Nujaimin, Udin
(2008)
Intracranial pressure, cerebral perfusion
pressure and cerebral compliance monitoring and
their relationship amongst adult severe head
injury.
Masters thesis, Universiti Sains Malaysia.
Abstract
The study is to observe the correlation between intracranial physiological parameters
namely intracranial pressure (ICP), cerebral perfusion pressure (CPP) and cerebral
compliance in adult severe head injured patients. In addition the relationship of the above
parameters with post operative computed tomography scan and other potential clinical,
non clinical factors and outcome were also analyzed.This is a prospective cohort study on severe head injured patients with Glasgow Coma
Score of eight and below. The patients were admitted into Neuroscience Intensive Care
Unit for monitoring of intracranial and extracranial physiological parameters after
evacuation of mass lesion. We excluded patients with bilateral fixed and dilated pupil,
those who suffered from severe injury not expected to live longer than 24 hours, those
with bleeding diathesis, those whose follow up was not possible or those with significant
brain stem involvement. All patients were treated with standard protocols and guidelines
in the management of severe head injury. These patients were monitored continuously
until the parameters were normal and stabilized or death. Post operative computed
tomography was obtained within 48 hours after surgical evacuation of mass lesion or
earlier if intracranial hypertension was refractory. Outcomes of the patients at first and
sixth month after the injury were assessed using Glasgow Outcome Scale.The study included 30 patients with 24 males and 6 females, between 13 and 65 years of
age who were admitted with severe head injury. We demonstrated higher CPP and
compliance values were obtained whenever the ICP was maintained at 20 mmHg or
lower, while reduced CPP and compliance value once the ICP was elevated above 20
mmHg following surgery to remove the mass lesion in severe head injured patients, p
value = 0.001 and 0.030 respectively. The similar findings were demonstrated when
cerebral compliance was measured using PVI, p value < 0.001. There was a statistically
significant correlation between CPP and compliance as well as CPP and PVI at ICP
above 20 mmHg, p value < 0. 001 . Our study also revealed higher ICP and lower
compliance and PVI when the CPP was below 60 mmHg. The ICP reduced (p value <
0.001) and both compliance (p value = 0.002) as well as PVI (p value < 0.001) improved
when the CPP was preserved above 60 mmHg.
Post operatively, our study revealed significant relationship between ICP and CPP with
states of basal cistern (p value = 0.001 and 0.022) as well as ICP with Marshall
Classification (p value < 0.001). However we fai led to demonstrate significant relation
between compliance with post operative CT scan findings even though higher compliance
value was observed when the basal cistern was opened, less midline shift and Marshall I
or ll. We also found an association between preoperative GCS with ICP and type of
operation with compliance value which may help in the management plan of severe head
injured patients,p value = 0.006 and 0.033 respectively.
Age, preoperative GCS, pupil equality and reactivity, basal cistern, post operative CT
scan edema and ICP were associated with the outcome of the patients at one month aftersevere head injury, p value< 0.050, although we only found pupil equality and reactivity
(p value = 0.025) and barely ICP (p value = 0.057) as independent outcome predictors.
Larger sample size is required to demonstrate the validity of other parameters as an
independent predictor. Lastly the invasive procedure such as insertion of ICP monitoring
is not without catastrophic complication.There were correlation between ICP, CPP and cerebral compliance as long as the cerebral
autoregulation remained intact However no significant relation was observed between
these intracranial parameters with the patient's outcome. Other than that, the findings of
post operative CT scan obtained after evacuation of mass lesion may help in predicting
the intracranial pressure.
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