The role of intracranial pressure in the arrest of hemorrhage in patients with ruptured intracranial aneurysm

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✓ Intracranial epidural pressure (EDP) was recorded in 29 patients admitted with ruptured saccular aneurysms, but unfit for immediate surgery. In 10 patients a total of 13 recurrent hemorrhages were recorded; the average time before rerupture was 7.7 days after the last hemorrhage. Ten of the rebleedings started from intracranial pressure levels at or below 400 mm H2O whereas three started from higher prerupture levels. The observations indicate an increasing risk of rebleeding as the epidural pressure decreases toward normal pressure. Most repeat hemorrhages are arrested at EDP levels about that of the diastolic blood pressure. The resulting reduced pressure gradient across the aneurysm wall is important in the arrest of hemorrhage and the maintenance of hemostasis. Measurement of internal carotid artery blood flow during the acute stage of recurrent hemorrhage shows marked changes in blood flow pattern. Arrest of blood flow occurred only at the end of diastole; forward flow occurred only during systole. The effect of intracranial-pressure-buffering mechanisms on the increased EDP after rupture is discussed. Activation of these mechanisms may reduce the EDP to acceptable pressure levels within minutes and should be awaited before decompressive management is considered. Continuous recording of the EDP in patients unfit for immediate aneurysm surgery is important in the selection of the optimal time for operation.

Article Information

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

© AANS, except where prohibited by US copyright law.

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Figures

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    Graph showing the instant increase in epidural pressure (EDP) due to recurrent hemorrhage. Note the different pressure patterns following subarachnoid hemorrhage (SAH) Types 1 and 2.

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    Record of epidural pressure (EDP) after SAH up to time of rerupture in 13 recurrent hemorrhages. Horizontal interrupted line = 400 mm H2O.

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    EDP records in 23 SAH patients at risk of rebleeding whose pressure sequence did not end in rerupture. F = failure (transducer breakdown). The terminal stage with a BP drop to zero and concomitant EDP fall seen with death is not shown.

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    Number of patients monitored per day after SAH.

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    Case 7. Tracing of EDP pressure during recurrent SAH Type 1. Lumbar puncture with a 5 ml/CSF tap at 1100 mm H2O, reduced the EDP pressure to about 625 mm H2O and was followed by an instant increase in EDP.

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    Case 10. Tracings of EDP pressure during recurrent SAH Type 1. At the first pressure peak 75 gm of mannitol was given intravenously. Note the following three peaks, each returning to progressively higher post-peak pressures. Interrupted line = pressure “baseline.”

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    Case 4. Three sequences presenting epidural pressure, internal carotid artery blood flow, and brachial blood pressure. Rebleeding occurred during the second and third sequence. A and B refer to the original flow tracings in Fig. 8. Electromagnetic flow recording was made discontinuously. Note vasopressor response after the first but not the second rehemorrhage.

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    Case 4. Internal carotid artery blood flow, mean and instantaneous. A = before rerupture. B = 10 minutes after rerupture, the corresponding epidural pressure was 1850 mm H2O (136 mm Hg). Note the zero blood flow during the last part of diastole. Compare with Fig. 7.

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