A Retrospective Study of Intracranial Pressure in Head-Injured Patients Undergoing Decompressive Craniectomy: A Comparison of Hypertonic Saline and Mannitol

Abstract OBJECTIVE: Controversy exists about the indications and timing for surgery in head injured patients with an intradural mass lesion. The aim of this study was to survey contemporary approaches to the treatment of head injured patients with an intradural lesion, placing a particular focus on the utilization of decompressive craniectomy. METHODS: A prospective international survey was conducted over a 3-month period in 67 centers from 24 countries on the neurosurgical management of head injured patients with an intradural mass lesion and/or radiological signs of raised intracranial pressure. Information was obtained about demographic, clinical, and radiological features; surgical management, and mortality at discharge. RESULTS: Over the period of the study, data were collected about 729 patients consecutively admitted to one of the participating centers. The survey included 397 patients with a severe head injury (Glasgow Coma Scale [GCS] 3–8), 155 with a moderate head injury (GCS 9–12) and 143 patients with a mild head injury (GCS 13–15). An operation was performed on 502 patients (69%). Emergency surgery (<24 h) was most frequently performed for patients with an extracerebral mass lesions (subdural hematomas) whereas delayed surgery was most frequently performed for an intracerebral hematoma or contusion. Decompressive craniectomy was performed in a substantial number of patients, either during an emergency procedure (n = 134, 33%) or a delayed procedure (n = 47, 31%). The decompressive procedure was nearly always combined with evacuation of a mass lesion. The size of the decompression was however considered too small in 25% of cases. CONCLUSION: The results provide a contemporary picture of neurosurgical surgical approaches to the management of head injured patients with an intradural mass lesion and/or signs of raised intracranial pressure in some Neurosurgical Units across the world. The relative benefits of early versus delayed surgery in patients with intraparenchymal lesions and on the indications, technique and benefits of decompressive craniectomy could be topics for future head injury research.

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Comparison of Craniotomy and Decompressive Craniectomy in Severely Head-Injured Patients With Acute Subdural Hematoma

Yearbook of Neurology and Neurosurgery ◽

10.1016/j.yneu.2012.05.062 ◽

2012 ◽

Vol 2012 ◽

pp. 316-318

Author(s):

B.T. Ragel ◽

A.M. Raslan

Keyword(s):

Decompressive Craniectomy ◽

Subdural Hematoma ◽

Acute Subdural Hematoma ◽

Head Injured ◽

Injured Patients

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Interhemispheric Gradients in Head-Injured Patients: Their Evidence in Epidural Intracranial Pressure Measurement

Advances in Neurosurgery - Intracerebral Hemorrhage Hydrocephalus malresorptivus Peripheral Nerves ◽

10.1007/978-3-642-77997-8_29 ◽

1993 ◽

pp. 169-172 ◽

Cited By ~ 2

Author(s):

D. Woischneck ◽

M. R. Gaab ◽

T. Barner

Keyword(s):

Intracranial Pressure ◽

Pressure Measurement ◽

Head Injured ◽

Injured Patients

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824 A Multicenter Prospective Randomized Controlled Trial on the Efficacy of Mild Hypothermia for Severely Head-injured Patients with Low Intracranial Pressure

Neurosurgery ◽

10.1097/00006123-200008000-00172 ◽

2000 ◽

Vol 47 (2) ◽

pp. 535-536

Author(s):

Tadahiko Shiozaki ◽

Toshiaki Hayakata ◽

Hiroshi Tanaka ◽

Takeshi Shimazu ◽

Hisashi Sugimoto

Keyword(s):

Randomized Controlled Trial ◽

Intracranial Pressure ◽

Mild Hypothermia ◽

Controlled Trial ◽

Randomized Controlled ◽

Prospective Randomized Controlled Trial ◽

Head Injured ◽

Injured Patients

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Resuscitation of Hypotensive Head-Injured Patients: Is Hypertonic Saline the Answer?

The American Surgeon ◽

10.1177/000313480807400316 ◽

2008 ◽

Vol 74 (3) ◽

pp. 253-259

Author(s):

Jose L. Pascual ◽

Eileen Maloney-Wilensky ◽

Patrick M. Reilly ◽

Corinna Sicoutris ◽

Michael K. Keutmann ◽

...

Keyword(s):

Brain Tissue ◽

Hypertonic Saline ◽

Trauma Center ◽

Tissue Oxygenation ◽

Perfusion Pressure ◽

Inclusion Criteria ◽

Brain Tissue Oxygenation ◽

Head Injured ◽

Level I ◽

Injured Patients

Hypertonic saline (HTS) may decrease intracranial pressure (ICP) in severe traumatic brain injury (STBI) and effectively resuscitates hypotensive patients. No data exist on institutional standardization of HTS for hypotensive patients with STBI. It remains unclear how HTS affects brain tissue oxygenation (PbtO2) in STBI. We hypothesized HTS could be safely standardized in patients with STBI and would lower ICP while improving cerebral perfusion pressure (CPP) and PbtO2. Under institutional guidelines in a Level I trauma center, 12 hypotensive STBI intensive care unit subjects received HTS. Inclusion criteria included mean arterial pressure (MAP) ≤ 90 mmHg, Glasgow Coma Scale (GCS) ≤ 8, ICP ≥ 20 mmHg, and serum [Na+] < 155 mEq/L. All patients underwent ICP monitoring. Hemodynamics, CPP, ICP, and PbtO2 data were collected before and hourly for 6 hours after HTS infusion. Guideline criteria compliance was greater than 95 per cent. No major complications occurred. Mean ICP levels dropped by 45 per cent (P < 0.01) and this drop persisted for 6 hours. CPP levels increased by 20 per cent (P < 0.05). PbtO2 remained persistently elevated for all time points after HTS infusion. Institutional use of HTS in STBI can be safely implemented in a center caring for neurotrauma patients. HTS infusion in hypotensive STBI reduces ICP and raises CPP. Brain tissue oxygenation tends to improve after HTS infusion.

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