Hyperacute measurement of intracranial pressure, cerebral perfusion pressure, jugular venous oxygen saturation, and laser Doppler flowmetry, before and during removal of traumatic acute subdural hematoma

Restricted access

Object. The poor prognosis for traumatic acute subdural hematoma (ASDH) might be due to underlying primary brain damage, ischemia, or both. Ischemia in ASDH is likely caused by increased intracranial pressure (ICP) leading to decreased cerebral perfusion pressure (CPP), but the degree to which these phenomena occur is unknown. The authors report data obtained before and during removal of ASDH in five cases.

Methods. Five patients who underwent emergency evacuation of ASDH were monitored. In all patients, without delaying treatment, a separate surgical team (including the senior author) placed an ICP monitor and a jugular bulb catheter, and in two patients a laser Doppler probe was placed.

The ICP prior to removing the bone flap in the five patients was 85, 85, 50, 59, and greater than 40 mm Hg, resulting in CPPs of 25, 3, 25, 56, and less than 50 mm Hg, respectively. Removing the bone flap as well as opening the dura and removing the blood clot produced a significant decrease in ICP and an increase in CPP. Jugular venous oxygen saturation (SjvO2) increased in four patients and decreased in the other during removal of the hematoma. Laser Doppler flow also increased, to 217% and 211% compared with preevacuation flow.

Conclusions. Intracranial pressure is higher than previously suspected and CPP is very low in patients with ASDH. Removal of the bone flap yielded a significant reduction in ICP, which was further decreased by opening the dura and evacuating the hematoma. The SjvO2 as well as laser Doppler flow increased in all patients but one immediately after removal of the hematoma.

Article Information

Address reprint requests to: J. Paul Muizelaar, M.D., Ph.D., Department of Neurosurgery, University of California at Davis Medical Center, 4860 Y Street, Room No. 3740, Sacramento, California 95817. email: J.Paul.Muizelaar@UCDMC.ucdavis.edu.

© AANS, except where prohibited by US copyright law.

Headings

References

  • 1.

    Anonymous: Guidelines for the management of severe head injury. Brain Trauma Foundation, American Association of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care. J Neurotrauma 13:6417341996Anonymous: Guidelines for the management of severe head injury. Brain Trauma Foundation American Association of Neurological Surgeons Joint Section on Neurotrauma and Critical Care. J Neurotrauma 13:641–734 1996

    • Search Google Scholar
    • Export Citation
  • 2.

    Bergsneider MHovda DALee SMet al: Dissociation of cerebral glucose metabolism and level of consciousness during the period of metabolic depression following human traumatic brain injury. J Neurotrauma 17:3894012000Bergsneider M Hovda DA Lee SM et al: Dissociation of cerebral glucose metabolism and level of consciousness during the period of metabolic depression following human traumatic brain injury. J Neurotrauma 17:389–401 2000

    • Search Google Scholar
    • Export Citation
  • 3.

    Bouma GJMuizelaar JP: Cerebral blood flow, cerebral blood volume, and cerebrovascular reactivity after severe head injury. J Neurotrauma 9 (Suppl 1):S333S3481992Bouma GJ Muizelaar JP: Cerebral blood flow cerebral blood volume and cerebrovascular reactivity after severe head injury. J Neurotrauma 9 (Suppl 1):S333–S348 1992

    • Search Google Scholar
    • Export Citation
  • 4.

    Bullock RChesnut RMClifton Get al: Guidelines for the management of severe head injury. Brain Trauma Foundation. Eur J Emerg Med 3:1091271996Bullock R Chesnut RM Clifton G et al: Guidelines for the management of severe head injury. Brain Trauma Foundation. Eur J Emerg Med 3:109–127 1996

    • Search Google Scholar
    • Export Citation
  • 5.

    Chambers JW: Acute subdural haematoma. J Neurosurg 8:2632681951Chambers JW: Acute subdural haematoma. J Neurosurg 8:263–268 1951

    • Search Google Scholar
    • Export Citation
  • 6.

    Chen MHBullock RGraham DIet al: Ischemic neuronal damage after acute subdural hematoma in the rat: effects of pretreatment with a glutamate antagonist. J Neurosurg 74:9449501991Chen MH Bullock R Graham DI et al: Ischemic neuronal damage after acute subdural hematoma in the rat: effects of pretreatment with a glutamate antagonist. J Neurosurg 74:944–950 1991

    • Search Google Scholar
    • Export Citation
  • 7.

    Coles JPFryer TDWilliams EJet al: Evidence of cerebral ischemia following traumatic brain injury. Rest Neurol Neurosci 16:2152000 (Abstract)Coles JP Fryer TD Williams EJ et al: Evidence of cerebral ischemia following traumatic brain injury. Rest Neurol Neurosci 16:215 2000 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 8.

    Cruz J: Continuous versus serial global cerebral hemometabolic monitoring: applications in acute brain trauma. Acta Neurochir Suppl 42:35391988Cruz J: Continuous versus serial global cerebral hemometabolic monitoring: applications in acute brain trauma. Acta Neurochir Suppl 42:35–39 1988

    • Search Google Scholar
    • Export Citation
  • 9.

    Gennarelli TAChampion HRSacco WJet al: Mortality of patients with head injury and extracranial injury treated in trauma centers. J Trauma 29:119312021989Gennarelli TA Champion HR Sacco WJ et al: Mortality of patients with head injury and extracranial injury treated in trauma centers. J Trauma 29:1193–1202 1989

    • Search Google Scholar
    • Export Citation
  • 10.

    Gennarelli TAThibault L: Biomechanics of acute subdural hematoma. J Trauma 22:6806861982Gennarelli TA Thibault L: Biomechanics of acute subdural hematoma. J Trauma 22:680–686 1982

    • Search Google Scholar
    • Export Citation
  • 11.

    Gopinath SPRobertson CSContant CFet al: Jugular venous desaturation and outcome after head injury. J Neurol Neurosurg Psychiatry 57:7177231994Gopinath SP Robertson CS Contant CF et al: Jugular venous desaturation and outcome after head injury. J Neurol Neurosurg Psychiatry 57:717–723 1994

    • Search Google Scholar
    • Export Citation
  • 12.

    Guerra WKWGaab MRDietz Het al: Surgical decompression for traumatic brain swelling: indications and results. J Neurosurg 90:1871961999Guerra WKW Gaab MR Dietz H et al: Surgical decompression for traumatic brain swelling: indications and results. J Neurosurg 90:187–196 1999

    • Search Google Scholar
    • Export Citation
  • 13.

    Haselsberger KPucher RAuer LM: Prognosis after acute subdural or epidural haemorrhage. Acta Neurochir 90:1111161988Haselsberger K Pucher R Auer LM: Prognosis after acute subdural or epidural haemorrhage. Acta Neurochir 90:111–116 1988

    • Search Google Scholar
    • Export Citation
  • 14.

    Jamieson KGYelland JDN: Surgically treated traumatic subdural hematomas. J Neurosurg 37:1371491972Jamieson KG Yelland JDN: Surgically treated traumatic subdural hematomas. J Neurosurg 37:137–149 1972

    • Search Google Scholar
    • Export Citation
  • 15.

    Jenkins LWMoszynski KLyeth BGet al: Increased vulnerability of the mildly traumatized rat brain to cerebral ischemia: the use of controlled secondary ischemia as a research tool to identify common or different mechanisms contributing to mechanical and ischemic brain injury. Brain Res 477:2112241989Jenkins LW Moszynski K Lyeth BG et al: Increased vulnerability of the mildly traumatized rat brain to cerebral ischemia: the use of controlled secondary ischemia as a research tool to identify common or different mechanisms contributing to mechanical and ischemic brain injury. Brain Res 477:211–224 1989

    • Search Google Scholar
    • Export Citation
  • 16.

    Macpherson PGraham DI: Correlation between angiographic findings and the ischemia of head injury. J Neurol Neurosurg Psychiatry 41:1221271978Macpherson P Graham DI: Correlation between angiographic findings and the ischemia of head injury. J Neurol Neurosurg Psychiatry 41:122–127 1978

    • Search Google Scholar
    • Export Citation
  • 17.

    Marshall JFToole BMBowers SA: The National Traumatic Coma Data Bank. Part 2: Patients who talk and deteriorate: implications for treatment. J Neurosurg 59:2852881983Marshall JF Toole BM Bowers SA: The National Traumatic Coma Data Bank. Part 2: Patients who talk and deteriorate: implications for treatment. J Neurosurg 59:285–288 1983

    • Search Google Scholar
    • Export Citation
  • 18.

    Miller JDBullock RGraham DIet al: Ischemic brain damage in a model of acute subdural hematoma. Neurosurgery 27:4334391990Miller JD Bullock R Graham DI et al: Ischemic brain damage in a model of acute subdural hematoma. Neurosurgery 27:433–439 1990

    • Search Google Scholar
    • Export Citation
  • 19.

    Richards THoff J: Factors affecting survival from acute subdural hematoma. Surgery 75:2532581974Richards T Hoff J: Factors affecting survival from acute subdural hematoma. Surgery 75:253–258 1974

    • Search Google Scholar
    • Export Citation
  • 20.

    Robertson CSNarayan RKGokaslan ZLet al: Cerebral arteriovenous oxygen difference as an estimate of cerebral blood flow in comatose patients. J Neurosurg 70:2222301989Robertson CS Narayan RK Gokaslan ZL et al: Cerebral arteriovenous oxygen difference as an estimate of cerebral blood flow in comatose patients. J Neurosurg 70:222–230 1989

    • Search Google Scholar
    • Export Citation
  • 21.

    Salvant JB JrMuizelaar JP: Changes in cerebral blood flow and metabolism related to the presence of subdural hematoma. Neurosurgery 33:3873931993Salvant JB Jr Muizelaar JP: Changes in cerebral blood flow and metabolism related to the presence of subdural hematoma. Neurosurgery 33:387–393 1993

    • Search Google Scholar
    • Export Citation
  • 22.

    Schroder MLMuizelaar JPKuta AJ: Documented reversal of global ischemia immediately after removal of an acute subdural hematoma. Report of two cases. J Neurosurg 80:3243271994Schroder ML Muizelaar JP Kuta AJ: Documented reversal of global ischemia immediately after removal of an acute subdural hematoma. Report of two cases. J Neurosurg 80:324–327 1994

    • Search Google Scholar
    • Export Citation
  • 23.

    Sciamanna MALee CP: Ischemia/reperfusion—induced injury of forebrain mitochondria and protection by ascorbate. Arch Biochem Biophys 305:2152241993Sciamanna MA Lee CP: Ischemia/reperfusion—induced injury of forebrain mitochondria and protection by ascorbate. Arch Biochem Biophys 305:215–224 1993

    • Search Google Scholar
    • Export Citation
  • 24.

    Seelig JMBecker DPMiller JDet al: Traumatic acute subdural hematoma. Major mortality reduction in comatose patients treated within four hours. N Engl J Med 304:151115181981Seelig JM Becker DP Miller JD et al: Traumatic acute subdural hematoma. Major mortality reduction in comatose patients treated within four hours. N Engl J Med 304:1511–1518 1981

    • Search Google Scholar
    • Export Citation
  • 25.

    Valadka ABGopinath SPRobertson CS: Midline shift after severe head injury: pathophysiologic implications. J Trauma 49:1102000Valadka AB Gopinath SP Robertson CS: Midline shift after severe head injury: pathophysiologic implications. J Trauma 49:1–10 2000

    • Search Google Scholar
    • Export Citation
  • 26.

    Verweij BHMuizelaar JPVinas FCet al: Impaired cerebral mitochondrial function after traumatic brain injury in humans. J Neurosurg 93:8158202000Verweij BH Muizelaar JP Vinas FC et al: Impaired cerebral mitochondrial function after traumatic brain injury in humans. J Neurosurg 93:815–820 2000

    • Search Google Scholar
    • Export Citation
  • 27.

    Verweij BHMuizelaar JPVinas FCet al: Improvement in mitochondrial dysfunction as a new surrogate efficiency measure for preclinical trials: dose-response and time-window profiles for administration of the calcium channel blocker Ziconotide in experimental brain injury. J Neurosurg 93:8298342000Verweij BH Muizelaar JP Vinas FC et al: Improvement in mitochondrial dysfunction as a new surrogate efficiency measure for preclinical trials: dose-response and time-window profiles for administration of the calcium channel blocker Ziconotide in experimental brain injury. J Neurosurg 93:829–834 2000

    • Search Google Scholar
    • Export Citation
  • 28.

    Verweij BHMuizelaar JPVinas FCet al: Mitochondrial dysfunction after experimental and human brain injury and its possible reversal with a selective N-type calcium channel antagonist (SNX-111). Neurol Res 19:3343391997Verweij BH Muizelaar JP Vinas FC et al: Mitochondrial dysfunction after experimental and human brain injury and its possible reversal with a selective N-type calcium channel antagonist (SNX-111). Neurol Res 19:334–339 1997

    • Search Google Scholar
    • Export Citation
  • 29.

    Wilberger JE JrHarris MDiamond DL: Acute subdural hematoma: morbidity, mortality, and operative timing. J Neurosurg 74:2122181991Wilberger JE Jr Harris M Diamond DL: Acute subdural hematoma: morbidity mortality and operative timing. J Neurosurg 74:212–218 1991

    • Search Google Scholar
    • Export Citation
  • 30.

    Xiong YGu QPeterson PLet al: Mitochondrial dysfunction and calcium perturbation induced by traumatic brain injury. J Neurotrauma 14:23341997Xiong Y Gu Q Peterson PL et al: Mitochondrial dysfunction and calcium perturbation induced by traumatic brain injury. J Neurotrauma 14:23–34 1997

    • Search Google Scholar
    • Export Citation

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 78 78 3
Full Text Views 131 104 2
PDF Downloads 70 51 0
EPUB Downloads 0 0 0

PubMed

Google Scholar