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Intracranial Pressure Monitoring in Poor-Grade Patients with Aneurysmal Subarachnoid Hemorrhage Treated by Coiling
Roberto Imberti1, Edoardo Picetti2, Sandra Rossi2
1Phase I Clinical Trials Unit and Experimental Therapy, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
Insights
Early monitoring of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) during coiling for aneurysmal subarachnoid hemorrhage (aSAH) is not linked to rebleeding and may improve patient outcomes.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Aneurysmal subarachnoid hemorrhage (aSAH) is a critical condition often requiring neurovascular intervention.
- Managing intracranial pressure (ICP) and cerebral perfusion pressure (CPP) is vital for poor-grade aSAH patients.
- Coiling is a common endovascular treatment for aSAH.
Purpose of the Study:
- To analyze intracranial pressure (ICP) and cerebral perfusion pressure (CPP) dynamics during coiling in poor-grade aSAH patients.
- To evaluate the impact of early ICP/CPP monitoring on rebleeding rates and patient outcomes.
- To assess the prevalence of intracranial hypertension and reduced CPP during the procedure.
Main Methods:
- Prospective observational study of 99 poor-grade aSAH patients (WFNS grade IV-V).
- Patients divided into early ICP monitoring (n=31, monitoring started before coiling) and late ICP monitoring (n=68, monitoring started after coiling) groups.
- ICP and CPP were monitored, and outcomes assessed at 90 days using the modified Rankin scale.
Main Results:
- Significant episodes of intracranial hypertension (ICP >20 mm Hg) and reduced CPP (CPP <60 mm Hg) occurred during coiling in over 50% of monitored patients.
- Early ICP monitoring (before coiling) was not associated with an increased risk of rebleeding.
- Functional recovery at 90 days was significantly better in the early ICP monitoring group (P=0.004).
Conclusions:
- Poor-grade aSAH patients undergoing coiling frequently experience ICP and CPP fluctuations.
- Early ICP monitoring and management during coiling do not increase rebleeding risk.
- Initiating ICP monitoring before coiling may lead to improved functional outcomes in aSAH patients.
Objective:
The main objective of the present study was to analyze the intracranial pressure (ICP) and cerebral perfusion pressure (CPP) changes during coiling. We also evaluated the prevalence of rebleeding and outcomes for patients monitored before and after coiling.
Methods:
Ninety-nine consecutive poor-grade patients with aneurysmal subarachnoid hemorrhage (aSAH; World Federation of Neurological Surgeons grade IV and V) were enrolled in our prospective observational study. For 31 patients, ICP and CPP monitoring was started immediately after the diagnosis of aSAH, and the values were recorded every 15 minutes during coiling (early ICP group). For 68 patients, ICP and CPP monitoring began after coiling (late ICP group). The outcomes were evaluated at 90 days using the modified Rankin scale.
Results:
At the beginning of coiling, the ICP was >20 mm Hg in 10 patients (35.7%). The median ICP was 18 mm Hg (range, 5-60 mm Hg). The CPP was <60 mm Hg in 6 patients (24%). The median CPP was 70 mm Hg (range, 30-101 mm Hg). Despite medical treatment and/or cerebrospinal fluid drainage, 51.6% of the patients monitored during coiling had at least one episode of intracranial hypertension (defined as ICP >20 mm Hg), and 51.6% had at least one episode of reduced CPP (defined as CPP <60 mm Hg). Early monitoring (before aneurysm repair) was not associated with rebleeding. At 90 days, the functional recovery was better in the early ICP group (P = 0.004).
Conclusions:
During coiling, patients with poor-grade aSAH can experience episodes of intracranial hypertension and reduced CPP. Early and appropriate treatment of elevated ICP was not associated with rebleeding and might have improved the outcomes.
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