatic intracranial 
hypertension has been associated with increased morbidity and mortality 1 2 1 4. When elevated ICP 
occurs, cerebral blood flow may decrease7. Conversely, increases in cerebral blood flow (cerebral 
luxury perfusion) may also significantly contribute to relevant ICP increments 4- 5 1 7. In addition to 
cerebral hemodynamic changes, brain edema may also play a role in the pathophysiology of intracranial 
hypertension6 9. 
Routine ICP monitoring has been adopted at our institution since 1989. Over the years, our 
preference has been for subarachnoid catheter monitoring. This technique appears to satisfactorily 
comply with clinical requirements, particularly because it is practical, inexpensive, and carries just 
a small risk of complications. The present work is an outgrowth of our experience. Attempts were 
Intensive Care Unit* and Department of Neurology**, Hospital das Clinicas, Universidade Estadual de 
Campinas (UNICAMP), São Paulo. Aceite: 22-fevereiro-1995. 
Dr. Antonio L. E. Falcão - Rua Dr. Lauro Pimentel 195 - Cidade Universitária, UNICAMP -13083-250 Campinas 
SP - Brasil. 
made to delineate statistical associations between elevated ICP and other parameters related to the 
diagnosis and management of severe acute brain trauma. 
CLINICAL MATERIAL AND METHODS 
During the period from June 1989 to April 1992, one hundred patients were prospectively evaluated in 
our Intensive Care Unit (ICU). Age ranged from 11 to 70 years, with 81 % of the patients in the range of 11 to 40 
years. There were 81 males and 19 females. All patients were comatose, with Glasgow Coma Scale 2 0 (GCS) 
scores of 8 or less on admission to the ICU. Automobile accidents represented the most frequent cause of injury 
(54%), followed by motorcycle accidents (17%) and other causes (29%). 
All patients underwent mechanical ventilation and ICP monitoring. The latter was by means of a 
subarachnoid catheter in 89 of the patients, or a subarachnoid bolt in the remaining 11. Placement of the ICP 
monitor was in the ICU, at bedside, in most patients. Only if acute surgical lesions were diagnosed, ICP monitors 
were placed in the operating room, immediately after intracranial surgery. The catheter was filled with a 
cephalosporin. As to complications of this technique, only one patient (1%) developed cerebrospinal fluid 
infection which responded to therapy. 
For classification purposes, ICP was considered normal if < 10 mm Hg, mildly elevated if from 11 to 20 
mm Hg, moderately elevated if from 21 to 40 mm Hg, and markedly elevated if > 40 mm Hg. Intracranial 
hypertension was managed according to a cumulative protocol to maintain ICP below 20 mm Hg 2 . According to 
Cruz protocol, in addition to therapeutic ICP normalization, we have also recently attempted to maintain 
normalized cerebral extraction of oxygen (CEO,) 3 - 5 (arteriojugular oxyhemoglobin saturation difference). This 
additional management modality is because CEO, normalization represents adequate therapeutic match between 
global cerebral consumption of oxygen and cerebral blood flow 3 5 . 
Statistical associations were evaluated between ICP and : 1) GCS scores on admission to the ICU; 2) 
predominant findings on the admission computed tomography (CT) scan of the head; and 3) mortality. Statistically 
assessed ICP values were the highest documented throughout the acute phase. Chi-squared test (with Yates' 
correction if necessary) was used for statistical evaluation, and a p value < 0.05 was considered significant. 
RESULTS 
There was a significant association between low GCS scores (3 to 5) and severe intracranial 
hypertension (Table 1). Likewise, there was a significant association between predominantly focal 
CT findings and markedly elevated ICP (Table 2). A significant association was also found between 
mortality and severe intracranial hypertension (Table 3). 
DISCUSSION 
ICP monitoring 
Intracranial pressure monitoring in patients with acute traumatic coma has been advocated 
under a variety of circumstances. While Miller has previously proposed ICP monitoring in all comatose 
patients with acute brain injuries15, Cruz has recently reported ICP and C E 0 2 monitoring in selected 
patients only, in whom the cerebrospinal fluid spaces were compromised. This excluded patients 
with normal CT findings, and those with pure diffuse axonal injury (without associated brain 
swelling)5. 
ICP monitoring has also been addressed as a means of monitoring cerebral perfusion pressure 
(the difference between mean arterial pressure and intracranial pressure). In fact, this monitoring 
capability has been advocated as a guide for management of cerebral perfusion pressure, besides 
I C p l 4 . 1 5 . 1 8 
Conversely, management of severely brain-injured patients has also been reported without 
ICP monitoring19. In this single report by Stuart and co-workers, the overall mortality rate was 34%. 
However, a comparative group of patients undergoing aggressive ICP monitoring and management 
was not evaluated, so that mortality rates were not thoroughly compared. 
As to the monitoring technique, indications, limitations, and complications of different technical 
modalities have been previously addressed 1 , 8 1 6 2 1 . Mollman and co-workers1 6 conducted a comparative 
study on ICP monitoring with a ventricular catheter, a subarachnoid catheter, and a subarachnoid 
bolt. In this study1 6, monitoring with a subarachnoid bolt tended to underestimate ICP increases, 
while no significant differences were found between ventricular and subarachnoid catheter monitoring. 
These findings add support to our routine adoption of subarachnoid catheter monitoring in most 
patients. 
GCS scores and ICP 
Our results disclosed a significant association between low GCS scores and markedly elevated 
ICP. These findings are in agreement with those of Yano and co-workers2 1. Whether elevated ICP 
contributed to neurologic impairment (low GCS scores) is not clear. In fact, according to our findings 
and those of others2 1, just associations were found. The latter, however, do not necessarily indicate 
cause-and-effect relationships. 
CT findings and ICP 
Our data revealed a tendency for patients with focal CT findings to have more pronounced 
ICP problems. This involved post-operative ICP recordings, and those in patients with non-surgical 
hemorrhagic contusions as well. It should be emphasized, however, that severe ICP problems may 
also be found in patients with predominantly diffuse brain swelling4. Thus, our results do not rule 
out the relevance of ICP monitoring in patients with predominantly diffuse traumatic brain swelling; 
rather, they highlight the importance of ICP monitoring even in patients in whom acute intracranial 
hematomas have been emergently removed. 
Mortality and ICP 
Our findings of increased mortality in patients who developed markedly elevated ICP are in 
agreement with previous reports 1 2 1 3 , 2 1 . Yano and co-workers2 1 have previously found a mortality rate 
of 93.4% in patients with ICP levels > 40 mm Hg (versus 72.2% in our series). These impressive 
figures have been found despite relatively sophisticated standards for intensive care and monitoring, 
and argue for additional research efforts on novel therapeutic modalities for adequate control of 
markedly elevated ICP in these critically ill patients. 
CONCLUSIONS 
From the above described, it is apparent that routine ICP monitoring in severely brain-injured 
patients should be taken into account, particularly in cases with CT scan evidence of compromised 
cerebrospinal fluid spaces. This would involve patients without surgical lesions, as well as selected 
cases in whom acute intracranial hematomas have been emergently removed. 
Acknowledgment - The authors thank Julio Cruz, M.D.,Ph.D., for critically reviewing and editing the 
manuscript. 
REFERENCES 
1. Colli BO, Falcão ALE, Dantas VP Filho. [Intracranial hypertension - monitoring and treatment]. In Terzi 
RGG, Araújo S (eds). Técnicas Básicas em UTI. São Paulo: Manole, 1992, p 401-417 (Port). 
2. Cruz J. On-line monitoring of global cerebral hypoxia in acute brain injury: relationship to intracranial 
hypertension. J Neurosurg 1993, 79:228-233. 
3. Cruz J, Jaggi JL, Hoffstad OJ. Cerebral blood flow and oxygen consumption in acute brain injury with 
acute anemia: An alternative for the cerebral metabolic rate of oxygen consumption ? Crit Care Med 1993, 
21:1218-1224. 
4. Cruz J. Combined continuous monitoring of systemic and cerebral oxygenation in acute brain injury: 
Preliminary observations. Crit Care Med 1993, 21:1225-1232. 
5. Cruz J. An additional therapeutic effect of adequate hyperventilation in severe acute brain trauma: 
normalization of cerebral glucose uptake. J Neurosurg 1995, 82:379-385. 
6. Dearden NM. Brain edema and raised intracranial pressure after head injury. In Vincent JL (ed). Yearbook 
of intensive care and emergency medicine. Berlin: Springer-Verlag, 1992, p 537-552. 
7. Dickman CA, Carter P, Baldwin HZ, Harrington T, Tallman D. Continuous regional cerebral blood flow 
monitoring in acute craniocerebral trauma. Neurosurgery 1991, 28:467-472. 
8. Falcão ALE, Dantas VP Filho, Saraiva JFK, Sardinha LAC, Araújo S, Terzi RGG. Bedside ICP monitoring 
in head trauma patients by using a simple, safe and low cost methodology (Abstr). Clin Int Care 1992, 
(Suppl) 3:112. 
9. Fishman RA. Brain edema. N Engl J Med 1975, 393:706-711. 
10. Guillaume J, Janny P. Manometrie intracrânienne continue: intérêt de la méthode et premiers résultats. Rev 
Neurol 1951, 84:131-142. 
11. Lundberg N. Continuous recording and control of ventricular fluid pressure in neurosurgical practice. Acta 
Psychiatr Neurol Scand 1960, (Suppl 149) 36:1-193. 
12. Marmarou A, Anderson RL, Ward JD, Choi SC, Young HF, Eisenberg HM, Foulkes MA, Marshall LF, Jane 
JA. Impact of ICP instability and hypotension on outcome in patients with severe head trauma. J Neurosurg 
1991, (Suppl) 75:S59-S66. 
13. Marshall LF, Smith RW, Shapiro HM. The outcome with aggressive treatment in severe head injuries. Part 
1: The significance of intracranial pressure monitoring. J Neurosurg 1979, 50:20-25. 
14. McGillicuddy JE. Cerebral protection, pathophysiology and treatment of increased intracranial pressure. 
Chest 1985, 87:85-93. 
15. Miller JD. ICP monitoring: current status and future directions. Acta Neurochir 1987, 85:80-86. 
16. Mollman HD, Rockswold GL, Ford SE. A clinical comparison of subarachnoid catheters to ventriculostomy 
and subarachnoid bolts: a prospective study. J Neurosurg 1988, 68:737-741. 
17. Obrist WD, Langfitt TW, Jaggi JL, Cruz J, Gennarelli TA. Cerebral blood flow and metabolism in comatose 
patients with acute head injury: relationship to intracranial hypertension. J Neurosurg 1984, 61:241-253. 
18. Rosner MJ, Daughton S. Cerebral perfusion pressure management in head injury. J Trauma 1990, 
30 :933-941 . 
19. Stuart GG, Merry GS, Smith JA, Yelland DN. Severe head injury managed without intracranial pressure 
monitoring. J Neurosurg 1983, 59:601-605. 
20. Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet 1974, 
2:81-84. 
21 . Yano M, Kobayashi S, Otsuka T. Useful ICP monitoring with subarachnoid catheter method in severe head 
injuries. J Trauma 1988, 28:476-480. 


HIGHLIGHTING INTRACRANIAL-PRESSURE MONITORING IN PATIENTS WITH SEVERE ACUTE BRAIN TRAUMA

http://repositorio.unicamp.br/jspui/bitstream/REPOSIP/68401/1/WOSA1995RT76400004.pdf

HIGHLIGHTING INTRACRANIAL-PRESSURE MONITORING IN PATIENTS WITH SEVERE ACUTE BRAIN TRAUMA

Abstract

Similar works

Full text

Available Versions

Repositorio da Producao Cientifica e Intelectual da Unicamp