[Epidural cerebrospinal fluid pressure measurement and therapy of intracranial hypertension in "malignant" middle cerebral artery infarct].
OBJECTIVE
A permanent elevation of ICP after severe brain injury for instance in subarachnoid or intracerebral hemorrhage or neurotrauma is associated with a poor clinical outcome. Although increasingly being used in the intensive care of patients with elevated ICP, continuous epidural ICP monitoring in ischemic stroke has not been firmly established yet.


METHODS
We prospectively evaluated the clinical course and outcome of patients with raised ICP due to space occupying ischemic middle cerebral artery (MCA) infarction as seen in CT, who underwent continuous ICP monitoring. Epidural ICPprobes were inserted ipsilaterally (all patients) and contralaterally (additional in 7 patients) to the side of infarctation. Glasgow Coma and Scandinavian Stroke Scales (GCS and SSS) were obtained initially and in the further clinical course. All patients were subjected to a standardized treatment protocol for raised ICP. ICP values were correlated with clinical presentation at the time point of deterioration, with outcome and CT findings. Effectiveness of different treatment modalities to lower ICP were analyzed and discussed.


RESULTS
9 of 48 patients survived the MCA infarct (19%), with the cause of death being transtentorial herniation with subsequent brain death in all 39 patients. Mean SSS at admission was 20.6 (survivors 21.5 +/- 5.6, nonsurvivers 19.8 +/- 6.5). All patients showed clinical signs of herniation before the increase of ICP. All 39 patients who died developed ICP values higher than 35 mmHg and no patient with ICP values of more than 35 mmHg survived. CCT changes dit not necessarily reflect the absolute measured ICP values. All treatment modalities for raised ICP including osmotherapy, controlled hyperventilation, tromethamol and barbiturates were initially effective, but only in a minority of patients ICP control could be sustained.


CONCLUSIONS
We conclude that ICP monitoring in large hemispheric infarction may predict clinical outcome. ICP monitoring was not helpful in guiding long term treatment of ICP. It remains doubtful, whether ICP monitoring has a positive influence on clinical outcome of acute severe ischemic stroke.
Schwab
S
S
Neurologische Klinik, Ruprecht-Karls-Universität, Heidelberg.
Schellinger
P
P
Aschoff
A
A
Albert
F
F
Spranger
M
M
Hacke
W
W
D000328:Adult; D000368:Aged; D001463:Barbiturates / Q000008:administration & dosage; D001929:Brain Edema / Q000188:drug therapy*; D002544:Cerebral Infarction / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality; D003131:Combined Modality Therapy; D004566:Electrodes; D005260:Female; D005990:Glycerol / Q000008:administration & dosage; D006493:Heparin / Q000008:administration & dosage; D006801:Humans; D007427:Intracranial Pressure / Q000187:drug effects; D008297:Male; D008353:Mannitol / Q000008:administration & dosage; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000295:instrumentation*; D011559:Pseudotumor Cerebri / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality; D015996:Survival Rate; D014696:Ventriculostomy / Q000295:instrumentation*
D001463:Barbiturates; D008353:Mannitol; D006493:Heparin; D005990:Glycerol