Effect of decompressive craniectomy on intracranial pressure and cerebrospinal compensation following traumatic brain injury

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Object

Decompressive craniectomy is an advanced treatment option for intracranial pressure (ICP) control in patients with traumatic brain injury. The purpose of this study was to evaluate the effect of decompressive craniectomy on ICP and cerebrospinal compensation both within and beyond the first 24 hours of craniectomy.

Methods

This study was a retrospective analysis of the physiological parameters from 27 moderately to severely head-injured patients who underwent decompressive craniectomy for progressive brain edema. Of these, 17 patients had undergone prospective digital recording of ICP with estimation of ICP waveform–derived indices. The pressure-volume compensatory reserve (RAP) index and the cerebrovascular pressure reactivity index (PRx) were used to assess those parameters. The values of parameters prior to and during the 72 hours after decompressive craniectomy were included in the analysis.

Results

Decompressive craniectomy led to a sustained reduction in median (interquartile range) ICP values (21.2 mm Hg [18.7; 24.2 mm Hg] preoperatively compared with 15.7 mm Hg [12.3; 19.2 mm Hg] postoperatively; p = 0.01). A similar improvement was observed in RAP. A significantly lower mean arterial pressure (MAP) was needed after decompressive craniectomy to maintain optimum cerebral perfusion pressure (CPP) levels, compared with the preoperative period (99.5 mm Hg [96.2; 102.9 mm Hg] compared with 94.2 mm Hg [87.9; 98.9 mm Hg], respectively; p = 0.017). Following decompressive craniectomy, the PRx had positive values in all patients, suggesting acquired derangement in pressure reactivity.

Conclusions

In this study, decompressive craniectomy led to a sustained reduction in ICP and improvement in cerebral compliance. Lower MAP levels after decompressive craniectomy are likely to indicate a reduced intensity of treatment. Derangement in cerebrovascular pressure reactivity requires further studies to evaluate its significance and influence on outcome.

Abbreviations used in this paper:ABP = arterial blood pressure; AMP = amplitude of the fundamental component of the intracranial pressure pulse waveform; CBF = cerebral blood flow; CPP = cerebral perfusion pressure; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICP = intracranial pressure; IQR = interquartile range; MAP = mean arterial pressure; PRx = cerebrovascular pressure reactivity index; RAP = pressure-volume compensatory reserve; TBI = traumatic brain injury.
Article Information

Contributor Notes

Address correspondence to: Ivan Timofeev, University of Cambridge Academic Neurosurgery Unit, Box 166, Addenbrooke's Hospital, Hills Road, Cambridge CB2 2QQ, United Kingdom. email: it227@cam.ac.uk.

© AANS, except where prohibited by US copyright law.

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