Is there an upper limit of intracranial pressure in patients with severe head injury if cerebral perfusion pressure is maintained?

Abstract

<jats:p>Authors of recent studies have championed the importance of maintaining cerebral perfusion pressure (CPP) to prevent secondary brain injury following traumatic head injury. Data from these studies have provided little information regarding outcome following severe head injury in patients with an intracranial pressure (ICP) greater than 40 mm Hg, however, in July 1997 the authors instituted a protocol for the management of severe head injury in patients with a Glasgow Coma Scale score lower than 9. The protocol was focused on resuscitation from acidosis, maintenance of a CPP greater than 60 mm Hg through whatever means necessary as well as elevation of the head of the bed, mannitol infusion, and ventriculostomy with cerebrospinal fluid drainage for control of ICP. Since the institution of this protocol, nine patients had a sustained ICP greater than 40 mm Hg for 2 or more hours, and five of these had an ICP greater than 75 mm Hg on insertion of the ICP monitor and later experienced herniation and expired within 24 hours. Because of the severe nature of the injuries demonstrated on computerized tomography scans and their physical examinations, these patients were not aggressively treated under this protocol. The authors vigorously attempted to maintain a CPP greater than 60 mm Hg with intensive fluid resuscitation and the administration of pressor agents in the four remaining patients who had developed an ICP higher than 40 mm Hg after placement of the ICP monitor. Two patients had an episodic ICP greater than 40 mm Hg for more than 36 hours, the third patient had an episodic ICP greater than of 50 mm Hg for more than 36 hours, and the fourth patient had an episodic ICP greater than 50 mm Hg for more than 48 hours. On discharge, all four patients were able to perform normal activities of daily living with minimal assistance and experience ongoing improvement.</jats:p> <jats:p>Data from this preliminary study indicate that intense, aggressive management of CPP can lead to good neurological outcomes despite extremely high ICP. Aggressive CPP therapy should be performed and maintained even though apparently lethal ICP levels may be present. Further study is needed to support these encouraging results.</jats:p>

Severe Traumatic Brain Injury in Austria IV: Intensive care management

“…This, however, is most probably attributable to the underlying cause of haemodynamic instability, and not to the effects of volume loading. A recent paper suggests that long periods of ICP > 40 mm Hg may be survived with good outcome as long as CPP > 60 mm Hg is maintained [23]; the authors used large volumes of fluids as well as catecholamines to achieve that.…”

Neurointensive Care Monitoring for Severe Traumatic Brain Injury

“…In a non-compliant system, P2 wave is exceeding P1. (Young et al, 2003). Four patients in their study had comparatively good neurological outcome after receiving such management for extremely high ICP.…”

Interaction between Brain Chemistry and Physiology after Traumatic Brain Injury: Impact of Autoregulation and Microdialysis Catheter Location

“…A debate on the relative importance of ICP versus CPP is ongoing between proponents of ICP-and CPP-oriented treatment approaches. Reports on good outcome in patients in whom the ICP was persistently high but satisfactory levels of CPP were maintained (Young et al, 2003) as well as observations from other pathologies in which very high ICP may be associated with minimal clinical symptoms and metabolic changes (Agren-Wilsson et al, 2005), question the importance of ICP in the presence of adequate CPP. However, maintenance of adequate CPP in the presence of uncontrolled intracranial pressure is difficult and associated with risks and complications (Robertson et al, 1999) and in most cases both ICP-and CPP-directed strategies can be used.…”