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LaBuzetta JN, Bongbong DN, Mlodzinski E, Sheth R, Trando A, Ibrahim N, Yip B, Malhotra A, Dinglas VD, Needham DM, Kamdar BB. Survivorship After Neurocritical Care: A Scoping Review of Outcomes Beyond Physical Status. Neurocrit Care 2024; 41:651-664. [PMID: 38622487 PMCID: PMC11377172 DOI: 10.1007/s12028-024-01965-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 02/21/2024] [Indexed: 04/17/2024]
Abstract
Following intensive care unit hospitalization, survivors of acute neurological injury often experience debilitating short-term and long-term impairments. Although the physical/motor impairments experienced by survivors of acute neurological injury have been described extensively, fewer studies have examined cognitive, mental health, health-related quality of life (HRQoL), and employment outcomes. This scoping review describes the publication landscape beyond physical and/or motor sequelae in neurocritical care survivors. Databases were searched for terms related to critical illness, intensive care, and outcomes from January 1970 to March 2022. English-language studies of critically ill adults with a primary neurological diagnosis were included if they reported on at least one outcome of interest: cognition, mental health, HRQoL or employment. Data extraction was performed in duplicate for prespecified variables related to study outcomes. Of 16,036 abstracts screened, 74 citations were identified for inclusion. The studies encompassed seven worldwide regions and eight neurocritical diagnosis categories. Publications reporting outcomes of interest increased from 3 before the year 2000 to 71 after. Follow-up time points included ≤ 1 (n = 15 [20%] citations), 3 (n = 28 [38%]), 6 (n = 28 [38%]), and 12 (n = 21 [28%]) months and 1 to 5 (n = 19 [26%]) and > 5 years (n = 8 [11%]), with 28 (38%) citations evaluating outcomes at multiple time points. Sixty-six assessment tools were used to evaluate the four outcomes of interest: 22 evaluating HRQoL (56 [76%] citations), 21 evaluating cognition (20 [27%] citations), 21 evaluating mental health (18 [24%] citations), and 2 evaluating employment (9 [12%] citations). This scoping review aimed to better understand the literature landscape regarding nonphysical outcomes in survivors of neurocritical care. Although a rising number of publications highlight growing awareness, future efforts are needed to improve study consistency and comparability and characterize outcomes in a disease-specific manner, including outlining of a minimum core outcomes set and associated assessment tools.
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Affiliation(s)
- Jamie Nicole LaBuzetta
- Division of Neurocritical Care, Department of Neurosciences, University of California, San Diego Health, 9444 Medical Center Dr., East Campus Office Building 3-028, La Jolla, CA, 92037-7740, USA.
| | - Dale N Bongbong
- Division of Neurocritical Care, Department of Neurosciences, University of California, San Diego Health, 9444 Medical Center Dr., East Campus Office Building 3-028, La Jolla, CA, 92037-7740, USA
| | - Eric Mlodzinski
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California, San Diego Health, La Jolla, CA, USA
| | - Richa Sheth
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California, San Diego Health, La Jolla, CA, USA
| | - Aaron Trando
- Division of Neurocritical Care, Department of Neurosciences, University of California, San Diego Health, 9444 Medical Center Dr., East Campus Office Building 3-028, La Jolla, CA, 92037-7740, USA
| | - Nicholas Ibrahim
- Division of Neurocritical Care, Department of Neurosciences, University of California, San Diego Health, 9444 Medical Center Dr., East Campus Office Building 3-028, La Jolla, CA, 92037-7740, USA
| | - Brandon Yip
- Division of Neurocritical Care, Department of Neurosciences, University of California, San Diego Health, 9444 Medical Center Dr., East Campus Office Building 3-028, La Jolla, CA, 92037-7740, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California, San Diego Health, La Jolla, CA, USA
| | - Victor D Dinglas
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, MD, USA
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, MD, USA
- Department of Physical Medicine and Rehabilitation, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Biren B Kamdar
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California, San Diego Health, La Jolla, CA, USA
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Sengupta SK, Aggarwal R, Singh MK. Correlation Between Volume and Pressure of Intracranial Space With Craniectomy Surface Area and Brain Herniation: A Phantom-Based Study. Neurotrauma Rep 2024; 5:293-303. [PMID: 38560491 PMCID: PMC10979661 DOI: 10.1089/neur.2024.0006] [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] [Indexed: 04/04/2024] Open
Abstract
There are proponents of decompressive craniectomy (DC) and its various modifications who claim reasonable clinical outcomes for each of them. Clinical outcome in cases of traumatic brain injury, managed conservatively or aided by different surgical techniques, depends on multiple factors, which vary widely among patients and have complex interplay, making it difficult to compare one case with another in absolute terms. This forms the basis of the perceived necessity to have a standard model to study, compare, and strategize in this field. We designed a phantom-based model and present the findings of the study aimed at establishing a correlation of the volume of intracranial space and changes in intracranial pressure (ICP) with surface area of the craniectomy defect created during DC and brain herniation volume. A roughly hemispherical radio-opaque container was scanned on a 128-slice computed tomography scanner. Craniectomies of different sizes and shapes were marked on the walls of the phantom. Two spherical sacs of stretchable materials were subsequently placed inside the phantom, fixed to three-way connectors, filled with water, and connected with transducers. The terminals of the transducer cables were coupled with the display monitor through a signal amplifier and processor module. Parts of the wall of the phantom were removed to let portions of the sac herniate through the defect, simulating a DC. Volume measurements using AW volume share 7® software were done. Resection of a 12.7 × 11.5 cm part of the wall resulted in a 10-cm-diameter defect in the wall. Volume differential of 35 mL created a midline shift of 5 mm to the side with lesser volume. When measuring pressure in two stretchable sacs contained inside the phantom, there always remained a pressure differential ranging from 1 to 2 mm Hg in different recordings, even with sacs on both sides containing an equal volume of fluids. Creating a circular wall defect of 10 cm in diameter with an intracavitary pressure of 35 mm Hg on the ipsilateral sac and 33 mm on the contralateral sac recorded with intact walls, resulted in a true volume expansion of 48.411 cm3. The herniation resulted in a reduction of pressure in both sacs, with the pressure recorded as 25 mm in the ipsilateral sac and 24 mm in the contralateral sac. The findings closely matched those of the other model-based studies. Refinement of the materials used is likely to provide a valid platform to study cranial volume, ICP, craniectomy size, and brain prolapse volume in real time. The model will help in pre-operatively choosing the most appropriate technique between a classical DC, a hinge craniotomy, and an expansive cranioplasty technique in cases of refractory raised ICP.
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Affiliation(s)
| | - Rohit Aggarwal
- Department of Radiology, Command Hospital Southern Command (Pune), India
| | - Manish Kumar Singh
- Department of Anaesthesia, Command Hospital Southern Command (Pune), India
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Mishra NR, Agrawal A, Das RR. Hypertonic Saline vs. Mannitol in Management of Elevated Intracranial Pressure in Children: A Meta-Analysis. Indian J Pediatr 2023; 90:899-906. [PMID: 37225962 DOI: 10.1007/s12098-023-04532-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 12/26/2022] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To compare the efficacy and safety of two hyperosmolar agents (hypertonic saline vs. mannitol) used for the reduction of elevated intracranial pressure (ICP) in children. METHODS A meta-analysis of randomized controlled trials (RCTs) was conducted and GRADE system (Grading of Recommendations, Assessment, Development and Evaluation) of evidence was applied. Relevant databases were searched till 31st May 2022. Primary outcome was mortality rate. RESULTS Of 720 citations retrieved, 4 RCTs were included in the meta-analysis (n = 365, male = 61%). Traumatic and non-traumatic cases of elevated ICP were included. There was no significant difference in the mortality rate between the two groups [relative risk (RR), 1.09; (95% confidence interval (CI), 0.74 to 1.6)]. No significant difference was found for any of the secondary outcomes, except serum osmolality (being significantly higher in mannitol group). Adverse events like shock and dehydration were significantly higher in the mannitol group, and hypernatremia in the hypertonic saline group. The evidence generated for primary outcome was of "low certainty", and for secondary outcomes, it varied from "very-low to moderate certainty". CONCLUSIONS There is no significant difference between hypertonic saline and mannitol used for the reduction of elevated ICP in children. The evidence generated for primary outcome (mortality rate) was of "low certainty", and for secondary outcomes, it varied from "very-low to moderate certainty". More data from high-quality RCTs are needed to guide any recommendation.
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Affiliation(s)
- Nihar Ranjan Mishra
- Department of Pediatrics, All India Institute of Medical Sciences, Kalyani, West Bengal, India
| | - Amit Agrawal
- Department of Pediatrics, Gandhi Medical College, Bhopal, Madhya Pradesh, India
| | - Rashmi Ranjan Das
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India.
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Fan TH, Rosenthal ES. Physiological Monitoring in Patients with Acute Brain Injury: A Multimodal Approach. Crit Care Clin 2023; 39:221-233. [PMID: 36333033 DOI: 10.1016/j.ccc.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Neurocritical care management of acute brain injury (ABI) is focused on identification, prevention, and management of secondary brain injury (SBI). Physiologic monitoring of the brain and other organ systems has a role to predict patient recovery or deterioration, guide individualized therapeutic interventions, and measure response to treatment, with the goal of improving patient outcomes. In this review, we detail how specific physiologic markers of brain injury and neuromonitoring tools are integrated and used in ABI patients to develop therapeutic approaches to prevent SBI.
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Affiliation(s)
- Tracey H Fan
- Department of Neurology, Division of Neurocritical Care, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02493, USA; Department of Neurology, Division of Neurocritical Care, Brigham and Women's Hospital, 55 Fruit Street, Boston, MA 02493, USA
| | - Eric S Rosenthal
- Department of Neurology, Division of Neurocritical Care, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02493, USA; Department of Neurology, Division of Clinical Neurophysiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02493, USA.
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Zhao JL, Song J, Yuan Q, Bao YF, Sun YR, Li ZQ, Xi CH, Yao HJ, Wang MH, Wu G, Du ZY, Hu J, Yu J. Characteristics and therapeutic profile of TBI patients who underwent bilateral decompressive craniectomy: experience with 151 cases. Scand J Trauma Resusc Emerg Med 2022; 30:59. [PMID: 36397136 PMCID: PMC9670501 DOI: 10.1186/s13049-022-01046-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 11/08/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Decompressive craniectomy (DC) and intracranial pressure (ICP) monitoring are common approaches to reduce the death rate of Traumatic brain injury (TBI) patients, but the outcomes of these patients are unfavorable, particularly those who receive bilateral DC. The authors discuss their experience using ICP and other potential methods to improve the outcomes of TBI patients who receive bilateral DC. METHODS Data from TBI patients receiving bilateral DC from Jan. 2008 to Jan. 2022 were collected via a retrospective chart review. Included patients who received unplanned contralateral DC after initial surgery were identified as unplanned secondary surgery (USS) patients. Patients' demographics and baseline medical status; pre-, intra-, and postoperative events; and follow-up visit outcome data were analyzed. RESULTS A total of 151 TBI patients were included. Patients who underwent USS experienced more severe outcomes as assessed using the 3-month modified Rankin Scale score (P = 0.024). In bilateral DC TBI patients, USS were associated with worsen outcomes, moreover, ICP monitoring was able to lower their death rate and was associated with a lower USS incidence. In USS patients, ICP monitoring was not associated with improved outcomes but was able to lower their mortality rate (2/19, 10.5%, vs. 10/25, 40.0%; P = 0.042). CONCLUSION The avoidance of USS may be associated with improved outcomes of TBI patients who underwent bilateral DC. ICP monitoring was a potential approach to lower USS rate in TBI patients, but its specific benefits were uncertain.
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Affiliation(s)
- Jian-Lan Zhao
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Jie Song
- Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Fudan University, Shanghai, 200040 China
| | - Qiang Yuan
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Yi-Feng Bao
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Yi-Rui Sun
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Zhi-Qi Li
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Cai-Hua Xi
- Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Fudan University, Shanghai, 200040 China
| | - Hai-Jun Yao
- Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Fudan University, Shanghai, 200040 China
| | - Mei-Hua Wang
- Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Fudan University, Shanghai, 200040 China
| | - Gang Wu
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Zhuo-Ying Du
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
| | - Jin Hu
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
- Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Fudan University, Shanghai, 200040 China
| | - Jian Yu
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040 China
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The Application of Guideline-Based Care for Traumatic Brain and Spinal Cord Injury in Low- and Middle-Income Countries: A Provider-Based Survey. World Neurosurg X 2022; 15:100121. [PMID: 35515346 PMCID: PMC9061784 DOI: 10.1016/j.wnsx.2022.100121] [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: 01/02/2022] [Accepted: 03/04/2022] [Indexed: 11/22/2022] Open
Abstract
Objective Neurosurgical guidelines have resulted in improved clinical outcomes and more optimized care for many complex neurosurgical pathologies. As momentum in global neurosurgical efforts has grown, there is little understanding about the application of these guidelines in low- and middle-income countries. Methods A 29-question survey was developed to assess the application of specific recommendations from neurosurgical brain and spinal cord injury guidelines. Surveys were distributed to an international cohort of neurosurgeons and neurotrauma stakeholders. Results A total of 82 of 222 (36.9%) neurotrauma providers responded to the survey. The majority of respondents practiced in low- and middle-income countries settings (49/82, 59.8%). There was a significantly greater mean traumatic brain injury volume in low-income countries (56% ± 13.5) and middle-income countries (46.5% ± 21.3) compared with high-income countries (27.9% ± 13.2), P < 0.001. Decompressive hemicraniectomy was estimated to occur in 61.5% (±30.8) of cases of medically refractory intracranial pressure with the lowest occurrence in the African region (44% ± 37.5). The use of prehospital cervical immobilization varied significantly by income status, with 36% (±35.6) of cases in low-income countries, 52.4% (±35.5) of cases in middle-income countries, and 95.2% (±10) in high-income countries, P < 0.001. Mean arterial pressure elevation greater than 85 mm Hg to improve spinal cord perfusion was estimated to occur in 71.7% of cases overall with lowest occurrence in Eastern Mediterranean region (55.6% ± 24). Conclusions While some disparities in guideline implementation are inevitably related to the availability of clinical resources, other differences could be more quickly improved with accessibility of current evidence-based guidelines and development of local data.
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Key Words
- AMR-US/Can, Region of the Americas (US and Canada)
- CT, Computed tomography
- Evidence-based guidelines
- Global neurosurgery
- HIC, High-income country
- ICP, Intracranial pressure
- LIC, Low-income country
- LMICs, Low- and middle-income countries
- Low- and middle-income countries
- MAP, Mean arterial pressure
- MIC, Middle-income country
- Neurotrauma
- Spinal cord injury
- TBI, Traumatic brain injury
- TSI, Traumatic spinal injury
- Traumatic brain injury
- WHO, World Health Organization
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Han C, Yang F, Guo S, Zhang J. Hypertonic Saline Compared to Mannitol for the Management of Elevated Intracranial Pressure in Traumatic Brain Injury: A Meta-Analysis. Front Surg 2022; 8:765784. [PMID: 35071311 PMCID: PMC8776988 DOI: 10.3389/fsurg.2021.765784] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 12/07/2021] [Indexed: 11/13/2022] Open
Abstract
Background: We performed a meta-analysis to evaluate the effect of hypertonic saline compared to mannitol for the management of elevated intracranial pressure in traumatic brain injury.Methods: A systematic literature search up to July 2021 was performed and 17 studies included 1,392 subjects with traumatic brain injury at the start of the study; 708 of them were administered hypertonic saline and 684 were given mannitol. They were reporting relationships between the effects of hypertonic saline compared to mannitol for the management of elevated intracranial pressure in traumatic brain injury. We calculated the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CIs) to assess the effect of hypertonic saline compared to mannitol for the management of elevated intracranial pressure in traumatic brain injury using the dichotomous or continuous method with a random or fixed-effect model.Results: Hypertonic saline had significantly lower treatment failure (OR, 0.38; 95% CI, 0.15–0.98, p = 0.04), lower intracranial pressure 30–60 mins after infusion termination (MD, −1.12; 95% CI, −2.11 to −0.12, p = 0.03), and higher cerebral perfusion pressure 30–60 mins after infusion termination (MD, 5.25; 95% CI, 3.59–6.91, p < 0.001) compared to mannitol in subjects with traumatic brain injury.However, hypertonic saline had no significant effect on favorable outcome (OR, 1.61; 95% CI, 1.01–2.58, p = 0.05), mortality (OR, 0.59; 95% CI, 0.34–1.02, p = 0.06), intracranial pressure 90–120 mins after infusion termination (MD, −0.90; 95% CI, −3.21–1.41, p = 0.45), cerebral perfusion pressure 90–120 mins after infusion termination (MD, 4.28; 95% CI, −0.16–8.72, p = 0.06), and duration of elevated intracranial pressure per day (MD, 2.20; 95% CI, −5.44–1.05, p = 0.18) compared to mannitol in subjects with traumatic brain injury.Conclusions: Hypertonic saline had significantly lower treatment failure, lower intracranial pressure 30–60 mins after infusion termination, and higher cerebral perfusion pressure 30–60 mins after infusion termination compared to mannitol in subjects with traumatic brain injury. However, hypertonic saline had no significant effect on the favorable outcome, mortality, intracranial pressure 90–120 mins after infusion termination, cerebral perfusion pressure 90–120 mins after infusion termination, and duration of elevated intracranial pressure per day compared to mannitol in subjects with traumatic brain injury. Further studies are required to validate these findings.
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Affiliation(s)
- Chengchen Han
- Department of Neurosurgery, The Sixth Medical Center of PLA General Hospital, Beijing, China
| | - Fan Yang
- Department of Neurosurgery, The First Medical Center of PLA General Hospital, Beijing, China
| | - Shengli Guo
- Department of Neurosurgery, The First Medical Center of PLA General Hospital, Beijing, China
| | - Jianning Zhang
- Department of Neurosurgery, The First Medical Center of PLA General Hospital, Beijing, China
- *Correspondence: Jianning Zhang
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Kuo LT, Lu HY, Huang APH. Prognostic Value of Circadian Rhythm of Brain Temperature in Traumatic Brain Injury. J Pers Med 2021; 11:jpm11070620. [PMID: 34208924 PMCID: PMC8307466 DOI: 10.3390/jpm11070620] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/21/2021] [Accepted: 06/28/2021] [Indexed: 11/16/2022] Open
Abstract
Hypothermia has been used in postoperative management of traumatic brain injury (TBI); however, the rhythmic variation and prognostic value of brain temperature after TBI have never been studied. This study describes diurnal brain temperature patterns in comatose patients with TBI. Mesors of brain temperature, amplitude, and acrophase were estimated from recorded temperature measurements using cosinor analysis. The association of these patterns with clinical parameters, mortality, and functional outcomes in a 12-month follow-up was examined. According to the cosinor analysis, 59.3% of patients presented with circadian rhythms of brain temperature in the first 72 h postoperatively. The rhythm-adjusted mesor of brain temperature was 37.39 ± 1.21 °C, with a diminished mean amplitude of 0.28 (±0.25) °C; a shift of temperature acrophase was also observed. Multivariate logistic regression analysis revealed that initial Glasgow coma scale score, age, elevated blood glucose level, and circadian rhythm of brain temperature seemed to be predictive and prognostic factors of patients' functional outcomes. For the prediction of survival status, younger patients or those patients with mesor within the middle 50% of brain temperature were more likely to survive. The analysis of brain temperature rhythms in patients with moderate and severe TBI provided additional predictive information related to mortality and functional outcomes.
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Affiliation(s)
- Lu-Ting Kuo
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, No. 7 Chung San South Road, Taipei 100, Taiwan;
| | - Hsueh-Yi Lu
- Department of Industrial Engineering and Management, National Yunlin University of Science and Technology, Yunlin 64002, Taiwan;
| | - Abel Po-Hao Huang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, No. 7 Chung San South Road, Taipei 100, Taiwan;
- Institute of Polymer Science and Engineering, National Taiwan University, Taipei 100, Taiwan
- Correspondence: ; Tel.: +886-2-2312-3456
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9
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Lee YS, Kim KT, Kwon BK. Hemodynamic Management of Acute Spinal Cord Injury: A Literature Review. Neurospine 2020; 18:7-14. [PMID: 33211951 PMCID: PMC8021842 DOI: 10.14245/ns.2040144.072] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 08/04/2020] [Indexed: 01/01/2023] Open
Abstract
The goal of acute spinal cord injury (SCI) management is to reduce secondary injuries and improve neurological recovery after its occurrence. This review aimed to explore the literature regarding hemodynamic management to reduce ischemic secondary injury and improve neurologic outcome following acute SCI. The PubMed database was searched for studies investigating blood flow, mean arterial pressure (MAP), and spinal cord perfusion pressure after SCI. The 2013 guidelines of the American Association of Neurological Surgeons/Congress of Neurological Surgeons recommended maintaining MAP at 85-90 mmHg for 7 days after SCI to potentially improve outcome. However, this recommendation was based on weak evidence for neurologic benefit. The maintenance of MAP will typically require vasopressors, which may have their own set of complications. More recently, studies have suggested the potential importance of considering spinal cord perfusion pressure in addition to the MAP. Further research on the hemodynamic management of acute SCI is required to determine how to optimize neurologic recovery. Evidence-based guidelines for hemodynamic management should acknowledge the gaps in knowledge and the limitations of the current literature.
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Affiliation(s)
- Young-Seok Lee
- Department of Neurosurgery, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Kyoung-Tae Kim
- Department of Neurosurgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea.,International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada
| | - Brian K Kwon
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC, Canada.,Vancouver Spine Surgery Institute, Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada
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Al Saiegh F, Philipp L, Mouchtouris N, Chalouhi N, Khanna O, Shah SO, Jallo J. Comparison of Outcomes of Severe Traumatic Brain Injury in 36,929 Patients Treated with or without Intracranial Pressure Monitoring in a Mature Trauma System. World Neurosurg 2020; 136:e535-e541. [PMID: 31954892 DOI: 10.1016/j.wneu.2020.01.070] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/09/2020] [Accepted: 01/09/2020] [Indexed: 10/25/2022]
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Abstract
The care of patients with traumatic brain injury can be one of the most challenging and rewarding aspects of clinical neurocritical care. This article reviews the approach to unique aspects specific to the care of this patient population. These aspects include appropriate use of sedation and analgesia, and the principles and the clinical use of intracranial monitors. Common clinical challenges encountered in these patients are also discussed, including the treatment of intracranial hypertension, temperature management, and control of sympathetic hyperactivity.
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Abraham P, Rennert RC, Gabel BC, Sack JA, Karanjia N, Warnke P, Chen CC. ICP management in patients suffering from traumatic brain injury: a systematic review of randomized controlled trials. Acta Neurochir (Wien) 2017; 159:2279-2287. [PMID: 29058090 DOI: 10.1007/s00701-017-3363-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 10/10/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Severe traumatic brain injury (sTBI) is a major cause of morbidity and mortality. Intracranial pressure (ICP) monitoring and management form the cornerstone of treatment paradigms for sTBI in developed countries. We examine the available randomized controlled trial (RCT) data on the impact of ICP management on clinical outcomes after sTBI. METHODS A systematic review of the literature on ICP management following sTBI was performed to identify pertinent RCT articles. RESULTS We identified six RCT articles that examined whether ICP monitoring, decompressive craniectomy, or barbiturate coma improved clinical outcomes after sTBI. These studies support (1) the utility of ICP monitoring in the management of sTBI patients and (2) craniectomy and barbiturate coma as effective methods for the management of intracranial hypertension secondary to sTBI. However, despite adequate ICP control in sTBI patients, a significant proportion of surviving patients remain severely disabled. CONCLUSIONS If one sets the bar at the level of functional independence, then the RCT data raises questions pertaining to the utility of decompressive craniectomy and barbiturate coma in the setting of sTBI.
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Squair JW, Bélanger LM, Tsang A, Ritchie L, Mac-Thiong JM, Parent S, Christie S, Bailey C, Dhall S, Street J, Ailon T, Paquette S, Dea N, Fisher CG, Dvorak MF, West CR, Kwon BK. Spinal cord perfusion pressure predicts neurologic recovery in acute spinal cord injury. Neurology 2017; 89:1660-1667. [PMID: 28916535 DOI: 10.1212/wnl.0000000000004519] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 07/10/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether spinal cord perfusion pressure (SCPP) as measured with a lumbar intrathecal catheter is a more predictive measure of neurologic outcome than the conventionally measured mean arterial pressure (MAP). METHODS A total of 92 individuals with acute spinal cord injury were enrolled in this multicenter prospective observational clinical trial. MAP and CSF pressure (CSFP) were monitored during the first week postinjury. Neurologic impairment was assessed at baseline and at 6 months postinjury. We used logistic regression, systematic iterations of relative risk, and Cox proportional hazard models to examine hemodynamic patterns commensurate with neurologic outcome. RESULTS We found that SCPP (odds ratio 1.039, p = 0.002) is independently associated with positive neurologic recovery. The relative risk for not recovering neurologic function continually increased as individuals were exposed to SCPP below 50 mm Hg. Individuals who improved in neurologic grade dropped below SCPP of 50 mm Hg fewer times than those who did not improve (p = 0.012). This effect was not observed for MAP or CSFP. Those who were exposed to SCPP below 50 mm Hg were less likely to improve from their baseline neurologic impairment grade (p = 0.0056). CONCLUSIONS We demonstrate that maintaining SCPP above 50 mm Hg is a strong predictor of improved neurologic recovery following spinal cord injury. This suggests that SCPP (the difference between MAP and CSFP) can provide useful information to guide the hemodynamic management of patients with acute spinal cord injury.
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Affiliation(s)
- Jordan W Squair
- From the International Collaboration on Repair Discoveries (ICORD) (J.W.S., M.F.D., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), Department of Orthopaedics (J.S., C.G.F., M.F.D, B.K.K) and Division of Neurosurgery (T.A., S. Paquette, N.D.), Vancouver Spine Surgery Institute, Blusson Spinal Cord Centre, and School of Kinesiology (C.R.W.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital; Department of Surgery, Hôpital du Sacré-Coeur de Montréal (J.-M.M.-T., S. Parent), and Chu Sainte-Justine, Department of Surgery (S.C.), Université de Montréal; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; and Department of Neurological Surgery (S.D.), University of California, San Francisco
| | - Lise M Bélanger
- From the International Collaboration on Repair Discoveries (ICORD) (J.W.S., M.F.D., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), Department of Orthopaedics (J.S., C.G.F., M.F.D, B.K.K) and Division of Neurosurgery (T.A., S. Paquette, N.D.), Vancouver Spine Surgery Institute, Blusson Spinal Cord Centre, and School of Kinesiology (C.R.W.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital; Department of Surgery, Hôpital du Sacré-Coeur de Montréal (J.-M.M.-T., S. Parent), and Chu Sainte-Justine, Department of Surgery (S.C.), Université de Montréal; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; and Department of Neurological Surgery (S.D.), University of California, San Francisco
| | - Angela Tsang
- From the International Collaboration on Repair Discoveries (ICORD) (J.W.S., M.F.D., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), Department of Orthopaedics (J.S., C.G.F., M.F.D, B.K.K) and Division of Neurosurgery (T.A., S. Paquette, N.D.), Vancouver Spine Surgery Institute, Blusson Spinal Cord Centre, and School of Kinesiology (C.R.W.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital; Department of Surgery, Hôpital du Sacré-Coeur de Montréal (J.-M.M.-T., S. Parent), and Chu Sainte-Justine, Department of Surgery (S.C.), Université de Montréal; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; and Department of Neurological Surgery (S.D.), University of California, San Francisco
| | - Leanna Ritchie
- From the International Collaboration on Repair Discoveries (ICORD) (J.W.S., M.F.D., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), Department of Orthopaedics (J.S., C.G.F., M.F.D, B.K.K) and Division of Neurosurgery (T.A., S. Paquette, N.D.), Vancouver Spine Surgery Institute, Blusson Spinal Cord Centre, and School of Kinesiology (C.R.W.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital; Department of Surgery, Hôpital du Sacré-Coeur de Montréal (J.-M.M.-T., S. Parent), and Chu Sainte-Justine, Department of Surgery (S.C.), Université de Montréal; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; and Department of Neurological Surgery (S.D.), University of California, San Francisco
| | - Jean-Marc Mac-Thiong
- From the International Collaboration on Repair Discoveries (ICORD) (J.W.S., M.F.D., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), Department of Orthopaedics (J.S., C.G.F., M.F.D, B.K.K) and Division of Neurosurgery (T.A., S. Paquette, N.D.), Vancouver Spine Surgery Institute, Blusson Spinal Cord Centre, and School of Kinesiology (C.R.W.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital; Department of Surgery, Hôpital du Sacré-Coeur de Montréal (J.-M.M.-T., S. Parent), and Chu Sainte-Justine, Department of Surgery (S.C.), Université de Montréal; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; and Department of Neurological Surgery (S.D.), University of California, San Francisco
| | - Stefan Parent
- From the International Collaboration on Repair Discoveries (ICORD) (J.W.S., M.F.D., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), Department of Orthopaedics (J.S., C.G.F., M.F.D, B.K.K) and Division of Neurosurgery (T.A., S. Paquette, N.D.), Vancouver Spine Surgery Institute, Blusson Spinal Cord Centre, and School of Kinesiology (C.R.W.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital; Department of Surgery, Hôpital du Sacré-Coeur de Montréal (J.-M.M.-T., S. Parent), and Chu Sainte-Justine, Department of Surgery (S.C.), Université de Montréal; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; and Department of Neurological Surgery (S.D.), University of California, San Francisco
| | - Sean Christie
- From the International Collaboration on Repair Discoveries (ICORD) (J.W.S., M.F.D., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), Department of Orthopaedics (J.S., C.G.F., M.F.D, B.K.K) and Division of Neurosurgery (T.A., S. Paquette, N.D.), Vancouver Spine Surgery Institute, Blusson Spinal Cord Centre, and School of Kinesiology (C.R.W.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital; Department of Surgery, Hôpital du Sacré-Coeur de Montréal (J.-M.M.-T., S. Parent), and Chu Sainte-Justine, Department of Surgery (S.C.), Université de Montréal; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; and Department of Neurological Surgery (S.D.), University of California, San Francisco
| | - Christopher Bailey
- From the International Collaboration on Repair Discoveries (ICORD) (J.W.S., M.F.D., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), Department of Orthopaedics (J.S., C.G.F., M.F.D, B.K.K) and Division of Neurosurgery (T.A., S. Paquette, N.D.), Vancouver Spine Surgery Institute, Blusson Spinal Cord Centre, and School of Kinesiology (C.R.W.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital; Department of Surgery, Hôpital du Sacré-Coeur de Montréal (J.-M.M.-T., S. Parent), and Chu Sainte-Justine, Department of Surgery (S.C.), Université de Montréal; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; and Department of Neurological Surgery (S.D.), University of California, San Francisco
| | - Sanjay Dhall
- From the International Collaboration on Repair Discoveries (ICORD) (J.W.S., M.F.D., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), Department of Orthopaedics (J.S., C.G.F., M.F.D, B.K.K) and Division of Neurosurgery (T.A., S. Paquette, N.D.), Vancouver Spine Surgery Institute, Blusson Spinal Cord Centre, and School of Kinesiology (C.R.W.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital; Department of Surgery, Hôpital du Sacré-Coeur de Montréal (J.-M.M.-T., S. Parent), and Chu Sainte-Justine, Department of Surgery (S.C.), Université de Montréal; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; and Department of Neurological Surgery (S.D.), University of California, San Francisco
| | - John Street
- From the International Collaboration on Repair Discoveries (ICORD) (J.W.S., M.F.D., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), Department of Orthopaedics (J.S., C.G.F., M.F.D, B.K.K) and Division of Neurosurgery (T.A., S. Paquette, N.D.), Vancouver Spine Surgery Institute, Blusson Spinal Cord Centre, and School of Kinesiology (C.R.W.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital; Department of Surgery, Hôpital du Sacré-Coeur de Montréal (J.-M.M.-T., S. Parent), and Chu Sainte-Justine, Department of Surgery (S.C.), Université de Montréal; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; and Department of Neurological Surgery (S.D.), University of California, San Francisco
| | - Tamir Ailon
- From the International Collaboration on Repair Discoveries (ICORD) (J.W.S., M.F.D., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), Department of Orthopaedics (J.S., C.G.F., M.F.D, B.K.K) and Division of Neurosurgery (T.A., S. Paquette, N.D.), Vancouver Spine Surgery Institute, Blusson Spinal Cord Centre, and School of Kinesiology (C.R.W.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital; Department of Surgery, Hôpital du Sacré-Coeur de Montréal (J.-M.M.-T., S. Parent), and Chu Sainte-Justine, Department of Surgery (S.C.), Université de Montréal; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; and Department of Neurological Surgery (S.D.), University of California, San Francisco
| | - Scott Paquette
- From the International Collaboration on Repair Discoveries (ICORD) (J.W.S., M.F.D., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), Department of Orthopaedics (J.S., C.G.F., M.F.D, B.K.K) and Division of Neurosurgery (T.A., S. Paquette, N.D.), Vancouver Spine Surgery Institute, Blusson Spinal Cord Centre, and School of Kinesiology (C.R.W.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital; Department of Surgery, Hôpital du Sacré-Coeur de Montréal (J.-M.M.-T., S. Parent), and Chu Sainte-Justine, Department of Surgery (S.C.), Université de Montréal; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; and Department of Neurological Surgery (S.D.), University of California, San Francisco
| | - Nicolas Dea
- From the International Collaboration on Repair Discoveries (ICORD) (J.W.S., M.F.D., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), Department of Orthopaedics (J.S., C.G.F., M.F.D, B.K.K) and Division of Neurosurgery (T.A., S. Paquette, N.D.), Vancouver Spine Surgery Institute, Blusson Spinal Cord Centre, and School of Kinesiology (C.R.W.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital; Department of Surgery, Hôpital du Sacré-Coeur de Montréal (J.-M.M.-T., S. Parent), and Chu Sainte-Justine, Department of Surgery (S.C.), Université de Montréal; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; and Department of Neurological Surgery (S.D.), University of California, San Francisco
| | - Charles G Fisher
- From the International Collaboration on Repair Discoveries (ICORD) (J.W.S., M.F.D., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), Department of Orthopaedics (J.S., C.G.F., M.F.D, B.K.K) and Division of Neurosurgery (T.A., S. Paquette, N.D.), Vancouver Spine Surgery Institute, Blusson Spinal Cord Centre, and School of Kinesiology (C.R.W.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital; Department of Surgery, Hôpital du Sacré-Coeur de Montréal (J.-M.M.-T., S. Parent), and Chu Sainte-Justine, Department of Surgery (S.C.), Université de Montréal; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; and Department of Neurological Surgery (S.D.), University of California, San Francisco
| | - Marcel F Dvorak
- From the International Collaboration on Repair Discoveries (ICORD) (J.W.S., M.F.D., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), Department of Orthopaedics (J.S., C.G.F., M.F.D, B.K.K) and Division of Neurosurgery (T.A., S. Paquette, N.D.), Vancouver Spine Surgery Institute, Blusson Spinal Cord Centre, and School of Kinesiology (C.R.W.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital; Department of Surgery, Hôpital du Sacré-Coeur de Montréal (J.-M.M.-T., S. Parent), and Chu Sainte-Justine, Department of Surgery (S.C.), Université de Montréal; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; and Department of Neurological Surgery (S.D.), University of California, San Francisco
| | - Christopher R West
- From the International Collaboration on Repair Discoveries (ICORD) (J.W.S., M.F.D., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), Department of Orthopaedics (J.S., C.G.F., M.F.D, B.K.K) and Division of Neurosurgery (T.A., S. Paquette, N.D.), Vancouver Spine Surgery Institute, Blusson Spinal Cord Centre, and School of Kinesiology (C.R.W.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital; Department of Surgery, Hôpital du Sacré-Coeur de Montréal (J.-M.M.-T., S. Parent), and Chu Sainte-Justine, Department of Surgery (S.C.), Université de Montréal; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; and Department of Neurological Surgery (S.D.), University of California, San Francisco
| | - Brian K Kwon
- From the International Collaboration on Repair Discoveries (ICORD) (J.W.S., M.F.D., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), Department of Orthopaedics (J.S., C.G.F., M.F.D, B.K.K) and Division of Neurosurgery (T.A., S. Paquette, N.D.), Vancouver Spine Surgery Institute, Blusson Spinal Cord Centre, and School of Kinesiology (C.R.W.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital; Department of Surgery, Hôpital du Sacré-Coeur de Montréal (J.-M.M.-T., S. Parent), and Chu Sainte-Justine, Department of Surgery (S.C.), Université de Montréal; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; and Department of Neurological Surgery (S.D.), University of California, San Francisco.
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Abstract
The care of patients with traumatic brain injury can be one of the most challenging and rewarding aspects of clinical neurocritical care. This article reviews the approach to unique aspects specific to the care of this patient population. These aspects include appropriate use of sedation and analgesia, and the principles and the clinical use of intracranial monitors. Common clinical challenges encountered in these patients are also discussed, including the treatment of intracranial hypertension, temperature management, and control of sympathetic hyperactivity.
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Affiliation(s)
- Mohamed H Abou El Fadl
- Neurocritical Care, Department of Neurology, University of Miami, Miller School of Medicine, 1120 Northwest 14th Street, Suite 1356, Miami, FL 33136, USA
| | - Kristine H O'Phelan
- Neurocritical Care, Department of Neurology, University of Miami, Miller School of Medicine, 1120 Northwest 14th Street, Suite 1356, Miami, FL 33136, USA.
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15
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Hu GW, Lang HL, Guo H, Wu L, Zhang P, Kuang W, Zhu XG. A risk score based on admission characteristics to predict progressive hemorrhagic injury from traumatic brain injury in children. Eur J Pediatr 2017; 176:689-696. [PMID: 28343321 DOI: 10.1007/s00431-017-2897-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 03/14/2017] [Accepted: 03/21/2017] [Indexed: 10/19/2022]
Abstract
UNLABELLED Traumatic brain injury (TBI) is one of the leading causes of death and disability in children, and progressive hemorrhagic injury (PHI) post TBI is associated with poor outcomes. Therefore, the objective of this study was to develop and validate a prognostic model that uses the information available at admission to determine the likelihood of PHI occurrence after TBI in children. The identified demographic data, cause of injury, clinical predictors on admission, computed tomography scan characteristics, and routine laboratory parameters were collected and used to develop a PHI prognostic model with logistic regression analysis, and the prediction model was validated in 68 children. Eight independent prognostic factors were identified: lower Glasgow coma scale score (3 ~ 8) (6 points), intra-axial bleeding/brain contusion (4 points), midline shift ≥5 mm (9 points), platelets <100 × 109/L (11 points), prothrombin time >14 s (6 points), international normalized ratio >1.25 (7 points), D-dimer ≥5 mg/L (14 points), and glucose ≧10 mmol/L (11 points). We calculated risk scores for each child and defined three risk groups: low risk (0-16 points), intermediate risk (17-36 points), and high risk (37-68 points). In the development cohort, the PHI rates after TBI for the low-, intermediate-, and high-risk groups were 10.1, 47.9, and 84.2%, respectively. In the validation cohort, the corresponding PHI rates were 10.9, 47.5, and 85.4%, respectively. The C-statistic for the point system was 0.873 (p = 0.586 by the Hosmer-Lemeshow test) in the development cohort and 0.877 (p = 0.524 by the Hosmer-Lemeshow test) in the validation cohort. CONCLUSION Using admission predictors, we developed a relatively simple risk score that accurately predicted the risk of PHI after TBI in children. What is Known: • TBI is one of the leading causes of death and disability in children, and PHI post TBI is associated with poor outcomes. •Prediction of patients at low risk of PHI could help reduce treatment costs, whereas identification of patients at high risk of PHI could direct early medical intervention to improve outcomes. What is New: • This study firstly developed a risk score system by assessing the admission information that could provide an earlier prediction of the occurrence of PHI after acute TBI in children.
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Affiliation(s)
- Guo-Wen Hu
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Hai-Li Lang
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Hua Guo
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Lei Wu
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Pei Zhang
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Wei Kuang
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Xin-Gen Zhu
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, China.
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16
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Twenty-Four-Hour Real-Time Continuous Monitoring of Cerebral Edema in Rabbits Based on a Noninvasive and Noncontact System of Magnetic Induction. SENSORS 2017; 17:s17030537. [PMID: 28282851 PMCID: PMC5375823 DOI: 10.3390/s17030537] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 02/24/2017] [Accepted: 03/06/2017] [Indexed: 01/08/2023]
Abstract
Cerebral edema is a common disease, secondary to craniocerebral injury, and real-time continuous monitoring of cerebral edema is crucial for treating patients after traumatic brain injury. This work established a noninvasive and noncontact system by monitoring the magnetic induction phase shift (MIPS) which is associated with brain tissue conductivity. Sixteen rabbits (experimental group n = 10, control group, n = 6) were used to perform a 24 h MIPS and intracranial pressure (ICP) simultaneously monitored experimental study. For the experimental group, after the establishment of epidural freeze-induced cerebral edema models, the MIPS presented a downward trend within 24 h, with a change magnitude of −13.1121 ± 2.3953°; the ICP presented an upward trend within 24 h, with a change magnitude of 12–41 mmHg. The ICP was negatively correlated with the MIPS. In the control group, the MIPS change amplitude was −0.87795 ± 1.5146 without obvious changes; the ICP fluctuated only slightly at the initial value of 12 mmHg. MIPS had a more sensitive performance than ICP in the early stage of cerebral edema. These results showed that this system is basically capable of monitoring gradual increases in the cerebral edema solution volume. To some extent, the MIPS has the potential to reflect the ICP changes.
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17
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You W, Feng J, Tang Q, Cao J, Wang L, Lei J, Mao Q, Gao G, Jiang J. Intraventricular intracranial pressure monitoring improves the outcome of older adults with severe traumatic brain injury: an observational, prospective study. BMC Anesthesiol 2016; 16:35. [PMID: 27401211 PMCID: PMC4940906 DOI: 10.1186/s12871-016-0199-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 06/01/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intracranial pressure (ICP) monitoring is widely used in the management of patients with severe traumatic brain injury (TBI). However, there is limited evidence about the efficacy of ICP monitoring in older subjects (aged ≥65 years). This study evaluated the effect of intraventricular ICP monitoring on the outcome of older adults suffering from a severe TBI. METHODS This prospective, observational study included 166 older TBI patients (aged ≥65 years) with Glasgow Coma scale (GCS) scores lower than 9 at admission. The study cohort was divided into two groups, intraventricular ICP monitoring and non-ICP monitoring. The primary outcome was in-hospital mortality. The secondary outcomes included the Glasgow Outcome Scale (GOS) score 6 months after injury, the ICU and total hospital lengths of stay, and mechanical ventilation days. RESULTS There were 80 patients in the intraventricular ICP monitoring group and 86 patients in non-ICP monitoring group. There was no statistical difference between groups in demographics and severity of head injury. Patients treated with intraventricular ICP monitoring had lower in-hospital mortality (33.8 % vs 51.2 %, P < 0.05), a higher 6-month GOS score (3.0 ± 1.4 vs 2.5 ± 1.2 P < 0.05), and a lower dosage (514 ± 246 g vs 840 ± 323 g, P < 0.0001) and shorter duration (7.2 ± 3.6 days vs 8.4 ± 4.3 days, P < 0.01) of mannitol use. However, the ICU length of stay (14.3 ± 6.4 days vs 11.6 ± 5.8 days, P < 0.01) and mechanical ventilation days (6.7 ± 3.5 days vs 5.6 ± 2.4 days, P < 0.05) were longer in the ICP monitoring group. The total length of hospital stay did not differ between the two groups (28.5 ± 12.1 days vs 26.1 ± 13.5 days, P = 0.23). CONCLUSIONS Intraventricular ICP monitoring may have beneficial effects on the decreased in-hospital mortality and improved 6-month outcome of older patients with severe TBI. However, given that this was an observational study conducted in a single institution, further well-designed randomized control trials are needed to evaluate the effect of intraventricular ICP monitoring on the outcome of older severe TBI patients.
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Affiliation(s)
- Wendong You
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
- Shanghai Institute of Head Trauma, Shanghai, 200127, People's Republic of China
| | - Junfeng Feng
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
- Shanghai Institute of Head Trauma, Shanghai, 200127, People's Republic of China
| | - Qilin Tang
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
- Shanghai Institute of Head Trauma, Shanghai, 200127, People's Republic of China
| | - Jun Cao
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
- Shanghai Institute of Head Trauma, Shanghai, 200127, People's Republic of China
| | - Lei Wang
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
- Shanghai Institute of Head Trauma, Shanghai, 200127, People's Republic of China
| | - Jin Lei
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
- Shanghai Institute of Head Trauma, Shanghai, 200127, People's Republic of China
| | - Qing Mao
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
- Shanghai Institute of Head Trauma, Shanghai, 200127, People's Republic of China
| | - Guoyi Gao
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China.
- Shanghai Institute of Head Trauma, Shanghai, 200127, People's Republic of China.
| | - Jiyao Jiang
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, People's Republic of China
- Shanghai Institute of Head Trauma, Shanghai, 200127, People's Republic of China
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Luca L, Rogobete AF, Bedreag OH, Sarandan M, Cradigati CA, Papurica M, Gruneantu A, Patrut R, Vernic C, Dumbuleu CM, Sandesc D. Intracranial Pressure Monitoring as a Part of Multimodal Monitoring Management of Patients with Critical Polytrauma: Correlation between Optimised Intensive Therapy According to Intracranial Pressure Parameters and Clinical Picture. Turk J Anaesthesiol Reanim 2015; 43:412-7. [PMID: 27366538 DOI: 10.5152/tjar.2015.56933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Accepted: 07/06/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Trauma patient requires a complex therapeutic management because of multiple severe injuries or secondary complications. The most significant injury found in patients with trauma is head injury, which has the greatest impact on mortality. Intracranial pressure (ICP) monitoring is required in severe traumatic head injury because it optimises treatment based on ICP values and cerebral perfusion pressure (CPP). METHODS From a total of 64 patients admitted in the intensive care unit (ICU) 'Casa Austria', from the Polytraumatology Clinic of the Emergency County Hospital "Pius Brinzeu" Timisoara, Romania, between January 2014 and December 2014; only patients who underwent ICP monitoring (n=10) were analysed. The study population was divided into several categories depending on the time passed since trauma to the time of installation of ICP monitoring (<18 h, 19-24 h and >24 h). Comparisons were made in terms of the number of days admitted in the ICU and mortality between patients with head injury who benefited and those who did not benefit from ICP monitoring. RESULTS The results show the positive influence of ICP monitoring on the number of admission days in ICU because of the possibility that the number of admission days to augment therapeutic effects in patients who benefited from ICP monitoring reduces by 1.93 days compared with those who did not undergo ICP monitoring. CONCLUSION ICP monitoring and optimizing therapy according to the ICP and CPP has significant influence on the rate of survival. ICP monitoring is necessary in all patients with head trauma injury according to recent guidelines. The main therapeutic goal in the management of the trauma patient with head injury is to minimize the destructive effects of the associated side effects.
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Affiliation(s)
- Loredana Luca
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu", Timisoara, Romania
| | - Alexandru Florin Rogobete
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu", Timisoara, Romania
| | - Ovidiu Horea Bedreag
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu", Timisoara, Romania
| | - Mirela Sarandan
- Clinic of Anaesthesia and Intensive Care "Casa Austria", Emergency County Hospital "Pius Brinzeu", Timisoara, Romania
| | - Carmen Alina Cradigati
- Clinic of Anaesthesia and Intensive Care "Casa Austria", Emergency County Hospital "Pius Brinzeu", Timisoara, Romania
| | - Marius Papurica
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu", Timisoara, Romania
| | - Anelore Gruneantu
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu", Timisoara, Romania
| | - Raluca Patrut
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu", Timisoara, Romania
| | - Corina Vernic
- Faculty of Medicine, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Corina Maria Dumbuleu
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu", Timisoara, Romania
| | - Dorel Sandesc
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital "Pius Brinzeu", Timisoara, Romania
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Reis C, Wang Y, Akyol O, Ho WM, Ii RA, Stier G, Martin R, Zhang JH. What's New in Traumatic Brain Injury: Update on Tracking, Monitoring and Treatment. Int J Mol Sci 2015; 16:11903-65. [PMID: 26016501 PMCID: PMC4490422 DOI: 10.3390/ijms160611903] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 05/04/2015] [Accepted: 05/06/2015] [Indexed: 12/11/2022] Open
Abstract
Traumatic brain injury (TBI), defined as an alteration in brain functions caused by an external force, is responsible for high morbidity and mortality around the world. It is important to identify and treat TBI victims as early as possible. Tracking and monitoring TBI with neuroimaging technologies, including functional magnetic resonance imaging (fMRI), diffusion tensor imaging (DTI), positron emission tomography (PET), and high definition fiber tracking (HDFT) show increasing sensitivity and specificity. Classical electrophysiological monitoring, together with newly established brain-on-chip, cerebral microdialysis techniques, both benefit TBI. First generation molecular biomarkers, based on genomic and proteomic changes following TBI, have proven effective and economical. It is conceivable that TBI-specific biomarkers will be developed with the combination of systems biology and bioinformation strategies. Advances in treatment of TBI include stem cell-based and nanotechnology-based therapy, physical and pharmaceutical interventions and also new use in TBI for approved drugs which all present favorable promise in preventing and reversing TBI.
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Affiliation(s)
- Cesar Reis
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
| | - Yuechun Wang
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
- Department of Physiology, School of Medicine, University of Jinan, Guangzhou 250012, China.
| | - Onat Akyol
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
| | - Wing Mann Ho
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
- Department of Neurosurgery, University Hospital Innsbruck, Tyrol 6020, Austria.
| | - Richard Applegate Ii
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
| | - Gary Stier
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
| | - Robert Martin
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
| | - John H Zhang
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
- Department of Neurosurgery, Loma Linda University School of Medicine, Loma Linda, CA 92354, USA.
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Rahmanian A, Haghnegahdar A, Rahmanian A, Ghaffarpasand F. Effects of Intracranial Pressure Monitoring on Outcome of Patients with Severe Traumatic Brain Injury; Results of a Historical Cohort Study. Bull Emerg Trauma 2014; 2:151-155. [PMID: 27162888 PMCID: PMC4771290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 09/02/2014] [Accepted: 09/20/2014] [Indexed: 06/05/2023] Open
Abstract
OBJECTIVE To investigate the effects of intracranial pressure (ICP) monitoring on mortality rate and functional outcome of patients with severe traumatic brain injury (TBI). METHODS This was historical cohort study being performed in Nemazee hospital of Shiraz during a 4-year period (from 2006 to 2010) including those patients with severe TBI who had undergone care based on ICP monitoring (case group) or clinical evaluation (control group).Patients and controls were matched regarding the age, sex, initial GCS, initial pupils, and CT findings. The functional outcome, complications and mortality rate were recorded and compared between those who underwent ICP monitoring and those who did not. RESULTS There was no significant difference between two study groups regarding the baseline characteristics. The rate of meningitis was significantly higher in those who underwent Ventriculostomy and ICP monitoring when compared to those who were managed without ICP monitoring. [14 (23.3%) vs. 7 (11.6%); p=0.041]. We found that the mortality rate (28.3% vs. 11.6%; p=0.172) as well as the frequency of persistent vegetative state (5.0% vs. 5.0%; p=0.998) were comparable between two study groups. However the frequency of severe disability was higher in control group compared to case group (26.7% vs. 15.0; p=0.046). In the same way, the frequency of good recovery (26.7% vs. 15.0; p=0.046) and favorable outcome (51.7% vs. 33.3%; p=0.021) was significantly higher in case group. CONCLUSION Care based on ICP monitoring in patients with severe TBI was associated with increased frequency of good recovery and favorable outcome and decreased frequency of moderate disability. However higher meningitis rate was associated with Ventriculostomy and ICP monitoring.
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Affiliation(s)
| | - Ali Haghnegahdar
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
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21
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Hawthorne C, Piper I. Monitoring of intracranial pressure in patients with traumatic brain injury. Front Neurol 2014; 5:121. [PMID: 25076934 PMCID: PMC4100218 DOI: 10.3389/fneur.2014.00121] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 06/25/2014] [Indexed: 02/01/2023] Open
Abstract
Since Monro published his observations on the nature of the contents of the intracranial space in 1783, there has been investigation of the unique relationship between the contents of the skull and the intracranial pressure (ICP). This is particularly true following traumatic brain injury (TBI), where it is clear that elevated ICP due to the underlying pathological processes is associated with a poorer clinical outcome. Consequently, there is considerable interest in monitoring and manipulating ICP in patients with TBI. The two techniques most commonly used in clinical practice to monitor ICP are via an intraventricular or intraparenchymal catheter with a microtransducer system. Both of these techniques are invasive and are thus associated with complications such as hemorrhage and infection. For this reason, significant research effort has been directed toward development of a non-invasive method to measure ICP. The principle aims of ICP monitoring in TBI are to allow early detection of secondary hemorrhage and to guide therapies that limit intracranial hypertension (ICH) and optimize cerebral perfusion. However, information from the ICP value and the ICP waveform can also be used to assess the intracranial volume-pressure relationship, estimate cerebrovascular pressure reactivity, and attempt to forecast future episodes of ICH.
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Affiliation(s)
- Christopher Hawthorne
- Clinical Lecturer, Academic Unit of Anaesthesia, Pain and Critical Care Medicine, University of Glasgow, Glasgow, UK
| | - Ian Piper
- Clinical Physics, Southern General Hospital, Greater Glasgow Health Board, Glasgow, UK
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