title: Posttraumatic refractory intracranial hypertension and brain herniation syndrome: cerebral hemodynamic assessment before decompressive craniectomy.
abstract: BACKGROUND
  The pathophysiology of traumatic brain swelling remains little understood. An improved understanding of intracranial circulatory process related to brain herniation may have treatment implications.
  
  
  OBJECTIVE
  To investigate the cerebral hemodynamic changes associated with brain herniation syndrome due to traumatic brain swelling.
  
  
  METHODS
  Nineteen head-injured patients with evidence of refractory intracranial hypertension and transtentorial herniation were prospectively studied. Cerebral hemodynamic assessment by transcranial Doppler (TCD) ultrasonography was performed prior to decompressive craniectomy. Patients and their cerebral hemispheres were classified according to TCD-hemodynamic patterns, and the data correlated with neurological status, midline shift on CT scan, and Glasgow outcome scale scores at 6 months after injury.
  
  
  RESULTS
  A wide variety of cerebral hemodynamic findings were observed. Ten patients (52.7%) presented with cerebral oligoemia, 3 patients (15.8%) with cerebral hyperemia, and 6 patients with nonspecific circulatory pattern. Circulatory disturbances were more frequently found in the side of maximal cerebral swelling than in the opposite side. Pulsatility index (PI) values suggested that ICP varied from acceptable to considerably high; patients with increased PI, indicating higher microvascular resistance. No correlation was found between cerebral hemodynamic findings and outcome.
  
  
  CONCLUSIONS
  There is a marked heterogeneity of cerebral hemodynamic disturbances among patients with brain herniation syndrome.
authors.affiliation: Division of Neurological Surgery, Hospital das Clinicas, University of Sao Paulo, School of Medicine, 255 Eneas Aguiar Street, Office 4079, 05403010 Sao Paulo, SP, Brazil.
authors.forename: Edson
authors.initials: E
authors.lastname: Bor-Seng-Shu
authors.affiliation: Division of Neurological Surgery, Hospital das Clinicas, University of Sao Paulo, School of Medicine, 255 Eneas Aguiar Street, Office 4079, 05403010 Sao Paulo, SP, Brazil.
authors.forename: Wellingson Silva
authors.initials: WS
authors.lastname: Paiva
authors.affiliation: Division of Neurological Surgery, Hospital das Clinicas, University of Sao Paulo, School of Medicine, 255 Eneas Aguiar Street, Office 4079, 05403010 Sao Paulo, SP, Brazil.
authors.forename: Eberval G
authors.initials: EG
authors.lastname: Figueiredo
authors.affiliation: Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Yasunori
authors.initials: Y
authors.lastname: Fujimoto
authors.affiliation: Division of Neurological Surgery, Hospital das Clinicas, University of Sao Paulo, School of Medicine, 255 Eneas Aguiar Street, Office 4079, 05403010 Sao Paulo, SP, Brazil.
authors.forename: Almir Ferreira
authors.initials: AF
authors.lastname: de Andrade
authors.affiliation: Division of Neurological Surgery, Hospital das Clinicas, University of Sao Paulo, School of Medicine, 255 Eneas Aguiar Street, Office 4079, 05403010 Sao Paulo, SP, Brazil.
authors.forename: Erich Talamoni
authors.initials: ET
authors.lastname: Fonoff
authors.affiliation: Division of Neurological Surgery, Hospital das Clinicas, University of Sao Paulo, School of Medicine, 255 Eneas Aguiar Street, Office 4079, 05403010 Sao Paulo, SP, Brazil.
authors.forename: Manoel Jacobsen
authors.initials: MJ
authors.lastname: Teixeira
mesh_terms: D000293:Adolescent; D000328:Adult; D001921:Brain / Q000098:blood supply* / Q000000981:diagnostic imaging / Q000601:surgery; D001929:Brain Edema / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery; D001930:Brain Injuries / Q000150:complications / Q000473:pathology*; D002560:Cerebrovascular Circulation; D056424:Decompressive Craniectomy; D004677:Encephalocele / Q000097:blood / Q000473:pathology* / Q000601:surgery; D005260:Female; D006439:Hemodynamics; D006801:Humans; D019586:Intracranial Hypertension / Q000097:blood / Q000209:etiology / Q000473:pathology* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D017585:Ultrasonography, Doppler, Transcranial