HIC Refractaria

Posgrado de Medicina Intensiva

Cátedra de Medicina Intensiva

Semestre Neurorreanimación
Agosto 2019

Grupo de Neurointensivismo
 TRATAMIENTO DE LA HIC

OBJETIVOS DE LA PRIMERA SEMANA

HEMODINAMIA INTRACRANEANA

• PIC < 20-25 mmHg (15) ✓✓ DESCOMPRESIVA

LESIÓN TEMPORAL(única o bilateral)
✓ COMPRESIÓN CISTERNAS DE LA BASE
✓ DLM
✓Rosner y col. (1996)
• PPC entre 50-70 mmHg (60-80) ✓Robertson y col.(1999)
✓Steiner, Czosnyka y col.
(2002)
 TRATAMIENTO DE LA HIC
SIN DESCONOCER LA IMPORTANCIA DE
LOS UMBRALES DE PIC

✓ PUEDE EXISTIR NEURODETERIORO AÚN CON VALORES

SUBUMBRAL

(Marshall y col, J Neurosurg 1983. Alteraciones pupilares)

✓ TOLERAR NIVELES SUPRAUMBRAL PUEDE SER ADECUADO

EN PACIENTES CON BUENA EVOLUCIÓN CLÍNICA Y
TOMOGRÁFICA
(Chambers IR y col, J Neurosurg 2001)
 TRATAMIENTO DE LA HIC
1- MEDIDAS INESPECIFÍCAS

• APLICABLES A TODOS

• EFECTIVAS
 TRATAMIENTO DE LA HIC
ESTRATEGIA PROGRESIVA

• ESCALONADA: NIVELES
TERAPÉUTICOS
• BALANCE RIESGO / BENEFICIO
(mayor complejidad e invasividad)
• ADITIVA

✓RETIRADA LENTA E INVERSA

 TRATAMIENTO DE LA HIC
• 4 edición 2016
✓ GUÍAS DE FRANCIA

✓ GUÍAS DE LA UNIVERSIDAD DE LUND COINCIDENCIAS

EBIC Y
DISCREPANCIAS

GUÍAS LABIC

REVISIONES COCHRANE
 TRATAMIENTO DE LA HIC

PRIMER NIVEL PRIMER NIVEL

SEGUNDO NIVEL: SEGUNDO NIVEL

BBT (Pentobarbital) (Intermedias)

OPCIONES TERCER NIVEL

 TRATAMIENTO DE LA HIC
GUÍAS DEL SUR

• PRIMER NIVEL •PASO 1 DRENAJE LCR

•PASO 2 OSMOTERAPIA
•PASO 3 HV MODERADA
•PASO 4 BNM

• SEGUNDO NIVEL •INDOMETACINA

•THAM
•HV INTENSA
•PPC TARGET

• TERCER NIVEL •BBT

•DESCOMPRESIVA
•HIPOTERMIA MODERADA
•DRENAJE LUMBAR
 HIC REFRACTARIA

DEFINICIÓN

• AUSENCIA DE RESPUESTA A
MEDIDAS DE PRIMER NIVEL (A TOPE)

• PIC PERSISTENTEMENTE >20-25mmHg

 HIC REFRACTARIA
INCIDENCIA

15-30%
 HIC REFRACTARIA
FISIOPATOLOGÍA

• VASORREACTIVIDAD CEREBRAL

• COMPLIANCE INTRACRANEANA
 HIC REFRACTARIA
IMPACTO PRONÓSTICO

MORTALIDAD
60-70%
HIC REFRACTARIA
HERALDOS

1. HIPOXIA - HIPOTENSIÓN
2. SINDROME HERNIARIO PREVIO
3. SWELLING INTRAOPERATORIO
4. “OPEN PRESSURE” > 18 mm Hg
5. TRASTORNO DE CRASIS
6. HIPERLEUCOCITOSIS MANTENIDA
 TRATAMIENTO DE LA HIC
GUÍAS DEL SUR

• PRIMER NIVEL •PASO 1 DRENAJE LCR

•PASO 2 OSMOTERAPIA
•PASO 3 HV MODERADA
•PASO 4 BNM

“ALTERNATIVAS TERAPEÚTICAS MÁS ALLÁ DE LAS GUÍAS”

• SEGUNDO NIVEL •INDOMETACINA

•THAM
•(HV INTENSA)
•PPC TARGET

• TERCER NIVEL •BBT

•DESCOMPRESIVA
•HIPOTERMIA MODERADA
•DRENAJE LUMBAR
 TRATAMIENTO DE LA HIC
REFRACTARIA
MEDIDAS DE SEGUNDO NIVEL O
INTERMEDIAS

• SENCILLAS DE IMPLEMENTAR (menos

invasivas que TERCER NIVEL)

• BAJO COSTO

• ADECUADO BALANCE RIESGO/BENEFICIO

 TRATAMIENTO DE LA HIC
REFRACTARIA
INDOMETACINA

• AINE (EICOSANOIDES)
• ESPECIAL ACCIÓN CEREBRAL

• VASOMODULADOR
 EFECTO DEL BOLO DE
INDOMETACINA SOBRE PIC

47,5 n= 11
45

35 34,4
PIC

25
21,3 23,6

15 16,4

9,2
5
t
ANTES DESPUES
P = 0.0001
BIESTRO Y COL
J NEUROSURG; 83:627-630, 199
 INDOMETACINA
FSC-CMRO2

35% SN

10% NS

CYTOCHROME C OXIDASE AFFINITY ?

INDOMETACINA
AUTORREGULACIÓN CEREBRAL
 INDOMETACINA

✓ FUERTE DESCENSO DE LA PIC

✓ MANTENIMIENTO DE LA PPC

✓ REDUCCIÓN DEL FSC MANTENIENDO CMRO2

AFINIDAD CYTOCHROME C OXIDASE
MEJORA ACOPLAMIENTO (DEMANDA/CONSUMO)

✓ MEJORÍA DE AUTORREGULACIÓN
(Otras medidas resultan más efectivas)
 INDOMETACINA

DOSIS
• BOLO 50 mg 15-20 min
• INFUSIÓN 30 mg/h

CONTROL CON SJO2 ?

JAMÁS SUSPENDER BRUSCAMENTE!!

EFECTO REBOTE PUEDE SER GRAVE
Indomethacin for control of ICP.

Sader N1, Zeiler FA, Gillman LM, West M, Kazina CJ.

Abstract
Our goal was to perform a systematic review of the literature on the use of indomethacin and its effects on intracranial
pressure (ICP) in patients with neurological illness. All articles from MEDLINE, BIOSIS, EMBASE, Global Health,
Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to July 2014), reference lists of
relevant articles, and gray literature were searched. Two reviewers independently identified all manuscripts utilizing
the following inclusion and exclusion criteria.

INCLUSION CRITERIA:
Humans, prospective studies (five or more patients), documented ICP response to indomethacin, and English.

EXCLUSION CRITERIA:
non-English, retrospective studies, no documentation of ICP response to indomethacin, and animal studies. A two-tier
filter of references was conducted. First, we screened manuscripts by title and abstract. Second, those references
passing the first filter were pulled, and the full manuscript was checked to see if it matched the criteria for inclusion.
Two reviewers independently extracted data including population characteristics and treatment characteristics. The
strength of evidence was adjudicated using both the Oxford and GRADE methodology. Our search strategy produced
a total of 208 citations. Twelve original articles, 10 manuscripts, and 2 meeting proceeding, were considered for the
review with all utilizing indomethacin, while documenting ICP in neurological patients. All studies were prospective.
Across all studies, there were a total of 177 patients studied, with 152 receiving indomethacin and 25 serving as
controls in a variety of heterogeneous studies. All but one study documented a decrease in ICP with indomethacin
administration, with both bolus and continuous infusions. No significant complications were described. There
currently exists Oxford level 2b, GRADE C evidence to support that indomethacin reduces ICP in the severe TBI
population. Similar conclusions in other populations cannot be made at this time.

Comments on its impact, on patient outcome, and side effects cannot be made given the
available data. At this time, indomethacin for ICP control remains experimental and
further prospective study is warranted.

Neurocritical Care, Junio 2015

CSIC Grupos - INDOPET
TRATAMIENTO DE LA HIC
REFRACTARIA

TROMETAMINA (THAM)
0,3 M
ACETATO

• pH 8,6
• pk 7,82 (Bic. Na pK 6,1)
• 380 mOsmol/L
 THAM
PROPIEDADES FARMACOLÓGICAS

• BASE DÉBIL

• CAPACIDAD AMORTIGUADORA
 THAM
CAPACIDAD AMORTIGUADORA

• R-NH2 + H+ + La-  R-NH3+ + La-

H2CO3 H+ + HCO3 -

• R-NH2 + H2O + CO2  R-NH3+ +HCO3-

 THAM

PROPIEDADES FARMACOLÓGICAS

• PENETRACIÓN CELULAR

• PASAJE A TRAVÉS DE LA BHE

 THAM

PROPIEDADES FARMACOLÓGICAS

• ELIMINACIÓN RENAL

• CONTRAINDICADO EN LA I. RENAL
 THAM
MECANISMO DE ACCIÓN
• SE POSTULA:

1) REGULACIÓN DEL VSC

2) REGULACIÓN DEL EDEMA CELULAR-VOLUMEN CELULAR

3) AUTORREGULACION CEREBRAL?

“BOMBA ASPIRADORA DE PROTONES”

ACIDOSIS INTERSTICIAL Y CELULAR POST-INJURIA

ACCIÓN A DISTANCIA
 THAM
INDICACIONES NEUROINJURIA

1- PIC REFRACTARIA

2- CORRECCIÓN DE HV ACCIDENTAL

3- IPA/DISTRESS
 THAM y PIC
Experiencia CTI-HC
45
40,6 n=7
40
35
31,7
30
25
22,8
20 18,4
15
12,1
10
5,8
5
0

p = 0.005 Dr. Codina

Dr. A Biestro
 THAM
• MODO DE USO
INDICACIONES • DOSIS

1- PIC REFRACTARIA (SjO2)

SINERGIA

HIPERVENTILACIÓN HIPOTERMIA

SSH?
 THAM
INDICACIONES

2- CORRECCIÓN HV ACCIDENTAL

200-300 mL 3-6 hs (repetir)

 THAM
INDICACIONES
3- IPA/DISTRES
THAM for control of ICP

Zeiler FA1, Teitelbaum J, Gillman LM, West M.

Abstract

Our goal was to perform a systematic review of the literature on the use of tromethamine (THAM) and its effects on intracranial pressure (ICP) in
patients with neurological illness. All articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the
International Clinical Trials Registry Platform (inception to February 2014), reference lists of relevant articles, and gray literature were searched.
Two reviewers independently identified all manuscripts pertaining to the administration of THAM in human patients that recorded effects on ICP.
Secondary outcomes of effect on cerebral perfusion pressure, mean arterial pressure, patient outcome, and adverse effects were recorded. Two
reviewers independently extracted data including population characteristics and treatment characteristics. The strength of evidence was
adjudicated using both the Oxford and GRADE methodology. Our search strategy produced a total 2,268 citations. Twelve articles, 9
manuscripts, and 3 meeting proceedings were considered for the review with all utilizing THAM while documenting ICP in neurosurgical patients.
All studies were prospective. Across all studies, there were a total of 488 patients studied, with 263 receiving THAM and 225 serving as controls
in a variety of heterogeneous studies. All but one study documented a decrease in ICP with THAM administration, with both bolus and
continuous infusions. One study documented a reduction in cerebral perfusion pressure. No significant renal dysfunction, hepatocellular injury,
or hypoglycemia were reported.

Three prospective randomized control trials displayed trends to improved outcome in severe traumatic
brain injury (TBI) patients with THAM administration.
There currently exists Oxford level 2b, GRADE B evidence to support that THAM reduces ICP in the TBI and malignant ischemic infarct
population, with minimal side effects.

The literature suggests THAM may be useful for ICP reduction in certain cases, though the
safety of the compound in these circumstances is still unclear. Further prospective study
is warranted.

Neurocritical Care, Octubre 2014

 TRATAMIENTO DE LA HIC
ESTRATEGIA “TARGET”

• “PPC ÓPTIMA” : MEJOR Mx o PRx

PPC>60(70)mmHg ES SUFICIENTE?
 TRATAMIENTO DE LA HIC
REFRACTARIA
HV INTENSA 25-30 mmHg

• POTENTE MEDIDA TRANSITORIA

• OPTIMIZADA: SJO2 ≥ 50-55%

• ASOCIAR THAM (TRABAJO de WOLF y col.)

 TRATAMIENTO DE LA HIC
REFRACTARIA
MEDIDAS DE TERCER NIVEL

• LA CORRECTA SELECCIÓN DEL

PACIENTE ES CRUCIAL

• DESICIÓN DIFÍCIL (NQ)

• FACTOR TIEMPO
 TRATAMIENTO DE LA HIC
GUÍAS DEL SUR

• PRIMER NIVEL •PASO 1 DRENAJE LCR

•PASO 2 OSMOTERAPIA
•PASO 3 HV MODERADA
•PASO 4 BNM

“ALTERNATIVAS TERAPEÚTICAS MÁS ALLÁ DE LAS GUÍAS”

• SEGUNDO NIVEL •INDOMETACINA

•THAM
•(HV INTENSA)
•PPC TARGET

• TERCER NIVEL •BBT

•DESCOMPRESIVA
•HIPOTERMIA MODERADA
•DRENAJE LUMBAR
 BBT
UNA ALTERNATIVA : PROPOFOL

• EXCELENTE VENTANA CLÍNICA

• REPERCUSIÓN HEMODINÁMICA

• DOSIS <5 mg /K /h

• 3 - 4DÍAS
 TRATAMIENTO DE LA HIC
REFRACTARIA

HIPOTERMIA MODERADA 32-34

 TRATAMIENTO DE LA HIC
REFRACTARIA
HIPOTERMIA TERAPÉUTICA INTRAVASCULAR
POTENCIALES EFECTOS BENEFICIOSOS

• METABOLISMO CEREBRAL (BASAL)

EDEMA CEREBRAL
•REDUCCIÓN METABOLISMO
GLUCOSA (ACOPLE FSC)

• CASCADAS INFLAMATORIAS DESCENSO PIC

• AA EXCITATORIOS

• FLUJOS IÓNICOS TRANSMEMBRANA MUERTE CELULAR

 TRATAMIENTO DE LA HIC
REFRACTARIA

POBLACIÓN BIEN SELECCIONADA

✓ EDAD < 45 AÑOS

✓ SIN COMPROMISO SISTÉMICO

✓ CORTA EVOLUCIÓN DE LA LESIÓN (4-5 DÍAS)

Hypothermia for traumatic head injury.
Sydenham E, Roberts I, Alderson P
Cochrane Database Syst Rev. 2009;(1):CD001048.
AUTHORS' CONCLUSIONS:
• There is no evidence that hypothermia is beneficial in the treatment of head injury.
• Hypothermia may be effective in reducing death and unfavourable outcomes, but significant
benefit was only found in low quality trials (tendency to overestimate the treatment effect).
• The high quality trials found no decrease in the likelihood of death with hypothermia,
but this finding was not statistically significant and could be due to the play of chance.
• Hypothermia should not be used except in the context of a high quality randomised
controlled trial with good allocation concealment.
Hypothermia treatment for traumatic brain injury: a systematic review and
meta-analysis.
Peterson K, Carson S, Carney N.
J Neurotrauma. 2008 Jan;25(1):62-71.
• Reductions in risk of mortality were greatest and favorable neurologic outcomes
much more common when hypothermia was maintained for more than 48 h.
• Potential benefits of hypothermia may likely be offset by a significant increase in risk
of pneumonia.
• In sum, the present study's updated meta-analysis supports previous findings that
hypothermic therapy constitutes a beneficial treatment of TBI in specific circumstances.
 HIPOTERMIA TERAPÉUTICA
¨CLAVES PARA EL ÉXITO¨

1.NIVEL o GRADO
2.DURACIÓN (48hs o PIC)
3.RECALIENTAMIENTO PASIVO
4.NO asociar BBT
 HIPOTERMIA TERAPÉUTICA
PROBLEMAS ¨VITALES¨

1.MANEJO MEDIO INTERNO y Eq. A-B

2.MANEJO HEMODINAMIA / VOLEMIA
3.INMUNODEPRESIÓN / INFECCIÓN
4.CRASIS
 Indicaciones
• HIPOTERMIA PROFILÁCTICA:

NO esta recomendado en el TEC

• HIPOTERMIA TERAPÉUTICA:

Opción en HIC refractaria

• < 45 años
• manteniendo otras medidas
• sólo en centros con entrenamiento
Hipotermia Profiláctica
Neurosurg Clin N Am. 2016 Oct;27(4):489-97.
Hipotermia - PCR
 TRATAMIENTO DE LA HIC
REFRACTARIA

DESCOMPRESIVA
(1900)
 DESCOMPRESIVA
DEFINICIÓN: procedimiento BIFÁSICO
• RESECCIÓN ÓSEA + DUROPLASTIA (Yoo 1999, PIVOT)
• CRANIECTOMÍA (1) CRANIOPLASTIA (2)

DIMENSIONES
• PUNTO CLAVE PARA QUE REALMENTE CUMPLA
SU ROL
AUMENTO
≥12 cm CAPACIDAD
INTRACRANEANA
FOSA TEMPORAL
DECOMPRESIVA TÉRMICA

37º

?
<36º
36.5º
 DESCOMPRESIVA
CLASIFICACIÓN
• PRIMARIA
• SECUNDARIA

TIPOS
• BIFRONTAL
• TEMPORAL
• FOSA POSTERIOR
DESCOMPRESIVA
LATERAL
 DESCOMPRESIVA

• TRABAJO de TAYLOR A. y col.

(Childs Nervus System. FEB 2001)

• HIC REFRACTARIA
¨…….ICP will be reduced, fewer episodes of intracranial
hypertension will occur, and functional outcome and quality of life
may be better than in children treated with medical management
alone¨.
 DESCOMPRESIVA
CANDIDATOS

• < 60 AÑOS
• LESIÓN III- IV
• COMPROMISO SISTÉMICO Y/O
POLITRAUMA

TIMING

• < 48 horas
• HIC refractaria: >25
• En el contexto de manejo
progresivo
 DESCOMPRESIVA
COMPLICACIONES
EN MAS o EXPANSIVAS EN MENOS o EXCAVADAS
• PIC ELEVADA • PIC BAJA
1. AGUDAS 1. Presentación ALEJADA
• HEMATOMAS 2. Agravados por PL y el
• LESIONES DE REPERFUSIÓN Ortostatismo
3. Mejoran con CRANIOPLASTIA
2. SUBAGUDA o CRÓNICA
• HIDROCEFALIA
Precedida por FÍSTULA LCR y/o
HIGROMA lateral/interhemisférico
 DESCOMPRESIVA
SEMIOLOGÍA DE LA DESCOMPRESIVA

• HERIDA

• LATIDO

• TENSIÓN (MODIF. CON LA POSICIÓN)

• COLGAJO ÓSEO (ABDOMINAL)

• VERIFICAR POSICIÓN DE CATETER DE PIC (TC)

INFARTO VENOSO
Descompresiva
 Lesiones del DECRA

✓ No realizar esta técnica en pacientes

con aumento transitorio (10-15min) de
PIC>20

✓ Los pacientes deberán tener HIC

refractaria > 25-30? mantenida (1 hora o
mas?)
Descompresiva Secundaria
Decompressive Craniectomy in Patients with Traumatic Brain Injury: Are the Usual Indications
Congruent with Those Evaluated in Clinical Trials?

Kramer AH1,2,3, Deis N4,5, Ruddell S4, Couillard P4,5,6, Zygun DA7, Doig CJ4,8, Gallagher C4,5,6.

BACKGROUND:
In patients with traumatic brain injury (TBI), multicenter randomized controlled trials have assessed
decompressive craniectomy (DC) exclusively as treatment for refractory elevation of intracranial pressure (ICP).
DC reliably lowers ICP but does not necessarily improve outcomes. However, some patients undergo DC as
treatment for impending or established transtentorial herniation, irrespective of ICP.
METHODS:
We performed a population-based cohort study assessing consecutive patients with moderate-severe TBI.
Indications for DC were compared with enrollment criteria for the DECRA and RESCUE-ICP trials.
RESULTS:
Of 644 consecutive patients, 51 (8 %) were treated with DC. All patients undergoing DC had compressed basal
cisterns, 82 % had at least temporary preoperative loss of ≥1 pupillary light reflex (PLR), and 80 % had >5 mm of
midline shift. Most DC procedures (67 %) were "primary," having been performed concomitantly with evacuation of
a space-occupying lesion. ICP measurements influenced the decision to perform DC in 18 % of patients. Only 10
and 16 % of patients, respectively, would have been eligible for the DECRA and RESCUE-ICP trials. DC improved
basal cistern compression in 76 %, and midline shift in 94 % of patients. Among patients with ≥1 absent PLR at
admission, DC was associated with lower mortality (46 vs. 68 %, p = 0.03), especially when the admission Marshall
CT score was 3-4 (p = 0.0005). No patients treated with DC progressed to brain death. Variables predictive of poor
outcome following DC included loss of PLR(s), poor motor score, midline shift ≥11 mm, and development of
perioperative cerebral infarcts.

CONCLUSIONS:
DC is most often performed for clinical and radiographic evidence of herniation, rather than for
refractory ICP elevation. Results of previously completed randomized trials do not directly apply
to a large proportion of patients undergoing DC in practice.

Neurocritical Care, Agosto 2016

http://www.rescueasdh.org/
UMBRALES DSC 2aria
Umbral de PIC
 TRATAMIENTO DE LA HIC
REFRACTARIA

DRENAJE LUMBAR CONTROLADO

(DLC)
 DRENAJE LUMBAR
CONTROLADO
• PL, edema de papila e HIC

• RESURGIMIENTO
1.Pseudotumor Cerebral
2.Meningitis Criptocóccica
OPCIÓN
REQUISITOS
1. VENTRICULOSTOMÍA
2. CISTERNAS PRESENTES
3. AUSENCIA LESION MASA y/o DLM
 DRENAJE LUMBAR

FUNDAMENTOS
• ESPACIO ESPINAL : > 50 % DE LCR
>30% DE LA COMPLIANCE CRANIOSPINAL

• NO COMPRESIÓN POR EDEMA

• MENOR RIESGO DE INFECCIÓN

Y HEMORRAGIA
Clinical evaluation of the safety and efficacy of lumbar cerebrospinal fluid drainage for the treatment of refractory
increased intracranial pressure.
Tuettenberg J, Czabanka M, Horn P, Woitzik J, Barth M, Thomé C, Vajkoczy P, Schmiedek P, Muench E.

J Neurosurg. 2009 Jun;110(6):1200-8.

J Neurosurg. 2009 Dec;111(6):1295; author reply 1295-6.

Neurologic outcome of posttraumatic refractory intracranial hypertension treated with external

lumbar drainage.
Abadal-Centellas JM, Llompart-Pou JA, Homar-Ramírez J, Pérez-Bárcena J, Rosselló-Ferrer A, Ibáñez-
Juvé J.

J Trauma. 2007 Feb;62(2):282-6; discussion 286.

J Trauma. 2007 Sep;63(3):720-1; author reply 721.

Therapy of malignant intracranial hypertension by controlled lumbar cerebrospinal fluid drainage.

Münch EC, Bauhuf C, Horn P, Roth HR, Schmiedek P, Vajkoczy P.

Crit Care Med. 2001 May;29(5):976-81.

External lumbar drainage in uncontrollable intracranial pressure in adults with severe head injury: a
report of 7 cases.
Willemse RB, Egeler-Peerdeman SM.

Acta Neurochir Suppl. 1998;71:37-9.

Lumbar drainage for the treatment of severe bacterial meningitis.

Abulhasan YB, Al-Jehani H, Valiquette MA, McManus A, Dolan-Cake M, Ayoub

O, Angle M, Teitelbaum J. Neurocrit Care. 2013 Oct;19(2):199-205.

Meningitis aguda grave

Neuro-intensive treatment targeting intracranial hypertension improves outcome

in severe bacterial meningitis: an intervention-control study.

Glimåker M, Johansson B, Halldorsdottir H, Wanecek M, Elmi-Terander A,

Ghatan PH, Lindquist L, Bellander BM. PLoS One. 2014; 9(3):e91976. Epub
2014 Mar 25.
 DRENAJE LUMBAR
CONTROLADO
EN LA PRÁCTICA

1. DRENAJE CERRADO CON APERTURA SOLAMENTE

CUANDO LA PIC SUPERA 25 mmHg DURANTE 10-20 min

2. DRENAJE CONTRA PRESIÓN DE 15 mmHg

3. MONITOREO RIGUROSO DEL RIESGO DE DESCENSO

CEREBRAL: TENTORIAL (foramen de Pacchioni) y
TONSILAR (foramen Magno)
 DRENAJE LUMBAR
CONTROLADO
TOMOGRAFÍA CRANEO
✓IDEAL CONTAR CON ESTUDIO PREVIO A
LA MEDIDA TERAPEÚTICA
✓CORTES FINOS A NIVEL DEL TENTORIO
Y FOSA POSTERIOR
• ¨sag ratio¨(Tentorio 0.91; 1 desplasamiento)
• Compresión Cisternal
• Compresión III y IV ventrículo
 DRENAJE LUMBAR

CONTRAINDICACIONES

• LESIÓN MASA Y DESVÍO DE LA LÍNEA MEDIA

• CISTERNAS BASALES BORRADAS

APROX. 10% RIESGO HERNIACIÓN

NO CONFIARSE EN AUSENCIA DE
CONTRAINDICACIONES
 DRENAJE LUMBAR
CONTROLADO
MEDIDAS CORRECTIVAS

1.CIERRE INMEDIATO

2.POSICIÓN DE TRENDELENBURG
URGENTE
DRENAJE LUMBAR

?
Sindrome Levy-Rekate
EDEMA CEREBRAL
F. CENTRÍPETA SUMA ARITMÉTICA

Hipertensión Intracraneana

RESTA GIOMÉTRICA
HIDROCEFALIA
F. CENTRÍFUGA
¨Cisternas Presentes¨

PATRÓN SEUDONORMAL

HSA, MENINGITIS, TRAUMA

 Caída GCS + anisocoria
(Chequear respuesta después de cada
medida)
✓Elevar Cabecera Cama
✓Asegurar PAM 80-90
Chequear y Solucionar A-B-C
✓Corregir Hipoxemia
Rechequear en forma seriada
✓Normoventilación 35
✓Iniciar SAC

Osmoterapia carga iv
HV 25-30 BBT bolo iv
SSH/Manitol

Convocar NQ TC Independientemente de la respuesta

Urgente clínica la TC debe realizarse siempre
urgente

✓Evacuación Lesión pasible de

✓Derivación Ext. Neurocirugía Unidad Lesión no pasible de Neurocirugía
✓Decompresiva BQ Neurointensivismo
Primaria

Neuromonitoreo
Multimodal
✓Si persiste HIC:
1-Chequear topes terapéuticos
Si disponemos DVE y continuamos de otras medidas de 1 Nivel utilizadas
Si se realizó Dsc. PIC
con HIC abrirla dado que es No contamos DVE 2- Si están al máximo, pasar al 2 y/o 3 N
usualmente controlada
altamente efectiva 3- Rechequear topes en la evolución
y mantener medidas al máximo mientra
continúe con HIC refractaria
THAM Indometacina

Descompresiva
Propofol Hipotermia Terapéutica Drenaje Lumbar
Secundaria