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

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

Search for other papers by Niels Juul in
Current site
Google Scholar
PubMed
Close
 M.D.
,
Gabrielle F. MorrisDivision of Neurological Surgery, University of California, San Diego, California; and Department of Neuroanesthesia and Neurointensive Care, Aalborg Hospital, Aalborg, Denmark

Search for other papers by Gabrielle F. Morris in
Current site
Google Scholar
PubMed
Close
 M.D.
,
Sharon B. MarshallDivision of Neurological Surgery, University of California, San Diego, California; and Department of Neuroanesthesia and Neurointensive Care, Aalborg Hospital, Aalborg, Denmark

Search for other papers by Sharon B. Marshall in
Current site
Google Scholar
PubMed
Close
 B.S.N.
,
the Executive Committee of the International Selfotel TrialDivision of Neurological Surgery, University of California, San Diego, California; and Department of Neuroanesthesia and Neurointensive Care, Aalborg Hospital, Aalborg, Denmark

Search for other papers by the Executive Committee of the International Selfotel Trial in
Current site
Google Scholar
PubMed
Close
, and
Lawrence F. MarshallDivision of Neurological Surgery, University of California, San Diego, California; and Department of Neuroanesthesia and Neurointensive Care, Aalborg Hospital, Aalborg, Denmark

Search for other papers by Lawrence F. Marshall in
Current site
Google Scholar
PubMed
Close
 M.D.
View More View Less
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $525.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $624.00
USD  $45.00
USD  $525.00
USD  $624.00
Print or Print + Online Sign in

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.

  • Collapse
  • Expand
  • 1.

    Barzó P, , Marmarou A, & Fatouros P, et al: Acute blood-brain barrier changes in experimental closed head injury as measured by MRI and Gd-DTPA. Acta Neurochir Suppl 70:243246, 1997 Barzó P, Marmarou A, Fatouros P, et al: Acute blood-brain barrier changes in experimental closed head injury as measured by MRI and Gd-DTPA. Acta Neurochir Suppl 70:243–246, 1997

    • Search Google Scholar
    • Export Citation
  • 2.

    Bullock R, , Chesnut RM, & Clifton G, et al: Intracranial pressure treatment threshold. J Neurotrauma 13:681683, 1996 Bullock R, Chesnut RM, Clifton G, et al: Intracranial pressure treatment threshold. J Neurotrauma 13:681–683, 1996

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3.

    Chan KH, , Dearden NM, & Miller JD, et al: Multimodality monitoring as a guide to treatment of intracranial hypertension after severe brain injury. Neurosurgery 32:547553, 1993 Chan KH, Dearden NM, Miller JD, et al: Multimodality monitoring as a guide to treatment of intracranial hypertension after severe brain injury. Neurosurgery 32:547–553, 1993

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4.

    Chesnut RM, , Marshall LF, & Klauber MR, et al: The role of secondary brain injury in determining outcome from severe head injury. J Trauma 34:216222, 1993 Chesnut RM, Marshall LF, Klauber MR, et al: The role of secondary brain injury in determining outcome from severe head injury. J Trauma 34:216–222, 1993

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5.

    Chesnut RM, , Marshall SB, & Piek J, et al: Early and late systemic hypotension as a frequent and fundamental source of cerebral ischemia following severe brain injury in the Traumatic Coma Data Bank. Acta Neurochir Suppl 59:121125, 1993 Chesnut RM, Marshall SB, Piek J, et al: Early and late systemic hypotension as a frequent and fundamental source of cerebral ischemia following severe brain injury in the Traumatic Coma Data Bank. Acta Neurochir Suppl 59:121–125, 1993

    • Search Google Scholar
    • Export Citation
  • 6.

    Jennett B, & Bond M: Assessment of outcome after severe brain damage. A practical scale. Lancet 1:480484, 1975 Jennett B, Bond M: Assessment of outcome after severe brain damage. A practical scale. Lancet 1:480–484, 1975

    • Search Google Scholar
    • Export Citation
  • 7.

    Joint Section on Trauma and Critical Care of the American Association of Neurological Surgeons and the Brain Trauma Foundation: Guidelines for the Management of Severe Head Injury. Park Ridge, Ill: American Association of Neurological Surgeons, 1995 Joint Section on Trauma and Critical Care of the American Association of Neurological Surgeons and the Brain Trauma Foundation: Guidelines for the Management of Severe Head Injury. Park Ridge, Ill: American Association of Neurological Surgeons, 1995

    • Search Google Scholar
    • Export Citation
  • 8.

    Marmarou A, , Barzo P, & Fatouros P, et al: Traumatic brain swelling in head injured patients: brain edema or vascular engorgement? Acta Neurochir Suppl 70:6870, 1997 Marmarou A, Barzo P, Fatouros P, et al: Traumatic brain swelling in head injured patients: brain edema or vascular engorgement? Acta Neurochir Suppl 70:68–70, 1997

    • Search Google Scholar
    • Export Citation
  • 9.

    Marmarou A, , Ward JD, & Young HF, et al: Impact of ICP instability and hypotension on outcome in patients with severe head trauma. J Neurosurg 75 (Suppl):S59S66, 1991 Marmarou A, Ward JD, Young HF, et al: Impact of ICP instability and hypotension on outcome in patients with severe head trauma. J Neurosurg 75 (Suppl):S59–S66, 1991

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10.

    Marshall LF, , Marshall SB, & Klauber MR, et al: A new classification of head injury based on computerized tomography. J Neurosurg 75 (Suppl):S14S20, 1991 Marshall LF, Marshall SB, Klauber MR, et al: A new classification of head injury based on computerized tomography. J Neurosurg 75 (Suppl):S14–S20, 1991

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11.

    Marshall LF, , Toole BM, & Bowers SB: The National Traumatic Coma Data Bank. Part 2: Patients who talk and deteriorate: implications for treatment. J Neurosurg 59:285288, 1983 Marshall LF, Toole BM, Bowers SB: The National Traumatic Coma Data Bank. Part 2: Patients who talk and deteriorate: implications for treatment. J Neurosurg 59:285–288, 1983

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12.

    Mathew P, , Graham DI, & Bullock R, et al: Focal brain injury: histological evidence of delayed inflammatory response in a new rodent model of focal cortical injury. Acta Neurochir Suppl 60:428430, 1994 Mathew P, Graham DI, Bullock R, et al: Focal brain injury: histological evidence of delayed inflammatory response in a new rodent model of focal cortical injury. Acta Neurochir Suppl 60:428–430, 1994

    • Search Google Scholar
    • Export Citation
  • 13.

    Miller JD: Disorders of cerebral blood flow and intracranial pressure after head injury. Clin Neurosurg 29:162173, 1982 Miller JD: Disorders of cerebral blood flow and intracranial pressure after head injury. Clin Neurosurg 29:162–173, 1982

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14.

    Morris GF, , Bullock R, & Marshall SB, et al: Failure of the competitive N-methyl-d-aspartate antagonist Selfotel (CGS 19755) in the treatment of severe head injury: results of two Phase III clinical trials. J Neurosurg 91:737743, 1999 Morris GF, Bullock R, Marshall SB, et al: Failure of the competitive N-methyl-d-aspartate antagonist Selfotel (CGS 19755) in the treatment of severe head injury: results of two Phase III clinical trials. J Neurosurg 91:737–743, 1999

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15.

    Morris GF, , Juul N, & Marshall SB, et al: Neurological deterioration as a potential alternative endpoint in human clinical trials of experimental pharmacological agents for treatment of severe traumatic brain injuries. Neurosurgery 43:13691374, 1998 Morris GF, Juul N, Marshall SB, et al: Neurological deterioration as a potential alternative endpoint in human clinical trials of experimental pharmacological agents for treatment of severe traumatic brain injuries. Neurosurgery 43:1369–1374, 1998

    • Search Google Scholar
    • Export Citation
  • 16.

    Narayan RK, , Greenberg RP, & Miller JD, et al: Improved confidence of outcome prediction in severe head injury. A comparative analysis of the clinical examination, multimodality evoked potentials, CT scanning, and intracranial pressure. J Neurosurg 54:751762, 1981 Narayan RK, Greenberg RP, Miller JD, et al: Improved confidence of outcome prediction in severe head injury. A comparative analysis of the clinical examination, multimodality evoked potentials, CT scanning, and intracranial pressure. J Neurosurg 54:751–762, 1981

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17.

    Rosner MJ: Introduction to cerebral perfusion pressure management. Neurosurg Clin N Am 6:761773, 1995 Rosner MJ: Introduction to cerebral perfusion pressure management. Neurosurg Clin N Am 6:761–773, 1995

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 18.

    Shackford SR, , Mackersie RC, & Holbrook TL, et al: The epidemiology of traumatic death. A population-based analysis. Arch Surg 128:571575, 1993 Shackford SR, Mackersie RC, Holbrook TL, et al: The epidemiology of traumatic death. A population-based analysis. Arch Surg 128:571–575, 1993

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 19.

    Stein SC, , Spettell C, & Young G, et al: Delayed and progressive brain injury in closed-head trauma: radiological demonstration. Neurosurgery 32:2531, 1993 Stein SC, Spettell C, Young G, et al: Delayed and progressive brain injury in closed-head trauma: radiological demonstration. Neurosurgery 32:25–31, 1993

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 20.

    Teasdale E, , Cardoso E, & Galbraith S, et al: CT scan in severe diffuse head injury: physiological and clinical correlations. J Neurol Neurosurg Psychiatry 47:600603, 1984 Teasdale E, Cardoso E, Galbraith S, et al: CT scan in severe diffuse head injury: physiological and clinical correlations. J Neurol Neurosurg Psychiatry 47:600–603, 1984

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 21.

    Teasdale G, & Jennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet 2:8184, 1974 Teasdale G, Jennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81–84, 1974

    • Search Google Scholar
    • Export Citation
  • 22.

    Toutant SM, , Klauber MR, & Marshall LF, et al: Absent or compressed basal cisterns on first CT scan: ominous predictors of outcome in severe head injury. J Neurosurg 61:691694, 1984 Toutant SM, Klauber MR, Marshall LF, et al: Absent or compressed basal cisterns on first CT scan: ominous predictors of outcome in severe head injury. J Neurosurg 61:691–694, 1984

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 23.

    Unterberg AW, , Kiening KL, & Hartl R, et al: Multimodal monitoring in patients with head injury: evaluation of the effects of treatment on cerebral oxygenation. J Trauma 42 (Suppl 5):S32S37, 1997 Unterberg AW, Kiening KL, Hartl R, et al: Multimodal monitoring in patients with head injury: evaluation of the effects of treatment on cerebral oxygenation. J Trauma 42 (Suppl 5):S32–S37, 1997

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 24.

    van Dongen KJ, , Braakman R, & Gelpke GJ: The prognostic value of computerized tomography in comatose head-injured patients. J Neurosurg 59:951957, 1983 van Dongen KJ, Braakman R, Gelpke GJ: The prognostic value of computerized tomography in comatose head-injured patients. J Neurosurg 59:951–957, 1983

    • Crossref
    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 1785 453 28
Full Text Views 493 19 0
PDF Downloads 199 38 0
EPUB Downloads 0 0 0