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Midline Shift after Severe Head Injury: Pathophysiologic Implications

Valadka, Alex B. MD; Gopinath, Shankar P. MD; Robertson, Claudia S. MD

The Journal of Trauma: Injury, Infection, and Critical Care: July 2000 - Volume 49 - Issue 1 - p 1-10
Annual Meeting Articles
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Objective To investigate the mechanism of the adverse effect of midline shift after severe traumatic brain injury.

Methods This study compared averaged cerebral metabolic parameters of patients with midline shift > 5 mm (S) on initial computerized tomography scan to those of patients with shift ≤ 5 mm (NS). The effect of an acute subdural hematoma (SDH) was determined by separating patients into those with and those without SDH and then re-examining the effect of shift in these subgroups.

Results Four hundred fifty-four patients were studied. Cerebral metabolic rate of oxygen (CMRo2, in mL/100 g per min) was always lower with shift: 1.74 for SDH-S versus 2.21 for SDH-NS (p < 0.001), and 1.80 for non–SDH-S versus 2.24 for non–SDH-NS (p < 0.001). No other major effects of shift were seen in SDH patients. Among non-SDH patients, shift was associated with higher intracranial pressure (ICP): 23.1 mm Hg versus 16.3 mm Hg (p < 0.001). Other differences between shift and nonshift patients in the non-SDH group were due at least in part to interventions to treat the elevated ICP.

Conclusion Midline shift after severe traumatic brain injury is associated with reduced CMRo2, regardless of whether or not SDH is present. The deleterious effects of subdural blood may be related more to the mass effect of large SDHs than to the biochemical abnormalities caused by small amounts of blood in the subdural space.

Address for reprints: Alex B. Valadka, MD, Department of Neurosurgery, Baylor College of Medicine, 6560 Fannin Street, Suite 944, Houston, TX 77030.

Submitted for publication September 24, 1999.

Accepted for publication March 29, 2000.

Department of Neurosurgery, Baylor College of Medicine, Houston, Texas

Supported by National Institutes of Health Grant NS-38660.

Presented at the 59th Annual Meeting of the American Association for the Surgery of Trauma, September 16, 1999, Boston, Massachusetts.

© 2000 Lippincott Williams & Wilkins, Inc.