Intracranial pressure before and after cranioplasty: insights into intracranial physiology

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OBJECTIVE

Decompressive craniectomy (DC) is an emergency neurosurgical procedure used in cases of severe intracranial hypertension or impending intracranial herniation. The procedure is often lifesaving, but it exposes the brain to atmospheric pressure in the subsequent rehabilitation period, which changes intracranial physiology and probably leads to complications such as hydrocephalus, hygromas, and “syndrome of the trephined.” The objective of the study was to study the effect of cranioplasty on intracranial pressure (ICP), postural ICP changes, and intracranial pulse wave amplitude (PWA).

METHODS

The authors performed a prospective observational study including patients who underwent DC during a 12-month period. Telemetric ICP sensors were implanted in all patients at the time of DC. ICP was evaluated before and after cranioplasty during weekly measurement sessions including a standardized postural change program.

RESULTS

Twelve of the 17 patients enrolled in the study had cranioplasty performed and were included in the present investigation. Their mean ICP in the supine position increased from –0.5 ± 4.8 mm Hg the week before cranioplasty to 6.3 ± 2.5 mm Hg the week after cranioplasty (p < 0.0001), whereas the mean ICP in the sitting position was unchanged (–1.2 ± 4.8 vs –1.1 ± 3.6 mm Hg, p = 0.90). The difference in ICP between the supine and sitting positions was minimal before cranioplasty (1.1 ± 1.8 mm Hg) and increased to 7.4 ± 3.6 mm Hg in the week following cranioplasty (p < 0.0001). During the succeeding 2 weeks of the follow-up period, the mean ICP in the supine and sitting positions decreased in parallel to, respectively, 4.6 ± 3.0 mm Hg (p = 0.0003) and –3.9 ± 2.7 mm Hg (p = 0.040), meaning that the postural ICP difference remained constant at around 8 mm Hg. The mean intracranial PWA increased from 0.7 ± 0.7 mm Hg to 2.9 ± 0.8 mm Hg after cranioplasty (p < 0.0001) and remained around 3 mm Hg throughout the following weeks.

CONCLUSIONS

Cranioplasty restores normal intracranial physiology regarding postural ICP changes and intracranial PWA. These findings complement those of previous investigations on cerebral blood flow and cerebral metabolism in patients after decompressive craniectomy.

ABBREVIATIONS CBF = cerebral blood flow; CSF = cerebrospinal fluid; DC = decompressive craniectomy; ICP = intracranial pressure; IQR = interquartile range; MCA = middle cerebral artery; NICU = neuro-intensive care unit; PWA = pulse wave amplitude; TBI = traumatic brain injury; TCD = transcranial Doppler.
Article Information

Contributor Notes

Correspondence Alexander Lilja-Cyron: Rigshospitalet, Copenhagen, Denmark. alexander.lilja-cyron@regionh.dk.INCLUDE WHEN CITING Published online October 18, 2019; DOI: 10.3171/2019.7.JNS191077.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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References
  • 1

    Andresen MHadi APetersen LGJuhler M: Effect of postural changes on ICP in healthy and ill subjects. Acta Neurochir (Wien) 157:1091132015

    • Search Google Scholar
    • Export Citation
  • 2

    Andresen MJuhler M: Intracranial pressure following complete removal of a small demarcated brain tumor: a model for normal intracranial pressure in humans. J Neurosurg 121:7978012014

    • Search Google Scholar
    • Export Citation
  • 3

    Antes STschan CAHeckelmann MBreuskin DOertel J: Telemetric intracranial pressure monitoring with the Raumedic Neurovent P-tel. World Neurosurg 91:1331482016

    • Search Google Scholar
    • Export Citation
  • 4

    Ashayeri KM Jackson EHuang JBrem HGordon CR: Syndrome of the trephined: a systematic review. Neurosurgery 79:5255342016

  • 5

    Bozanovic-Sosic RMollanji RJohnston MG: Spinal and cranial contributions to total cerebrospinal fluid transport. Am J Physiol Regul Integr Comp Physiol 281:R909R9162001

    • Search Google Scholar
    • Export Citation
  • 6

    Carmelo AFicola AFravolini MLLa Cava MMaira GMangiola A: ICP and CBF regulation: a new hypothesis to explain the “windkessel” phenomenon. Acta Neurochir Suppl 81:1121162002

    • Search Google Scholar
    • Export Citation
  • 7

    Carney NTotten AMO’Reilly CUllman JSHawryluk GWJBell MJ: Guidelines for the Management of Severe Traumatic Brain InjuryFourth Edition. Neurosurgery 80:6152017

    • Search Google Scholar
    • Export Citation
  • 8

    Cooper DJRosenfeld JVMurray LArabi YMDavies ARD’Urso P: Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 364:149315022011

    • Search Google Scholar
    • Export Citation
  • 9

    Czosnyka MCopeman JCzosnyka ZMcConnell RDickinson CPickard JD: Post-traumatic hydrocephalus: influence of craniectomy on the CSF circulation. J Neurol Neurosurg Psychiatry 68:2462482000

    • Search Google Scholar
    • Export Citation
  • 10

    Davson HSegal MB: The return of the CSF to the blood: the drainage mechanism in Physiology of the CSF and Blood-Brain Barriersed 1. Boca Raton, FL: CRC Press1996 pp 489523

    • Search Google Scholar
    • Export Citation
  • 11

    De Bonis PPompucci AMangiola ARigante LAnile C: Post-traumatic hydrocephalus after decompressive craniectomy: an underestimated risk factor. J Neurotrauma 27:196519702010

    • Search Google Scholar
    • Export Citation
  • 12

    Edsbagge MTisell MJacobsson LWikkelso C: Spinal CSF absorption in healthy individuals. Am J Physiol Regul Integr Comp Physiol 287:R1450R14552004

    • Search Google Scholar
    • Export Citation
  • 13

    Ekstedt J: CSF hydrodynamic studies in man. 2. Normal hydrodynamic variables related to CSF pressure and flow. J Neurol Neurosurg Psychiatry 41:3453531978

    • Search Google Scholar
    • Export Citation
  • 14

    Fodstad HLove JAEkstedt JFridén HLiliequist B: Effect of cranioplasty on cerebrospinal fluid hydrodynamics in patients with the syndrome of the trephined. Acta Neurochir (Wien) 70:21301984

    • Search Google Scholar
    • Export Citation
  • 15

    Freimann FBSchulz MHaberl HThomale UW: Feasibility of telemetric ICP-guided valve adjustments for complex shunt therapy. Childs Nerv Syst 30:6896972014

    • Search Google Scholar
    • Export Citation
  • 16

    Holmlund PJohansson EQvarlander SWåhlin AAmbarki KKoskinen LD: Human jugular vein collapse in the upright posture: implications for postural intracranial pressure regulation. Fluids Barriers CNS 14:172017

    • Search Google Scholar
    • Export Citation
  • 17

    Honeybul S: Neurological susceptibility to a skull defect. Surg Neurol Int 5:832014

  • 18

    Hutchinson PJKolias AGTimofeev ISCorteen EACzosnyka MTimothy J: Trial of decompressive craniectomy for traumatic intracranial hypertension. N Engl J Med 375:111911302016

    • Search Google Scholar
    • Export Citation
  • 19

    Iwabuchi TSobata ESuzuki MSuzuki SYamashita M: Dural sinus pressure as related to neurosurgical positions. Neurosurgery 12:2032071983

    • Search Google Scholar
    • Export Citation
  • 20

    Lawley JSPetersen LGHowden EJSarma SCornwell WKZhang R: Effect of gravity and microgravity on intracranial pressure. J Physiol 595:211521272017

    • Search Google Scholar
    • Export Citation
  • 21

    Lee AGMader THGibson CRTarver W: Space flight-associated neuro-ocular syndrome. JAMA Ophthalmol 135:9929942017

  • 22

    Lilja-Cyron AAndresen MKelsen JAndreasen THFugleholm KJuhler M: Long-term effect of decompressive craniectomy on intracranial pressure and possible implications for intracranial fluid movements. Neurosurgery [epub ahead of print] 2019

    • Search Google Scholar
    • Export Citation
  • 23

    Lilja-Cyron AKelsen JAndresen MFugleholm KJuhler M: Feasibility of telemetric intracranial pressure monitoring in the neuro intensive care unit. J Neurotrauma 35:157815862018

    • Search Google Scholar
    • Export Citation
  • 24

    Norager NHLilja-Cyron ABjarkam CRDuus SJuhler M: Telemetry in intracranial pressure monitoring: sensor survival and drift. Acta Neurochir (Wien) 160:213721442018

    • Search Google Scholar
    • Export Citation
  • 25

    Orakcioglu BBeynon CKentar MMEymann RKiefer MSakowitz OW: Intracranial pressure telemetry: first experience of an experimental in vivo study using a new device. Acta Neurochir Suppl 114:1051102012

    • Search Google Scholar
    • Export Citation
  • 26

    Paredes ICastaño AMCepeda SAlén JAFSalvador EMillán JM: The effect of cranioplasty on cerebral hemodynamics as measured by perfusion computed tomography and Doppler ultrasonography. J Neurotrauma 33:158615972016

    • Search Google Scholar
    • Export Citation
  • 27

    Petersen LGPetersen JCGAndresen MSecher NHJuhler M: Postural influence on intracranial and cerebral perfusion pressure in ambulatory neurosurgical patients. Am J Physiol Regul Integr Comp Physiol 310:R100R1042016

    • Search Google Scholar
    • Export Citation
  • 28

    Petersen LGLawley JSLilja-Cyron APetersen JCGHowden EJSarma S: Lower body negative pressure to safely reduce intracranial pressure. J Physiol 597:2372482019

    • Search Google Scholar
    • Export Citation
  • 29

    Plog BANedergaard M: The glymphatic system in central nervous system health and disease: past, present, and future. Annu Rev Pathol 13:3793942018

    • Search Google Scholar
    • Export Citation
  • 30

    Pollay M: Overview of the CSF dual outflow system. Acta Neurochir Suppl 113:47502012

  • 31

    Qvarlander SSundström NMalm JEklund A: Postural effects on intracranial pressure: modeling and clinical evaluation. J Appl Physiol (1985) 115:147414802013

    • Search Google Scholar
    • Export Citation
  • 32

    Robles LACuevas-Solórzano A: Massive brain swelling and death after cranioplasty: a systematic review. World Neurosurg 111:991082018

    • Search Google Scholar
    • Export Citation
  • 33

    Scollato AGallina PBahl GDi Lorenzo N: Decompressive craniectomy arrests pulsatile aqueductal CSF flux: an in vivo demonstration using phase-contrast MRI. Case report. Br J Neurosurg 29:4404422015

    • Search Google Scholar
    • Export Citation
  • 34

    Shahid AHMohanty MSingla NMittal BRGupta SK: The effect of cranioplasty following decompressive craniectomy on cerebral blood perfusion, neurological, and cognitive outcome. J Neurosurg 128:2292352018

    • Search Google Scholar
    • Export Citation
  • 35

    Shapiro KFried ATakei FKohn I: Effect of the skull and dura on neural axis pressure-volume relationships and CSF hydrodynamics. J Neurosurg 63:76811985

    • Search Google Scholar
    • Export Citation
  • 36

    Smielewski PCzosnyka MSteiner LBelestri MPiechnik SPickard JD: ICM+: software for on-line analysis of bedside monitoring data after severe head trauma. Acta Neurochir Suppl 95:43492005

    • Search Google Scholar
    • Export Citation
  • 37

    Stiver SIWintermark MManley GT: Motor trephine syndrome: a mechanistic hypothesis. Acta Neurochir Suppl 102:2732772008

  • 38

    Stula D: [Intracranial pressure measurement in large skull defect.] Neurochirurgica 28:1641691985 (German)

  • 39

    Timofeev ICzosnyka MNortje JSmielewski PKirkpatrick PGupta A: Effect of decompressive craniectomy on intracranial pressure and cerebrospinal compensation following traumatic brain injury. J Neurosurg 108:66732008

    • Search Google Scholar
    • Export Citation
  • 40

    Vahedi KHofmeijer JJuettler EVicaut EGeorge BAlgra A: Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 6:2152222007

    • Search Google Scholar
    • Export Citation
  • 41

    von Elm EAltman DGEgger MPocock SJGøtzsche PCVandenbroucke JP: The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 61:3443492008

    • Search Google Scholar
    • Export Citation
  • 42

    Wagshul MEEide PKMadsen JR: The pulsating brain: a review of experimental and clinical studies of intracranial pulsatility. Fluids Barriers CNS 8:52011

    • Search Google Scholar
    • Export Citation
  • 43

    Welschehold SSchmalhausen EDodier PVulcu SOertel JWagner W: First clinical results with a new telemetric intracranial pressure-monitoring system. Neurosurgery 70 (1 Suppl Operative):44492012

    • Search Google Scholar
    • Export Citation
  • 44

    Wijdicks EFMSheth KNCarter BSGreer DMKasner SEKimberly WT: Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 45:122212382014

    • Search Google Scholar
    • Export Citation
  • 45

    Winkler PAStummer WLinke RKrishnan KGTatsch K: Influence of cranioplasty on postural blood flow regulation, cerebrovascular reserve capacity, and cerebral glucose metabolism. J Neurosurg 93:53612000

    • Search Google Scholar
    • Export Citation
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