gms | German Medical Science

59th Annual Meeting of the German Society of Neurosurgery (DGNC)
3rd Joint Meeting with the Italian Neurosurgical Society (SINch)

German Society of Neurosurgery (DGNC)

1 - 4 June 2008, Würzburg

Intracranial hypertension in aneurysmal subarachnoid hemorrhage Relation to metabolism, decompressive surgery and outcome

Intrakranielle Hypertension und Hirnstoffwechselveränderungen bei Patienten mit aneurysmatischer Subarachnoidalblutung

Meeting Abstract

  • corresponding author A. Nagel - Klinik für Neurochirurgie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin
  • D. Graetz - Klinik für Neurochirurgie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin
  • T. Schink - Institut für Biometrie und Klinische Epidemiologie, Charité - Universitätsmedizin Berlin, Campus Mitte, Berlin
  • F. Schlenk - Klinik für Neurochirurgie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin
  • O. Sakowitz - Neurochirurgische Klinik, Universitätsklinikum Heidelberg
  • A. S. Sarrafzadeh - Klinik für Neurochirurgie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin

Deutsche Gesellschaft für Neurochirurgie. Società Italiana di Neurochirurgia. 59. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie e.V. (DGNC), 3. Joint Meeting mit der Italienischen Gesellschaft für Neurochirurgie (SINch). Würzburg, 01.-04.06.2008. Düsseldorf: German Medical Science GMS Publishing House; 2008. DocSO.04.11

The electronic version of this article is the complete one and can be found online at: http://www.egms.de/en/meetings/dgnc2008/08dgnc034.shtml

Published: May 30, 2008

© 2008 Nagel et al.
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Outline

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Objective: Intracranial hypertension occurs in up to 50-60% of patients with aneurysmal subarachnoid hemorrhage (SAH) and is associated with high levels of excitotoxic mediators, edema formation and poor outcome. We investigated the cerebral metabolic changes, such as glutamate-mediated excitotoxicity, in relation to high intracranial pressure (ICP>20 mmHg), decompressive surgery and outcome in patients with aneurysmal SAH.

Methods: In 182 SAH patients classified into low (n=164) and high (n=18) ICP-groups, a microdialysis catheter was inserted into the brain parenchyma of interest. Parameters of energy metabolism, glycerol and glutamate were analyzed hourly for seven days. ICP was monitored by a ventricular drainage. Seven patients with uncontrollable ICP underwent decompressive surgery. In all patients, the 12-month outcome was evaluated.

Results: In all patients with intracranial hypertension, cerebral metabolism was severely deranged. On days 1-7 after SAH, the glycerol concentrations and the lactate/pyruvate ratio (LP-ratio) were significantly higher in the high-ICP group (p=0.01). Secondarily, glutamate increased on days 5-7 (p=0.038). In 5 patients, who underwent decompressive surgery, cerebral metabolism was severely deranged already 39.5±12 before the start of refractory intracranial hypertension which occurred 21±15.5 hrs before decompressive surgery. Glycerol was the earliest marker of a metabolic crisis exceeding >80µM in all 6 patients compared to glutamate (4 patients, >10 µM) and LP-ratio (1 patient, >25). The outcome was significantly worse in the high-ICP group, independent of the WFNS grade (p<0.01).

Conclusions: Intracranial hypertension is associated with a severely deranged cerebral metabolism and an unfavourable outcome. A deterioration of markers of a cerebral crisis can be supporting factors to select patients and timing for decompressive surgery.