Comparison of Ventricular Type and Parenchymal Type Intracranial Pressure (ICP) Monitoring for the Severe Traumatic Brain Injury Patients / 대한신경손상학회지

OBJECTIVE: Intracranial pressure (ICP) is one of the critical parameter for the patients of severe traumatic brain injury (TBI) to determine the treatment modalities and predict clinical outcomes. Hence, the ICP monitoring with accuracy and safety is essential for the TBI patients. The purpose of this study is to compare its safety and clinical usefulness of intraventricular ICP monitoring method to the parenchymal type. METHODS: We retrospectively reviewed the medical records and imaging data of 18 severe TBI patients. We used intraventricular ICP monitoring in 10 patients and parenchymal 8 patients. We compared the clinical findings of the two type ICP monitoring methods including procedure time, neurological status, outcome, complications and mortality. RESULTS: The initial Glasgow Coma Scale of intraventricular ICP monitoring and parenchymal ICP monitoring patients were 5.8 (range: 4-7) and 6.5 (range: 3-7) respectively. The Glasgow Outcome Scale after 6 months was a little higher in intraventricular monitoring patients than parenchymal monitoring patients (2.8 vs. 2.0, p=0.25). We could not find any intraventricular catheter related complication in intraventricular ICP monitoring patients. There was no difference in mortality in both groups (p=0.56). CONCLUSION: Our results suggest that intraventricular catheter insertion for ICP monitoring is relatively a safe procedure in the severe TBI patients. We could not demonstrate the significant benefit of intraventricular type ICP monitoring compared with parenchymal type ICP monitoring. Considering intraventricular type ICP monitoring have advantages of the accuracy and extraventricular drainage, intraventricular type ICP monitoring could be considered for severe TBI patients, regardless of hydrocephalus.

Epidural Hematomas due to Occipital Artery Injury Following Ventriculoperitoneal Shunt and Extraventricular Drainage

Ventriculoperitoneal (VP) shunt is a common treatment for hydrocephalic patients. However, complications, such as shunt tube occlusion, infection, intracranial hemorrhage, seizure can occur. Of these, intracranial hemorrhage may occur due to intracranial vascular injury or a rapid decrease of intracranial pressure (ICP). Most of these hemorrhages are subdural hematomas (SDH) while a few are epidural hematomas (EDH). It is extremely rare for an intracranial hemorrhage to occur due to an extension of the bleeding from an injured extracranial vessel. We report two cases of EDH due to occipital artery injury following VP shunt and extraventricular drainage (EVD).

A Clinical Comparison between Epidural Pressure Measurements and Intraventricular Pressure: Technical Note

OBJECTIVE: Measurement of intracranial pressure(ICP) is important in patients at risk of raised ICP. To evaluate the usefulness of measuring epidural pressure measurements for the estimation of intracranial pressure, we studied the relationship between epidural pressure and ventricular pressure. PATIENTS AND METHODS: From Nov. '97 to Jul. '98, 10 patients of extraventricular drainage(Group A) and 12 patients of decompressive craniectomy(Group B) are included in this study. Simultaneous recording of intracranial pressure (ICP) from an air-pouch epidural pressure monitoring system and a ventricular catheter was compared. RESULTS: The epidural pressure group(Group A) showed marked high epidural pressure(32.6+/-13.4mmHg) compared with those of intraventricular pressure, but in decompressive craniectomy group(Group B) shows nearly the same values(2.1+/-6.9mmHg). CONCLUSIONS: On the basis of the available comparison between these two methods of measuring intracranial pressure, in the light of the data we had established and the importance of ICP monitoring in neurosurgical critical care, intradural monitoring technique appears to be our measuring method of choice.

Early Surgery Extraventricular Drainage, Cisternal Drainage with Nimodipine Irrigation and Intravenous Nimodipine for Ruptured Intracranial Aneurysms

During the eleven months from September, 1989 to July, 1990, a total of 118 subarachnoid hemorrhage(SAH) patients were admitted. Among these, in 2 cases, the etiology was unknown and another 8 cases of Hunt & Hess clinical grade V patients died in the emergency room or intensive care unit within 24 hours after admission. The remaning 108 cases were managed with protocol as follows. 1) Surgery was done within 9 days after the SAH(total 67 cases) : Extraventricular drainage(EVD) was performed and a cisternal drainage(CD) catheter was positioned during surgery. EVD, CD nimodipine irrigation(0.4mg) through the CD catheter, and intravenous injection(IV) of nimodipine(1~2mg/hr)continued for 13days after the SAH. 2) Surgery was done after the 9th SAH day due to late transfer neurology or other hospitals or posterior circulation aneurysms(32 cases), and 9 cases refused surgery : Nimodipine was used orally(240mg/day) in 35 cases and an IV route(1~2mg/hr) in 6 cases. Total management outcome and results were obtained as follows. 1) A total unsatisfactory management outcome was 18.52%(serve disabled : 4.63%, vegetative : 0.93%, death : 12.96%. In the surgical cases only, 40.8%, 1.02%, 9.19%, respectively). 2) An unsatisfactory surgical outcome in cases following surgery after the 9th SAH day was 6.24%(severe disabled : 3.12%, death : 3.12%). 3) An unsatisfactory management outcome in cases of admission grades I & II following surgery within the 9th SAH day or those non-surgical patients was 19.15%(severe disabled : 4.25%, death : 14.89%. In surgical cases only 2.33%, 9.30%, respectively). 4) An unsatisfactory management outcome in cases of admission grades III & IV with surgery within the 9th SAH day or non-surgical patients was 29.63%(severe disabled : 7.41%, vegetative : 3.70%. death : 18.52%. In surgical cases only 9.09%, 4.55%, 13.64%, respectively). One case of admission grade V died. 5) Causes of unsatisfactory outcome were vasospasm : 9 cases(8.33%), SAH itself : 4 cases, rebleeding : 3 cases, surgical complication : 1 case, medical complication : 1 case, anesthesia : 1 case, and head trauma : 1 case. 6) Complications in management protocol with EVD, CD, CD nimodipine irrigation, and IV of nimodipine were transient hypotension(1 case) and meningitis(5 cases). These complications were improved without sequelae with discontinuing the IV of nimodipine and using antibiotics. We concluded that this protocol may improved the total management outcome of aneurysmal SAH patients, especially poor grade patients(Hunt & Hess grade III & IV) without significant complications. However, in spite of this protocol, the leading cause of an unsatisfactory outcome is vasospasm.

Classification of Spontaneous Thalamic Hemorrhagy for Management and Prediction of Prognosis

65 patients with spontaneous thalamic hemorrhage(TH) diagnosed by CT scan were treated in Catholic Medical Center. Of total 340 patients with spontaneous intracerebral hemorrhage from 1980 to 1983, TH occured in 19.1%. In order to analyse prognosis and guideline of management we classified TH into 4 types with the topographic involvement of thalamus : Type I-the anteromedial TH in 3 cases(4.8%) showed no specific correlation between symptoms and site of hematoma. The prognosis was good with medical treatment alone. Type II-the posterolateral TH in 23 cases(35.2%), mainly spreaded into the internal capsule and the midbrain. Aphasia was one of the main clinical features and the prognosis was worse with both conservative and surgical treatment than those of type I and III. Type III-the dorsal TH in 26 cases(40%), often extended to the lateral ventricle and were localizing in the thalamic area. Emotional change was more occasionally indicated. Type IV-the massive TH in 13 cases(20%), was extensively involved in the thalamus and spreaded to all direction. Symptoms and signs were various and surgery was not indicated because the prognosis was poor. Aphasia was noted in the left TH, but right-hemisphere cortical dysfunction were found mainly in the right TH. The prognoses of the patients with aphaia and/or right hemisphere cortical dysfunction were poorer than those of the patients without. We consider that the patients in type II or III with aphasia and/or right-hemisphere cortical dysfunction should be managed with EVD or stereotaxic urokinase therapy for better neurological outcome.