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      Delayed Rise in Intracranial Pressure in       <br />              Patients with Head Injury     <br />Pankaj  Ailaw...
ICP MONITORING	HI STORICAL PERSPECTIVE<br />-      EARLIEST  DESCRIPTIONS  DATE BACK ALMOST 100 YEARS <br />           -  ...
                                     ICP MONITORING<br />         -    METHODS  <br />               A.  LUMBAR  PUNCTURE ...
                           INDICATIONS OF ICP MONITORING AFTER<br />                                       TRAUMATIC BRAIN...
BUT THE QUESTION IS<br />                                WHEN TO MONITOR?<br />                                           ...
CT   BASED  HEAD   INJURY   CLASSIFICATION                          BY MARSHALL   <br />
                                           AIIMS AND OBJECTIVES<br />               1.    TO  EVALUATE THE SIGNIFICANCE OF...
                                     MATERIAL AND METHODS<br />       TYPE OF STUDY                 :                PROSP...
                                     MATERIAL AND METHODS( CONTD.)<br />PATIENTS ENROLLED                               - ...
                               MATERIAL AND METHODS( CONTD.)<br />RADIOLOGY                               :   NCCT HEAD ON...
                               MATERIAL   AND    METHODS (  CONTD.)<br />            MONITORING    DEVICE               : ...
MATERIAL S AND METHODS( CONTD.)<br />PATIENTS WERE DIVIDED IN 3 CATEGORIES:<br />        1.  INITIAL HIGH ICP  (IHICP )  G...
MATERIAL’S AND METHODS( CONTD.)<br /> OUTCOMES             ASSESSED BY USING GLASGOW     <br />                           ...
RESULTS AND  OUTCOMES<br />TOTAL PATIENTS EVALUATED :21 <br />MALES      : 21 <br />FEMALES :  O<br />
RESULTS  AND  OUTCOMES<br />MODE OF INJURY<br />RTA     :       15<br />FALL    :       06<br />
RESULTS AND OUTCOMES<br />                    AGE DISTRIBUTION  <br />          AGE      RANGE    :     15  -  50  YRS.<br...
RESULTS AND OUTCOMES<br />TYPE OF INJURY <br />MODERATE   :     3<br />SEVERE          :    18     <br />
RESULTS AND OUTCOMES<br />         GROUP 1 (IHICP) <br />TOTAL PATIENTS    5 <br />MEAN ICP   35 cm  h20  <br />ABNORMAL C...
RESULTS AND OUTCOMES<br />GROUP 2 (DHICP) <br />TOTAL PATIENTS    6 <br />MEAN INITIAL  ICP   12 cm<br />ABNORMAL CT     4...
RESULTS AND OUTCOMES<br />GROUP 2 (CONTD.)<br />PERIOD OF ICP MONITORING     <br />                 RANGE  24- 92 HRS.<br ...
GROUP 2 <br />INITIAL CT WHEN ICP NORMAL<br />CT WHEN PT HAD  DELAYED HICP<br />
RESULTS AND OUTCOMES<br /> GROUP 3 (NICP) <br />TOTAL PATIENTS   10 <br />MEAN ICP   13 cm  h20  <br />ABNORMAL CT     2  ...
RESULTS AND OUTCOME<br />CORRELATION OF INITIAL ABNORMAL CT AND FINAL SURGICAL MANAGEMENT<br />GROUP 1       3/3<br />GROU...
RESULTS AND OUTCOME<br />           MORTALITY <br />GROUP 1   :   NIL/5 <br />GROUP  2   :   3/6 <br />GROUP 3    : NIL /1...
RESULTS AND OUTCOME<br />      AS PER GOS<br />GROUP 1    :      3.2<br />GROUP  2   :      2.0<br />GROUP 3    :      3.2...
REVIEW OF LITERATURE <br />Patients with either high-density or low-density lesions on computerized tomography (CT) at adm...
REVIEW OF LITERATURE <br />After traumatic brain injury (TBI), Half of the patients had their highest mean ICP during the ...
REVIEW OF LITERATURE<br />The mortality rates were 77%, 39%, and 22% among those with absent, compressed, and normal basal...
                        CONCLUSIONS<br />1.  Delayed ICP rise , known phenomenon after  <br />     traumatic head injury i...
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Delayed rise in icp following head injury

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Delayed rise in icp following head injury

  1. 1. Delayed Rise in Intracranial Pressure in <br /> Patients with Head Injury <br />Pankaj Ailawadhi , Deepak Agrawal<br />Department of Neurosurgery, JPN Apex Trauma centre, AIIMS, New Delhi <br />
  2. 2. ICP MONITORING HI STORICAL PERSPECTIVE<br />- EARLIEST DESCRIPTIONS DATE BACK ALMOST 100 YEARS <br /> - IN 1960, FIRST LARGE SERIES BY LUNDBERG ON <br /> DIRECT CONTINUOUS MONITORING<br /> - IN 1977 , BECKER AND COLLEAGUES SUGGESTED ICP <br /> MONITORING TO BE INCLUDED AS A METHOD OF <br /> IMPROVING OUTCOME IN SEVERELY HEAD INJURED <br /> PATIENTS <br />
  3. 3. ICP MONITORING<br /> - METHODS <br /> A. LUMBAR PUNCTURE ,FIRST DESCRIBED BY QUINCKE IN 1891<br /> NOT PRACTICED <br /> B. CRANIAL <br /> INTRAVENTRICLAR<br /> INTRAPARENCHYMAL<br /> SUBDURAL<br /> SUBARACHNOID<br /> - VALUES <br /> GENERALLY ACCEPTED NORMAL RANGE IS 5 – 20 CM H2O<br /> ICP > 20 IS SIGNIFICANT PREDICTOR OF INCREASED MORBIDITY <br /> AND WARRANTS TREATMENT <br />
  4. 4. INDICATIONS OF ICP MONITORING AFTER<br /> TRAUMATIC BRAIN INJURY <br />1. GLASGOW COMA SCALE <br /> With <br /> A. An abnormal CT head scan<br /> Or<br /> B.. A normal CT head scan but with 2 or more high risk factors<br /> – Age >40<br /> – Hypotension systolic BP <90mmHg<br /> – Abnormal motor posturing <br />PATIENTS WHO REQUIRE SEDATION AND VENTILATION hence making clinical examination such as in a setting of multiple system injury. <br />POST SURGERY MONITORING<br />
  5. 5. BUT THE QUESTION IS<br /> WHEN TO MONITOR?<br /> AND<br /> WHEN TO DIRECTLY PROCEED <br /> WITH SURGERY ??<br />
  6. 6. CT BASED HEAD INJURY CLASSIFICATION BY MARSHALL <br />
  7. 7. AIIMS AND OBJECTIVES<br /> 1. TO EVALUATE THE SIGNIFICANCE OF <br /> DELAYED RISE IN ICP AFTER TRAUMATIC <br /> BRAIN INJURY <br /> 2 . TO CHECK FOR ANY CORRELATION BETWEEN <br /> INITIAL CT FINDINGS AND NEUROLOGICAL <br /> OUTCOME .<br />
  8. 8. MATERIAL AND METHODS<br /> TYPE OF STUDY : PROSPECTIVE<br /> PLACE : JPNATC, AIIMS <br /> DURATION : 2 MONTHS <br /> PATIENTS ENROLLED : - FULFILLING THE STANDARD C RITERIA OF<br /> ICP MONITORING AS DESCRIBED <br /> - PATIENTS WITH WELL DEFINED OPERABLE <br /> MASSES MORE THAN 1 CM IN DIAMETER <br /> EXCLUDED FROM THE STUDY<br />
  9. 9. MATERIAL AND METHODS( CONTD.)<br />PATIENTS ENROLLED - PATIENTS WITH DIFFUSE INJURY ,<br /> HAEMMORHAGE , CONTUSION, <br /> HEMISPHERICAL OEDEMA PRODUCING<br /> MIDLINE SHIFT MORE THAN 5 MM WERE <br /> EXCLUDED FROM STUDY <br />
  10. 10. MATERIAL AND METHODS( CONTD.)<br />RADIOLOGY : NCCT HEAD ON PRESENTATION, DAY2 , <br /> DAY 3, AND AS PER CLINICAL STATUS <br /> CT SCA NS EVALUATED FOR <br /> - PRESCENCE OF EFFACEMENT OF <br /> CISTERNS <br /> (CISTERNS PRIMARILY EVALUATED <br /> SUPRASELLLAR, PERIMESENCEPHALIC) <br /> - MIDLINE SHIFT < OR > 5 MM <br />
  11. 11. MATERIAL AND METHODS ( CONTD.)<br /> MONITORING DEVICE : FIBREOPTIC CATHETERS<br /> POSITION : INTRAPARENCHYMAL <br />
  12. 12. MATERIAL S AND METHODS( CONTD.)<br />PATIENTS WERE DIVIDED IN 3 CATEGORIES:<br /> 1. INITIAL HIGH ICP (IHICP ) GROUP WITH INITIAL ICP >20 CM H2O <br /> 2. DELAYED HIGH ICP(DHICP) GROUP WITH INITIAL ICP < 20 CM H2O <br /> BUT WITH DELAYED RISE AFTER A VARIABLE PERIOD <br /> 3. NORMAL ICP( NICP )GROUP WITH ICP VALUES PERSISTENTLY<20 <br />
  13. 13. MATERIAL’S AND METHODS( CONTD.)<br /> OUTCOMES ASSESSED BY USING GLASGOW <br /> OUTCOME SCALE :<br /> 1. DEAD <br /> 2. VEGETATIVE STATE <br /> unable to interact with environment, <br /> unresponsive<br /> 3. SEVERE DISABILITY<br /> able to follow commands/ Unable to live <br /> independently <br /> 4. MODERATE DISABILITY<br /> able to live independently /unable to return to <br /> work or school<br /> 5. GOOD RECOVERY<br /> able to return to work or school <br />
  14. 14. RESULTS AND OUTCOMES<br />TOTAL PATIENTS EVALUATED :21 <br />MALES : 21 <br />FEMALES : O<br />
  15. 15. RESULTS AND OUTCOMES<br />MODE OF INJURY<br />RTA : 15<br />FALL : 06<br />
  16. 16. RESULTS AND OUTCOMES<br /> AGE DISTRIBUTION <br /> AGE RANGE : 15 - 50 YRS.<br /> MEDIAN AGE : 30 YRS. <br />
  17. 17. RESULTS AND OUTCOMES<br />TYPE OF INJURY <br />MODERATE : 3<br />SEVERE : 18 <br />
  18. 18. RESULTS AND OUTCOMES<br /> GROUP 1 (IHICP) <br />TOTAL PATIENTS 5 <br />MEAN ICP 35 cm h20 <br />ABNORMAL CT 3 <br />NORMAL CT 2 <br />
  19. 19. RESULTS AND OUTCOMES<br />GROUP 2 (DHICP) <br />TOTAL PATIENTS 6 <br />MEAN INITIAL ICP 12 cm<br />ABNORMAL CT 4 <br />NORMAL CT 2 <br />
  20. 20. RESULTS AND OUTCOMES<br />GROUP 2 (CONTD.)<br />PERIOD OF ICP MONITORING <br /> RANGE 24- 92 HRS.<br /> MEAN 66 HRS.<br />DELAYED ICP LEVELS<br /> RANGE 21- 40 CM OF H2O<br /> MEAN 30 <br />
  21. 21. GROUP 2 <br />INITIAL CT WHEN ICP NORMAL<br />CT WHEN PT HAD DELAYED HICP<br />
  22. 22. RESULTS AND OUTCOMES<br /> GROUP 3 (NICP) <br />TOTAL PATIENTS 10 <br />MEAN ICP 13 cm h20 <br />ABNORMAL CT 2 <br />NORMAL CT 8 <br />
  23. 23. RESULTS AND OUTCOME<br />CORRELATION OF INITIAL ABNORMAL CT AND FINAL SURGICAL MANAGEMENT<br />GROUP 1 3/3<br />GROUP 2 4/4<br />GROUP 3 0/2 <br />TOTAL 7/9 ( 80%)<br />
  24. 24. RESULTS AND OUTCOME<br /> MORTALITY <br />GROUP 1 : NIL/5 <br />GROUP 2 : 3/6 <br />GROUP 3 : NIL /10 <br /> MORTALITY WAS SEEN ONLY IN GROUP 2 WHERE PT WERE KEPT ON INITIAL CONSERVATIVE MANAGEMENT DESPITE ABNORMAL CT BUT NORMAL INITIAL ICP VALUES<br />
  25. 25. RESULTS AND OUTCOME<br /> AS PER GOS<br />GROUP 1 : 3.2<br />GROUP 2 : 2.0<br />GROUP 3 : 3.2 <br />
  26. 26. REVIEW OF LITERATURE <br />Patients with either high-density or low-density lesions on computerized tomography (CT) at admission had a high incidence (53% to 63%) of intracranial hypertension (ICP persistently over 20 mm Hg).<br />Narayan RK, Greenberg RP, Miller JD, et al: Improved confidence of outcome prediction in severe head injury: a comparative analysis of the clinical examination, multimodality evoked potentials, CT scanning, and intracranial pressure. J Neurosurg 54:751–762, 1981<br />
  27. 27. REVIEW OF LITERATURE <br />After traumatic brain injury (TBI), Half of the patients had their highest mean ICP during the first 3 days after injury, but many showed delayed ICP elevation, with 25% showing highest mean ICP after day 5. In these cases, HICP was significantly worse and required more intense therapies.<br />Nino Stocchetti, Angelo Colombo, Fabrizio Ortolano, Walter Videtta, Roberta Marchesi, Luca Longhi, Elisa R. Zanier. Time Course of Intracranial Hypertension after Traumatic Brain Injury Journal of Neurotrauma. August 2007, 24(8): 1339-1346.<br />
  28. 28. REVIEW OF LITERATURE<br />The mortality rates were 77%, 39%, and 22% among those with absent, compressed, and normal basal cisterns Patients with GCS scores of 6 to 8, with cisterns absent or not visualized, suffered nearly a fourfold additional risk of poor outcome, compared to those with normal cisterns<br />Toutant S, Klauber MR, Marshall L et al. Absent or compressed basal cisterns on the first CT scan: ominous predictors of outcome in severe head injury. J Neurosurg 61:691-694, 1984<br />
  29. 29. CONCLUSIONS<br />1. Delayed ICP rise , known phenomenon after <br /> traumatic head injury is associated with poor <br /> prognosis.<br /> 2. 80% of patients with abnormal CT developed <br /> raised ICP (initial or delayed) and required <br /> subsequent Surgery.<br />3.Patients of head injury with effaced cisterns on <br /> initial CT head and delayed rise in ICP in our study <br /> had the worst outcome(GOS2).<br />

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