Intracranial pressure in patients with ruptured saccular aneurysm

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✓ Intracranial pressure was recorded in 21 patients with subarachnoid hemorrhage due to rupture of a saccular aneurysm. Two different pressure patterns were found in nine patients who had verified recurrent hemorrhages while awaiting clinical improvement. One was associated with massive hematoma while the other occurred with edema but only minimal hematoma; the terms “hemorrhagic-compressive lesion” and “ischemic-edematous lesion” have been used for these two conditions. Four patients showed transient deterioration concomitant with marked pressure peaks in the continuous record. Although there was no evidence of fresh hemorrhage, three of these episodes were followed by a verified hemorrhage within 24 hours. Since no such “warning episode” was seen after the aneurysm had been clipped, the authors consider this pressure peak and concomitant clinical deterioration to be related to the mechanism of aneurysm rupture and possibly a forerunner of a life-threatening hemorrhage. These three pressure patterns showed the whole range from full spatial compensation to total decompensation. The determining factors are considered to be the volume of extravasated blood, the vasomoter reaction, and the intracranial spatial buffering capacity.

Article Information

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

© AANS, except where prohibited by US copyright law.

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Figures

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    A. Case 3. Subarachnoid hemorrhage type 1. Initial pressure peak and secondary increase in intracranial pressure due to edema. B. Case 13. Subarachnoid hemorrhage type 2. Instant increase in pressure followed by a high pressure plateau. Terminal drop in EDP due to falling blood pressure. Tracing partly off scale.

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    Upper Tracings: Subarachnoid hemorrhage type 1. Initial pressure peak and secondary pressure increase. A. Case 10. B. Case 3. Lower Tracing: Subarachnoid hemorrhage type 2. Instant increase in pressure followed by a high pressure plateau. C. Case 7. D. Case 13.

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    A. Case 7. Two pressure peaks (“warning episodes”) without secondary increase in EDP, followed by SAH type 1. Clinical grading in Roman numerals. B. Classical plateau waves for comparison, from a patient with posterior fossa tumor.

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    Graph of EDP in two patients with warning episodes (W. E.) and recurrent hemorrhage. Upper Tracing: Case 2. Lower Tracing: Case 7.

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    Case 17. Tracings during and following warning episode (w.e.). Aneurysm was clipped 28 hours after w.e. Clinical grading in Roman numerals.

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    Case 19. Graph depicting two warning episodes, followed by four recurrent pressure peaks with clinical deterioration. Aneurysm was clipped with the patient under 29°C hypothermia. Clinical grading in Roman numerals.

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    Case 21. Simultaneous recording of ventricular fluid pressure (VFP) and epidural pressure (EDP) during recurrent hemorrhage (SAH type 1). Ventricular drainage (VF) performed during first and second peak. The third peak occurred while the patient was receiving respiratory assistance. FB = forced breathing.

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    Case 10. EDP records from the 5th hour after the initial hemorrhage to the 6th postoperative day. Note return to normal after first and second hemorrhages. Clinical grading in Roman numerals.

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    Case 18. Graph showing return of EDP to normal and clinical improvement to Grade I nearly 2 weeks after hemorrhage.

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