ANTERIOR FONTANELLE PRESSURE MONITORING IN INFANTS Fontaneldrukmeting bij jonge kinderen Vormgeving: Th. Vanoordt, Amsterdam. Druk- en zetwerk: Roos en Roos drukkers, Arnhem. CIP-GEGEVENS KONINKLIJKE BIBLIOTHEEK, DEN HAAG Overweg-Plandsoen, Wouterina Cornelia Geertruida Anterior fontanelle pressure monitoring in infants I Wouterina Cornelia Geertruida Overweg­ Plandsoen. - [S.l. : s.n.]. - Ill. Proefschrift Rotterdam.- Met lit. opg.- Met samenvatting in het Nederlands. ISBN 90-9003637-7 SISO 605.2 UDC 611.7:611.911.93-052-053.2(043.3) Trefw.: fontaneldrukmeting I kindergeneeskunde. Copyright© 1990 by W.C.G. Overweg-Plandsoen All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior permission of the author. Adress: Academic medical centre, Department of child neurology GS-205, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. ANTERIOR FONTANELLE PRESSURE MONITORING IN INFANTS F ontaneldrukmeting bij jonge kinderen proefschrift ter verkrijging van de graad van doctor aan de Erasmus Universiteit Rotterdam op gezag van de rector magnificus prof.dr. C.J. Rijnvos en volgens besluit van het college van dekanen. De openbare verdediging zal plaatsvinden op woensdag 3 oktober 1990 om 15.45 uur precies door Wouterina Cornelia Geertruida Overweg-Plandsoen geboren te Rotterdam Promotiecommissie Promotor Prof.dr. C.J.J. A vezaat Co-promotor Dr. M.C.B. Loonen Overige leden Prof.dr. H. van Crevel Prof.dr. P.J.J. Sauer Prof.dr.ir. C.J. Snijders M eten is we ten Voor alle kinderen die zich hebben laten meten (met toestemming van Toonder Studio's B. V.) H et verschijnen van dit proefschrift in deze vorm werd mogelijk gemaakt door steun van het Van Leersumfonds, Katwijk Farma BV, Hoechst, Wellcome, Sanofi, N ourypharma en het R.A. Laanfonds. CONTENTS 1 General introduction ....................................................... 9 2 ICP monitoring techniques in children ................................... 13 3 The Rotterdam T eletransducer ........................................... 28 4 Anterior Fontanelle Pressure in normal newborns and infants ................................................................. 38 5 Anterior Fontanelle Pressure measurements in patients .................. 52 6 Inter-observer analysis in a random sample of Anterior Fontanelle Pressure recordings ............................................ 74 7 Anterior Fontanelle Pressure monitoring in clinical practice ............. 81 Summary ................................................................... 95 Samenvatting ............................................................. 101 References ................................................................ 106 Abbreviations ............................................................. 120 N awoord .................................................................. 121 Curriculum Vitae ......................................................... 123 7 CHAPTER 1 GENERAL INTRODUCTION The idea of measuring intracranial pres­ dicating a disturbance in cerebral function, sure (I CP) dates back to 1866 when Leyden appeared. Lundberg (1960) regarded the attempted to measure the ICP directly via normal range of VFP as between 0 and a trephined opening. With the introduc­ 15 mmHg. Welch (1980) has more recently tion of the lumbar puncture by Quincke pointed out that in infants, an upper level in 1891 the possibility of examining the of 5 mmHg would be more appropriate. cerebrospinal fluid (CSF) and of measuring A mean ICP in excess of 20 mmHg is the cerebrospinal fluid pressure (CSFP) agreed to be abnormal. was born. When continuous recording of ICP be­ The role of (continuous) ICP monitoring came possible in clinical practice (Guillau­ in clinical practice is still open to discus­ me andJanny 1951, Lundberg 1960) a new sion (Miller 1985, Ropper 1985). Its prop­ dimension was given to clinical research onents claim that the technique is an in the field of intracranial hypertension. integral part of neurologic and neuro­ Since then a continuous flow of papers surgical intensive care and should play a on ICP has appeared in the international part in the management of every comatose journals and a cycle of, so far, seven patient, while opponents hold that there international symposia on this subject has is no evidence that the implementation of been held between 1972 and 1988; the ICP monitoring influences outcome to an eighth symposium to come in 1991. extent that justifies the risks of this in­ vasive procedure. For a long time the diagnosis of 'normal', 'low', or 'high' ICP was mainly based on Many former beliefs about the clinical the presence or absence of certain neuro­ features of raised ICP are erroneous. The logical symptoms and signs in patients. symptomatology of raised ICP depends as Neurologists and neurosurgeons especial­ much on its cause as the level of pressure ly, were aware of the fact that intracranial attained. In benign intracranial hyperten­ pressure could influence cerebral function. sion, for instance, ICP may be in excess This was based mainly on clinical obser­ of 60 mmHg, yet the patient may remain vations and upon sporadically performed conscious with no abnormal neurologic animal experiments. signs, however, papilloedema is usually Due to the extensive work of Lundberg present (Grant 1971, Van Crevel 1982). (1960) more insight was gained into the In the patient with a head injury, an variations of- ICP in normal and patho­ increase in ICP to 30 mmHg may be logical conditions. With the routine use associated with a marked reduction in the of ventricular catheters to measure ven­ consciousness level with dilatation of a tricular fluid pressure (VFP) it was pos­ pupil and alterations in arterial pressure sible to detect pathological alterations in and heart rate. The only way to exclude the level of ICP, before clinical signs in- raised ICP is to measure it. Raised ICP 9 (a mean of more than 20 mmHg) occurs cardiac arrest, strangulation or near­ in 50% of all comatose patients with head drowning (Donn and Philip 1978, Dean injury, while papilloedema is present in less and McComb 1981, Levene and Evans than 5% (Miller et al. 1981). It occurs in 1983, Nussbaum and Galant 1983, Sarnaik the majority of comatose patients with et al. 1985). subarachnoid haemorrhage or intracere­ bral haematoma and is common in patients It is important to have accurate informa­ who are comatose as a result of hypoxia, tion on the ICP. Besides the ventricular meningitis and encephalitis, toxic ence­ catheter (Lundberg 1960) other methods phalopathies and even hepatic coma for measuring ICP were developed. Suba­ (Lundberg 1972, Moss and McDowall rachnoid, subdural, intraparenchymal and 1979, Brock 1983, Miller 1985). epidural devices were introduced. Now­ The higher the ICP, the poorer is the adays, the subarachnoid screw (Vries et al. prognosis. This is most clearly seen in 1973), the intraparenchymal fiber-optic patients with head injuries (Miller 1985). transducer tipped catheter (Ostrup et al. The most extreme example is where ICP 1987) and (telemetric) epidural transducers rises to the level of arterial pressure, (DeJong et al. 1975, 1979, 1982, Kostel­ perfusion of the cerebral hemispheres and janetz et al. 1986, Nornes and Serck­ upper brainstem ceases and clinical brain Hansen 1970, Tindall et al. 1972, Chap­ death occurs. man et al. 1980) are being used in neuro­ Additional indications of the desirability surgical practice. However, leakage of of measuring ICP exist in patients with CSF, blockage of a catheter or screw by papilloedema of unknown origin or in swollen brain tissue, or errors in positio­ patients with normal pressure hydro­ ning and calibration of the transducer can cephalus where it is important to know contribute to an inaccurate record of ICP. whether ICP is normal or increased (Hoff­ Furthermore, physiologic parameters man 1986, Borgesen and Gjerris 1982). In might influence ICP such as the systemic cases of hydrocephalus ICP recording may arterial pressure and respiration. Also in­ be used for pre-operative assessment and tracranial pressure monitoring is invasive also to check the effect of a shunt ope­ and introduces the risk of infection (Smith ration (Symon and Dorsch 1975). In the and Alksne 1976). postoperative management of neurosurgi­ cal patients ICP monitoring may help in It is essential to balance benefit and risk the early detection of a developing haema­ in every patient in whom an ICP moni­ toma (Tagaki et al. 1986). toring technique is used. There is no definite evidence that ICP monitoring will In pediatric patients, besides the above improve outcome, the only exception mentioned criteria for measuring ICP, spe­ being perhaps in the management of cial indications exist such as intraven­ Reye's syndrome in children. In this con­ tricular haemorrhage in prematures and dition there is diffuse swelling of the brain newborns (Ahmann et al. 1980, Dykes et and raised ICP that in some cases ends al. 1989), (posthaemorrhagic) hydrocepha­ in brain death (Mickell and Ward 1984). lus (Hayden et al. 1970, Shapiro et al. 1984, In the management of patients with head Volpe 1989a,b), bacterial mening1t1s injury it is difficult to prove that ICP (Minns and Engleman 1988), and hypoxic­ monitoring improves outcome or morta­ ischaemic encephalopathy secondary to lity (Miller 1985, Stuart et al. 1983). 10 ICP monitoring can aid management. It