Delayed rise in intracranial pressure in patients with head injury

Abstract

This prospective study was done on patients of severe and moderate head injury (GCS<=12) admitted in the department of neurosurgery over a two month period to evaluate the significance of delayed rise in intracranial pressure in patients with severe and moderate head injury and to see for any correlation with CT head findings and neurological outcome. Patients who presented within 8 hours of injury and in whom intracranial pressure (ICP) monitoring was done were enrolled in the study. Patients were managed as per departmental protocols. Based on serial intracranial pressure patients were divided in three groups: Initial high ICP group (IHICP group) consisting of patients with initial high ICP value of >20 cm H₂O. Delayed high ICP group (DHICP group) consisting of patients with initial normal ICP <20 cmH2O with a delayed rise after a variable period (24-96 hrs), & normal ICP group (NICP group) comprising patients with persistently normal ICP of < 20 cmH₂O. A total of 21 patients were enrolled in the study. All were males with a mean age of 33 years. 17 (80.9%) patients had severe head injury (GCS d” 8) and 4 (19%) patients had moderate head injury (GCS 9 e” 12). There were five patients in IHICP group with a mean initial ICP of 35 cmH2O. Three (60%) patients in this group had effaced cisterns on CT whereas remaining two had grossly normal CT scans. All patients in this group were operated within 24 hours of injury and had excellent recovery with a mean GOS of 3.4. There were six patients in DHICP group with a mean initial ICP of 12 cmH2O. Four (66%) patients had effaced cisterns on initial CT and two had grossly normal CT scans. Mean ICP rose to 30 cmH2O (range 21–40 cmH2O) over a mean period of 66 hours (range 24–192 hours). All patients in this group were also operated. The mortality in this group was 50% (n=3) with mean GOS of 2. NICP group had 10 patients with mean ICP value of 13 cmH2O. Eight (80%) of these patients had normal CT Scans whereas two patients had effaced cisterns on initial CT. All patients in this group were managed conservatively with good recovery (mean GOS3.2). Patients of head injury with effaced cisterns on CT head and delayed rise in ICP had the worst outcome in our study. This the first study of its kind showing correlation between delayed rise in ICP and outcome. More studies are warranted to assess whether early surgery in this group of patients could improve outcome.

Keywords

Complications - Head injury - Intracranial pressure - ICP monitoring

^* Manuscript for consideration for best paper award at Annual conference of NTSI-2009

• References

• 1 Venes J. Intracranial pressure monitoring in perspective. Childs Brain 1980; 07: 236-251
• 2 Guillaume J, Janny P. Manométrie intracranienne continue: interêt de la méthode et premiers résultats. Rev Neurol 1951; 84: 131-142
• 3 Lundberg N. Continuous recording and control of ventricular fluid pressure in neurosurgical practice. Acta Psychiatr Neurol Scand 36 (Suppl 149):1-193.
• 4 Miller JD, Becker D P, Ward JD. et al Significance of intracranial hypertension in severe head injury. J Neurosurg 1977; 47: 503-516
• 5 Vries JK, Becker DP. Technical note. J Neurosurg 1973; 39: 416-419
• 6 Winn HR, Dacey RG, Jane JA. Intracranial subarachnoid pressure recording: experience with 650 patients. Surg Neurol 1977; 08: 41-47
• 7 Friedman WA, Vries JK. Summary of 100 procedures. J Neurosurg 1980; 53: 662-665
• 8 McGraw CP. Continuous intracranial pressure monitoring: review of techniques and presentation of method. Surg Neurol 1976; 06: 149-155
• 9 Miller JD. Intracranial pressure monitoring. Br J Hosp Med 1978; 19: 497-503
• 10 Becker D P, Miller JD, Ward JD. et al The outcome from severe head injury with early diagnosis and intensive management. J Neurosurg 1977; 47: 491-502
• 11 Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 02: 81-94
• 12 Colquhoun IR, Burrows EH. The prognostic significance of the third ventricle and basal cisterns in severe closed head injury. Clin Radiol 1989; 40: 13-16
• 13 Kishore PRS, Lipper MH, Becker D P. et al Significance of CT in head injury: correlation with intracranial pressure. AJNR 1981; 02: 307-311
• 14 Tabaddor K, Danziger A, Wisoff HS. Estimation of intracranial pressure by CT scan in closed head trauma. Surg Neurol 1982; 18: 212-215
• 15 Teasdale E, Cardoso E, Galbraith S. CT scan in severe diffuse head injury: physiological and clinical correlations. J Neurol Neurosurg Psychiatry 1984; 47: 600-603
• 16 Toutant SM, Klauber MR, Marshall L F. et al Absent or compressed basal cisterns on first CT scan: ominous predictors of outcome in severe head injury. J Neurosurg 1984; 61: 691-694
• 17 Narayan RK, Greenberg R P, 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 1981; 54: 751-762
• 18 Galbraith S, Teasdale G. Predicting the need for operation in the patient with an occult traumatic intracranial hematoma. J Neurosurg 1981; 55: 75-81
• 19 Stocchetti N, Colombo A, Ortolano Fabrizio. et al Time course of intracranial hypertension after traumatic brain injury. J Neurotrauma 2007; 24: 1339-1346