Supratentorial epidural pressure recorded during posterior fossa surgery

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✓ Supratentorial epidural pressure (EDP) was recorded during posterior fossa surgery in 14 patients. It was found that the operative position had great influence on the supratentorial EDP and that a correct position, especially of the head, was important in the control of the intracranial pressure. Rapid and extensive ventricular drainage may set up a secondary rise in pressure and must be avoided. Craniectomy alone did not have any definite decompressive effect as judged from the EDP. Splitting of the dura or resection of a tumor usually resulted in a fall in the EDP in patients with previously increased pressure. Inadequate ventilation as well as hyperventilation was rapidly manifested through variations in the EDP. EDP monitoring combined with single determinations of PaCO2 was a valuable guide in securing adequate ventilation.

Article Information

Address reprint requests to: Helge Nornes, M.D., Department of Neurosurgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway.

© AANS, except where prohibited by US copyright law.

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Figures

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    A 24-hr simultaneous recording of ventricular fluid pressure (VFP) and epidural pressure (EDP) in a patient with suspected “normal pressure hydrocephalus.” Interrupted line indicates line of identity.

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    Group A. Recordings of six patients operated on in the sitting position showing marked elevation in EDP when flexing the neck to the intended position for craniectomy. After minor corrections in the position of head, there was reduction in EDP. Case 5 was operated on twice.

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    Group B. Recordings of four patients with previous ventriculocaval shunts operated on in the sitting position. The EDP pattern is as in Group A but without the effect of ventricular fluid (VF) drainaee. Case 10 had no correction of the primary position.

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    Group C. Recordings of four patients operated on in the prone position. There was a rise in EDP when turning the patients to the prone position, which was reduced following proper support under the shoulders and pelvis and minor corrections in the head position. Case 13 had hypothermia (H).

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    Case 12. Recording during rapid ventricular drainage (VD) to zero VFP. After 10 min, VFP remains zero but EDP has returned to previous level.

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    Recording showing temporary effect of ventricular drainage to zero VFP followed by increasing EDP (PaCO2 at 24 mm Hg). 0 = EDP above 400 mm H2O, VFP still zero. Further reduction in the flexion of the neck, hyperventilation, and mannitol 1 gm/kg body weight had only slight effect on EDP. X = instillations of 7 ml of saline into the ventricle during the following hour. Note change in speed.

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    A. Case 13. Preoperative EDP was normal. The patient was operated on in hypothermia, with no ventricular puncture. CM = cisterna magna (x - - - - x change in paper speed). B. Case 11. The patient had previously increased EDP and ventricular drainage (not shown). The EDP increased during craniectomy and then fell markedly after opening of the dura and extirpation of the tumor.

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    Cerebellar swelling was observed with concomitant rise in supratentorial EDP. A. Case 4. The PaCO2 was 27 mm Hg before hyperventilation (HV). B. Case 8. The PaCO2 was 31 mm Hg before HV.

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    Recording showing the effect on EDP of different respirator settings (R). The EDP rose during inadequate ventilation (R2) after tracheal suction, and fell during hyperventilation (HV) by hand until final setting (R3).

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    Recording after extubation showing increased EDP due to insufficient ventilation. Assisted ventilation (AV) with face mask achieved temporary reduction in EDP. Normal pressure followed tracheostomy. S = suction (x - - - - x change in paper speed).

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    Recording during mishap with the respirator (A) showing marked increase in EDP. HV = hyperventilation by hand; R = on respirator.

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