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BJA Advance Access published online on April 1, 2005
British Journal of Anaesthesia, doi:10.1093/bja/aei121
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© The Board of Management and Trustees of the British Journal of Anaesthesia 2005. All rights reserved. For Permissions, please e-mail: journal.permissions@oupjournals.org
Accepted February 11, 2005

Clinical Investigation

Value of Cushing reflex as warning sign for brain ischaemia during neuroendoscopy{dagger}

A. F. Kalmar 1*, J. Van Aken 1, J. Caemaert 2, E. P. Mortier 1, and M. M. R. F. Struys 1

1 Department of Anaesthesia, Ghent University Hospital, Ghent, Belgium
2 Department of Neurosurgery, Ghent University Hospital, Ghent, Belgium

* To whom correspondence should be addressed.
A. F. Kalmar, E-mail: alain.kalmar{at}Ugent.be


  Abstract

Background. During an endoscopic neurosurgical procedure a sudden increase in intracranial pressure may occur at any time. We present a prospective study of haemodynamic changes during such procedures.

Methods. Physiological data were recorded during the whole operative procedure in 17 consecutive patients who underwent an endoscopic neurosurgical procedure under general anaesthesia. Monitoring included invasive blood pressure, intracranial pressure, electrocardiogram, end-expired carbon dioxide, pulse oximetry and heart rate. Pressure and ECG waveforms were recorded at 100 Hz and evaluated in a subsequent offline analysis.

Results. In almost every case, the occurrence of hypertension and tachycardia was clearly the result of an increase in intracranial pressure. Also, a Cushing reflex developed in almost every case where the cerebral perfusion pressure dropped below 15 mm Hg. The occurrence of bradycardia was not systematically associated with a low cerebral perfusion pressure.

Conclusion. In this study, we describe the haemodynamic effects of increased intracranial pressure during endoscopic neurosurgical procedures and their respective sequence of events at high temporal resolution. Although most clinicians rely on the occurrence of bradycardia to diagnose intracranial hypertension during endoscopic neurosurgical procedures, we show that a simultaneous onset of hypertension and tachycardia is a better indicator of impaired brain perfusion. Waiting for a persistent bradycardia to alert the surgeon during endoscopic neurosurgical procedures could allow severe bradycardia or even asystole to develop.

Keywords: brain, cerebral blood flow; brain, cerebral perfusion pressure; brain, intracranial pressure; brain, ventriculostomy; complications, hydrocephalus; equipment, endoscope; procedure, endoscopic third ventriculostomy; reflexes, Cushing.
{dagger} This work was performed at the Department of Anaesthesia, Ghent University Hospital, Ghent, Belgium.
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A. F. Kalmar, G. De Ley, C. Van Den Broecke, J. Van Aken, M. M. R. F. Struys, M. M. Praet, and E. P. Mortier
Influence of an increased intracranial pressure on cerebral and systemic haemodynamics during endoscopic neurosurgery: an animal model
Br. J. Anaesth., March 1, 2009; 102(3): 361 - 368.
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