Incidence and characteristics of cerebral hypoxia after craniectomy in brain-injured patients: a cohort study

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  • 1 Nursing School, Université de Montréal;
  • 2 Neurosurgical Department, Université de Montréal;
  • 3 Pharmacy Department, Université de Montréal;
  • 4 Medicine Department, Université de Montréal; and
  • 5 Centre Intégré Universitaire de Santé et de Services Sociaux (CIUSSS) du Nord-de-l’Ile-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
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OBJECTIVE

After craniectomy, although intracranial pressure (ICP) is controlled, episodes of brain hypoxia might still occur. Cerebral hypoxia is an indicator of poor outcome independently of ICP and cerebral perfusion pressure. No study has systematically evaluated the incidence and characteristics of brain hypoxia after craniectomy. The authors’ objective was to describe the incidence and characteristics of brain hypoxia after craniectomy.

METHODS

The authors included 25 consecutive patients who underwent a craniectomy after traumatic brain injury or intracerebral hemorrhage and who were monitored afterward with a brain tissue oxygen pressure monitor.

RESULTS

The frequency of hypoxic values after surgery was 14.6% despite ICP being controlled. Patients had a mean of 18 ± 23 hypoxic episodes. Endotracheal (ET) secretions (17.4%), low cerebral perfusion pressure (10.3%), and mobilizing the patient (8.6%) were the most common causes identified. Elevated ICP was rarely identified as the cause of hypoxia (4%). No cause of cerebral hypoxia could be determined 31.2% of the time. Effective treatments that were mainly used included sedation/analgesia (20.8%), ET secretion suctioning (15.4%), and increase in fraction of inspired oxygen or positive end-expiratory pressure (14.1%).

CONCLUSIONS

Cerebral hypoxia is common after craniectomy, despite ICP being controlled. ET secretion and patient mobilization are common causes that are easily treatable and often not identified by standard monitoring. These results suggest that monitoring should be pursued even if ICP is controlled. The authors’ findings might provide a hypothesis to explain the poor functional outcome in the recent randomized controlled trials on craniectomy after traumatic brain injury where in which brain tissue oxygen pressure was not measured.

ABBREVIATIONS ABI = acute brain injury; BOOST-II = brain oxygen optimization in severe traumatic brain injury–II; CPP = cerebral perfusion pressure; DC = decompressive craniectomy; ET = endotracheal; FiO2 = fraction of inspired oxygen; GCS = Glasgow Coma Scale; ICH = intracerebral hemorrhage; ICP = intracranial pressure; MAP = mean arterial pressure; PaO2 = partial pressure of oxygen; PbtO2 = brain tissue oxygen pressure; PCO2 = partial pressure of carbon dioxide; PEEP = positive end-expiratory pressure; SDH = subdural hematoma; TBI = traumatic brain injury.

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Contributor Notes

Correspondence Francis Bernard: Hôpital du Sacré-Cœur de Montréal, QC, Canada. f.bernard@umontreal.ca.

INCLUDE WHEN CITING Published online November 6, 2020; DOI: 10.3171/2020.6.JNS20776.

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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