Significance of Monitoring the Initial Intracranial Pressure on Hematoma Irrigation with Trephination Therapy for Acute
Acute subdural hematoma (ASDH) patients presenting in a severe condition tend to have poor outcomes due to the significant brain edema required to maintain the ICP at less than 20–25 mmHg. This study compared the surgical outcomes of 16 critically ill pat
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Abstract Acute subdural hematoma (ASDH) patients presenting in a severe condition tend to have poor outcomes due to the significant brain edema required to maintain the ICP at less than 20–25 mmHg. This study compared the surgical outcomes of 16 critically ill patients with ASDH who underwent hematoma irrigation with trephination therapy (HITT) based on their initial ICP values. The initial mean GCS score upon admission was four. A unilateral dilated pupil was seen in one and bilateral dilated pupils were seen in seven patients. The co-existence of a brain contusion was seen in seven patients, brain swelling was noted in six patients, and both basal cistern effacement and a midline shift greater than 5 mm were observed in all patients. The mean initial ICP value was 45mmHg (range: 3 to 85 mmHg). Ten patients (62.5%) underwent a rapid external decompression to evacuate the hematoma. By using the Glasgow Outcome Scale upon discharge a score of good recovery (GR) was assigned to two (12.5 %), moderate disability (MD) to four (25.0 %), vegetative state (VS) to two (12.5 %), and death (D) to eight (50.0 %) patients. All six patients who showed an initial ICP greater than 60 mmHg died despite intensive care. Eight patients who showed an initial ICP less than 40 mmHg had a favorable outcome, but two patients deteriorated due to a traumatic cerebrovascular disorder. It seems that the initial ICP monitoring with HITT for ASDH patients in critical condition may be an important factor for predicting both surgical outcome and clinical course. Keywords Acute subdural hematoma • brain edema • external decompression • intracranial pressure
N. Otani (), Y. Takasato, H. Masaoka, T. Hayakawa, Y. Yoshino, H. Yatsushige, H. Miyawaki, K. Sumiyoshi, T. Sugawara, A. Chikashi, S. Takeuchi, G. Suzuki Department of Neurosurgery, National Hospital Organization Disaster Medical Center, 3256 Midoricho, Tachikawa, Tokyo, Japan e-mail: [email protected]
Introduction Acute subdural hematoma (ASDH) in patients in severe condition is associated with a poor outcome due to significant brain edema (5). The surgical indications are determined based on careful consideration of the neurological deficit and the radiological findings with the intent to maintain an ICP of less than 25 mmHg (2). If the pathophysiology of the ASDH is complicated with brain edema or cerebral contusion, however, it can overwhelm the surgical strategy. It is sometimes necessary to immediately perform hematoma irrigation with trephination therapy (HITT) to control the ICP (4). This study compared the surgical outcome in critically ill patients with ASDH who underwent HITT based on their initial ICP value.
Patients and Methods There were 56 patients with ASDH surgically treated between April 2005 and September 2007. Among these 56 patients, 16 patients (mean age 56.8, male 10, female 6) who underwent HITT were analyzed to measure the initial ICP. The patients’ hospital records, including medical charts, intensive care unit flow sheets, operative records, and radiologic
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