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.

References

  • 1.

    Björkesten G afTroupp H: Changes in the size of intracranial arterial aneurysms. J Neurosurg 19:5835881962Björkesten G af Troupp H: Changes in the size of intracranial arterial aneurysms. J Neurosurg 19:583–588 1962

    • Search Google Scholar
    • Export Citation
  • 2.

    Boyd W: A Textbook of Pathology. PhiladelphiaLea & Febiger1961ed 7Boyd W: A Textbook of Pathology. Philadelphia Lea & Febiger 1961 ed 7

    • Search Google Scholar
    • Export Citation
  • 3.

    Ecker ARiemenschneider PA: Arteriographic demonstration of spasm of the intracranial arteries. J Neurosurg 8:6606671951Ecker A Riemenschneider PA: Arteriographic demonstration of spasm of the intracranial arteries. J Neurosurg 8:660–667 1951

    • Search Google Scholar
    • Export Citation
  • 4.

    Forbus WD: On the origin of miliary aneurysms of the superficial cerebral arteries. Bull Johns Hopkins Hosp 47:2392841930Forbus WD: On the origin of miliary aneurysms of the superficial cerebral arteries. Bull Johns Hopkins Hosp 47:239–284 1930

    • Search Google Scholar
    • Export Citation
  • 5.

    Greenfield CJTindall GT: Effect of acute increase in intracranial pressure on blood flow in the internal carotid artery in man. J Clin Invest 44:134313511965Greenfield CJ Tindall GT: Effect of acute increase in intracranial pressure on blood flow in the internal carotid artery in man. J Clin Invest 44:1343–1351 1965

    • Search Google Scholar
    • Export Citation
  • 6.

    Hovig T: Aggregation of rabbit blood platelets produced in vitro by saline “extract” of tendons. Thrombos Diath Haemorrh 9:2482631963Hovig T: Aggregation of rabbit blood platelets produced in vitro by saline “extract” of tendons. Thrombos Diath Haemorrh 9:248–263 1963

    • Search Google Scholar
    • Export Citation
  • 7.

    Hovig T: Release of a platelet-aggregating substance (adenosine diphosphate) from rabbit blood platelets induced by saline “extract” of tendons. Thrombos Diath Haemorrh 9:2642781963Hovig T: Release of a platelet-aggregating substance (adenosine diphosphate) from rabbit blood platelets induced by saline “extract” of tendons. Thrombos Diath Haemorrh 9:264–278 1963

    • Search Google Scholar
    • Export Citation
  • 8.

    Hovig TDodds WJRowsell HCet al: The transformation of hemostatic platelet plugs in normal and factor IX deficient dogs. Am J Path 53:3553741968Hovig T Dodds WJ Rowsell HC et al: The transformation of hemostatic platelet plugs in normal and factor IX deficient dogs. Am J Path 53:355–374 1968

    • Search Google Scholar
    • Export Citation
  • 9.

    Hovig TRowsell HCDodds WJet al: Experimental hemostasis in normal dogs and dogs with congenital disorders of blood coagulation. Blood 30:6366681967Hovig T Rowsell HC Dodds WJ et al: Experimental hemostasis in normal dogs and dogs with congenital disorders of blood coagulation. Blood 30:636–668 1967

    • Search Google Scholar
    • Export Citation
  • 10.

    Jain KK: Mechanism of rupture of intracranial saccular aneurysms. Surgery 54:3473501963Jain KK: Mechanism of rupture of intracranial saccular aneurysms. Surgery 54:347–350 1963

    • Search Google Scholar
    • Export Citation
  • 11.

    Klafta LA JrHamby WB: Significance of cerebrospinal fluid pressure in determining time for repair of intracranial aneurysms. J Neurosurg 31:2172191969Klafta LA Jr Hamby WB: Significance of cerebrospinal fluid pressure in determining time for repair of intracranial aneurysms. J Neurosurg 31:217–219 1969

    • Search Google Scholar
    • Export Citation
  • 12.

    Langfitt TWKassel NF: Non-filling of cerebral vessels during angiography: correlation with intracranial pressure. Acta Neurochir 14:961041966Langfitt TW Kassel NF: Non-filling of cerebral vessels during angiography: correlation with intracranial pressure. Acta Neurochir 14:96–104 1966

    • Search Google Scholar
    • Export Citation
  • 13.

    Langfitt TWWeinstein JDKassel NFet al: Transmission of increased intracranial pressure. I. Within the craniospinal axis. J Neurosurg 21:9899971964Langfitt TW Weinstein JD Kassel NF et al: Transmission of increased intracranial pressure. I. Within the craniospinal axis. J Neurosurg 21:989–997 1964

    • Search Google Scholar
    • Export Citation
  • 14.

    Locksley HB: Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage. Section V, Part I. Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations: based on 6368 cases in the cooperative study. J Neurosurg 25:2192391966Locksley HB: Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage. Section V Part I. Natural history of subarachnoid hemorrhage intracranial aneurysms and arteriovenous malformations: based on 6368 cases in the cooperative study. J Neurosurg 25:219–239 1966

    • Search Google Scholar
    • Export Citation
  • 15.

    Locksley HB: Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage. Section V, Part II. Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations: based on 6368 cases in the cooperative study. J Neurosurg 25:3213681966Locksley HB: Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage. Section V Part II. Natural history of subarachnoid hemorrhage intracranial aneurysms and arteriovenous malformations: based on 6368 cases in the cooperative study. J Neurosurg 25:321–368 1966

    • Search Google Scholar
    • Export Citation
  • 16.

    Mullan SDawley J: Antifibrinolytic therapy for intracranial aneurysms. J Neurosurg 28:21231968Mullan S Dawley J: Antifibrinolytic therapy for intracranial aneurysms. J Neurosurg 28:21–23 1968

    • Search Google Scholar
    • Export Citation
  • 17.

    Norlen GThulin C-A: Experiences with epsilon-aminocaproic acid in neurosurgery. (A preliminary report.) Neurochirurgia 10:81861967Norlen G Thulin C-A: Experiences with epsilon-aminocaproic acid in neurosurgery. (A preliminary report.) Neurochirurgia 10:81–86 1967

    • Search Google Scholar
    • Export Citation
  • 18.

    Nornes H: Long-term implanted electromagnetic flow probes in man: observations during graded occlusion for internal carotid artery aneurysms in Cappelen C (ed): New Findings in Blood Flowmetry. OsloUniversitetsforlaget1968 pp 215219Nornes H: Long-term implanted electromagnetic flow probes in man: observations during graded occlusion for internal carotid artery aneurysms in Cappelen C (ed): New Findings in Blood Flowmetry. Oslo Universitetsforlaget 1968 pp 215–219

    • Search Google Scholar
    • Export Citation
  • 19.

    Nornes HHauge T: Longtime intracranial epidural pressure recording. Acta Neurol Scand 45:2401969 (Abstract)Nornes H Hauge T: Longtime intracranial epidural pressure recording. Acta Neurol Scand 45:240 1969 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 20.

    NornesHMagnaes B: Supratentorial epidural pressure recorded during posterior fossa surgery. J Neurosurg 35:5415491971Nornes H Magnaes B: Supratentorial epidural pressure recorded during posterior fossa surgery. J Neurosurg 35:541–549 1971

    • Search Google Scholar
    • Export Citation
  • 21.

    Nornes HMagnaes B: Intracranial pressure in patients with ruptured saccular aneurysm. J Neurosurg 36:5375471972Nornes H Magnaes B: Intracranial pressure in patients with ruptured saccular aneurysm. J Neurosurg 36:537–547 1972

    • Search Google Scholar
    • Export Citation
  • 22.

    Nornes HSerck-Hanssen F: Miniature transducer for intracranial pressure monitoring in man. Acta Neurol Scand 46:2032141970Nornes H Serck-Hanssen F: Miniature transducer for intracranial pressure monitoring in man. Acta Neurol Scand 46:203–214 1970

    • Search Google Scholar
    • Export Citation
  • 23.

    Nornes HSundbärg G: Simultaneous recordings of the ventricular fluid pressure and the epidural pressure. Europ Neurol 7:3643721972.Nornes H Sundbärg G: Simultaneous recordings of the ventricular fluid pressure and the epidural pressure. Europ Neurol 7:364–372 1972.

    • Search Google Scholar
    • Export Citation
  • 24.

    Nyström SHM: Development of intracranial aneurysms as revealed by electron microscopy. J Neurosurg 20:3293371963Nyström SHM: Development of intracranial aneurysms as revealed by electron microscopy. J Neurosurg 20:329–337 1963

    • Search Google Scholar
    • Export Citation
  • 25.

    Patterson RH JrHarpel P: The effect of epsilon aminocaproic acid and tranexamic acid on thrombus size and strength in a simulated arterial aneurysm. J Neurosurg 34:3653711971Patterson RH Jr Harpel P: The effect of epsilon aminocaproic acid and tranexamic acid on thrombus size and strength in a simulated arterial aneurysm. J Neurosurg 34:365–371 1971

    • Search Google Scholar
    • Export Citation
  • 26.

    Pool JLPotts DG: Aneurysms and Arteriovenous Anomalies of the Brain: Diagnosis and Treatment. New YorkHarper & Row1965 p 201Pool JL Potts DG: Aneurysms and Arteriovenous Anomalies of the Brain: Diagnosis and Treatment. New York Harper & Row 1965 p 201

    • Search Google Scholar
    • Export Citation
  • 27.

    Porter JMAcinapura AJKapp JPet al: Fibrinolysis in the central nervous system. Neurology 19:47521969Porter JM Acinapura AJ Kapp JP et al: Fibrinolysis in the central nervous system. Neurology 19:47–52 1969

    • Search Google Scholar
    • Export Citation
  • 28.

    Schemm GW: Blood clot absorption and organization in the cerebrospinal fluid. Surg Forum 17:4234251966Schemm GW: Blood clot absorption and organization in the cerebrospinal fluid. Surg Forum 17:423–425 1966

    • Search Google Scholar
    • Export Citation
  • 29.

    Schutta HSKassel NFLangfitt TW: Brain swelling produced by injury and aggrevated by arterial hypertension. Brain 91:2812941968Schutta HS Kassel NF Langfitt TW: Brain swelling produced by injury and aggrevated by arterial hypertension. Brain 91:281–294 1968

    • Search Google Scholar
    • Export Citation
  • 30.

    Stehbens WE: Histopathology of cerebral aneurysms. Arch Neurol 8:2722851963Stehbens WE: Histopathology of cerebral aneurysms. Arch Neurol 8:272–285 1963

    • Search Google Scholar
    • Export Citation
  • 31.

    Stornelli SAFrench JD: Subarachnoid hemorrhage—factors in prognosis and management. J Neurosurg 21:7697801964Stornelli SA French JD: Subarachnoid hemorrhage—factors in prognosis and management. J Neurosurg 21:769–780 1964

    • Search Google Scholar
    • Export Citation
  • 32.

    Taylor PE: Delayed post operative hemorrhage from intracranial aneurysm after craniotomy for tumor. Neurology 11:2252311961Taylor PE: Delayed post operative hemorrhage from intracranial aneurysm after craniotomy for tumor. Neurology 11:225–231 1961

    • Search Google Scholar
    • Export Citation
  • 33.

    Tominaga S: An experimental study of hemodynamic factors in the rupture of intracranial aneurysms. Arch Jap Chir 35:67881966 (Jap)Tominaga S: An experimental study of hemodynamic factors in the rupture of intracranial aneurysms. Arch Jap Chir 35:67–88 1966 (Jap)

    • Search Google Scholar
    • Export Citation

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