(685) Verticalization for Refractory Intracranial Hypertension

Introduction: Intracranial hypertension is strongly associated with mortality and current management guidelines recommend a tiered approach. This study evaluated verticalization as a non-invasive method for managing intracranial hypertension refractory to standard management. We propose that verticalization is an effective tool in reducing ICP.

Methods: Retrospective, single-center study of 27 patients verticalized for refractory intracranial hypertension. Patients were managed per guidelines in a tiered manner. Those who sustained ICP >20 mmHg were verticalized ranging from 6 to 180 hours. Hourly ICP values in the 24 hours pre-and-post verticalization were collected via an external ventricular drain, with comparison of the change in median ICP, number of ICP spikes, and ICP targeting interventions aggregated into the therapy intensity level (TIL), a validated scoring system.

Results: 9 TBI and 18 vascular patients. 8 survived to discharge. Median ICP across all patients pre-and-post verticalization was 17 mmHg and 16 mmHg respectively. 12 patients demonstrated improvement in median ICP from 19.5 mmHg to 11.5 mmHg, with an average reduction of 5.4 mmHg. The number of ICP spikes greater than 20 mmHg reduced from 219 to 208. Percentage of ICPs >20 mmHg decreased from 38% to 34%. Average TIL score decreased from 19.3 to 15.1 after verticalization. Adverse outcomes included one case of lower extremity compartment syndrome and 11 patients with pressure-related injuries.

Conclusions: Verticalization is an effective tool for lowering ICP in refractory intracranial hypertension. Although the overall median ICP pre-and-post were not significantly different, average ICP alone may not be a reliable marker of mortality. Pooled time spent over the ICP threshold may play a role in secondary brain injury and verticalization appears to reduce ICP spikes. We suspect that ICP reduction is due to improved venous outflow by gravity. Verticalization also has an impact on ICP targeting interventions, with a reduction in TIL post-verticalization. Adverse events included pressure wounds and compartment syndrome.. Our population had a high mortality rate which may reflect the use of verticalization as salvage therapy. Future directions include investigating optimal timing for verticalization and long term outcomes.