Ventricular pressure monitoring during bilateral decompression with dural expansion

Object. The management of massive brain swelling remains an unsolved proble m in neurosurgery. Despite newly developed medical and pharmacological ther apy, the rates of mortality and morbidity caused by massive brain swelling remain high. According to many recent reports, surgical decompression with dural expansion is superior to medical management in patients with massive brain swelling. To show the quantitative effect of decompressive surgery on intracranial pressure (ICP), the authors performed a ventricular puncture and measured the ventricular ICP continuously during decompressive surgery and the postoperative period. Methods. Twenty patients with massive brain swelling who underwent bilatera l decompressive craniectomy with dural expansion were included in this stud y. In all patients, ventricular puncture was performed at Kocher's point on the side opposite the massive brain swelling. The ventricular puncture tub e was connected to the continuous monitor via a transducer device. The vent ricular pressure was monitored continuously, during the bilateral decompres sive procedures and postoperative period. The initial ventricular ICP was variable, ranging from 16 to 65.8 mm Hg. Im mediately after the bilateral craniectomy, the mean ventricular ICP decreas ed to 50.2 +/- 16.6% of the initial ICP (range 5-51.5 mm Hg). Additional op ening of the dura decreased the mean ICP by an additional 34.5% and reduced the ventricular pressure to 15.7 +/- 10.7% of the initial pressure (range 0-15 mm Hg). Ventricular pressure measured postoperatively in the neurosurg ical intensive care unit was lowered to 15.1 +/- 16.5% of the initial ICP. The ventricular ICP trend in the first 24 hours after decompressive surgery was an important prognostic factor; if it was greater than 35 mm Hg, the m ortality rate was 100%. Conclusions. Bilateral decompression with dural expansion is an effective t herapeutic modality in the control of ICP. To obtain favorable clinical out comes in patients with massive brain swelling, early decision making and pr oper patient selection are very important.