Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury

Niels Juul Division of Neurological Surgery, University of California, San Diego, California; and Department of Neuroanesthesia and Neurointensive Care, Aalborg Hospital, Aalborg, Denmark

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Gabrielle F. Morris Division of Neurological Surgery, University of California, San Diego, California; and Department of Neuroanesthesia and Neurointensive Care, Aalborg Hospital, Aalborg, Denmark

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Sharon B. Marshall Division of Neurological Surgery, University of California, San Diego, California; and Department of Neuroanesthesia and Neurointensive Care, Aalborg Hospital, Aalborg, Denmark

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the Executive Committee of the International Selfotel Trial Division of Neurological Surgery, University of California, San Diego, California; and Department of Neuroanesthesia and Neurointensive Care, Aalborg Hospital, Aalborg, Denmark

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Lawrence F. Marshall Division of Neurological Surgery, University of California, San Diego, California; and Department of Neuroanesthesia and Neurointensive Care, Aalborg Hospital, Aalborg, Denmark

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Object. Recently, a renewed emphasis has been placed on managing severe head injury by elevating cerebral perfusion pressure (CPP), which is defined as the mean arterial pressure minus the intracranial pressure (ICP). Some authors have suggested that CPP is more important in influencing outcome than is intracranial hypertension, a hypothesis that this study was designed to investigate.

Methods. The authors examined the relative contribution of these two parameters to outcome in a series of 427 patients prospectively studied in an international, multicenter, randomized, double-blind trial of the N-methyl-d-aspartate antagonist Selfotel. Mortality rates rose from 9.6% in 292 patients who had no clinically defined episodes of neurological deterioration to 56.4% in 117 patients who suffered one or more of these episodes; 18 patients were lost to follow up. Correspondingly, favorable outcome, defined as good or moderate on the Glasgow Outcome Scale at 6 months, fell from 67.8% in patients without neurological deterioration to 29.1% in those with neurological deterioration. In patients who had clinical evidence of neurological deterioration, the relative influence of ICP and CPP on outcome was assessed. The most powerful predictor of neurological worsening was the presence of intracranial hypertension (ICP ≥ 20 mm Hg) either initially or during neurological deterioration. There was no correlation with the CPP as long as the CPP was greater than 60 mm Hg.

Conclusions. Treatment protocols for the management of severe head injury should emphasize the immediate reduction of raised ICP to less than 20 mm Hg if possible. A CPP greater than 60 mm Hg appears to have little influence on the outcome of patients with severe head injury.

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