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CONTINUOUS, DIRECT MEASUREMENT OF ICP BY A SUBARACHANOID BOLT IN ASPHXYIATED TERM NEONATES

A newly developed infant subarachnoid bolt was used to continuously and directly monitor intracranial pressure (ICP) in four severely asphyxiated (Apgars 11 and 25) full-term neonates. The plastic bolt was inserted through a dural puncture and secured to the margins of a right frontal bone craniotomy. No hemorrhage, CSF leak, infection or mechanical dislodgement occurred. The bolt was successfully used until the patients' death at postnatal ages 30, 42, 71 and 84 hours. Direct (bolt) ICP values were polygraphically recorded and correlated with simultaneous indirect (transfontanelle) ICP values, mean arterial blood pressure, clinical status and seizures confirmed by EEG. After the transfontanelle pressure transducer was applied with sufficient external tension to produce indirect ICP values that matched direct values, subsequent indirect ICP measurements correlated well from 4 to 13 torr (direct/indirect ratio: M = 1.07; range = 0.8 to 1.5). Indirect ICP measurements consistently and significantly underestimated true ICP from 14 to 35 torr (direct/indirect ratio; M = 2.3; range 2.1 to 3.2). Clinical neurological and/or EEG abnormalities preceded (by age 28 hrs) peak ICP (peak ICP = 18 torr) in all infants. A modest (4 torr) ICP elevation accompanied only 2 of 128 brief (duration = 39 sec; range = 12 to 180 sec), focal electrographic seizures. We conclude that direct ICP measurements by a subarachnoid bolt in appropriately selected, critically ill neonates can be safely achieved and may be more reliable than transfontanelle measurements.