Effects of hyperbaric oxygenation therapy on cerebral metabolism and intracranial pressure in severely brain injured patients

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Object. Hyperbaric oxygenation (HBO) therapy has been shown to reduce mortality by 50% in a prospective randomized trial of severely brain injured patients conducted at the authors' institution. The purpose of the present study was to determine the effects of HBO on cerebral blood flow (CBF), cerebral metabolism, and intracranial pressure (ICP), and to determine the optimal HBO treatment paradigm.

Methods. Oxygen (100% O2, 1.5 atm absolute) was delivered to 37 patients in a hyperbaric chamber for 60 minutes every 24 hours (maximum of seven treatments/patient). Cerebral blood flow, arteriovenous oxygen difference (AVDO2), cerebral metabolic rate of oxygen (CMRO2), ventricular cerebrospinal fluid (CSF) lactate, and ICP values were obtained 1 hour before and 1 hour and 6 hours after a session in an HBO chamber. Patients were assigned to one of three categories according to whether they had reduced, normal, or raised CBF before HBO.

In patients in whom CBF levels were reduced before HBO sessions, both CBF and CMRO2 levels were raised 1 hour and 6 hours after HBO (p < 0.05). In patients in whom CBF levels were normal before HBO sessions, both CBF and CMRO2 levels were increased at 1 hour (p < 0.05), but were decreased by 6 hours after HBO. Cerebral blood flow was reduced 1 hour and 6 hours after HBO (p < 0.05), but CMRO2 was unchanged in patients who had exhibited a raised CBF before an HBO session. In all patients AVDO2 remained constant both before and after HBO. Levels of CSF lactate were consistently decreased 1 hour and 6 hours after HBO, regardless of the patient's CBF category before undergoing HBO (p < 0.05). Intracranial pressure values higher than 15 mm Hg before HBO were decreased 1 hour and 6 hours after HBO (p < 0.05). The effects of each HBO treatment did not last until the next session in the hyperbaric chamber.

Conclusions. The increased CMRO2 and decreased CSF lactate levels after treatment indicate that HBO may improve aerobic metabolism in severely brain injured patients. This is the first study to demonstrate a prolonged effect of HBO treatment on CBF and cerebral metabolism. On the basis of their data the authors assert that shorter, more frequent exposure to HBO may optimize treatment.

Article Information

Address reprint requests to: Gaylan L. Rockswold, M.D., Division of Neurosurgery, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, Minnesota 55415–1829.

© AANS, except where prohibited by US copyright law.

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Figures

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    Graph demonstrating mean CBF values for individual treatment sessions stratified by pretreatment CBF category. The CBF was raised for at least 6 hours after HBO treatment when patients began treatment sessions with a reduced CBF. The CBF was raised 1 hour after treatment when patients began a treatment session with a normal CBF. The CBF fell for 6 hours after treatment in patients in whom CBF was raised before treatment. Error bars indicate the SEMs. *p = 0.012, **p < 0.01, and ***p < 0.001 when compared with values recorded before treatment. Circles, treatment sessions begun by patients with a reduced CBF (18 sessions); squares, treatment sessions begun by patients with a normal CBF (32 sessions); triangles, treatment sessions begun by patients with a raised CBF (28 sessions). Pre-dive refers to the time before a session in the hyperbaric chamber.

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    Graph depicting AVDO2 values before treatment and 1 hour and 6 hours after treatment for Session 1 (circles, 12 sessions) and for Sessions 2 through 7 (triangles, 71 sessions). The AVDO2 of Session 1 was higher than that of Sessions 2 through 7. The AVDO2 remained relatively constant after HBO treatment. Error bars indicate SEMs. *p < 0.05 when Sessions 2 through 7 are compared with Session 1.

  • View in gallery

    Graph demonstrating CMRO2 values for individual sessions stratified by pretreatment CBF category. The CMRO2 was raised for at least 6 hours after HBO treatment when patients began a session with a reduced CBF. The CMRO2 was raised 1 hour posttreatment when patients began sessions with a normal CBF. The CMRO2 was not affected when patients began sessions with a raised CBF. Error bars indicate SEMs. *p < 0.05 and **p < 0.001 when compared with pretreatment values. Circles, sessions begun by patients with a reduced CBF (18 sessions); squares, sessions begun by patients with a normal CBF (30 sessions); triangles, sessions begun by patients with a raised CBF (27 sessions).

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    Graph showing mean CSF lactate values for individual sessions before and after HBO treatment. The lactate levels were consistently decreased 1 and 6 hours posttreatment, regardless of the pretreatment CBF. Error bars indicate SEMs. *p < 0.05 and **p = 0.001 when compared with pretreatment values.

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    Graph depicting ICP values for individual sessions before, during, and after HBO treatment, stratified by pretreatment ICP category. The ICP rose linearly in both groups during the session. However, raised pretreatment ICP values (> 15 mm Hg; triangles, 14 sessions) dropped during the first 15 minutes after the patient reached depth, and did not reach pretreatment levels until 30 minutes into the session. The ICP was raised for at least 6 hours after sessions in which patients began a session with a reduced ICP (< 15 mm Hg; circles, 96 sessions). The ICP fell for at least 6 hours after sessions in which patients began a session with a raised ICP. Error bars indicate SEMs. *p < 0.001 linear increase during the session; **p < 0.01, and ***p < 0.001 compared with pretreatment values.

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