gms | German Medical Science

Objective: The role of intracranial pressure (ICP) monitoring has long been established in traumatic brain injury (TBI), where it aids clinicians in their therapeutic decision-making, including the indication for decompressive craniectomy (DHC). In malignant stroke (mStroke), there are no guidelines for ICP monitoring, even though this condition is associated with cerebral edema, ischemia and secondary injury. Furthermore, there are no thresholds of ICP to guide therapeutic decisions after DHC. In this study, we aimed to investigatethe course of ICP values and how they correlated with mortality, attempting to establish thresholds to guide clinical decision-making.

Methods: We conducted a retrospective study of mStroke patients undergoing DHC at our center between 2011 and 2018. Postoperative ICP was analyzed hourly, recording minimum, mean and maximum values for each day and patient. Then, mean values were calculated for the entire cohort, based on the mean daily values for mean, minimum, and maximum ICP. Patients were categorized in two groups: deceased and survivor. These groups were then compared in their ICP course with an independent sample t-test.

Results: A total of 110 patients were included. Mean age was 60 years (range: 18-54). The majority were males (n=67, 60%), and presented between 6 to 12 hours after symptom begin (n=26, 23%). Mean Aspects Score was 2.7 (range: 0-10). Preoperative factors failed to be significantly associated with a higher postoperative ICP course. The same holds true for size of defect. A statistically significant difference was seen in mean and maximum ICP values between patients who passed and those who survived: Mean ICP was 7.4 mmHg in the survival group, and 9.3 mmHg in the mortality group (p<0.01); Maximum ICP values were 13 mmHg and 17 mmHg (p<0.01), respectively. Maximum ICP also exhibited a statistically significant correlation with mortality (Pearson’s correlation coefficient=.225, p=.018).

Conclusion: Our study reveals a clear correlation between ICP and mortality. Interestingly, values associated with mortality were well below the commonly accepted 20 mmHg threshold referenced in the literature, thus raising the question of whether patients withmStroke undergoing DHC should receive more aggressive management at lower ICP thresholds to avoid further secondary injury due to generalized cerebral edema and resulting intracranial hypertension.