Neurological examination on sedated patients is challenging and no gold standard monitoring is currently available. We report the case of a patient deeply sedated for the management of acute respiratory distress syndrome secondary to pneumonia. Delay in awakening led to cerebral exploration by transcranial Doppler (TCD) and measurement of optic nerve sheath diameter (ONSD). Abnormal values of ONSD prompted immediate brain computed tomography scan that confirmed high intracranial pressure (ICP) due to multiple deep parenchymal hematomas. Despite raised ICP, values obtained by TCD were normal, thanks to the persistence of cerebral autoregulation. This case highlights the interest of combining noninvasive techniques for neurological examination, especially for sedated patients.
Nasraway SA Jr., Wu EC, Kelleher RM, Yasuda CM, Donnelly AM. How reliable is the bispectral index in critically ill patients? A prospective, comparative, single-blinded observer study. Crit Care Med 2002;30:1483-7.
McKenzie CA, McKinnon W, Naughton DP, Treacher D, Davies G, Phillips GJ, et al. Differentiating midazolam over-sedation from neurological damage in the Intensive Care Unit. Crit Care 2005;9:R32-6.
Czosnyka M, Matta BF, Smielewski P, Kirkpatrick PJ, Pickard JD. Cerebral perfusion pressure in head-injured patients: A noninvasive assessment using transcranial Doppler ultrasonography. J Neurosurg 1998;88:802-8.
Geeraerts T, Merceron S, Benhamou D, Vigué B, Duranteau J. Non-invasive assessment of intracranial pressure using ocular sonography in neurocritical care patients. Intensive Care Med 2008;34:2062-7.
Kress JP, Pohlman AS, O'Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000;342:1471-7.
Dubost C, Motuel J, Geeraerts T. Non-invasive evaluation of intracranial pressure: How and for whom? Ann Fr Anesth Reanim 2012;31:e125-32.
Dubourg J, Javouhey E, Geeraerts T, Messerer M, Kassai B. Ultrasonography of optic nerve sheath diameter for detection of raised intracranial pressure: A systematic review and meta-analysis. Intensive Care Med 2011;37:1059-68.
Münch E, Weigel R, Schmiedek P, Schürer L. The Camino intracranial pressure device in clinical practice: Reliability, handling characteristics and complications. Acta Neurochir (Wien) 1998;140:1113-9.