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Stroh JN, Foreman B, Bennett TD, Briggs JK, Park S, Albers DJ. Intracranial pressure-flow relationships in traumatic brain injury patients expose gaps in the tenets of models and pressure-oriented management. Front Physiol 2024; 15:1381127. [PMID: 39189028 PMCID: PMC11345185 DOI: 10.3389/fphys.2024.1381127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 06/28/2024] [Indexed: 08/28/2024] Open
Abstract
Background: The protocols and therapeutic guidance established for treating traumatic brain injury (TBI) in neurointensive care focus on managing cerebral blood flow (CBF) and brain tissue oxygenation based on pressure signals. The decision support process relies on assumed relationships between cerebral perfusion pressure (CPP) and blood flow, pressure-flow relationships (PFRs), and shares this framework of assumptions with mathematical intracranial hemodynamics models. These foundational assumptions are difficult to verify, and their violation can impact clinical decision-making and model validity. Methods: A hypothesis- and model-driven method for verifying and understanding the foundational intracranial hemodynamic PFRs is developed and applied to a novel multi-modality monitoring dataset. Results: Model analysis of joint observations of CPP and CBF validates the standard PFR when autoregulatory processes are impaired as well as unmodelable cases dominated by autoregulation. However, it also identifies a dynamical regime -or behavior pattern-where the PFR assumptions are wrong in a precise, data-inferable way due to negative CPP-CBF coordination over long timescales. This regime is of both clinical and research interest: its dynamics are modelable under modified assumptions while its causal direction and mechanistic pathway remain unclear. Conclusion: Motivated by the understanding of mathematical physiology, the validity of the standard PFR can be assessed a) directly by analyzing pressure reactivity and mean flow indices (PRx and Mx) or b) indirectly through the relationship between CBF and other clinical observables. This approach could potentially help to personalize TBI care by considering intracranial pressure and CPP in relation to other data, particularly CBF. The analysis suggests a threshold using clinical indices of autoregulation jointly generalizes independently set indicators to assess CA functionality. These results support the use of increasingly data-rich environments to develop more robust hybrid physiological-machine learning models.
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Affiliation(s)
- J. N. Stroh
- Department of Biomedical Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Bioengineering, University of Colorado Denver |Anschutz Medical Campus, Denver, CO, United States
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, United States
- Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, United States
| | - Tellen D. Bennett
- Department of Biomedical Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Pediatric Intensive Care, Children’s Hospital of Colorado, Aurora, CO, United States
| | - Jennifer K. Briggs
- Department of Bioengineering, University of Colorado Denver |Anschutz Medical Campus, Denver, CO, United States
| | - Soojin Park
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
- Department of Neurology, New York Presbyterian/Columbia University Irving Medical Center, New York, NY, United States
| | - David J. Albers
- Department of Biomedical Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Bioengineering, University of Colorado Denver |Anschutz Medical Campus, Denver, CO, United States
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
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Hladky SB, Barrand MA. Regulation of brain fluid volumes and pressures: basic principles, intracranial hypertension, ventriculomegaly and hydrocephalus. Fluids Barriers CNS 2024; 21:57. [PMID: 39020364 PMCID: PMC11253534 DOI: 10.1186/s12987-024-00532-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 03/21/2024] [Indexed: 07/19/2024] Open
Abstract
The principles of cerebrospinal fluid (CSF) production, circulation and outflow and regulation of fluid volumes and pressures in the normal brain are summarised. Abnormalities in these aspects in intracranial hypertension, ventriculomegaly and hydrocephalus are discussed. The brain parenchyma has a cellular framework with interstitial fluid (ISF) in the intervening spaces. Framework stress and interstitial fluid pressure (ISFP) combined provide the total stress which, after allowing for gravity, normally equals intracerebral pressure (ICP) with gradients of total stress too small to measure. Fluid pressure may differ from ICP in the parenchyma and collapsed subarachnoid spaces when the parenchyma presses against the meninges. Fluid pressure gradients determine fluid movements. In adults, restricting CSF outflow from subarachnoid spaces produces intracranial hypertension which, when CSF volumes change very little, is called idiopathic intracranial hypertension (iIH). Raised ICP in iIH is accompanied by increased venous sinus pressure, though which is cause and which effect is unclear. In infants with growing skulls, restriction in outflow leads to increased head and CSF volumes. In adults, ventriculomegaly can arise due to cerebral atrophy or, in hydrocephalus, to obstructions to intracranial CSF flow. In non-communicating hydrocephalus, flow through or out of the ventricles is somehow obstructed, whereas in communicating hydrocephalus, the obstruction is somewhere between the cisterna magna and cranial sites of outflow. When normal outflow routes are obstructed, continued CSF production in the ventricles may be partially balanced by outflow through the parenchyma via an oedematous periventricular layer and perivascular spaces. In adults, secondary hydrocephalus with raised ICP results from obvious obstructions to flow. By contrast, with the more subtly obstructed flow seen in normal pressure hydrocephalus (NPH), fluid pressure must be reduced elsewhere, e.g. in some subarachnoid spaces. In idiopathic NPH, where ventriculomegaly is accompanied by gait disturbance, dementia and/or urinary incontinence, the functional deficits can sometimes be reversed by shunting or third ventriculostomy. Parenchymal shrinkage is irreversible in late stage hydrocephalus with cellular framework loss but may not occur in early stages, whether by exclusion of fluid or otherwise. Further studies that are needed to explain the development of hydrocephalus are outlined.
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Affiliation(s)
- Stephen B Hladky
- Department of Pharmacology, Tennis Court Rd, Cambridge, CB2 1PD, UK.
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3
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Gholampour S. Feasibility of assessing non-invasive intracranial compliance using FSI simulation-based and MR elastography-based brain stiffness. Sci Rep 2024; 14:6493. [PMID: 38499758 PMCID: PMC10948846 DOI: 10.1038/s41598-024-57250-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 03/15/2024] [Indexed: 03/20/2024] Open
Abstract
Intracranial compliance (ICC) refers to the change in intracranial volume per unit change in intracranial pressure (ICP). Magnetic resonance elastography (MRE) quantifies brain stiffness by measuring the shear modulus. Our objective is to investigate the relationship between ICC and brain stiffness through fluid-structure interaction (FSI) simulation, and to explore the feasibility of using MRE to assess ICC based on brain stiffness. This is invaluable due to the clinical importance of ICC, as well as the fast and non-invasive nature of the MRE procedure. We employed FSI simulation in hydrocephalus patients with aqueductal stenosis to non-invasively calculate ICP which is the basis of the calculation of ICC and FSI-based brain stiffness. The FSI simulated parameters used have been validated with experimental data. Our results showed that there is no relationship between FSI simulated-based brain stiffness and ICC in hydrocephalus patients. However, MRE-based brain stiffness may be sensitive to changes in intracranial fluid dynamic parameters such as cerebral perfusion pressure (CPP), cerebral blood flow (CBF), and ICP, as well as to mechano-vascular changes in the brain, which are determining parameters in ICC assessment. Although optimism has been found regarding the assessment of ICC using MRE-based brain stiffness, especially for acute-onset brain disorders, further studies are necessary to clarify their direct relationship.
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Affiliation(s)
- Seifollah Gholampour
- Department of Neurological Surgery, The University of Chicago, 5841 S. Maryland Ave, Chicago, IL, 60637, USA.
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4
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Chu KH, Olakorede I, Beqiri E, Czosnyka M, Smielewski P. Mathematical modelling of cerebral haemodynamics and their effects on ICP. BRAIN & SPINE 2024; 4:102772. [PMID: 38510619 PMCID: PMC10951776 DOI: 10.1016/j.bas.2024.102772] [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: 07/02/2023] [Revised: 01/17/2024] [Accepted: 02/18/2024] [Indexed: 03/22/2024]
Abstract
Introduction Electrical-equivalence mathematical models that integrate vascular and cerebrospinal fluid (CSF) compartments perform well in simulations of dynamic cerebrovascular variations and their transient effects on intracranial pressure (ICP). However, ICP changes due to sustained vascular diameter changes have not been comprehensively examined. We hypothesise that changes in cerebrovascular resistance (CVR) alter the resistance of the bulk flow of interstitial fluid (ISF). Research question We hypothesise that changes in CVR alter the resistance of the bulk flow of ISF, thus allowing simulations of ICP in response to sustained vascular diameter changes. Material and methods A lumped parameter model with vascular and CSF compartments was constructed and converted into an electrical analogue. The flow and pressure responses to transient hyperaemic response test (THRT) and CSF infusion test (IT) were observed. Arterial blood pressure (ABP) was manipulated to simulate ICP plateau waves. The experiments were repeated with a modified model that included the ISF compartment. Results Simulations of the THRT produced identical cerebral blood flow (CBF) responses. ICP generated by the new model reacted in a similar manner as the original model during ITs. Plateau pressure reached during ITs was however higher in the ISF model. Only the latter was successful in simulating the onset of ICP plateau waves in response to selective blood pressure manipulations. Discussion and conclusion Our simulations highlighted the importance of including the ISF compartment, which provides mechanism explaining sustained haemodynamic influences on ICP. Consideration of such interactions enables accurate simulations of the cerebrovascular effects on ICP.
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Affiliation(s)
- Ka Hing Chu
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Ihsane Olakorede
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
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Itoh H, Itamoto T, Tani K, Sunahara H, Nemoto Y, Nakaichi M, Iseri T, Horikirizono H, Itamoto K. Relationship between clinical parameters and malformations in dogs diagnosed with atlanto-axial instability. PLoS One 2024; 19:e0293363. [PMID: 38324604 PMCID: PMC10849214 DOI: 10.1371/journal.pone.0293363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 10/11/2023] [Indexed: 02/09/2024] Open
Abstract
Atlanto-axial instability is a common disease that affects toy-breed dogs. Most cases of atlanto-axial instability are congenital. Furthermore, patients with atlanto-axial instability are predisposed to other concurrent diseases. Therefore, this study aimed to retrospectively determine the presence of concurrent diseases in cases with atlanto-axial instability using imaging data and analyze the relationship between clinical parameters and the incidence of complex malformations. The clinical data and imaging findings of 41 toy-breed dogs diagnosed with atlanto-axial instability were analyzed using their medical records and imaging data. Occipital dysplasia (17/27), atlanto-occipital overlapping (22/34), dens dysplasia (27/41), Chiari-like malformation (8/34), syringomyelia (5/34), lateral ventricular enlargement (20/36), and intracranial arachnoid cyst (5/35) were observed in patients with atlanto-axial instability. The body weight of the patients in the groups with atlanto-occipital overlapping and lateral ventricular enlargement was lower than that of those in the groups without these diseases (1.78 ± 0.71 vs 2.71 ± 1.15 kg, P = 0.0269, 1.60 ± 0.40 vs 2.75 ± 1.08 kg, P = 0.001, respectively). Furthermore, when the correlation between the total number of concurrent diseases and the age at onset and body weight was examined, it became clear that lower body weight was associated with the incidence of a greater number of concurrent diseases. Thus, the findings of this study suggest that toy-breed dogs are more likely to present with complex malformations and should be evaluated carefully with additional examinations and treatment methods.
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Affiliation(s)
- Harumichi Itoh
- Department of Small Animal Clinical Science, Joint Faculty of Veterinary Medicine, Yamaguchi University, Yamaguchi City, Yamaguchi, Japan
| | - Takuya Itamoto
- Department of Small Animal Clinical Science, Joint Faculty of Veterinary Medicine, Yamaguchi University, Yamaguchi City, Yamaguchi, Japan
| | - Kenji Tani
- Department of Veterinary Surgery, Joint Faculty of Veterinary Medicine, Yamaguchi University, Yamaguchi City, Yamaguchi, Japan
| | - Hiroshi Sunahara
- Department of Veterinary Surgery, Joint Faculty of Veterinary Medicine, Yamaguchi University, Yamaguchi City, Yamaguchi, Japan
| | - Yuki Nemoto
- Department of Veterinary Surgery, Joint Faculty of Veterinary Medicine, Yamaguchi University, Yamaguchi City, Yamaguchi, Japan
| | - Munekazu Nakaichi
- Laboratory of Veterinary Radiology Yamaguchi University, Yamaguchi City, Yamaguchi, Japan
| | - Toshie Iseri
- Laboratory of Veterinary Radiology Yamaguchi University, Yamaguchi City, Yamaguchi, Japan
| | - Hiro Horikirizono
- Laboratory of Veterinary Radiology Yamaguchi University, Yamaguchi City, Yamaguchi, Japan
| | - Kazuhito Itamoto
- Department of Small Animal Clinical Science, Joint Faculty of Veterinary Medicine, Yamaguchi University, Yamaguchi City, Yamaguchi, Japan
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Toader C, Ples H, Covache-Busuioc RA, Costin HP, Bratu BG, Dumitrascu DI, Glavan LA, Ciurea AV. Decoding Chiari Malformation and Syringomyelia: From Epidemiology and Genetics to Advanced Diagnosis and Management Strategies. Brain Sci 2023; 13:1658. [PMID: 38137106 PMCID: PMC10741770 DOI: 10.3390/brainsci13121658] [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: 11/06/2023] [Accepted: 11/24/2023] [Indexed: 12/24/2023] Open
Abstract
Chiari Malformation and Syringomyelia are neurosurgical entities that have been the subject of extensive research and clinical interest. Globally prevalent, these disorders vary demographically and have witnessed evolving temporal trends. Chiari Malformation impacts the normal cerebrospinal fluid flow, consequently affecting overall health. Key observations from canine studies offer pivotal insights into the pathogenesis of Syringomyelia and its extrapolation to human manifestations. Genetics plays a pivotal role; contemporary knowledge identifies specific genes, illuminating avenues for future exploration. Clinically, these disorders present distinct phenotypes. Diagnostically, while traditional methods have stood the test of time, innovative neurophysiological techniques are revolutionizing early detection and management. Neuroradiology, a cornerstone in diagnosis, follows defined criteria. Advanced imaging techniques are amplifying diagnostic precision. In therapeutic realms, surgery remains primary. For Chiari 1 Malformation, surgical outcomes vary based on the presence of Syringomyelia. Isolated Syringomyelia demands a unique surgical approach, the effectiveness of which is continually being optimized. Post-operative long-term prognosis and quality of life measures are crucial in assessing intervention success. In conclusion, this review amalgamates existing knowledge, paving the way for future research and enhanced clinical strategies in the management of Chiari Malformation and Syringomyelia.
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Affiliation(s)
- Corneliu Toader
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
- Department of Vascular Neurosurgery, National Institute of Neurology and Neurovascular Diseases, 077160 Bucharest, Romania
| | - Horia Ples
- Department of Neurosurgery, Centre for Cognitive Research in Neuropsychiatric Pathology 6 (NeuroPsy-Cog), 300736 Timișoara, Romania
- Department of Neurosurgery, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Razvan-Adrian Covache-Busuioc
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
| | - Horia Petre Costin
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
| | - Bogdan-Gabriel Bratu
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
| | - David-Ioan Dumitrascu
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
| | - Luca Andrei Glavan
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
| | - Alexandru Vlad Ciurea
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
- Neurosurgery Department, Sanador Clinical Hospital, 010991 Bucharest, Romania
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Yang H, Wei XS, Gong J, Du XM, Feng HB, Su C, Gilmore C, Yue C, Yu SB, Li C, Sui HJ. The relationship between myodural bridge, atrophy and hyperplasia of the suboccipital musculature, and cerebrospinal fluid dynamics. Sci Rep 2023; 13:18882. [PMID: 37919345 PMCID: PMC10622500 DOI: 10.1038/s41598-023-45820-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 10/24/2023] [Indexed: 11/04/2023] Open
Abstract
The Myodural Bridge (MDB) is a physiological structure that is highly conserved in mammals and many of other tetrapods. It connects the suboccipital muscles to the cervical spinal dura mater (SDM) and transmits the tensile forces generated by the suboccipital muscles to the SDM. Consequently, the MDB has broader physiological potentials than just fixing the SDM. It has been proposed that MDB significantly contributes to the dynamics of cerebrospinal fluid (CSF) movements. Animal models of suboccipital muscle atrophy and hyperplasia were established utilizing local injection of BTX-A and ACE-031. In contrast, animal models with surgical severance of suboccipital muscles, and without any surgical operation were set as two types of negative control groups. CSF secretion and reabsorption rates were then measured for subsequent analysis. Our findings demonstrated a significant increase in CSF secretion rate in rats with the hyperplasia model, while there was a significant decrease in rats with the atrophy and severance groups. We observed an increase in CSF reabsorption rate in both the atrophy and hyperplasia groups, but no significant change was observed in the severance group. Additionally, our immunohistochemistry results revealed no significant change in the protein level of six selected choroid plexus-CSF-related proteins among all these groups. Therefore, it was indicated that alteration of MDB-transmitted tensile force resulted in changes of CSF secretion and reabsorption rates, suggesting the potential role that MDB may play during CSF circulation. This provides a unique research insight into CSF dynamics.
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Affiliation(s)
- Heng Yang
- Department of Anatomy, Dalian Medical University, Dalian, Liaoning, China
| | - Xiao-Song Wei
- Department of Anatomy, Dalian Medical University, Dalian, Liaoning, China
| | - Jin Gong
- Department of Anatomy, Dalian Medical University, Dalian, Liaoning, China
| | - Xue-Mei Du
- Department of Nuclear Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Hong-Bo Feng
- Department of Nuclear Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Chang Su
- The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | | | - Chen Yue
- Department of Gynecology ands Obstetrics, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning, China
| | - Sheng-Bo Yu
- Department of Anatomy, Dalian Medical University, Dalian, Liaoning, China
| | - Chan Li
- Department of Anatomy, Dalian Medical University, Dalian, Liaoning, China.
| | - Hong-Jin Sui
- Department of Anatomy, Dalian Medical University, Dalian, Liaoning, China.
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Bellettieri MPG, Anderloni M, Rass V, Kindl P, Donadello K, Taccone FS, Helbok R, Gouvea Bogossian E. Cerebrospinal fluid analysis of metabolites is not correlated to microdialysis measurements in acute brain injured patients. Clin Neurol Neurosurg 2023; 234:108011. [PMID: 37862729 DOI: 10.1016/j.clineuro.2023.108011] [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: 08/28/2023] [Revised: 10/03/2023] [Accepted: 10/05/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Cerebral microdialysis (CMD) has become an established bedside monitoring modality but its implementation remains complex and costly and is therefore performed only in a few well-trained academic centers. This study investigated the relationship between cerebrospinal fluid (CSF) and CMD glucose and lactate concentrations. METHODS Two centers retrospective study of prospectively collected data. Consecutive adult (>18 years) acutely brain injured patients admitted to the Intensive Care Unit between 2010 and 2021 were eligible if CSF and CMD glucose and lactate concentrations were concomitantly measured at least once. RESULTS Of 113 patients being monitored with an external ventricular drainage and CMD, 49 patients (25 from Innsbruck and 24 from Brussels) were eligible for the final analysis, including a total of 96 measurements. Median CMD glucose and lactate concentrations were 1.15 (0.51-1.57) mmol/L and 3.44 (2.24-5.37) mmol/L, respectively; median CSF glucose and lactate concentrations were 4.67 (4.03-5.34) mmol/L and 3.40 (2.85-4.10) mmol/L, respectively. For the first measurements, no correlation between CSF and CMD glucose concentrations (R2 <0.01; p = 0.95) and CSF and CMD lactate concentrations (R2 =0.16; p = 0.09) was found. Considering all measurements, the repeated measure correlation analysis also showed no correlation for glucose (rrm = -0.01; 95% Confidence Intervals -0.306 to 0.281; p = 0.93) and lactate (rrm = -0.11; 95% Confidence Intervals -0.424 to 0.236; p = 0.55). CONCLUSIONS In this study including acute brain injured patients, no correlation between CSF and brain tissue measurements of glucose and lactate was observed. As such, CSF measurements of such metabolites cannot replace CMD findings.
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Affiliation(s)
| | - Marco Anderloni
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles, Brussels, Belgium; Department of Anesthesia and Intensive Care B, Department of Surgery, Dentistry, Ginaecology and Paediatrics, University of Verona, University Hospital Integrated Trust of Verona, Verona, Italy
| | - Verena Rass
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Philipp Kindl
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Katia Donadello
- Department of Anesthesia and Intensive Care B, Department of Surgery, Dentistry, Ginaecology and Paediatrics, University of Verona, University Hospital Integrated Trust of Verona, Verona, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles, Brussels, Belgium
| | - Raimund Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria; Department of Neurology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles, Brussels, Belgium.
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9
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Steffensen AB, Edelbo BL, Barbuskaite D, Andreassen SN, Olsen MH, Møller K, MacAulay N. Nocturnal increase in cerebrospinal fluid secretion as a circadian regulator of intracranial pressure. Fluids Barriers CNS 2023; 20:49. [PMID: 37353833 DOI: 10.1186/s12987-023-00451-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/06/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND It is crucial to maintain the intracranial pressure (ICP) within the physiological range to ensure proper brain function. The ICP may fluctuate during the light-dark phase cycle, complicating diagnosis and treatment choice in patients with pressure-related disorders. Such ICP fluctuations may originate in circadian or sleep-wake cycle-mediated modulation of cerebrospinal fluid (CSF) flow dynamics, which in addition could support diurnal regulation of brain waste clearance. METHODS ICP was monitored continuously in patients who underwent placement of an external ventricular drain (EVD) and by telemetric monitoring in experimental rats. CSF was collected via the EVD in patients and the rodent CSF secretion rate determined by in vivo experimentation. Rodent choroid plexus transporter transcripts were quantified with RNAseq and transport activity with ex vivo isotope transport assays. RESULTS We demonstrated that ICP increases by 30% in the dark phase in both species, independently of vascular parameters. This increase aligns with elevated CSF collection in patients (12%) and CSF production rate in rats (20%), the latter obtained with the ventriculo-cisternal perfusion assay. The dark-phase increase in CSF secretion in rats was, in part, assigned to increased transport activity of the choroid plexus Na+,K+,2Cl- cotransporter (NKCC1), which is implicated in CSF secretion by this tissue. CONCLUSION CSF secretion, and thus ICP, increases in the dark phase in humans and rats, irrespective of their diurnal/nocturnal activity preference, in part due to altered choroid plexus transport activity in the rat. Our findings suggest that CSF dynamics are modulated by the circadian rhythm, rather than merely sleep itself.
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Affiliation(s)
- Annette Buur Steffensen
- Faculty of Health and Medical Sciences, Department of Neuroscience, University of Copenhagen, Blegdamsvej 3, DK-2200, Copenhagen N, Denmark
| | - Beatriche Louise Edelbo
- Faculty of Health and Medical Sciences, Department of Neuroscience, University of Copenhagen, Blegdamsvej 3, DK-2200, Copenhagen N, Denmark
| | - Dagne Barbuskaite
- Faculty of Health and Medical Sciences, Department of Neuroscience, University of Copenhagen, Blegdamsvej 3, DK-2200, Copenhagen N, Denmark
| | - Søren Norge Andreassen
- Faculty of Health and Medical Sciences, Department of Neuroscience, University of Copenhagen, Blegdamsvej 3, DK-2200, Copenhagen N, Denmark
| | - Markus Harboe Olsen
- Department of Neuroanaesthesiology, The Neuroscience Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, The Neuroscience Center, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Nanna MacAulay
- Faculty of Health and Medical Sciences, Department of Neuroscience, University of Copenhagen, Blegdamsvej 3, DK-2200, Copenhagen N, Denmark.
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10
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Kheram N, Boraschi A, Pfender N, Spiegelberg A, Kurtcuoglu V, Curt A, Schubert M, Zipser CM. Queckenstedt's test repurposed for the quantitative assessment of the cerebrospinal fluid pulsatility curve. Acta Neurochir (Wien) 2023; 165:1533-1543. [PMID: 37079108 DOI: 10.1007/s00701-023-05583-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 03/16/2023] [Indexed: 04/21/2023]
Abstract
PURPOSE Before the era of spinal imaging, presence of a spinal canal block was tested through gross changes in cerebrospinal fluid pressure (CSFP) provoked by manual compression of the jugular veins (referred to as Queckenstedt's test; QT). Beyond these provoked gross changes, cardiac-driven CSFP peak-to-valley amplitudes (CSFPp) can be recorded during CSFP registration. This is the first study to assess whether the QT can be repurposed to derive descriptors of the CSF pulsatility curve, focusing on feasibility and repeatability. METHOD Lumbar puncture was performed in lateral recumbent position in fourteen elderly patients (59.7±9.3 years, 6F) (NCT02170155) without stenosis of the spinal canal. CSFP was recorded during resting state and QT. A surrogate for the relative pulse pressure coefficient was computed from repeated QTs (i.e., RPPC-Q). RESULTS Resting state mean CSFP was 12.3 mmHg (IQR 3.2) and CSFPp was 1.0 mmHg (0.5). Mean CSFP rise during QT was 12.5 mmHg (7.3). CSFPp showed an average 3-fold increase at peak QT compared to the resting state. Median RPPC-Q was 0.18 (0.04). There was no systematic error in the computed metrics between the first and second QT. CONCLUSION This technical note describes a method to reliably derive, beyond gross CSFP increments, metrics related to cardiac-driven amplitudes during QT (i.e., RPPC-Q). A study comparing these metrics as obtained by established procedures (i.e., infusion testing) and by QT is warranted.
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Affiliation(s)
- Najmeh Kheram
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Andrea Boraschi
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Nikolai Pfender
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
| | - Andreas Spiegelberg
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Vartan Kurtcuoglu
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland
- Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Armin Curt
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
| | - Martin Schubert
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
| | - Carl Moritz Zipser
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland.
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11
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Zadka Y, Doron O, Rosenthal G, Barnea O. Mechanisms of reduced cerebral blood flow in cerebral edema and elevated intracranial pressure. J Appl Physiol (1985) 2023; 134:444-454. [PMID: 36603049 DOI: 10.1152/japplphysiol.00287.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
A mechanism of elevated intracranial pressure (ICP) in cerebral edema and its effects on cerebral blood flow (CBF) are presented in this paper. To study and demonstrate these effects, a mathematical model of intracranial hydrodynamics was developed. The model simulates the intracranial hydrodynamics and the changes that occur when cerebral edema predominates. To account for an edema pathology, the model includes resistances to cerebrospinal fluid (CSF) and interstitial fluid (ISF) flows within the parenchyma. The resistances change as the intercellular space becomes smaller due to swelling of brain cells. The model demonstrates the effect of changes in these resistances on ICP and venous resistance to blood flow by accounting for the key interactions between pressure, volume, and flow in the intracranial compartments in pathophysiological conditions. The model represents normal intracranial physiology as well as pathological conditions. Simulating cerebral edema with increased resistance to cerebral ISF flow resulted in elevated ICP, increased brain volume, markedly reduced ventricular volume, and decreased CBF as observed in the neurointensive care patients. The model indicates that in high ICP values, alternation of the arterial-arteriolar resistance to flow minimally affects CBF, whereas at low ICP they have a much greater effect on CBF. The model demonstrates and elucidates intracranial mechanisms related to elevated ICP.NEW & NOTEWORTHY Study goal was to elucidate the role of "bulk flow" of ISF through brain parenchyma. A model was developed to simulate fluid shifts in brain edema, ICP elevation, and their effect on CBF. Bulk flow resistance affected by edema elevates ICP and reduces CBF. Bulk flow affects transmural pressure and volume distribution in brain compartments. Changes in bulk flow resistance result in increase of venous resistance to flow and decrease in CBF.
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Affiliation(s)
- Yuliya Zadka
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Omer Doron
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Guy Rosenthal
- Department of Neurosurgery, Hadassah University Medical Center, Jerusalem, Israel
| | - Ofer Barnea
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
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12
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Holmlund P, Støverud KH, Eklund A. Mathematical modelling of the CSF system: effects of microstructures and posture on optic nerve subarachnoid space dynamics. Fluids Barriers CNS 2022; 19:67. [PMID: 36042452 PMCID: PMC9426285 DOI: 10.1186/s12987-022-00366-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/18/2022] [Indexed: 11/21/2022] Open
Abstract
Background The pressure difference between the eye and brain in upright postures may be affected by compartmentalization of the optic nerve subarachnoid space (ONSAS). Both pressure and deformation will depend on the microstructures of the ONSAS, and most likely also on ocular glymphatic clearance. Studying these factors could yield important knowledge regarding the translaminar pressure difference, which is suspected to play a role in normal-tension glaucoma. Methods A compartment model coupling the ONSAS with the craniospinal CSF system was used to investigate the effects of microstructures on the pressure transfer through the ONSAS during a posture change from supine to upright body postures. ONSAS distensibility was based on MRI measurements. We also included ocular glymphatic flow to investigate how local pressure gradients alter this flow with changes in posture. Results A compartmentalization of the ONSAS occurred in the upright posture, with ONSAS porosity (degree of microstructural content) affecting the ONSAS pressure (varying the supine/baseline porosity from 1.0 to 0.75 yielded pressures between − 5.3 and − 2 mmHg). Restricting the minimum computed porosity (occurring in upright postures) to 0.3 prevented compartmentalization, and the ONSAS pressure could equilibrate with subarachnoid space pressure (− 6.5 mmHg) in \documentclass[12pt]{minimal}
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\begin{document}$$\le$$\end{document}≤ 1 h. The ocular glymphatics analysis predicted that substantial intraocular-CSF flows could occur without substantial changes in the ONSAS pressure. The flow entering the ONSAS in supine position (both from the intraocular system and from the cranial subarachnoid space) exited the ONSAS through the optic nerve sheath, while in upright postures the flow through the ONSAS was redirected towards the cranial subarachnoid space. Conclusions Microstructures affect pressure transmission along the ONSAS, potentially contributing to ONSAS compartmentalization in upright postures. Different pathways for ocular glymphatic flow were predicted for different postures.
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Affiliation(s)
- Petter Holmlund
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University, 901 87, Umeå, Sweden.
| | - Karen-Helene Støverud
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University, 901 87, Umeå, Sweden.,Department of Health Research, SINTEF Digital, Trondheim, Norway
| | - Anders Eklund
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University, 901 87, Umeå, Sweden.,Umeå Center for Functional Brain Imaging, Umeå University, 901 87, Umeå, Sweden
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Gholampour S, Yamini B, Droessler J, Frim D. A New Definition for Intracranial Compliance to Evaluate Adult Hydrocephalus After Shunting. Front Bioeng Biotechnol 2022; 10:900644. [PMID: 35979170 PMCID: PMC9377221 DOI: 10.3389/fbioe.2022.900644] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 06/13/2022] [Indexed: 12/26/2022] Open
Abstract
The clinical application of intracranial compliance (ICC), ∆V/∆P, as one of the most critical indexes for hydrocephalus evaluation was demonstrated previously. We suggest a new definition for the concept of ICC (long-term ICC) where there is a longer amount of elapsed time (up to 18 months after shunting) between the measurement of two values (V1 and V2 or P1 and P2). The head images of 15 adult patients with communicating hydrocephalus were provided with nine sets of imaging in nine stages: prior to shunting, and 1, 2, 3, 6, 9, 12, 15, and 18 months after shunting. In addition to measuring CSF volume (CSFV) in each stage, intracranial pressure (ICP) was also calculated using fluid–structure interaction simulation for the noninvasive calculation of ICC. Despite small increases in the brain volume (16.9%), there were considerable decreases in the ICP (70.4%) and CSFV (80.0%) of hydrocephalus patients after 18 months of shunting. The changes in CSFV, brain volume, and ICP values reached a stable condition 12, 15, and 6 months after shunting, respectively. The results showed that the brain tissue needs approximately two months to adapt itself to the fast and significant ICP reduction due to shunting. This may be related to the effect of the “viscous” component of brain tissue. The ICC trend between pre-shunting and the first month of shunting was descending for all patients with a “mean value” of 14.75 ± 0.6 ml/cm H2O. ICC changes in the other stages were oscillatory (nonuniform). Our noninvasive long-term ICC calculations showed a nonmonotonic trend in the CSFV–ICP graph, the lack of a linear relationship between ICC and ICP, and an oscillatory increase in ICC values during shunt treatment. The oscillatory changes in long-term ICC may reflect the clinical variations in hydrocephalus patients after shunting.
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14
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Papaioannou V, Czosnyka Z, Czosnyka M. Hydrocephalus and the neuro-intensivist: CSF hydrodynamics at the bedside. Intensive Care Med Exp 2022; 10:20. [PMID: 35618965 PMCID: PMC9135922 DOI: 10.1186/s40635-022-00452-9] [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: 03/17/2022] [Accepted: 05/19/2022] [Indexed: 12/05/2022] Open
Abstract
Hydrocephalus (HCP) is far more complicated than a simple disorder of cerebrospinal fluid (CSF) circulation. HCP is a common complication in patients with subarachnoid hemorrhage (SAH) and after craniectomy. Clinical measurement in HCP is mainly related to intracranial pressure (ICP) and cerebral blood flow. The ability to obtain quantitative variables that describe CSF dynamics at the bedside before potential shunting may support clinical intuition with a description of CSF dysfunction and differentiation between normal pressure hydrocephalus and brain atrophy. This review discusses the advanced research on HCP and how CSF is generated, stored and absorbed within the context of a mathematical model developed by Marmarou. Then, we proceed to explain the main quantification analysis of CSF dynamics using infusion techniques for deciding on definitive treatment. We consider that such descriptions of multiple parameters of measurements need to be significantly appreciated by the caring neuro-intensivist, for better understanding of the complex pathophysiology and clinical management and finally, improve of the prognosis of these patients with HCP. In this review article, we present current and novel theories of CSF circulation and pathophysiology of hydrocephalus, along with results from infusion studies for evaluating CSF dynamics at the bedside.
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Affiliation(s)
- Vasilios Papaioannou
- Department of Intensive Care Medicine, Alexandroupolis Hospital, Democritus University of Thrace, 68100, Alexandroupolis, Greece. .,Academic Neurosurgery Unit, Brain Physics Lab, Addenbrooke's Hospital, P.O. Box 167, CB20QQ, Cambridge, UK. .,Department of Intensive Care Medicine, Alexandroupolis Hospital, Democritus University of Thrace, Polyviou 6-8, 55132, Thessaloniki, Greece.
| | - Zofia Czosnyka
- Academic Neurosurgery Unit, Brain Physics Lab, Addenbrooke's Hospital, P.O. Box 167, CB20QQ, Cambridge, UK
| | - Marek Czosnyka
- Academic Neurosurgery Unit, Brain Physics Lab, Addenbrooke's Hospital, P.O. Box 167, CB20QQ, Cambridge, UK
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15
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Li L, Ding G, Zhang L, Davoodi-Bojd E, Chopp M, Li Q, Zhang ZG, Jiang Q. Aging-Related Alterations of Glymphatic Transport in Rat: In vivo Magnetic Resonance Imaging and Kinetic Study. Front Aging Neurosci 2022; 14:841798. [PMID: 35360203 PMCID: PMC8960847 DOI: 10.3389/fnagi.2022.841798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 02/18/2022] [Indexed: 11/23/2022] Open
Abstract
Objective Impaired glymphatic waste clearance function during brain aging leads to the accumulation of metabolic waste and neurotoxic proteins (e.g., amyloid-β, tau) which contribute to neurological disorders. However, how the age-related glymphatic dysfunction exerts its effects on different cerebral regions and affects brain waste clearance remain unclear. Methods We investigated alterations of glymphatic transport in the aged rat brain using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and advanced kinetic modeling. Healthy young (3-4 months) and aged (18-20 months) male rats (n = 12/group) underwent the identical MRI protocol, including T2-weighted imaging and 3D T1-weighted imaging with intracisternal administration of contrast agent (Gd-DTPA). Model-derived parameters of infusion rate and clearance rate, characterizing the kinetics of cerebrospinal fluid (CSF) tracer transport via the glymphatic system, were evaluated in multiple representative brain regions. Changes in the CSF-filled cerebral ventricles were measured using contrast-induced time signal curves (TSCs) in conjunction with structural imaging. Results Compared to the young brain, an overall impairment of glymphatic transport function was detected in the aged brain, evidenced by the decrease in both infusion and clearance rates throughout the brain. Enlarged ventricles in parallel with reduced efficiency in CSF transport through the ventricular regions were present in the aged brain. While the age-related glymphatic dysfunction was widespread, our kinetic quantification demonstrated that its impact differed considerably among cerebral regions with the most severe effect found in olfactory bulb, indicating the heterogeneous and regional preferential alterations of glymphatic function. Conclusion The robust suppression of glymphatic activity in the olfactory bulb, which serves as one of major efflux routes for brain waste clearance, may underlie, in part, age-related neurodegenerative diseases associated with neurotoxic substance accumulation. Our data provide new insight into the cerebral regional vulnerability to brain functional change with aging.
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Affiliation(s)
- Lian Li
- Department of Neurology, Henry Ford Health System, Detroit, MI, United States
| | - Guangliang Ding
- Department of Neurology, Henry Ford Health System, Detroit, MI, United States
| | - Li Zhang
- Department of Neurology, Henry Ford Health System, Detroit, MI, United States
| | | | - Michael Chopp
- Department of Neurology, Henry Ford Health System, Detroit, MI, United States
- Department of Physics, Oakland University, Rochester, MI, United States
| | - Qingjiang Li
- Department of Neurology, Henry Ford Health System, Detroit, MI, United States
| | - Zheng Gang Zhang
- Department of Neurology, Henry Ford Health System, Detroit, MI, United States
| | - Quan Jiang
- Department of Neurology, Henry Ford Health System, Detroit, MI, United States
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16
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Zverev AG, Tokarev UN. A Noninvasive Approach in the Hydrodynamics of the Cerebrospinal Fluid in the Spinal Cavity. Biophysics (Nagoya-shi) 2022. [DOI: 10.1134/s0006350922010201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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17
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Kaipainen AL, Martoma E, Puustinen T, Tervonen J, Jyrkkänen HK, Paterno JJ, Kotkansalo A, Rantala S, Vanhanen U, Leinonen V, Lehto SM, Iso-Mustajärvi M, Elomaa AP, Qvarlander S, Huuskonen TJ. Cerebrospinal fluid dynamics in idiopathic intracranial hypertension: a literature review and validation of contemporary findings. Acta Neurochir (Wien) 2021; 163:3353-3368. [PMID: 34453214 PMCID: PMC8599224 DOI: 10.1007/s00701-021-04940-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/06/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Idiopathic intracranial hypertension (IIH) is a rare disease of unknown aetiology related possibly to disturbed cerebrospinal fluid (CSF) dynamics and characterised by elevated intracranial pressure (ICP) causing optic nerve atrophy if not timely treated. We studied CSF dynamics of the IIH patients based on the available literature and our well-defined cohort. METHOD A literature review was performed from PubMed between 1980 and 2020 in compliance with the PRISMA guideline. Our study includes 59 patients with clinical, demographical, neuro-ophthalmological, radiological, outcome data, and lumbar CSF pressure measurements for suspicion of IIH; 39 patients had verified IIH while 20 patients did not according to Friedman's criteria, hence referred to as symptomatic controls. RESULTS The literature review yielded 19 suitable studies; 452 IIH patients and 264 controls had undergone intraventricular or lumbar CSF pressure measurements. In our study, the mean CSF pressure, pulse amplitudes, power of respiratory waves (RESP), and the pressure constant (P0) were higher in IIH than symptomatic controls (p < 0.01). The mean CSF pressure was higher in IIH patients with psychiatric comorbidity than without (p < 0.05). In IIH patients without acetazolamide treatment, the RAP index and power of slow waves were also higher (p < 0.05). IIH patients with excess CSF around the optic nerves had lower relative pulse pressure coefficient (RPPC) and RESP than those without (p < 0.05). CONCLUSIONS Our literature review revealed increased CSF pressure, resistance to CSF outflow and sagittal sinus pressure (SSP) as key findings in IIH. Our study confirmed significantly higher lumbar CSF pressure and increased CSF pressure waves and RAP index in IIH when excluding patients with acetazolamide treatment. In overall, the findings reflect decreased craniospinal compliance and potentially depleted cerebral autoregulation resulting from the increased CSF pressure in IIH. The increased slow waves in patients without acetazolamide may indicate issues in autoregulation, while increased P0 could reflect the increased SSP.
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Affiliation(s)
- Aku L Kaipainen
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.
- Institute of Clinical Medicine / Neurology, University of Eastern Finland, Kuopio, Finland.
| | - Erik Martoma
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Tero Puustinen
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Joona Tervonen
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Henna-Kaisa Jyrkkänen
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Jussi J Paterno
- Opthalmology KUH, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Anna Kotkansalo
- Division of Clinical Neurosciences, Department of Neurosurgery, Turku University Hospital, Turku, Finland
| | - Susanna Rantala
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Ulla Vanhanen
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Ville Leinonen
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Soili M Lehto
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- R&D department, Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
- Department of Psychiatry, University of Helsinki, Helsinki, Finland
| | | | - Antti-Pekka Elomaa
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- Eastern Finland Microsurgery Center, Kuopio University Hospital, Kuopio, Finland
| | - Sara Qvarlander
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Terhi J Huuskonen
- Neurosurgery KUH NeuroCenter, Kuopio University Hospital, and Faculty of Health Sciences, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
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Nur İH, Keleş H, Ünlükal N, Solmaz M, Erdoğan E, Pérez W. A new definition about the relationship of intercellular fluid in the brain with the mandibular and parotid lymph nodes. Microsc Res Tech 2021; 85:220-232. [PMID: 34369631 DOI: 10.1002/jemt.23898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/20/2021] [Accepted: 07/25/2021] [Indexed: 11/12/2022]
Abstract
This study was carried out to reveal the relationship of the brain with both the mandibular lymph node (MLN) and parotid lymph node (PLN) by the hyperspectral fluorescence imaging techniques of Qdot 800 (QD) nanoparticles using in vivo. This relationship of the brain with both lymph nodes offers the preliminary morphological definition of lymphatic drainage. QD was injected into the left parietal brain lobe of each rat at a depth of 2.50 mm. In 65% of the rats that were imaged in vivo, signals were received first from the right MLN and PLN, and then from the left MLN and PLN. In contrast, in two female rats, the first signal was received from the right PLN. There was no difference between the female and male rats overall. The most noteworthy finding of this study was that the tracer injected into the left parietal lobe reached the right mandibular and parotid lymph nodules earlier. This result indicates a different and unknown pathway in the brain that communicates with the lymph nodes. Moreover, this study shows that these lymph nodes pathways can be used in the treatment of diseases such as brain trauma, cerebral edema, and Alzheimer's disease (AD).
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Affiliation(s)
- İsmail Hakkı Nur
- Department of Anatomy, Faculty of Veterinary Medicine, Erciyes University, Kayseri, Turkey
| | - Hacı Keleş
- Department of Anatomy, Faculty of Medicine, Nigde Omer Halisdemir University, Nigde, Turkey
| | - Nejat Ünlükal
- Department of Histology and Embryology, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Merve Solmaz
- Department of Histology and Embryology, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - Ender Erdoğan
- Department of Histology and Embryology, Faculty of Medicine, Selcuk University, Konya, Turkey
| | - William Pérez
- Unidad de Anatomia, Facultad de Veterinaria, Universidad de la Republica, Montevideo, Uruguay
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Kazimierska A, Kasprowicz M, Czosnyka M, Placek MM, Baledent O, Smielewski P, Czosnyka Z. Compliance of the cerebrospinal space: comparison of three methods. Acta Neurochir (Wien) 2021; 163:1979-1989. [PMID: 33852065 PMCID: PMC8195969 DOI: 10.1007/s00701-021-04834-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 03/26/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cerebrospinal compliance describes the ability of the cerebrospinal space to buffer changes in volume. Diminished compliance is associated with increased risk of potentially threatening increases in intracranial pressure (ICP) when changes in cerebrospinal volume occur. However, despite various methods of estimation proposed so far, compliance is seldom used in clinical practice. This study aimed to compare three measures of cerebrospinal compliance. METHODS ICP recordings from 36 normal-pressure hydrocephalus patients who underwent infusion tests with parallel recording of transcranial Doppler blood flow velocity were retrospectively analysed. Three methods were used to calculate compliance estimates during changes in the mean ICP induced by infusion of fluid into the cerebrospinal fluid space: (a) based on Marmarou's model of cerebrospinal fluid dynamics (CCSF), (b) based on the evaluation of changes in cerebral arterial blood volume (CCaBV), and (c) based on the amplitudes of peaks P1 and P2 of ICP pulse waveform (CP1/P2). RESULTS Increase in ICP caused a significant decrease in all compliance estimates (p < 0.0001). Time courses of compliance estimators were strongly positively correlated with each other (group-averaged Spearman correlation coefficients: 0.94 [0.88-0.97] for CCSF vs. CCaBV, 0.77 [0.63-0.91] for CCSF vs. CP1/P2, and 0.68 [0.48-0.91] for CCaBV vs. CP1/P2). CONCLUSIONS Indirect methods, CCaBV and CP1/P2, allow for the assessment of relative changes in cerebrospinal compliance and produce results exhibiting good correlation with the direct method of volumetric manipulation. This opens the possibility of monitoring relative changes in compliance continuously.
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Affiliation(s)
- Agnieszka Kazimierska
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wroclaw, Poland.
| | - Magdalena Kasprowicz
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- Institute of Electronic Systems, Faculty of Electronics and Information Technology, Warsaw University of Technology, Warsaw, Poland
| | - Michał M Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Olivier Baledent
- Department of Medical Image Processing, CHU Amiens, University of Picardy Jules Verne, Amiens, France
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Zofia Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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The Role of Cerebrospinal Fluid Dynamics in Normal Pressure Hydrocephalus Diagnosis and Shunt Prognostication. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021. [PMID: 33839875 DOI: 10.1007/978-3-030-59436-7_69] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND Over the years, there have been several reports and trials of the resistance to cerebrospinal fluid (CSF) outflow (Rout) in normal pressure hydrocephalus (NPH). This work aimed to revisit the utility of testing CSF circulation in a large population of patients clinically presenting with NPH. MATERIALS AND METHODS We retrospectively analyzed the data of 369 NPH patients-either shunted or with endoscopic third ventriculostomy (ETV)-in Cambridge between 1992 and 2018. We determined the patients' outcomes (improvement versus no improvement at 6 months) by applying a threshold on R out values and compared our results with those of existing literature. We also conducted a correlation analysis between all variables and calculated Chi-Statistics (as a measure of separability between improvement and no improvement outcomes) to determine a subset of variables which achieved the highest accuracy in prediction of outcome. RESULTS In our dataset, R out of 18 mmHg*min/mL achieved the highest Chi-statistics of 9.7 with p-value <0.01 when adjusted for age. In addition to R out, intracranial pressure (ICP) values at the baseline and plateau, CSF production rate and ICP amplitude to slope ratio showed significant Chi-Statistics values (more than 5). Using these variables, an overall accuracy of 0.70 ± 0.09 was achieved for prediction of the shunt outcome. CONCLUSION Rout can be used for selecting patients for shunt surgery but not for excluding patients from treatment. Critical, multivariable approaches are required to comprehend CSF dynamics and pressure-volume compensation in NPH. Outcome definition and assessment could also be brought to question.
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Differences in Cerebrospinal Fluid Dynamics in Posttraumatic Hydrocephalus Versus Atrophy, Including Effect of Decompression and Cranioplasty. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021. [PMID: 33839872 DOI: 10.1007/978-3-030-59436-7_66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
INTRODUCTION Challenges in diagnosing post-traumatic hydrocephalus (PTH) have created a need for an accurate diagnostic tool. We aim to report CSF dynamics in PTH and atrophy, along with differences before and after cranioplasty. METHODS We retrospectively analyzed traumatic brain injury patients with ventriculomegaly who had infusion studies. We divided patients depending on CSF dynamics into two groups: 'likely PTH' (A) and 'likely atrophy' (B). A group of idiopathic normal pressure hydrocephalus shunt-responsive patients was used for comparison (C). RESULTS Group A consisted of 36 patients who were non-decompressed or had a cranioplasty in situ for over 1 month. Group B included 16 patients with low Rout, AMP, and dAMP, 9 of whom were decompressed. Rout and dAMP were significantly higher in Group A than B, but significantly lower than Group C (45 iNPH patients). RAP change during infusion in group A indicated depleted compensatory reserve compared to ample reserve in group B. Repeat studies in five decompressed patients post-cranioplasty showed all parameters increased. CONCLUSIONS Infusion tests are not useful in decompressed patients, whilst cranioplasty allowed differentiation between possible PTH and atrophy. Rout and AMP were significantly lower in PTH compared to iNPH and did not always reflect the degree of hydrocephalus reported on imaging.
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Dias SF, Jehli E, Haas-Lude K, Bevot A, Okechi H, Zipfel J, Schuhmann MU. Ventriculomegaly in children: nocturnal ICP dynamics identify pressure-compensated but active paediatric hydrocephalus. Childs Nerv Syst 2021; 37:1883-1893. [PMID: 33884480 DOI: 10.1007/s00381-021-05164-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/12/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Paediatric ventriculomegaly without obvious signs or symptoms of raised intracranial pressure (ICP) is often interpreted as resulting from either relative brain atrophy, arrested "benign" hydrocephalus, or "successful" endoscopic third ventriculostomy (ETV). We hypothesise that the typical ICP "signature" found in symptomatic hydrocephalus can be present in asymptomatic or oligosymptomatic children, indicating pressure-compensated, but active hydrocephalus. METHODS A total of 37 children fulfilling the mentioned criteria underwent computerised ICP overnight monitoring (ONM). Fifteen children had previous hydrocephalus treatment. ICP was analysed for nocturnal dynamics of ICP, ICP amplitudes (AMP), magnitude of slow waves (SLOW), and ICP/AMP correlation index RAP. Depending on the ONM results, children were either treated or observed. The ventricular width was determined at the time of ONM and at 1-year follow-up. RESULTS The recordings of 14 children (group A) were considered normal. In the 23 children with pathologic recordings (group B), all ICP values and dependent variables (AMP, SLOW) were significantly higher, except for RAP. In group B, 12 of 15 children had received a pre-treatment and 11 of 22 without previous treatment. All group B children received treatment for hydrocephalus and showed a significant reduction of frontal-occipital horn ratio at 1 year. During follow-up, a positive neurological development was seen in 74% of children of group A and 100% of group B. CONCLUSION Ventriculomegaly in the absence of signs and symptoms of raised ICP was associated in 62% of cases to pathological ICP dynamics. In 80% of pre-treated cases, ETV or shunt failure was found. Treating children with abnormal ICP dynamics resulted in an outcome at least as favourable as in the group with normal ICP dynamics. Thus, asymptomatic ventriculomegaly in children deserves further investigation and, if associated with abnormal ICP dynamics, should be treated in order to provide a normalised intracranial physiology as basis for best possible long-term outcome.
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Affiliation(s)
- Sandra F Dias
- Section of Paediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tübingen, Tübingen, Germany. .,Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.
| | - Elisabeth Jehli
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Karin Haas-Lude
- Department of Paediatric Neurology, University Children's Hospital of Tübingen, Tübingen, Germany
| | - Andrea Bevot
- Department of Paediatric Neurology, University Children's Hospital of Tübingen, Tübingen, Germany
| | - Humphrey Okechi
- Section of Paediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tübingen, Tübingen, Germany
| | - Julian Zipfel
- Section of Paediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tübingen, Tübingen, Germany
| | - Martin U Schuhmann
- Section of Paediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tübingen, Tübingen, Germany
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Chen T, Bosco DB, Ying Y, Tian DS, Wu LJ. The Emerging Role of Microglia in Neuromyelitis Optica. Front Immunol 2021; 12:616301. [PMID: 33679755 PMCID: PMC7933531 DOI: 10.3389/fimmu.2021.616301] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 01/04/2021] [Indexed: 12/13/2022] Open
Abstract
Neuromyelitis optica (NMO) is an autoantibody-triggered neuro-inflammatory disease which preferentially attacks the spinal cord and optic nerve. Its defining autoantibody is specific for the water channel protein, aquaporin-4 (AQP4), which primarily is localized at the end-feet of astrocytes. Histopathology studies of early NMO lesions demonstrated prominent activation of microglia, the resident immune sentinels of the central nervous system (CNS). Significant microglial reactivity is also observed in NMO animal models induced by introducing AQP4-IgG into the CNS. Here we review the potential roles for microglial activation in human NMO patients as well as different animal models of NMO. We will focus primarily on the molecular mechanisms underlying microglial function and microglia-astrocyte interaction in NMO pathogenesis. Understanding the role of microglia in NMO pathology may yield novel therapeutic approaches for this disease.
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Affiliation(s)
- Tingjun Chen
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Dale B. Bosco
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Yanlu Ying
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Dai-Shi Tian
- Department of Neurology, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Long-Jun Wu
- Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, United States
- Department of Immunology, Mayo Clinic, Rochester, MN, United States
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Kasprowicz M, Kazimierska A, Ziółkowski A, Lalou A, Czosnyka Z, Czosnyka M. Mathematical Modelling in Hydrocephalus. Neurol India 2021; 69:S275-S282. [DOI: 10.4103/0028-3886.332259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Harkins D, Cooper HM, Piper M. The role of lipids in ependymal development and the modulation of adult neural stem cell function during aging and disease. Semin Cell Dev Biol 2020; 112:61-68. [PMID: 32771376 DOI: 10.1016/j.semcdb.2020.07.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/24/2020] [Accepted: 07/29/2020] [Indexed: 01/10/2023]
Abstract
Within the adult mammalian central nervous system, the ventricular-subventricular zone (V-SVZ) lining the lateral ventricles houses neural stem cells (NSCs) that continue to produce neurons throughout life. Developmentally, the V-SVZ neurogenic niche arises during corticogenesis following the terminal differentiation of telencephalic radial glial cells (RGCs) into either adult neural stem cells (aNSCs) or ependymal cells. In mice, these two cellular populations form rosettes during the late embryonic and early postnatal period, with ependymal cells surrounding aNSCs. These aNSCs and ependymal cells serve a number of key purposes, including the generation of neurons throughout life (aNSCs), and acting as a barrier between the CSF and the parenchyma and promoting CSF bulk flow (ependymal cells). Interestingly, the development of this neurogenic niche, as well as its ongoing function, has been shown to be reliant on different aspects of lipid biology. In this review we discuss the developmental origins of the rodent V-SVZ neurogenic niche, and highlight research which has implicated a role for lipids in the physiology of this part of the brain. We also discuss the role of lipids in the maintenance of the V-SVZ niche, and discuss new research which has suggested that alterations to lipid biology could contribute to ependymal cell dysfunction in aging and disease.
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Affiliation(s)
- Danyon Harkins
- School of Biomedical Sciences, The University of Queensland, Brisbane, 4072, Australia
| | - Helen M Cooper
- Queensland Brain Institute, The University of Queensland, Brisbane, 4072, Australia
| | - Michael Piper
- School of Biomedical Sciences, The University of Queensland, Brisbane, 4072, Australia; Queensland Brain Institute, The University of Queensland, Brisbane, 4072, Australia.
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Debnam JM, Said RB, Liu HH, Sun J, Wang J, Wei W, Suki D, Mayer RR, Chi TL, Ketonen L, Guha-Thakurta N, Weinberg JS. Ventricular apparent diffusion coefficient measurements in patients with neoplastic leptomeningeal disease. Cancer Imaging 2020; 20:41. [PMID: 32600415 PMCID: PMC7322838 DOI: 10.1186/s40644-020-00305-2] [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: 12/02/2019] [Accepted: 04/01/2020] [Indexed: 12/05/2022] Open
Abstract
Background To test the hypothesis that intraventricular ADC values can be used to determine the presence of neoplastic leptomeningeal disease (LMD). Materials and methods ADC values were measured at multiple sites in the ventricular system in 32 patients with cytologically-proven LMD and 40 control subjects. Multiple linear regression analysis was used to determine the mean difference of ADCs between the LMD and control groups after adjusting for ventricle size and tumor type. Receiver operating characteristics (ROC) analysis was performed and optimal ADC value cut-off point for predicting the presence of LMD. ADC was compared to T1 enhancement and FLAIR signal hyperintensity for determining the presence of LMD. Results After adjusting for ventricular volume and tumor type, the mid body of lateral ventricles showed no significant difference in ventricular volume and a significant difference in ADC values between the control and LMD groups (p > 0.05). In the mid-body of the right lateral ventricle the AUC was 0.69 (95% CI 0.57–0.81) with an optimal ADC cut off point of 3.22 × 10− 9 m2/s (sensitivity, specificity; 0.72, 0.68). In the mid-body of left lateral ventricle the AUC was 0.7 (95% CI 0.58–0.82) with an optimal cut-off point of 3.23 × 10− 9 m2/s (0.81, 0.62). Using an average value of HU measurements in the lateral ventricles the AUC was 0.73 (95% CI 0.61–0.84) with an optimal cut off point was 3.11 × 10− 9 m2/s (0.78, 0.65). Compared to the T1 post-contrast series, ADC was predictive of the presence of LMD in the mid-body of the left lateral ventricle (p = 0.036). Conclusion Complex interactions affect ADC measurements in patients with LMD. ADC values in the lateral ventricles may provide non-invasive clues to the presence of LMD.
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Affiliation(s)
- James M Debnam
- Department of Neuroradiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Blvd., Unit 1482, Houston, TX, 77030, USA.
| | - Ryan B Said
- Department of Neuroradiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Blvd., Unit 1482, Houston, TX, 77030, USA
| | - Heng-Hsiao Liu
- Department of Neuroradiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Blvd., Unit 1482, Houston, TX, 77030, USA
| | - Jia Sun
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jihong Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wei Wei
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dima Suki
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rory R Mayer
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
| | - T Linda Chi
- Department of Neuroradiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Blvd., Unit 1482, Houston, TX, 77030, USA
| | - Leena Ketonen
- Department of Neuroradiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Blvd., Unit 1482, Houston, TX, 77030, USA
| | - Nandita Guha-Thakurta
- Department of Neuroradiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Blvd., Unit 1482, Houston, TX, 77030, USA
| | - Jeffrey S Weinberg
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Lalou AD, Czosnyka M, Czosnyka ZH, Krishnakumar D, Pickard JD, Higgins NJ. Coupling of CSF and sagittal sinus pressure in adult patients with pseudotumour cerebri. Acta Neurochir (Wien) 2020; 162:1001-1009. [PMID: 31832847 PMCID: PMC7156361 DOI: 10.1007/s00701-019-04095-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 10/08/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Pseudotumour cerebri syndrome (PTCS including idiopathic intracranial hypertension) is characterised by the symptoms and signs of raised cerebrospinal fluid pressure (CSFp) in the absence of ventricular dilatation or an intracranial mass lesion. Its aetiology is unknown in the majority of cases but there is much evidence for impaired CSF absorption. Traditionally, sagittal sinus pressure has been considered to be independent of CSF pressure in adults. However, the discovery of stenoses of intracranial venous sinuses and introduction of venous sinus stenting has highlighted the importance of the venous drainage in PTCS. In this study, we have explored the relationship between CSFp and SSp before and during a CSF infusion test and during CSF drainage. MATERIALS AND METHODS Ten patients (9 females:1 male) with PTCS underwent infusion studies in parallel with direct retrograde cerebral venography. Both SSp and CSFp were recorded at a baseline and during CSFp elevation in a course of a CSF infusion test. The drainage of CSF after the CSF infusion was performed in 7 patients. In 5 cases, jugular venous pressure was also measured. RESULTS CSFp and SSp including their amplitudes correlated significantly and strongly both at baseline (R = 0.96; p = 0.001) and during infusion (R = 0.92; p = 0.0026). During drainage, this correlation was maintained until SSp reached a stable value, whereas CSFp continued to decrease. CONCLUSIONS In this series of ten patients with PTCS, CSFp and SSp were coupled, both at baseline and during infusion. The implications of such coupling for the calculation of CSF outflow resistance are discussed.
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Affiliation(s)
- Afroditi-Despina Lalou
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital, Cambridge, UK.
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital, Cambridge, UK
| | - Zofia H Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital, Cambridge, UK
| | - Deepa Krishnakumar
- Department of Paediatric Neurology, Cambridge University Hospital, Cambridge, UK
| | - John D Pickard
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital, Cambridge, UK
| | - Nick J Higgins
- Department of Radiology, Addenbrooke's Hospital, Cambridge, UK
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28
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Lalou AD, Czosnyka M, Garnett MR, Nabbanja E, Petrella G, Hutchinson PJ, Pickard JD, Czosnyka Z. Shunt infusion studies: impact on patient outcome, including health economics. Acta Neurochir (Wien) 2020; 162:1019-1031. [PMID: 32078047 PMCID: PMC7156359 DOI: 10.1007/s00701-020-04212-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 01/06/2020] [Indexed: 12/03/2022]
Abstract
Objectives The diagnosis of shunt malfunction is often not straightforward. We have explored, in symptomatic shunted patients with hydrocephalus or pseudotumour cerebri syndrome (PTCS), the accuracy of CSF infusion tests in differentiating a functioning shunt from one with possible problems, and the health economic consequences. Methods Participants: hydrocephalus/PTCS patients with infusion tests performed from January 2013 until December 2015. We followed patients up after 6 and 12 months from the test to determine whether they had improved, had persisting symptoms or had required urgent revision. We calculated the total cost savings of revision versus infusion tests and standard protocol of revision and ICP monitoring versus infusion tests. Results Three hundred sixty-five shunt infusion tests had been performed where a shunt prechamber/reservoir was present. For hydrocephalus patients, more than half of the tests (~ 55%, 155 out of 280) showed no shunt malfunction versus 125 with possible malfunction (ages 4 months to 90 years old). For PTCS patients aged 10 to 77 years old, 47 had possible problems and 38 no indication for shunt malfunction. Overall, > 290 unnecessary revisions were avoided over 3 years’ time. Two hundred fifty-eight (> 85%) of those non-surgically managed, remained well, did not deteriorate and did not require surgery. No infections were associated with infusion studies. For Cambridge, the overall savings from avoiding revisions was £945,415 annually. Conclusions Our results provide evidence of the importance of shunt testing in vivo to confirm shunt malfunction. Avoiding unnecessary shunt revisions carries a strong health benefit for patients that also translates to a significant financial benefit for the National Health Service and potentially for other healthcare systems worldwide. Electronic supplementary material The online version of this article (10.1007/s00701-020-04212-0) contains supplementary material, which is available to authorized users.
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29
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Bajpai BK, Zakelis R, Deimantavicius M, Imbrasiene D. Comparative Study of Novel Noninvasive Cerebral Autoregulation Volumetric Reactivity Indices Reflected by Ultrasonic Speed and Attenuation as Dynamic Measurements in the Human Brain. Brain Sci 2020; 10:brainsci10040205. [PMID: 32244750 PMCID: PMC7226251 DOI: 10.3390/brainsci10040205] [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: 03/03/2020] [Revised: 03/22/2020] [Accepted: 03/26/2020] [Indexed: 11/20/2022] Open
Abstract
This is a comparative study of two novel noninvasive cerebrovascular autoregulation (CA) monitoring methods based on intracranial blood volume (IBV) changes in the human brain. We investigated the clinical applicability of the new volumetric reactivity index (VRx2), reflected by intracranial ultrasonic attenuation dynamics for noninvasive CA monitoring. The CA was determined noninvasively on 43 healthy participants by calculating the volumetric reactivity index (VRx1 from time-of-flight of ultrasound, VRx2 from attenuation of ultrasound). The VRx was calculated as a moving correlation coefficient between the arterial blood pressure and noninvasively measured IBV slow waves. Linear regression between VRx1 and VRx2 (averaged per participants) showed a significant correlation (r = 0.731, p < 0.0001, 95% confidence interval [0.501–0.895]) in data filtered by bandpass filtering. On the other hand, FIR filtering demonstrated a slightly better correlation (r = 0.769, p < 0.0001, 95% confidence interval [0.611–0.909]). The standard deviation of the difference by bandpass filtering was 0.1647 and bias −0.3444; and by FIR filtering 0.1382 and bias −0.3669. This comparative study showed a significant coincidence of the VRx2 index compared to that of VRx1. Hence, VRx2 could be used as an alternative, cost-effective noninvasive cerebrovascular autoregulation index in the same way as VRx1 values are used.
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Affiliation(s)
- Basant K. Bajpai
- Health Telematics Science Institute, Kaunas University of Technology, LT-51423 Kaunas, Lithuania
- Correspondence: ; Tel.: +370-6478-3364
| | - Rolandas Zakelis
- Health Telematics Science Institute, Kaunas University of Technology, LT-51423 Kaunas, Lithuania
| | - Mantas Deimantavicius
- Health Telematics Science Institute, Kaunas University of Technology, LT-51423 Kaunas, Lithuania
| | - Daiva Imbrasiene
- Department of Health Promotion and Rehabilitation, Lithuanian Sports University, LT-44221 Kaunas, Lithuania
- Institute of Physiology and Pharmacology, Lithuanian University of Health Sciences, LT-44307 Kaunas, Lithuania
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Lalou AD, Levrini V, Czosnyka M, Gergelé L, Garnett M, Kolias A, Hutchinson PJ, Czosnyka Z. Cerebrospinal fluid dynamics in non-acute post-traumatic ventriculomegaly. Fluids Barriers CNS 2020; 17:24. [PMID: 32228689 PMCID: PMC7106631 DOI: 10.1186/s12987-020-00184-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 03/06/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Post-traumatic hydrocephalus (PTH) is potentially under-diagnosed and under-treated, generating the need for a more efficient diagnostic tool. We aim to report CSF dynamics of patients with post-traumatic ventriculomegaly. MATERIALS AND METHODS We retrospectively analysed post-traumatic brain injury (TBI) patients with ventriculomegaly who had undergone a CSF infusion test. We calculated the resistance to CSF outflow (Rout), AMP (pulse amplitude of intracranial pressure, ICP), dAMP (AMPplateau-AMPbaseline) and compensatory reserve index correlation coefficient between ICP and AMP (RAP). To avoid confounding factors, included patients had to be non-decompressed or with cranioplasty > 1 month previously and Rout > 6 mmHg/min/ml. Compliance was assessed using the elasticity coefficient. We also compared infusion-tested TBI patients selected for shunting versus those not selected for shunting (consultant decision based on clinical and radiological assessment and the infusion results). Finally, we used data from a group of shunted idiopathic Normal Pressure Hydrocephalus (iNPH) patients for comparison. RESULTS Group A consisted of 36 patients with post-traumatic ventriculomegaly and Group B of 45 iNPH shunt responders. AMP and dAMP were significantly lower in Group A than B (0.55 ± 0.39 vs 1.02 ± 0.72; p < 0.01 and 1.58 ± 1.21 vs 2.76 ± 1.5; p < 0.01. RAP baseline was not significantly different between the two. Elasticity was higher than the normal limit in all groups (average 0.18 1/ml). Significantly higher Rout was present in those with probable PTH selected for shunting compared with unshunted. Mild/moderate hydrocephalus, ex-vacuo ventriculomegaly/encephalomalacia were inconsistently reported in PTH patients. CONCLUSIONS Rout and AMP were significantly lower in PTH compared to iNPH and did not always reflect the degree of hydrocephalus or atrophy reported on CT/MRI. Compliance appears reduced in PTH.
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Affiliation(s)
- Afroditi D Lalou
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospital NHS Foundation Trust, Cambridge, UK.
| | - Virginia Levrini
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Laurent Gergelé
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
- Department of Intensive Care, Hôpital privé de la Loire, Saint Etienne, France
| | - Matthew Garnett
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Zofia Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
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Characterizing the Response to Cerebrospinal Fluid Drainage in Patients with an External Ventricular Drain: The Pressure Equalization Ratio. Neurocrit Care 2020; 30:340-347. [PMID: 30251075 DOI: 10.1007/s12028-018-0612-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND An external ventricular drain (EVD) is the gold standard for measurement of intracranial pressure (ICP) and allows for drainage of cerebrospinal fluid (CSF). Different causes of elevated ICP, such as CSF outflow obstruction or cerebral swelling, respond differently to CSF drainage. This is a widely recognized but seldom quantified distinction. We sought to define an index to characterize the response to CSF drainage in neurocritical care patients. METHODS We studied consecutive patients admitted to the neurointensive care unit who had an EVD. The EVD was closed for 30 min prior to assessment. We documented pre-drainage ICP, opened EVD to drainage allowing CSF to drain until it ceased, and recorded post-drainage ICP at EVD closure. We calculated the pressure equalization (PE) ratio as the difference between pre-drainage ICP and post-drainage ICP divided by the difference between pre-drainage ICP and EVD height. RESULTS We studied 60 patients (36 traumatic brain injury [TBI], 24 non-TBI). As expected, TBI patients had more signs of cerebral swelling on CT and smaller ventricles. Although TBI patients had significantly higher pre-drainage ICP (26 ± 10 mm Hg) than non-TBI patients (19 ± 5 mm Hg, p < 0.001) they drained less CSF (7 cc vs. 4 cc, p < 0.01). PE ratio was substantially higher in non-TBI than in TBI patients (0.86 ± 0.36 vs. 0.43 ± 0.31, p < 0.0001), indicating that non-TBI patients were better able to equalize pressure with EVD height than TBI patients. CONCLUSIONS PE ratio reflects the ability to equalize pressure with the preset height of the EVD and differs substantially between TBI and non-TBI patients. A high PE ratio likely indicates CSF outflow obstruction effectively treated by CSF diversion, while a lower PE ratio occurs when cerebral swelling predominates. Further studies could assess whether the PE ratio would be useful as a surrogate marker for cerebral edema or the state of intracranial compliance.
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Value of computerized shunt infusion study in assessment of pediatric hydrocephalus shunt function-a two center cross-sectional study. Childs Nerv Syst 2020; 36:59-71. [PMID: 31372736 DOI: 10.1007/s00381-019-04264-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 06/17/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Hydrocephalus shunt malfunction can-also in children-occur insidiously without clear symptoms of raised intracranial pressure (ICP) or changes in ventricular size, imposing a diagnostic challenge. Computerized shunt infusion studies enable quantitative shunt function assessment. We report on feasibility and results of this technique in children in a two center cross-sectional study. MATERIAL AND METHODS Shunt infusion study (SIS) is performed with two needles inserted into a pre-chamber for ICP recording and CSF infusion. After baseline ICP recording, constant rate infusion is started until a new ICP plateau (ICPpl) is reached. Dedicated software containing the shunt's resistance characteristics calculates ICP and its amplitude outflow resistance and critical shunt pressure (CSP). Overall, 203 SIS were performed in 166 children. Shunts were defined as functional if ICPpl was <CSP and obstructed if ICPpl was > 5 mmHg above CSP and borderline in between. RESULTS Forty-one shunts (20.2%) were found obstructed, 26 (12.8%) had borderline characteristics, and 136 (67%) were functional. Baseline ICP in obstructed shunts was significantly above shunt operating pressure. CSF outflow resistance (Rout) and ∆ICP plateau were significantly elevated in obstructed shunts, with cut-off thresholds of 8.07 mmHg min/ml and 11.74 mmHg respectively. Subgroup analysis showed smaller ventricles in 69% of revised cases. CONCLUSION SIS is a feasible, reliable, and radiation-free technique for quantitative shunt assessment to rule out or prove shunt malfunction. Dedicated software containing shunt hydrodynamic characteristics is necessary and small children may need short-term sedation. Due to the clinical and inherent economic advantages, SIS should be more frequently used in pediatric neurosurgery.
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Cerebrospinal fluid dynamics in pediatric pseudotumor cerebri syndrome. Childs Nerv Syst 2020; 36:73-86. [PMID: 31325030 DOI: 10.1007/s00381-019-04263-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 06/17/2019] [Indexed: 12/18/2022]
Abstract
PURPOSE There is a growing body of evidence highlighting the importance of comprehensive intracranial pressure (ICP) values in pseudotumor cerebri syndrome (PTCS). Due to the highly dynamic nature of ICP, several methods of ICP monitoring have been established, including the CSF infusion study. We have performed a retrospective review of the CSF dynamics measurements for all pediatric patients investigated for PTCS in our center and examined their diagnostic value compared with clinical classification. METHODS We retrospectively recruited 31 patients under 16 years of age investigated for PTCS by CSF infusion test. We used the clinically provided Friedman classification 13/31 patients with definite PTCS (group A), 13/31 with probable PTCS (group B), and 5/31 not PTCS (group C), to compare CSF dynamics in the 3 groups. RESULTS CSF pressure (CSFp) was significantly increased in group A (29.18 ± 7.72 mmHg) compared with B (15.31 ± 3.47 mmHg; p = 1.644e-05) and C (17.51 ± 5.87; p = 0.01368). The amplitude (AMP) was higher in the definite (2.18 ± 2.06 mmHg) than in group B (0.68 ± 0.37; p = 0.01382). There was no in either CSFp or AMP between groups B and C. No lower breakpoint of the AMP-P line was observed in group A but was present in 2/13 and 2/5 patients in groups B and C. In group A, sagittal sinus pressure (SSp) and elasticity were the only parameters above threshold (p = 4.2e-06 and p = 0.001953, respectively), In group B, only the elasticity was significantly higher than the threshold (p = 004257). Group C did not have any of the parameters raised. The AUC of CSFp, elasticity, and SSp for the 3 groups was 93.8% (84.8-100% CI). CONCLUSIONS Monitoring of CSFp and its dynamics, besides providing a more precise methodology for measuring CSFp, could yield information on the dynamic parameters of CSFp that cannot be derived from CSFp as a number, accurately differentiating between the clinically and radiologically derived entities of PTCS.
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Busch KJ, Kiat H, Avolio A, Butlin M, Davidson A. Obstructive Hydrocephalus Due to Unruptured Brain Arteriovenous Malformation: Demonstrating Transcranial Color Duplex Confirmation of Cerebral Venous Hemodynamic Alterations and Color Duplex Ultrasound Confirmation of Shunt Patency. Cureus 2019; 11:e6181. [PMID: 31890387 PMCID: PMC6913917 DOI: 10.7759/cureus.6181] [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] [Indexed: 11/27/2022] Open
Abstract
Given the rarity of arteriovenous malformations of the brain (bAVMs) with concomitant obstructive hydrocephalus, few papers have commented on the resultant hydrodynamic perturbations. To date, no study has specifically investigated the effect of ventricular shunting on intracranial venous parameters as measured by transcranial color duplex ultrasound (TCCD). This study investigates whether TCCD and color duplex ultrasound are useful modalities to elucidate the physiological and hemodynamic changes in a patient with bAVM following ventricular shunting. Using TCCD, this study demonstrates that preoperatively, there is a decrease in cerebral capacitance, manifesting in a decrease in cerebral inflow and reduced venous outflow. Following shunt insertion, intracranial compliance is increased, resulting in the dilatation of previously compressed capacitance vessels and restoration of venous compliance. Color duplex ultrasound (CDU) was a useful determinant of shunt patency in the neck. We report the first TCCD assessment of hemodynamic changes of the intracranial circulation in a patient with bAVM following ventricular-peritoneal shunting. The results lend conceptual support of a pressure gradient change with high pressure that occurs in the veins as compared to the subarachnoid space.
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Affiliation(s)
- Kathryn J Busch
- Miscellaneous, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, AUS
| | - Hosen Kiat
- Cardiology, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, AUS
| | - Alberto Avolio
- Cardiovascular Research, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, AUS
| | - Mark Butlin
- Cardiology, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, AUS
| | - Andrew Davidson
- Neurosurgery, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, AUS
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Petkus V, Preiksaitis A, Chaleckas E, Chomskis R, Zubaviciute E, Vosylius S, Rocka S, Rastenyte D, Aries MJ, Ragauskas A, Neumann JO. Optimal Cerebral Perfusion Pressure: Targeted Treatment for Severe Traumatic Brain Injury. J Neurotrauma 2019; 37:389-396. [PMID: 31583962 DOI: 10.1089/neu.2019.6551] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Identification of individual therapy targets is critical for traumatic brain injury (TBI) patients. Clinical outcomes depend on cerebrovascular autoregulation (CA) impairment. Here, we compare the effectiveness of optimal cerebral perfusion pressure (CPPopt)-targeted therapy in younger (<45 years of age) and elderly (≥45 years of age) TBI patients. Single-center multi-modal invasive arterial blood pressure(t), intracranial pressure (ICP)(t), cerebral perfusion pressure CPP(t), and CPPopt(t) monitoring (n = 81) was performed. ICM+ software was used for continuous CPPopt(t) status assessment by identification of pressure reactivity index (PRx). The most significant prognostic factors were age, Glasgow Coma Scale, serum glucose, and duration of longest CA ompairment event (LCAI) when PRx(t) >0.5 within 24 h after admission. The modeled accuracies for favorable and unfavorable outcome prediction were 86.5% and 90.9%, respectively. Age above 45 years and averaged ICP during all monitoring time above 21.3 mm Hg was associated with unfavorable outcome of an individual patient. Averaged CPP values close to CPPopt were associated with a better outcome in younger patients. Averaged ΔCPPopt <-5.0 mm Hg, averaged PRx >0.36, and LCAI >100 min were significantly associated with mortality for the younger patients. The critical values of averaged PRx >0.26 and LCAI >61 min were significantly associated with mortality for the elderly group. Autoregulation-guided treatment was important for individual TBI management, especially in younger patients. Further randomized multi-center studies are needed to prove final benefit.
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Affiliation(s)
- Vytautas Petkus
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Aidanas Preiksaitis
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania.,Department of Neurology, Academy of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania.,Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Department of Neurosurgery, Republic Vilnius University Hospital, Vilnius, Lithuania
| | - Edvinas Chaleckas
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Romanas Chomskis
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Erika Zubaviciute
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Saulius Vosylius
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Department of Neurosurgery, Republic Vilnius University Hospital, Vilnius, Lithuania
| | - Saulius Rocka
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Department of Neurosurgery, Republic Vilnius University Hospital, Vilnius, Lithuania
| | - Daiva Rastenyte
- Department of Neurology, Academy of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Marcel J Aries
- Department of Intensive Care, University of Maastricht Medical Center, Maastricht, The Netherlands
| | - Arminas Ragauskas
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Jan-Oliver Neumann
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
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36
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Martinez-Tejada I, Arum A, Wilhjelm JE, Juhler M, Andresen M. B waves: a systematic review of terminology, characteristics, and analysis methods. Fluids Barriers CNS 2019; 16:33. [PMID: 31610775 PMCID: PMC6792201 DOI: 10.1186/s12987-019-0153-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 09/15/2019] [Indexed: 11/18/2022] Open
Abstract
Background Although B waves were introduced as a concept in the analysis of intracranial pressure (ICP) recordings nearly 60 years ago, there is still a lack consensus on precise definitions, terminology, amplitude, frequency or origin. Several competing terms exist, addressing either their probable physiological origin or their physical characteristics. To better understand B wave characteristics and ease their detection, a literature review was carried out. Methods A systematic review protocol including search strategy and eligibility criteria was prepared in advance. A literature search was carried out using PubMed/MEDLINE, with the following search terms: B waves + review filter, slow waves + review filter, ICP B waves, slow ICP waves, slow vasogenic waves, Lundberg B waves, MOCAIP. Results In total, 19 different terms were found, B waves being the most common. These terminologies appear to be interchangeable and seem to be used indiscriminately, with some papers using more than five different terms. Definitions and etiologies are still unclear, which makes systematic and standardized detection difficult. Conclusions Two future lines of action are available for automating macro-pattern identification in ICP signals: achieving strict agreement on morphological characteristics of “traditional” B waveforms, or starting a new with a fresh computerized approach for recognition of new clinically relevant patterns.
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Affiliation(s)
- Isabel Martinez-Tejada
- Clinic of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark. .,Department of Health Technology, Technical University of Denmark, Kongens Lyngby, Denmark.
| | - Alexander Arum
- Clinic of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jens E Wilhjelm
- Department of Health Technology, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Marianne Juhler
- Clinic of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Morten Andresen
- Clinic of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Jacobsson J, Qvarlander S, Eklund A, Malm J. Comparison of the CSF dynamics between patients with idiopathic normal pressure hydrocephalus and healthy volunteers. J Neurosurg 2019; 131:1018-1023. [PMID: 30497143 DOI: 10.3171/2018.5.jns173170] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 05/29/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intracranial pressure (ICP), outflow resistance (Rout), and amplitude of cardiac-related ICP pulsations (AMPs) are established parameters to describe the CSF hydrodynamic system and are assumed, but not confirmed, to be disturbed in idiopathic normal pressure hydrocephalus (INPH). The aim of this study was to compare the CSF hydrodynamic profile between patients with INPH and healthy volunteers. METHODS Sixty-two consecutive INPH patients (mean age 74 years) and 40 healthy volunteers (mean age 70 years) were included. Diagnosis was made by two independent neurologists who assessed patients' history, neurological status, and MRI studies. A CSF dynamic investigation through the lumbar route was performed: ICP and other CSF dynamic variables were blinded to the neurologists during the diagnostic process and were not used for establishing the diagnosis of INPH. RESULTS Rout was significantly higher in INPH (Rout 17.1 vs 11.1; p < 0.001), though a substantial number of INPH subjects had normal Rout. There were no differences between INPH patients and controls regarding ICP (mean 11.5 mm Hg). At resting pressure, there was a trend that AMP in INPH was increased (2.4 vs 2.0 mm Hg; p = 0.109). The relationship between AMP and ICP was that they shared the same slope, but the curve was significantly shifted to the left for INPH (reduced P0 [p < 0.05]; i.e., higher AMP for the same ICP). CONCLUSIONS This study established that the CSF dynamic profile of INPH deviates from that of healthy volunteers and that INPH should thus be regarded as a disease in which intracranial hydrodynamics are part of the pathophysiology.Clinical trial registration no.: NCT01188382 (clinicaltrials.gov).
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Affiliation(s)
| | - Sara Qvarlander
- 2Radiation Sciences-Biomedical Engineering, and
- 3Centre for Biomedical Engineering and Physics, Umeå University, Umeå, Sweden
| | - Anders Eklund
- 2Radiation Sciences-Biomedical Engineering, and
- 3Centre for Biomedical Engineering and Physics, Umeå University, Umeå, Sweden
| | - Jan Malm
- Departments of1Pharmacology and Clinical Neuroscience and
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Norwood JN, Zhang Q, Card D, Craine A, Ryan TM, Drew PJ. Anatomical basis and physiological role of cerebrospinal fluid transport through the murine cribriform plate. eLife 2019; 8:44278. [PMID: 31063132 PMCID: PMC6524970 DOI: 10.7554/elife.44278] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 05/06/2019] [Indexed: 12/25/2022] Open
Abstract
Cerebrospinal fluid (CSF) flows through the brain, transporting chemical signals and removing waste. CSF production in the brain is balanced by a constant outflow of CSF, the anatomical basis of which is poorly understood. Here, we characterized the anatomy and physiological function of the CSF outflow pathway along the olfactory sensory nerves through the cribriform plate, and into the nasal epithelia. Chemical ablation of olfactory sensory nerves greatly reduced outflow of CSF through the cribriform plate. The reduction in CSF outflow did not cause an increase in intracranial pressure (ICP), consistent with an alteration in the pattern of CSF drainage or production. Our results suggest that damage to olfactory sensory neurons (such as from air pollution) could contribute to altered CSF turnover and flow, providing a potential mechanism for neurological diseases.
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Affiliation(s)
- Jordan N Norwood
- Cellular and Developmental Biology Graduate Program, Pennsylvania State University, University Park, United States
| | - Qingguang Zhang
- Department of Engineering Science and Mechanics, Pennsylvania State University, University Park, United States
| | - David Card
- Department of Physics, Pennsylvania State University, University Park, United States
| | - Amanda Craine
- Department of Biomedical Engineering, Pennsylvania State University, University Park, United States
| | - Timothy M Ryan
- Department of Anthropology, Pennsylvania State University, University Park, United States
| | - Patrick J Drew
- Department of Engineering Science and Mechanics, Pennsylvania State University, University Park, United States.,Department of Biomedical Engineering, Pennsylvania State University, University Park, United States.,Department of Neurosurgery, Pennsylvania State University, University Park, United States
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Benninghaus A, Balédent O, Lokossou A, Castelar C, Leonhardt S, Radermacher K. Enhanced in vitro model of the CSF dynamics. Fluids Barriers CNS 2019; 16:11. [PMID: 31039805 PMCID: PMC6492379 DOI: 10.1186/s12987-019-0131-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 04/15/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Fluid dynamics of the craniospinal system are complex and still not completely understood. In vivo flow and pressure measurements of the cerebrospinal fluid (CSF) are limited. Whereas in silico modeling can be an adequate pathway for parameter studies, in vitro modeling of the craniospinal system is essential for testing and evaluation of therapeutic measures associated with innovative implants relating to, for example, normal pressure hydrocephalus and other fluid disorders. Previously-reported in vitro models focused on the investigation of only one hypothesis of the fluid dynamics rather than developing a modular set-up to allow changes in focus of the investigation. The aim of this study is to present an enhanced and validated in vitro model of the CSF system which enables the future embedding of implants, the validation of in silico models or phase-contrast magnetic resonance imaging (PC-MRI) measurements and a variety of sensitivity analyses regarding pathological behavior, such as reduced CSF compliances, higher resistances or altered blood dynamics. METHODS The in vitro model consists of a ventricular system which is connected via the aqueduct to the cranial and spinal subarachnoid spaces. Two compliance chambers are integrated to cushion the arteriovenous blood flow generated by a cam plate unit enabling the modeling of patient specific flow dynamics. The CSF dynamics are monitored using three cranial pressure sensors and a spinal ultrasound flow meter. Measurements of the in vitro spinal flow were compared to cervical flow data recorded with PC-MRI from nine healthy young volunteers, and pressure measurements were compared to the literature values reported for intracranial pressure (ICP) to validate the newly developed in vitro model. RESULTS The maximum spinal CSF flow recorded in the in vitro simulation was 133.60 ml/min in the caudal direction and 68.01 ml/min in the cranial direction, whereas the PC-MRI flow data of the subjects showed 122.82 ml/min in the caudal and 77.86 ml/min in the cranial direction. In addition, the mean ICP (in vitro) was 12.68 mmHg and the pressure wave amplitude, 4.86 mmHg, which is in the physiological range. CONCLUSIONS The in vitro pressure values were in the physiological range. The amplitudes of the flow results were in good agreement with PC-MRI data of young and healthy volunteers. However, the maximum cranial flow in the in vitro model occurred earlier than in the PC-MRI data, which might be due to a lack of an in vitro dynamic compliance. Implementing dynamic compliances and related sensitivity analyses are major aspects of our ongoing research.
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Affiliation(s)
- Anne Benninghaus
- Chair of Medical Engineering, Helmholtz-Institute for Biomedical Engineering, RWTH Aachen University, Pauwelsstraße 20, 52074, Aachen, Germany.
| | - Olivier Balédent
- Department of Image Processing, University Hospital, E.A 7516, CHIMERE, Jules Verne University of Picardy, 80054, Amiens cedex, France
| | - Armelle Lokossou
- Department of Image Processing, University Hospital, E.A 7516, CHIMERE, Jules Verne University of Picardy, 80054, Amiens cedex, France
| | - Carlos Castelar
- Chair for Medical Information Technology, Helmholtz-Institute for Biomedical Engineering, RWTH Aachen University, Pauwelsstraße 20, 52074, Aachen, Germany
| | - Steffen Leonhardt
- Chair for Medical Information Technology, Helmholtz-Institute for Biomedical Engineering, RWTH Aachen University, Pauwelsstraße 20, 52074, Aachen, Germany
| | - Klaus Radermacher
- Chair of Medical Engineering, Helmholtz-Institute for Biomedical Engineering, RWTH Aachen University, Pauwelsstraße 20, 52074, Aachen, Germany
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40
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Petkus V, Preiksaitis A, Krakauskaite S, Bartusis L, Chomskis R, Hamarat Y, Zubaviciute E, Vosylius S, Rocka S, Ragauskas A. Non-invasive Cerebrovascular Autoregulation Assessment Using the Volumetric Reactivity Index: Prospective Study. Neurocrit Care 2019; 30:42-50. [PMID: 29951960 DOI: 10.1007/s12028-018-0569-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND This prospective study of an innovative non-invasive ultrasonic cerebrovascular autoregulation (CA) monitoring method is based on real-time measurements of intracranial blood volume (IBV) reactions following changes in arterial blood pressure. In this study, we aimed to determine the clinical applicability of a non-invasive CA monitoring method by performing a prospective comparative clinical study of simultaneous invasive and non-invasive CA monitoring on intensive care patients. METHODS CA was monitored in 61 patients with severe traumatic brain injuries invasively by calculating the pressure reactivity index (PRx) and non-invasively by calculating the volumetric reactivity index (VRx) simultaneously. The PRx was calculated as a moving correlation coefficient between intracranial pressure and arterial blood pressure slow waves. The VRx was calculated as a moving correlation coefficient between arterial blood pressure and non-invasively-measured IBV slow waves. RESULTS A linear regression between VRx and PRx averaged per patients' monitoring session showed a significant correlation (r = 0.843, p < 0.001; 95% confidence interval 0.751 - 0.903). The standard deviation of the difference between VRx and PRx was 0.192; bias was - 0.065. CONCLUSIONS This prospective clinical study of the non-invasive ultrasonic volumetric reactivity index VRx monitoring, based on ultrasonic time-of-flight measurements of IBV dynamics, showed significant coincidence of non-invasive VRx index with invasive PRx index. The ultrasonic time-of-flight method reflects blood volume changes inside the acoustic path, which crosses both hemispheres of the brain. This method does not reflect locally and invasively-recorded intracranial pressure slow waves, but the autoregulatory reactions of both hemispheres of the brain. Therefore, VRx can be used as a non-invasive cerebrovascular autoregulation index in the same way as PRx and can also provide information about the CA status encompassing all intracranial hemodynamics.
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Affiliation(s)
- Vytautas Petkus
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania.
| | - Aidanas Preiksaitis
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania.,Department of Neurology, Academy of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania.,Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Department of Neurosurgery, Republic Vilnius University Hospital, Vilnius, Lithuania
| | - Solventa Krakauskaite
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Laimonas Bartusis
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Romanas Chomskis
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Yasin Hamarat
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Erika Zubaviciute
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Department of Neurosurgery, Republic Vilnius University Hospital, Vilnius, Lithuania
| | - Saulius Vosylius
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Department of Neurosurgery, Republic Vilnius University Hospital, Vilnius, Lithuania
| | - Saulius Rocka
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Department of Neurosurgery, Republic Vilnius University Hospital, Vilnius, Lithuania
| | - Arminas Ragauskas
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
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Lalou AD, Czosnyka M, Donnelly J, Pickard JD, Nabbanja E, Keong NC, Garnett M, Czosnyka ZH. Cerebral autoregulation, cerebrospinal fluid outflow resistance, and outcome following cerebrospinal fluid diversion in normal pressure hydrocephalus. J Neurosurg 2019; 130:154-162. [PMID: 29547089 DOI: 10.3171/2017.7.jns17216] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 07/24/2017] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Normal pressure hydrocephalus is not simply the result of a disturbance in CSF circulation, but often includes cardiovascular comorbidity and abnormalities within the cerebral mantle. In this study, the authors have examined the relationship between the global autoregulation pressure reactivity index (PRx), the profile of disturbed CSF circulation and pressure-volume compensation, and their possible effects on outcome after surgery. METHODS The authors studied a cohort of 131 patients in whom a clinical suspicion of normal pressure hydrocephalus was investigated. Parameters describing CSF compensation and circulation were calculated during the CSF infusion test, and PRx was calculated from CSF pressure and mean arterial blood pressure (MAP) recordings. A simple scale was used to mark the patients’ outcome 6 months after surgery (improvement, temporary improvement, and no improvement). RESULTS The PRx was negatively correlated with resistance to CSF outflow (R = -0.18; p = 0.044); patients with normal CSF circulation tended to have worse autoregulation. The correlation for patients who were surgically treated (n = 83) was R = -0.28; p = 0.01, and it was stronger in patients who experienced sustained improvement after surgery (n = 48, R = -0.43; p = 0.002). In patients who did not improve, the correlation was not significantly different from zero (n = 19, R = -0.07; p = 0.97). There was a trend toward higher values for PRx in nonresponders than in responders (0.16 ± 0.04 vs 0.09 ± 0.02, respectively; p = 0.061), associated with higher MAP values (107.2 ± 8.2 in nonresponders vs 89.5 ± 3.5 in responders; p = 0.195). The product of MAP × (1 + PRx), which was proposed as a measure of combined arterial hypertension and deranged autoregulation, showed a significant association with outcome (greater value in nonresponders; p = 0.013). CONCLUSION Autoregulation proves to associate with CSF circulation and appears strongest in shunt responders. Outcome following CSF diversion is possibly most favorable when CSF outflow resistance is increased and global cerebral autoregulation is intact, in combination with arterial normotension.
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Affiliation(s)
- Afroditi Despina Lalou
- 1Division of Neurosurgery, University of Cambridge Department of Clinical Neuroscience, Addenbrooke's Hospital, Cambridge, United Kingdom; and
| | - Marek Czosnyka
- 1Division of Neurosurgery, University of Cambridge Department of Clinical Neuroscience, Addenbrooke's Hospital, Cambridge, United Kingdom; and
| | - Joseph Donnelly
- 1Division of Neurosurgery, University of Cambridge Department of Clinical Neuroscience, Addenbrooke's Hospital, Cambridge, United Kingdom; and
| | | | - Eva Nabbanja
- 1Division of Neurosurgery, University of Cambridge Department of Clinical Neuroscience, Addenbrooke's Hospital, Cambridge, United Kingdom; and
| | - Nicole C Keong
- 1Division of Neurosurgery, University of Cambridge Department of Clinical Neuroscience, Addenbrooke's Hospital, Cambridge, United Kingdom; and
- 2Department of Neurosurgery, National Neuroscience Institute and Duke-NUS Medical School, Singapore
| | - Matthew Garnett
- 1Division of Neurosurgery, University of Cambridge Department of Clinical Neuroscience, Addenbrooke's Hospital, Cambridge, United Kingdom; and
| | - Zofia H Czosnyka
- 1Division of Neurosurgery, University of Cambridge Department of Clinical Neuroscience, Addenbrooke's Hospital, Cambridge, United Kingdom; and
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García M, Poza J, Santamarta D, Romero-Oraá R, Hornero R. Continuous wavelet transform in the study of the time-scale properties of intracranial pressure in hydrocephalus. PHILOSOPHICAL TRANSACTIONS. SERIES A, MATHEMATICAL, PHYSICAL, AND ENGINEERING SCIENCES 2018; 376:rsta.2017.0251. [PMID: 29986920 PMCID: PMC6048580 DOI: 10.1098/rsta.2017.0251] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/03/2018] [Indexed: 06/01/2023]
Abstract
Normal pressure hydrocephalus (NPH) encompasses a heterogeneous group of disorders generally characterized by clinical symptoms, ventriculomegaly and anomalous cerebrospinal fluid (CSF) dynamics. Lumbar infusion tests (ITs) are frequently performed in the preoperatory evaluation of patients who show NPH features. The analysis of intracranial pressure (ICP) signals recorded during ITs could be useful to better understand the pathophysiology underlying NPH and to assist treatment decisions. In this study, 131 ICP signals recorded during ITs were analysed using two continuous wavelet transform (CWT)-derived parameters: Jensen divergence (JD) and spectral flux (SF). These parameters were studied in two frequency bands, associated with different components of the signal: B1(0.15-0.3 Hz), related to respiratory blood pressure oscillations; and B2 (0.67-2.5 Hz), related to ICP pulse waves. Statistically significant differences (p < 1.70 × 10-3, Bonferroni-corrected Wilcoxon signed-rank tests) in pairwise comparisons between phases of ITs were found using the mean and standard deviation of JD and SF. These differences were mainly found in B2, where a lower irregularity and variability, together with less prominent time-frequency fluctuations, were found in the hypertension phase of ITs. Our results suggest that wavelet analysis could be useful for understanding CSF dynamics in NPH.This article is part of the theme issue 'Redundancy rules: the continuous wavelet transform comes of age'.
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Affiliation(s)
- María García
- Biomedical Engineering Group (GIB), Department T.S.C.I.T., E.T.S. Ingenieros de Telecomunicación, University of Valladolid, Valladolid, Spain
| | - Jesús Poza
- Biomedical Engineering Group (GIB), Department T.S.C.I.T., E.T.S. Ingenieros de Telecomunicación, University of Valladolid, Valladolid, Spain
- IMUVA, Instituto de Investigación en Matemáticas, University of Valladolid, Valladolid, Spain
- INCYL, Instituto de Neurociencias de Castilla y León, University of Salamanca, Salamanca, Spain
| | - David Santamarta
- Servicio de Neurocirugía, Complejo Asistencial Universitario de León, León, Spain
| | - Roberto Romero-Oraá
- Biomedical Engineering Group (GIB), Department T.S.C.I.T., E.T.S. Ingenieros de Telecomunicación, University of Valladolid, Valladolid, Spain
| | - Roberto Hornero
- Biomedical Engineering Group (GIB), Department T.S.C.I.T., E.T.S. Ingenieros de Telecomunicación, University of Valladolid, Valladolid, Spain
- IMUVA, Instituto de Investigación en Matemáticas, University of Valladolid, Valladolid, Spain
- INCYL, Instituto de Neurociencias de Castilla y León, University of Salamanca, Salamanca, Spain
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Nabbanja E, Pickard JD, Lalou AD, Czosnyka ZH. Use of CSF infusion studies to unblock occluded hydrocephalus ventricular shunt catheters: a preliminary report of two patients. BMJ Case Rep 2018; 2018:bcr-2017-223861. [PMID: 29769186 DOI: 10.1136/bcr-2017-223861] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Two patients with ventriculoperitoneal shunts presented with symptoms of raised intracranial pressure indicative of possible shunt malfunction. During investigation, to eliminate this possibility, cerebral spinal fluid infusion studies were performed, which indicated proximal occlusion of the shunts in both cases. Retrograde flush of the ventricular catheter was performed during temporary compression of the siphon-control device, a manoeuvre which blocks distal flow. After the use of this technique, both patients' symptoms improved and they have remained symptom-free for over 2 years. This case report validates the role that infusion studies can play in clearing a blocked ventricular catheter shunt.
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Affiliation(s)
- Eva Nabbanja
- Clinical Neurosciences, Division of Neurosurgery, Cambridge University Hospital, Cambridge, UK
| | - John Douglas Pickard
- Clinical Neurosciences, Division of Neurosurgery, Cambridge University Hospital, Cambridge, UK
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Kumpaitiene B, Svagzdiene M, Sirvinskas E, Adomaitiene V, Petkus V, Zakelis R, Krakauskaite S, Chomskis R, Ragauskas A, Benetis R. Cerebrovascular autoregulation impairments during cardiac surgery with cardiopulmonary bypass are related to postoperative cognitive deterioration: prospective observational study. Minerva Anestesiol 2018; 85:594-603. [PMID: 29756691 DOI: 10.23736/s0375-9393.18.12358-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Postoperative cognitive dysfunction (POCD) occurs in approximately 33-83% of patients after cardiac surgery with cardiopulmonary bypass (CPB). Recent clinical data suggest that real-time, intraoperative monitoring of patient-specific cerebrovascular autoregulation (CA) may help to prevent POCD by detecting individual critical limits for mean arterial pressure (MAP) outside which CA is impaired. Objectives of the study were to detect the episodes of impaired CA during cardiac surgery with CPB, and to investigate the association between CA impairment and POCD. METHODS The observational study of non-invasive ultrasonic volumetric CA monitoring included 59 patients undergoing elective coronary artery bypass graft surgery with CPB. All patients underwent series of neuropsychological tests the day before and ten days after the surgery in order to evaluate cognitive function. RESULTS Twenty-two patients (37%) experienced POCD, 37 patients (63%) showed no cognitive deterioration. The duration of the single longest CA impairment event was found reliably associated with occurrence of POCD (P<0.05). The critical duration of the single longest CA impairment event was 5.03 minutes (odds ratio 14.5; CI 3.9-51.8) for studied population. CONCLUSIONS Prospective clinical study showed that single longest CA impairment may result in post-operative deterioration of mental abilities. The duration of the single longest CA impairment event is the risk factor that is associated with POCD.
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Affiliation(s)
| | - Milda Svagzdiene
- Lithuanian University of Health Sciences, Kaunas, Lithuania.,Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Edmundas Sirvinskas
- Lithuanian University of Health Sciences, Kaunas, Lithuania.,Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Vytautas Petkus
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Rolandas Zakelis
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Solventa Krakauskaite
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Romanas Chomskis
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Arminas Ragauskas
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Rimantas Benetis
- Lithuanian University of Health Sciences, Kaunas, Lithuania.,Institute of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
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45
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Validation of Davson's equation in patients suffering from idiopathic normal pressure hydrocephalus. Acta Neurochir (Wien) 2018. [PMID: 29520439 DOI: 10.1007/s00701-018-3497-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION The so-called Davson's equation relates baseline intracranial pressure (ICP) to resistance to cerebrospinal fluid outflow (Rout), formation of cerebrospinal fluid (If) and sagittal sinus pressure (PSS) There is a controversy over whether this fundamental equation is applicable in patients with normal pressure hydrocephalus (NPH). We investigated the relationship between Rout and ICP and also other compensatory, clinical and demographic parameters in NPH patients. METHOD We carried out a retrospective study of 229 patients with primary NPH who had undergone constant-rate infusion studies in our hospital. Data was recorded and processed using ICM+ software. Relationships between variables were sought by calculating Pearson product correlation coefficients and p values. RESULTS We found a significant, albeit weak, relationship between ICP and Rout (R = 0.17, p = 0.0049), Rout and peak-to-peak amplitude of ICP (AMP) (R = 0.27, p = 3.577e-05) and Rout and age (R = 0.16, p = 0.01306). CONCLUSIONS The relationship found between ICP and Rout provides indirect evidence to support disturbed Cerebrospinal fluid circulation as a key factor in disturbed CSF dynamics in NPH. Weak correlation may indicate that other factors-variable PSS and formation of CSF outflow-contribute heavily to linear model expressed by Davson's equation.
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Krovvidi H, Flint G, Williams A. Perioperative management of hydrocephalus. BJA Educ 2018; 18:140-146. [PMID: 33456824 PMCID: PMC7808083 DOI: 10.1016/j.bjae.2018.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2018] [Indexed: 11/23/2022] Open
Affiliation(s)
- H. Krovvidi
- Department of Anaesthesia, Queen Elizabeth Hospital, Birmingham, UK
| | - G. Flint
- Department of Neurosciences, Queen Elizabeth Hospital, Birmingham, UK
| | - A.V. Williams
- Department of Anaesthesia, Queen Elizabeth Hospital, Birmingham, UK
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Becker AS, Boss A, Klarhoefer M, Finkenstaedt T, Wurnig MC, Rossi C. Investigation of the pulsatility of cerebrospinal fluid using cardiac-gated Intravoxel Incoherent Motion imaging. Neuroimage 2018; 169:126-133. [DOI: 10.1016/j.neuroimage.2017.12.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 12/06/2017] [Accepted: 12/07/2017] [Indexed: 02/09/2023] Open
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Würzer B, Laza C, Pons-Kühnemann J, Kaps M, Junge B, Roessler FC. Speckle Tracking in Transcranial Ultrasound Allows Noninvasive Analysis of Pulsation Patterns of the Third Ventricle. ULTRASONIC IMAGING 2018; 40:127-138. [PMID: 29207924 DOI: 10.1177/0161734617745670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Cerebrospinal fluid (CSF) flow is sensitive to many cerebral disorders. We aimed to develop a noninvasive bedside method to detect physiological and pathological CSF phenomena by measuring pulsation patterns of the third ventricle. By transcranial B-mode ultrasound, electrocardiography (ECG)-gated video loops of the third ventricle were acquired. "Speckle tracking" software was used to quantify the relative change of its width. We conducted measurements of nine cardiac cycles in 11 healthy subjects in sitting and in supine position during Valsalva maneuver to investigate the influence of an increased intracranial pressure on the relative deformation of the third ventricle. In one patient with occlusive hydrocephalus, 19 cardiac cycles were measured in sitting position before and after removal of a tumorous obstruction of the aqueduct of Sylvius. Healthy subjects expressed a pulse-related increased width of the third ventricle ([Formula: see text]: +5.69, 95% confidence interval [CI] = [4.38, 7.00]). No significant difference was found between the sitting and the supine position in healthy adults. In the preoperative state of occlusive hydrocephalus, we found a negative, pulse-related deformation ([Formula: see text]: -1.86, 95% CI = [-2.15, -1.58]) with delayed onset. After surgery, the deformation pattern resembled that of our healthy controls. The difference between pre- and postoperative condition was significant (p < 0.001). Transcranial B-mode sonography can be used to record small movements of the sidewalls of the third ventricle. This noninvasive bedside method is suitable to assess CSF pulsatility within the third ventricle and might be able to distinguish between physiological and pathological flows.
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Affiliation(s)
- Benjamin Würzer
- 1 Department of Neurology, Justus-Liebig University Giessen, Giessen, Germany
| | - Cristina Laza
- 2 Clinic of Neurology, County Clinical Emergency Hospital "Sfântul Apostol Andrei," Constanța, Romania
| | - Jörn Pons-Kühnemann
- 3 Medical Statistics, Institute of Medical Informatics, Justus-Liebig University Giessen, Giessen, Germany
| | - Manfred Kaps
- 1 Department of Neurology, Justus-Liebig University Giessen, Giessen, Germany
| | - Bernd Junge
- 1 Department of Neurology, Justus-Liebig University Giessen, Giessen, Germany
| | - Florian C Roessler
- 1 Department of Neurology, Justus-Liebig University Giessen, Giessen, Germany
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Rouzaud-Laborde C, Lafitte P, Balardy L, Czosnyka Z, Schmidt EA. ICP and Antihypertensive Drugs. ACTA NEUROCHIRURGICA. SUPPLEMENT 2018; 126:163-165. [PMID: 29492554 DOI: 10.1007/978-3-319-65798-1_34] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Arterial hypertension is among the leading risks for mortality. This burden requires in hypertensive patients the use of single, double or more antihypertensive drugs. The relationship between intracranial pressure (ICP) and arterial blood pressure is complex and still under debate. The impact of antihypertensive drugs on ICP is unknown. We wanted to understand whether the use of antihypertensive drugs has a significant influence on ICP and cerebrospinal fluid (CSF)/brain related parameters. MATERIALS AND METHODS In a cohort of 95 patients with suspected normal pressure hydrocephalus, we prospectively collected drug details according to the Anatomical Therapeutic Chemical (ATC) classification. Lumbar infusion studies were performed. Using ICM+ software, we calculated at baseline and plateau ICP and pulse amplitude, resistance to CSF outflow, elastance, and pressure in the sagittal sinus and CSF production rate. We studied the influence of the administration of 1, 2, 3 or more antihypertensive drugs on ICP-derived parameters. We compared the data using Student's and Mann-Whitney tests or Chi-squared and Fisher's exact test. RESULTS Elastance is significantly higher in patients with at least one antihypertensive drug compared with patients without medication. On the contrary, pressure volume index (PVI) is significantly decreased in patients with antihypertensive drugs compared with patients not on these medications. However, the number of antihypertensive drugs does not seem to influence other ICP parameters. CONCLUSIONS Patients on antihypertensive drugs seem to have a stiffer brain than those not on them.
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Affiliation(s)
| | - Pierre Lafitte
- Department of Pharmacy, University Hospital Toulouse, Toulouse, France
| | - Laurent Balardy
- Department of Geriatry, University Hospital Toulouse, Toulouse, France
| | - Zofia Czosnyka
- Brain Physics Lab, Academic Neurosurgery, University of Cambridge, Cambridge, UK
| | - Eric A Schmidt
- Department of Neurosurgery, University Hospital Toulouse, Toulouse, France
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Weisenberg SH, TerMaath SC, Barbier CN, Hill JC, Killeffer JA. A computational fluid dynamics simulation framework for ventricular catheter design optimization. J Neurosurg 2017; 129:1067-1077. [PMID: 29125413 DOI: 10.3171/2017.5.jns161882] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In this research an optimization methodology and 3D computational fluid dynamics algorithm were coupled to reach an important design objective for ventricular catheters: uniform inlet flow distribution. The optimized catheter design presented significantly improves on previous designs explored in the literature and on standard catheter designs used clinically. The automated, iterative fluid simulation framework described in this work can be used to rapidly explore design parameter influence on other flow-related objectives in the future.
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Affiliation(s)
- Sofy H Weisenberg
- 1Department of Mechanical, Aerospace, and Biomedical Engineering, University of Tennessee, Knoxville
| | - Stephanie C TerMaath
- 1Department of Mechanical, Aerospace, and Biomedical Engineering, University of Tennessee, Knoxville
| | | | - Judith C Hill
- 3Scientific Computing Group, National Center for Computational Sciences, Oak Ridge National Laboratory, Oak Ridge, Tennessee; and
| | - James A Killeffer
- 4Division of Neurosurgery, Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee
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