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BioMed Research International
Volume 2013, Article ID 750809, 7 pages
Clinical Study

Posttraumatic Refractory Intracranial Hypertension and Brain Herniation Syndrome: Cerebral Hemodynamic Assessment before Decompressive Craniectomy

1Division of Neurological Surgery, Hospital das Clinicas, University of Sao Paulo, School of Medicine, 255 Eneas Aguiar Street, Office 4079, 05403010 Sao Paulo, SP, Brazil
2Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan

Received 24 July 2013; Accepted 17 October 2013

Academic Editor: Joachim Oertel

Copyright © 2013 Edson Bor-Seng-Shu et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Background. The pathophysiology of traumatic brain swelling remains little understood. An improved understanding of intracranial circulatory process related to brain herniation may have treatment implications. Objective. To investigate the cerebral hemodynamic changes associated with brain herniation syndrome due to traumatic brain swelling. Methods. Nineteen head-injured patients with evidence of refractory intracranial hypertension and transtentorial herniation were prospectively studied. Cerebral hemodynamic assessment by transcranial Doppler (TCD) ultrasonography was performed prior to decompressive craniectomy. Patients and their cerebral hemispheres were classified according to TCD-hemodynamic patterns, and the data correlated with neurological status, midline shift on CT scan, and Glasgow outcome scale scores at 6 months after injury. Results. A wide variety of cerebral hemodynamic findings were observed. Ten patients (52.7%) presented with cerebral oligoemia, 3 patients (15.8%) with cerebral hyperemia, and 6 patients with nonspecific circulatory pattern. Circulatory disturbances were more frequently found in the side of maximal cerebral swelling than in the opposite side. Pulsatility index (PI) values suggested that ICP varied from acceptable to considerably high; patients with increased PI, indicating higher microvascular resistance. No correlation was found between cerebral hemodynamic findings and outcome. Conclusions. There is a marked heterogeneity of cerebral hemodynamic disturbances among patients with brain herniation syndrome.