1. Papilloedema as a Non-Invasive Marker for Raised ICP Following Decompressive Craniectomy for Severe Head Injury SHEJOY JOSHUA, DEEPAK AGRAWAL BS SHARMA, AK MAHAPATRA Department of Neurosurgery, JPN Apex Trauma Center, AIIMS, Dew Delhi.

2. Background Decompressive craniectomy (DC) – the time tested treatment for Severe HI

3. Background It is generally believed that ICP normalises after an adequate decompressive craniectomy Especially as CT usually shows open cisterns & resolution of MLS

4. Hypothesis Some patients may redevelop raised ICP after a variable period following decompressive craniectomy Possibly due to hydrocephalus &/or reduced brain compliance CT scan is not a sensitive indicator of raised intracranial pressure

5. Research Question(s) How to assess for raised ICP in these patients reliably and non-invasively

6. Possible solution Fundoscopy – a simple clinical examination to pick up raised ICP Papilloedema is considered pathognomic of raised ICP

7. Aims and objectives To study the temporal course of fundoscopic findings in patients with severe HI following decompressive craniectomy. To correlate Fundoscopy findings with ventriculomegaly on serial CT’s in these patients

8. Aims and objectives (Secondary) To correlate ICP readings with papilloedoma in patients who had ICP monitoring Time-course of resolution of papilloedema in selected patients who had lumbar drain placed

9. Material & Methods Prospective study over 5 month period Fundoscopic examination and serial CT to diagnose Ventriculomegaly Papilloedema

10. Material & Methods Inclusion criteria Severe HI pts (GCS ≤8) who underwent DC Exclusion criteria Pre-existing DM/HT Pts in which fundoscopy is not possible Cataract Eyeball injury

11. Material & Methods Surgery All patients underwent a wide decompressive craniectomy with lax duraplasty and were electively ventilated for a variable period of time (Range-3-30days).

12. Material & Methods Serial fundoscopic examinations at day 1, 2, 3, 5, 7 & 14 Serial CT scans (according to surgeon’s preference)

13. Definitions Papilloedema presence of hyperemia of the disc or blurring of disc margins along with absent spontaneous venous pulsations.

17. Definitions Ventriculomegaly ratio of frontal horn diameter to intracranial diameter taken at the same level was >50% along with 2 or more of the following criteria dilatation of temporal horn > 2 mm ballooning of III rd ventricle Peri-ventricular lucency

18. Results Total patients- 32 Age 12-75 years (Mean 33.75 SD 13.93). Glasgow coma scale on admission ranged from 3/15- 8/15 (Mean 6.28 Std. Dev. 1.63) Acute SDH 12 Contusion 20

19. Results PAPILLEDEMA CLOSELY CORRELATED WITH RAISED ICP MEASURED WITH INVASIVE MONITORING

20. Incidence of papilloedema following Decompressive craniectomy on serial Fundoscopic examination

21. Comparison of ventriculomegaly on C.T head with Papilloedema on Fundoscopic examination at the same time interval

25. Discussion No similar studies in literature! This study validates the use of papilloedema as an extremely sensitive marker for acute changes in ICP.

26. Conclusion(s) Significant number of patients (12.5% in our study) had recurrence of raised ICP following decompressive craniectomy for severe HI There was prompt resolution of the ICP on lumbar drainage suggesting CSF absorption block as a possible mechainsm of this raised ICP

27. Conclusion(s) Papilloedema is an early indicator of raised ICP and correlates well with the intracranial pressure in head injured patients This study validates the use of papilloedema as an extremely sensitive marker for acute changes in ICP.

28. Thank you