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Agrawal M, Mishra K. Neurocognitive outcome post cranioplasty: The role of cerebral hemodynamics and cerebrospinal fluid dynamics. Surg Neurol Int 2024; 15:204. [PMID: 38974537 PMCID: PMC11225513 DOI: 10.25259/sni_1003_2023] [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: 12/21/2023] [Accepted: 05/23/2024] [Indexed: 07/09/2024] Open
Abstract
Background Cranioplasty has been useful in treating the symptoms associated with the "Sunken skin flap syndrome" post decompressive craniectomy, for which various mechanisms have been proposed. In this study, we aim to assess the changes in the cerebral blood flow and intracranial cerebrospinal fluid (CSF) dynamics post cranioplasty and correlate with the improvement in the neurocognitive status. Methods Computed tomography perfusion and cine magnetic resonance imaging studies were done to study the changes in cerebral perfusion and CSF flow dynamics postcranioplasty. The cognitive status was assessed using Montreal cognitive assessment, mini-mental state examination, and frontal assessment battery scores in the preoperative period and at 1 and 6 months follow-up. Results There was a significant change in cognitive status postcranioplasty, both at 1 and 6 months follow-up, which was associated with a significant improvement in cerebral blood flow, decreased mean transit time, and improvement in the mean and peak CSF flow velocities at the foramen of Magendie and aqueduct of Sylvius. Conclusion Cranioplasty leads to a marked improvement in cerebral hemodynamics, which is more significant on the ipsilateral side. It also leads to increased CSF turnover and improved CSF circulation. Improved cerebral perfusion and, more importantly, CSF dynamics may be responsible for the demonstrable improvement in the neurocognition in the postcranioplasty period.
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Affiliation(s)
- Manish Agrawal
- Department of Neurosurgery, SMS Medical College and Hospital, Jaipur, Rajasthan, India
| | - Keshav Mishra
- Department of Neurosurgery, SMS Medical College and Hospital, Jaipur, Rajasthan, India
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Huo H, Lu Y, Lu J, Wang X, Wang Z, Jiang J, Lou G. Optimal Timing of Cranioplasty After Decompressive Craniectomy: Timing or Collapse Ratio. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01193. [PMID: 38888307 DOI: 10.1227/ons.0000000000001220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 03/18/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Although cranioplasty (CP) is a relatively straightforward surgical procedure, it is associated with a high complication rate. The optimal timing for this surgery remains undetermined. This study aimed to identify the most suitable timing for CP to minimize postoperative complications. METHODS We conducted a retrospective analysis of all CP cases performed in our department from August 2015 to March 2022. Data were gathered through case statistics and categorized based on the occurrence of complications. The collapse ratio was determined using 3-dimensional Slicer software. RESULTS In our retrospective study of 266 patients, 51 experienced postoperative complications, including hydrocephalus, epidural effusion, subdural hematoma, epilepsy, and subcutaneous infection. Logistic regression analysis identified independent predictors of postcranioplasty complications, and a nomogram was developed. The predictive value of the logistic regression model, collapse ratio, and decompression craniotomy-CP operation interval for post-skull repair complications was assessed using receiver operating characteristic curve analysis. No significant differences were observed in postoperative complications and decompression craniotomy-CP intervals between the groups (P = .07, P > .05). However, significant differences were noted in postoperative collapse ratios and CP complications between the groups (P = .023, P < .05). Logistic regression revealed that the collapse ratio (odds ratio = 1.486; 95% CI: 1.001-2.008; P = .01) and CP operation time (odds ratio = 1.017; 95% CI: 1.008-1.025, P < .001) were independent risk factors for postoperative complications. Receiver operating characteristic curve analysis indicated that the collapse ratio could predict CP postoperative complications, with a cutoff value of 0.274, an area under the curve of 0.621, a sensitivity of 62.75%, and a specificity of 63.26%. CONCLUSION The post-skull repair collapse ratio is a significant predictor of postoperative complications. It is advisable to base the timing of surgery on the extent of brain tissue collapse, rather than solely on the duration between cranial decompression and CP.
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Affiliation(s)
- Hongyue Huo
- Taizhou Fourth People's Hospital, Taizhou, Jiangsu, China
- Graduate School of Dalian Medical University, Dalian, Liaoning, China
- Taizhou Fourth People's Hospital, Taizhou City, Jiangsu Province, China
| | - Yizhou Lu
- Taizhou Fourth People's Hospital, Taizhou City, Jiangsu Province, China
- Department of Neurosurgery, Taizhou People's Hospital, Taizhou, Jiangsu, China
| | - Jun Lu
- Taizhou Fourth People's Hospital, Taizhou City, Jiangsu Province, China
- Department of Neurosurgery, Taizhou People's Hospital, Taizhou, Jiangsu, China
| | - Xiaolin Wang
- Taizhou Fourth People's Hospital, Taizhou City, Jiangsu Province, China
- Department of Neurosurgery, Taizhou People's Hospital, Taizhou, Jiangsu, China
| | - Zheng Wang
- Taizhou Fourth People's Hospital, Taizhou City, Jiangsu Province, China
- Department of Neurosurgery, Taizhou People's Hospital, Taizhou, Jiangsu, China
| | - Jianxin Jiang
- Taizhou Fourth People's Hospital, Taizhou, Jiangsu, China
- Taizhou Fourth People's Hospital, Taizhou City, Jiangsu Province, China
- Department of Neurosurgery, Taizhou People's Hospital, Taizhou, Jiangsu, China
| | - Gaojie Lou
- Taizhou Fourth People's Hospital, Taizhou City, Jiangsu Province, China
- Department of Neurosurgery, Taizhou People's Hospital, Taizhou, Jiangsu, China
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Oliveira AMP, De Andrade AF, Pipek LZ, Iaccarino C, Rubiano AM, Amorim RL, Teixeira MJ, Paiva WS. New perspectives on assessment and understanding of the patient with cranial bone defect: a morphometric and cerebral radiodensity assessment. Front Surg 2024; 11:1329019. [PMID: 38379817 PMCID: PMC10876786 DOI: 10.3389/fsurg.2024.1329019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/24/2024] [Indexed: 02/22/2024] Open
Abstract
Background Skull defects after decompressive craniectomy (DC) cause physiological changes in brain function and patients can have neurologic symptoms after the surgery. The objective of this study is to evaluate whether there are morphometric changes in the cortical surface and radiodensity of brain tissue in patients undergoing cranioplasty and whether those variables are correlated with neurological prognosis. Methods This is a prospective cohort with 30 patients who were submitted to cranioplasty and followed for 6 months. Patients underwent simple head CT before and after cranioplasty for morphometric and cerebral radiodensity assessment. A complete neurological exam with Mini-Mental State Examination (MMSE), modified Rankin Scale, and the Barthel Index was performed to assess neurological prognosis. Results There was an improvement in all symptoms of the syndrome of the trephined, specifically for headache (p = 0.004) and intolerance changing head position (p = 0.016). Muscle strength contralateral to bone defect side also improved (p = 0.02). Midline shift of intracranial structures decreased after surgery (p = 0.004). The Anterior Distance Difference (ADif) and Posterior Distance Difference (PDif) were used to assess morphometric changes and varied significantly after surgery. PDif was weakly correlated with MMSE (p = 0.03; r = -0.4) and Barthel index (p = 0.035; r = -0.39). The ratio between the radiodensities of gray matter and white matter (GWR) was used to assess cerebral radiodensity and was also correlated with MMSE (p = 0.041; r = -0.37). Conclusion Morphological anatomy and radiodensity of the cerebral cortex can be used as a tool to assess neurological prognosis after DC.
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Affiliation(s)
- Arthur Maynart Pereira Oliveira
- Department of Neurosurgery, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Almir Ferreira De Andrade
- Department of Neurosurgery, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Leonardo Zumerkorn Pipek
- Department of Neurology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Corrado Iaccarino
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Andres M. Rubiano
- Department of Neurosurgery, Universidad de Bogotá Jorge Tadeo Lozano, Bogotá, Colombia
- Centre for Neuroscience in Education, University of Cambridge, Cambridge, United Kingdom
| | - Robson Luis Amorim
- Department of Neurosurgery, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Department of Neurosurgery, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Wellingson Silva Paiva
- Department of Neurosurgery, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
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Szczygielski J, Hubertus V, Kruchten E, Müller A, Albrecht LF, Schwerdtfeger K, Oertel J. Prolonged course of brain edema and neurological recovery in a translational model of decompressive craniectomy after closed head injury in mice. Front Neurol 2023; 14:1308683. [PMID: 38053795 PMCID: PMC10694459 DOI: 10.3389/fneur.2023.1308683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/01/2023] [Indexed: 12/07/2023] Open
Abstract
Background The use of decompressive craniectomy in traumatic brain injury (TBI) remains a matter of debate. According to the DECRA trial, craniectomy may have a negative impact on functional outcome, while the RescueICP trial revealed a positive effect of surgical decompression, which is evolving over time. This ambivalence of craniectomy has not been studied extensively in controlled laboratory experiments. Objective The goal of the current study was to investigate the prolonged effects of decompressive craniectomy (both positive and negative) in an animal model. Methods Male mice were assigned to the following groups: sham, decompressive craniectomy, TBI and TBI followed by craniectomy. The analysis of functional outcome was performed at time points 3d, 7d, 14d and 28d post trauma according to the Neurological Severity Score and Beam Balance Score. At the same time points, magnetic resonance imaging was performed, and brain edema was analyzed. Results Animals subjected to both trauma and craniectomy presented the exacerbation of the neurological impairment that was apparent mostly in the early course (up to 7d) after injury. Decompressive craniectomy also caused a significant increase in brain edema volume (initially cytotoxic with a secondary shift to vasogenic edema and gliosis). Notably, delayed edema plus gliosis appeared also after decompression even without preceding trauma. Conclusion In prolonged outcomes, craniectomy applied after closed head injury in mice aggravates posttraumatic brain edema, leading to additional functional impairment. This effect is, however, transient. Treatment options that reduce brain swelling after decompression may accelerate neurological recovery and should be explored in future experiments.
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Affiliation(s)
- Jacek Szczygielski
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
- Instutute of Neuropathology, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
- Institute of Medical Sciences, University of Rzeszów, Rzeszow, Poland
| | - Vanessa Hubertus
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
- Department of Neurosurgery, Charité University Medicine, Berlin, Germany
- Berlin Institute of Health at Charité, Berlin, Germany
| | - Eduard Kruchten
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
- Institute of Interventional and Diagnostic Radiology, Karlsruhe, Germany
| | - Andreas Müller
- Department of Radiology, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Lisa Franziska Albrecht
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Karsten Schwerdtfeger
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Joachim Oertel
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
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Chen R, Ye G, Zheng Y, Zhang Y, Zheng S, Fang W, Mei W, Xie B. Optimal Timing of Cranioplasty and Predictors of Overall Complications After Cranioplasty: The Impact of Brain Collapse. Neurosurgery 2023; 93:84-94. [PMID: 36706042 DOI: 10.1227/neu.0000000000002376] [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: 09/14/2022] [Accepted: 11/27/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The optimal timing of cranioplasty (CP) and predictors of overall postoperative complications are still controversial. OBJECTIVE To determine the optimal timing of CP. METHODS Patients were divided into collapsed group and noncollapsed group based on brain collapse or not, respectively. Brain collapse volume was calculated in a 3-dimensional way. The primary outcomes were overall complications and outcomes at the 12-month follow-up after CP. RESULTS Of the 102 patients in this retrospective observation cohort study, 56 were in the collapsed group, and 46 were in the noncollapsed group. Complications were noted in 30.4% (n = 31), 24 (42.9%) patients in the collapsed group and 7 (15.2%) patients in the noncollapsed group, with a significant difference ( P = .003). Thirty-three (58.9%) patients had good outcomes (modified Rankin Scale 0-3) in the collapsed group, and 34 (73.9%) patients had good outcomes in the noncollapsed group without a statistically significant difference ( P = .113). Brain collapse ( P = .005) and Karnofsky Performance Status score at the time of CP ( P = .025) were significantly associated with overall postoperative complications. The cut-off value for brain collapse volume was determined as 11.26 cm 3 in the receiver operating characteristic curve. The DC-CP interval was not related to brain collapse volume or postoperative complications. CONCLUSION Brain collapse and lower Karnofsky Performance Status score at the time of CP were independent predictors of overall complications after CP. The optimal timing of CP may be determined by tissue window based on brain collapse volume instead of time window based on the decompressive craniectomy-CP interval.
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Affiliation(s)
- Renlong Chen
- Department of Neurosurgery, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Institute of Neurology, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Gengzhao Ye
- Department of Neurosurgery, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Institute of Neurology, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yan Zheng
- Department of Neurosurgery, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Institute of Neurology, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yuanlong Zhang
- Department of Neurosurgery, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Institute of Neurology, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Shufa Zheng
- Department of Neurosurgery, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Institute of Neurology, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wenhua Fang
- Department of Neurosurgery, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Institute of Neurology, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wenzhong Mei
- Department of Neurosurgery, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Institute of Neurology, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Bingsen Xie
- Department of Neurosurgery, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Institute of Neurology, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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The intracranial pressure-volume relationship following decompressive hinge craniotomy compared to decompressive craniectomy-a human cadaver study. Acta Neurochir (Wien) 2023; 165:271-277. [PMID: 36369396 DOI: 10.1007/s00701-022-05409-1] [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] [Received: 07/06/2022] [Accepted: 10/06/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Decompressive hinge craniotomy (DHC) is an alternative treatment option to decompressive craniectomy (DC) for elevated intracranial pressure (ICP). The aim of this study was to characterize the difference in pressure-volume relationship between DHC and DC. METHODS We compared the intracranial pressure-volume relationship in a human cadaver model following either DHC, DC, or fixing of the bone plate by titanium clamps. We inserted an intracranial expandable device in two human cadaver specimens, performed either DHC, DC, or bone plate fixation, and gradually increased the intracranial volume while measuring ICP. Following DHC, we also performed CT-scans at pre-defined intervals. RESULTS Before ICP exceeded a threshold of 20 mmHg, a fixed bone plate tolerated an increase of 130 ml of intracranial volume, while DHC and DC allowed an increase of 190 ml and 290 ml, respectively. CT-derived calculations following DHC determined that the increase in intracranial volume at ICP 22 mmHg was 65 ml, the maximal increase of intracranial volume was 84 ml, the maximal bone displacement was 21 mm, and the bone plate volume to be 82 ml. Manual stress test of the hinged bone plate did not allow misalignment or intracranial displacement of the bone plate. CONCLUSION DHC increases the intracranial volume by up to 84 ml and allows for approximately 60 ml increase of intracranial volume before ICP exceeds 20 mmHg. This indicates, when comparing with results from previous studies of herniation volumes, that DHC will be sufficient in many patients with head injury or cerebral infarction with treatment refractory intracranial hypertension.
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[Epidural photobiomodulation accelerates the drainage of brain interstitial fluid and its mechanism]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2022. [PMID: 36241244 PMCID: PMC9568398 DOI: 10.19723/j.issn.1671-167x.2022.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To evaluate the effect of photobiomodulation (PBM) on the drainage of brain interstitial fluid (ISF) and to investigate the possible mechanism of the positive effect of PBM on Alzheimer's disease (AD). METHODS Twenty-four SD male rats were randomly divided into PBM group (n=12), sham PBM group (n=6), and negative control group (n=6). According to the injection site of tracer, the PBM group was further divided into PBM-ipsilateral traced group (n=6) and PBM-contralateral traced group (n=6). Rats in the PBM group and the sham PBM group were exposed to the dura minimally invasively on the skull corresponding to the frontal cortical area reached by ISF drainage from caudate nucleus region. The PBM group was irradiated by using 630 nm red light (5-6 mW/cm2), following an irradiation of 5 min with a 2 min pause, and a total of 5 times; the sham PBM group was kept in the same position for the same time using the light without power. The negative control group was kept without any measure. After PBM, tracer was injected into caudate nucleus of each group. The changes of ISF drainage in caudate nucleus were observed according to the diffusion and distribution of tracer molecule by tracer-based magnetic resonance imaging, and the structural changes of brain extracellular space (ECS) were analyzed by diffusion rate in ECS-mapping (DECS-mapping) technique. Finally, parameters reflecting the structure of brain ECS and the drainage of ISF were obtained: volume fraction (α), tortuo-sity (λ), half-life (T1/2), and DECS. The differences of parameters among different groups were compared to analyze the effect of PBM on brain ECS and ISF. One-Way ANOVA post hoc tests and independent sample t test were used for statistical analysis. RESULTS The parameters including T1/2, DECS, and λ were significantly different among the PBM-ipsilateral traced group, the PBM-contralateral traced group, and the sham PBM group (F=79.286, P < 0.001; F=13.458, P < 0.001; F=10.948, P=0.001), while there was no difference in the parameter α of brain ECS among the three groups (F=1.217, P=0.324). Compared with the sham PBM group and the PBM-contralateral traced group, the PBM-ipsilateral traced group had a significant decrease in the parameter T1/2 [(45.45±6.76) min vs. (76.01±3.44) min, P < 0.001; (45.45±6.76) min vs. (78.07±4.27) min, P < 0.001], representing a significant acceleration of ISF drainage; the PBM-ipsilateral traced group had a significant increase in the parameter DECS [(4.51±0.77)×10-4 mm2/s vs. (3.15±0.44)×10-4 mm2/s, P < 0.001; (4.51±0.77)×10-4 mm2/s vs. (3.01±0.38)×10-4 mm2/s, P < 0.001], representing a significantly increased molecular diffusion rate of in the brain ECS; the PBM-ipsilateral traced group had a significant decrease in the parameter λ (1.51±0.21 vs. 1.85±0.12, P=0.001; 1.51±0.21 vs. 1.89±0.11, P=0.001), representing a significant decrease in the degree of tortuosity in the brain ECS. CONCLUSION PBM can regulate the brain ISF drainage actively, which may be one of the potential mechanisms of the effect of PBM therapy on AD. This study provides a new method for enhancing the brain function via ECS pathway.
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Muacevic A, Adler JR. The Evaluation of Skin Turgor in Relation to Changes in Intracranial Pressure in Patients After Decompressive Hemicraniectomy. Cureus 2022; 14:e29828. [PMCID: PMC9626371 DOI: 10.7759/cureus.29828] [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: 09/01/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction Decompressive hemicraniectomies have been the mainstay of treating medically refractory elevated intracranial pressures (ICPs). Afterward, ICP continues to be monitored. However, the reliability of monitoring the ICP in a patient after craniectomy has been shown to be variable, at best. We propose the use of a durometer to investigate a temporal relationship between skin turgor and elevated ICP. Methods Patients were included via the following criteria: age >18 and unilateral decompressive craniectomy, with an external ventricular drain (EVD) in place. Patients were excluded if they were younger than 18, underwent bilateral decompressive craniectomy, or did not have an ICP monitor. Skin turgor over the skin flap was measured with a durometer over the center of the defect. ICPs were monitored using an EVD. The optic nerve sheath diameter (ONSD) was measured with ultrasound with the eye closed and Tegaderm (3M, Saint Paul, MN) covering the eyelid. The optic nerve was measured 3 mm behind the globe, and the diameter of the optic nerve at the widest point was recorded. The Neurological Pupil index (NPi) was recorded with a pupillometer. Results Fourteen patients were included, with over 100 data points for ICP, skin turgor, ONSD, and NPi. Five patients went on to have elevated ICP after decompressive hemicraniectomy. The correlation coefficient (R) for ONSD to ICP correlation was 0.62. The R for ICP to skin turgor was 0.31. The data shows that a skin turgor of >9 is related to increasing ICP within 24 hours, a skin turgor of 6-9 is a warning, and a skin turgor of <6 is normal. Conclusion A temporal relationship between skin turgor and ICP exists, which could be used to predict impending elevations in ICP sooner than an ICP monitor can determine. By using this in conjunction with traditional methods of evaluating these patients, we could sooner act on elevations in ICP and potentially improve outcomes.
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Ged C, Samson E, Riffaud L. Syndrome of the trephined: When bone becomes the cure. Neurochirurgie 2022; 68:544-545. [PMID: 35260279 DOI: 10.1016/j.neuchi.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 01/20/2022] [Indexed: 02/06/2023]
Affiliation(s)
- C Ged
- Department of Neurosurgery, Rennes University Hospital, 35000 Rennes, France
| | - E Samson
- Department of Physical Medicine and Rehabilitation, Rennes University Hospital, 35000 Rennes, France
| | - L Riffaud
- Department of Neurosurgery, Rennes University Hospital, 35000 Rennes, France; Inserm MediCIS, Unit U1099 LTSI, Rennes 1 University, Rennes, France.
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Arai N, Abe H, Nishitani H, Kanemaru S, Yasunaga M, Yamamoto S, Seki S, Metani H, Hiraoka T, Hanayama K. Characteristics of Patients with Trephine Syndrome: A Retrospective Study. Prog Rehabil Med 2022; 7:20220008. [PMID: 35280326 PMCID: PMC8858714 DOI: 10.2490/prm.20220008] [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: 09/13/2021] [Accepted: 01/24/2022] [Indexed: 11/27/2022] Open
Abstract
Objectives: This study retrospectively investigated the prevalence and clinical features of trephine syndrome, which is a late complication of craniectom, in patients who underwent craniectomy decompression. Methods: Trephine syndrome was defined as an increase of ≥2 points in the functional independent measure (FIM) score at 7 days after cranioplasty compared with that 3 days before cranioplasty. Patients who underwent craniectomy at Kawasaki Medical School Hospital between January 1, 2010, and March 15, 2020, were included in the study. Results: During the observation period, 102 patients underwent craniectomy decompression; 71 of them later underwent cranioplasty. In total, 12 and 59 patients were assigned to the trephine and non-trephine syndrome groups, respectively. The patients in the trephine syndrome group were significantly younger than those in the non-trephine syndrome group (P<0.05). The mean durations±standard deviations (in days) from craniectomy decompression to cranioplasty were 57.1±38.9 and 83.6±69.3 for the trephine and non-trephine syndrome groups, respectively (P<0.05). Improvements in the FIM motor scores were greater than the improvements in the cognitive scores for all but one case (P<0.05). The frequency with which patients experienced exacerbation (worsened consciousness and sudden anisocoria) after hospitalization was significantly higher in the trephine syndrome group than in the non-trephine syndrome group (P<0.05). Conclusions: Performing cranioplasty as early as possible in young patients may lead to functional improvement. In the trephine syndrome group, the improvement in motor FIM score was greater than that of the cognitive score. Moreover, post-hospitalization exacerbation was more frequent in the trephine syndrome group.
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Affiliation(s)
- Nobuyuki Arai
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Hiromasa Abe
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Haruhiko Nishitani
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Shimon Kanemaru
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Masaru Yasunaga
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Sayako Yamamoto
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Sousuke Seki
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Hiromichi Metani
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Takashi Hiraoka
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
| | - Kozo Hanayama
- Department of Rehabilitation Medicine, Kawasaki Medical School, Okayama, Japan
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Barami K. Letter to the Editor. Intracranial physiology and ICP. J Neurosurg 2021; 135:980. [PMID: 33862591 DOI: 10.3171/2020.12.jns204282] [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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12
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Navigated TMS in the ICU: Introducing Motor Mapping to the Critical Care Setting. Brain Sci 2020; 10:brainsci10121005. [PMID: 33352857 PMCID: PMC7765929 DOI: 10.3390/brainsci10121005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/13/2020] [Accepted: 12/16/2020] [Indexed: 12/20/2022] Open
Abstract
Navigated transcranial magnetic stimulation (nTMS) is a modality for noninvasive cortical mapping. Specifically, nTMS motor mapping is an objective measure of motor function, offering quantitative diagnostic information regardless of subject cooperation or consciousness. Thus far, it has mostly been restricted to the outpatient setting. This study evaluates the feasibility of nTMS motor mapping in the intensive care unit (ICU) setting and solves the challenges encountered in this special environment. We compared neuronavigation based on computed tomography (CT) and magnetic resonance imaging (MRI). We performed motor mappings in neurocritical patients under varying conditions (e.g., sedation or hemicraniectomy). Furthermore, we identified ways of minimizing electromyography (EMG) noise in the interference-rich ICU environment. Motor mapping was performed in 21 patients (six females, median age: 69 years). In 18 patients, motor evoked potentials (MEPs) were obtained. In three patients, MEPs could not be evoked. No adverse reactions occurred. We found CT to offer a comparable neuronavigation to MRI (CT maximum e-field 52 ± 14 V/m vs. MRI maximum e-field 52 ± 11 V/m; p = 0.6574). We detailed EMG noise reduction methods and found that propofol sedation of up to 80 mcg/kg/h did not inhibit MEPs. Yet, nTMS equipment interfered with exposed pulse oximetry. nTMS motor mapping application and use was illustrated in three clinical cases. In conclusion, we present an approach for the safe and reliable use of nTMS motor mapping in the ICU setting and outline possible benefits. Our findings support further studies regarding the clinical value of nTMS in critical care settings.
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13
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Decompressive craniectomy of post-traumatic brain injury: an in silico modelling approach for intracranial hypertension management. Sci Rep 2020; 10:18673. [PMID: 33122800 PMCID: PMC7596483 DOI: 10.1038/s41598-020-75479-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 10/12/2020] [Indexed: 12/28/2022] Open
Abstract
Traumatic brain injury (TBI) causes brain edema that induces increased intracranial pressure and decreased cerebral perfusion. Decompressive craniectomy has been recommended as a surgical procedure for the management of swollen brain and intracranial hypertension. Proper location and size of a decompressive craniectomy, however, remain controversial and no clinical guidelines are available. Mathematical and computational (in silico) models can predict the optimum geometric conditions and provide insights for the brain mechanical response following a decompressive craniectomy. In this work, we present a finite element model of post-traumatic brain injury and decompressive craniectomy that incorporates a biphasic, nonlinear biomechanical model of the brain. A homogenous pressure is applied in the brain to represent the intracranial pressure loading caused by the tissue swelling and the models calculate the deformations and stresses in the brain as well as the herniated volume of the brain tissue that exits the skull following craniectomy. Simulations for different craniectomy geometries (unilateral, bifrontal and bifrontal with midline bar) and sizes are employed to identify optimal clinical conditions of decompressive craniectomy. The reported results for the herniated volume of the brain tissue as a function of the intracranial pressure loading under a specific geometry and size of craniectomy are exceptionally relevant for decompressive craniectomy planning.
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14
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Mitchell KAS, Anderson W, Shay T, Huang J, Luciano M, Suarez JI, Manson P, Brem H, Gordon CR. First-In-Human Experience With Integration of Wireless Intracranial Pressure Monitoring Device Within a Customized Cranial Implant. Oper Neurosurg (Hagerstown) 2020; 19:341-350. [PMID: 31993644 PMCID: PMC7594174 DOI: 10.1093/ons/opz431] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/01/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Decompressive craniectomy is a lifesaving treatment for intractable intracranial hypertension. For patients who survive, a second surgery for cranial reconstruction (cranioplasty) is required. The effect of cranioplasty on intracranial pressure (ICP) is unknown. OBJECTIVE To integrate the recently Food and Drug Administration-approved, fully implantable, noninvasive ICP sensor within a customized cranial implant (CCI) for postoperative monitoring in patients at high risk for intracranial hypertension. METHODS A 16-yr-old female presented for cranioplasty 4-mo after decompressive hemicraniectomy for craniocerebral gunshot wound. Given the persistent transcranial herniation with concomitant subdural hygroma, there was concern for intracranial hypertension following cranioplasty. Thus, cranial reconstruction was performed utilizing a CCI with an integrated wireless ICP sensor, and noninvasive postoperative monitoring was performed. RESULTS Intermittent ICP measurements were obtained twice daily using a wireless, handheld monitor. The ICP ranged from 2 to 10 mmHg in the supine position and from -5 to 4 mmHg in the sitting position. Interestingly, an average of 7 mmHg difference was consistently noted between the sitting and supine measurements. CONCLUSION This first-in-human experience demonstrates several notable findings, including (1) newfound safety and efficacy of integrating a wireless ICP sensor within a CCI for perioperative neuromonitoring; (2) proven restoration of normal ICP postcranioplasty despite severe preoperative transcranial herniation; and (3) proven restoration of postural ICP adaptations following cranioplasty. To the best of our knowledge, this is the first case demonstrating these intriguing findings with the potential to fundamentally alter the paradigm of cranial reconstruction.
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Affiliation(s)
- Kerry-Ann S Mitchell
- Section of Neuroplastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - William Anderson
- Section of Neuroplastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tamir Shay
- Section of Neuroplastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark Luciano
- Section of Neuroplastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose I Suarez
- Division of Neurocritical Care, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Paul Manson
- Section of Neuroplastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Henry Brem
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chad R Gordon
- Section of Neuroplastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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15
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Affiliation(s)
- Patrick M Kochanek
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, John G. Rangos Research Center, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 6th Floor, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA, USA.
| | - Ruchira M Jha
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, John G. Rangos Research Center, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 6th Floor, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert S B Clark
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, John G. Rangos Research Center, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 6th Floor, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA, USA
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16
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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] [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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17
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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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18
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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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19
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Sorby-Adams AJ, Leonard AV, Hoving JW, Yassi N, Vink R, Wells AJ, Turner RJ. NK1-r Antagonist Treatment Comparable to Decompressive Craniectomy in Reducing Intracranial Pressure Following Stroke. Front Neurosci 2019; 13:681. [PMID: 31333402 PMCID: PMC6624444 DOI: 10.3389/fnins.2019.00681] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 06/13/2019] [Indexed: 12/29/2022] Open
Abstract
Background and Purpose: The morbidity and early mortality associated with stroke is largely attributable to cerebral edema and elevated intracranial pressure (ICP). Existing pharmacotherapies do not target the underlying pathophysiology and are often ineffective in sustainably lowering ICP, whilst decompressive craniectomy (DC) surgery is life-saving yet with surgical/peri-operative risk and increased morbidity in the elderly. Accordingly, there is an urgent need for therapies that directly target the mechanisms of edema genesis. Neurogenic inflammation, mediated by substance P (SP) binding to the tachykinin NK1 receptor (NK1-r), is associated with blood-brain barrier (BBB) disruption, cerebral edema and poor outcome post-stroke. NK1-r antagonist treatment ameliorates BBB dysfunction and cerebral edema in rodent stroke models. However, treatment has not been investigated in a large animal model, an important step toward clinical translation. Consequently, the current study compared the efficacy of NK1-r antagonist treatment to DC surgery in reducing ICP post-stroke in a clinically relevant ovine model. Methods: Anesthetized female Merino sheep (65 ± 6 kg, 18–24 months) underwent sham surgery (n = 4) or permanent middle cerebral artery occlusion (n = 22). Stroke animals were randomized into one of 5 treatments: 1×NK1 bolus (4 h), 2×NK1 bolus (4 h;9 h), 3×NK1 bolus (4 h;9 h;14 h), DC surgery (performed at 4 h) or saline vehicle. ICP, blood pressure and blood gasses were monitored for 24 h post-stroke. At 24 h post-stroke anesthetized animals underwent MRI followed by perfusion and brains removed and processed for histological assessment. Results: 2×NK1, 3×NK1 administration or DC surgery significantly (p < 0.05) reduced ICP compared to vehicle. 1×NK1 was ineffective in sustainably lowering ICP. On MRI, midline shift and cerebral edema were more marked in vehicles compared to NK1-r treatment groups. Conclusion: Two or three boluses of NK1-r antagonist treatment reduced ICP comparable to DC surgery, suggesting it may provide a novel alternative to invasive surgery for the management of elevated ICP.
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Affiliation(s)
- Annabel J Sorby-Adams
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, The University of Adelaide, Adelaide, SA, Australia
| | - Anna V Leonard
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, The University of Adelaide, Adelaide, SA, Australia
| | - Jan W Hoving
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia.,Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Nawaf Yassi
- Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
| | - Robert Vink
- Division of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Adam J Wells
- Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Renée J Turner
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, The University of Adelaide, Adelaide, SA, Australia
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