0
Raised intracranial pressure:
keeping a lid on it
UNSW
John Myburgh
MBBCh PhD FCICM
The George Institute for Global Health...
P(mmHg)
V (ml)
1783, 1824
Monro-Kelly doctrine
Intracranial volume
remains constant at any
given time
Bryan Jennett
Douglas Miller
Larry Marshall
1978
1979
1980
Fearnside: Br J Neurosurg 1992
Inflammatory modulation
Bayir: Crit Care Med 2003
Neuroprotective trials
Maas: Neurosurgery 1999
HIT I (n=351)
HIT II (n=852)
HIT III (n=123)
PEGSOD (n=463)
Tirilizad (n=11...
Rat / human model 20th century
Take a young male rat.
Infuse alcohol or speed until intoxicated.
Throw rat at high speed i...
Randy Chesnut
Nino Stocchetti
Andrew Maas
www.braintrauma.org
2001, 2003, 2007
Critical pathway
BTF Guidelines 1st, 2nd editions
Tier 1
Critical pathway: proposed
Tier 2
Tier 3
Low dose mannitol
Normothermia
Decompressive craniectomy
Induced hypotherm...
Rat / human model 21th century
Take a rat of any age.
If young, infuse alcohol or speed until intoxicated.
If old, give wa...
Comparative data
ATBIS
GCS<9
SAFE TBI
GCS<9
(Albumin)
SAFE TBI
GCS<9
(Saline)
n 363 160 158
Inception period 2000-2001 200...
Decompressive craniectomy
Indication
Age
Diffuse vs mass lesion
Traumatic vs non-traumatic
Timing
Pre-emptive
Rescue
Trigg...
Honeybul: Brian inj 2013
Jiang:J Neurotrauma: 2005
Multicentred RCT, blinded outcome adjudication
1998 – 2001
n=486
Age < 70
Clinical / CT triggers...
Jiang:J Neurotrauma: 2005
GR / MD SD / PVS Dead
0
10
20
30
40
50
Standard DC (n=241))
Limited DC (n=245)
6m GOS
%
0
10
20
...
Cooper: New Eng J Med 2011
Multicentred RCT, blinded outcome adjudication
2002-2011
N=155 (age <60)
Age < 60; < 72h post i...
Cooper: New Eng J Med 2011
Unfavourable Favourable
70% 51%
OR: 2.21 95%CI 1.14 to 4.26; P=0.02
www.rescueicp.com
Multi-centre RCT, blinded outcome adjudication
366/400 patients recruited
Age 18-65
ICP>25 mmHg
Refracto...
Honeybul: Brian inj 2013
Decompression for TBI
Survivors with unfavourable outcomes
Survivors with favourable outcomes
Sur...
Honeybul: Brian inj 2013
Middle cerebral artery infarction
Age limited: <60y
Time limited: < 48 hours
Co-morbidity / non-dominant hemisphere
DECIMA...
Middle cerebral artery infarction
Age limited: >60y
Time limited: < 48 hours
Low co-morbidity / non-dominant hemisphere
Ju...
Honeybul: Brian inj 2013
Decompression for non-TBI
Survivors with unfavourable outcomes
Survivors with favourable outcomes
Does Intensive Care improve outcome
from TBI?
Chesnut: NEJM 2012
Multi-centred RCT, blinded outcome adjudication
2008-2011
N=324
Age >13 <60
GCS<9 , < 48h post injury
P...
Chesnut: NEJM 2012
ICP monitoring group
Imaging/exam group
P=0.60
ICP
(n=157)
ICE
(n=167)
OR (95%CI) p
CFOS 56 (22-37) 53 ...
T H Huxley
1825 - 1895
m
“That the great tragedy of
Science is the slaying of a
beautiful hypothesis with an
ugly fact”
Some concluding thoughts
Outcome from ABI is primarily determined by geography…
… and genetics
ICP is primarily an indicat...
Some concluding thoughts
Beware the therapeutic imperative to do what we can…
… and not what we should
Myburgh, John — Raised ICP: Keeping a Lid on It
Myburgh, John — Raised ICP: Keeping a Lid on It
Myburgh, John — Raised ICP: Keeping a Lid on It
Myburgh, John — Raised ICP: Keeping a Lid on It
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Myburgh, John — Raised ICP: Keeping a Lid on It

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John Myburgh on the misunderstood craniectomy. The management of raised ICP and what we do when our options run out.

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Transcript of "Myburgh, John — Raised ICP: Keeping a Lid on It"

  1. 1. Raised intracranial pressure: keeping a lid on it UNSW John Myburgh MBBCh PhD FCICM The George Institute for Global Health St George Clinical School, University of New South Wales
  2. 2. P(mmHg) V (ml) 1783, 1824 Monro-Kelly doctrine Intracranial volume remains constant at any given time
  3. 3. Bryan Jennett Douglas Miller Larry Marshall 1978 1979 1980 Fearnside: Br J Neurosurg 1992
  4. 4. Inflammatory modulation Bayir: Crit Care Med 2003
  5. 5. Neuroprotective trials Maas: Neurosurgery 1999 HIT I (n=351) HIT II (n=852) HIT III (n=123) PEGSOD (n=463) Tirilizad (n=1128) Triamcinolone (n=396) HIT II tSAH Tirilizad tSAH Triamcinolone GCS 8 +focal lesion Neuroprotective agents All steroids mean = 435
  6. 6. Rat / human model 20th century Take a young male rat. Infuse alcohol or speed until intoxicated. Throw rat at high speed into brick wall Break its femur and pelvis. Leave it lying in the corner for 1 hour. Get resident to resuscitate it using albumin Include an oesophageal intubation and hypoxia for 20m. Get orthopod to fix femur and lose 20% blood volume. Do a CT head, but don’t tell the researcher the results. Get a resident to put in ICP monitor 6-36 hours after injury. Do the intervention. Random use of mannitol, hyperventilation, hypothermia, barbs Count how many rats are dead after 1 week.
  7. 7. Randy Chesnut Nino Stocchetti Andrew Maas www.braintrauma.org 2001, 2003, 2007
  8. 8. Critical pathway BTF Guidelines 1st, 2nd editions
  9. 9. Tier 1 Critical pathway: proposed Tier 2 Tier 3 Low dose mannitol Normothermia Decompressive craniectomy Induced hypothermia Neuromuscular blockade High dose mannitol Hypertonic saline Mild hypothermia (35-37) BTF Guidelines Working Group: 2009
  10. 10. Rat / human model 21th century Take a rat of any age. If young, infuse alcohol or speed until intoxicated. If old, give warfarin and aspirin Early intubation and resuscitation Pan-scan and damage control surgery Standardise ICP monitoring Do the intervention. Flog CPP with noradrenaline Use hypothermia, barbiturates to keep ICP<20 Decompressive craniectomy if these don’t work Keep going until the rat’s family tells you when to stop Count how many rats are dead after 6 months.
  11. 11. Comparative data ATBIS GCS<9 SAFE TBI GCS<9 (Albumin) SAFE TBI GCS<9 (Saline) n 363 160 158 Inception period 2000-2001 2001-2003 2001-2003 12-month mortality: n/N (%) 105/299 (35.1) 61/153 (39.9) 32/149 (21.5) Myburgh J Trauma: 2008
  12. 12. Decompressive craniectomy Indication Age Diffuse vs mass lesion Traumatic vs non-traumatic Timing Pre-emptive Rescue Trigger CT / clinical ICP Technique Bifrontal vs unilateral Dura open vs closed Outcome Physiological Death / functional outcome
  13. 13. Honeybul: Brian inj 2013
  14. 14. Jiang:J Neurotrauma: 2005 Multicentred RCT, blinded outcome adjudication 1998 – 2001 n=486 Age < 70 Clinical / CT triggers for decompression Primary outcome: 6m GOS Standard Limited
  15. 15. Jiang:J Neurotrauma: 2005 GR / MD SD / PVS Dead 0 10 20 30 40 50 Standard DC (n=241)) Limited DC (n=245) 6m GOS % 0 10 20 30 40 50 Day ICP(mmHg) Pre DC 1 day 3 days 7 days Standard DC (n=36) Limited DC (n=47) p=0.03
  16. 16. Cooper: New Eng J Med 2011 Multicentred RCT, blinded outcome adjudication 2002-2011 N=155 (age <60) Age < 60; < 72h post injury CT trigger: Diffuse injury ICP trigger: >20 mmHg Primary outcome: 6m GOS vs Medical therapy
  17. 17. Cooper: New Eng J Med 2011 Unfavourable Favourable 70% 51% OR: 2.21 95%CI 1.14 to 4.26; P=0.02
  18. 18. www.rescueicp.com Multi-centre RCT, blinded outcome adjudication 366/400 patients recruited Age 18-65 ICP>25 mmHg Refractory to medical therapy (2nd tier) Included evacuated mass lesions Clinically directed decompression Primary outcome: Discharge + 6m GOSE
  19. 19. Honeybul: Brian inj 2013 Decompression for TBI Survivors with unfavourable outcomes Survivors with favourable outcomes Survivors with favourable outcomes
  20. 20. Honeybul: Brian inj 2013
  21. 21. Middle cerebral artery infarction Age limited: <60y Time limited: < 48 hours Co-morbidity / non-dominant hemisphere DECIMAL: n=38 (Germany) DESTINY: n=32 (France) HAMLET: n=39 (Netherlands) Hofmeijer: Lancet 2009
  22. 22. Middle cerebral artery infarction Age limited: >60y Time limited: < 48 hours Low co-morbidity / non-dominant hemisphere Juttler: NEJM 2014
  23. 23. Honeybul: Brian inj 2013 Decompression for non-TBI Survivors with unfavourable outcomes Survivors with favourable outcomes
  24. 24. Does Intensive Care improve outcome from TBI?
  25. 25. Chesnut: NEJM 2012 Multi-centred RCT, blinded outcome adjudication 2008-2011 N=324 Age >13 <60 GCS<9 , < 48h post injury Pressure/monitoring: ICP >20 mmHg + 3-tiered protocol Imaging/clinical exam: 3-tiered protocol Primary outcome: composite functional outcome 6m
  26. 26. Chesnut: NEJM 2012 ICP monitoring group Imaging/exam group P=0.60 ICP (n=157) ICE (n=167) OR (95%CI) p CFOS 56 (22-37) 53 (21-76) 1.09 (0.74 to 1.58) 0.49 Death 56/144 (39%) 67 (41%) 1.10 (0.77 to 1.57) 0.60
  27. 27. T H Huxley 1825 - 1895 m “That the great tragedy of Science is the slaying of a beautiful hypothesis with an ugly fact”
  28. 28. Some concluding thoughts Outcome from ABI is primarily determined by geography… … and genetics ICP is primarily an indicator of severity of injury Treating ICP comes at a cost … … saving the head, but killing the body… … and those who care for the patient
  29. 29. Some concluding thoughts Beware the therapeutic imperative to do what we can… … and not what we should
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