High-Resolution Intracranial Pressure Burden and Outcome in Subarachnoid Hemorrhage

Magni, Federico; Pozzi, Matteo; Rota, Matteo; Vargiolu, Alessia; Citerio, Giuseppe

doi:10.1161/strokeaha.115.010219

Cited by 37 publications

(30 citation statements)

References 22 publications

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“…Intracranial hypertension is common in SAH, especially in poor grade patients where occurrence in up to 80 % of patients has been described [ 40 ]. It is associated with severely deranged cerebral metabolism [ 41 ] and consistently leads to poor outcome [ 42 , 43 ], warranting aggressive management. ICP monitoring also permits cerebral perfusion pressure (CPP) measurement.…”

Section: Detection and Diagnosismentioning

confidence: 99%

Management of delayed cerebral ischemia after subarachnoid hemorrhage

2016

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For patients who survive the initial bleeding event of a ruptured brain aneurysm, delayed cerebral ischemia (DCI) is one of the most important causes of mortality and poor neurological outcome. New insights in the last decade have led to an important paradigm shift in the understanding of DCI pathogenesis. Large-vessel cerebral vasospasm has been challenged as the sole causal mechanism; new hypotheses now focus on the early brain injury, microcirculatory dysfunction, impaired autoregulation, and spreading depolarization. Prevention of DCI primarily relies on nimodipine administration and optimization of blood volume and cardiac performance. Neurological monitoring is essential for early DCI detection and intervention. Serial clinical examination combined with intermittent transcranial Doppler ultrasonography and CT angiography (with or without perfusion) is the most commonly used monitoring paradigm, and usually suffices in good grade patients. By contrast, poor grade patients (WFNS grades 4 and 5) require more advanced monitoring because stupor and coma reduce sensitivity to the effects of ischemia. Greater reliance on CT perfusion imaging, continuous electroencephalography, and invasive brain multimodality monitoring are potential strategies to improve situational awareness as it relates to detecting DCI. Pharmacologically-induced hypertension combined with volume is the established first-line therapy for DCI; a good clinical response with reversal of the presenting deficit occurs in 70 % of patients. Medically refractory DCI, defined as failure to respond adequately to these measures, should trigger step-wise escalation of rescue therapy. Level 1 rescue therapy consists of cardiac output optimization, hemoglobin optimization, and endovascular intervention, including angioplasty and intra-arterial vasodilator infusion. In highly refractory cases, level 2 rescue therapies are also considered, none of which have been validated. This review provides an overview of current state-of-the-art care for DCI management.

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Section: Detection and Diagnosismentioning

confidence: 99%

Management of delayed cerebral ischemia after subarachnoid hemorrhage

2016

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“…However, for patients with high intracranial pressure or intracranial haematoma, there is a risk of induced brain herniation in the lumbar cistern drainage, especially for patients who have completed the craniotomy for aneurysm clipping. The intracranial pressure further increases due to surgical trauma and brain oedema [13][14][15][16][17]. Patients who have undergone the craniotomy, intraoperative placement of carotid cistern drainage tubes and continuous drainage after the operation are performed.…”

Section: Discussionmentioning

confidence: 99%

A clinical study on the value of carotid cistern drainage during intracranial aneurysm clipping

Jin

Yuan

et al. 2020

Arch Med Sci

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Introduction: To investigate the value of carotid cistern drainage in patients with aneurysmal subarachnoid haemorrhage during intracranial aneurysm clipping. Material and methods: Patients with ruptured intracranial aneurysms were included in this study. During the operation, the craniotomy was performed via a pterional approach to separate the Sylvian cistern and carotid cistern. After completing the clipping of the intracranial aneurysm, a drainage tube was placed in the carotid cistern between the ipsilateral internal carotid artery and optic nerve or lateral internal carotid artery, which was led out through the dura mater, cranial flap foramen or gap and scalp, and connected with an external drainage device. Results: A total of 6 patients with aneurysmal subarachnoid haemorrhage, who required craniotomy for clipping, were enrolled in the study. These patients were given carotid cistern drainage during the operation. Among these 6 patients, 2 had anterior communicating aneurysms, 1 had a posterior communicating aneurysm of the internal carotid artery, 2 had middle cerebral artery furcation aneurysms, and 1 patient had multiple intracranial aneurysms. For the Hunt-Hess score before the operation, 5 patients were in grade II and 1 patient was in grade III. Furthermore, the postoperative drainage was unobstructed, with a daily drainage of 130-290 ml of haemorrhagic cerebrospinal fluid (CSF). Conclusions: The CSF drainage of the carotid cistern applied in patients with aneurysmal subarachnoid haemorrhage during the craniotomy for clipping can effectively remove the subarachnoid haemorrhage, control the intracranial hypertension, and reduce the incidence of cerebral vasospasm and hydrocephalus.

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“…According to the clinical classification, patients were performed multimodal neurocritical monitoring, including vital signs, electroencephalogram, bispectral index (BIS), intracranial pressure (ICP) and transcranial doppler (TCD) (Ko, 2013). The application of brain protective bundle based on step-wised protocol under multimodal monitoring was performed to treat patients (Lee et al, 2014;Green et al, 2013;Magni et al, 2015). According to the results of H&H classification and multimodal monitoring, the patients with H&H grade III, mild brain injury and moderate increase of ICP were controlled by body position, sedation and analgesia, lumbar puncture or external drainage of lumbar cistern.…”

Section: The Critical Care Of Neurosurgerymentioning

confidence: 99%

The effect of step-wised protocol on critical care management of severe aneurysmal subarachnoid hemorrhage

Shang

et al. 2022

Food Sci. Technol

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To explore the critical care treatment and clinical outcome of patients with severe aneurysmal subarachnoid hemorrhage (SaSAH), and to provide clinical evidence for the treatment of patients with SaSAH. 160 patients with SaSAH of Hunt and Hess (H&H) grade III or above in the neurosurgical critical care unit at ourospital between June 2016 and June 2018 were enrolled in this study. Patients were treated with brain protective bundle based on step-wised protocol under multimodal monitoring and followed up for 3 months. The incidence of various clinical complications and the clinical prognosis after discharge were statistically analyzed. Furthermore, it carried on the correlation analysis to the risk factors and the prognosis. In 160 patients with SaSAH, 127 patients had responsible aneurysms located in the anterior circulation, and the other 33 patients were located in the posterior circulation. 70 patients (43.8%) underwent transcranial clipping, 81 patients (50.6%) underwent endovascular embolization and 9 patients (5.6%) did not intervene. Patients with IV and V grades of Glasgow Outcome Scale (GOS) were considered good recovery, and those with grade I, II and III were poor prognosis. The 30-day good prognosis rate was 41.3% (66/160) and the poor prognosis rate was 58.7% (94/160). Multivariate logistic regression analysis showed that the Hunt & Hess classification correlated well with prognosis (OR: 4.367,95% CI, 2.254-8.460, P < 0.001). The clinical prognosis of patients with SaSAH is still poor. In particular, under the critical care of neurosurgery, the application of brain protective bundle based on step-wised protocol under multimodal monitoring might improve the clinical prognosis of patients with SaSAH.

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High-Resolution Intracranial Pressure Burden and Outcome in Subarachnoid Hemorrhage

Cited by 37 publications

References 22 publications

Management of delayed cerebral ischemia after subarachnoid hemorrhage

Management of delayed cerebral ischemia after subarachnoid hemorrhage

A clinical study on the value of carotid cistern drainage during intracranial aneurysm clipping

The effect of step-wised protocol on critical care management of severe aneurysmal subarachnoid hemorrhage

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