Multimodality Monitoring in Patients with Elevated Intracranial Pressure

  • D. B. Seder
  • J. M. Schmidt
  • S. A. Mayer
Conference paper


Conventional paradigms for the management of elevated intracranial pressure (ICP) are in many ways imperfect. Clinicians respond to increases in ICP, or to worsening of the clinical neurological examination, after critical thresholds of brain ischemia have been crossed, at a point when irreversible injury may have already occurred and the window of opportunity for therapeutic intervention has closed. Even with the benefit of direct ICP monitoring, the true biochemical environment of the brain is unknown, so that measurable changes in blood pressure, cerebral perfusion pressure (CPP), circulating blood volume and rheology, blood oxygen and glucose levels, and other clinical parameters result in uncertain global or regional effects in areas of the brain at risk. The goal of multimodality monitoring is to titrate clinical therapy at the bedside to foster a biochemical environment that favors preservation of function and healing within the brain — a proactive, in place of a reactive, approach. This chapter suggests different ways in which ICP, brain tissue and jugular bulb oxygen content, microdialysis, continuous electroencephalography (EEG), and transcranial Doppler ultrasound data can be integrated into a practical management algorithm for patients with elevated ICP.


Mean Arterial Pressure Cerebral Perfusion Pressure Elevated Intracranial Pressure Intracranial Compliance Multimodality Monitoring 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Mayer SA, Chong JY (2002) Critical care management of increased intracranial pressure. J Intensive Care Med 17:55–67CrossRefGoogle Scholar
  2. 2.
    Cormio M, Valadka AB, Robertson CS (1999) Elevated jugular venous oxygen saturation after severe head injury. J Neurosurg 90:9–15PubMedGoogle Scholar
  3. 3.
    White H, Baker A (2002) Continuous jugular venous oximetry in the neurointensive care unita brief review. Can J Anaesth 49:623–629PubMedGoogle Scholar
  4. 4.
    Sarrafzadeh AS, Kiening KL, Unterberg AW (2003) Neuromonitoring: brain oxygenation and microdialysis. Curr Neurol Neurosci Rep 3:517–523PubMedCrossRefGoogle Scholar
  5. 5.
    Gopinath SP, Valadka AB, Uzura M, Robertson CS (1997) Comparison of jugular venous oxygen saturation and brain tissue PO2 as monitors of cerebral ischemia after head injury. Crit Care Med 27:2337–2345CrossRefGoogle Scholar
  6. 6.
    Zauner A, Doppenberg EM, Woodward JJ, Choi SC, Young HF, Bullock R (1997) Continuous monitoring of cerebral substrate delivery and clearance: initial experience in 24 patients with severe acute brain injuries. Neurosurgery 41:1082–1091PubMedCrossRefGoogle Scholar
  7. 7.
    Steifel MF, Spiotta AM, Gracias VH, et al (2005) Reduced mortality in patients with severe traumatic brain injury in patients treated with brain tissue oxygen monitoring. J Neurosurg 103:805–811Google Scholar
  8. 8.
    Steifel MF, Udoetuk JD, Spiotta AM, et al (2006) Conventional neurocritical care and cerebral oxygenation after traumatic brain injury. J Neurosurg 105:568–575CrossRefGoogle Scholar
  9. 9.
    Dohmen C, Bosche B, Graf R et al (2007) Identification and clinical impact of impaired cerebrovascular autoregulation in patients with malignant middle cerebral artery infarction. Stroke 38:56–61PubMedCrossRefGoogle Scholar
  10. 10.
    Goodman JC, Valadka AB, Gopinath SP, et al (1999) Extracellular lactate and glucose concentrations in the brain after head injury measured by microdialysis. Crit Care Med 27: 1965–1973PubMedCrossRefGoogle Scholar
  11. 11.
    Vespa PM, O’Phelan K, McArthur D, et al (2007) Pericontusional brain tissue exhibits persistent elevation of lactate/pyruvate ratio independent of cerebral perfusion pressure. Crit Care Med 35:1153–1160PubMedCrossRefGoogle Scholar
  12. 12.
    Bellander BM, Cantais E, Enblad P, et al (2004) Consensus meeting on microdialysis in neurocritical care. Intensive Care Med 30:2166–2169PubMedCrossRefGoogle Scholar
  13. 13.
    Vespa PM, McArthur D, O’Phelan K, et al (2003) Persistently low extracellular glucose correlates with poor outcome 6 months after human traumatic brain injury despite a lack of increased lactate: a microdialysis study. J Cereb Blood Flow Metab 23:865–877PubMedCrossRefGoogle Scholar
  14. 14.
    Wartenberg KE, Schmidt M, Mayer SA (2007) Multimodality monitoring in neurocritical care. Crit Care Clin 23:507–538PubMedCrossRefGoogle Scholar
  15. 15.
    Claassen J, Mayer SA, Kowalski RG, Emerson RG, Hirsch LJ (2004) Detection of electrophysiologic seizures with continuous EEG monitoring in critically ill patients. Neurology 62:1743–1748PubMedGoogle Scholar
  16. 16.
    Jordan KG (1995) Neurophysiologic monitoring in the neuroscience intensive care unit. Neurol Clin 13:579–626PubMedGoogle Scholar
  17. 17.
    Gabor AJ, Brooks AG, Scobey RP, et al (1984) Intracranial pressure during epileptic seizures. Electroencephalogr Clin Neurophysiol 57:497–506PubMedCrossRefGoogle Scholar
  18. 18.
    Vespa PM, O’Phelan K, Shah M, et al (2003) Acute seizures after intracerebral hemorrhage: A factor in progressive midline shift and outcome. Neurology 60:1441–1446PubMedGoogle Scholar
  19. 19.
    Michaeli D; Rappaport ZH (2002) Tissue resonance analysis; a novel method for noninvasive monitoring of intracranial pressure. J Neurosurg 96:1132–1137PubMedGoogle Scholar
  20. 20.
    Mayer SA, Thomas CE, Diamond BE (1996) Assymmetry of intracranial hemodynamics as an indicator of mass effect in acute intracranial hemorrhage. A transcranial doppler study. Stroke 27:1788–1792PubMedGoogle Scholar
  21. 21.
    Coles JP, Minhas PS, Fryer TD, et al (2002) Effect of hyperventilation on cerebral blood flow in traumatic head injury: clinical relevance and monitoring correlates. Crit Care Med 30:2619–2625CrossRefGoogle Scholar
  22. 22.
    Steiger HJ, Aaslid R, Stooss R, Seiler RW (1994) Transcranial doppler monitoring in head injury: relations between type of injury, flow velocity, vasoreactivity, and outcome. Neurosurgery 34:79–85PubMedCrossRefGoogle Scholar
  23. 23.
    Diehl RR, Linden D, Lucke D, Berlit P (1995) Phase relationship between cerebral blood flow velocity and blood pressure. A clinical test of autoregulation. Stroke 26:1801–1804PubMedGoogle Scholar
  24. 24.
    Tieks FP, Lam AM, Aaslid R, Newell DW (1995) Comparison of static and dynamic cerebral autoregulation measurements. Stroke 26:1014–1019Google Scholar
  25. 25.
    Smielewski P, Czosnyka M, Kirpatrick P, Pickard JD (1997) Evaluation of the transient hyperemic response test in head-injured patients. J Neurosurg 86:773–778PubMedCrossRefGoogle Scholar
  26. 26.
    Rose JC, Mayer SA (2004) Optimizing blood pressure in neurological emergencies. Neurocrit Care 1:287–299PubMedCrossRefGoogle Scholar
  27. 27.
    Wijdicks EFM (2003) The Clinical Practice of Critical Care Neurology. Oxford University Press, New YorkGoogle Scholar
  28. 28.
    Wartenberg KE, Schmidt JM, Krieger DW (2006) The future of the brain support: Multimodality monitoring. Future Neurology 1:465–488CrossRefGoogle Scholar

Copyright information

© Springer Science + Business Media Inc. 2008

Authors and Affiliations

  • D. B. Seder
    • 1
  • J. M. Schmidt
    • 1
  • S. A. Mayer
    • 1
  1. 1.Neurological Intensive Care Unit, Departments of Neurology, Neurological InstituteColumbia University Medical CenterNew YorkUSA

Personalised recommendations