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Ramin Eskandari, Michael R. Filtz, Gary E. Davis and Robert E. Hoesch

Object

Normal intracranial pressure (ICP) and cerebral perfusion pressure (CPP) have been identified as favorable prognostic factors in the outcome of patients with traumatic brain injuries (TBIs). Osmotic diuretics and hypertonic saline (HTS) are commonly used to treat elevated ICP in patients with TBI; however, sustained effects of repeated high-concentration HTS boluses for severely refractory ICP elevation have not been studied. The authors' goal in this study was to determine whether repeated 14.6% HTS boluses were efficacious in treating severely refractory intracranial hypertension in patients with TBI.

Methods

In a prospective cohort study in a neurocritical care unit, adult TBI patients with sustained ICP > 30 mm Hg for more than 30 minutes after exhaustive medical and/or surgical therapy received repeated 15-minute boluses of 14.6% HTS over 12 hours through central venous access.

Results

Response to treatment was evaluated in 11 patients. Within 5 minutes of bolus administration, mean ICP decreased from 40 to 33 mm Hg (30% reduction, p < 0.05). Intracranial pressure–lowering effects were sustained for 12 hours (41% reduction, p < 0.05) with multiple boluses (mean number of boluses 7 ± 5.5). The mean CPP increased 22% and 32% from baseline at 15 and 30 minutes, respectively (p < 0.05). The mean serum sodium level (SNa) at baseline was 155 ± 7.1 mEq/L, and after multiple boluses of 14.6% HTS, SNa at 12 hours was 154 ± 7.1 mEq/L. The mean heart rate, systolic blood pressure, blood urea nitrogen, and creatinine demonstrated no significant change throughout the study.

Conclusions

The subset of TBI patients with intracranial hypertension that is completely refractory to all other medical therapies can be treated effectively and safely with repeated boluses of 14.6% HTS rather than a one-time dose.

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Samuel R. Browd, Brian T. Ragel, Gary E. Davis, Amy M. Scott, Elaine J. Skalabrin and William T. Couldwell

The incidence of deep venous thrombosis (DVT) and subsequent pulmonary embolism (PE) in patients undergoing neurosurgery has been reported to be as high as 25%, with a mortality rate from PE between 9 and 50%. Even with the use of pneumatic compression devices, the incidence of DVT has been reported to be 32% in these patients, making prophylactic heparin therapy desirable. Both unfractionated and low-molecular-weight heparin have been shown to reduce the incidence of DVT consistently by 40 to 50% in neurosurgical patients. The baseline rate for major intracranial hemorrhage (ICH) following craniotomy has been reported to be between 1 and 3.9%, but after initiation of heparin therapy this rate has been found to be as high as 10.9%. Therefore, neurosurgeons must balance the risk of PE against the increased risk of postoperative ICH from prophylactic heparin for DVT. The authors review the literature on the incidence of DVT and PE in neurosurgical patients, focusing on the incidence of ICH related to the use of unfractionated and low-molecular-weight heparin in this patient population

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Oral Presentations

2010 AANS Annual Meeting Philadelphia, Pennsylvania May 1–5, 2010