Relationship between Intracranial Pressure or Cerebral Perfusion Pressure and Prognosis in Patients with Severe Traumatic Brain Injury Treated with Mild Hypothermia

Abstract BACKGROUND Hypertonic saline (HTS) and mannitol are effective in reducing intracranial pressure (ICP) after severe traumatic brain injury (TBI). However, their simultaneous effect on the cerebral perfusion pressure (CPP) and ICP has not been studied rigorously. OBJECTIVE To determine the difference in effects of HTS and mannitol on the combined burden of high ICP and low CPP in patients with severe TBI. METHODS We performed a case–control study using prospectively collected data from the New York State TBI-trac® database (Brain Trauma Foundation, New York, New York). Patients who received only 1 hyperosmotic agent, either mannitol or HTS for raised ICP, were included. Patients in the 2 groups were matched (1:1 and 1:2) for factors associated with 2-wk mortality: age, Glasgow Coma Scale score, pupillary reactivity, hypotension, abnormal computed tomography scans, and craniotomy. Primary endpoint was the combined burden of ICPhigh (> 25 mm Hg) and CPPlow (< 60 mm Hg). RESULTS There were 25 matched pairs for 1:1 comparison and 24 HTS patients matched to 48 mannitol patients in 1:2 comparisons. Cumulative median osmolar doses in the 2 groups were similar. In patients treated with HTS compared to mannitol, total number of days (0.6 ± 0.8 vs 2.4 ± 2.3 d, P < .01), percentage of days with (8.8 ± 10.6 vs 28.1 ± 26.9%, P < .01), and the total duration of ICPhigh + CPPlow (11.12 ± 14.11 vs 30.56 ± 31.89 h, P = .01) were significantly lower. These results were replicated in the 1:2 match comparisons. CONCLUSION HTS bolus therapy appears to be superior to mannitol in reduction of the combined burden of intracranial hypertension and associated hypoperfusion in severe TBI patients.

Download Full-text

Acute clinical grading in pediatric severe traumatic brain injury and its association with subsequent intracranial pressure, cerebral perfusion pressure, and brain oxygenation

Neurosurgical FOCUS ◽

10.3171/foc.2008.25.10.e4 ◽

2008 ◽

Vol 25 (4) ◽

pp. E4 ◽

Cited By ~ 13

Author(s):

Anthony A. Figaji ◽

Eugene Zwane ◽

A. Graham Fieggen ◽

Jonathan C. Peter ◽

Peter D. Leroux

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Cerebral Perfusion Pressure ◽

Severe Traumatic Brain Injury ◽

Cerebral Perfusion ◽

Perfusion Pressure ◽

Brain Oxygenation ◽

Clinical Scores ◽

The Relationship

Object The goal of this paper was to examine the relationship between methods of acute clinical assessment and measures of secondary cerebral insults in severe traumatic brain injury in children. Methods Patients who underwent intracranial pressure (ICP), cerebral perfusion pressure (CPP), and brain oxygenation (PbtO2) monitoring and who had an initial Glasgow Coma Scale score, Pediatric Trauma Score, Pediatric Index of Mortality 2 score, and CT classification were evaluated. The relationship between these acute clinical scores and secondary cerebral insult measures, including ICP, CPP, PbtO2, and systemic hypoxia were evaluated using univariate and multivariate analysis. Results The authors found significant associations between individual acute clinical scores and select physiological markers of secondary injury. However, there was a large amount of variability in these results, and none of the scores evaluated predicted each and every insult. Furthermore, a number of physiological measures were not predicted by any of the scores. Conclusions Although they may guide initial treatment, grading systems used to classify initial injury severity appear to have a limited value in predicting who is at risk for secondary cerebral insults.

Download Full-text