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Zhang C, Ge L, Li Z, Zhang T, Chen J. Single-Center Retrospective Analysis of Risk Factors for Hydrocephalus After Lateral Ventricular Tumor Resection. Front Surg 2022; 9:886472. [PMID: 35784941 PMCID: PMC9243456 DOI: 10.3389/fsurg.2022.886472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/24/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThere is no general consensus on the placement of preoperative and intraoperative external ventricular drainage (EVD) in patients with lateral ventricular tumors (LVTs). The aim of this study was to identify the predictors of postoperative acute and persistent hydrocephalus need for postoperative cerebrospinal fluid (CSF) drainage and guide the management of postoperative EVD in patients with LVTs.MethodsWe performed a single-institution, retrospective analysis of patients who underwent resection of LVTs in our Department between January 2011 and March 2021. Patients were divided between one group that required CSF drainage and another group without the need for CSF drainage. We analyzed the two groups by univariate and multivariate analyses to identify the predictors of the requirement for postoperative CSF drainage due to symptomatic intracranial hypertension caused by hydrocephalus.ResultsA total of 97 patients met the inclusion criteria, of which 31 patients received preoperative or intraoperative EVD. Ten patients without prophylactic EVD received postoperative EVD for postoperative acute hydrocephalus. Eleven patients received postoperative ventriculoperitoneal(VP) shunt subsequently. Logistic regression analysis showed that tumor invasion of the anterior ventricle (OR = 7.66), transependymal edema (OR = 8.76), and a large volume of postoperative intraventricular hemorrhage (IVH) (OR = 6.51) were independent risk factors for postoperative acute hydrocephalus. Perilesional edema (OR = 33.95) was an independent risk factor for postoperative VP shunt due to persistent hydrocephalus.ConclusionPostoperative hydrocephalus is a common complication in patients with LVTs. These findings might help to determine whether to conduct earlier interventions.
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Affiliation(s)
- Chengda Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Department of Neurosurgery, The Affiliated Hospital of Hubei University of Medicine, The First People’s Hospital of Xiangyang, Xiangyang, China
| | - Lingli Ge
- Department of Paediatrics, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, The Central Hospital of Xiangyang, Xiangyang, China
| | - Zhengwei Li
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Tingbao Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Correspondence: Jincao Chen Tingbao Zhang
| | - Jincao Chen
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Correspondence: Jincao Chen Tingbao Zhang
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Doron O, Hemphill JC, Manley G, Rosenthal G. Improved Pressure Equalization Ratio Following Mannitol Administration in Patients With Severe TBI: A Preliminary Study of a Potential Bedside Marker for Response to Therapy. Neurocrit Care 2021; 36:519-526. [PMID: 34498204 PMCID: PMC8425582 DOI: 10.1007/s12028-021-01332-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/13/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Performing a cerebrospinal fluid (CSF) drainage challenge can be used to measure the pressure equalization (PE) ratio, which describes the extent to which CSF drainage can equalize pressure to the height of the external ventricular drain and may serve as a correlate of cerebral edema. We sought to assess whether treatment with mannitol improves PE ratio in patients with severe traumatic brain injury (TBI) with elevated intracranial pressure (ICP). METHODS We studied consecutive patients with TBI and brain edema on computed tomography scan and an external ventricular drain (EVD), admitted to the neurointensive care unit. PE ratio, defined as ICP prior to CSF drainage minus ICP after CSF drainage divided by ICP prior to CSF drainage minus EVD height, was measured as previously described. Patients were treated with mannitol for raised ICP based on clinical indication and PE ratio measured before and after mannitol administration. RESULTS We studied 20 patients with severe TBI with raised ICP. Mean ICP prior to mannitol treatment was 29 ± 7 mm Hg. PE ratio rose substantially after mannitol treatment (0.62 ± 0.24 vs. 0.29 ± 0.20, p < 0.0001), indicating an improved ability to drain CSF and equalize ICP with the preset height of the EVD. The combination of mannitol and CSF drainage led to an improved reduction in ICP compared with that seen before mannitol therapy (11 ± 2 mm Hg vs. 6 ± 2 mm Hg, p < 0.01), and led to a decrease in ICP below the 20 mm Hg threshold in 77% of cases. CONCLUSIONS Treatment with mannitol leads to a substantial improvement in PE ratio that reflects the ability to achieve a greater decrease in ICP when CSF drainage is performed after mannitol administration. This preliminary study raises the possibility that PE ratio may be useful to follow response to therapy in patients with cerebral edema and raised ICP. Further studies to determine whether PE ratio may serve as an easily obtained and clinically useful surrogate marker for the extent of brain edema are warranted.
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Affiliation(s)
- Omer Doron
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Engineering, Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - J Claude Hemphill
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Geoffrey Manley
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | - Guy Rosenthal
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Cook AM, Morgan Jones G, Hawryluk GWJ, Mailloux P, McLaughlin D, Papangelou A, Samuel S, Tokumaru S, Venkatasubramanian C, Zacko C, Zimmermann LL, Hirsch K, Shutter L. Guidelines for the Acute Treatment of Cerebral Edema in Neurocritical Care Patients. Neurocrit Care 2020; 32:647-666. [PMID: 32227294 PMCID: PMC7272487 DOI: 10.1007/s12028-020-00959-7] [Citation(s) in RCA: 148] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Acute treatment of cerebral edema and elevated intracranial pressure is a common issue in patients with neurological injury. Practical recommendations regarding selection and monitoring of therapies for initial management of cerebral edema for optimal efficacy and safety are generally lacking. This guideline evaluates the role of hyperosmolar agents (mannitol, HTS), corticosteroids, and selected non-pharmacologic therapies in the acute treatment of cerebral edema. Clinicians must be able to select appropriate therapies for initial cerebral edema management based on available evidence while balancing efficacy and safety. METHODS The Neurocritical Care Society recruited experts in neurocritical care, nursing, and pharmacy to create a panel in 2017. The group generated 16 clinical questions related to initial management of cerebral edema in various neurological insults using the PICO format. A research librarian executed a comprehensive literature search through July 2018. The panel screened the identified articles for inclusion related to each specific PICO question and abstracted necessary information for pertinent publications. The panel used GRADE methodology to categorize the quality of evidence as high, moderate, low, or very low based on their confidence that the findings of each publication approximate the true effect of the therapy. RESULTS The panel generated recommendations regarding initial management of cerebral edema in neurocritical care patients with subarachnoid hemorrhage, traumatic brain injury, acute ischemic stroke, intracerebral hemorrhage, bacterial meningitis, and hepatic encephalopathy. CONCLUSION The available evidence suggests hyperosmolar therapy may be helpful in reducing ICP elevations or cerebral edema in patients with SAH, TBI, AIS, ICH, and HE, although neurological outcomes do not appear to be affected. Corticosteroids appear to be helpful in reducing cerebral edema in patients with bacterial meningitis, but not ICH. Differences in therapeutic response and safety may exist between HTS and mannitol. The use of these agents in these critical clinical situations merits close monitoring for adverse effects. There is a dire need for high-quality research to better inform clinicians of the best options for individualized care of patients with cerebral edema.
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Affiliation(s)
- Aaron M Cook
- UK Healthcare, University of Kentucky College of Pharmacy, Lexington, KY, USA.
| | | | | | | | | | | | - Sophie Samuel
- Memorial Hermann-Texas Medical Center, Houston, TX, USA
| | - Sheri Tokumaru
- The Daniel K. Inouye College of Pharmacy | University of Hawaii at Hilo, Honolulu, HI, USA
| | | | - Christopher Zacko
- Penn State University Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | | | - Karen Hirsch
- Stanford University Medical Center, Stanford, CA, USA
| | - Lori Shutter
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Zusman BE, Kochanek PM, Jha RM. Cerebral Edema in Traumatic Brain Injury: a Historical Framework for Current Therapy. Curr Treat Options Neurol 2020; 22:9. [PMID: 34177248 PMCID: PMC8223756 DOI: 10.1007/s11940-020-0614-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE OF REVIEW The purposes of this narrative review are to (1) summarize a contemporary view of cerebral edema pathophysiology, (2) present a synopsis of current management strategies in the context of their historical roots (many of which date back multiple centuries), and (3) discuss contributions of key molecular pathways to overlapping edema endophenotypes. This may facilitate identification of important therapeutic targets. RECENT FINDINGS Cerebral edema and resultant intracranial hypertension are major contributors to morbidity and mortality following traumatic brain injury. Although Starling forces are physical drivers of edema based on differences in intravascular vs extracellular hydrostatic and oncotic pressures, the molecular pathophysiology underlying cerebral edema is complex and remains incompletely understood. Current management protocols are guided by intracranial pressure measurements, an imperfect proxy for cerebral edema. These include decompressive craniectomy, external ventricular drainage, hyperosmolar therapy, hypothermia, and sedation. Results of contemporary clinical trials assessing these treatments are summarized, with an emphasis on the gap between intermediate measures of edema and meaningful clinical outcomes. This is followed by a brief statement summarizing the most recent guidelines from the Brain Trauma Foundation (4th edition). While many molecular mechanisms and networks contributing to cerebral edema after TBI are still being elucidated, we highlight some promising molecular mechanism-based targets based on recent research including SUR1-TRPM4, NKCC1, AQP4, and AVP1. SUMMARY This review outlines the origins of our understanding of cerebral edema, chronicles the history behind many current treatment approaches, and discusses promising molecular mechanism-based targeted treatments.
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Affiliation(s)
- Benjamin E. Zusman
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Institute for Clinical Research Education, University of Pittsburgh, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick M. Kochanek
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC Children’s Hospital of Pittsburgh, UPMC, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, PA, USA
| | - Ruchira M. Jha
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Lee KS, Zhang JJY, Bolem N, Leong ML, Goh CP, Hassan R, Salek AAM, Sein Lwin APT, Teo K, Chou N, Nga V, Yeo TT. Freehand Insertion of External Ventricular Drainage Catheter: Evaluation of Accuracy in a Single Center. Asian J Neurosurg 2020; 15:45-50. [PMID: 32181172 PMCID: PMC7057862 DOI: 10.4103/ajns.ajns_292_19] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 01/10/2020] [Indexed: 12/15/2022] Open
Abstract
Introduction External ventricular drain (EVD) placement is the gold standard for managing acute hydrocephalus. Freehand EVD, using surface anatomical landmarks, is performed for ventricular cannulation due to its simplicity and efficiency. This study evaluates accuracy and reason(s) for misplacements as few studies have analyzed the accuracy of freehand EVD insertion. Patients and Methods Preoperative and postoperative computed tomography scans of patients who underwent EVD insertion in 2014 were retrospectively reviewed. Diagnosis, Evans ratio, midline shift, position of burr hole, length of the catheter, and procedural complications were tabulated. The procedures were classified as satisfactory (catheter tip in the frontal horn ipsilateral lateral ventricle) and unsatisfactory. Unsatisfactory cases were further analyzed in relation to position of burr hole from midline and length of the catheter. Results Seventy-seven EVD placements in seventy patients were evaluated. The mean age of the patients was 57.5 years. About 83.1% were satisfactory placements and 11.7% were unsatisfactory in the contralateral ventricle, corpus callosum, and interhemispheric fissure. Nearly 5.2% were in extraventricular locations. Almost 2.6% EVD placements were complicated by hemorrhage and 1 catheter was reinserted. Suboptimal placements were significantly associated with longer intracranial catheter length. The mean length was 66.54 ± 10.1 mm in unsatisfactory placements compared to 58.32 ± 4.85 mm in satisfactory placements. Between the two groups, no significant difference was observed in Evans ratio, midline shift, surgeon's experience, distance of burr hole from midline, and coronal suture. Conclusion Freehand EVD insertion is safe and accurate. In small number of cases, unsatisfactory placement is related to longer catheter length.
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Affiliation(s)
- Keng Siang Lee
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - John Jiong Yang Zhang
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Nagarjun Bolem
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - May Lian Leong
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Chun Peng Goh
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Rashidul Hassan
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Al Amin Maa Salek
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | | | - Kejia Teo
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Ning Chou
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Vincent Nga
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
| | - Tseng Tsai Yeo
- Division of Neurosurgery, Department of Surgery, National University Hospital, Singapore
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Assessment of intracranial pressure monitoring in patients with moderate traumatic brain injury: A retrospective cohort study. Clin Neurol Neurosurg 2020; 189:105538. [DOI: 10.1016/j.clineuro.2019.105538] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 09/13/2019] [Accepted: 09/26/2019] [Indexed: 11/17/2022]
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Chau CYC, Craven CL, Rubiano AM, Adams H, Tülü S, Czosnyka M, Servadei F, Ercole A, Hutchinson PJ, Kolias AG. The Evolution of the Role of External Ventricular Drainage in Traumatic Brain Injury. J Clin Med 2019; 8:E1422. [PMID: 31509945 PMCID: PMC6780113 DOI: 10.3390/jcm8091422] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 09/05/2019] [Accepted: 09/05/2019] [Indexed: 02/06/2023] Open
Abstract
External ventricular drains (EVDs) are commonly used in neurosurgery in different conditions but frequently in the management of traumatic brain injury (TBI) to monitor and/or control intracranial pressure (ICP) by diverting cerebrospinal fluid (CSF). Their clinical effectiveness, when used as a therapeutic ICP-lowering procedure in contemporary practice, remains unclear. No consensus has been reached regarding the drainage strategy and optimal timing of insertion. We review the literature on EVDs in the setting of TBI, discussing its clinical indications, surgical technique, complications, clinical outcomes, and economic considerations.
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Affiliation(s)
- Charlene Y C Chau
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
| | - Claudia L Craven
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N3BG, UK
| | - Andres M Rubiano
- Neurosciences Institute, INUB-MEDITECH Research Group, El Bosque University, 113033 Bogotá, Colombia
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB20QQ, UK
| | - Hadie Adams
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
| | - Selma Tülü
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
- Department of Neurosurgery, Innsbruck Medical University, 6020 Innsbruck, Austria
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
| | - Franco Servadei
- Department of Neurosurgery, Humanitas University and Research Hospital, 20090 Milan, Italy
| | - Ari Ercole
- Division of Anaesthesia, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB20QQ, UK
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK.
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB20QQ, UK.
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