Decreased risk of secondary brain herniation with intracranial pressure monitoring in patients with haemorrhagic stroke

Nerve-Targeted Surgical Treatments for Spasticity: A Narrative Review

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.

The Role of ICP Monitoring in Minimally Invasive Surgery for the Management of Intracerebral Hemorrhage

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.

The Significance of Intracranial Pressure Monitoring for Reducing Mortality in Patients with Traumatic Brain Injury: A Systematic Review and Meta-Analysis

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.

Intracranial Pressure Monitoring in Patients With Spontaneous Intracerebral Hemorrhage: Insights From the SYNAPSE-ICU Study

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.

Intracranial Hypertension After Spontaneous Intracerebral Hemorrhage: A Systematic Review and Meta-analysis of Prevalence and Mortality Rate

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.

Inconsistency in Reporting Variables Related to Intracranial Pressure Measurement in Scientific Literature

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.

Randomized Controlled Trials on Intracerebral Hemorrhage: A Cross Sectional Retrospective Analysis of CONSORT Item Adherence

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.

Therapeutic Hypothermia Reduces Intracranial Pressure and Partial Brain Oxygen Tension in Patients with Severe Traumatic Brain Injury: Preliminary Data from the Eurotherm3235 Trial

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.

Steps to consider in the approach and management of critically ill patient with spontaneous intracerebral hemorrhage

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.

Changes in intracranial pressure gradients between the cerebral hemispheres in patients with intracerebral hematomas in one cerebral hemisphere

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.