Monitoring intracranial pressure in patients with malignant middle cerebral artery infarction: is it useful?

Clinical article

Restricted access

Object

Intracranial pressure (ICP) monitoring is increasingly used in the treatment of patients with malignant middle cerebral artery (MCA) infarction. However, neurological deterioration may exist independent from intracranial hypertension. This study aimed to present the findings of continuous ICP monitoring in a cohort of patients with malignant MCA infarction and to correlate these findings with clinical and radiological features.

Methods

The authors studied a prospective cohort of 25 patients with malignant MCA infarction consecutively admitted to the neurotrauma intensive care unit of the Vall d'Hebron University Hospital between March 2002 and September 2006. The patients were treated using a combined protocol of initial moderate hypothermia and hemicraniectomy. The latter was performed when patients showed a midline shift (MLS) ≥ 5 mm or ICP > 20 mm Hg. Six patients had an MLS ≥ 5 mm on the first CT scan and underwent surgery without prior ICP monitoring. This study focuses on the subgroup of 19 patients who underwent intraparenchymatous ICP monitoring before surgery.

Results

Intracranial pressure readings were evaluated and correlated with pupillary abnormalities, MLS, and ischemic tissue volume. In 12 of the 19 patients, ICP values were always ≤ 20 mm Hg, despite a mean (± SD) MLS of 6.7 ± 2 mm and a mean ischemic tissue volume of 241.3 ± 83 cm3. In 2 patients with anisocoria, ICP values were also normal.

Conclusions

In patients with a malignant MCA infarction, pupillary abnormalities and severe brainstem compression may be present despite normal ICP values. Therefore, continuous ICP monitoring cannot substitute for close clinical and radiological follow-up in the management of these patients.

Abbreviations used in this paper: E-TILS = Extended TILS; GCS = Glasgow Coma Scale; ICP = intracranial pressure; ICU = intensive care unit; IQR = interquartile range; MCA = middle cerebral artery; MLS = midline shift; NICU = neurocritical ICU; NIH = National Institutes of Health; TILS = Therapy Intensity Level Scale.
Article Information

Contributor Notes

Address correspondence to: Maria Antonia Poca, M.D., Ph.D., Department of Neurosurgery, Vall d'Hebron University Hospital, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain. email: pocama@neurotrauma.net.Please include this information when citing this paper: published online August 7, 2009; DOI: 10.3171/2009.7.JNS081677.
Headings
References
  • 1

    Bamford JSandercock PDennis MBurn JWarlow C: Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 337:152115261991

    • Search Google Scholar
    • Export Citation
  • 2

    Benejam BPoca MAJunque CAlvarez-Sabin JDelgado PFrascheri L: [A proposal of a neuropsychological and quality of life assessment protocol in patients with malignant middle cerebral artery infarction.]. Neurologia 23:40512008. (Span)

    • Search Google Scholar
    • Export Citation
  • 3

    Bennett JARiegel BBittner VNichols J: Validity and reliability of the NYHA classes for measuring research outcomes in patients with cardiac disease. Heart Lung 31:2622702002

    • Search Google Scholar
    • Export Citation
  • 4

    Berrouschot JSterker MBettin SKöster JSchenider D: Mortality of space-occupying (‘malignant’) middle cerebral artery infarction under conservative intensive care. Intensive Care Med 24:6206231998

    • Search Google Scholar
    • Export Citation
  • 5

    The Brain Trauma Foundation The American Association of Neurological Surgeons The Joint Section on Neurotrauma and Critical Care: Computed tomography scan features. J Neurotrauma 17:5976272000

    • Search Google Scholar
    • Export Citation
  • 6

    The Brain Trauma Foundation The American Association of Neurological Surgeons The Joint Section on Neurotrauma and Critical Care: Pupillary diameter and light reflex. J Neurotrauma 17:5835902000

    • Search Google Scholar
    • Export Citation
  • 7

    Brandt TGrau AJHacke W: Severe stroke. Baillieres Clin Neurol 5:5155411996

  • 8

    Carhuapoma JRQureshi AIBhardwaj AWilliams MA: Interhemispheric intracranial pressure gradients in massive cerebral infarction. J Neurosurg Anesthesiol 14:2993032002

    • Search Google Scholar
    • Export Citation
  • 9

    Cho DYChen TCLee HC: Ultra-early decompressive craniectomy for malignant middle cerebral artery infarction. Surg Neurol 60:2272322003

    • Search Google Scholar
    • Export Citation
  • 10

    Delgado-Lopez PMateo-Sierra OGarcia-Leal RAgustín-Gutiérrez FFernández-Carballal CCarrillo-Yagüe R: [Decompressive craniectomy in malignant infarction of the middle cerebral artery.]. Neurocirugia (Astur) 15:43552004. (Span)

    • Search Google Scholar
    • Export Citation
  • 11

    Desco MLopez JBenito CSantos ADominguez PReig S: A multimodality workstation in practice. Lemke HUVannier MWInamura KFarman AG: Computer Assisted Radiology and Surgery (CARS'99) ParisElsevier Science1999. 218222

    • Search Google Scholar
    • Export Citation
  • 12

    Doerfler AForsting MReith WStaff CHeiland SSchäbitz WR: Decompressive craniectomy in a rat model of “malignant” cerebral hemispheric stroke: experimental support for an aggressive therapeutic approach. J Neurosurg 85:8538591996

    • Search Google Scholar
    • Export Citation
  • 13

    Els TOehm EVoigt SKlisch JHetzel AKassubek J: Safety and therapeutical benefit of hemicraniectomy combined with mild hypothermia in comparison with hemicraniectomy alone in patients with malignant ischemic stroke. Cerebrovasc Dis 21:79852006

    • Search Google Scholar
    • Export Citation
  • 14

    Forsting MReith WSchabitz WRHeiland Svon Kummer RHacke W: Decompressive craniectomy for cerebral infarction. An experimental study in rats. Stroke 26:2592641995

    • Search Google Scholar
    • Export Citation
  • 15

    Frank JI: Large hemispheric infarction, deterioration, and intracranial pressure. Neurology 45:128612901995

  • 16

    Georgiadis DSchwarz SAschoff ASchwab S: Hemicraniectomy and moderate hypothermia in patients with severe ischemic stroke. Stroke 33:158415882002

    • Search Google Scholar
    • Export Citation
  • 17

    Hacke WSchwab SHorn MSpranger MDe Georgia Mvon Kummer R: ‘Malignant’ middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol 53:3093151996

    • Search Google Scholar
    • Export Citation
  • 18

    Jian SYongming QZhihua CYan C: Feasibility and safety of moderate hypothermia after acute ischemic stroke. Int J Dev Neurosci 21:3533562003

    • Search Google Scholar
    • Export Citation
  • 19

    Keller EWietasch GRingleb PScholz MSchwarz SStinguele R: Bedside monitoring of cerebral blood flow in patients with acute hemispheric stroke. Crit Care Med 28:5115162000

    • Search Google Scholar
    • Export Citation
  • 20

    Kraus JJMetzler MDCoplin WM: Critical care issues in stroke and subarachnoid hemorrhage. Neurol Res 24:1 SupplS47S572002

  • 21

    Marion DWObrist WDCarlier PMPenrod LEDarby JM: The use of moderate therapeutic hypothermia for patients with severe head injuries: a preliminary report. J Neurosurg 79:3543621993

    • Search Google Scholar
    • Export Citation
  • 22

    Maset ALMarmarou AWard JDChoi SLutz HABrooks D: Pressure-volume index in head injury. J Neurosurg 67:8328401987

  • 23

    Metz CHolzschuh MBein TWoertgen CFrey AFrey I: Moderate hypothermia in patients with severe head injury: cerebral and extracerebral effects. J Neurosurg 85:5335411996

    • Search Google Scholar
    • Export Citation
  • 24

    Polderman KHTjong Tjin JRPeerdeman SMVandertop WPGirbes AR: Effects of therapeutic hypothermia on intracranial pressure and outcome in patients with severe head injury. Intensive Care Med 28:156315732002

    • Search Google Scholar
    • Export Citation
  • 25

    Rieke KSchwab SKrieger Dvon Kummer RAschoff ASchuchardt V: Decompressive surgery in space-occupying hemispheric infarction: results of an open, prospective trial. Crit Care Med 23:157615871995

    • Search Google Scholar
    • Export Citation
  • 26

    Sahuquillo JMena MPVilalta APoca MA: Moderate hypothermia in the management of severe traumatic brain injury: a good idea proved ineffective?. Curr Pharm Des 10:219322042004

    • Search Google Scholar
    • Export Citation
  • 27

    Schneweis SGrond MStaub FBrinker GNeveling MDohmen C: Predictive value of neurochemical monitoring in large middle cerebral artery infarction. Stroke 32:186318672001

    • Search Google Scholar
    • Export Citation
  • 28

    Schwab S: Therapy of severe ischemic stroke: breaking the conventional thinking. Cerebrovasc Dis 20:2 Suppl1691782005

  • 29

    Schwab SAschoff ASpranger MAlbert FHacke W: The value of intracranial pressure monitoring in acute hemispheric stroke. Neurology 47:3933981996

    • Search Google Scholar
    • Export Citation
  • 30

    Schwab SGeorgiadis DBerrouschot JSchellinger PDGraffagnino CMayer SA: Feasibility and safety of moderate hypothermia after massive hemispheric infarction. Stroke 32:203320352001

    • Search Google Scholar
    • Export Citation
  • 31

    Schwab SSchwarz SAschoff AKeller EHacke W: Moderate hypothermia and brain temperature in patients with severe middle cerebral artery infarction. Acta Neurochir Suppl 71:1311341998

    • Search Google Scholar
    • Export Citation
  • 32

    Schwab SSteiner TAschoff ASchwarz SSteiner HHJansen O: Early hemicraniectomy in patients with complete middle cerebral artery infarction. Stroke 29:188818931998

    • Search Google Scholar
    • Export Citation
  • 33

    Shiozaki TSugimoto HTaneda MYoshida HIwai AYoshioka T: Effect of mild hypothermia on uncontrollable intracranial hypertension after severe head injury. J Neurosurg 79:3633681993

    • Search Google Scholar
    • Export Citation
  • 34

    Steiner TRingleb PHacke W: Treatment options for large hemispheric stroke. Neurology 57:2 SupplS61S682001

  • 35

    Stolz EKaps MDorndorf W: Assessment of intracranial venous hemodynamics in normal individuals and patients with cerebral venous thrombosis. Stroke 30:70751999

    • Search Google Scholar
    • Export Citation
  • 36

    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
  • 37

    van Swieten JCKoudstaal PJVisser MCSchouten HJvan Gijn J: Interobserver agreement for the assessment of handicap in stroke patients. Stroke 19:6046071988

    • Search Google Scholar
    • Export Citation
  • 38

    Yanamoto HNagata INiitsu YZhang ZXue JHSakai N: Prolonged mild hypothermia therapy protects the brain against permanent focal ischemia. Stroke 32:2322392001

    • Search Google Scholar
    • Export Citation
TrendMD
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 486 330 38
Full Text Views 251 56 1
PDF Downloads 196 43 2
EPUB Downloads 0 0 0
PubMed
Google Scholar