Application Of Intracranial Pressure Monitoring In The Treatment Of Hypertensive Basal Ganglia Hemorrhage By Trans-frontal Puncture Aspiration And Drainage

Objective To explore the relevant factors that affect intracranial pressure(ICP)in patients with hypertension basal ganglia hemorrhage and the significance of dynamic intracranial pressure monitoring in the treatment of hypertensive intracerebral hemorrhage by puncture aspiration and drainage.Method From 2017-01-01 to 2018-01-30,21 cases with hypertensive basal ganglia hemorrhage were prospectivly continuously included at the Neurosurgical Department of the Third Affiliated Hospital of Soochow University,who underwent trans-frontal puncture aspiration and drainage operation while intraoperative and postoperative intracranial pressure were dynamically monitored.The parameters,including patient demographics,preoperative clinical features,radiological data,initial ICP before hematoma aspiration,postoperative ICP after partial hematoma aspiration,postoperative dynamic ICP and cerebral perfusion pressure(CPP),postoperative rebleeding rate,intracranial infection rate,postoperative 30-day mortality,GOS at discharge were detailly recorded.To analyze the factors that affect ICP in patients with cerebral hemorrhage by comparing the characteristics in patients with different hematoma volume,age,and state of consciousness.The effect of intraoperative hematoma aspiration rate and ICP decline rate on postoperative rebleeding was analyzed.Meanwhile the dynamic changes of ICP and CPP and its effect on outcome were also observed.Results(1)General clinical data.13 male and 8 female were included in 21 patients,ranging from 29~76 years of age,mean(54.71±13.61)years;hematoma volume ranging from 20~103 ml,mean(55.54±20.79)ml;GCS score ranging from 5~14,mean(8.33±2.22);initial ICP value ranging from 5~70mm Hg,mean(28.71±16.38)mm Hg;ICP value after hematoma aspiration ranging from 3~17mm Hg,mean(8.05±3.78)mm Hg;ICP monitoring time ranging from 10~289h,mean(98.48±67.37)h;Postoperative rebleeding happened in 2 cases(9.5%),3 cases died(14.3%),the outcome was good(GOS≥3)in 18 cases(85.7%);Intracranial infection happened in no one.(2)Analysis of ICP influencing factors in patients with cerebral hemorrhage.There was a positive correlation between intracranial pressure and hematoma volume in patients with intracerebral hemorrhage(r=0.588,P=0.005),negative correlation with age(r=-0.571,P=0.016),and negative correlation with GCS score(r=-0.486,P=0.025).When ages were similar,the ICP in the enormous hematoma group(≥60 ml)was significantly higher than that in the moderate volume group(40~60ml)and the critical volume group(<40ml)(ICP was 43.5±12.96 mm Hg,19.67±11.42 mm Hg,19.5±10.38 mm Hg,respectively,P<0.05).When the amount of hematoma was similar,the ICP in elderly patients was significantly lower than that in young and middle-aged patients(ICP was 16.0±9.08 mm Hg,29.5±15.23 mm Hg,42.4±15.45 mm Hg,respectively,P<0.05).The ICP in critically ill patients(GCS ≤8 points)was significantly higher than that in non-critically ill patients(GCS>8 points)(ICP was 34.92±15.22 mm Hg,18.63±13.48 mm Hg,P=0.023).(3)The relationship between the hematoma aspiration rate and ICP decline rate in different ICP groups.Intraoperative hematoma aspiration volume ranged from 5~60ml in 21 patients,mean(18.81±12.11)ml,while its aspiration rate ranged from 7%~74%,mean(35±18)%,ICP decline rate ranged from 24%~90%,mean(65±18)%.The hematoma aspiration rate were 40±21%,27±11%,and 52±19% in mild,moderate and severe group respectively.The higher the initial ICP,the more pronounced decline in the ICP(the decline rate in ICP among the three groups were 50±18%,71±10%,85±5%,respectively,P<0.05).The aspiration rate of 2 patients with rebleeding were 54% and 17%,while the ICP decline rate after hematoma aspiration were 67% and 24%.(4)Regulation of postoperative ICP changes and its effect on outcome.Compared with ICP after hematoma aspiration,the first recorded ICP after patients returned to NICU increased by 0~73mm Hg,mean(13.71±15.65)mm Hg;In 18 patients with good outcome,the duration of postoperative intracranial hypertension in non-critical patients was significantly lower than that in critically ill patients(73±17h,133±76h,P=0.028);The mean maximum ICP was significantly higher in the death group than in the good outcome group(96±18mm Hg,34±12mm Hg,P<0.05);the mean ratio of patients with severe intracranial hypertension in the death group was 51%,while in the good outcome group it was 1.2%;Three patients with intracranial changes had persistent severe intracranial hypertension before recheck of cranial CT.While ICP continues above 80mm Hg in two patients who died of brain failure.(5)Regulation of postoperative CPP changes and its effect on outcome.The minimum CPP value in the death group were significantly lower than that in the good outcome group(14±4mm Hg,52±13mm Hg,P<0.05);In the death group,the CPP<50mm Hg accounted for an average of 15%,the CPP<50mm Hg accounted for an average of 0.8% in the good outcome group;While the CPP>90mm Hg accounted for an average of 10% in the death group,and the CPP>90mm Hg accounted for an average of 16% in the good outcome group.Conclusion(1)Large amount of hematoma,critical ICH patients often lead to more severe intracranial hypertension.The ICP in elderly is significantly lower than that in young and middle-aged patients when hematoma volume were the same.Thus the choice of surgical timing needs to be considered comprehensively based on the amount of hematoma,age,and the state of consciousness of patients.(2)Partial aspiration of hematoma does not lead to postoperative rebleeding,and whether controlled aspiration under ICP monitoring needs further investigation.(3)The higher the initial ICP,the more significant decline in ICP after partial aspiration,which is consistent with the volume-pressure curve.The ICP of all patients after hematoma aspiration declined below 20 mm Hg,confirming the effectiveness of the puncture procedure in reducing intracranial pressure.(4)In real state,ICP should be higher than that under general anesthesia,suggesting that general anesthesia with tracheal intubation and moderate sedation,analgesia play an important role in confirming efficacy and safety by maintaining airway patency during surgery and perioperative period.(5)ICP monitoring has an early warning effect,but it does not affect the outcome.(6)Persistent cerebral hypoperfusion indicates the poor outcome of patients,while the significance of the upper limit of CPP needs further study.