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Brasil S, Romeijn H, Haspels EK, Paiva W, Schaafsma A. Improved Transcranial Doppler Waveform Analysis for Intracranial Hypertension Assessment in Patients with Traumatic Brain Injury. Neurocrit Care 2024; 40:931-940. [PMID: 37932509 DOI: 10.1007/s12028-023-01849-4] [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: 03/17/2023] [Accepted: 08/28/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Transcranial Doppler (TCD) is a noninvasive bedside tool for cerebral hemodynamic assessments in multiple clinical scenarios. TCD, by means of measuring systolic and diastolic blood velocities, allows the calculation of the pulsatility index (PI), a parameter that is correlated with intracranial pressure (ICP). Nevertheless, the predictive value of the PI for raised ICP appears to be low, as it is subjected to several, often confounding, factors not related to ICP. Recently, the pulsatile apparent resistance (PaR) index was developed as a PI corrected for arterial blood pressure, reducing some of the confounding factors influencing PI. This study compares the predictive value of PaR versus PI for intracranial hypertension (IH) (ICP > 20 mm Hg) in patients with traumatic brain injury. METHODS Patients with traumatic brain injury admitted to the neurocritical care unit who required invasive ICP monitoring were included prospectively within 5 days of admission. TCD measurements were performed in both middle cerebral arteries, allowing calculations of the PI and PaR. The optimal cutoff, discriminative power of these parameters for ICP ≥ 20 mm Hg, was assessed by calculating the area under the receiver operator characteristics curve (AUC). RESULTS In total, 93 patients were included. A total of 20 (22%) patients experienced IH during the recording sessions. The discriminative power was low for PI (AUC 0.63) but slightly higher for PaR (AUC 0.77). Nonparametric analysis indicated significant difference for PaR when comparing patients with (median 0.169) and without IH (median - 0.052, p = 0.001), whereas PI medians for patients with and without IH were 0.86 and 0.77, respectively (p = 0.041). Regarding subanalyses, the discriminative power of these parameters increased after exclusion of patients who had undergone a neurosurgical procedure. This was especially true for the PaR (AUC 0.89) and PI (AUC 0.72). Among these patients, a PaR cutoff value of - 0.023 had 100% sensitivity and 52.9% specificity. CONCLUSIONS In the present study, discriminative power of the PaR for discriminating IH was superior to the PI. The PaR seems to be a reliable noninvasive parameter for detecting IH. Further studies are warranted to define its clinical application, especially in aiding neurosurgical decision making, following up in intensive care units, and defining its ability to indicate responses according to the therapies administered.
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Affiliation(s)
- Sérgio Brasil
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil.
| | - Hannah Romeijn
- Intensive Care Department, Martini General Hospital, Groningen, The Netherlands
| | - Esther K Haspels
- Intensive Care Department, Martini General Hospital, Groningen, The Netherlands
| | - Wellingson Paiva
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | - Arjen Schaafsma
- Department of Clinical Neurophysiology, Martini General Hospital, Groningen, The Netherlands
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Rajajee V. Noninvasive Intracranial Pressure Monitoring: Are We There Yet? Neurocrit Care 2024:10.1007/s12028-024-01951-1. [PMID: 38429611 DOI: 10.1007/s12028-024-01951-1] [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: 12/14/2023] [Accepted: 01/25/2024] [Indexed: 03/03/2024]
Abstract
There is an urgent unmet need for a reliable noninvasive tool to detect elevations in intracranial pressure (ICP) above guideline-recommended thresholds for treatment. Gold standard invasive ICP monitoring is unavailable in many settings, including resource-limited environments, and in situations such as liver failure in which coagulopathy increases the risk of invasive monitoring. Although a large number of noninvasive techniques have been evaluated, this article reviews the potential clinical role, if any, of the techniques that have undergone the most extensive evaluation and are already in clinical use. Elevations in ICP transmitted through the subarachnoid space result in distension of the optic nerve sheath. The optic nerve sheath diameter (ONSD) can be measured with ultrasound, and an ONSD threshold can be used to detect elevated ICP. Although many studies suggest this technique accurately detects elevated ICP, there is concern for risk of bias and variations in ONSD thresholds across studies that preclude routine use of this technique in clinical practice. Multiple transcranial Doppler techniques have been used to assess ICP, but the best studied are the pulsatility index and the Czosnyka method to estimate cerebral perfusion pressure and ICP. Although there is inconsistency in the literature, recent prospective studies, including an international multicenter study, suggest the estimated ICP technique has a high negative predictive value (> 95%) but a poor positive predictive value (≤ 30%). Quantitative pupillometry is a sensitive and objective method to assess pupillary size and reactivity. Proprietary indices have been developed to quantify the pupillary light response. Limited data suggest these quantitative measurements may be useful for the early detection of ICP elevation. No current noninvasive technology can replace invasive ICP monitoring. Where ICP monitoring is unavailable, multimodal noninvasive assessment may be useful. Further innovation and research are required to develop a reliable, continuous technique of noninvasive ICP assessment.
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Affiliation(s)
- Venkatakrishna Rajajee
- Departments of Neurosurgery and Neurology, University of Michigan, 3552 Taubman Health Care Center, SPC 5338, 1500 E. Medial Center Drive, Ann Arbor, MI, 48109-5338, USA.
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Giglio A, Reccius A, Ferre A, Dreyse J. Severe osmotic demyelination syndrome with cortical involvement in the context of severe hyponatremia and central diabetes insipidus: an uncommon presentation of an unusual combination. BMJ Case Rep 2024; 17:e257210. [PMID: 38171637 PMCID: PMC10773298 DOI: 10.1136/bcr-2023-257210] [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: 01/05/2024] Open
Abstract
BACKGROUND Osmotic demyelination syndrome (ODS) with cerebral cortical involvement is a rare complication of severe hyponatremia correction. Careful management of hyponatremia is crucial, particularly in patients with risk factors, such as alcohol use disorder and diabetes insipidus. CASE A patient in his 40s with a history of alcohol use disorder and central diabetes insipidus developed ODS after a 24 mEq/L osmolar increase during the treatment of hyponatremia. The patient's condition progressed into locked-in syndrome and then improved to spastic tetraparesis after cortical basal ganglia ODS improved. DISCUSSION The differential diagnosis of cortical demyelination includes laminar cortical necrosis, being the interpretation of Apparent Diffusion Coefficient (ADC) MRI sequence is a useful tool.This case underscores the need to investigate and improve diagnosis and treatment strategies in patients with ODS. It also emphasises the significance of careful hyponatremia correction and frequent monitoring, particularly in patients with known risk factors for ODS.
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Affiliation(s)
- Andres Giglio
- Critical Care Department, Finis Terrae University, Santiago, Chile
- Critical Care Department, Clinica Las Condes Hospital, Santiago, Chile
| | - Andres Reccius
- Critical Care Department, Finis Terrae University, Santiago, Chile
- Critical Care Department, Clinica Las Condes Hospital, Santiago, Chile
- Neurology Department, Clinica Las Condes Hospital, Santiago, Chile
| | - Andres Ferre
- Critical Care Department, Finis Terrae University, Santiago, Chile
- Critical Care Department, Clinica Las Condes Hospital, Santiago, Chile
| | - Jorge Dreyse
- Critical Care Department, Finis Terrae University, Santiago, Chile
- Critical Care Department, Clinica Las Condes Hospital, Santiago, Chile
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Rajajee V, Soroushmehr R, Williamson CA, Najarian K, Ward K, Tiba H. Transcranial Color-Coded Sonography With Angle Correction As a Screening Tool for Raised Intracranial Pressure. Crit Care Explor 2023; 5:e0953. [PMID: 37644975 PMCID: PMC10461938 DOI: 10.1097/cce.0000000000000953] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVES Transcranial Doppler (TCD) has been evaluated as a noninvasive intracranial pressure (ICP) assessment tool. Correction for insonation angle, a potential source of error, with transcranial color-coded sonography (TCCS) has not previously been reported while evaluating ICP with TCD. Our objective was to study the accuracy of TCCS for detection of ICP elevation, with and without the use of angle correction. DESIGN Prospective study of diagnostic accuracy. SETTING Academic neurocritical care unit. PATIENTS Consecutive adults with invasive ICP monitors. INTERVENTIONS Ultrasound assessment with TCCS. MEASUREMENTS AND MAIN RESULTS End-diastolic velocity (EDV), time-averaged peak velocity (TAPV), and pulsatility index (PI) were measured in the bilateral middle cerebral arteries with and without angle correction. Concomitant mean arterial pressure (MAP) and ICP were recorded. Estimated cerebral perfusion pressure (CPP) was calculated as estimated CPP (CPPe) = MAP × (EDV/TAPV) + 14, and estimated ICP (ICPe) = MAP-CPPe. Sixty patients were enrolled and 55 underwent TCCS. Receiver operating characteristic curve analysis of ICPe for detection of invasive ICP greater than 22 mm Hg revealed area under the curve (AUC) 0.51 (0.37-0.64) without angle correction and 0.73 (0.58-0.84) with angle correction. The optimal threshold without angle correction was ICPe greater than 18 mm Hg with sensitivity 71% (29-96%) and specificity 28% (16-43%). With angle correction, the optimal threshold was ICPe greater than 21 mm Hg with sensitivity 100% (54-100%) and specificity 30% (17-46%). The AUC for PI was 0.61 (0.47-0.74) without angle correction and 0.70 (0.55-0.92) with angle correction. CONCLUSIONS Angle correction improved the accuracy of TCCS for detection of elevated ICP. Sensitivity was high, as appropriate for a screening tool, but specificity remained low.
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Affiliation(s)
- Venkatakrishna Rajajee
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI
- Department of Neurology, University of Michigan, Ann Arbor, MI
- Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI
| | - Reza Soroushmehr
- Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
- Department of Computational Medicine & Bioinformatics, University of Michigan, Ann Arbor, MI
| | - Craig A Williamson
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI
- Department of Neurology, University of Michigan, Ann Arbor, MI
- Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI
| | - Kayvan Najarian
- Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
- Department of Computational Medicine & Bioinformatics, University of Michigan, Ann Arbor, MI
- Department of Electrical Engineering, University of Michigan, Ann Arbor, MI
| | - Kevin Ward
- Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI
| | - Hakam Tiba
- Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
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Dattilo M. Noninvasive methods to monitor intracranial pressure. Curr Opin Neurol 2023; 36:1-9. [PMID: 36630209 DOI: 10.1097/wco.0000000000001126] [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: 01/12/2023]
Abstract
PURPOSE OF REVIEW Intracranial pressure (ICP) is determined by the production of and outflow facility of cerebrospinal fluid. Since alterations in ICP are implicated in several vision-threatening and life-threatening diseases, measurement of ICP is necessary and common. All current clinical methods to measure ICP are invasive and carry the risk for significant side effects. Therefore, the development of accurate, reliable, objective, and portal noninvasive devices to measure ICP has the potential to change the practice of medicine. This review discusses recent advances and barriers to the clinical implementation of noninvasive devices to determine ICP. RECENT FINDINGS Many noninvasive methods to determine ICP have been developed. Although most have significant limitations limiting their clinical utility, several noninvasive methods have shown strong correlations with invasively obtained ICP and have excellent potential to be developed further to accurately quantify ICP and ICP changes. SUMMARY Although invasive methods remain the mainstay for ICP determination and monitoring, several noninvasive biomarkers have shown promise to quantitatively assess and monitor ICP. With further refinement and advancement of these techniques, it is highly possible that noninvasive methods will become more commonplace and may complement or even supplant invasively obtained methods to determine ICP in certain situations.
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Affiliation(s)
- Michael Dattilo
- Emory Eye Center, Neuro-Ophthalmology Division, Emory University School of Medicine, Atlanta, Georgia, USA
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Sharma R, Tsikvadze M, Peel J, Howard L, Kapoor N, Freeman WD. Multimodal monitoring: practical recommendations (dos and don'ts) in challenging situations and uncertainty. Front Neurol 2023; 14:1135406. [PMID: 37206910 PMCID: PMC10188941 DOI: 10.3389/fneur.2023.1135406] [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: 12/31/2022] [Accepted: 04/06/2023] [Indexed: 05/21/2023] Open
Abstract
With the advancements in modern medicine, new methods are being developed to monitor patients in the intensive care unit. Different modalities evaluate different aspects of the patient's physiology and clinical status. The complexity of these modalities often restricts their use to the realm of clinical research, thereby limiting their use in the real world. Understanding their salient features and their limitations can aid physicians in interpreting the concomitant information provided by multiple modalities to make informed decisions that may affect clinical care and outcomes. Here, we present a review of the commonly used methods in the neurological intensive care unit with practical recommendations for their use.
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Affiliation(s)
- Rohan Sharma
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
- *Correspondence: Rohan Sharma
| | - Mariam Tsikvadze
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Jeffrey Peel
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Levi Howard
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Nidhi Kapoor
- Department of Neurology, Baptist Medical Center, Jacksonville, FL, United States
| | - William D. Freeman
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
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Dong J, Li Q, Wang X, Fan Y. A Review of the Methods of Non-Invasive Assessment of Intracranial Pressure through Ocular Measurement. Bioengineering (Basel) 2022; 9:bioengineering9070304. [PMID: 35877355 PMCID: PMC9312000 DOI: 10.3390/bioengineering9070304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/06/2022] [Accepted: 07/08/2022] [Indexed: 01/19/2023] Open
Abstract
The monitoring of intracranial pressure (ICP) is essential for the detection and treatment of most craniocerebral diseases. Invasive methods are the most accurate approach to measure ICP; however, these methods are prone to complications and have a limited range of applications. Therefore, non-invasive ICP measurement is preferable in a range of scenarios. The current non-invasive ICP measurement methods comprise fluid dynamics, and ophthalmic, otic, electrophysiological, and other methods. This article reviews eight methods of non-invasive estimation of ICP from ocular measurements, namely optic nerve sheath diameter, flash visual evoked potentials, two-depth transorbital Doppler ultrasonography, central retinal venous pressure, optical coherence tomography, pupillometry, intraocular pressure measurement, and retinal arteriole and venule diameter ratio. We evaluated and presented the indications and main advantages and disadvantages of these methods. Although these methods cannot completely replace invasive measurement, for some specific situations and patients, non-invasive measurement of ICP still has great potential.
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Tu YF, Wu PM, Yu WH, Li CI, Wu CL, Kang L, Lin YC, Shih HI, Huang CC. Lactate Predicts Neurological Outcomes after Perinatal Asphyxia in Post-Hypothermia Era: A Prospective Cohort Study. Life (Basel) 2021; 11:life11111193. [PMID: 34833069 PMCID: PMC8618528 DOI: 10.3390/life11111193] [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: 09/23/2021] [Revised: 10/31/2021] [Accepted: 11/03/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Neonatal hypoxic-ischemic encephalopathy (HIE) is the most common cause of mortality and neurological disability in infancy after perinatal asphyxia. Reliable biomarkers to predict neurological outcomes of neonates after perinatal asphyxia are still not accessible in clinical practice. Methods: A prospective cohort study enrolled neonates with perinatal asphyxia. Biochemical blood tests and cerebral Doppler ultrasound were measured within 6 h of age and at the 4th day old. Neurological outcomes were assessed at 1 year old. Results: Sixty-four neonates with perinatal asphyxia were enrolled. Fifty-eight (90%) had hypoxic-ischemic encephalopathy (HIE) including 20 (34%) Stage I, 21 (36%) Stage II, and 17 (29%) Stage III. In the asphyxiated infants without therapeutic hypothermia, HIE stage, PH, and base excess levels within 6 h of age were the predictors of adverse outcomes. In the asphyxiated infants receiving therapeutic hypothermia, HIE stage failed to predict outcomes. Instead, blood lactate levels and pulsatility index (PI) of medial cerebral arteries (MCA) either in 6 h of age or at the 4th day old independently predicted adverse outcomes. Conclusions: Blood lactate, which is a common accessible test at the hospital and MCA PI on cerebral ultrasound could predict adverse outcomes in asphyxiated infants receiving therapeutic hypothermia.
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Affiliation(s)
- Yi-Fang Tu
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City 70403, Taiwan; (P.-M.W.); (W.-H.Y.); (Y.-C.L.)
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan City 70101, Taiwan;
- Correspondence: (Y.-F.T.); (C.-C.H.); Tel.: +886-6-235-3535 (ext. 5273) (Y.-F.T.)
| | - Po-Ming Wu
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City 70403, Taiwan; (P.-M.W.); (W.-H.Y.); (Y.-C.L.)
| | - Wen-Hao Yu
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City 70403, Taiwan; (P.-M.W.); (W.-H.Y.); (Y.-C.L.)
| | - Chung-I Li
- Department of Statistics, College of Management, National Cheng Kung University, Tainan City 70101, Taiwan;
| | - Cheng-Lin Wu
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan City 70101, Taiwan;
- Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City 70403, Taiwan
| | - Lin Kang
- Department of Obstetrics and Gynecology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City 70403, Taiwan;
| | - Yung-Chieh Lin
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City 70403, Taiwan; (P.-M.W.); (W.-H.Y.); (Y.-C.L.)
| | - Hsin-I Shih
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City 70403, Taiwan;
| | - Chao-Ching Huang
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City 70403, Taiwan; (P.-M.W.); (W.-H.Y.); (Y.-C.L.)
- Correspondence: (Y.-F.T.); (C.-C.H.); Tel.: +886-6-235-3535 (ext. 5273) (Y.-F.T.)
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