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Pedersen SH, Henriksen KA, Gustafsen SD, Hansen TS, Guldager R, Juhler M. Telemetric ICP monitoring in children: a national questionnaire-based study. Childs Nerv Syst 2024; 40:2391-2399. [PMID: 38587626 PMCID: PMC11269325 DOI: 10.1007/s00381-024-06383-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/27/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE Telemetric monitoring of intracranial pressure (ICP) facilitates long-term measurements and home monitoring, thus potentially reducing diagnostic imaging and acute hospital admissions in favour of outpatient appointments. Especially in paediatric patients, telemetric ICP monitoring requires a high level of collaboration and compliance from patients and parents. In this study, we aim to systematically investigate (1) patient and parent perception of telemetric ICP system utility and (2) hospital contact history and thus the potential cost-benefit of telemetric ICP monitoring in paediatric patients with a cerebrospinal fluid disorder. METHODS We conducted a nationwide questionnaire study, including paediatric patients with either a current or previous telemetric ICP sensor and their parents. Additionally, a retrospective review of electronic health records for all included children was performed. RESULTS We included 16 children (age range 3-16 years), with a total of 41 telemetric ICP sensors implanted. Following sensor implantation, the frequency of telephone contacts and outpatient visits increased. No corresponding decrease in hospital admissions or total length of stay was found. The telemetric ICP sensor provided most parents with an improved sense of security and was seen as a necessary and valuable tool in treatment guidance. The size and shape of the sensor itself were reported as disadvantages, while the external monitoring equipment was reported as easy to use but too large and heavy for a child to carry. CONCLUSION Though, in quantitative terms, there was no cost-benefit of the telemetric ICP sensor, it contributed to extended parental involvement and a sense of improved safety.
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Affiliation(s)
- Sarah Hornshøj Pedersen
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark.
| | - Kasper Amund Henriksen
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
| | - Sara Duus Gustafsen
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
| | - Torben Skovbo Hansen
- Department of Neurosurgery, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Rikke Guldager
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 8, 2100, Copenhagen, Denmark
- Department of Neurosurgery, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
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Hornshøj Pedersen S, Gustafsen SD, Juhler M, Guldager R. Parent perception of telemetric intracranial pressure monitoring in children - A qualitative case study. BRAIN & SPINE 2024; 4:102820. [PMID: 38764889 PMCID: PMC11099310 DOI: 10.1016/j.bas.2024.102820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 04/09/2024] [Accepted: 04/20/2024] [Indexed: 05/21/2024]
Abstract
Introduction Telemetric monitoring of intracranial pressure (ICP) in children with a complex cerebrospinal disorder might help parents distinguish acute and potential life-threatening symptoms of hydrocephalus from other illnesses. Research question What is patient and parent perceptions of system utility of telemetric ICP monitoring, and how does a long-term telemetric implant influence daily life of both patients and their families? Material and methods A qualitative case study design with a focus group interview including parents of children with a complex cerebrospinal fluid disorder and an implanted telemetric ICP sensor. Results Three parents participated. Based on thematic analysis, three themes were created: 'Daily living with telemetric ICP monitoring', 'Parenting a child with a CSF disorder', and 'The healthy sibling'. The ICP sensor provided the parents with security and made them trust their intuition, while the possibility of home monitoring ensured stability for the entire family and had a calming effect on healthy siblings. Home monitoring was seen as the system's greatest advantages, whereas size, weight, and functionality of the external monitoring equipment were highlighted as disadvantages. Discussion and conclusion All parents supported the telemetric ICP sensor as a valued tool in treatment guidance of their child and stated that advantages exceeded disadvantages. It was stated that the possibility of conducting ICP measurements at home reduced the need for acute hospital admissions, which consequently led to a more stable daily life for the entire family. Suggestions regarding technical improvements with focus on more compatible external monitoring equipment were raised by all parents included.
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Affiliation(s)
- Sarah Hornshøj Pedersen
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 8, 2100, Copenhagen E, Denmark
| | - Sara Duus Gustafsen
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 8, 2100, Copenhagen E, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 8, 2100, Copenhagen E, Denmark
- Department of Neurosurgery, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Rikke Guldager
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 8, 2100, Copenhagen E, Denmark
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Pandit AS, Kamal MA, Reischer G, Aldabbagh Y, Alradhawi M, Lee FMY, Sekhon PP, Moncur EM, Banks PDW, Thompson S, Thorne L, Watkins LD, Toma AK. The Impact of Intracranial Pressure Telesensors: An Observational Propensity-Matched Control Analysis of Service Demand and Costs. Neurosurgery 2024; 95:00006123-990000000-01074. [PMID: 38445908 PMCID: PMC11155581 DOI: 10.1227/neu.0000000000002893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/06/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Implantable telemetric intracranial pressure (ICP) sensors (telesensors) enable routine, noninvasive ICP feedback, aiding clinical decision-making and attribution of pressure-related symptoms in patients with cerebrospinal fluid shunt systems. Here, we aim to explore the impact of these devices on service demand and costs in patients with adult hydrocephalus. METHODS We performed an observational propensity-matched control study, comparing patients who had an MScio/Sensor Reservoir (Christoph Miethke, GmbH & Co) against those with a nontelemetric reservoir inserted between March 2016 and March 2018. Patients were matched on demographics, diagnosis, shunt-type, and revision status. Service usage was recorded with frequencies of neurosurgical admissions, outpatient clinics, scans, and further surgical procedures in the 2 years before and after shunt insertion. RESULTS In total, 136 patients, 73 telesensors, and 63 controls were included in this study (48 matched pairs). Telesensor use led to a significant decrease in neurosurgical inpatient admissions, radiographic encounters, and procedures including ICP monitoring. After multivariate adjustment, the mean cumulative saving after 2 years was £5236 ($6338) in telesensor patients (£5498 on matched pair analysis). On break-even analysis, cost-savings were likely to be achieved within 8 months of clinical use, postimplantation. Telesensor patients also experienced a significant reduction in imaging-associated radiation (4 mSv) over 2 years. CONCLUSION The findings of this exploratory study reveal that telesensor implantation is associated with reduced service demand and provides net financial savings from an institutional perspective. Moreover, telesensor patients required fewer appointments, invasive procedures, and had less radiation exposure, indicating an improvement in both their experience and safety.
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Affiliation(s)
- Anand S. Pandit
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, London, UK
- High-Dimensional Neurology, Institute of Neurology, University College London, London, UK
| | - Muhammad A. Kamal
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, London, UK
| | - Gerda Reischer
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, London, UK
| | - Yousif Aldabbagh
- UCL Medical School, Faculty of Medical Sciences, University College London, London, UK
| | - Mohammad Alradhawi
- UCL Medical School, Faculty of Medical Sciences, University College London, London, UK
| | - Faith M. Y. Lee
- UCL Medical School, Faculty of Medical Sciences, University College London, London, UK
| | - Priya P. Sekhon
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, London, UK
| | - Eleanor M. Moncur
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, London, UK
| | - Ptolemy D. W. Banks
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, London, UK
| | - Simon Thompson
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, London, UK
| | - Lewis Thorne
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, London, UK
| | - Laurence D. Watkins
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, London, UK
| | - Ahmed K. Toma
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology & Neurosurgery, London, UK
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Podgoršak A, Flürenbrock F, Trimmel NE, Korn L, Oertel MF, Stieglitz L, Fernandes Dias S, Hierweger MM, Zeilinger M, Weisskopf M, Schmid Daners M. Toward the "Perfect" Shunt: Historical Vignette, Current Efforts, and Future Directions. Adv Tech Stand Neurosurg 2024; 50:1-30. [PMID: 38592526 DOI: 10.1007/978-3-031-53578-9_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
As a concept, drainage of excess fluid volume in the cranium has been around for more than 1000 years. Starting with the original decompression-trepanation of Abulcasis to modern programmable shunt systems, to other nonshunt-based treatments such as endoscopic third ventriculostomy and choroid plexus cauterization, we have come far as a field. However, there are still fundamental limitations that shunts have yet to overcome: namely posture-induced over- and underdrainage, the continual need for valve opening pressure especially in pediatric cases, and the failure to reinstall physiologic intracranial pressure dynamics. However, there are groups worldwide, in the clinic, in industry, and in academia, that are trying to ameliorate the current state of the technology within hydrocephalus treatment. This chapter aims to provide a historical overview of hydrocephalus, current challenges in shunt design, what members of the community have done and continue to do to address these challenges, and finally, a definition of the "perfect" shunt is provided and how the authors are working toward it.
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Affiliation(s)
- Anthony Podgoršak
- Product Development Group Zurich, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Fabian Flürenbrock
- Institute for Dynamic Systems and Control, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Nina Eva Trimmel
- Center for Preclinical Development, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Leonie Korn
- Institute for Dynamic Systems and Control, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Markus Florian Oertel
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Lennart Stieglitz
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sandra Fernandes Dias
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Melanie Michaela Hierweger
- Center for Preclinical Development, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Melanie Zeilinger
- Institute for Dynamic Systems and Control, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Miriam Weisskopf
- Center for Preclinical Development, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Marianne Schmid Daners
- Institute for Dynamic Systems and Control, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland.
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Yiangou A, Mollan SP, Sinclair AJ. Idiopathic intracranial hypertension: a step change in understanding the disease mechanisms. Nat Rev Neurol 2023; 19:769-785. [PMID: 37957260 DOI: 10.1038/s41582-023-00893-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2023] [Indexed: 11/15/2023]
Abstract
The understanding of idiopathic intracranial hypertension (IIH) has evolved over the past few years. Previously, IIH was considered a disease exclusively affecting the neuro-ophthalmic axis, characterized by raised intracranial pressure, headache and papilloedema, and resulting in the risk of severe and permanent visual loss and life-changing disabling headaches. Recent advances have begun to redefine IIH as a probable metabolic disease involving a range of systemic manifestations. More than 95% of individuals affected by the disease are women of reproductive age with obesity. The incidence is rapidly rising and parallels the escalating worldwide obesity rates. Contemporary insights identify associations with insulin resistance, type 2 diabetes and a twofold increased risk of cardiovascular disease in excess of that driven by obesity alone. Adipose distribution in people with IIH, like that in other metabolic diseases, is preferentially centripetal and is associated with changes in intracranial pressure. Evidence now demonstrates adipose tissue dysfunction in people with IIH, involving transcriptional and metabolic priming for lipogenesis and weight gain. Hormonal perturbations are also observed, including a unique phenotype of androgen excess that promotes cerebrospinal fluid secretion. Knowledge of these additional disease features is driving research into novel therapeutic targets and altering the approach to multidisciplinary care.
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Affiliation(s)
- Andreas Yiangou
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Neurology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Susan P Mollan
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Alexandra J Sinclair
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
- Department of Neurology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.
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Jirlow U, Arvidsson L, Magneli S, Cesarini K, Rostami E. Evaluation of Miethke M.scio Device Implantation for Intracranial Pressure Monitoring in Patients with Cerebrospinal Fluid Disorders. World Neurosurg 2023; 179:e63-e74. [PMID: 37506838 DOI: 10.1016/j.wneu.2023.07.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Patients with complex shunt-related problems and varying diagnoses of cerebrospinal fluid (CSF) disturbance can present with headache and clinical symptoms that may be difficult to relate to underdrainage or overdrainage. Telemetric intracranial pressure (ICP) monitoring may assist in evaluating individual patients and assessing shunt function and adjustment. We report a case series of patients receiving a Miethke M.scio sensor. METHODS Between June 2016 and August 2021, 14 patients older than 18 years with different diagnoses underwent ventriculoperitoneal shunt surgery and received a Miethke M.scio sensor. RESULTS Patients had idiopathic intracranial hypertension (n = 3), obstructive hydrocephalus caused by tumors (n = 4), and malformations (n = 5). Headaches (71%) and visual impairment (50%) were the most common symptoms before surgery and 65% of the symptoms were improved after surgery. In total, 25 measurements were made and 11 of these led to changes in the shunt settings. Postoperative measurements were taken in 8 patients and the most common indication of ICP measurement was headache and/or control of the shunt settings. CONCLUSIONS The Miethke M.scio is a safe and valuable device to use in shunt-treated patients, in particular those expected to need assessment of ICP monitoring postoperatively. Repeated ICP measurements can also assist in personalized adjustment of the shunt setting to optimize CSF flow in this diverse patient group. Future studies should include a standardized protocol with ICP measurements correlated to the symptoms and cause of CSF disturbances to provide better understanding of the dynamics of the ICP in each patient.
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Affiliation(s)
- Unni Jirlow
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Lisa Arvidsson
- Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Sara Magneli
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Kristina Cesarini
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Elham Rostami
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden; Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden.
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Literature Commentary. J Neuroophthalmol 2023; 43:e26-e36. [PMID: 37626015 DOI: 10.1097/wno.0000000000001813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
In this issue of JNO, Drs. Mark L. Moster, Marc J. Dinkin, and Deborah I. Friedman discuss the following 6 articles:Piehl F, Eriksson-Dufva A, Budzianowska A, Feresiadou A, Hansson W, Hietala MA, Håkansson I, Johansson R, Jons D, Kmezic I, Lindberg C, Lindh J, Lundin F, Nygren I, Punga AR, Press R, Samuelsson K, Sundström P, Wickberg O, Brauner S, Frisell T. Efficacy and safety of rituximab for new-onset generalized myasthenia gravis: the RINOMAX randomized clinical trial. JAMA Neurol. 2022;79:1105-1112.Cortese R, Carrasco FP, Tur C, Bianchi A, Brownlee W, De Angelis F, De La Paz I, Grussu F, Haider L, Jacob A, Kanber B, Magnollay L, Nicholas RS, Trip A, Yiannakas M, Toosy AT, Hacohen Y, Barkhof F, Ciccarelli O. Differentiating multiple sclerosis from AQP4-neuromyelitis optica spectrum disorder and MOG-antibody disease with imaging. Neurology. 2022. doi: 10.1212/WNL.0000000000201465.Carelli V, Newman NJ, Yu-Wai-Man P, Biousse V, Moster ML, Subramanian PS, Vignal-Clermont C, Wang AG, Donahue SP, Leroy BP, Sergott RC, Klopstock T, Sadun AA, Rebolleda Fernández G, Chwalisz BK, Banik R, Girmens JF, La Morgia C, DeBusk AA, Jurkute N, Priglinger C, Karanjia R, Josse C, Salzmann J, Montestruc F, Roux M, Taiel M, Sahel JA; the LHON Study Group. Indirect comparison of Lenadogene Nolparvovec gene therapy versus natural history in patients with leber hereditary optic neuropathy carrying the m.11778G>A MT-ND4 mutation. Ophthalmol Ther. 2022. doi: 10.1007/s40123-022-00611-x.Noll C, Hiltensperger M, Aly L, Wicklein R, Afzali AM, Mardin C, Gasperi C, Berthele A, Hemmer B, Korn T, Knier B. Association of the retinal vasculature, intrathecal immunity, and disability in multiple sclerosis. Front Immunol. 2022;13:997043.Mitchell JL, Buckham R, Lyons H, Walker JK, Yiangou A, Sassani M, Thaller M, Grech O, Alimajstorovic Z, Julher M, Tsermoulas G, Brock K, Mollan SP, Sinclair AJ. Evaluation of diurnal and postural intracranial pressure employing telemetric monitoring in idiopathic intracranial hypertension. Fluids Barriers CNS. 2022;19:85.Pan Y, Chen YX, Zhang J, Lin ML, Liu GM, Xu XL, Fan XQ, Zhong Y, Li Q, Ai SM, Xu W, Tan J, Zhou HF, Xu DD, Zhang HY, Xu B, Wang S, Ma JJ, Zhang S, Gan LY, Cui JT, Li L, Xie YY, Guo X, Pan-Doh N, Zhu ZT, Lu Y, Shi YX, Xia YW, Li ZY, Liang D. Doxycycline vs placebo at 12 weeks in patients with mild thyroid-associated ophthalmopathy: a randomized clinical trial. JAMA Ophthalmol. 2022;140:1076-1083.
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Pennacchietti V, Schaumann A, Thomale UW. Maneuver protocol for outpatient telemetric intracranial pressure monitoring in hydrocephalus patients. Childs Nerv Syst 2023; 39:185-195. [PMID: 36098768 PMCID: PMC9968677 DOI: 10.1007/s00381-022-05659-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 09/01/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Telemetric intracranial pressure measurement (tICPM) offers new opportunities to acquire objective information in shunted and non-shunted patients. The sensor reservoir (SR) provides tICPM modality at a decent sampling rate as an integrated component of the CSF shunt system. The aim of this study is to perform tICPM during a defined protocol of maneuvers in an outpatient setting as feasibility study including either shunt-dependent patients or candidates for possible shunt therapy. METHODS A total of 17 patients received a SR and were investigated within a protocol of maneuver measurements involving different body postures (90°, 10°, 0°, and - 10°), breathing patterns (hypo- and hyperventilation), and mild venous congestion (Valsalva, Jugular vein compression), while the latter two were performed in lying postures (10° and 0°). The cohort included 11 shunted and 6 non-shunted (stand-alone-SR) patients. All measurements were evaluated using an ICP-analysis software (ICPicture, Miethke, Germany) looking at ICP changes and amplitude (AMP) characteristics. RESULTS The shunted patient group consisted of 11 patients (median age: 15.8 years; range: 4-35.2 years) with either a primary shunt (n=9) and 2 patients received a shunt after stand-alone-SR tICPM. Six patients were enrolled with a stand-alone SR (median age 11.9 years, range 3.6-17.7 years). In the stand-alone SR group, maneuver related ICP and AMP changes were more sensitive compared to shunted patients. Postural maneuvers caused significant ICP changes in all body positions in both groups. The highest ICP values were seen during Valsalva maneuver, provoked by the patients themselves. In the stand-alone group, significant higher ICP values during hyperventilation were observed compared to shunted individuals. In shunted patients, a significant correlation between ICP and AMP was observed only during hyperventilation maneuver, while this correlation was additionally seen in Valsalva and jugular vein compression in stand-alone patients. CONCLUSION SR-related tICPM is helpful to objectify diagnostic evaluation in patients with CSF dynamic disturbances. The defined protocol did result in a wide range of ICP changes with promising potential for effective outpatient tICPM investigation. Since the correlation of ICP and AMP was observed during mild venous congestion maneuvers it appears to be specifically helpful for the evaluation of intracranial compliance. Further investigations of maneuver-related tICPM in a larger population, including variable pathologies, are needed to further establish the protocol in the clinical practice.
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Affiliation(s)
- Valentina Pennacchietti
- Pediatric Neurosurgery, Charité Universitaetsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Andreas Schaumann
- Pediatric Neurosurgery, Charité Universitaetsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Ulrich-Wilhelm Thomale
- Pediatric Neurosurgery, Charité Universitaetsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.
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Juhler M, Hansen TS, Novrup HVG, MacAulay N, Munch TN. Hydrocephalus Study Design: Testing New Hypotheses in Clinical Studies and Bench-to-Bedside Research. World Neurosurg 2022; 161:424-431. [PMID: 35505563 DOI: 10.1016/j.wneu.2021.12.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/23/2021] [Accepted: 12/24/2021] [Indexed: 10/18/2022]
Abstract
In this article, we aimed to describe some of the currently most challenging problems in neurosurgical management of hydrocephalus and how these can be reasons for inspiration for and development of research. We chose 4 areas of focus: 2 dedicated to improvement of current treatments (shunt implant surgery and endoscopic hydrocephalus surgery) and 2 dedicated to emerging future treatment principles (molecular mechanisms of cerebrospinal fluid secretion and hydrocephalus genetics).
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Affiliation(s)
- Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | | | - Hans V G Novrup
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
| | - Nanna MacAulay
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark
| | - Tina Nørgaard Munch
- Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
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Norager NH, Olsen MH, Pedersen SH, Riedel CS, Czosnyka M, Juhler M. Reference values for intracranial pressure and lumbar cerebrospinal fluid pressure: a systematic review. Fluids Barriers CNS 2021; 18:19. [PMID: 33849603 PMCID: PMC8045192 DOI: 10.1186/s12987-021-00253-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although widely used in the evaluation of the diseased, normal intracranial pressure and lumbar cerebrospinal fluid pressure remain sparsely documented. Intracranial pressure is different from lumbar cerebrospinal fluid pressure. In addition, intracranial pressure differs considerably according to the body position of the patient. Despite this, the current reference values do not distinguish between intracranial and lumbar cerebrospinal fluid pressures, and body position-dependent reference values do not exist. In this study, we aim to establish these reference values. METHOD A systematic search was conducted in MEDLINE, EMBASE, CENTRAL, and Web of Sciences. Methodological quality was assessed using an amended version of the Joanna Briggs Quality Appraisal Checklist. Intracranial pressure and lumbar cerebrospinal fluid pressure were independently evaluated and subdivided into body positions. Quantitative data were presented with mean ± SD, and 90% reference intervals. RESULTS Thirty-six studies were included. Nine studies reported values for intracranial pressure, while 27 reported values for the lumbar cerebrospinal fluid pressure. Reference values for intracranial pressure were - 5.9 to 8.3 mmHg in the upright position and 0.9 to 16.3 mmHg in the supine position. Reference values for lumbar cerebrospinal fluid pressure were 7.2 to 16.8 mmHg and 5.7 to 15.5 mmHg in the lateral recumbent position and supine position, respectively. CONCLUSIONS This systematic review is the first to provide position-dependent reference values for intracranial pressure and lumbar cerebrospinal fluid pressure. Clinically applicable reference values for normal lumbar cerebrospinal fluid pressure were established, and are in accordance with previously used reference values. For intracranial pressure, this study strongly emphasizes the scarcity of normal pressure measures, and highlights the need for further research on the matter.
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Affiliation(s)
| | | | | | - Casper Schwartz Riedel
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
- Department of Neurophysiology, Rigshospitalet, Glostrup, Denmark
| | - Marek Czosnyka
- Brain Physics Laboratory, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Marianne Juhler
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
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Bjornson A, Henderson D, Lawrence E, McMullan J, Ushewokunze S. The Sensor Reservoir-does it change management? Acta Neurochir (Wien) 2021; 163:1087-1095. [PMID: 33587185 DOI: 10.1007/s00701-021-04729-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND The Miethke Sensor Reservoir sits within a ventriculoperitoneal shunt system to give a reading of the pressure within the shunt. This information can guide the management of hydrocephalus patients who present frequently with headaches. METHODS We reviewed a cohort of 12 patients who underwent implantation of a Sensor Reservoir to assess how the management of their symptoms changed over a 4-year period. RESULTS When comparing the group before the Sensor Reservoir and after the Sensor Reservoir insertion, there was a 75% reduction in number of CT head scans (P<0.05), 100% reduction in episodes of ICP monitoring (P<0.05), 55% reduction in number of X-ray shunt series, and a 50% reduction in acute presentation to hospital with shunt-related symptoms. The number of clinic attendances increased by 44%. In addition, cost analysis showed a saving of £6952 per patients over the 2-year period following Sensor Reservoir insertion as a result of reduced admissions and investigations. Complications were seen in 3 patients-two patients developed shunt-related infections, and 1 patient underwent shunt revision due to a proximal shunt obstruction. Seventy-five percent of patients showed an improvement in their symptoms at the end of the 4-year period. CONCLUSION Implantation of a Sensor Reservoir in shunt patients with chronic headaches can reduce the number of investigations and hospital admissions and guide management resulting in a clinical improvement.
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12
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Riedel CS, Martinez-Tejada I, Norager NH, Kempfner L, Jennum P, Juhler M. B-waves are present in patients without intracranial pressure disturbances. J Sleep Res 2020; 30:e13214. [PMID: 33155362 DOI: 10.1111/jsr.13214] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/11/2020] [Accepted: 09/17/2020] [Indexed: 01/01/2023]
Abstract
Intracranial pressure (ICP) B-waves are defined as short, repeating elevations of ICP of up to 50 mmHg with a frequency of 0.5-2 waves/min. The presence of B-waves in overnight recordings is regarded as a pathological phenomenon. However, the physiology of B-waves is still not fully understood and studies with transcranial Doppler, as a surrogate marker for ICP, have suggested that B-waves could be a normal physiological phenomenon. We present four patients without known structural neurological disease other than a coincidentally found unruptured intracranial aneurysm. One of the patients had experienced well-controlled epilepsy for several years, but was included because ICP under these conditions is unlikely to be abnormal. Following informed consent, all four patients had a telemetric ICP probe implanted during a prophylactic operation with closure of the aneurysm. They underwent overnight ICP monitoring with simultaneous polysomnography (PSG) sleep studies at 8 weeks after the operation. These patients exhibited nocturnal B-waves, but did not have major structural brain lesions. Their ICP values were within the normal range. Nocturnal B-waves occurred in close association with sleep-disordered breathing (SDB) in rapid eye movement (REM) and non-REM sleep stages. SDB during REM sleep was associated with ramp-type B-waves; SDB during non-REM sleep was associated with the sinusoidal type of B-wave. We propose that B-waves are a physiological phenomenon associated with SDB and that the mechanical changes during respiration could have an essential and previously unrecognised role in the generation of B-waves.
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Affiliation(s)
- Casper Schwartz Riedel
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark.,Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Rigshospitalet, Glostrup, Denmark
| | - Isabel Martinez-Tejada
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark.,Department of Health Technology, Technical University of Denmark, Copenhagen, Denmark
| | | | - Lykke Kempfner
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Rigshospitalet, Glostrup, Denmark
| | - Poul Jennum
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Rigshospitalet, Glostrup, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Rot S, Dweek M, Gutowski P, Goelz L, Meier U, Lemcke J. Comparative investigation of different telemetric methods for measuring intracranial pressure: a prospective pilot study. Fluids Barriers CNS 2020; 17:63. [PMID: 33069242 PMCID: PMC7568395 DOI: 10.1186/s12987-020-00225-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 10/08/2020] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES Measurement of intracranial pressure (ICP) plays an important role in long-term monitoring and neuro-intensive treatment of patients with a cerebral shunt. Currently, only two complete telemetric implants with different technical features are available worldwide. This prospective pilot study aims to examine patients who had both probes implanted at overlapping times for clinical reasons and represents the first in vivo comparison of both measurement methods. MATERIALS AND METHODS Patients with a primary subarachnoid hemorrhage or a spontaneous intracerebral hemorrhage with ventricular hemorrhage who had received a telemetric ICP probe (Raumedic® NEUROVENT®-P-tel) were included in the study. Conventional external ventricular drainages (EVD) and ventriculoperitoneal shunts with a telemetric ICP probe (Miethke Sensor Reservoir) were implanted in patients with hydrocephalus who required CSF (cerebrospinal fluid) drainage. Absolute ICP values from all systems were obtained. Due to the overlapping implantation time, parallel ICP measurements were performed via two devices simultaneously. ICP measurements via the sensor reservoir were repeated after 3 and 9 months. Differences between the absolute ICP values measured via the NEUROVENT®-P-tel probe, the Miethke sensor reservoir®, and the EVD were analyzed. RESULTS Seventeen patients were included in the present study between 2016 and 2018. 63% of all patients were male. In 11 patients the ICP measurements were followed up with both devices for 3 months. ICP measurements of the sensor reservoir showed corresponding trends in 9 cases compared to ICP measurement via the telemetry probe or EVD. Difference in absolute ICP values ranged between 14.5 mmHg and 0.0 mmHg. The average difference of the absolute ICP values in 8 cases was ≤ 3.5 mmHg. CONCLUSION ICP measurements with both systems continuously showed synchronous absolute ICP values, however absolute values of ICP measurement with the different systems did not match.
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Affiliation(s)
- S Rot
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Germany.
| | - M Dweek
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Germany
| | - P Gutowski
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Germany
| | - L Goelz
- Department of Radiology and Neuroradiology, Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Germany
| | - U Meier
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Germany
| | - J Lemcke
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Straße 7, 12683, Berlin, Germany
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Abstract
Telemetric intracranial pressure (ICP) monitoring is a new method of measuring ICP which eliminates some of the shortcomings of previous methods. However, there are limited data on specific characteristics, including the advantages and disadvantages of this method. The main aim of this study was to demonstrate the indications, benefits, and complications of telemetric ICP monitoring. PubMed, MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for relevant studies without language or date restriction in May 2019. Human studies in which telemetric ICP monitoring was the main subject of the study were included. Our initial search resulted in 1650 articles from which 50 studies were included. There were no randomized controlled trials. The majority of the studies were case reports or case series (68%). The most common aim of studies was testing of the device (52%), and monitoring the disease progression or recovery (46%). The most common indications for telemetric ICP monitoring in these studies were testing cerebrospinal fluid shunt function (46%), ICP control after the procedure (36%), and diagnosing intracranial hypertension (22%) and hydrocephalus (12%). In total, 1423 brain disease patients had been monitored in studies. The possibility of long-term ICP monitoring as the main benefit was reported in 38 (76%) studies. The associated complication rate was 7.1%. Despite the increasing application of telemetric monitoring devices, studies to evaluate specific characteristics of this method have been infrequent and inadequate. Future research using a higher level of scientific methods is needed to evaluate advantage and disadvantages.
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15
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Evensen KB, Eide PK. Measuring intracranial pressure by invasive, less invasive or non-invasive means: limitations and avenues for improvement. Fluids Barriers CNS 2020; 17:34. [PMID: 32375853 PMCID: PMC7201553 DOI: 10.1186/s12987-020-00195-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/19/2020] [Indexed: 12/20/2022] Open
Abstract
Sixty years have passed since neurosurgeon Nils Lundberg presented his thesis about intracranial pressure (ICP) monitoring, which represents a milestone for its clinical introduction. Monitoring of ICP has since become a clinical routine worldwide, and today represents a cornerstone in surveillance of patients with acute brain injury or disease, and a diagnostic of individuals with chronic neurological disease. There is, however, controversy regarding indications, clinical usefulness and the clinical role of the various ICP scores. In this paper, we critically review limitations and weaknesses with the current ICP measurement approaches for invasive, less invasive and non-invasive ICP monitoring. While risk related to the invasiveness of ICP monitoring is extensively covered in the literature, we highlight other limitations in current ICP measurement technologies, including limited ICP source signal quality control, shifts and drifts in zero pressure reference level, affecting mean ICP scores and mean ICP-derived indices. Control of the quality of the ICP source signal is particularly important for non-invasive and less invasive ICP measurements. We conclude that we need more focus on mitigation of the current limitations of today's ICP modalities if we are to improve the clinical utility of ICP monitoring.
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Affiliation(s)
- Karen Brastad Evensen
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, P.O. Box 4950, Nydalen, 0424, Oslo, Norway
- Department of Informatics, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, P.O. Box 4950, Nydalen, 0424, Oslo, Norway.
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
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16
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Pedersen SH, Lilja-Cyron A, Astrand R, Juhler M. Monitoring and Measurement of Intracranial Pressure in Pediatric Head Trauma. Front Neurol 2020; 10:1376. [PMID: 32010042 PMCID: PMC6973131 DOI: 10.3389/fneur.2019.01376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/12/2019] [Indexed: 01/09/2023] Open
Abstract
Purpose of Review: Monitoring of intracranial pressure (ICP) is an important and integrated part of the treatment algorithm for children with severe traumatic brain injury (TBI). Guidelines often recommend ICP monitoring with a treatment threshold of 20 mmHg. This focused review discusses; (1) different ICP technologies and how ICP should be monitored in pediatric patients with severe TBI, (2) existing evidence behind guideline recommendations, and (3) how we could move forward to increase knowledge about normal ICP in children to support treatment decisions. Summary: Current reference values for normal ICP in adults lie between 7 and 15 mmHg. Recent studies conducted in “pseudonormal” adults, however, suggest a normal range below this level where ICP is highly dependent on body posture and decreases to negative values in sitting and standing position. Despite obvious physiological differences between children and adults, no age or body size related reference values exist for normal ICP in children. Recent guidelines for treatment of severe TBI in pediatric patients recommend ICP monitoring to guide treatment of intracranial hypertension. Decision on ICP monitoring modalities are based on local standards, the individual case, and the clinician's choice. The recommended treatment threshold is 20 mmHg for a duration of 5 min. Both prospective and retrospective observational studies applying different thresholds and treatment strategies for intracranial hypertension were included to support this recommendation. While some studies suggest improved outcome related to ICP monitoring (lower rate of mortality and severe disability), most studies identify high ICP as a marker of worse outcome. Only one study applied age-differentiated thresholds, but this study did not evaluate the effect of these different thresholds on outcome. The quality of evidence behind ICP monitoring and treatment thresholds in severe pediatric TBI is low and treatment can potentially be improved by knowledge about normal ICP from observational studies in healthy children and cohorts of pediatric “pseudonormal” patients expected to have normal ICP. Acceptable levels of ICP − and thus also treatment thresholds—probably vary with age, disease and whether the patient has intact cerebral autoregulation. Future treatment algorithms should reflect these differences and be more personalized and dynamic.
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Affiliation(s)
| | | | - Ramona Astrand
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
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Oertel JMK, Huelser MJM. Telemetric home monitoring of intracranial pressure-where are we now. Acta Neurochir (Wien) 2019; 161:1603-1604. [PMID: 31187266 DOI: 10.1007/s00701-019-03962-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 05/24/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Joachim M K Oertel
- Department of Neurosurgery, Saarland University Medical Center, Kirrbergerstrasse, Building 90.5, 66421, Homburg, Germany.
- Faculty of Medicine, Saarland University, Saarbrücken, Germany.
| | - Matthias J M Huelser
- Department of Neurosurgery, Saarland University Medical Center, Kirrbergerstrasse, Building 90.5, 66421, Homburg, Germany
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