Refractory Elevated Intracranial Pressure Research Articles

Use of extracorporeal membrane oxygenation during a decompressive hemicraniectomy for severe traumatic brain injury: illustrative case.

Decompressive hemicraniectomy (DHC) can be a life-saving treatment for patients with severe traumatic brain injury (TBI) with a focal mass lesion who develop refractory elevated intracranial pressure (ICP). Nonetheless, successful completion of this procedure requires maintaining hemodynamic and respiratory stability. Extracorporeal membrane oxygenation (ECMO) use in patients with respiratory or cardiac failure is well described in the literature and has become routinely used in patients with refractory hypoxia unresponsive to traditional mechanical ventilation strategies, but few cases of its use have been reported in the neurosurgical literature. Herein, the authors describe a unique case in which a man presented after an unwitnessed fall that caused severe TBI without a focal mass lesion. The patient subsequently developed medically refractory elevated ICP secondary to traumatic cerebral edema. He required DHC, but the procedure could only be completed safely with the utilization of intraoperative ECMO. As more is learned about the techniques and pitfalls of ECMO, its indications are rapidly expanding. The case presented describes the safe use of ECMO during a major neurosurgical procedure, showing that the technique can be completed safely and offering a therapeutic option for effectively addressing refractory hypoxia and hypercarbia in patients with severe TBI who require urgent or emergency neurosurgical procedures. https://thejns.org/doi/10.3171/CASE24264.

Managing medically refractory elevated intracranial pressure in a pediatric patient on ECMO: illustrative case.

We demonstrate the complexities of managing pediatric patients on extracorporeal membrane oxygenation (ECMO) therapy requiring neurosurgery, focusing on systemic anticoagulation, cardiac function, and medically refractory intracranial pressure (ICP). A 3.5-year-old female with Tetralogy of Fallot developed severe ischemic cerebral edema following post-operative cardiac arrest and required ECMO. This case, along with four additional cases of children requiring neurosurgery while on ECMO, was examined. Emergency neurosurgical intervention in the primary case led to significant improvement, highlighting the delicate balance between managing ECMO-induced anticoagulation and urgent neurosurgical needs. The additional cases had variable outcomes, emphasizing the challenges of caring for these critically ill patients. Successful management of children requiring ECMO support and neurosurgical intervention requires thoughtful multidisciplinary care. This report illustrates some of the nuances in such decision-making, and demonstrates one potential path to a good outcome.

Decompressive craniectomy as a second/third-tier intervention in traumatic brain injury: A multicenter observational study

ObjectivesRESCUEicp studied decompressive craniectomy (DC) applied as third-tier option in severe traumatic brain injury (TBI) patients in a randomized controlled setting and demonstrated a decrease in mortality with similar rates of favorable outcome in the DC group compared to the medical management group. In many centers, DC is being used in combination with other second/third-tier therapies. The aim of the present study is to investigate outcomes from DC in a prospective non-RCT context. MethodsThis is a prospective observational study of 2 patient cohorts: one from the University Hospitals Leuven (2008–2016) and one from the Brain-IT study, a European multicenter database (2003–2005). In thirty-seven patients with refractory elevated intracranial pressure who underwent DC as a second/third-tier intervention, patient, injury and management variables including physiological monitoring data and administration of thiopental were analysed, as well as Extended Glasgow Outcome score (GOSE) at 6 months. ResultsIn the current cohorts, patients were older than in the surgical RESCUEicp cohort (mean 39.6 vs. 32.3; p < 0.001), had higher Glasgow Motor Score on admission (GMS < 3 in 24.3% vs. 53.0%; p = 0.003) and 37.8% received thiopental (vs. 9.4%; p < 0.001). Other variables were not significantly different. GOSE distribution was: death 24.3%; vegetative 2.7%; lower severe disability 10.8%; upper severe disability 13.5%; lower moderate disability 5.4%; upper moderate disability 2.7%, lower good recovery 35.1%; and upper good recovery 5.4%. The outcome was unfavorable in 51.4% and favorable in 48.6%, as opposed to 72.6% and 27.4% respectively in RESCUEicp (p = 0.02). ConclusionOutcomes in DC patients from two prospective cohorts reflecting everyday practice were better than in RESCUEicp surgical patients. Mortality was similar, but fewer patients remained vegetative or severely disabled and more patients had a good recovery. Although patients were older and injury severity was lower, a potential partial explanation may be in the pragmatic use of DC in combination with other second/third-tier therapies in real-life cohorts. The findings underscore that DC maintains an important role in managing severe TBI.

Evaluation of Outcomes Among Patients With Traumatic Intracranial Hypertension Treated With Decompressive Craniectomy vs Standard Medical Care at 24 Months

Trials often assess primary outcomes of traumatic brain injury at 6 months. Longer-term data are needed to assess outcomes for patients receiving surgical vs medical treatment for traumatic intracranial hypertension. To evaluate 24-month outcomes for patients with traumatic intracranial hypertension treated with decompressive craniectomy or standard medical care. Prespecified secondary analysis of the Randomized Evaluation of Surgery With Craniectomy for Uncontrollable Elevation of Intracranial Pressure (RESCUEicp) randomized clinical trial data was performed for patients with traumatic intracranial hypertension (>25 mm Hg) from 52 centers in 20 countries. Enrollment occurred between January 2004 and March 2014. Data were analyzed between 2018 and 2021. Eligibility criteria were age 10 to 65 years, traumatic brain injury (confirmed via computed tomography), intracranial pressure monitoring, and sustained and refractory elevated intracranial pressure for 1 to 12 hours despite pressure-controlling measures. Exclusion criteria were bilateral fixed and dilated pupils, bleeding diathesis, or unsurvivable injury. Patients were randomly assigned 1:1 to receive a decompressive craniectomy with standard care (surgical group) or to ongoing medical treatment with the option to add barbiturate infusion (medical group). The primary outcome was measured with the 8-point Extended Glasgow Outcome Scale (1 indicates death and 8 denotes upper good recovery), and the 6- to 24-month outcome trajectory was examined. This study enrolled 408 patients: 206 in the surgical group and 202 in the medical group. The mean (SD) age was 32.3 (13.2) and 34.8 (13.7) years, respectively, and the study population was predominantly male (165 [81.7%] and 156 [80.0%], respectively). At 24 months, patients in the surgical group had reduced mortality (61 [33.5%] vs 94 [54.0%]; absolute difference, -20.5 [95% CI, -30.8 to -10.2]) and higher rates of vegetative state (absolute difference, 4.3 [95% CI, 0.0 to 8.6]), lower or upper moderate disability (4.7 [-0.9 to 10.3] vs 2.8 [-4.2 to 9.8]), and lower or upper severe disability (2.2 [-5.4 to 9.8] vs 6.5 [1.8 to 11.2]; χ27 = 24.20, P = .001). For every 100 individuals treated surgically, 21 additional patients survived at 24 months; 4 were in a vegetative state, 2 had lower and 7 had upper severe disability, and 5 had lower and 3 had upper moderate disability, respectively. Rates of lower and upper good recovery were similar for the surgical and medical groups (20 [11.0%] vs 19 [10.9%]), and significant differences in net improvement (≥1 grade) were observed between 6 and 24 months (55 [30.0%] vs 25 [14.0%]; χ22 = 13.27, P = .001). At 24 months, patients with surgically treated posttraumatic refractory intracranial hypertension had a sustained reduction in mortality and higher rates of vegetative state, severe disability, and moderate disability. Patients in the surgical group were more likely to improve over time vs patients in the medical group. ISRCTN Identifier: 66202560.

Elevated intracranial pressure requiring decompressive craniectomy in a child with progressive primary angiitis of the central nervous system: a\xa0case report

BackgroundElevated intracranial pressure is a potentially catastrophic complication of neurologic injury in children. Successful management of elevated intracranial pressure requires prompt recognition and therapy directed at both reducing intracranial pressure and reversing its underlying cause. A rare condition that causes elevated intracranial pressure is childhood primary angiitis of the central nervous system, which is a rare inflammatory central nervous system disease that poses diagnostic and therapeutic challenges. To our knowledge, this is the first reported case of angiography-positive progressive childhood primary angiitis of the central nervous system requiring decompressive hemicraniectomy for refractory elevated intracranial pressure in children.Case presentationWe report the case of a 5-year-old Saudi girl who presented to the pediatric emergency department with fever and new-onset status epilepticus. She had elevated inflammatory markers with radiological and histopathological evidence of angiography-positive progressive childhood primary angiitis of the central nervous system, complicated by elevated intracranial pressure. Despite medical management for both childhood primary angiitis of the central nervous system and elevated intracranial pressure, her neurological status continued to deteriorate and the elevated intracranial pressure became refractory. She developed right uncal, right subfalcine, and tonsillar herniation requiring decompressive hemicraniectomy with a favorable neurological outcome.ConclusionDecompressive craniectomy might be considered in cases of angiography-positive progressive childhood primary angiitis of the central nervous system with elevated intracranial pressure refractory to medication. A multidisciplinary approach for the decision of decompressive craniectomy is advised to ensure patient safety and avoid possible morbidities and mortality.

Invasive neuromonitoring and neurological intensive care unit management in life-threatening central nervous system infections.

Patients with infectious diseases of the central nervous system (CNS) commonly require treatment in the intensive care unit (ICU). In a subset of patients with a life-threatening course, a more aggressive and invasive management is required. Treatment relies on the expertise of the intensivists as most recommendations are currently not based on a high level of evidence. Published data suggest that an invasive brain-focused management should be considered in life-threatening CNS infections. Brain resuscitation by adequate control of intracranial pressure (ICP) and optimization of cerebral perfusion, oxygen and glucose delivery supports the idea of personalized medicine. Recent advances in monitoring techniques help to guide clinicians to improve neurocritical care management in these patients with severe disease. Robust data on the long-term effect of decompressive craniectomy and targeted temperature management are lacking, however, these interventions can be life-saving in individual patients in the setting of a potentially fatal situation such as refractory elevated ICP. Advances in the neurocritical care management and progress in monitoring techniques in specialized neuro-ICUs may help to preserve brain function and prevent a deleterious cascade of secondary brain damage in life-threatening CNS infections.

Inhalational Isoflurane Sedation in Patients with Decompressive Craniectomy Suffering from Severe Subarachnoid Hemorrhage: A Case Series

Abstract Background Severe aneurysmal subarachnoid hemorrhage (SAH) may lead to the necessity of decompressive craniectomy (DC) to treat refractory elevated intracranial pressure (ICP). In some patients, adequate deep sedation, as one part of conservative treatment, cannot be achieved. Recent investigations suggest that inhalative sedation might not be as detrimental as considered before, and therefore a treatment option. Materials and Methods A retrospective analysis of seven patients was performed who suffered from aneurysmal SAH (Hunt-Hess grade 3–5, Fisher's score 3) and underwent DC due to a critically elevated ICP. In these patients, the target sedation level could not be achieved even with high doses of intravenous sedatives. Thus, the sedative regimen was switched to inhaled anesthesia with isoflurane. Mean arterial pressure (MAP), ICP, cerebral perfusion pressure (CPP), levels of vasopressors, and respiratory parameters were analyzed. Results Deep sedation (Richmond Agitation-Sedation Scale [RASS] −5, mean–fractional end-expiratory gas concentration [mean-Fet] 0.78%) was rapidly achieved in all patients after commencing general anesthesia with isoflurane. ICP remained stable when comparing 1 hour before the onset of isoflurane sedation (1) with 6 (2), and 12 hours (3) after commencing isoflurane anesthesia (mean ICP [1] 13.83 mm Hg; [2] 12.57 mm Hg; [3] 11.14 mm Hg). The mean duration of application was 9 (± 4) days. CPP could be maintained above 70 mm Hg without the need for extended vasopressor usage. Conclusion In a setting of severe SAH and critically elevated ICP with the need for aggressive multimodal therapy, isoflurane was safely applied in those patients. Our sedation goal was rapidly achieved and critical rise in ICP was not observed. Further investigations are required to demonstrate that inhaled anesthesia with isoflurane can be a promising alternative option, as this drug has better controllable pharmacokinetics, no clinically relevant accumulation of the drug itself, and potential neuroprotective effects (so far reported in different animal models).

Refractory intracranial hypertension in traumatic brain injury: Proposal for a novel score to assess the safety of lumbar cerebrospinal fluid drainage.

Background:Cerebrospinal fluid (CSF) drainage via ventricular puncture is an established therapy of elevated intracranial pressure (ICP). In contrast, lumbar CSF removal is believed to be contraindicated with intracranial hypertension.Methods:We investigated the safety and efficacy of lumbar CSF drainage to decrease refractory elevated ICP in a small cohort of patients with traumatic brain injury (TBI). A score (0–8 points) was used to assess computed tomography (CT) images for signs of herniation and for patency of the basal cisterns. All patients received lumbar CSF drainage either as a continuous drainage or as a single lumbar puncture (LP). Type and method of CSF drainage, mean ICP 24 h prior and after CSF removal, and adverse events were documented. Outcome was assessed after 3 months (with dichotomized Glasgow outcome scale).Results:Eight patients were evaluated retrospectively. n = 5 suffered a moderate, n = 2 a severe TBI (one Glasgow coma score not documented). The CT score was ≥5 in all patients prior to LP and decreased after puncture without clinical consequences in two patients. The amount of CSF removal did not correlate with score changes (P = 0.45). CSF drainage led to a significant reduction of mean ICP (from 22.3 to 13.9 mmHg, P = 0.002). Continuous drainage was more effective than a single LP. Three of eight patients reached a favorable outcome.Conclusions:Lumbar CSF removal for the treatment of intracranial hypertension is effective and safe, provided the basal cisterns are discernible, equivalent to ≥5 points in the proposed new score. The score needs further validation.

Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension

BackgroundThe effect of decompressive craniectomy on clinical outcomes in patients with refractory traumatic intracranial hypertension remains unclear.MethodsFrom 2004 through 2014, we randomly assigned 408 patients, 10 to 65 years of age, with traumatic brain injury and refractory elevated intracranial pressure (>25 mm Hg) to undergo decompressive craniectomy or receive ongoing medical care. The primary outcome was the rating on the Extended Glasgow Outcome Scale (GOS-E) (an 8-point scale, ranging from death to “upper good recovery” [no injury-related problems]) at 6 months. The primary-outcome measure was analyzed with an ordinal method based on the proportional-odds model. If the model was rejected, that would indicate a significant difference in the GOS-E distribution, and results would be reported descriptively.ResultsThe GOS-E distribution differed between the two groups (P<0.001). The proportional-odds assumption was rejected, and therefore results are reported descriptively. At 6 months, the GOS-E distributions were as follows: death, 26.9% among 201 patients in the surgical group versus 48.9% among 188 patients in the medical group; vegetative state, 8.5% versus 2.1%; lower severe disability (dependent on others for care), 21.9% versus 14.4%; upper severe disability (independent at home), 15.4% versus 8.0%; moderate disability, 23.4% versus 19.7%; and good recovery, 4.0% versus 6.9%. At 12 months, the GOS-E distributions were as follows: death, 30.4% among 194 surgical patients versus 52.0% among 179 medical patients; vegetative state, 6.2% versus 1.7%; lower severe disability, 18.0% versus 14.0%; upper severe disability, 13.4% versus 3.9%; moderate disability, 22.2% versus 20.1%; and good recovery, 9.8% versus 8.4%. Surgical patients had fewer hours than medical patients with intracranial pressure above 25 mm Hg after randomization (median, 5.0 vs. 17.0 hours; P<0.001) but had a higher rate of adverse events (16.3% vs. 9.2%, P=0.03).ConclusionsAt 6 months, decompressive craniectomy in patients with traumatic brain injury and refractory intracranial hypertension resulted in lower mortality and higher rates of vegetative state, lower severe disability, and upper severe disability than medical care. The rates of moderate disability and good recovery were similar in the two groups. (Funded by the Medical Research Council and others; RESCUEicp Current Controlled Trials number, ISRCTN66202560.)

Decompressive Craniectomy: An Update

Craniectomy is a valuable technique in the management of evacuatable mass lesions and elevated intracranial pressure (ICP). This review will examine the indications for and benefits of craniectomy in patients with traumatic brain injury (TBI). Recent data have questioned the utility of surgical decompression in the management of refractory intracranial hypertension; however, decompressive craniectomy (DC) remains a common practice at many trauma centers. Recent data have also questioned the use of invasive ICP monitors. However, despite this study, ICP monitors are standard of care in most major centers. Further research is needed before abandoning decompression for refractory elevated ICP or invasive ICP monitoring. While most patients with TBI are managed non-operatively, many patients do require decompression for refractory elevated ICP or evacuatable mass lesions. Current guidelines help direct patient selection for DC, and specific indications for DC vary by the type of intracranial hemorrhage. DC can be lifesaving in patients with severe or progressive intracranial hemorrhage.

Role of barbiturate coma in the management of focally induced, severe cerebral edema in children

Barbiturates are widely used in the management of high intracranial pressure (ICP) caused by diffuse brain swelling. The cardiovascular, renal, and immunological side effects of these drugs limit them to last-line therapy. There are few published data regarding the role of barbiturates in focal brain lesions causing refractory elevated ICP and intraoperative brain swelling in the pediatric population. The authors here present 3 cases of nontraumatic, focally induced, refractory intracranial hypertension due to 2 tumors and 1 arteriovenous malformation, in which barbiturate therapy was used successfully to control elevated ICP. They focus on cardiovascular, renal, and immune function during the course of pentobarbital therapy. They also discuss the role of pentobarbital-induced hypothermia. From this short case series, they demonstrate that barbiturates in conjunction with standard medical therapy can be used to safely reduce postoperative refractory intracranial hypertension and intraoperative brain swelling in children with focal brain lesions.

Retrospective analysis of the hemodynamic effects of induction of barbiturate coma in patients with refractory elevated intracranial pressure

Standard clinical practice in patients with elevated intracranial pressure (ICP) is to keep cerebral perfusion pressure (CPP) at (or above) 60 mmHg: we performed this retrospective study to analyze whether induction of barbiturate coma impedes compliance to this target CPP value. It has been repetitively shown that, although proven as an efficient therapy for refractory elevated ICP, barbiturate coma may cause a decrease in mean arterial pressure (MAP) and CPP [1].

Management of Refractory Elevated Intracranial Pressure (ICP) in an Immunocompetant Host with Cryptococcal Meningitis (P03.249)

Management of Refractory Elevated Intracranial Pressure (ICP) in an Immunocompetant Host with Cryptococcal Meningitis (P03.249)

Therapeutic Hypothermia for Traumatic Brain Injury

Experimental evidence demonstrates that therapeutic temperature modulation with the use of mild induced hypothermia (MIH, defined as the maintenance of body temperature at 32-35 °C) exerts significant neuroprotection and attenuates secondary cerebral insults after traumatic brain injury (TBI). In adult TBI patients, MIH has been used during the acute "early" phase as prophylactic neuroprotectant and in the sub-acute "late" phase to control brain edema. When used to control brain edema, MIH is effective in reducing elevated intracranial pressure (ICP), and is a valid therapy of refractory intracranial hypertension in TBI patients. Based on the available evidence, we recommend: applying standardized algorithms for the management of induced cooling; paying attention to limit potential side effects (shivering, infections, electrolyte disorders, arrhythmias, reduced cardiac output); and using controlled, slow (0.1-0.2 °C/h) rewarming, to avoid rebound ICP. The optimal temperature target should be titrated to maintain ICP <20 mmHg and to avoid temperatures <35 °C. The duration of cooling should be individualized until the resolution of brain edema, and may be longer than 48 h. Patients with refractory elevated ICP following focal TBI (e.g. hemorrhagic contusions) may respond better to MIH than those with diffuse injury. Randomized controlled trials are underway to evaluate the impact of MIH on neurological outcome in adult TBI patients with elevated ICP. The use of MIH as prophylactic neuroprotectant in the early phase of adult TBI is not supported by clinical evidence and is not recommended.

Decompressive craniectomy: a meta-analysis of influences on intracranial pressure and cerebral perfusion pressure in the treatment of traumatic brain injury

In recent years, the role of decompressive craniectomy for the treatment of traumatic brain injury (TBI) in patients with refractory intracranial hypertension has been the subject of several studies. The purpose of this review was to evaluate the contribution of decompressive craniectomy in reducing intracranial pressure (ICP) and increasing cerebral perfusion pressure (CPP) in these patients. Comprehensive literature searches were performed for articles related to the effects of decompressive craniectomy on ICP and CPP in patients with TBI. Inclusion criteria were as follows: 1) published manuscripts, 2) original articles of any study design except case reports, 3) patients with refractory elevated ICP due to traumatic brain swelling, 4) decompressive craniectomy as a type of intervention, and 5) availability of pre- and postoperative ICP and/or CPP data. Primary outcomes were ICP decrease and/or CPP increase for assessing the efficacy of decompressive craniectomy. The secondary outcome was the persistence of reduced ICP 24 and 48 hours after the operation. Postoperative ICP values were significantly lower than preoperative values immediately after decompressive craniectomy (weighted mean difference [WMD] -17.59 mm Hg, 95% CI -23.45 to -11.73, p < 0.00001), 24 hours after (WMD -14.27 mm Hg, 95% CI -24.13 to -4.41, p < 0.00001), and 48 hours after (WMD -12.69 mm Hg, 95% CI -22.99 to -2.39, p < 0.0001). Postoperative CPP was significantly higher than preoperative values (WMD 7.37 mm Hg, 95% CI 2.32 to 12.42, p < 0.0001). Decompressive craniectomy can effectively decrease ICP and increase CPP in patients with TBI and refractory elevated ICP. Further studies are necessary to define the group of patients that can benefit most from this procedure.

Decompressive Craniectomy Is Not an Independent Risk Factor for Communicating Hydrocephalus in Patients With Increased Intracranial Pressure

It was recently suggested that communicating hydrocephalus is an almost universal finding after hemicraniectomy and that early cranioplasty may prevent the need for permanent cerebrospinal fluid diversion in these patients. To conduct a study in an attempt to verify these findings. The medical records of all patients who underwent decompressive craniectomy for medically refractory elevated intracranial pressure between 2001 and 2009 were retrospectively reviewed. Patients with subarachnoid hemorrhage, intraventricular hemorrhage, or head trauma were excluded. Hydrocephalus was classified as internal or external and as clinically significant or asymptomatic. The patient population consisted of 17 patients, 8 men and 9 women, with a median age of 44 years (range, 27-53 years). Etiologies included malignant middle cerebral artery territory infarction in 12 patients, hemorrhagic transformation of ischemic cerebrovascular accident in 2 patients, dural sinus thrombosis in 2 patients, and hemorrhagic cerebrovascular accident in 1 patient. The extent of craniectomy ranged from a large bone flap in 4 patients to a standard hemicraniectomy in 13 patients. Two patients died and 1 was lost to follow-up during the acute stage. The remaining 14 patients underwent cranioplasty after a median interval of 21 days (range, 3-42 days). In none of these patients did clinically significant hydrocephalus develop requiring cerebrospinal fluid diversion. Asymptomatic extra-axial cerebrospinal fluid collections developed in 2 patients that resolved spontaneously after cranioplasty. Our results suggest that, contrary to some beliefs, hydrocephalus does not frequently occur after decompressive craniectomy.

Pharmacologic Strategies for the Treatment of Elevated Intracranial Pressure

Elevations in intracranial pressure often occur after traumatic brain injury. A limited array of medications is available for the treatment of intracranial hypertension. Metabolic suppression agents may be used in this situation to suppress electrical activity in the brain, diminish the cerebral metabolic rate of oxygen consumption, and, as a consequence, decrease cerebral blood volume and intracranial pressure. Propofol and pentobarbital have unique characteristics that make each desirable, yet difficult to use in the setting of traumatic brain injury. The subject of this review is to discuss the role of these agents in treating refractory elevated intracranial pressure through metabolic suppression.

Refractory elevated intracranial pressure: intensivist's role in solving the dilemma of decompressive craniectomy

Refractory elevated intracranial pressure: intensivist's role in solving the dilemma of decompressive craniectomy

Decompressive Hemicraniectomy for the Treatment of Intractable Intracranial Hypertension After Aneurysmal Subarachnoid Hemorrhage

Decompressive hemicraniectomy and duroplasty (DHCD) can improve survival in patients with severe cerebral edema. We present our clinical experience with DHCD for the treatment of refractory elevated intracranial pressure (ICP) in patients with aneurysmal subarachnoid hemorrhage (aSAH). DHCD was performed in 16 patients (11 female; median age, 49.5 years) with aSAH (11 Hunt-Hess grade 4 to 5) for sustained ICP >250 mm H(2)O refractory to maximal medical treatment and cerebrospinal fluid drainage at a median of 2 days from admission. Half of the patients were treated with endovascular coiling and the other half with surgical clipping. DHCD (mean flap size, 8536 mm(2)) reduced ICP from 350+/-157 to 147+/-124 mm H(2)O. Eleven patients survived (69%), and at latest follow-up (median, 450 days), 7 (64%) had a modified Rankin score of 0 to 3 and 4 (36%) a score of 4 to 5. Peak herniated brain volume was inversely associated with good outcome (P<0.005). Early craniectomy performed within 48 hours after the aSAH was associated with better outcome: 6 of 8 patients had good outcomes (75%) compared with 1 of 8 patients in whom late decompression was performed (P<0.01). Midline shift, Hunt-Hess grade, presence of hemorrhage, hematoma volume, craniectomy area, peak ICP, and relative ICP reduction were not associated with outcome in this patient population. DHCD is a useful adjunct modality for management of refractory intracranial hypertension in patients with high-grade aSAH, even in the absence of large intraparenchymal hemorrhage. In our series, long-term outcome was better in patients who underwent early intervention.

Refractory elevated intracranial pressure: intensivist's role in solving the dilemma of decompressive craniectomy

Refractory elevated intracranial pressure: intensivist's role in solving the dilemma of decompressive craniectomy