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Intracranial pressure in subarachnoid hemorrhage. Preliminary report in 36 cases
Insights
Continuous intracranial pressure (ICP) monitoring in subarachnoid hemorrhage (SAH) patients revealed elevated ICP across all clinical grades. Cerebrospinal fluid (CSF) drainage improved outcomes only in lower-grade SAH patients, highlighting varied therapeutic responses.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Subarachnoid hemorrhage (SAH) frequently leads to elevated intracranial pressure (ICP), a critical factor influencing patient outcomes.
- Continuous ICP monitoring is essential for managing SAH, but its correlation with clinical status and the efficacy of interventions require further elucidation.
Purpose of the Study:
- To investigate the relationship between ICP levels, clinical grades (Hunt and Hess scale), and the effectiveness of cerebrospinal fluid (CSF) drainage in patients with SAH.
- To analyze ICP waveforms (A, B, and C waves) and their association with specific clinical conditions like normal pressure hydrocephalus (NPH) and vasospasm.
Main Methods:
- Continuous ICP monitoring using ventricular or extradural transducers in 36 SAH patients.
- Classification of patients according to the Hunt and Hess grading scale.
- Intervention with CSF drainage in 33 acutely registered patients to manage intracranial hypertension.
Main Results:
- Elevated ICP was observed in all clinical grades of SAH, including lower grades (I and II), making direct correlation with clinical status challenging.
- CSF drainage led to ICP reduction and clinical improvement in patients with lower Hunt and Hess grades (I and II).
- In higher-grade SAH patients (IV and V), CSF drainage did not significantly alter clinical evolution, even when ICP was maintained below 10 mmHg.
Conclusions:
- ICP monitoring is crucial in SAH, revealing elevated pressures irrespective of initial clinical severity.
- CSF drainage is a beneficial intervention for lower-grade SAH patients, improving both ICP and clinical outcomes.
- The limited efficacy of CSF drainage in severe SAH suggests alternative or adjunctive management strategies are necessary for these patients.
Abstract:
Thirty-six patients with SAH were submitted to continuous ICP monitoring: in 33 cases a continuous ventricular fluid pressure recording was performed in acute stage. According to Hunt and Hess, 2 patients were graded I, one II, one III, 13 IV and 16 V. In the remaining 3 cases who developed a normal pressure hydrocephalus 15, 20 and 40 days from bleeding an extradural miniaturized transducer was applied. B and C waves were common findings in acutely recorded patients. Typical A waves accompanied base line recordings in patients with NPH. From analysis of data the authors evidenced that elevated ICP values have been registered not only in patients graded as III, IV and V but also in those graded I and II: as 89% of patients belong to grades IV and V it was impossible to correlate clinical status with ICP. In patients with spasm it was never noted ICP values higher than 20 mmHg during recording time (from 60 hours to 10 days). In order to reduce intracranial hypertension CSF drainage was performed in 33 patients acutely registered. In patients graded I and II this procedure was followed by an ICP reduction and an improvement of the clinical status. In none of the patients graded IV and V in spite of pressure maintained at 10 mmHg, CSF drainage affected clinical evolution.