Intracranial Pressure After Aneurysmal Subarachnoid Hemorrhage
Intracranial Pressure After Aneurysmal Subarachnoid Hemorrhage
Object: Elevated intracranial pressure (ICP) is an important consequence of aneurysmal subarachnoid hemorrhage (SAH) that often results in decreased cerebral perfusion and secondary clinical decline. No definitive guidelines exist regarding methods and techniques for ICP management following aneurysm rupture. The authors describe monitoring practices and outcome data in 621 patients with aneurysmal SAH admitted to their neurological intensive care unit during an 8-year period (1996-2003).
Methods: A fiberoptic catheter tip probe or external ventricular drain (EVD) was used to record ICP values. The percentage of monitored patients varied, as expected, according to admission Hunt and Hess grade (p < 0.0001). Intracranial pressure monitoring devices were used in 27 (10%) of 264 Grade I to II patients, 72 (38%) of 189 Grade III patients, and 134 (80%) of 168 Grade IV to V patients. There was a strong propensity to favor transduced ventricular drains over parenchymal fiberoptic bolts, with the former used in 221 (95%) of 233 cases. This tendency was particularly strong in the poor-grade cohort, in which EVDs were placed in 99% of monitored individuals. The rates of cerebrospinal fluid infection in patients in whom ICP probes (0%) and ventricular drains (12%) were placed accorded with those in the literature.
Conclusions: Following aneurysmal SAH, ICP monitoring prevalence and techniques differ with respect to admission Hunt and Hess grade and are associated with the patient's functional status at discharge.
Following aneurysmal SAH, the sudden introduction of blood into the subarachnoid space results in CSF outflow resistance. Increased ICP and a resultant decrease in cerebral perfusion play a principal role in the development of cortical damage. Persistent ICP elevations have been correlated with poor clinical condition after aneurysm rupture. The continuous monitoring of ICP aids in the early detection of secondary cerebral insults and guides therapeutic interventions by providing real-time, physiological feedback. Intracranial pressure control affords the opportunity for surgical treatment and postoperative intensive care to effect a favorable outcome in patients suffering from aneurysmal SAH.
The two predominant methods for quantifying ICP measurements include placement of EVDs and fiberoptic catheter tip transducers. No definitive guidelines exist to delineate optimal monitoring practices or techniques. Decisions must account for the clinical condition of the patient and the inherent risks associated with applying each device or strategy. This study examines a large cohort of patients with aneurysmal SAH who underwent ICP monitoring with fiberoptic probe or EVD; data obtained in these patients were compared with results in a group of patients in whom ICP was not monitored. We compare patient demographics, functional outcome data, hospital LOS, and CSF infection rates across the cohorts.
Object: Elevated intracranial pressure (ICP) is an important consequence of aneurysmal subarachnoid hemorrhage (SAH) that often results in decreased cerebral perfusion and secondary clinical decline. No definitive guidelines exist regarding methods and techniques for ICP management following aneurysm rupture. The authors describe monitoring practices and outcome data in 621 patients with aneurysmal SAH admitted to their neurological intensive care unit during an 8-year period (1996-2003).
Methods: A fiberoptic catheter tip probe or external ventricular drain (EVD) was used to record ICP values. The percentage of monitored patients varied, as expected, according to admission Hunt and Hess grade (p < 0.0001). Intracranial pressure monitoring devices were used in 27 (10%) of 264 Grade I to II patients, 72 (38%) of 189 Grade III patients, and 134 (80%) of 168 Grade IV to V patients. There was a strong propensity to favor transduced ventricular drains over parenchymal fiberoptic bolts, with the former used in 221 (95%) of 233 cases. This tendency was particularly strong in the poor-grade cohort, in which EVDs were placed in 99% of monitored individuals. The rates of cerebrospinal fluid infection in patients in whom ICP probes (0%) and ventricular drains (12%) were placed accorded with those in the literature.
Conclusions: Following aneurysmal SAH, ICP monitoring prevalence and techniques differ with respect to admission Hunt and Hess grade and are associated with the patient's functional status at discharge.
Following aneurysmal SAH, the sudden introduction of blood into the subarachnoid space results in CSF outflow resistance. Increased ICP and a resultant decrease in cerebral perfusion play a principal role in the development of cortical damage. Persistent ICP elevations have been correlated with poor clinical condition after aneurysm rupture. The continuous monitoring of ICP aids in the early detection of secondary cerebral insults and guides therapeutic interventions by providing real-time, physiological feedback. Intracranial pressure control affords the opportunity for surgical treatment and postoperative intensive care to effect a favorable outcome in patients suffering from aneurysmal SAH.
The two predominant methods for quantifying ICP measurements include placement of EVDs and fiberoptic catheter tip transducers. No definitive guidelines exist to delineate optimal monitoring practices or techniques. Decisions must account for the clinical condition of the patient and the inherent risks associated with applying each device or strategy. This study examines a large cohort of patients with aneurysmal SAH who underwent ICP monitoring with fiberoptic probe or EVD; data obtained in these patients were compared with results in a group of patients in whom ICP was not monitored. We compare patient demographics, functional outcome data, hospital LOS, and CSF infection rates across the cohorts.
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