Multimodal monitoring during emergency hemicraniectomy for vein of Labbe thrombosis

Cortical venous thrombosis is a rarely encountered mechanism for intracerebral hemorrhage. Multimodal monitoring may guide neurosurgical and critical care treatment in the setting of cerebral venous thrombosis. We report a 37-year-old service member who was admitted to a local field hospital for complaints of severe headache and left ear pain during Operation Iraqi Freedom. CT scan revealed a left temporal intracranial hematoma and subarachnoid hemorrhage. Angiogram revealed thrombosis of the vein of Labbe. Intracranial pressure (ICP), brain tissue oxygenation (PbO2), and cerebral blood flow (CBF) were monitored. There was a progressive increase in ICP despite ventricular drainage, sedation, and intubation. There was an ominous decrease in brain tissue oxygen and CBF became undetectable concomitantly with the increase in ICP. There was a dramatic decrease in ICP and improvement in brain tissue oxygenation and CBF after decompression and evacuation of the hematoma. Six weeks after the hemorrhage, the patient was able to follow simple commands and complete short sentences. To our knowledge, this is the first description of the use of ICP, PbO2, and laser Doppler method for obtaining CBF in the same setting. Information obtained from monitoring may lead to timely decompression and avoidance of poor outcome.