Pappiloedema as a mrker for raised icp in head injury

Papilloedema as a Non-Invasive Marker for

Raised ICP Following Decompressive

Craniectomy for Severe Head Injury

SHEJOY JOSHUA, DEEPAK AGRAWALBS SHARMA, AK MAHAPATRA

Department of Neurosurgery,JPN Apex Trauma Center, AIIMS, Dew Delhi.

Background

Decompressive craniectomy (DC) – the time tested treatment for Severe HI

Background

It is generally believed that ICP normalises after an adequate decompressive craniectomy

Especially as CT usually shows open cisterns & resolution of MLS

Hypothesis

Some patients may redevelop raised ICP after a variable period following decompressive craniectomy

Possibly due to hydrocephalus &/or reduced brain compliance

CT scan is not a sensitive indicator of raised intracranial pressure

Research Question(s)

How to assess for raised ICP in these patients reliably and non-invasively

Possible solution

Fundoscopy – a simple clinical examination to pick up raised ICP

Papilloedema is considered pathognomic of raised ICP

Aims and objectives

To study the temporal course of fundoscopic findings in patients with severe HI following decompressive craniectomy.

To correlate Fundoscopy findings with ventriculomegaly on serial CT’s in these patients

Aims and objectives (Secondary)

To correlate ICP readings with papilloedoma in patients who had ICP monitoring

Time-course of resolution of papilloedema in selected patients who had lumbar drain placed

Material & Methods

Prospective study over 5 month period

Fundoscopic examination and serial CT to diagnose

Ventriculomegaly Papilloedema

Material & Methods

Inclusion criteria– Severe HI pts (GCS ≤8) who underwent DC

Exclusion criteria– Pre-existing DM/HT– Pts in which fundoscopy is not possible

Cataract Eyeball injury

Material & Methods

Surgery– All patients underwent a wide decompressive

craniectomy with lax duraplasty and were electively ventilated for a variable period of time (Range-3-30days).

Material & Methods

Serial fundoscopic examinations at day 1, 2, 3, 5, 7 & 14

Serial CT scans (according to surgeon’s preference)

Definitions

Papilloedema presence of hyperemia of the disc or blurring of

disc margins along with absent spontaneous venous pulsations.

Definitions

Ventriculomegaly– ratio of frontal horn diameter to intracranial diameter taken

at the same level was >50% along with 2 or more of the following criteria

dilatation of temporal horn > 2 mm ballooning of III rd ventricle

Peri-ventricular lucency

Results

Total patients- 32

– Age 12-75 years (Mean 33.75 SD 13.93). – Glasgow coma scale on admission ranged from

3/15- 8/15 (Mean 6.28 Std. Dev. 1.63)

– Acute SDH 12– Contusion 20

Results

PAPILLEDEMA CLOSELY CORRELATED WITH RAISED ICP MEASURED WITH INVASIVE MONITORING

ICP on day 1

(cm of water)

Papilloedema ICP

(cm of water)

ICP on day 2

(cm of water)

Papilloedema

9 - 12 -

10 - 14 -

18 - 17 -

23 + 16 -

24 + 30 +

25 + 17 -

26 + 24 +

Incidence of papilloedema following Decompressive craniectomy on serial Fundoscopic examination

81

62

28

13

6

0

10

20

30

40

50

60

70

80

90

POD 1 POD3 POD5 POD7 POD14

Papilloedema

Per

cen

tag

e

Comparison of ventriculomegaly on C.T head with Papilloedema on

Fundoscopic examination at the same time interval

0

20

40

60

80

100

At 48 hourspost op

At 1wk postop

Pe

rce

nta

ge

Ventriculomegaly onC.T

Papilloedema

Results

• 4 Patients (12.5%) developed deterioration of GCS (by 1 or 2) and an inability to wean off the ventilator along with systemic signs of raised ICP viz. Bradycardia and hypertension on 7-10th post operative day

Recurrence and Resolution

• All 4 patients had a recurrence of papilledema in

the form of hyperemia of disc, engorgement of

vessels and worsening of disc blurr

• Although CT showed mild ventriculomegaly in all

cases, Evan’s ratio was within normal range

Recurrence and Resolution

A lumbar drain was placed in all these patients which resulted in improvement of GCS

This was associated with resolution of papilledema in the form of clearing up the disc hyperemia and decrease in the vessel engorgement within 6 hours post procedure

Discussion

No similar studies in literature!

This study validates the use of papilloedema as an extremely sensitive marker for acute changes in ICP.

Conclusion(s)

Significant number of patients (12.5% in our study) had recurrence of raised ICP following decompressive craniectomy for severe HI

There was prompt resolution of the ICP on lumbar drainage suggesting CSF absorption block as a possible mechainsm of this raised ICP

Conclusion(s)

Papilloedema is an early indicator of raised ICP and correlates well with the intracranial pressure in head injured patients

This study validates the use of papilloedema as an extremely sensitive marker for acute changes in ICP.