[Increasing the pressure of cerebral perfusion to control intracranial pressure]

ICP control can be achieved removing the surgical masses and manipulating the intracranial compartments; in the intensive care setting that can be attempted using CSF withdrawal or changing the cerebrovascular resistances, the intracranial blood content and the cerebral water content. The reduction of the ICP and the maintenance of a good cerebral perfusion pressure are the main aims of the therapy; when any standard treatment fails to control ICP a further attempt to preserve cerebral perfusion should be done by increasing the mean arterial pressure. In 10 patients with severe brain damage (GCS on admission ranging from 3 to 7, mean 5) from subarachnoid hemorrhage (3 cases) or trauma an infusion of dopamine (25-150 mg/h) and noradrenaline (0.4-2.4 mg/h) was started in case of intractable ICP. The ICP was defined intractable when the pressure was more than 40 mmHg for more than 5 m' after maximum therapy, as evaluated using the Therapy Intensity Level score. The infusion obtained a raise of the MAP of approximately 25% and a variable response on ICP. In 9 cases ICP dropped, in one case, instead, the ICP increased together with the arterial pressure. The reduction of ICP was 20-30%, with a good improvement of the CPP. The patients with a good response survived, the only patient without control of the ICP died. The physiopathologic mechanisms of this treatment are discussed; the most suitable explanation is indicated in an autoregulatory process. The infusion of cathecolamines can be harmful, and the patients eligible for this treatment must be carefully chosen. Notwithstanding this approach deserves further studies for the cases of intractable ICP.