The use of indomethacin in the treatment of plateau waves: Effects on cerebral perfusion and oxygenation

Roberto Imberti, Marinella Fuardo, Guido Bellinzona, Michele Pagani, Martin Langer

Research output: Contribution to journalArticle

Abstract

Object. Plateau waves are sudden and steep increases in intracranial pressure (ICP) that can develop in patients with cerebral injuries, reduced pressure-volume compensatory reserve, and preserved autoregulation. They are caused by cerebral vasodilation in response to a reduction in cerebral perfusion and are associated with increased cerebral blood volume and reduced cerebral blood flow. The authors evaluated the hypothesis that administration of indomethacin, a potent cerebral arteriolar vasoconstrictor, could interrupt the vicious cycle that occurs during plateau waves, extinguishing these waves and, ultimately, restoring cerebral perfusion and oxygenation. Methods. Plateau waves developed in nine patients, seven with severe traumatic brain injury and two with intraparenchymal hemorrhage. One to four episodes of plateau waves per patient were treated with indomethacin (15-20 mg), which was delivered by an intravenous bolus injection. Each patient's mean arterial blood flow (MABP), ICP, cerebral perfusion pressure (CPP), and cerebral tissue PO2 were continuously monitored and the data obtained were stored in a personal computer. Each patient's jugular venous O2 saturation (SjvO2) and venoarterial difference in PCO2 were evaluated by intermittent blood sampling. During five episodes of plateau waves, middle cerebral artery flow velocities were evaluated by transcranial Doppler ultrasonography. Indomethacin extinguished all plateau waves. On average, the ICP decreased from an initial value of 58.9 ± 11.6 mm Hg to 21.2 ± 8.6 and 25.8 ± 13.7 mm Hg after 5 and 10 minutes, respectively (p <0.01). The MABP did not change significantly. As a consequence the CPP increased by 98 and 81% after 5 and 10 minutes, respectively (p <0.01). Five and 10 minutes after indomethacin was administered, SjvO2 increased from an initial value of 50 ± 10.5% to 62 ± 7.6 and 59.9 ± 9.3%, respectively (p <0.01); the cerebral tissue PO2 increased from an initial value of 13.4 ± 10.6 mm Hg to 23.6 ± 9.58 and 21.9 ± 9.2 mm Hg, respectively (p <0.05); and the venous-arterial PCO2 decreased significantly. The mean and diastolic flow velocities increased significantly, whereas the pulsatility index decreased from 1.39 ± 0.56 to 1.09 ± 0.4 at 5 minutes and 1.06 ± 0.36 at 10 minutes (p <0.05). Conclusions. The findings confirm that plateau waves are caused by vasodilation and show that indomethacin, by constricting the cerebral arteries, is effective in extinguishing plateau waves, ultimately restoring cerebral perfusion and oxygenation.

Original languageEnglish
Pages (from-to)455-459
Number of pages5
JournalJournal of Neurosurgery
Volume102
Issue number3
DOIs
Publication statusPublished - Mar 2005

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Cerebrovascular Circulation
Indomethacin
Perfusion
Intracranial Pressure
Vasodilation
Doppler Transcranial Ultrasonography
Therapeutics
Cerebral Arteries
Intracranial Hypertension
Middle Cerebral Artery
Microcomputers
Vasoconstrictor Agents
Intravenous Injections
Homeostasis
Neck
Hemorrhage
Pressure
Wounds and Injuries

Keywords

  • Cerebral oxygenation
  • Intracranial pressure
  • Plateau wave
  • Transcranial Doppler ultrasonography
  • Venoarterial difference in partial pressure of carbon dioxide

ASJC Scopus subject areas

  • Clinical Neurology
  • Neuroscience(all)

Cite this

The use of indomethacin in the treatment of plateau waves : Effects on cerebral perfusion and oxygenation. / Imberti, Roberto; Fuardo, Marinella; Bellinzona, Guido; Pagani, Michele; Langer, Martin.

In: Journal of Neurosurgery, Vol. 102, No. 3, 03.2005, p. 455-459.

Research output: Contribution to journalArticle

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T2 - Effects on cerebral perfusion and oxygenation

AU - Imberti, Roberto

AU - Fuardo, Marinella

AU - Bellinzona, Guido

AU - Pagani, Michele

AU - Langer, Martin

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N2 - Object. Plateau waves are sudden and steep increases in intracranial pressure (ICP) that can develop in patients with cerebral injuries, reduced pressure-volume compensatory reserve, and preserved autoregulation. They are caused by cerebral vasodilation in response to a reduction in cerebral perfusion and are associated with increased cerebral blood volume and reduced cerebral blood flow. The authors evaluated the hypothesis that administration of indomethacin, a potent cerebral arteriolar vasoconstrictor, could interrupt the vicious cycle that occurs during plateau waves, extinguishing these waves and, ultimately, restoring cerebral perfusion and oxygenation. Methods. Plateau waves developed in nine patients, seven with severe traumatic brain injury and two with intraparenchymal hemorrhage. One to four episodes of plateau waves per patient were treated with indomethacin (15-20 mg), which was delivered by an intravenous bolus injection. Each patient's mean arterial blood flow (MABP), ICP, cerebral perfusion pressure (CPP), and cerebral tissue PO2 were continuously monitored and the data obtained were stored in a personal computer. Each patient's jugular venous O2 saturation (SjvO2) and venoarterial difference in PCO2 were evaluated by intermittent blood sampling. During five episodes of plateau waves, middle cerebral artery flow velocities were evaluated by transcranial Doppler ultrasonography. Indomethacin extinguished all plateau waves. On average, the ICP decreased from an initial value of 58.9 ± 11.6 mm Hg to 21.2 ± 8.6 and 25.8 ± 13.7 mm Hg after 5 and 10 minutes, respectively (p <0.01). The MABP did not change significantly. As a consequence the CPP increased by 98 and 81% after 5 and 10 minutes, respectively (p <0.01). Five and 10 minutes after indomethacin was administered, SjvO2 increased from an initial value of 50 ± 10.5% to 62 ± 7.6 and 59.9 ± 9.3%, respectively (p <0.01); the cerebral tissue PO2 increased from an initial value of 13.4 ± 10.6 mm Hg to 23.6 ± 9.58 and 21.9 ± 9.2 mm Hg, respectively (p <0.05); and the venous-arterial PCO2 decreased significantly. The mean and diastolic flow velocities increased significantly, whereas the pulsatility index decreased from 1.39 ± 0.56 to 1.09 ± 0.4 at 5 minutes and 1.06 ± 0.36 at 10 minutes (p <0.05). Conclusions. The findings confirm that plateau waves are caused by vasodilation and show that indomethacin, by constricting the cerebral arteries, is effective in extinguishing plateau waves, ultimately restoring cerebral perfusion and oxygenation.

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KW - Cerebral oxygenation

KW - Intracranial pressure

KW - Plateau wave

KW - Transcranial Doppler ultrasonography

KW - Venoarterial difference in partial pressure of carbon dioxide

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