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Norager NH, Lilja-Cyron A, Riedel CS, Holst AV, Pedersen SH, Juhler M. Intracranial pressure following surgery of an unruptured intracranial aneurysm-a model for normal intracranial pressure in humans. Fluids Barriers CNS 2024; 21:44. [PMID: 38773608 PMCID: PMC11110356 DOI: 10.1186/s12987-024-00549-1] [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: 02/07/2024] [Accepted: 05/07/2024] [Indexed: 05/24/2024] Open
Abstract
OBJECTIVE Optimizing the treatment of several neurosurgical and neurological disorders relies on knowledge of the intracranial pressure (ICP). However, exploration of normal ICP and intracranial pressure pulse wave amplitude (PWA) values in healthy individuals poses ethical challenges, and thus the current documentation remains scarce. This study explores ICP and PWA values for healthy adults without intracranial pathology expected to influence ICP. METHODS Adult patients (age > 18 years) undergoing surgery for an unruptured intracranial aneurysm without any other neurological co-morbidities were included. Patients had a telemetric ICP sensor inserted, and ICP was measured in four different positions: supine, lateral recumbent, standing upright, and 45-degree sitting, at day 1, 14, 30, and 90 following the surgery. RESULTS ICP in each position did not change with time after surgery. Median ICP was 6.7 mmHg and median PWA 2.1 mmHg in the supine position, while in the upright standing position median ICP was - 3.4 mmHg and median PWA was 1.9 mmHg. After standardization of the measurements from the transducer site to the external acoustic meatus, the median ICPmidbrain was 8.3 mmHg in the supine position and 1.2 mmHg in the upright standing position. CONCLUSION Our study provides insights into normal ICP dynamics in healthy adults following a uncomplicated surgery for an unruptured aneurysm. These results suggest a slightly wider normal reference range for invasive intracranial pressure than previously suggested, and present the first normal values for PWA in different positions. Further studies are, however, essential to enhance our understanding of normal ICP. Trial registration The study was preregistered at www. CLINICALTRIALS gov (NCT03594136) (11 July 2018).
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Affiliation(s)
- Nicolas Hernandez Norager
- Clinic of Neurosurgery, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen East, Denmark.
| | - Alexander Lilja-Cyron
- Clinic of Neurosurgery, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen East, Denmark
| | - Casper Schwartz Riedel
- Clinic of Neurosurgery, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen East, Denmark
| | - Anders Vedel Holst
- Clinic of Neurosurgery, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen East, Denmark
| | - Sarah Hornshoej Pedersen
- Clinic of Neurosurgery, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen East, Denmark
| | - Marianne Juhler
- Clinic of Neurosurgery, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Copenhagen East, Denmark
- Clinic of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
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2
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da Silva Junior EB, Hamasaki EE, Smaili HY, Wozniak A, Tristão ESY, Loureiro MDP, Milano JB, de Meneses MS, de Oliveira RM, Ramina R. Fiber-Optic Intracranial Pressure Monitoring System Using Wi-Fi-An In Vivo Study. Neurosurgery 2023; 92:647-656. [PMID: 36512829 DOI: 10.1227/neu.0000000000002250] [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: 08/12/2022] [Accepted: 09/20/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Continuous invasive monitoring of intracranial pressure (ICP) is essential in neurocritical care for surveillance and management of raised ICP. Fluid-based systems and strain gauge microsensors remain the current standard. In the past few decades, several studies with wireless monitoring were developed aiming to reduce invasiveness and complications. OBJECTIVE To describe a novel Wi-Fi fiber-optic device for continuous ICP monitoring using smartphone in a swine model. METHODS Two ICP sensors (wireless prototype and wire-based reference) were implanted in the cerebral parenchyma of a swine model for a total of 120 minutes of continuous monitoring. Every 5 minutes, jugular veins compression was performed to evaluate ICP changes. The experimentation was divided in 3 phases for comparison and analysis. RESULTS Phase 1 showed agreement in ICP changes for both sensors during jugular compression and releasing, with a positive and strong Spearman correlation (r = 0.829, P < .001). Phase 2 started after inversion of the sensors in the burr holes; there was a positive and moderately weak Spearman correlation (r = 0.262, P < .001). For phase 3, the sensors were returned to the first burr holes; the prototype behaved similarly to the reference sensor, presenting a positive and moderately strong Spearman correlation (r = 0.669, P < .001). CONCLUSION A Wi-Fi ICP monitoring system was demonstrated in a comprehensive and feasible way. It was possible to observe, using smartphone, an adequate correlation regarding ICP variations. Further adaptations are already being developed.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Ricardo Ramina
- Department of Neurosurgery, Instituto de Neurologia de Curitiba, Curitiba, Brazil
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3
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Ong J, Tavakkoli A, Strangman G, Zaman N, Kamran SA, Zhang Q, Ivkovic V, Lee AG. Neuro-ophthalmic Imaging and Visual Assessment Technology for Spaceflight Associated Neuro-ocular Syndrome (SANS). Surv Ophthalmol 2022; 67:1443-1466. [DOI: 10.1016/j.survophthal.2022.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 04/15/2022] [Accepted: 04/18/2022] [Indexed: 12/11/2022]
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Martinez-Tejada I, Riedel CS, Juhler M, Andresen M, Wilhjelm JE. k-Shape clustering for extracting macro-patterns in intracranial pressure signals. Fluids Barriers CNS 2022; 19:12. [PMID: 35123535 PMCID: PMC8817510 DOI: 10.1186/s12987-022-00311-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 01/21/2022] [Indexed: 11/27/2022] Open
Abstract
Background Intracranial pressure (ICP) monitoring is a core component of neurosurgical diagnostics. With the introduction of telemetric monitoring devices in the last years, ICP monitoring has become feasible in a broader clinical setting including monitoring during full mobilization and at home, where a greater diversity of ICP waveforms are present. The need for identification of these variations, the so-called macro-patterns lasting seconds to minutes—emerges as a potential tool for better understanding the physiological underpinnings of patient symptoms. Methods We introduce a new methodology that serves as a foundation for future automatic macro-pattern identification in the ICP signal to comprehensively understand the appearance and distribution of these macro-patterns in the ICP signal and their clinical significance. Specifically, we describe an algorithm based on k-Shape clustering to build a standard library of such macro-patterns. Results In total, seven macro-patterns were extracted from the ICP signals. This macro-pattern library may be used as a basis for the classification of new ICP variation distributions based on clinical disease entities. Conclusions We provide the starting point for future researchers to use a computational approach to characterize ICP recordings from a wide cohort of disorders.
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Norager NH, Olsen MH, Pedersen SH, Riedel CS, Czosnyka M, Juhler M. Reference values for intracranial pressure and lumbar cerebrospinal fluid pressure: a systematic review. Fluids Barriers CNS 2021; 18:19. [PMID: 33849603 PMCID: PMC8045192 DOI: 10.1186/s12987-021-00253-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although widely used in the evaluation of the diseased, normal intracranial pressure and lumbar cerebrospinal fluid pressure remain sparsely documented. Intracranial pressure is different from lumbar cerebrospinal fluid pressure. In addition, intracranial pressure differs considerably according to the body position of the patient. Despite this, the current reference values do not distinguish between intracranial and lumbar cerebrospinal fluid pressures, and body position-dependent reference values do not exist. In this study, we aim to establish these reference values. METHOD A systematic search was conducted in MEDLINE, EMBASE, CENTRAL, and Web of Sciences. Methodological quality was assessed using an amended version of the Joanna Briggs Quality Appraisal Checklist. Intracranial pressure and lumbar cerebrospinal fluid pressure were independently evaluated and subdivided into body positions. Quantitative data were presented with mean ± SD, and 90% reference intervals. RESULTS Thirty-six studies were included. Nine studies reported values for intracranial pressure, while 27 reported values for the lumbar cerebrospinal fluid pressure. Reference values for intracranial pressure were - 5.9 to 8.3 mmHg in the upright position and 0.9 to 16.3 mmHg in the supine position. Reference values for lumbar cerebrospinal fluid pressure were 7.2 to 16.8 mmHg and 5.7 to 15.5 mmHg in the lateral recumbent position and supine position, respectively. CONCLUSIONS This systematic review is the first to provide position-dependent reference values for intracranial pressure and lumbar cerebrospinal fluid pressure. Clinically applicable reference values for normal lumbar cerebrospinal fluid pressure were established, and are in accordance with previously used reference values. For intracranial pressure, this study strongly emphasizes the scarcity of normal pressure measures, and highlights the need for further research on the matter.
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Affiliation(s)
| | | | | | - Casper Schwartz Riedel
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
- Department of Neurophysiology, Rigshospitalet, Glostrup, Denmark
| | - Marek Czosnyka
- Brain Physics Laboratory, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Marianne Juhler
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
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Oertel JMK, Huelser MJM. Benefits and obstacles of telemetric ICP monitoring. Acta Neurochir (Wien) 2021; 163:1083-1085. [PMID: 33550517 PMCID: PMC7966137 DOI: 10.1007/s00701-021-04730-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 01/21/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Joachim M K Oertel
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Saarland, Germany.
| | - Matthias J M Huelser
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Saarland, Germany
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Bjornson A, Henderson D, Lawrence E, McMullan J, Ushewokunze S. The Sensor Reservoir-does it change management? Acta Neurochir (Wien) 2021; 163:1087-1095. [PMID: 33587185 DOI: 10.1007/s00701-021-04729-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND The Miethke Sensor Reservoir sits within a ventriculoperitoneal shunt system to give a reading of the pressure within the shunt. This information can guide the management of hydrocephalus patients who present frequently with headaches. METHODS We reviewed a cohort of 12 patients who underwent implantation of a Sensor Reservoir to assess how the management of their symptoms changed over a 4-year period. RESULTS When comparing the group before the Sensor Reservoir and after the Sensor Reservoir insertion, there was a 75% reduction in number of CT head scans (P<0.05), 100% reduction in episodes of ICP monitoring (P<0.05), 55% reduction in number of X-ray shunt series, and a 50% reduction in acute presentation to hospital with shunt-related symptoms. The number of clinic attendances increased by 44%. In addition, cost analysis showed a saving of £6952 per patients over the 2-year period following Sensor Reservoir insertion as a result of reduced admissions and investigations. Complications were seen in 3 patients-two patients developed shunt-related infections, and 1 patient underwent shunt revision due to a proximal shunt obstruction. Seventy-five percent of patients showed an improvement in their symptoms at the end of the 4-year period. CONCLUSION Implantation of a Sensor Reservoir in shunt patients with chronic headaches can reduce the number of investigations and hospital admissions and guide management resulting in a clinical improvement.
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Intracranial pressure monitoring following traumatic brain injury: evaluation of indications, complications, and significance of follow-up imaging-an exploratory, retrospective study of consecutive patients at a level I trauma center. Eur J Trauma Emerg Surg 2020; 48:863-870. [PMID: 33351163 PMCID: PMC7754179 DOI: 10.1007/s00068-020-01570-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 12/02/2020] [Indexed: 12/04/2022]
Abstract
Background Measurement of intracranial pressure (ICP) is an essential part of clinical management of severe traumatic brain injury (TBI). However, clinical utility and impact on clinical outcome of ICP monitoring remain controversial. Follow-up imaging using cranial computed tomography (CCT) is commonly performed in these patients. This retrospective cohort study reports on complication rates of ICP measurement in severe TBI patients, as well as on findings and clinical consequences of follow-up CCT. Methods We performed a retrospective clinical chart review of severe TBI patients with invasive ICP measurement treated at an urban level I trauma center between January 2007 and September 2017. Results Clinical records of 213 patients were analyzed. The mean Glasgow Coma Scale (GCS) on admission was 6 with an intra-hospital mortality of 20.7%. Overall, complications in 12 patients (5.6%) related to the invasive ICP-measurement were recorded of which 5 necessitated surgical intervention. Follow-up CCT scans were performed in 192 patients (89.7%). Indications for follow-up CCTs included routine imaging without clinical deterioration (n = 137, 64.3%), and increased ICP values and/or clinical deterioration (n = 55, 25.8%). Follow-up imaging based on clinical deterioration and increased ICP values were associated with significantly increased likelihoods of worsening of CCT findings compared to routinely performed CCT scans with an odds ratio of 5.524 (95% CI 1.625–18.773) and 6.977 (95% CI 3.262–14.926), respectively. Readings of follow-up CCT imaging resulted in subsequent surgical intervention in six patients (3.1%). Conclusions Invasive ICP-monitoring in severe TBI patients was safe in our study population with an acceptable complication rate. We found a high number of follow-up CCT. Our results indicate that CCT imaging in patients with invasive ICP monitoring should only be considered in patients with elevated ICP values and/or clinical deterioration.
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Riedel CS, Martinez-Tejada I, Norager NH, Kempfner L, Jennum P, Juhler M. B-waves are present in patients without intracranial pressure disturbances. J Sleep Res 2020; 30:e13214. [PMID: 33155362 DOI: 10.1111/jsr.13214] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/11/2020] [Accepted: 09/17/2020] [Indexed: 01/01/2023]
Abstract
Intracranial pressure (ICP) B-waves are defined as short, repeating elevations of ICP of up to 50 mmHg with a frequency of 0.5-2 waves/min. The presence of B-waves in overnight recordings is regarded as a pathological phenomenon. However, the physiology of B-waves is still not fully understood and studies with transcranial Doppler, as a surrogate marker for ICP, have suggested that B-waves could be a normal physiological phenomenon. We present four patients without known structural neurological disease other than a coincidentally found unruptured intracranial aneurysm. One of the patients had experienced well-controlled epilepsy for several years, but was included because ICP under these conditions is unlikely to be abnormal. Following informed consent, all four patients had a telemetric ICP probe implanted during a prophylactic operation with closure of the aneurysm. They underwent overnight ICP monitoring with simultaneous polysomnography (PSG) sleep studies at 8 weeks after the operation. These patients exhibited nocturnal B-waves, but did not have major structural brain lesions. Their ICP values were within the normal range. Nocturnal B-waves occurred in close association with sleep-disordered breathing (SDB) in rapid eye movement (REM) and non-REM sleep stages. SDB during REM sleep was associated with ramp-type B-waves; SDB during non-REM sleep was associated with the sinusoidal type of B-wave. We propose that B-waves are a physiological phenomenon associated with SDB and that the mechanical changes during respiration could have an essential and previously unrecognised role in the generation of B-waves.
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Affiliation(s)
- Casper Schwartz Riedel
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark.,Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Rigshospitalet, Glostrup, Denmark
| | - Isabel Martinez-Tejada
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark.,Department of Health Technology, Technical University of Denmark, Copenhagen, Denmark
| | | | - Lykke Kempfner
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Rigshospitalet, Glostrup, Denmark
| | - Poul Jennum
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Rigshospitalet, Glostrup, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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10
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Lilja-Cyron A, Andresen M, Kelsen J, Andreasen TH, Fugleholm K, Juhler M. Long-Term Effect of Decompressive Craniectomy on Intracranial Pressure and Possible Implications for Intracranial Fluid Movements. Neurosurgery 2020; 86:231-240. [PMID: 30768137 DOI: 10.1093/neuros/nyz049] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 01/29/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Decompressive craniectomy (DC) is used in cases of severe intracranial hypertension or impending intracranial herniation. DC effectively lowers intracranial pressure (ICP) but carries a risk of severe complications related to abnormal ICP and/or cerebrospinal fluid (CSF) circulation, eg, hygroma formation, hydrocephalus, and "syndrome of the trephined." OBJECTIVE To study the long-term effect of DC on ICP, postural ICP regulation, and intracranial pulse wave amplitude (PWA). METHODS Prospective observational study including patients undergoing DC during a 12-mo period. Telemetric ICP sensors (Neurovent-P-tel; Raumedic, Helmbrechts, Germany) were implanted in all patients. Following discharge from the neuro intensive care unit (NICU), scheduled weekly ICP monitoring sessions were performed during the rehabilitation phase. RESULTS A total of 16 patients (traumatic brain injury: 7, stroke: 9) were included (median age: 55 yr, range: 19-71 yr). Median time from NICU discharge to cranioplasty was 48 d (range: 16-98 d) and during this period, mean ICP gradually decreased from 7.8 ± 2.0 mm Hg to -1.8 ± 3.3 mm Hg (P = .02). The most pronounced decrease occurred during the first month. Normal postural ICP change was abolished after DC for the entire follow-up period, ie, there was no difference between ICP in supine and sitting position (P = .67). PWA was markedly reduced and decreased from initially 1.2 ± 0.7 mm Hg to 0.4 ± 0.3 mm Hg (P = .05). CONCLUSION Following NICU discharge, ICP decreases to negative values within 4 wk, normal postural ICP regulation is lost and intracranial PWA is diminished significantly. These abnormalities might have implications for intracranial fluid movements (eg, CSF and/or glymphatic flow) following DC and warrants further investigations.
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Affiliation(s)
| | - Morten Andresen
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Jesper Kelsen
- Department of Orthopedic Surgery (Spine Section), Rigshospitalet, Copenhagen, Denmark
| | | | - Kåre Fugleholm
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
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Long-term monitoring of intracranial pressure in freely-moving rats; impact of different physiological states. Fluids Barriers CNS 2020; 17:39. [PMID: 32517699 PMCID: PMC7285467 DOI: 10.1186/s12987-020-00199-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 05/27/2020] [Indexed: 12/17/2022] Open
Abstract
Background Elevated intracranial pressure (ICP) is observed in association with a range of brain disorders. There is limited insight into the regulatory mechanisms of ICP under physiological conditions, and consequently also under pathological conditions. Thereby, to understand the mechanisms underlying ICP dynamics, precise, valid and long-term ICP recordings are of importance in the preclinical setting. Herein, we used a novel telemetric system for ICP recordings which allowed for long-term recordings in freely-moving rats. The aim was to investigate ICP dynamics under different physiological states and investigate how factors such as surgery/recovery, body position, light–dark, co-housing, weight and anesthesia may influence ICP and its waveforms. Methods A telemetric device was implanted epidurally in rats and signals were recorded continuously for up to 50 days (n = 14). Recording was divided into three experimental periods: a surgical recovery period (RP), a physiological period (PP) and an experimental period (EP). Histology was performed to study the morphology of implanted rats and non-implanted rats (n = 17). Results For the first time, we can demonstrate continuous ICP recordings in freely-moving and co-housed rats for up to 50 days with a high degree of stability. The mean ICP in the recording periods were; RP: 3.2 ± 0.6 mmHg, PP: 5.0 ± 0.6 mmHg and EP: 4.7 ± 0.6 mmHg. In the RP, the ICP was significantly lower compared to the PP (P = 0.0034). Significant light–dark difference in ICP with 21% increase in respiratory slow-wave amplitude was observed in the co-housed animals but not in single-housed animals. The ICP signal was raised during the dark period relative to the light (Δ0.3 ± 0.07 mmHg, P = 0.0043). Administration of anesthesia gave a short-term increase in ICP followed by a significant decrease in ICP. No signs of tissue damage or inflammation were found in the implanted brains. Conclusions ICP dynamics were influenced by several factors such as, use of anesthesia, light–dark difference and housing conditions. Our study demonstrates the importance of performing ICP physiological measurements in freely-moving animals. This has significant implications for moving the preclinical research field forward in order to properly study ICP physiology during disease development and to explore drug targets for alleviating increased ICP.
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Abstract
Telemetric intracranial pressure (ICP) monitoring is a new method of measuring ICP which eliminates some of the shortcomings of previous methods. However, there are limited data on specific characteristics, including the advantages and disadvantages of this method. The main aim of this study was to demonstrate the indications, benefits, and complications of telemetric ICP monitoring. PubMed, MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for relevant studies without language or date restriction in May 2019. Human studies in which telemetric ICP monitoring was the main subject of the study were included. Our initial search resulted in 1650 articles from which 50 studies were included. There were no randomized controlled trials. The majority of the studies were case reports or case series (68%). The most common aim of studies was testing of the device (52%), and monitoring the disease progression or recovery (46%). The most common indications for telemetric ICP monitoring in these studies were testing cerebrospinal fluid shunt function (46%), ICP control after the procedure (36%), and diagnosing intracranial hypertension (22%) and hydrocephalus (12%). In total, 1423 brain disease patients had been monitored in studies. The possibility of long-term ICP monitoring as the main benefit was reported in 38 (76%) studies. The associated complication rate was 7.1%. Despite the increasing application of telemetric monitoring devices, studies to evaluate specific characteristics of this method have been infrequent and inadequate. Future research using a higher level of scientific methods is needed to evaluate advantage and disadvantages.
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13
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Evensen KB, Eide PK. Measuring intracranial pressure by invasive, less invasive or non-invasive means: limitations and avenues for improvement. Fluids Barriers CNS 2020; 17:34. [PMID: 32375853 PMCID: PMC7201553 DOI: 10.1186/s12987-020-00195-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/19/2020] [Indexed: 12/20/2022] Open
Abstract
Sixty years have passed since neurosurgeon Nils Lundberg presented his thesis about intracranial pressure (ICP) monitoring, which represents a milestone for its clinical introduction. Monitoring of ICP has since become a clinical routine worldwide, and today represents a cornerstone in surveillance of patients with acute brain injury or disease, and a diagnostic of individuals with chronic neurological disease. There is, however, controversy regarding indications, clinical usefulness and the clinical role of the various ICP scores. In this paper, we critically review limitations and weaknesses with the current ICP measurement approaches for invasive, less invasive and non-invasive ICP monitoring. While risk related to the invasiveness of ICP monitoring is extensively covered in the literature, we highlight other limitations in current ICP measurement technologies, including limited ICP source signal quality control, shifts and drifts in zero pressure reference level, affecting mean ICP scores and mean ICP-derived indices. Control of the quality of the ICP source signal is particularly important for non-invasive and less invasive ICP measurements. We conclude that we need more focus on mitigation of the current limitations of today's ICP modalities if we are to improve the clinical utility of ICP monitoring.
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Affiliation(s)
- Karen Brastad Evensen
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, P.O. Box 4950, Nydalen, 0424, Oslo, Norway
- Department of Informatics, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, P.O. Box 4950, Nydalen, 0424, Oslo, Norway.
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
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Picard NA, Zanardi CA. Letter to the Editor. The skull as a brain shape-keeper: viscoelasticity and orthostatic intracranial pressure. J Neurosurg 2020; 133:1620-1622. [PMID: 32197245 DOI: 10.3171/2019.12.jns193367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Pedersen SH, Lilja-Cyron A, Astrand R, Juhler M. Monitoring and Measurement of Intracranial Pressure in Pediatric Head Trauma. Front Neurol 2020; 10:1376. [PMID: 32010042 PMCID: PMC6973131 DOI: 10.3389/fneur.2019.01376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/12/2019] [Indexed: 01/09/2023] Open
Abstract
Purpose of Review: Monitoring of intracranial pressure (ICP) is an important and integrated part of the treatment algorithm for children with severe traumatic brain injury (TBI). Guidelines often recommend ICP monitoring with a treatment threshold of 20 mmHg. This focused review discusses; (1) different ICP technologies and how ICP should be monitored in pediatric patients with severe TBI, (2) existing evidence behind guideline recommendations, and (3) how we could move forward to increase knowledge about normal ICP in children to support treatment decisions. Summary: Current reference values for normal ICP in adults lie between 7 and 15 mmHg. Recent studies conducted in “pseudonormal” adults, however, suggest a normal range below this level where ICP is highly dependent on body posture and decreases to negative values in sitting and standing position. Despite obvious physiological differences between children and adults, no age or body size related reference values exist for normal ICP in children. Recent guidelines for treatment of severe TBI in pediatric patients recommend ICP monitoring to guide treatment of intracranial hypertension. Decision on ICP monitoring modalities are based on local standards, the individual case, and the clinician's choice. The recommended treatment threshold is 20 mmHg for a duration of 5 min. Both prospective and retrospective observational studies applying different thresholds and treatment strategies for intracranial hypertension were included to support this recommendation. While some studies suggest improved outcome related to ICP monitoring (lower rate of mortality and severe disability), most studies identify high ICP as a marker of worse outcome. Only one study applied age-differentiated thresholds, but this study did not evaluate the effect of these different thresholds on outcome. The quality of evidence behind ICP monitoring and treatment thresholds in severe pediatric TBI is low and treatment can potentially be improved by knowledge about normal ICP from observational studies in healthy children and cohorts of pediatric “pseudonormal” patients expected to have normal ICP. Acceptable levels of ICP − and thus also treatment thresholds—probably vary with age, disease and whether the patient has intact cerebral autoregulation. Future treatment algorithms should reflect these differences and be more personalized and dynamic.
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Affiliation(s)
| | | | - Ramona Astrand
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
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Pedersen SH, Norager NH, Lilja-Cyron A, Juhler M. Telemetric intracranial pressure monitoring in children. Childs Nerv Syst 2020; 36:49-58. [PMID: 31309286 DOI: 10.1007/s00381-019-04271-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 06/19/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE Repeated intracranial pressure (ICP) measurements are essential in treatment of patients with complex cerebrospinal fluid (CSF) disorders. These patients often have a long surgical history with numerous invasive lumbar or intracranial pressure monitoring sessions and/or ventriculoperitoneal (VP) shunt revisions. Telemetric ICP monitoring might be an advantageous tool in treatment of these patients. In this paper, we evaluate our experience with this technology in paediatric patients. METHODS During a 4-year period, we implanted telemetric ICP sensors (Raumedic NEUROVENT-P-tel) in 20 paediatric patients to minimise the number of future invasive procedures. Patients were diagnosed with hydrocephalus, idiopathic intracranial hypertension (IIH) or an arachnoid cyst. Most patients (85%) had a VP shunt at the time of sensor implantation. RESULTS In total, 32 sensors were inserted in the 20 patients; the cause of re-implantation was technical malfunction of the implant. One sensor was explanted due to wound infection and one due to skin erosion. We experienced no complications directly related to the implantation/explantation procedures. A total of 149 recording sessions were conducted, including 68 home monitoring sessions. The median implantation period was 523 days with a median duration of clinical use at 202 days. The most likely consequence of a recording session was non-surgical treatment alteration (shunt valve adjustment or acetazolamide dose adjustment). CONCLUSION Telemetric ICP monitoring in children is safe and potentially decreases the number of invasive procedures. We find that telemetric ICP monitoring aids the clinical management of patients with complex CSF disorders and improves everyday life for both patient and parents. It allows continuous ICP measurement in the patient's home and thereby potentially reducing hospitalisations, leading to significant cost savings.
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Affiliation(s)
- Sarah Hornshøj Pedersen
- Department of Neurosurgery, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Neurosurgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark.
| | - Nicolas Hernandez Norager
- Department of Neurosurgery, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Alexander Lilja-Cyron
- Department of Neurosurgery, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Neurosurgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
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17
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Lilja-Cyron A, Andresen M, Kelsen J, Andreasen TH, Petersen LG, Fugleholm K, Juhler M. Intracranial pressure before and after cranioplasty: insights into intracranial physiology. J Neurosurg 2019; 133:1548-1558. [PMID: 31628275 DOI: 10.3171/2019.7.jns191077] [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] [Received: 04/17/2019] [Accepted: 07/24/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Decompressive craniectomy (DC) is an emergency neurosurgical procedure used in cases of severe intracranial hypertension or impending intracranial herniation. The procedure is often lifesaving, but it exposes the brain to atmospheric pressure in the subsequent rehabilitation period, which changes intracranial physiology and probably leads to complications such as hydrocephalus, hygromas, and "syndrome of the trephined." The objective of the study was to study the effect of cranioplasty on intracranial pressure (ICP), postural ICP changes, and intracranial pulse wave amplitude (PWA). METHODS The authors performed a prospective observational study including patients who underwent DC during a 12-month period. Telemetric ICP sensors were implanted in all patients at the time of DC. ICP was evaluated before and after cranioplasty during weekly measurement sessions including a standardized postural change program. RESULTS Twelve of the 17 patients enrolled in the study had cranioplasty performed and were included in the present investigation. Their mean ICP in the supine position increased from -0.5 ± 4.8 mm Hg the week before cranioplasty to 6.3 ± 2.5 mm Hg the week after cranioplasty (p < 0.0001), whereas the mean ICP in the sitting position was unchanged (-1.2 ± 4.8 vs -1.1 ± 3.6 mm Hg, p = 0.90). The difference in ICP between the supine and sitting positions was minimal before cranioplasty (1.1 ± 1.8 mm Hg) and increased to 7.4 ± 3.6 mm Hg in the week following cranioplasty (p < 0.0001). During the succeeding 2 weeks of the follow-up period, the mean ICP in the supine and sitting positions decreased in parallel to, respectively, 4.6 ± 3.0 mm Hg (p = 0.0003) and -3.9 ± 2.7 mm Hg (p = 0.040), meaning that the postural ICP difference remained constant at around 8 mm Hg. The mean intracranial PWA increased from 0.7 ± 0.7 mm Hg to 2.9 ± 0.8 mm Hg after cranioplasty (p < 0.0001) and remained around 3 mm Hg throughout the following weeks. CONCLUSIONS Cranioplasty restores normal intracranial physiology regarding postural ICP changes and intracranial PWA. These findings complement those of previous investigations on cerebral blood flow and cerebral metabolism in patients after decompressive craniectomy.
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Affiliation(s)
| | | | - Jesper Kelsen
- 2Orthopaedic Surgery (Spine Section), Rigshospitalet; and
| | | | - Lonnie Grove Petersen
- 3Department of Biomedical Sciences, Faculty of Health Services, University of Copenhagen, Copenhagen, Denmark
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18
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Dimitrov A, Moscote-Salazar LR, Agrawal A. Letter: Long-Term Effect of Decompressive Craniectomy on Intracranial Pressure and Possible Implications for Intracranial Fluid Movements. Neurosurgery 2019; 85:E625-E626. [PMID: 31418031 DOI: 10.1093/neuros/nyz275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Anatoli Dimitrov
- Department of Neurosurgery University Hospital "Sofiamed" Sofia, Bulgaria
| | - Luis Rafael Moscote-Salazar
- Center for Biomedical Research (CIB) Cartagena Neurotrauma Research Group Faculty of Medicine University of Cartagena Cartagena de Indias, Colombia
| | - Amit Agrawal
- Department of Neurosurgery Narayana Medical College and Hospital Nellore, India
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19
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Lilja-Cyron A, Juhler M. In Reply: Long-Term Effect of Decompressive Craniectomy on Intracranial Pressure and Possible Implications for Intracranial Fluid Movements. Neurosurgery 2019; 85:E627-E628. [PMID: 31418035 DOI: 10.1093/neuros/nyz279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
| | - Marianne Juhler
- Department of Neurosurgery Rigshospitalet Copenhagen, Denmark
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20
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Oertel JMK, Huelser MJM. Telemetric home monitoring of intracranial pressure-where are we now. Acta Neurochir (Wien) 2019; 161:1603-1604. [PMID: 31187266 DOI: 10.1007/s00701-019-03962-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 05/24/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Joachim M K Oertel
- Department of Neurosurgery, Saarland University Medical Center, Kirrbergerstrasse, Building 90.5, 66421, Homburg, Germany.
- Faculty of Medicine, Saarland University, Saarbrücken, Germany.
| | - Matthias J M Huelser
- Department of Neurosurgery, Saarland University Medical Center, Kirrbergerstrasse, Building 90.5, 66421, Homburg, Germany
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Yang J, Zhao H, Li G, Ran Q, Chen J, Bai Z, Jin G, Sun J, Xu J, Qin M, Chen M. An experimental study on the early diagnosis of traumatic brain injury in rabbits based on a noncontact and portable system. PeerJ 2019; 7:e6717. [PMID: 30997290 PMCID: PMC6463870 DOI: 10.7717/peerj.6717] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 03/05/2019] [Indexed: 12/21/2022] Open
Abstract
Closed cerebral hemorrhage (CCH) is a common symptom in traumatic brain injury (TBI) patients who suffer intracranial hemorrhage with the dura mater remaining intact. The diagnosis of CCH patients prior to hospitalization and in the early stage of the disease can help patients get earlier treatments that improve outcomes. In this study, a noncontact, portable system for early TBI-induced CCH detection was constructed that measures the magnetic induction phase shift (MIPS), which is associated with the mean brain conductivity caused by the ratio between the liquid (blood/CSF and the intracranial tissues) change. To evaluate the performance of this system, a rabbit CCH model with two severity levels was established based on the horizontal biological impactor BIM-II, whose feasibility was verified by computed tomography images of three sections and three serial slices. There were two groups involved in the experiments (group 1 with 10 TBI rabbits were simulated by hammer hit with air pressure of 600 kPa by BIM-II and group 2 with 10 TBI rabbits were simulated with 650 kPa). The MIPS values of the two groups were obtained within 30 min before and after injury. In group 1, the MIPS values showed a constant downward trend with a minimum value of −11.17 ± 2.91° at the 30th min after 600 kPa impact by BIM-II. After the 650 kPa impact, the MIPS values in group 2 showed a constant downward trend until the 25th min, with a minimum value of −16.81 ± 2.10°. Unlike group 1, the MIPS values showed an upward trend after that point. Before the injury, the MIPS values in both group 1 and group 2 did not obviously change within the 30 min measurement. Using a support vector machine at the same time point after injury, the classification accuracy of the two types of severity was shown to be beyond 90%. Combined with CCH pathological mechanisms, this system can not only achieve the detection of early functional changes in CCH but can also distinguish different severities of CCH.
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Affiliation(s)
- Jun Yang
- College of Biomedical Engineering, Army Medical University, Chongqing, China
| | - Hui Zhao
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Surgery Research, Third Military Medical University, Chongqing, China
| | - Gen Li
- Department of Biomedical Engineering, Chongqing University of Technology, Chongqing, China
| | - Qisheng Ran
- Department of Radiology, Army Medical Center, Chongqing, China
| | - Jingbo Chen
- College of Biomedical Engineering, Army Medical University, Chongqing, China
| | - Zelin Bai
- College of Biomedical Engineering, Army Medical University, Chongqing, China
| | - Gui Jin
- College of Biomedical Engineering, Army Medical University, Chongqing, China
| | - Jian Sun
- College of Biomedical Engineering, Army Medical University, Chongqing, China
| | - Jia Xu
- College of Biomedical Engineering, Army Medical University, Chongqing, China
| | - Mingxin Qin
- College of Biomedical Engineering, Army Medical University, Chongqing, China
| | - Mingsheng Chen
- College of Biomedical Engineering, Army Medical University, Chongqing, China
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22
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Telemetry in intracranial pressure monitoring: sensor survival and drift. Acta Neurochir (Wien) 2018; 160:2137-2144. [PMID: 30267207 DOI: 10.1007/s00701-018-3691-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/21/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Telemetric intracranial pressure (ICP) monitoring enable long-term ICP monitoring on patients during normal day activities and may accordingly be of use during evaluation and treatment of complicated ICP disorders. However, the benefits of such equipment depend strongly on the validity of the recordings and how often the telemetric sensor needs to be re-implanted. This study investigates the clinical and technical sensor survival time and drift of the telemetric ICP sensor: Raumedic Neurovent-P-tel. METHODS Implanted telemetric ICP sensors in the period from January 2011 to December 2017 were identified, and medical records reviewed for complications, explantation reasons, and parameters relevant for determining clinical and technical sensor survival time. Explanted sensors were tested in an experimental setup to study baseline drift. RESULTS In total, implantation of 119 sensors were identified. Five sensors (4.2%) were explanted due to skin damage, three (2.5%) due to wound infection, and two (1.7%) due to ethylene oxide allergy. No other complications were observed. The median clinical sensor survival time was 208 days (95% CI 150-382). The median technical sensor survival time was 556 days (95% CI 382-605). Explanted sensors had a median baseline drift of 2.5 mmHg (IQR 2.0-5.5). CONCLUSION In most cases, the ICP sensor provides reliable measurements beyond the approved implantation time of 90 days. Thus, the sensor should not be routinely removed after this period, if ICP monitoring is still indicated. However, some sensors showed technical malfunction prior to the CE-approval, underlining that caution should always be taken when analyzing telemetric ICP curves.
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