Multimodal online monitoring in middle cerebral artery territory stroke.
OBJECTIVE
Patients with large middle cerebral artery infarction and elevated intracranial pressure (ICP) who are undergoing invasive intensive care therapy require technical monitoring. However, the effectiveness of the current gold standard, measurement of ICP, is limited. Furthermore, the effects of what is considered to be standard antiedema medical treatment are not fully understood. We studied whether multimodal monitoring can help to overcome this problem.


METHODS
ICP, cerebral perfusion pressure (CPP), and partial brain tissue oxygen pressure (PbrO(2)) were continuously measured within the white matter of the frontal lobe unilaterally or bilaterally. We analyzed the effects of antiedema drugs and looked for pattern changes in the PbrO(2) before transtentorial herniation in patients in whom this could not be prevented. Furthermore, complications were registered.


RESULTS
We performed 27 measurements in 21 patients. A total of 297 antiedema drug administrations were analyzed in 11 patients. Hyper-HAES and mannitol were most often associated with an increase in CPP and PbrO(2), whereas the use of thiopental and tromethamine led to negative or contrary effects, although ICP was decreased in every case. Pattern changes in the PbrO(2) curve could be observed between 6 to 18 hours before transtentorial herniation. No bleeding complication or infections were observed.


CONCLUSIONS
Multimodal monitoring can be used to monitor antiedema drug effects. Our data suggest that with multimodal monitoring, pathophysiological changes could be predicted considerably in advance. ICP alone is of questionable use. Furthermore, this method might help to optimize the timing of invasive therapy in space-occupying infarction.
Steiner
T
T
Department of Neurology, Institute for Applied Mathematics, University of Heidelberg, Heidelberg, Germany. thorsten_steiner@med.uni-heidelberg.de
Pilz
J
J
Schellinger
P
P
Wirtz
R
R
Friederichs
V
V
Aschoff
A
A
Hacke
W
W
D001929:Brain Edema / Q000188:drug therapy; D005240:Feasibility Studies; D005625:Frontal Lobe / Q000737:chemistry / Q000503:physiopathology; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000175:diagnosis / Q000188:drug therapy* / Q000628:therapy; D019586:Intracranial Hypertension; D007427:Intracranial Pressure / Q000187:drug effects; D008991:Monitoring, Physiologic / Q000009:adverse effects / Q000379:methods*; D009862:Online Systems; D010100:Oxygen / Q000032:analysis; D010313:Partial Pressure
D010100:Oxygen