Intaoperative Diagnosis of Acute Subarachnoid Hemorrhage Using Continuous Pressure Monitoring via a Lumbar Subarachnoid Catheter

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At our institution the surgeon often requests that a catheter be inserted in the lumbar subarachnoid space to withdraw CSF intraoperatively. We report a case of a patient about to undergo clipping of a middle cerebral artery aneurysm, in whom aneurysmal rupture occurred shortly after induction of general anesthesia. The information provided by the lumbar catheter led to a major change in the operative plan and subsequent patient management

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Continued expansion of an artificial space-occupying lesion produced further increases in mean supratentorial and infratentorial pressures associated with increases in mean arterial pressure, heart rate, and systemic vascular resistance-the `Cushing' or systemic hypertensive response. These primary changes resulted in an increase in transtentorial pressure gradient and a decrease in arrhythmia index. Immediately before the onset of the systemic hypertensive response, supratentorial perfusion pressure was low, and the period of systemic hypertension did not appear to produce any worthwhile improvement in the perfusion pressure or in the blood flow in the supratentorial compartment. The studies demonstrated also that the systemic hypertensive response was a pre-terminal event and was followed rapidly by circulatory failure.
The effects of halothane and hypocapnia on cerebrospinal fluid pressure (CSFP) were ex amincd in 48 patients undergoing craniotomy for tumors (36 patients) or vascular lesions (12 patients). All patients were hyperventilated to Paco2 levels less than 30 mm IIg (mean 26). Twenty-one patients (Group I) received halothane (0.5 to 1.0 per cent) simultaneously with the onset of hyperventilation, and 17 patients (Group II) received halothane (0.5 to 1.0 percent) after hyperventilation had been established for 10 minutes. Large increases in CSFP occurred only in Group I (seven patients, mean increase = 260 mm H2O). Only small increases in CSFP occurred in Group II (10 patients, mean increase = 26 mm H2O). The pressure increases in all patients were transient (10 to 30 minutes). A third group (10 patients) was given Innovar in the absence of halothane, and no increases in CSFP occurred. The authors conclude that halothane is capable of increasing CSFP in patients with intracranial disease, but that these increases are transient and can be minimized or abolished by the prior induction of hypocapnia.
Continuous monitoring of intraventricular pressure (IVP) was performed before and during 13 recurrent hemorrhages occurring in 10 patients between the 3rd and 14th day after the initial rupture of an intracranial saccular aneurysm. Before re-rupture, nine patients were of Hunt and Hess' clinical Grade III of IV. Severe angiographic vasospasm was demonstrated in six patients. In the period between ruptures, IVP and mean arterial blood pressure were significantly increased compared to pressures in patients who did not rebleed. Ventricular drainage of cerebrospinal fluid (CSF) to a level of 25 mm Hg did not increase the rate of rebleeding (17% of patients). On the other hand, the use of drainage while the repeat rupture was taking place seemed to exert a deleterious effect on the natural mechanisms that lead to arrest of hemorrhage. In five patients with CSF drainage during their rebleed, the steady-state IVP level after the repeat rupture was significantly increased, and four patients died from large intracerebral hemorrhages. These results suggest that drainage of CSF should be avoided during recurrent hemorrhage, and should not be resumed until a steady-state IVP level has been reached.