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Duan S, Yuan Q, Wang M, Li R, Yuan H, Yao H, Hu J. Intracranial Pressure Monitoring in Patients with Spontaneous Intracerebral Hemorrhage: A Systematic Review with Meta-Analysis. World Neurosurg 2024; 189:447-455.e4. [PMID: 38972383 DOI: 10.1016/j.wneu.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Accepted: 07/01/2024] [Indexed: 07/09/2024]
Abstract
OBJECTIVE To describe the potential effects of Intracranial pressure monitoring on the outcome of patients with spontaneous intracerebral hemorrhage (ICH). METHODS This study is a systematic review with meta-analysis. Patients with spontaneous ICH treated with intracranial pressure monitoring were included. The primary outcome was mortality at 6 months and in-hospital mortality. The secondary outcome was poor neurological function outcome at 6 months. RESULTS This analysis compares in-hospital and 6-month mortality rates between patients with intracranial pressure monitoring (ICPm) and those without (no ICPm). Although the ICPm group had a lower in-hospital mortality rate, it was not statistically significant (24.9% vs. 34.1%; OR 0.51, 95% CI 0.20 to 1.31, P = 0.16). Excluding patients with intraventricular hemorrhage revealed a significant reduction in in-hospital mortality for the ICPm group (23.5% vs. 43%; OR 0.39, 95% CI 0.29 to 0.53, P < 0.00001). For 6-month mortality, the ICPm group showed a significant reduction (32% vs. 39.6%; OR 0.76, 95% CI 0.61 to 0.94, P = 0.01), with the effect being more pronounced after excluding intraventricular hemorrhage patients (29.1% vs. 47.2%; OR 0.45, 95% CI 0.34 to 0.60, P < 0.0001). However, there were no statistically significant differences in 6-month functional outcomes between the groups. Increased ICP was associated with higher 3-month mortality (OR 1.12, 95% CI 1.07 to 1.18, P < 0.00001) and lower likelihood of good functional outcomes (OR 1.11, 95% CI 1.04 to 1.18, P < 0.00001). CONCLUSIONS Elevated ICP is associated with increased mortality and poor prognosis in ICH patients. Although continuous intracranial pressure monitoring may reduce short-term mortality rates in specific subgroups of ICH patients, it does not improve neurological functional outcomes. While potential patient populations may benefit from ICP monitoring, more research is needed to screen suitable populations for ICP monitoring.
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Affiliation(s)
- Shanshan Duan
- Department of ICU of Hongqiao Campus, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Qiang Yuan
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Meihua Wang
- Department of ICU of Hongqiao Campus, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Rui Li
- Department of ICU of Hongqiao Campus, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Haoyue Yuan
- Department of ICU of Hongqiao Campus, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Haijun Yao
- Department of ICU of Hongqiao Campus, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jin Hu
- Department of ICU of Hongqiao Campus, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.
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Ran KR, Das O, Johnston DT, Vutakuri N, Ranganathan S, Broachwala M, Chopra H, Long Azad C, Azad TD, Robinson S, Belzberg AJ, Tuffaha SH, Lubelski D. Nerve-Targeted Surgical Treatments for Spasticity: A Narrative Review. World Neurosurg 2024; 187:104-113. [PMID: 38649021 DOI: 10.1016/j.wneu.2024.04.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 04/25/2024]
Abstract
Spasticity is a potentially debilitating symptom of various acquired and congenital neurologic pathologies that, without adequate treatment, may lead to long-term disability, compromise functional independence, and negatively impact mental health. Several conservative as well as non-nerve targeted surgical strategies have been developed for the treatment of spasticity, but these may be associated with significant drawbacks, such as adverse side effects to medication, device dependence on intrathecal baclofen pumps, and inadequate relief with tendon-based procedures. In these circumstances, patients may benefit from nerve-targeted surgical interventions such as (i) selective dorsal rhizotomy, (ii) hyperselective neurectomy, and (iii) nerve transfer. When selecting the appropriate surgical approach, preoperative patient characteristics, as well as the risks and benefits of nerve-targeted surgical intervention, must be carefully evaluated. Here, we review the current evidence on the efficacy of these nerve-targeted surgical approaches for treating spasticity across various congenital and acquired neurologic pathologies.
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Affiliation(s)
- Kathleen R Ran
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA.
| | - Oishika Das
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - David T Johnston
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Neha Vutakuri
- Department of Psychology & Neuroscience, Duke University, Durham, North Carolina, USA
| | | | - Mustafa Broachwala
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Harman Chopra
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Chao Long Azad
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Tej D Azad
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Shenandoah Robinson
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Allan J Belzberg
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sami H Tuffaha
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Zhang G, Li Y, Chen D, Wu Z, Pan C, Zhang P, Zhao X, Tao B, Ding H, Meng C, Chen D, Liu W, Tang Z. The Role of ICP Monitoring in Minimally Invasive Surgery for the Management of Intracerebral Hemorrhage. Transl Stroke Res 2023:10.1007/s12975-023-01219-4. [PMID: 38157144 DOI: 10.1007/s12975-023-01219-4] [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: 07/03/2023] [Revised: 11/10/2023] [Accepted: 11/26/2023] [Indexed: 01/03/2024]
Abstract
Intracerebral hemorrhage (ICH) is the second major stroke type, with high incidence, high disability rate, and high mortality. At present, there is no effective and reliable treatment for ICH. As a result, most patients have a poor prognosis. Minimally invasive surgery (MIS) is the fastest treatment method to remove hematoma, which is characterized by less trauma and easy operation. Some studies have confirmed the safety of MIS, but there are still no reports showing that it can significantly improve the functional outcome of ICH patients. Intracranial pressure (ICP) monitoring is considered to be an important part of successful treatment in traumatic brain diseases. By monitoring ICP in real time, keeping stable ICP could help patients with craniocerebral injury get a good prognosis. In the course of MIS treatment of ICH patients, keeping ICP stable may also promote patient recovery. In this review, we will take ICP monitoring as the starting point for an in-depth discussion.
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Affiliation(s)
- Ge Zhang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yunjie Li
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Danyang Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Zhuojin Wu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Chao Pan
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Ping Zhang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xingwei Zhao
- State Key Laboratory of Digital Manufacturing Equipment and Technology, School of Mechanical Science and Engineering, Huazhong University of Science and Technology, Wuhan, 430074, Hubei, China
| | - Bo Tao
- State Key Laboratory of Digital Manufacturing Equipment and Technology, School of Mechanical Science and Engineering, Huazhong University of Science and Technology, Wuhan, 430074, Hubei, China
| | - Han Ding
- State Key Laboratory of Digital Manufacturing Equipment and Technology, School of Mechanical Science and Engineering, Huazhong University of Science and Technology, Wuhan, 430074, Hubei, China
| | - Cai Meng
- School of Mechanical Engineering and Automation, Beihang University, Beijing, 100191, China
| | - Diansheng Chen
- School of Mechanical Engineering and Automation, Beihang University, Beijing, 100191, China
| | - Wenjie Liu
- Beijing WanTeFu Medical Apparatus Co., Ltd., Beijing, China
| | - Zhouping Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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The Significance of Intracranial Pressure Monitoring for Reducing Mortality in Patients with Traumatic Brain Injury: A Systematic Review and Meta-Analysis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:1956908. [PMID: 36254239 PMCID: PMC9569199 DOI: 10.1155/2022/1956908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 09/19/2022] [Accepted: 09/23/2022] [Indexed: 11/18/2022]
Abstract
Background Despite guidelines provided by the Brain Trauma Foundation (BTF) for treating patients with TBI, including advice to monitor intracranial pressure (ICP), the clinical application of ICP monitoring is far from universal. This laxity has been attributed to the relationship between mortality in TBI patients and ICP monitoring. Objective This systematic review and meta-analysis was aimed at determining the effect of intracranial pressure (ICP) monitoring on the mortality of patients with traumatic brain injury (TBI). Method A systematic search for articles was conducted on PubMed, Scopus, Cochrane Central Register of Control Trials (CENTRAL), and APA PsycNet for articles published from 1 January 2000 to 1 August 2022. Manager 5.4 was used to carry out statistical analysis. Results Article search yielded 1421 articles, but only 23 cohort studies were included in the systematic review and meta-analysis. The total number of study participants is 80,058. Seventeen studies reported unadjusted odds ratios (OR), and only 8 reported the adjusted odds ratio (OR). Nine out of seventeen studies reported an unadjusted OR of less than 1, and five out of eight studies reported an adjusted OR of less than 1. From this paper's analysis, the OR for in-hospital mortality was 1.01 [95% CI, 0.80, 1.28], with a p value of 0.92. OR for ICU mortality was 0.84 [95% CI, 0.52, 1.35], with a p value of 0.47. Conclusion But due to conflicting results, as evident above, it is unsatisfyingly challenging to draw any substantial conclusions from them. This paper thus calls for more research on this particular paper.
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Dallagiacoma S, Robba C, Graziano F, Rebora P, Hemphill JC, Galimberti S, Citerio G. Intracranial Pressure Monitoring in Patients With Spontaneous Intracerebral Hemorrhage: Insights From the SYNAPSE-ICU Study. Neurology 2022; 99:e98-e108. [PMID: 35508390 DOI: 10.1212/wnl.0000000000200568] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 03/04/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Uncertainties remain regarding the indications, management, and effect of intracranial pressure (ICP) monitoring and treatment on outcome in spontaneous intracranial hemorrhage (ICH) patients. METHODS Analysisof spontaneous ICH patients enrolled in the SYNAPSE-ICU study an international prospective observational study on the use of ICP monitoring. This study aimed to describe, in a large cohort of patients with spontaneous ICH admitted to ICU, the clinical practice of ICP monitoring, the occurrence of intracranial hypertension and its therapeutic management. We further assessed in-hospital mortality and the association between ICP monitoring and 6-months mortality and outcome by a propensity score approach with inverse probability weighting. RESULTS 587 ICH patients were included in this study; 281 (47.9%) received ICP monitoring. ICP-monitored patients, compared to non-monitored, were younger (61 vs 67 years, p<0.001), presented more frequently with both reactive pupils (67.2%, vs 55.2%, p=0.008), with better neurological status at admission (GCS≤ 8, 82.3% vs 88.8%, p=0.038) and received higher therapy intensity level during ICU stay. In 70.5% (170 out of 241) of ICP monitored patients the ICH score was equal to 3 or 4. Nearly half of monitored patients (46.6%) had at least one episode of ICP ≥ 20 mmHg during the first week. An intraventricular catheter (53.6%) was the most frequently used device and had fewer episodes of intracranial hypertension compared to the other monitoring devices (43.7% vs 64.9%, respectively). At weighted Cox regression model, ICP monitoring was associated with a significant reduction of 6-month mortality (Hazard Ratio, HR= 0.49 (95% Confidence Intervals CI=0.35-0.71, p=0.001), but not with neurological outcome (OR=0.83, 95%CI= 0.41-1.68, p=0.6077). CONCLUSIONS ICP monitoring in ICH was utilized mainly in moderately severe cases. ICP monitoring was associated with a reduction of in-hospital and 6-month mortality but did not improve 6-months functional outcomes. Further research and randomized controlled trials to generate higher-level medical evidence to support guidelines regarding ICP use and treatment in patients with ICH are needed.
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Affiliation(s)
- Stefania Dallagiacoma
- Neurology and Clinical Neurophysiology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Italy
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genoa, Italy. Department of Surgical Science and Diagnostic Integrated, University of Genoa, Italy
| | - Francesca Graziano
- School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy.,Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, University of Milano - Bicocca, Monza, Italy
| | - Paola Rebora
- School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy.,Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, University of Milano - Bicocca, Monza, Italy
| | - J Claude Hemphill
- Department of Neurology, University of California San Francisco, San Francisco, USA
| | - Stefania Galimberti
- School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy.,Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, University of Milano - Bicocca, Monza, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy .,Neurointensive Care Unit, Department Neuroscience, San Gerardo Hospital, ASST-Monza, Monza, Italy
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6
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Wilkinson CM, Kung TF, Jickling GC, Colbourne F. A translational perspective on intracranial pressure responses following intracerebral hemorrhage in animal models. BRAIN HEMORRHAGES 2021. [DOI: 10.1016/j.hest.2020.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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7
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Godoy DA, Núñez-Patiño RA, Zorrilla-Vaca A, Ziai WC, Hemphill JC. Intracranial Hypertension After Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-analysis of Prevalence and Mortality Rate. Neurocrit Care 2020; 31:176-187. [PMID: 30565090 DOI: 10.1007/s12028-018-0658-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The objective of this study was to determine the prevalence of intracranial hypertension (IHT) and the associated mortality rate in patients who suffered from primary intracerebral hemorrhage (ICH). A secondary objective was to assess predisposing factors to IHT development. We conducted a systematic literature search of major electronic databases (MEDLINE, EMBASE, and Cochrane Library), for studies that assessed intracranial pressure (ICP) monitoring in patients with acute ICH. Study level and outcome measures were extracted. The meta-analysis was performed using a random-effects model. A total of six studies comprising 381 patients were pooled to estimate the overall prevalence of any episode of IHT (ICP > 20 mmHg) after ICH. The pooled prevalence rate for any episode of IHT after ICH was 67% (95% CI 51-84%). Four studies comprising 239 patients were pooled in order to estimate the overall mortality rate associated with IHT. Pooled mortality rate was 50% (95% CI 24-76%). For both outcomes, heterogeneity was statistically significant, and risk of bias was nonsignificant. Reported variables correlated significantly with increased ICP were lower Glasgow Coma Scale score at admission, midline shift, hemorrhage volume, and hydrocephalus. The prevalence and mortality rates associated with IHT after ICH are high and may be underestimated. Predicting factors for the development of IHT reflect the magnitude of the primary injury. However, the results of present meta-analysis should be interpreted with caution due to methodological limitations such as selection bias of patients who had ICP monitoring, and lack of standardized IHT definition.
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Affiliation(s)
- Daniel Agustín Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, Intensive Care Unit, Hospital San Juan Bautista, Chacabuco 675, 4700, Catamarca, Argentina.
| | - Rafael A Núñez-Patiño
- Faculty of Health Sciences, School of Medicine, Pontificia Universidad Javeriana, Cali, Colombia
| | - Andres Zorrilla-Vaca
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA.,Faculty of Health, Universidad del Valle, Hospital Universitario del Valle, Cali, Colombia
| | - Wendy C Ziai
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA.,Division of Neurosciences Critical Care, Departments of Neurology, Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J Claude Hemphill
- Kenneth Rainin Endowed Chair in Neurocritical Care, Professor of Neurology and Neurological Surgery, University of California, San Francisco, USA
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Samudra NP, Park SM, Gray SE, Sebai MA, Olson DM. Inconsistency in Reporting Variables Related to Intracranial Pressure Measurement in Scientific Literature. J Nurs Meas 2019; 26:415-424. [PMID: 30593569 DOI: 10.1891/1061-3749.26.3.415] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess whether the collection and communication of intracranial pressure (ICP) values were standardized and reproducible. METHODS Integrative review of clinical trials (n = 357) reporting ICP as a variable. RESULTS Only 24.1% of studies reported adequate data required for replication. Of the 357 reports, 342 provided information about the design, 274 discussed sampling strategy, 294 identified the ICP device type, 312 provided a unit of measure, 121 provided anatomical localization for measuring ICP, and 83 provided information about patient positioning. CONCLUSIONS The majority of literature evaluated did not provide enough data for replication of results. Measuring and reporting ICP in the scientific literature is not standardized. A uniform standard would strengthen the quality of the evidence in neurocritical care and neurosurgical literature and better establish clinical guidelines for ICP management in neurologically injured patients.
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Affiliation(s)
| | | | - Sara E Gray
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - DaiWai M Olson
- University of Texas Southwestern Medical Center, Dallas, Texas
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Jauch K, Kowark A, Coburn M, Clusmann H, Höllig A. Randomized Controlled Trials on Intracerebral Hemorrhage: A Cross Sectional Retrospective Analysis of CONSORT Item Adherence. Front Neurol 2019; 10:991. [PMID: 31616358 PMCID: PMC6763943 DOI: 10.3389/fneur.2019.00991] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 09/02/2019] [Indexed: 01/23/2023] Open
Abstract
Object: Intracranial hemorrhage (ICH) is the second most common cause of stroke but still there is little consolidated knowledge about the optimal treatment strategies (e.g., the benefit of surgical evacuation). We evaluated the current randomized controlled trials (RCTs) on primary ICH (01.2013–03.2017) according to their fulfillment of the CONSORT statement's criteria (published in 2010) –as a marker of transparency and quality of study planning and realization. Methods: A Pubmed and a Cochrane database (including clinicaltrials.gov) search was carried out (01.2014–3.2017, respectively 01.2013–12.2013). Abstracts were screened for inclusion. Eligible full text manuscripts were assessed for the implementation of the CONSORT criteria. Citation frequencies and impact factors of the journals were related to ratio of CONSORT criteria fulfillment. Further, the risk of bias according to the Risk of bias tool 2 (RoB 2) was assessed. Results: Overall 3097 abstracts were screened for inclusion; 39 studies were suitable for final analysis. A mean fulfillment ratio of 51% (±28%) was found. A high correlation between impact factor and adherence to CONSORT criteria was shown (r = 0.7664; p < 0.0001). Citation frequency per year was related to ratio of CONSORT item fulfillment (r = 0.6747; p < 0.0001) and to the impact factor of the publishing journal (r = 0.7310; p < 0.0001). Of note, the items 10 (randomization: implementation) and 21 (generalizability) showed particularly high rates of non-fulfillment (87 and 85%). The majority of studies (95%) complied with item 2b (specific objectives or hypotheses), but strikingly objectives were mostly described vaguely. Other essential criteria such as sample size determination, definition of outcome parameters, and participant flow were only fulfilled weakly (51, 54, and 39%). Conclusions: Over 20 years after its inception there is still weak adherence to the CONSORT statement. As a consequence, conclusions are hampered by inadequate planning and/or reporting. Particularly with respect to pathologies as ICH lacking clear, evidence-based guidelines adherence to the CONSORT statement might improve research quality in order to define valuable treatment strategies.
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Affiliation(s)
- Kirstin Jauch
- Department of Neurosurgery, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Ana Kowark
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Mark Coburn
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Anke Höllig
- Department of Neurosurgery, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
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10
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Flynn LM, Rhodes J, Andrews PJ. Therapeutic Hypothermia Reduces Intracranial Pressure and Partial Brain Oxygen Tension in Patients with Severe Traumatic Brain Injury: Preliminary Data from the Eurotherm3235 Trial. Ther Hypothermia Temp Manag 2015; 5:143-51. [PMID: 26060880 PMCID: PMC4575517 DOI: 10.1089/ther.2015.0002] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Traumatic brain injury (TBI) is a significant cause of disability and death and a huge economic burden throughout the world. Much of the morbidity associated with TBI is attributed to secondary brain injuries resulting in hypoxia and ischemia after the initial trauma. Intracranial hypertension and decreased partial brain oxygen tension (PbtO2) are targeted as potentially avoidable causes of morbidity. Therapeutic hypothermia (TH) may be an effective intervention to reduce intracranial pressure (ICP), but could also affect cerebral blood flow (CBF). This is a retrospective analysis of prospectively collected data from 17 patients admitted to the Western General Hospital, Edinburgh. Patients with an ICP >20 mmHg refractory to initial therapy were randomized to standard care or standard care and TH (intervention group) titrated between 32°C and 35°C to reduce ICP. ICP and PbtO2 were measured using the Licox system and core temperature was recorded through rectal thermometer. Data were analyzed at the hour before cooling, the first hour at target temperature, 2 consecutive hours at target temperature, and after 6 hours of hypothermia. There was a mean decrease in ICP of 4.3±1.6 mmHg (p<0.04) from 15.7 to 11.4 mmHg, from precooling to the first epoch of hypothermia in the intervention group (n=9) that was not seen in the control group (n=8). A decrease in ICP was maintained throughout all time periods. There was a mean decrease in PbtO2 of 7.8±3.1 mmHg (p<0.05) from 30.2 to 22.4 mmHg, from precooling to stable hypothermia, which was not seen in the control group. This research supports others in demonstrating a decrease in ICP with temperature, which could facilitate a reduction in the use of hyperosmolar agents or other stage II interventions. The decrease in PbtO2 is not below the suggested treatment threshold of 20 mmHg, but might indicate a decrease in CBF.
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Affiliation(s)
- Liam M.C. Flynn
- Center for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kindgom
| | - Jonathan Rhodes
- Department of Anesthesia and Critical Care, University of Edinburgh and NHS Lothian, Western General Hospital, Edinburgh, United Kingdom
| | - Peter J.D. Andrews
- Center for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kindgom
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11
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Godoy DA, Piñero GR, Koller P, Masotti L, Napoli MD. Steps to consider in the approach and management of critically ill patient with spontaneous intracerebral hemorrhage. World J Crit Care Med 2015; 4:213-229. [PMID: 26261773 PMCID: PMC4524818 DOI: 10.5492/wjccm.v4.i3.213] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 03/03/2015] [Accepted: 06/08/2015] [Indexed: 02/06/2023] Open
Abstract
Spontaneous intracerebral hemorrhage is a type of stroke associated with poor outcomes. Mortality is elevated, especially in the acute phase. From a pathophysiological point of view the bleeding must traverse different stages dominated by the possibility of re-bleeding, edema, intracranial hypertension, inflammation and neurotoxicity due to blood degradation products, mainly hemoglobin and thrombin. Neurological deterioration and death are common in early hours, so it is a true neurological-neurosurgical emergency. Time is brain so that action should be taken fast and accurately. The most significant prognostic factors are level of consciousness, location, volume and ventricular extension of the bleeding. Nihilism and early withdrawal of active therapy undoubtedly influence the final result. Although there are no proven therapeutic measures, treatment should be individualized and guided preferably by pathophysiology. The multidisciplinary teamwork is essential. Results of recently completed studies have birth to promising new strategies. For correct management it’s important to establish an orderly and systematic strategy based on clinical stabilization, evaluation and establishment of prognosis, avoiding secondary insults and adoption of specific individualized therapies, including hemostatic therapy and intensive control of elevated blood pressure. Uncertainty continues regarding the role of surgery.
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12
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Qiu W, Jiang Q, Xiao G, Wang W, Shen H. Changes in intracranial pressure gradients between the cerebral hemispheres in patients with intracerebral hematomas in one cerebral hemisphere. BMC Anesthesiol 2014; 14:112. [PMID: 25506260 PMCID: PMC4265537 DOI: 10.1186/1471-2253-14-112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 11/25/2014] [Indexed: 01/10/2023] Open
Abstract
Background Intracranial-pressure (ICP) monitoring is useful for patients with increased ICP following hemorrhagic stroke. In this study, the changes in pressure gradients between the two cerebral hemispheres were investigated after hemorrhagic stroke of one side, and after a craniotomy. Methods Twenty-four patients with acute cerebral hemorrhages and intracerebral hematomas who exhibited mass effect and midline shift to the contralateral side on computed tomography were selected for this study. After admission, both sides of the cranium were drilled, and optical fiber sensors were implanted to monitor the brain parenchyma pressure (BPP) in both cerebral hemispheres. All patients underwent surgical hematoma evacuations. The preoperative and postoperative BPP data from both cerebral hemispheres were collected at various time points and compared pairwise. Results There were statistically significant differences (P < 0.01) in the preoperative BPP values between the two hemispheres at three different time points. Differences in the BPP values between the two hemispheres at the time of surgery, and 24 and 48 h after surgery, were not statistically significant (P > 0.05). The posteroperative BPPs of both hemispheres were statistically significantly lower than preoperative recordings. Conclusions BPP sensors should be applied to the injured cerebral hemisphere, because this becomes the source of increased ICP. Hematoma evacuation surgery effectively decreases ICP and eliminates pressure gradients between the two cerebral hemispheres, consequently enabling brain shift correction.
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Affiliation(s)
- Wusi Qiu
- Department of Neurosurgery, Hangzhou Second Hospital, College of Medicine, Hangzhou Normal University, 126 Wenzhou Road, Hangzhou, 310015 China
| | - Qizhou Jiang
- Department of Neurosurgery, Hangzhou Second Hospital, College of Medicine, Hangzhou Normal University, 126 Wenzhou Road, Hangzhou, 310015 China
| | - Guoming Xiao
- Department of Neurosurgery, Hangzhou Second Hospital, College of Medicine, Hangzhou Normal University, 126 Wenzhou Road, Hangzhou, 310015 China
| | - Weiming Wang
- Department of Neurosurgery, Hangzhou Second Hospital, College of Medicine, Hangzhou Normal University, 126 Wenzhou Road, Hangzhou, 310015 China
| | - Hong Shen
- Department of Neurosurgery, Second Affiliated Hospital, College of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009 China
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