Cerebral edema leading to decompressive craniectomy: An assessment of the preceding clinical and neuromonitoring trends

Abstract

The aim of this study was to examine the pre-operative clinical and neuromonitoring courses in patients with a decompressive craniectomy to assess and to compare clinical and neuromonitoring signs indicating extensive cerebral edema. We conducted a retrospective analysis of the clinical signs and courses of simultaneous monitoring of intracranial pressure (ICP) and cerebral oxygenation (P_tiO₂) in 26 consecutive patients who were sedated and treated with a decompressive craniectomy due to extensive cerebral edema after aneurysmal subarachnoid hemorrhage (SAH) (n = 20) or severe head injury (SHI) (n = 6). Pathological monitoring trends always preceded clinical deterioration. In 18 of 26 patients extensive cerebral edema was indicated solely by increasing ICP >20 mmHg or decreasing P_tiO₂ < 10 mmHg or both. Anisocoria occured in only 8 of 26 patients. As opposed to SHI patients, 9 of 20 SAH patients showed decreasing P_tiO₂ as first warning sign clearly before neurological deterioration or ICP increase. This series shows the utility of combined ICP and P_tiO₂ monitoring in patients who develop extensive cerebral edema. Pathological monitoring trends indicate deterioration prior to clinical signs which offers a wider therapeutical window. P_tiO₂ monitoring appears to be particularly valuable after aneurysmal SAH as adjunct to ICP monitoring and CT imaging.

Keywords:

• ANEURYSMAL SUBARACHNOID HEMORRHAGE
• BRAIN TISSUE PARTIAL PRESSURE OF OXYGEN
• DECOMPRESSIVE
• CRANIECTOMY
• INTRACRANIAL PRESSURE
• NEUROMONITORING
• SEVERE HEAD INJURY