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Pappiloedema as a mrker for raised icp in head injury


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Pappiloedema as a mrker for raised icp in head injury

  1. 1. Papilloedema as a Non-Invasive Marker for Raised ICP Following Decompressive Craniectomy for Severe Head Injury<br />SHEJOY JOSHUA, DEEPAK AGRAWAL<br />BS SHARMA, AK MAHAPATRA<br />Department of Neurosurgery,<br />JPN Apex Trauma Center, AIIMS, Dew Delhi.<br />
  2. 2. Background <br />Decompressive craniectomy (DC) – the time tested treatment for Severe HI<br />
  3. 3. Background<br />It is generally believed that ICP normalises after an adequate decompressive craniectomy<br />Especially as CT usually shows open cisterns & resolution of MLS<br />
  4. 4. Hypothesis<br />Some patients may redevelop raised ICP after a variable period following decompressive craniectomy<br />Possibly due to hydrocephalus &/or reduced brain compliance<br />CT scan is not a sensitive indicator of raised intracranial pressure<br />
  5. 5. Research Question(s)<br />How to assess for raised ICP in these patients reliably and non-invasively<br />
  6. 6. Possible solution <br />Fundoscopy – a simple clinical examination to pick up raised ICP<br />Papilloedema is considered pathognomic of raised ICP<br />
  7. 7. Aims and objectives<br />To study the temporal course of fundoscopic findings in patients with severe HI following decompressive craniectomy.<br />To correlate Fundoscopy findings with ventriculomegaly on serial CT’s in these patients<br />
  8. 8. Aims and objectives (Secondary)<br />To correlate ICP readings with papilloedoma in patients who had ICP monitoring<br />Time-course of resolution of papilloedema in selected patients who had lumbar drain placed <br />
  9. 9. Material & Methods<br />Prospective study over 5 month period<br />Fundoscopic examination and serial CT to diagnose<br />Ventriculomegaly <br />Papilloedema<br />
  10. 10. Material & Methods<br />Inclusion criteria<br />Severe HI pts (GCS ≤8) who underwent DC<br />Exclusion criteria<br />Pre-existing DM/HT<br />Pts in which fundoscopy is not possible<br />Cataract<br />Eyeball injury<br />
  11. 11. Material & Methods<br />Surgery<br />All patients underwent a wide decompressive craniectomy with lax duraplasty and were electively ventilated for a variable period of time (Range-3-30days). <br />
  12. 12. Material & Methods<br />Serial fundoscopic examinations at day 1, 2, 3, 5, 7 & 14<br />Serial CT scans (according to surgeon’s preference)<br />
  13. 13. Definitions <br />Papilloedema <br /> presence of hyperemia of the disc or blurring of disc margins along with absent spontaneous venous pulsations. <br />
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  17. 17. Definitions<br />Ventriculomegaly<br />ratio of frontal horn diameter to intracranial diameter taken at the same level was >50% along with 2 or more of the following criteria<br />dilatation of temporal horn > 2 mm<br />ballooning of III rd ventricle <br />Peri-ventricular lucency<br />
  18. 18. Results<br />Total patients- 32<br />Age 12-75 years (Mean 33.75 SD 13.93). <br />Glasgow coma scale on admission ranged from 3/15- 8/15 (Mean 6.28 Std. Dev. 1.63)<br />Acute SDH 12<br />Contusion 20<br />
  20. 20. Incidence of papilloedema following Decompressive craniectomy on serial Fundoscopic examination <br />
  21. 21. Comparison of ventriculomegaly on C.T head with Papilloedema on Fundoscopic examination at the same time interval<br />
  22. 22. Results <br /><ul><li>4 Patients (12.5%) developed deterioration of GCS (by 1 or 2) and an inability to wean off the ventilator along with systemic signs of raised ICP viz. Bradycardia and hypertension on 7-10th post operative day</li></li></ul><li>
  23. 23. Recurrence and Resolution<br /><ul><li>All 4 patients had a recurrence of papilledema in the form of hyperemia of disc, engorgement of vessels and worsening of disc blurr
  24. 24. Although CT showed mild ventriculomegaly in all cases, Evan’s ratio was within normal range</li></li></ul><li>Recurrence and Resolution<br />A lumbar drain was placed in all these patients which resulted in improvement of GCS <br />This was associated with resolution of papilledema in the form of clearing up the disc hyperemia and decrease in the vessel engorgement within 6 hours post procedure <br />
  25. 25. Discussion<br />No similar studies in literature!<br />This study validates the use of papilloedema as an extremely sensitive marker for acute changes in ICP.<br />
  26. 26. Conclusion(s)<br />Significant number of patients (12.5% in our study) had recurrence of raised ICP following decompressive craniectomy for severe HI<br />There was prompt resolution of the ICP on lumbar drainage suggesting CSF absorption block as a possible mechainsm of this raised ICP<br />
  27. 27. Conclusion(s)<br />Papilloedema is an early indicator of raised ICP and correlates well with the intracranial pressure in head injured patients<br />This study validates the use of papilloedema as an extremely sensitive marker for acute changes in ICP.<br />
  28. 28. Thank you<br />