pathophysiology of neurotraumaaok.pte.hu/docs/ideg/file/cranioplasty_buki_a.pdf · special issues...
TRANSCRIPT
AZ EacuteLETTUDOMAacuteNYI- KLINIKAI FELSŐOKTATAacuteS GYAKORLATORIENTAacuteLT EacuteS HALLGATOacuteBARAacuteT
KORSZERŰSIacuteTEacuteSE A VIDEacuteKI KEacutePZŐHELYEK NEMZETKOumlZI VERSENYKEacutePESSEacuteGEacuteNEK ERŐSIacuteTEacuteSEacuteRE
TAacuteMOP-411C-131KONV-2014-0001
Andras Buki MD PhDDScDepartment of Neurosurgery Medical Faculty of Pecs University Pecs Hungary H-7624
Cranioplasty
Goals of cranioplasty
facilitate neurological recovery
improve cerebral blood flow
restore cerebrospinal fluid dynamics and normal
cerebral compliance
prevent the consequences of hydrostatic
pressure -restore the gradient between
atmospheric- and intracranial pressure
provide better cosmetic resultsappearance
Introduction
Cranioplasty surgical procedure to repair cranial
defects for cosmetic and functional purposes
Indications
Definition
bull traumatic injuries
bull decompressive craniectomies
bull congenital anomalies
bull tumor removal
Contraindicationsbull hydrocephalus
bull infection
bull brain swelling due to any reasons
Chang Hyun Oh MD Chong Oon Park MD at al J Korean Neurosurg Soc 2008 Oct44(4)211-216 English
Comparative Study of Outcomes between Shunting after Cranioplasty and in Cranioplasty after Shunting in Large Concave
Flaccid Cranial Defect with Hydrocephalus
Major challenges in cranioplasty
What material to use
When to perform
PubMed stats
Cranioplasty 1519
bull Timetiming 33244
bull Early 142
bull Late 60
The earlier the better
Early ndash Late 142-60
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications are defined by
age
gender
comorbidities
material
site of skull defect
time between decompression and cranioplasty
Key questions
What is a decompressive craniectomy
bull Of 24 manuscripts only one defines the sizebull Paredes et al Neurocirurgica 201526(3)115-25
bull The average size of the bone defect was 695 (195-1495)cm2
Large defect ndash ample consequences
Small defect can also cause severe psychological problems
(Gilmour C CMJ 1919)
What is early
bull Immediately after edema disappears
bull Within 4 weeks
bull Within 3 months
What is late
bull After 3 months
bull After 6 months
bull Over a year
Key questions
Traditional thoughts about early cranioplasty
+
bull Safe when edema decreased
bull prevents sinking skin flap
bull Decreases the chance for altered CSF circulation
bull Cosmetic solution --- psychological aid facilitating recoveryrehabilitation
bull Prevents injury
Traditional thoughts about early cranioplasty
-
bull Early second hit
bull Pathobiology is not resolved the brain is more vulnerable
bull Higher tendency for edemaswelling
Complications of cranioplasty
CNS infection
hydrocephalus
intracranial hematoma and subdural fluid collection
All may prolong the hospitalization unfavorable prognosis
death
full text randomized and non-randomized controlled trials
(1994-2014)
early CP (1ndash3 months after DC)
late CP (3ndash6 months after DC)
Traumatic brain injury cerebral infarction subarachnoid
hemorrhage and ICH
significant difference in mean operating time mean difference =
minus1346 min
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Goals of cranioplasty
facilitate neurological recovery
improve cerebral blood flow
restore cerebrospinal fluid dynamics and normal
cerebral compliance
prevent the consequences of hydrostatic
pressure -restore the gradient between
atmospheric- and intracranial pressure
provide better cosmetic resultsappearance
Introduction
Cranioplasty surgical procedure to repair cranial
defects for cosmetic and functional purposes
Indications
Definition
bull traumatic injuries
bull decompressive craniectomies
bull congenital anomalies
bull tumor removal
Contraindicationsbull hydrocephalus
bull infection
bull brain swelling due to any reasons
Chang Hyun Oh MD Chong Oon Park MD at al J Korean Neurosurg Soc 2008 Oct44(4)211-216 English
Comparative Study of Outcomes between Shunting after Cranioplasty and in Cranioplasty after Shunting in Large Concave
Flaccid Cranial Defect with Hydrocephalus
Major challenges in cranioplasty
What material to use
When to perform
PubMed stats
Cranioplasty 1519
bull Timetiming 33244
bull Early 142
bull Late 60
The earlier the better
Early ndash Late 142-60
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications are defined by
age
gender
comorbidities
material
site of skull defect
time between decompression and cranioplasty
Key questions
What is a decompressive craniectomy
bull Of 24 manuscripts only one defines the sizebull Paredes et al Neurocirurgica 201526(3)115-25
bull The average size of the bone defect was 695 (195-1495)cm2
Large defect ndash ample consequences
Small defect can also cause severe psychological problems
(Gilmour C CMJ 1919)
What is early
bull Immediately after edema disappears
bull Within 4 weeks
bull Within 3 months
What is late
bull After 3 months
bull After 6 months
bull Over a year
Key questions
Traditional thoughts about early cranioplasty
+
bull Safe when edema decreased
bull prevents sinking skin flap
bull Decreases the chance for altered CSF circulation
bull Cosmetic solution --- psychological aid facilitating recoveryrehabilitation
bull Prevents injury
Traditional thoughts about early cranioplasty
-
bull Early second hit
bull Pathobiology is not resolved the brain is more vulnerable
bull Higher tendency for edemaswelling
Complications of cranioplasty
CNS infection
hydrocephalus
intracranial hematoma and subdural fluid collection
All may prolong the hospitalization unfavorable prognosis
death
full text randomized and non-randomized controlled trials
(1994-2014)
early CP (1ndash3 months after DC)
late CP (3ndash6 months after DC)
Traumatic brain injury cerebral infarction subarachnoid
hemorrhage and ICH
significant difference in mean operating time mean difference =
minus1346 min
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Introduction
Cranioplasty surgical procedure to repair cranial
defects for cosmetic and functional purposes
Indications
Definition
bull traumatic injuries
bull decompressive craniectomies
bull congenital anomalies
bull tumor removal
Contraindicationsbull hydrocephalus
bull infection
bull brain swelling due to any reasons
Chang Hyun Oh MD Chong Oon Park MD at al J Korean Neurosurg Soc 2008 Oct44(4)211-216 English
Comparative Study of Outcomes between Shunting after Cranioplasty and in Cranioplasty after Shunting in Large Concave
Flaccid Cranial Defect with Hydrocephalus
Major challenges in cranioplasty
What material to use
When to perform
PubMed stats
Cranioplasty 1519
bull Timetiming 33244
bull Early 142
bull Late 60
The earlier the better
Early ndash Late 142-60
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications are defined by
age
gender
comorbidities
material
site of skull defect
time between decompression and cranioplasty
Key questions
What is a decompressive craniectomy
bull Of 24 manuscripts only one defines the sizebull Paredes et al Neurocirurgica 201526(3)115-25
bull The average size of the bone defect was 695 (195-1495)cm2
Large defect ndash ample consequences
Small defect can also cause severe psychological problems
(Gilmour C CMJ 1919)
What is early
bull Immediately after edema disappears
bull Within 4 weeks
bull Within 3 months
What is late
bull After 3 months
bull After 6 months
bull Over a year
Key questions
Traditional thoughts about early cranioplasty
+
bull Safe when edema decreased
bull prevents sinking skin flap
bull Decreases the chance for altered CSF circulation
bull Cosmetic solution --- psychological aid facilitating recoveryrehabilitation
bull Prevents injury
Traditional thoughts about early cranioplasty
-
bull Early second hit
bull Pathobiology is not resolved the brain is more vulnerable
bull Higher tendency for edemaswelling
Complications of cranioplasty
CNS infection
hydrocephalus
intracranial hematoma and subdural fluid collection
All may prolong the hospitalization unfavorable prognosis
death
full text randomized and non-randomized controlled trials
(1994-2014)
early CP (1ndash3 months after DC)
late CP (3ndash6 months after DC)
Traumatic brain injury cerebral infarction subarachnoid
hemorrhage and ICH
significant difference in mean operating time mean difference =
minus1346 min
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Chang Hyun Oh MD Chong Oon Park MD at al J Korean Neurosurg Soc 2008 Oct44(4)211-216 English
Comparative Study of Outcomes between Shunting after Cranioplasty and in Cranioplasty after Shunting in Large Concave
Flaccid Cranial Defect with Hydrocephalus
Major challenges in cranioplasty
What material to use
When to perform
PubMed stats
Cranioplasty 1519
bull Timetiming 33244
bull Early 142
bull Late 60
The earlier the better
Early ndash Late 142-60
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications are defined by
age
gender
comorbidities
material
site of skull defect
time between decompression and cranioplasty
Key questions
What is a decompressive craniectomy
bull Of 24 manuscripts only one defines the sizebull Paredes et al Neurocirurgica 201526(3)115-25
bull The average size of the bone defect was 695 (195-1495)cm2
Large defect ndash ample consequences
Small defect can also cause severe psychological problems
(Gilmour C CMJ 1919)
What is early
bull Immediately after edema disappears
bull Within 4 weeks
bull Within 3 months
What is late
bull After 3 months
bull After 6 months
bull Over a year
Key questions
Traditional thoughts about early cranioplasty
+
bull Safe when edema decreased
bull prevents sinking skin flap
bull Decreases the chance for altered CSF circulation
bull Cosmetic solution --- psychological aid facilitating recoveryrehabilitation
bull Prevents injury
Traditional thoughts about early cranioplasty
-
bull Early second hit
bull Pathobiology is not resolved the brain is more vulnerable
bull Higher tendency for edemaswelling
Complications of cranioplasty
CNS infection
hydrocephalus
intracranial hematoma and subdural fluid collection
All may prolong the hospitalization unfavorable prognosis
death
full text randomized and non-randomized controlled trials
(1994-2014)
early CP (1ndash3 months after DC)
late CP (3ndash6 months after DC)
Traumatic brain injury cerebral infarction subarachnoid
hemorrhage and ICH
significant difference in mean operating time mean difference =
minus1346 min
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Major challenges in cranioplasty
What material to use
When to perform
PubMed stats
Cranioplasty 1519
bull Timetiming 33244
bull Early 142
bull Late 60
The earlier the better
Early ndash Late 142-60
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications are defined by
age
gender
comorbidities
material
site of skull defect
time between decompression and cranioplasty
Key questions
What is a decompressive craniectomy
bull Of 24 manuscripts only one defines the sizebull Paredes et al Neurocirurgica 201526(3)115-25
bull The average size of the bone defect was 695 (195-1495)cm2
Large defect ndash ample consequences
Small defect can also cause severe psychological problems
(Gilmour C CMJ 1919)
What is early
bull Immediately after edema disappears
bull Within 4 weeks
bull Within 3 months
What is late
bull After 3 months
bull After 6 months
bull Over a year
Key questions
Traditional thoughts about early cranioplasty
+
bull Safe when edema decreased
bull prevents sinking skin flap
bull Decreases the chance for altered CSF circulation
bull Cosmetic solution --- psychological aid facilitating recoveryrehabilitation
bull Prevents injury
Traditional thoughts about early cranioplasty
-
bull Early second hit
bull Pathobiology is not resolved the brain is more vulnerable
bull Higher tendency for edemaswelling
Complications of cranioplasty
CNS infection
hydrocephalus
intracranial hematoma and subdural fluid collection
All may prolong the hospitalization unfavorable prognosis
death
full text randomized and non-randomized controlled trials
(1994-2014)
early CP (1ndash3 months after DC)
late CP (3ndash6 months after DC)
Traumatic brain injury cerebral infarction subarachnoid
hemorrhage and ICH
significant difference in mean operating time mean difference =
minus1346 min
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
PubMed stats
Cranioplasty 1519
bull Timetiming 33244
bull Early 142
bull Late 60
The earlier the better
Early ndash Late 142-60
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications are defined by
age
gender
comorbidities
material
site of skull defect
time between decompression and cranioplasty
Key questions
What is a decompressive craniectomy
bull Of 24 manuscripts only one defines the sizebull Paredes et al Neurocirurgica 201526(3)115-25
bull The average size of the bone defect was 695 (195-1495)cm2
Large defect ndash ample consequences
Small defect can also cause severe psychological problems
(Gilmour C CMJ 1919)
What is early
bull Immediately after edema disappears
bull Within 4 weeks
bull Within 3 months
What is late
bull After 3 months
bull After 6 months
bull Over a year
Key questions
Traditional thoughts about early cranioplasty
+
bull Safe when edema decreased
bull prevents sinking skin flap
bull Decreases the chance for altered CSF circulation
bull Cosmetic solution --- psychological aid facilitating recoveryrehabilitation
bull Prevents injury
Traditional thoughts about early cranioplasty
-
bull Early second hit
bull Pathobiology is not resolved the brain is more vulnerable
bull Higher tendency for edemaswelling
Complications of cranioplasty
CNS infection
hydrocephalus
intracranial hematoma and subdural fluid collection
All may prolong the hospitalization unfavorable prognosis
death
full text randomized and non-randomized controlled trials
(1994-2014)
early CP (1ndash3 months after DC)
late CP (3ndash6 months after DC)
Traumatic brain injury cerebral infarction subarachnoid
hemorrhage and ICH
significant difference in mean operating time mean difference =
minus1346 min
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
The earlier the better
Early ndash Late 142-60
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications are defined by
age
gender
comorbidities
material
site of skull defect
time between decompression and cranioplasty
Key questions
What is a decompressive craniectomy
bull Of 24 manuscripts only one defines the sizebull Paredes et al Neurocirurgica 201526(3)115-25
bull The average size of the bone defect was 695 (195-1495)cm2
Large defect ndash ample consequences
Small defect can also cause severe psychological problems
(Gilmour C CMJ 1919)
What is early
bull Immediately after edema disappears
bull Within 4 weeks
bull Within 3 months
What is late
bull After 3 months
bull After 6 months
bull Over a year
Key questions
Traditional thoughts about early cranioplasty
+
bull Safe when edema decreased
bull prevents sinking skin flap
bull Decreases the chance for altered CSF circulation
bull Cosmetic solution --- psychological aid facilitating recoveryrehabilitation
bull Prevents injury
Traditional thoughts about early cranioplasty
-
bull Early second hit
bull Pathobiology is not resolved the brain is more vulnerable
bull Higher tendency for edemaswelling
Complications of cranioplasty
CNS infection
hydrocephalus
intracranial hematoma and subdural fluid collection
All may prolong the hospitalization unfavorable prognosis
death
full text randomized and non-randomized controlled trials
(1994-2014)
early CP (1ndash3 months after DC)
late CP (3ndash6 months after DC)
Traumatic brain injury cerebral infarction subarachnoid
hemorrhage and ICH
significant difference in mean operating time mean difference =
minus1346 min
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications are defined by
age
gender
comorbidities
material
site of skull defect
time between decompression and cranioplasty
Key questions
What is a decompressive craniectomy
bull Of 24 manuscripts only one defines the sizebull Paredes et al Neurocirurgica 201526(3)115-25
bull The average size of the bone defect was 695 (195-1495)cm2
Large defect ndash ample consequences
Small defect can also cause severe psychological problems
(Gilmour C CMJ 1919)
What is early
bull Immediately after edema disappears
bull Within 4 weeks
bull Within 3 months
What is late
bull After 3 months
bull After 6 months
bull Over a year
Key questions
Traditional thoughts about early cranioplasty
+
bull Safe when edema decreased
bull prevents sinking skin flap
bull Decreases the chance for altered CSF circulation
bull Cosmetic solution --- psychological aid facilitating recoveryrehabilitation
bull Prevents injury
Traditional thoughts about early cranioplasty
-
bull Early second hit
bull Pathobiology is not resolved the brain is more vulnerable
bull Higher tendency for edemaswelling
Complications of cranioplasty
CNS infection
hydrocephalus
intracranial hematoma and subdural fluid collection
All may prolong the hospitalization unfavorable prognosis
death
full text randomized and non-randomized controlled trials
(1994-2014)
early CP (1ndash3 months after DC)
late CP (3ndash6 months after DC)
Traumatic brain injury cerebral infarction subarachnoid
hemorrhage and ICH
significant difference in mean operating time mean difference =
minus1346 min
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications are defined by
age
gender
comorbidities
material
site of skull defect
time between decompression and cranioplasty
Key questions
What is a decompressive craniectomy
bull Of 24 manuscripts only one defines the sizebull Paredes et al Neurocirurgica 201526(3)115-25
bull The average size of the bone defect was 695 (195-1495)cm2
Large defect ndash ample consequences
Small defect can also cause severe psychological problems
(Gilmour C CMJ 1919)
What is early
bull Immediately after edema disappears
bull Within 4 weeks
bull Within 3 months
What is late
bull After 3 months
bull After 6 months
bull Over a year
Key questions
Traditional thoughts about early cranioplasty
+
bull Safe when edema decreased
bull prevents sinking skin flap
bull Decreases the chance for altered CSF circulation
bull Cosmetic solution --- psychological aid facilitating recoveryrehabilitation
bull Prevents injury
Traditional thoughts about early cranioplasty
-
bull Early second hit
bull Pathobiology is not resolved the brain is more vulnerable
bull Higher tendency for edemaswelling
Complications of cranioplasty
CNS infection
hydrocephalus
intracranial hematoma and subdural fluid collection
All may prolong the hospitalization unfavorable prognosis
death
full text randomized and non-randomized controlled trials
(1994-2014)
early CP (1ndash3 months after DC)
late CP (3ndash6 months after DC)
Traumatic brain injury cerebral infarction subarachnoid
hemorrhage and ICH
significant difference in mean operating time mean difference =
minus1346 min
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications are defined by
age
gender
comorbidities
material
site of skull defect
time between decompression and cranioplasty
Key questions
What is a decompressive craniectomy
bull Of 24 manuscripts only one defines the sizebull Paredes et al Neurocirurgica 201526(3)115-25
bull The average size of the bone defect was 695 (195-1495)cm2
Large defect ndash ample consequences
Small defect can also cause severe psychological problems
(Gilmour C CMJ 1919)
What is early
bull Immediately after edema disappears
bull Within 4 weeks
bull Within 3 months
What is late
bull After 3 months
bull After 6 months
bull Over a year
Key questions
Traditional thoughts about early cranioplasty
+
bull Safe when edema decreased
bull prevents sinking skin flap
bull Decreases the chance for altered CSF circulation
bull Cosmetic solution --- psychological aid facilitating recoveryrehabilitation
bull Prevents injury
Traditional thoughts about early cranioplasty
-
bull Early second hit
bull Pathobiology is not resolved the brain is more vulnerable
bull Higher tendency for edemaswelling
Complications of cranioplasty
CNS infection
hydrocephalus
intracranial hematoma and subdural fluid collection
All may prolong the hospitalization unfavorable prognosis
death
full text randomized and non-randomized controlled trials
(1994-2014)
early CP (1ndash3 months after DC)
late CP (3ndash6 months after DC)
Traumatic brain injury cerebral infarction subarachnoid
hemorrhage and ICH
significant difference in mean operating time mean difference =
minus1346 min
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications are defined by
age
gender
comorbidities
material
site of skull defect
time between decompression and cranioplasty
Key questions
What is a decompressive craniectomy
bull Of 24 manuscripts only one defines the sizebull Paredes et al Neurocirurgica 201526(3)115-25
bull The average size of the bone defect was 695 (195-1495)cm2
Large defect ndash ample consequences
Small defect can also cause severe psychological problems
(Gilmour C CMJ 1919)
What is early
bull Immediately after edema disappears
bull Within 4 weeks
bull Within 3 months
What is late
bull After 3 months
bull After 6 months
bull Over a year
Key questions
Traditional thoughts about early cranioplasty
+
bull Safe when edema decreased
bull prevents sinking skin flap
bull Decreases the chance for altered CSF circulation
bull Cosmetic solution --- psychological aid facilitating recoveryrehabilitation
bull Prevents injury
Traditional thoughts about early cranioplasty
-
bull Early second hit
bull Pathobiology is not resolved the brain is more vulnerable
bull Higher tendency for edemaswelling
Complications of cranioplasty
CNS infection
hydrocephalus
intracranial hematoma and subdural fluid collection
All may prolong the hospitalization unfavorable prognosis
death
full text randomized and non-randomized controlled trials
(1994-2014)
early CP (1ndash3 months after DC)
late CP (3ndash6 months after DC)
Traumatic brain injury cerebral infarction subarachnoid
hemorrhage and ICH
significant difference in mean operating time mean difference =
minus1346 min
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Complications related to cranioplasty
Reabsorption
Cosmetic failure
Infection
EDHSDHICH
Hydrocephalus
Complications are defined by
age
gender
comorbidities
material
site of skull defect
time between decompression and cranioplasty
Key questions
What is a decompressive craniectomy
bull Of 24 manuscripts only one defines the sizebull Paredes et al Neurocirurgica 201526(3)115-25
bull The average size of the bone defect was 695 (195-1495)cm2
Large defect ndash ample consequences
Small defect can also cause severe psychological problems
(Gilmour C CMJ 1919)
What is early
bull Immediately after edema disappears
bull Within 4 weeks
bull Within 3 months
What is late
bull After 3 months
bull After 6 months
bull Over a year
Key questions
Traditional thoughts about early cranioplasty
+
bull Safe when edema decreased
bull prevents sinking skin flap
bull Decreases the chance for altered CSF circulation
bull Cosmetic solution --- psychological aid facilitating recoveryrehabilitation
bull Prevents injury
Traditional thoughts about early cranioplasty
-
bull Early second hit
bull Pathobiology is not resolved the brain is more vulnerable
bull Higher tendency for edemaswelling
Complications of cranioplasty
CNS infection
hydrocephalus
intracranial hematoma and subdural fluid collection
All may prolong the hospitalization unfavorable prognosis
death
full text randomized and non-randomized controlled trials
(1994-2014)
early CP (1ndash3 months after DC)
late CP (3ndash6 months after DC)
Traumatic brain injury cerebral infarction subarachnoid
hemorrhage and ICH
significant difference in mean operating time mean difference =
minus1346 min
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Complications are defined by
age
gender
comorbidities
material
site of skull defect
time between decompression and cranioplasty
Key questions
What is a decompressive craniectomy
bull Of 24 manuscripts only one defines the sizebull Paredes et al Neurocirurgica 201526(3)115-25
bull The average size of the bone defect was 695 (195-1495)cm2
Large defect ndash ample consequences
Small defect can also cause severe psychological problems
(Gilmour C CMJ 1919)
What is early
bull Immediately after edema disappears
bull Within 4 weeks
bull Within 3 months
What is late
bull After 3 months
bull After 6 months
bull Over a year
Key questions
Traditional thoughts about early cranioplasty
+
bull Safe when edema decreased
bull prevents sinking skin flap
bull Decreases the chance for altered CSF circulation
bull Cosmetic solution --- psychological aid facilitating recoveryrehabilitation
bull Prevents injury
Traditional thoughts about early cranioplasty
-
bull Early second hit
bull Pathobiology is not resolved the brain is more vulnerable
bull Higher tendency for edemaswelling
Complications of cranioplasty
CNS infection
hydrocephalus
intracranial hematoma and subdural fluid collection
All may prolong the hospitalization unfavorable prognosis
death
full text randomized and non-randomized controlled trials
(1994-2014)
early CP (1ndash3 months after DC)
late CP (3ndash6 months after DC)
Traumatic brain injury cerebral infarction subarachnoid
hemorrhage and ICH
significant difference in mean operating time mean difference =
minus1346 min
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Key questions
What is a decompressive craniectomy
bull Of 24 manuscripts only one defines the sizebull Paredes et al Neurocirurgica 201526(3)115-25
bull The average size of the bone defect was 695 (195-1495)cm2
Large defect ndash ample consequences
Small defect can also cause severe psychological problems
(Gilmour C CMJ 1919)
What is early
bull Immediately after edema disappears
bull Within 4 weeks
bull Within 3 months
What is late
bull After 3 months
bull After 6 months
bull Over a year
Key questions
Traditional thoughts about early cranioplasty
+
bull Safe when edema decreased
bull prevents sinking skin flap
bull Decreases the chance for altered CSF circulation
bull Cosmetic solution --- psychological aid facilitating recoveryrehabilitation
bull Prevents injury
Traditional thoughts about early cranioplasty
-
bull Early second hit
bull Pathobiology is not resolved the brain is more vulnerable
bull Higher tendency for edemaswelling
Complications of cranioplasty
CNS infection
hydrocephalus
intracranial hematoma and subdural fluid collection
All may prolong the hospitalization unfavorable prognosis
death
full text randomized and non-randomized controlled trials
(1994-2014)
early CP (1ndash3 months after DC)
late CP (3ndash6 months after DC)
Traumatic brain injury cerebral infarction subarachnoid
hemorrhage and ICH
significant difference in mean operating time mean difference =
minus1346 min
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Large defect ndash ample consequences
Small defect can also cause severe psychological problems
(Gilmour C CMJ 1919)
What is early
bull Immediately after edema disappears
bull Within 4 weeks
bull Within 3 months
What is late
bull After 3 months
bull After 6 months
bull Over a year
Key questions
Traditional thoughts about early cranioplasty
+
bull Safe when edema decreased
bull prevents sinking skin flap
bull Decreases the chance for altered CSF circulation
bull Cosmetic solution --- psychological aid facilitating recoveryrehabilitation
bull Prevents injury
Traditional thoughts about early cranioplasty
-
bull Early second hit
bull Pathobiology is not resolved the brain is more vulnerable
bull Higher tendency for edemaswelling
Complications of cranioplasty
CNS infection
hydrocephalus
intracranial hematoma and subdural fluid collection
All may prolong the hospitalization unfavorable prognosis
death
full text randomized and non-randomized controlled trials
(1994-2014)
early CP (1ndash3 months after DC)
late CP (3ndash6 months after DC)
Traumatic brain injury cerebral infarction subarachnoid
hemorrhage and ICH
significant difference in mean operating time mean difference =
minus1346 min
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
What is early
bull Immediately after edema disappears
bull Within 4 weeks
bull Within 3 months
What is late
bull After 3 months
bull After 6 months
bull Over a year
Key questions
Traditional thoughts about early cranioplasty
+
bull Safe when edema decreased
bull prevents sinking skin flap
bull Decreases the chance for altered CSF circulation
bull Cosmetic solution --- psychological aid facilitating recoveryrehabilitation
bull Prevents injury
Traditional thoughts about early cranioplasty
-
bull Early second hit
bull Pathobiology is not resolved the brain is more vulnerable
bull Higher tendency for edemaswelling
Complications of cranioplasty
CNS infection
hydrocephalus
intracranial hematoma and subdural fluid collection
All may prolong the hospitalization unfavorable prognosis
death
full text randomized and non-randomized controlled trials
(1994-2014)
early CP (1ndash3 months after DC)
late CP (3ndash6 months after DC)
Traumatic brain injury cerebral infarction subarachnoid
hemorrhage and ICH
significant difference in mean operating time mean difference =
minus1346 min
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Traditional thoughts about early cranioplasty
+
bull Safe when edema decreased
bull prevents sinking skin flap
bull Decreases the chance for altered CSF circulation
bull Cosmetic solution --- psychological aid facilitating recoveryrehabilitation
bull Prevents injury
Traditional thoughts about early cranioplasty
-
bull Early second hit
bull Pathobiology is not resolved the brain is more vulnerable
bull Higher tendency for edemaswelling
Complications of cranioplasty
CNS infection
hydrocephalus
intracranial hematoma and subdural fluid collection
All may prolong the hospitalization unfavorable prognosis
death
full text randomized and non-randomized controlled trials
(1994-2014)
early CP (1ndash3 months after DC)
late CP (3ndash6 months after DC)
Traumatic brain injury cerebral infarction subarachnoid
hemorrhage and ICH
significant difference in mean operating time mean difference =
minus1346 min
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Traditional thoughts about early cranioplasty
-
bull Early second hit
bull Pathobiology is not resolved the brain is more vulnerable
bull Higher tendency for edemaswelling
Complications of cranioplasty
CNS infection
hydrocephalus
intracranial hematoma and subdural fluid collection
All may prolong the hospitalization unfavorable prognosis
death
full text randomized and non-randomized controlled trials
(1994-2014)
early CP (1ndash3 months after DC)
late CP (3ndash6 months after DC)
Traumatic brain injury cerebral infarction subarachnoid
hemorrhage and ICH
significant difference in mean operating time mean difference =
minus1346 min
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Complications of cranioplasty
CNS infection
hydrocephalus
intracranial hematoma and subdural fluid collection
All may prolong the hospitalization unfavorable prognosis
death
full text randomized and non-randomized controlled trials
(1994-2014)
early CP (1ndash3 months after DC)
late CP (3ndash6 months after DC)
Traumatic brain injury cerebral infarction subarachnoid
hemorrhage and ICH
significant difference in mean operating time mean difference =
minus1346 min
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
full text randomized and non-randomized controlled trials
(1994-2014)
early CP (1ndash3 months after DC)
late CP (3ndash6 months after DC)
Traumatic brain injury cerebral infarction subarachnoid
hemorrhage and ICH
significant difference in mean operating time mean difference =
minus1346 min
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
significant difference in mean operating time mean difference =
minus1346 min
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
No difference between the overall complications and infection
rate
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Hydrocephalus is significantly higher in the early cranioplasty
group
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
no difference between intracranial hematoma rates and
subdural fluid collection rates
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Chaturvedi et al 2015 BrJNs
74 patients mortality 135 overall complication rate 31
operating time more than 90 min Odds ratio (OR) 477 (161-
1420)
timing of CP less than 3 months after craniectomy OR 286
(148-811)
age more than 20 years OR 259 (120-653)
female gender OR 191 (113-417)
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
early cranioplasty within 3 months and late cranioplasty after
3 months
Intergroup differences according to cranioplasty time after
craniectomy were not observed (p=0083)
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Paredes I et al Neurocirurgia (Astur) 2015
independent risk factors for complications
bull Older age
bull poorer functional situation (worse Barthel index score)
bull early surgery (le85 days)
earlier surgery and larger bone defects increase clinical
improvement
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Mukherjee S Acta Neurochir 2014
174 patients who underwent TC at two London units over
seven year
non-significant trend craniectomy-to-cranioplasty interval
of 4-8 months with the lowest complication rate and
shortest postoperative hospital stay
Patients with a skull defect larger than 100 cm(2) had the
highest complication rate (p lt 0001) highest plate removal
rate (p = 0039) and longest postoperative hospital stay
(p = 0019)
Bifrontal versus unilateral cranioplasty was associated
with a significantly higher complication rate (40 vs 14 )
and length of hospital stay (50 vs 29 days)
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Special issues ndash Pediatric population
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Rocque BG et al J Neurosurg Pediatr 2013
in 3 of 4 manuscripts the effect of time between craniectomy
and cranioplasty on complication rate the authors found no
significant effect
in 1 of 4 the incidence of bone resorption was significantly
lower in children who had undergone early cranioplasty
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Piedra MP J Neurosurg Pediatr 2012
Sixty-one patients were divided into early (lt 6 weeks 28
patients) and late (ge 6 weeks 33 patients) cranioplasty cohorts
Bone resorption after cranioplasty was significantly more
common in the late (42) than the early (14) cranioplasty
cohort (p lt 005 OR 54)
No other complication differed in incidence between the
cohorts
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Special issues ndash DC-related Hydrocepohalus
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Schuss et al World Neurosurg 2015Cranioplasty and Ventriculoperitoneal Shunt Placement after Decompressive Craniectomy Staged Surgery Is Associated with Fewer Postoperative Complications
41 cranioplasty procedures with simultaneous or staged VPS
placement
overall complication rate27
47 vs 12 P = 003
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Pachatouridis D et al TurkNeurosurg 2014
Cranioplasty and ventriculostomy followed by a second stage
placement of a ventriculoperitoneal shunt are associated with
fewer complications in the treatment of hydrocephalus after
DC
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Conclusions
Decompressive craniectomy may harbor
significant consequences not a harmless
intervention
We lack solid scientific evidence to define the
optimal timing of cranioplasty
In case of hydrocephalus stage treatment with
the priority of CP (or CP+ventriculostomy) seems
advisable
In the pediatric population late cranioplasty may
increase the rate of reabsorption
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
J Neurotrauma 2015 Nov 5 [Epub ahead of print]
THE EFFECT OF CRANIOPLASTY ON CEREBRAL HEMODYNAMICS AS MEASURED BY PERFUSION CT AND DOPPLER ULTRASONOGRAPHY
Paredes I1 Castantildeo-Leon AM2 Cepeda S3 Alen JF4 Salvador E5 Millaacuten JMAuthor information
AbstractCranioplasties are performed to protect the brain and correct cosmetic defects but there is growing evidence that this procedure may result in neurological improvement We prospectively studied cranioplasties performed at our hospital over a 5
KEYWORDS
CBF autoregulation CEREBRAL VASCULAR DISEASE Cranioplasty DECOMPRESSIVE CRANIECTOMY LOCOMOTOR FUNCTION Lindegaard ratio Pe
PMID
26541365
[PubMed - as supplied by publisher]
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Thank You
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Definition
Decompressive craniectomy is a method to openexpand the space
that has defined closed by the Monro-Kellie doctrine in order to
reduce ICP
bull Primary DC
bull Preventivepreemptive craniectomy upon evacuation of a space
occupying lesion
bull Secondary DC
bull Decompressive craniectomy aimed at the reduction of ICP in lack of a
space occupying lesion
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Kocher 1901
there is an ongoing debate about
bull Indications
bull Timing
bull Methods
bull Cranium
bull Dura
bull Parenchyma
bull EBM
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Indications
Primary indication is uncontrollable ICP
what does this mean
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
CPP = MABP ndash ICP
60 = 80 - 20
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
ICP-threshold of 20mmHg
bull 6m outcome in 428 sTBI cases
bull Occurrence of ICP periods over 20 is associated with adverse
outcome
J Neurosurg 75S59-S66 1991
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
In 207 sTBI cases
ICP was over 20 if CT positive in 60
ICP was over 20 if CT negative in 13
ICP was over 20 if CT negative but two of the following occurred
age over 40
BPsyst under 90
decerebratedecorticate posturing
ICP
J Neurosurg 56 650-659 1982
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Peacutecs Severe TBI Database- 308 cases (062002-122008)
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Prolonged refractory ICP is a bad prognosticatorhellip
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Critical approach
bull ICP and CPP are global measures
bull Several studies including the BEST TRIP trial highlight that
bdquotreatingrdquo ICP does not necessarily mean a treatment for brain
injury
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Deterioration is not exclusively caused by
enlargement of the ICH hellip
bull cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
bull increased ICP detection is only responsible for half the
episodes of cerebral ischemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial pressure of brain tissue
oxygen in patients with severe head injury Neurosurgery 38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJMaas AI (2003)
Brain tissue oxygen response in severe traumatic brain injury Acta Neurochirurgica 145 429ndash438
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
bull low PbO2 was associated with normal CPP indicating that
CPP could be an inadequate estimate of regional CBF in
focal ischemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R Grimoldi N (1998)High cerebral perfusion
pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions
Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
bull MABP
bull ICP
bull CPPPRxCPPopt
bull SATO2 Astrup
bull Brain temperature
bull Brain oxygenationLycox
bull Jugular bulb oxymetry
bull ECG
bull ECoG
bull hemodynamics
bull coretympanic membrane temperature
bull microdialisisbiomarkers
Multimodality monitoring in severe TBI
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Causes of raised ICP following TBI
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Timing of DC
bull There is a lack of evidence to define when to perform DC
bull Multimodality monitoring including trend- and waveform- analysis
of ICP as well as PRx should provide a solid basis for this
bull First exclude technical and extra-CNS causes
bull Next define what measures had been done and what other
second tier therapies can be applied
bull The decision is based on local guidelines and individual
decision case-by case
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Forms
Frontal (bifrontal)
bull With bony bridge over the SSS
bull Without bony ridge over the SSS
bull With cut over the frontal insertion of the falx (crista galli)
bull Without
Lateral (bilateral) fronto-temporo-parietal
Dural opening
bull Slit
bull Curved-linear
bull Wide radiatestellate
Dural closure
bull None
bull Approximating
bull Watertight expansion (duroplasty)
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Size
The bigger the better
bull Any technical modification will be unnecessary when the size is
adequate
bull Minimum of 10cmx10cm
bull Optimal is 12cmx12cm or over
Large bone defect harbors more complications particularly that of
hydrocephalus
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Complications related to DC (and CP)
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
IJPS 2011 Vol44
Calvarial reconstruction using high-density porous polyethylene cranial hemispheres
Nitin J Mokal Mahinoor F Desai
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
65 ys
Sept 06 2015
Sept 07 2015 Sept 14 2015
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
65 ys
Sept 19 2015
Sept 20 2015 Sept 23 2015
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
EBM
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Cochrane Database Syst Rev 2006 Sahuquillo J Arikan F
Decompressive craniectomy for the treatment of refractory high intracranial
pressure in traumatic brain injury
bull There is no evidence to support the routine use of secondary DC to reduce
unfavorable outcome in adults with severe TBI and refractory high ICP
bull In the pediatric population DC reduces the risk of death and unfavorable outcome
bull this treatment maybe justified in patients below the age of 18 when maximal medical
treatment has failed to control ICP
bull To date there are no results from randomized trials to confirm or refute the
effectiveness of DC in adults
bull results of non-randomized trials and controlled trials with historical controls involving
adults suggest that DC may be a useful option when maximal medical treatment has
failed to control ICP
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Characteristics of the trial
In 8y sTBI patients (19-59y) in 15 tertiary care hospitals in
Australia New Zealand and Saudi Arabia
treatment for ICP over 20 mm Hg
early refractory elevation in intracranial pressure
bull a spontaneous (not stimulated) increase in intracranial pressure for
more than 15 minutes (continuously or intermittently) within a 1-hour
period despite optimized first-tier interventions
interventions included
bull optimized sedation the normalization of arterial carbon dioxide
pressure and the use of mannitol hypertonic saline neuromuscular
blockade and external ventricular drainage
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Randomization in 72 hours after injury to decompressive
craniectomy plus standard care or to receive
standard care alone
Standard care
bull Brain Trauma Foundation - Guidelines
Second-tier options for refractory elevation of intracranial
pressure
bull mild hypothermia (to 35degC)
bull optimized use of barbiturates
bull both
Patients randomized to continued standard care
bull protocol permitted the use of lifesaving decompressive craniectomy
after a period of 72 hours had elapsed since admission
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Conclusions of the study
The method bdquoworksrdquo
The outcome is unaffected
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
bull Decompressive craniectomy does not improve outcome when it
is done on patients who donrsquot need it
(Chesnut R 2014 INTS Budapest)
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Why do patients not require DC
bull ICP is not elevated
bull Is ICP relevant to define the treatment options
bull Sometimes yes sometimes not
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Letrsquos forget the bdquoone size fits allrdquo ndash approach
Individual pathobiology matters
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Mortality according to the main intracranial
pathology amp ICP monitoring
4783
5233
4222 4286
6471
30
40
50
60
70
80
ICH ICH+SDH SDH Diffuse Penetrating
Total ICP Monitoring+ ICP Monitoring-
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Individual assessment of the pathobiology
Courtesy of Peter Smielewski
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Conclusions
bull In order to introduce a treatment we have to understand the
pathobiology
bull We also have to understand pathobiological processes
evoked by operant at an individual level
bull Treatment plans and decisions should be tailored to the
actual patient
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
BESTTRIP trialn = 324
Randomization to Pressure monitoring group (n=157)Imaging - clinical examination group (n=167)
Power calculation 80 power to detect an increase of 10 percentage points in the of patient with a favorable outcome (GOSE)
Primary outcome measure composite outcome at 6 months
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Testing Two Protocols
Courtesy of R Chesnut
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Conclusions BESTTRIP
Apparently sound hypothesis and design
Groups comparable
Care focused on maintaining monitored ICP le 20 mm Hg was not shown to be superior to care based on imaging and clinical examination
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
BESTTRIPCritical commentshellip
Conceptual Any differences in outcome will be related to type and intensity of treatment and not to the monitoring itself
Both groups received ICP targeted treatment
Statistical Power calculations should NOT be based on the total number of patients but on the (expected) number with raised ICP
Medianmean of ICP gt 20 mmHg 7 and 20
In every fourth patient at the ICP group there was no raised ICP at all
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
bull Composite outcome measures half of them are
neuropsychological
bull GOSE 5 benefit for ICP-group
bull Confounding effects of
bull more agressive treatment in the cons
group
bull longer transfer times with no documetation
on hypoxiahypoperfusion
BESTTRIPCritical commentshellip
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
What is the problem
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
What should ICP monitoring provide to us
timely detection of space occupying lesionshellip
user friendly reliable cost- efficient tool with minimal
complication rate based upon evidence based medicinehellip
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Does ICP monitoring helphellip
hellipto identify those patients who are at risk for late
deterioration
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Deterioration is not exclusively caused by enlargement of the ICH hellipseveral studies have demonstrated that
cerebral infarction measured by brain tissue oxygen
monitoring can occur despite normal ICP readings
increased ICP detection is only responsible for half the
episodes of cerebral ischaemia
Van Santbrink H Maas AI Avezaat CJ (1996) Continuous monitoring of partial
pressure of brain tissue oxygen in patients with severe head injury Neurosurgery
38 21ndash31
Van Santbrink H van den Brink WA Steyerberg EW Carmona Suazo JA Avezaat CJ
Maas AI (2003) Brain tissue oxygen response in severe traumatic brain injury Acta
Neurochirurgica 145 429ndash438
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
low PbO2 was associated with normal CPP
indicating that CPP could be an inadequate
estimate of regional CBF in focal ischaemic areas
Stocchetti N Chieregato A De Marchi M Coroci M Benti R
Grimoldi N (1998)High cerebral perfusion pressure improves
low values of local brain tissue O2 tension (PtiO2) in focal
lesions Acta Neurochirurgica Supplementum (Wien) 71 162ndash165
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
44y car accident driver
EO 1 VR 2 MR 4 GCS 7 pupils equal reactive
left hemiparesis
severe pulmonary and mild liver contusion unstable rib cage
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
-5
0
5
10
15
20
25
30
20070919 500-2100
Hg
mm
0
20
40
60
80
100
120
ICP ART MEAN
CT
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
1293
855
14941575
0
20
40
60
80
100
120
140
160
180
20070919 500-2100
Hg
mm
0
5
10
15
20
25
30
35
40
PartO2 PbrO2
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
MMSE = 97100 IQ (TONI-3) = 108
full recovery
back to work
practically unaffected social functions
normal endocrine checkups
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Does ICP-monitoring improve outcome
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
In order to prove that ICP monitoring per se improves
outcome assuming a 9 mortality reduction a prospective
randomized study including approximately 768 patients would
be requiredhellip
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
On the basis of our present knowledge this is an irrelevant question ashellip
Can we cool down the room with the thermometer
hellip We do not have pathobiology driven therapeutic
targetsdecisions to make bull Connors AF Jr et al The effectiveness of right heart catheterization in the initial care of critically ill
patients SUPPORT Investigators JAMA 1996276889ndash97
bull Muizelaar JP et al Adverse effects of prolonged hyperventilation in patients with severe head injury a randomized clinical trial J Neurosurg 1991 Nov75(5)731-9
hellipwe do not have surrogate markers to compare with
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
General considerations about neuromonitoring
ICP monitoring the rationale
ICP monitoring the debate
Current practicefuture directions
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Rethinking our approaches to ICP monitoringtreatment
bull ICP monitoring should NOT be discarded
bullThink in terms of understanding what is going on
bull Think in terms of strategies
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Trend - Time - Multimodality
bull Trend is more important than a single actual value
bull Raised ICP in patients ldquoawakeningrdquo is normal
bullThe more widespread relevant physiological information we gather is the best
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
CPP Management
The conceptIncrease flow by increased driving force
Limitation not indicated if auto regulation severely disturbed
CPP ManagementPRX and CPP opt
CPP = MABP - ICPCPP ICP Treat ICP
MABP Treat MABP
Courtesy of A Maas
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
ldquoDoserdquo of ICP
Compared an ldquoICP Doserdquo based on correlation with disturbed autoregulation
(PRx) versus ldquostandardrdquo ICP gt 20 mmHg in predicting clinical
outcome
Courtesy of R Chesnut
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Goal directed therapy
in Neuro ICU
ICP lt 20
CPP gt 60
PBrO2 gt 15
SjO2 gt 55
Understanding what is going on
Courtesy of A Maas
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
While recognizing certain limitations of ICP monitoring the
most important message for the near future is
bull Maintain ICP monitoring as a cornerstone of treatment
bull Keep up the critical approach and pathophysiology-driven decision making with information gathered from multimodal monitoring
Thank you for your attention
Thank you for your attention