Trial of decompressive craniectomy for traumatic intracranial hypertension

Verticalization for Refractory Intracranial Hypertension: A Case Series

BACKGROUND

Severe intracranial hypertension is strongly associated with mortality. Guidelines recommend medical management involving sedation, hyperosmotic agents, barbiturates, hypothermia, and surgical intervention. When these interventions are maximized or are contraindicated, refractory intracranial hypertension poses risk for herniation and death. We describe a novel intervention of verticalization for treating intracranial hypertension refractory to aggressive medical treatment.

METHODS

This study was a single-center retrospective review of six cases of refractory intracranial hypertension in a tertiary care center. All patients were treated with a standard-of-care algorithm for lowering intracranial pressure (ICP) yet maintained an ICP greater than 20 mmHg. They were then treated with verticalization for at least 24 h. We compared the median ICP, the number of ICP spikes greater than 20 mmHg, and the percentage of ICP values greater than 20 mmHg in the 24 h before verticalization vs. after verticalization. We assessed the use of hyperosmotic therapies and any changes in the mean arterial pressure and cerebral perfusion pressure related with the intervention.

RESULTS

Five patients were admitted with subarachnoid hemorrhage and one with intracerebral hemorrhage. All patients had ICP monitoring by external ventricular drain. The median opening pressure was 30 mmHg (25th-75th interquartile range 22.5-30 mmHg). All patients demonstrated a reduction in ICP after verticalization, with a significant decrease in the median ICP (12 vs. 8 mmHg; p < 0.001), the number of ICP spikes (12 vs. 2; p < 0.01), and the percentage of ICP values greater than 20 mmHg (50% vs. 8.3%; p < 0.01). There was a decrease in total medical interventions after verticalization (79 vs. 41; p = 0.05) and a lower total therapy intensity level score after verticalization. The most common adverse effects included asymptomatic bradycardia (n = 3) and pressure wounds (n = 4).

CONCLUSIONS

Verticalization is an effective noninvasive intervention for lowering ICP in intracranial hypertension that is refractory to aggressive standard management and warrants further study.

Assessment of a Triage Protocol for Emergent Neurosurgical Cases at a Single Institution

BACKGROUND

Level I trauma centers use patient triaging systems to deploy neurosurgical resources and pursue good outcomes; however, data describing the effectiveness these triage systems are lacking. We reviewed the leveling protocol (cases designated urgent and emergent) of a regional Level I trauma center to obtain epidemiologic data about the efficiency of that system and identify areas for improvement.

METHODS

We retrospectively reviewed leveled neurosurgical cases from January 2015 to October 2017, assessing surgery date, neurosurgical procedure, posted surgical urgency level (levels 1-3, with 1 being most urgent), and post-to-room (PTR) time (i.e., the time between initial leveling and admission of the patient to the operating room). Mean PTR times were compared between case types using one-way analysis of variance with post hoc Tukey honestly significant difference analysis.

RESULTS

Of 1469 cases, 577 (39.3%) were shunt placement or revision, 231 (15.7%) were craniectomy or craniotomy for hematoma, 147 (10.0%) were craniectomy or craniotomy for tumor, and 514 (35.0%) were for other indications. Among level 1 cases, PTR time was lowest for craniotomies to evacuate intracranial hematoma (mean 16.2 minutes) and highest for spinal decompression procedures and wound washouts (mean 36.2 and 42.4 minutes, respectively).

CONCLUSIONS

To our knowledge, this is the first study of variability in PTR timing as a function of surgical urgency or indication. The most common leveled cases were craniectomies or craniotomies to relieve increased intracranial pressure, which were also the most common level 1 cases. Significant variability occurred within each leveling category; thus, further investigation is required.