ICP MONITORED

DECOMPRESSIVE
CRANIECTOMY
DR. MUHAMMAD SHAHZAD
PGR NEUROSURGERY
JINNAH HOSPITAL LAHORE

SUPERVISOR: PROFESSOR NAVEED ASHRAF

 INTRODUCTION

 
 Hypothesis: Decompressive craniectomy (DC)
leads to improved ICP control and favorable
outcomes when used as a step-up in an ICP
monitored protocol.
 Prospective analysis of consecutive patients
with severe TBI treated at our department from
January 2017 to June 2018.
 The improvement in ICP control and
outcome of the DC patients was analyzed.
 The effect of DC and mannitol on Intracranial
compliance was also evaluated.
MATERIALS & METHODS

SETTIN
G

JAN JUNE
2017 2018

NEUROSURGICAL ICU JINNAH HOSPITAL

MATERIALS & METHODS

INCLUSION CRITERIA: EXCLUSION CRITERIA:

 Age 14 – 70  Patients having poly-trauma
 GCS 8 at sedation and intubation  Significant comorbidities
 Arrival within 24 hours of injury  Penetrating brain injury were
excluded.
 CT scan showing features of
increased ICP (compression of basal
cisterns, midline shift) but having
intracranial pathology not fulfilling
the criteria for operative evacuation.
METHODS

ICP
 Raumedic Neurovent
Monitoring
Parenchymal microchip pressure catheters with
continuous recording of ICP and ICP-A .
 TREATMENT PARADIGM
SEVERE TBI GCS≤8

Standard Basal therapy

Sedation and analgesia Normotension
Normoventilation (PaCO2 30-35mm Hg)
Normovolemia Normothermia
Normoglycemia HOB elevation
Early enteral nutrition ICP
measurement

ICP>25 for 2 minutes

Mannitol bolus given
Decrease of ICP over next Decrease of ICP over next half Decrease of ICP over next half No decrease in ICP over next
half hour hour hour half hour

ICP again increased >25 ICP again increased >25 Mannitol bolus
ICP decreased to <25 mmHg
mmHg mmHg Repeat CT Brain

ICP surge >25 mmHg x4 ICP surge >25 mmHg x 4 Decompressive Craniectomy

ICP remained elevated >25

ICP decreased to <25 mmHg
mmHg
COMPLIANCE
COMPLIANCE (ICP A)

Compliance
(ICP Amplitude)
COMPLIANCE (ICP A)
METHODS

Craniecto
Outcome
my
Assessment tool
GLASGOW OUTCOME SCORE at 30 days

Performed by Two observers

 RESULTS

 28 patients met the inclusion criteria

 There were 20 males and 8 females.
 Mean age was 35.31 years with a range of 16 – 70 years.
 DC was performed in 16 patients (57.1%), and this group (11 males
and 5 females) had a mean age of 29.1 years.
 DC was performed after an average of 40 h (6-117h) of treatment in
our ICU.
 The median GCS at the time of intubation and sedation was 7 in both
the DC and NDC group. 5 patients in each group had a GCS of 4.
CT SCAN FINDINGS

CT SCAN DC NDC
FINDINGS

Contusion 9 (56.3%) 6 (50%)

Subdural 5 (31.2%) 4 (33.3%)

hematoma

TSAH 2 (12.5%) 2 (16.7%)

MECHANISM OF INJURY

Fall; 10.70%

RTA; 89.30%
FIRST ICP READING (At the time of insertion)

30
26.3
25
20
14.1
15
10
ICP

5
0
DC NDC
FIRST ICP A READING (At the time of insertion)

12 11.8

10
8
6 5

4
ICP A

2
0
DC NDC
ICP before and after first mannitol dose
for ICP>25 mmHg

DC NDC

Before After Before After

Mean 33.8 18.9 31.1 7.1

Median 33.4 18.4 29.6 8.6

Range 22.7-44.1 10.1-35.8 26.8-40.5 7.3-15

Mean ICP reduction with mannitol in DC pts:

14.9 mmHg
Mean ICP reduction with mannitol in NDC pts: 24
mmHg
 ICP A before and after first mannitol
dose for ICP>25 mmHg
DC NDC

Before After Before After

Mean 15.1 13.7 7.0 6.2

Median 14.5 13.0 4.6 1.6

Range 5.5-25.6 4.3-20.9 1.7-20.2 0.7-20.4

Mean ICP A reduction with mannitol in DC pts:

1.4 mmHg
Mean ICP A reduction with mannitol in NDC pts:
0.8 mmHg
 MEAN DAILY ICP FOR FIRST 7 DAYS
Average time of
surgical DC NDC
intervention
30
26.3 26
25 24
22
ICP (mm Hg)

20 19.2 19.5
20
15.3 16.1
14.9 14.8 15.1 15
14.1
15

10

0
1 2 3 4 5 6 7
Time (day)

SCHNEIDER, G.H., BARDT, T., LANKSCH, W.R., and UN-TERBERG, A. (2002). Decompressive craniectomy
following traumatic brain injury: ICP, CPP and neurological outcome. Acta Neurochir. Suppl.81,77–79.
WHITFIELD, P.C., PATEL, H., HUTCHINSON, P.J., et al.(2001). Bifrontal decompressive craniectomy in the
management of posttraumatic intracranial hypertension. Br. J.Neurosurg.15,500–507.
 MEAN DAILY ICP A FOR FIRST 7 DAYS
Average time of
surgical DC NDC
intervention
14
12.5
11.8 12
12

10
ICP A (mm Hg)

8.3
8

6 5.2
4.3 4 4.1
4 3.4 3.2
3.3
3.5
2.7 2.9

0
1 2 3 4 5 6 7
Time (day)
ICP READINGS BEFORE AND AFTER SURGERY
45

40

35
INTRACRANIAL PRESSURE

30

25

20

15

10

0
BEFORE DC 1 HR POST DC
 CLINICAL OUTCOME OF PATIENTS AT 1 MONTH ASSESSED BY GOS
5 4 3 2 1
41.6 41.6
% OF PATIENTS

31.2 31.2

18.8

12.5

8.3 8.3
6.2

0
DC NDC
Glasgow outcome score
LIMITATIONS OF STUDY

 Study group small

 Conclusion

 Use of decompressive craniectomy as a step in an ICP protocol-guided treatment

program leads to favorable outcomes and lower mortality in patients with severe
traumatic brain injury.

 Measurement of compliance using ICP- A may offer the potential for early detection
of raised intracranial pressure (ICP) before it rises to levels damaging to brain
parenchyma.