Refractory elevated intracranial pressure: intensivist's role in solving the dilemma of decompressive craniectomy

Excerpt

High intracranial pressure (ICP) remains a frequent secondary insult in neuro-intensive care and a leading cause of death and disability after a severe brain insult affecting particularly, but not exclusively, traumatic brain injury (TBI). Despite the lack of support from randomized trials the use of ICP monitoring devices aimed at identifying and guiding treatment is a common practice in many brain pathologies. ICP is in fact a reflection of the relationship between alterations in craniospinal volume and the ability of the craniospinal axis to accommodate additional volume [1]. High ICP is therefore the expression of a failed equilibrium between physiological volumes and indicates an increase in intracranial content, and it can be due to an increase in brain water content, i. e. oedema, or cerebral blood volume and/or mass lesions. Elevated ICP, usually defined in the adult as a level above 20 mmHg, is thus the final common pathway of different patophysiological processes. The explanation for this phenomenon is condensed in the doctrine credited to Monro (1783) and Kellie (1824) which states that once the fontanelles and sutures are closed the brain is enclosed in a nonexpandable case of bone. The importance of this observation is that the skull cannot easily accommodate any additional volume. …