Cerebral oxygenation following decompressive hemicraniectomy for the treatment of refractory intracranial hypertension

Abstract

All patients tolerated DCH without complications. Before the operation, the mean ICP was elevated in all patients (26 +/- 4 mm Hg), despite maximal medical management. After surgery, there was an immediate and sustained decrease in ICP (19 +/- 11 mm Hg) and an increase in CPP (81 +/- 17 mm Hg). Following DCH, cerebral oxygenation improved from a mean of 21.2 +/- 13.8 mm Hg to 45.5 +/- 25.4 mm Hg, a 114.8% increase. The change in brain tissue O2 and the change in ICP after DCH demonstrated only a modest relationship (r2 = 0.3). These results indicate that the use of DCH in the treatment of severe brain injury is associated with a significant improvement in brain O2.

Current Opinions on Epidemiology, Treatment and Outcome After Traumatic Brain Injury

“…The onset is described quickly usually within five minutes after infusion lasting between one and six hours achieving a maximum level after 60 minutes [58]. By drawing water into the blood vessels, blood viscosity is reduced, further increasing perfusion [68].…”

“…Therefore, volume replacement might commonly be required increasing potential risks of rebound ICP increase due to a reversed osmolar gradient [78]. Hyperosmolar saline acts similar to mannitol (3-3.4%), as it also creates an osmolar gradient across the blood brain barrier [58,78]. Several studies indicate that its effect is even enhanced compared in mannitol [79,80].…”

“…Hyperglycaemia and hypertension resulting in impaired autoregulation of cerebral perfusion have also been associated with poor mid-term outcome [23,24,63]. During clinical course various treatment options are available focusing on reduction of cerebral swelling, minimizing intracranial pressure and optimizing systemic co-morbidities [2,4,[51][52][53][56][57][58]. There is general agreement that optimized cerebral perfusion via oxygenation, glycemic control, temperature adjustment, balanced anaesthesia, as well as nutritional and electrolyte homeostasis should be preferred [1,64].…”

“…While mild TBI requires minor treatment focusing short term supervision and analgesia, the individualized treatment of moderate to severe TBI is described to be more complex [2,4,14,[50][51][52][53][54][55][56][57][58][59][60][61]. It has been shown that hypoxia and hypotension are strongly associated with secondary insults leading to poor outcome in TBI [62].…”

Critical care management of head injury – current concepts

“…Decompressive Craniectomy : Regarding surgical management of intractable intra-cranial hypertension, there is growing body of literature supporting the efficacy of decompressive craniectomy in reducing ICP, with improved brain oxygenation, especially after TBI. 8,9 However in the absence of randomized, controlled trails, it is difficult to make a definitive judgment about its efficacy.…”