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Zoerle T, Beqiri E, Åkerlund CAI, Gao G, Heldt T, Hawryluk GWJ, Stocchetti N. Intracranial pressure monitoring in adult patients with traumatic brain injury: challenges and innovations. Lancet Neurol 2024; 23:938-950. [PMID: 39152029 DOI: 10.1016/s1474-4422(24)00235-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 05/15/2024] [Accepted: 05/28/2024] [Indexed: 08/19/2024]
Abstract
Intracranial pressure monitoring enables the detection and treatment of intracranial hypertension, a potentially lethal insult after traumatic brain injury. Despite its widespread use, robust evidence supporting intracranial pressure monitoring and treatment remains sparse. International studies have shown large variations between centres regarding the indications for intracranial pressure monitoring and treatment of intracranial hypertension. Experts have reviewed these two aspects and, by consensus, provided practical approaches for monitoring and treatment. Advances have occurred in methods for non-invasive estimation of intracranial pressure although, for now, a reliable way to non-invasively and continuously measure intracranial pressure remains aspirational. Analysis of the intracranial pressure signal can provide information on brain compliance (ie, the ability of the cranium to tolerate volume changes) and on cerebral autoregulation (ie, the ability of cerebral blood vessels to react to changes in blood pressure). The information derived from the intracranial pressure signal might allow for more individualised patient management. Machine learning and artificial intelligence approaches are being increasingly applied to intracranial pressure monitoring, but many obstacles need to be overcome before their use in clinical practice could be attempted. Robust clinical trials are needed to support indications for intracranial pressure monitoring and treatment. Progress in non-invasive assessment of intracranial pressure and in signal analysis (for targeted treatment) will also be crucial.
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Affiliation(s)
- Tommaso Zoerle
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Cecilia A I Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden; Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Guoyi Gao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Thomas Heldt
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Gregory W J Hawryluk
- Cleveland Clinic Akron General Hospital, Uniformed Services University, Cleveland, OH, USA
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Makoshi Z, Hayek G, Aquino V, Arias A, Guido J, Radenovich V, Jimenez D, Yates D. Intraoperative Intracranial Pressure Changes in Children With Craniosynostosis Undergoing Endoscopic-Assisted Strip Craniectomy. Neurosurgery 2024:00006123-990000000-01312. [PMID: 39166852 DOI: 10.1227/neu.0000000000003141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 07/09/2024] [Indexed: 08/23/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Craniosynostosis can lead to progressive cranial and skull base deformities and can be associated with increased intracranial pressure (ICP), ophthalmological manifestations, behavioral changes, and developmental delay. Most published data on the incidence of elevated ICP include older children undergoing open surgical correction. Endoscopic-assisted release of fused sutures with postoperative helmet therapy is an established method for managing craniosynostosis presenting at an early age; however, the immediate effect of this approach on ICP in a young cohort has not been previously reported. METHODS Prospective data on 52 children undergoing endoscopic-assisted release of stenosed cranial sutures were included. Individuals were excluded if they underwent open correction or had previous cranial surgery. Individuals underwent a standardized endoscopic approach for each suture type. ICP was measured using an intraparenchymal sensor both before creation of the neosuture and after complete release of the stenosed suture. An ICP reading of >10 mm Hg was considered elevated. RESULTS The mean age was 5.3 months, range 1 to 32 months, and 94% was younger than 12 months. The mean opening pressure was 12.7 mm Hg, and the mean closing pressure was 2.9 mm Hg. Opening ICP ≥10 mm Hg was present in 58%, ≥15 mm Hg was present in 31%, and ≥20 mm Hg was present in 23%. No patient had an ICP above 10 mm Hg at closing. The mean percentage change in ICP among all craniosynostosis cases was a 64% decrease. Optic disk swelling was identified in 28 children preoperatively and improved in 22 children at follow-up. CONCLUSION Elevated ICP may occur in infants with craniosynostosis at higher rates than previously reported. Endoscopic-assisted craniectomy has an immediate effect on lowering ICP and improving postoperative ophthalmological findings.
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Affiliation(s)
- Ziyad Makoshi
- Neuroscience Department, El Paso Children's Hospital, El Paso, Texas, USA
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Gabriel Hayek
- Connecticut Children's Medical Center, Hartford, Connecticut, USA
- Avon Oral and Maxillofacial Surgery, Avon, Connecticut, USA
| | | | | | - Julia Guido
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Violeta Radenovich
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
- Children's Eye Center of El Paso, El Paso, Texas, USA
| | - David Jimenez
- Neuroscience Department, El Paso Children's Hospital, El Paso, Texas, USA
| | - David Yates
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
- El Paso Children's Hospital, El Paso, Texas, USA
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de Moraes FM, Brasil S, Frigieri G, Robba C, Paiva W, Silva GS. ICP wave morphology as a screening test to exclude intracranial hypertension in brain-injured patients: a non-invasive perspective. J Clin Monit Comput 2024; 38:773-782. [PMID: 38355918 DOI: 10.1007/s10877-023-01120-3] [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: 10/15/2023] [Accepted: 12/15/2023] [Indexed: 02/16/2024]
Abstract
Intracranial hypertension (IH) is a life-threating condition especially for the brain injured patient. In such cases, an external ventricular drain (EVD) or an intraparenchymal bolt are the conventional gold standard for intracranial pressure (ICPi) monitoring. However, these techniques have several limitations. Therefore, identifying an ideal screening method for IH is important to avoid the unnecessary placement of ICPi and expedite its introduction in patients who require it. A potential screening tool is the ICP wave morphology (ICPW) which changes according to the intracranial volume-pressure curve. Specifically, the P2/P1 ratio of the ICPW has shown promise as a triage test to indicate normal ICP. In this study, we propose evaluating the noninvasive ICPW (nICPW-B4C sensor) as a screening method for ICPi monitoring in patients with moderate to high probability of IH. This is a retrospective analysis of a prospective, multicenter study that recruited adult patients requiring ICPi monitoring from both Federal University of São Paulo and University of São Paulo Medical School Hospitals. ICPi values and the nICPW parameters were obtained from both the invasive and the noninvasive methods simultaneously 5 min after the closure of the EVD drainage. ICP assessment was performed using a catheter inserted into the ventricle and connected to a pressure transducer and a drainage system. The B4C sensor was positioned on the patient's scalp without the need for trichotomy, surgical incision or trepanation, and the morphology of the ICP waves acquired through a strain sensor that can detect and monitor skull bone deformations caused by changes in ICP. All patients were monitored using this noninvasive system for at least 10 min per session. The area under the curve (AUC) was used to describe discriminatory power of the P2/P1 ratio for IH, with emphasis in the Negative Predictive value (NPV), based on the Youden index, and the negative likelihood ratio [LR-]. Recruitment occurred from August 2017 to March 2020. A total of 69 patients fulfilled inclusion and exclusion criteria in the two centers and a total of 111 monitorizations were performed. The mean P2/P1 ratio value in the sample was 1.12. The mean P2/P1 value in the no IH population was 1.01 meanwhile in the IH population was 1.32 (p < 0.01). The best Youden index for the mean P2/P1 ratio was with a cut-off value of 1.13 showing a sensitivity of 93%, specificity of 60%, and a NPV of 97%, as well as an AUC of 0.83 to predict IH. With the 1.13 cut-off value for P2/P1 ratio, the LR- for IH was 0.11, corresponding to a strong performance in ruling out the condition (IH), with an approximate 45% reduction in condition probability after a negative test (ICPW). To conclude, the P2/P1 ratio of the noninvasive ICP waveform showed in this study a high Negative Predictive Value and Likelihood Ratio in different acute neurological conditions to rule out IH. As a result, this parameter may be beneficial in situations where invasive methods are not feasible or unavailable and to screen high-risk patients for potential invasive ICP monitoring.Trial registration: At clinicaltrials.gov under numbers NCT05121155 (Registered 16 November 2021-retrospectively registered) and NCT03144219 (Registered 30 September 2022-retrospectively registered).
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Affiliation(s)
| | - Sérgio Brasil
- Division of Neurosurgery, Department of Neurology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Gustavo Frigieri
- Medical Investigation Laboratory 62, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Chiara Robba
- Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS Per L'Oncologia E Le Neuroscienze, Genoa, Italy
| | - Wellingson Paiva
- Division of Neurosurgery, Department of Neurology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, Brazil
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Valentim W, Bertani R, Brasil S. A Narrative Review on Financial Challenges and Health Care Costs Associated with Traumatic Brain Injury in the United States. World Neurosurg 2024; 187:82-92. [PMID: 38583561 DOI: 10.1016/j.wneu.2024.03.175] [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: 03/29/2024] [Accepted: 03/30/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a highly prevalent and potentially severe medical condition. Challenges regarding TBI management are related to accurate diagnostics, defining its severity, and establishing prompt interventions to affect outcomes. Among the health care components in the TBI handling strategy is intracranial pressure (ICP) monitoring, which is fundamental to therapy decisions. However, ICP monitoring is an Achilles tendon, imposing a significant financial burden on health care systems, particularly in middle and low-income communities. This article arises from the understanding from the authors that there is insufficient scientific evidence about the potential economic impacts from the use of noninvasive technologies in the monitoring of TBI. Based on personal experience, as well as from reading other, clinically focused studies, the thesis is that the use of such technologies could greatly affect the health care system and this article seeks to address this lack of literature, show ways in which such systems could be evaluated, and show estimations of possible results from these investigations. OBJECTIVE This review primarily investigates the economic burden of TBI and whether new technologies are suitable to reduce its health care costs without compromising the quality of care, according to the levels of evidence available. The objective is to stimulate more research and attention in the area. METHODS For this narrative review, a PubMed search was conducted for articles discussing TBI health care costs, as well as monitoring technologies (tomography, magnetic resonance imaging, optic nerve sheath diameter, transcranial Doppler, pupillometry, and noninvasive ICP waveform) and their application in managing TBI. Strategies were first evaluated from a medical noninferiority perspective before calculating the average savings of each selected strategy. All applicable studies were analyzed for quality using the Consolidated Health Economic Evaluation Reporting Standards 2022 Statement117 and this article was written to conform as much as possible with it. RESULTS The review included 109 references and showed a consistent potential in noninvasive technologies to reduce costs and maintain or improve the quality of care. CONCLUSIONS TBI prevalence has increased with a disproportionate health care burden in the last decades. Noninvasive monitoring techniques seem to be effective in reducing TBI health care costs, with few limitations, especially the need for more supporting scientific evidence. The undeniable clinical and financial potential of these techniques is compelling to further investigate their role in TBI management, as well as the creation of more comprehensive monitoring models to the understanding of complex phenomena occurring in the injured brain.
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Affiliation(s)
- Wander Valentim
- Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil.
| | - Raphael Bertani
- Neurosurgery Division, Department of Neurology, São Paulo University School of Medicine, São Paulo, Brazil
| | - Sergio Brasil
- Neurosurgery Division, Department of Neurology, São Paulo University School of Medicine, São Paulo, Brazil
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Abdul-Rahman A, Morgan W, Vukmirovic A, Yu DY. Probability density and information entropy of machine learning derived intracranial pressure predictions. PLoS One 2024; 19:e0306028. [PMID: 38950055 PMCID: PMC11216561 DOI: 10.1371/journal.pone.0306028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 06/10/2024] [Indexed: 07/03/2024] Open
Abstract
Even with the powerful statistical parameters derived from the Extreme Gradient Boost (XGB) algorithm, it would be advantageous to define the predicted accuracy to the level of a specific case, particularly when the model output is used to guide clinical decision-making. The probability density function (PDF) of the derived intracranial pressure predictions enables the computation of a definite integral around a point estimate, representing the event's probability within a range of values. Seven hold-out test cases used for the external validation of an XGB model underwent retinal vascular pulse and intracranial pressure measurement using modified photoplethysmography and lumbar puncture, respectively. The definite integral ±1 cm water from the median (DIICP) demonstrated a negative and highly significant correlation (-0.5213±0.17, p< 0.004) with the absolute difference between the measured and predicted median intracranial pressure (DiffICPmd). The concordance between the arterial and venous probability density functions was estimated using the two-sample Kolmogorov-Smirnov statistic, extending the distribution agreement across all data points. This parameter showed a statistically significant and positive correlation (0.4942±0.18, p< 0.001) with DiffICPmd. Two cautionary subset cases (Case 8 and Case 9), where disagreement was observed between measured and predicted intracranial pressure, were compared to the seven hold-out test cases. Arterial predictions from both cautionary subset cases converged on a uniform distribution in contrast to all other cases where distributions converged on either log-normal or closely related skewed distributions (gamma, logistic, beta). The mean±standard error of the arterial DIICP from cases 8 and 9 (3.83±0.56%) was lower compared to that of the hold-out test cases (14.14±1.07%) the between group difference was statistically significant (p<0.03). Although the sample size in this analysis was limited, these results support a dual and complementary analysis approach from independently derived retinal arterial and venous non-invasive intracranial pressure predictions. Results suggest that plotting the PDF and calculating the lower order moments, arterial DIICP, and the two sample Kolmogorov-Smirnov statistic may provide individualized predictive accuracy parameters.
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Affiliation(s)
- Anmar Abdul-Rahman
- Department of Ophthalmology, Counties Manukau District Health Board, Auckland, New Zealand
| | - William Morgan
- Centre for Ophthalmology and Visual Science, The University of Western Australia, Perth, Australia
- Lions Eye Institute, University of Western Australia, Perth, Australia
| | - Aleksandar Vukmirovic
- Centre for Ophthalmology and Visual Science, The University of Western Australia, Perth, Australia
- Lions Eye Institute, University of Western Australia, Perth, Australia
| | - Dao-Yi Yu
- Centre for Ophthalmology and Visual Science, The University of Western Australia, Perth, Australia
- Lions Eye Institute, University of Western Australia, Perth, Australia
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Roldan M, Abay TY, Uff C, Kyriacou PA. A pilot clinical study to estimate intracranial pressure utilising cerebral photoplethysmograms in traumatic brain injury patients. Acta Neurochir (Wien) 2024; 166:109. [PMID: 38409283 PMCID: PMC10896864 DOI: 10.1007/s00701-024-06002-4] [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: 09/28/2023] [Accepted: 02/03/2024] [Indexed: 02/28/2024]
Abstract
PURPOSE In this research, a non-invasive intracranial pressure (nICP) optical sensor was developed and evaluated in a clinical pilot study. The technology relied on infrared light to probe brain tissue, using photodetectors to capture backscattered light modulated by vascular pulsations within the brain's vascular tissue. The underlying hypothesis was that changes in extramural arterial pressure could affect the morphology of recorded optical signals (photoplethysmograms, or PPGs), and analysing these signals with a custom algorithm could enable the non-invasive calculation of intracranial pressure (nICP). METHODS This pilot study was the first to evaluate the nICP probe alongside invasive ICP monitoring as a gold standard. nICP monitoring occurred in 40 patients undergoing invasive ICP monitoring, with data randomly split for machine learning. Quality PPG signals were extracted and analysed for time-based features. The study employed Bland-Altman analysis and ROC curve calculations to assess nICP accuracy compared to invasive ICP data. RESULTS Successful acquisition of cerebral PPG signals from traumatic brain injury (TBI) patients allowed for the development of a bagging tree model to estimate nICP non-invasively. The nICP estimation exhibited 95% limits of agreement of 3.8 mmHg with minimal bias and a correlation of 0.8254 with invasive ICP monitoring. ROC curve analysis showed strong diagnostic capability with 80% sensitivity and 89% specificity. CONCLUSION The clinical evaluation of this innovative optical nICP sensor revealed its ability to estimate ICP non-invasively with acceptable and clinically useful accuracy. This breakthrough opens the door to further technological refinement and larger-scale clinical studies in the future. TRIAL REGISTRATION NCT05632302, 11th November 2022, retrospectively registered.
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Affiliation(s)
- Maria Roldan
- Research Centre for Biomedical Engineering, School of Science & Technology, University of London, London, EC1V 0HB, UK.
| | - Tomas Ysehak Abay
- Research Centre for Biomedical Engineering, School of Science & Technology, University of London, London, EC1V 0HB, UK
| | - Christopher Uff
- Barts Health NHS Trust: Royal London Hospital, E1 1BB, London, UK
| | - Panayiotis A Kyriacou
- Research Centre for Biomedical Engineering, School of Science & Technology, University of London, London, EC1V 0HB, UK
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Riparbelli AC, Capion T, Møller K, Mathiesen TI, Olsen MH, Forsse A. Critical ICP thresholds in relation to outcome: Is 22 mmHg really the answer? Acta Neurochir (Wien) 2024; 166:63. [PMID: 38315234 PMCID: PMC10844356 DOI: 10.1007/s00701-024-05929-y] [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: 10/18/2023] [Accepted: 01/11/2024] [Indexed: 02/07/2024]
Abstract
PURPOSE Intensive care for patients with traumatic brain injury (TBI) aims, among other tasks, at avoiding high intracranial pressure (ICP), which is perceived to worsen motor and cognitive deficits and increase mortality. International recommendations for threshold values for ICP were increased from 20 to 22 mmHg in 2016 following the findings in a study by Sorrentino et al., which were based on an observational study of patients with TBI of averaged ICP values. We aimed to reproduce their approach and validate the findings in a separate cohort. METHODS Three hundred thirty-one patients with TBI were included and categorised according to survival/death and favourable/unfavourable outcome at 6 months (based on Glasgow Outcome Score-Extended of 6-8 and 1-5, respectively). Repeated chi-square tests of survival and death (or favourable and unfavourable outcome) vs. high and low ICP were conducted with discrimination between high and low ICP sets at increasing values (integers) between 10 and 35 mmHg, using the average ICP for the entire monitoring period. The ICP limit returning the highest chi-square score was assumed to be the threshold with best discriminative ability. This approach was repeated after stratification by sex, age, and initial Glasgow Coma Score (GCS). RESULTS An ICP limit of 18 mmHg was found for both mortality and unfavourable outcome for the entire cohort. The female and the low GCS subgroups both had threshold values of 18 mmHg; for all other subgroups, the threshold varied between 16 and 30 mmHg. According to a multiple logistic regression analysis, age, initial GCS, and average ICP are independently associated with mortality and outcome. CONCLUSIONS Using identical methods and closely comparable cohorts, the critical thresholds for ICP found in the study by Sorrentino et al. could not be reproduced.
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Affiliation(s)
- Agnes C Riparbelli
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
| | - Tenna Capion
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences SUND, University of Copenhagen, Copenhagen, Denmark
| | - Tiit I Mathiesen
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences SUND, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Markus H Olsen
- Department of Neuroanesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Axel Forsse
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Chopko A, Tian M, L'Huillier JC, Filipescu R, Yu J, Guo WA. Utility of intracranial pressure monitoring in patients with traumatic brain injuries: a propensity score matching analysis of TQIP data. Eur J Trauma Emerg Surg 2024; 50:173-184. [PMID: 36795136 DOI: 10.1007/s00068-023-02239-3] [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: 11/22/2022] [Accepted: 01/27/2023] [Indexed: 02/17/2023]
Abstract
PURPOSE Intracranial pressure monitoring (ICPM) is central to traumatic brain injury (TBI) management, but its utility is controversial. METHODS The 2016-2017 TQIP database was queried for isolated TBI. Patients with ICPM [(ICPM (+)] were propensity-score matched (PSM) to those without ICPM [ICPM (-)] and divided into three age groups by years (< 18, 18-54, ≥ 55). RESULTS PSM yielded 2125 patients in each group. Patients aged < 18 years had a higher survival probability (p = 0.013) and decreased mortality (p = 0.016) in the ICPM (+) group. Complications were higher and LOS was longer in ICPM (+) patients aged 18-54 years and ≥ 55 years, but not in patients aged < 18 years. CONCLUSIONS ICPM (+) is associated with a survival benefit without an increase in complications in patents aged < 18 years. In patients aged ≥ 18 years, ICPM (+) is associated with more complications and longer LOS without a survival benefit.
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Affiliation(s)
- Ashley Chopko
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Buffalo, NY, 14203, USA
| | - Mingmei Tian
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, 401 Kimball Tower, Buffalo, NY, 14214, USA
| | - Joseph C L'Huillier
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Buffalo, NY, 14203, USA
- Department of Epidemiology and Environmental Health, Division of Health Services Policy and Practice, School of Public Health and Health Professions, University at Buffalo, 270 Farber Hall, Buffalo, NY, 14214, USA
| | - Radu Filipescu
- Department of Pediatric Surgery, John R. Oishei Children's Hospital, 818 Ellicott Street, Buffalo, NY, 14203, USA
| | - Jinhee Yu
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, 401 Kimball Tower, Buffalo, NY, 14214, USA
| | - Weidun A Guo
- Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Buffalo, NY, 14203, USA.
- Erie County Medical Center, 462 Grider Street, Buffalo, NY, 14215, USA.
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Won SY, Herrmann S, Dubinski D, Behmanesh B, Trnovec S, Dinc N, Bernstock JD, Freiman TM, Gessler FA. Blood Clots May Compromise Intracranial Pressure Measurement Using Air-Pouch Intracranial Pressure Probes. J Clin Med 2023; 12:jcm12113661. [PMID: 37297856 DOI: 10.3390/jcm12113661] [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: 04/04/2023] [Revised: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 06/12/2023] Open
Abstract
Background: Air-pouch balloon-assisted probes have proven to be both simple and reliable tools for intracranial pressure (ICP) monitoring. However, we experienced reproducible falsely high ICP measurements when the ICP probe was inserted into the intracerebral hematoma cavity. Thus, the aim of the experimental and translational study was to analyze the influence of ICP probe placement with regard to measured ICP values. Methods: Two Spiegelberg 3PN sensors were simultaneously inserted into a closed drain system and were connected to two separate ICP monitors thereby allowing for simultaneous ICP measurements. This closed system was also engineered to allow for pressure to be gradually increased in a controlled fashion. Once the pressure was verified using two identical ICP probes, one of the probes was coated with blood in an effort to replicate placement within an intraparenchymal hematoma. Pressures recorded using the coated probe and control probe were then recorded and compared across a range of 0-60 mmHg. In an effort to further the translational relevance of our results, two ICP probes were inserted in a patient that presented with a large basal ganglia hemorrhage that met criteria for ICP monitoring. One probe was inserted into the hematoma and the other into brain parenchyma; ICP values were recorded from both probes and the results compared. Results: The experimental set-up demonstrated a reliable correlation between both control ICP probes. Interestingly, the ICP probe covered with clot displayed a significantly higher average ICP value when compared to the control probe between 0 mmHg and 50 mmHg (p < 0.001); at 60 mmHg, there was no significant difference noted. Critically, this trend in discordance was even more pronounced in the clinical setting with the ICP probe placed within the hematoma cavity having reported significantly higher ICP values as compared to the probe within brain parenchyma. Conclusions: Our experimental study and clinical pilot highlight a potential pitfall in ICP measurement that may result secondary to probe placement within hematoma. Such aberrant results may lead to inappropriate interventions in an effort to address falsely elevated ICPs.
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Affiliation(s)
- Sae-Yeon Won
- Department of Neurosurgery, University Rostock, 18057 Rostock, Germany
| | - Sascha Herrmann
- Department of Neurosurgery, University Rostock, 18057 Rostock, Germany
| | - Daniel Dubinski
- Department of Neurosurgery, University Rostock, 18057 Rostock, Germany
| | - Bedjan Behmanesh
- Department of Neurosurgery, University Rostock, 18057 Rostock, Germany
| | - Svorad Trnovec
- Department of Neurosurgery, University Rostock, 18057 Rostock, Germany
| | - Nazife Dinc
- Department of Neurosurgery, University Hospital Jena, 07743 Jena, Germany
| | - Joshua D Bernstock
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Thomas M Freiman
- Department of Neurosurgery, University Rostock, 18057 Rostock, Germany
| | - Florian A Gessler
- Department of Neurosurgery, University Rostock, 18057 Rostock, Germany
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Vitt JR, Loper NE, Mainali S. Multimodal and autoregulation monitoring in the neurointensive care unit. Front Neurol 2023; 14:1155986. [PMID: 37153655 PMCID: PMC10157267 DOI: 10.3389/fneur.2023.1155986] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/04/2023] [Indexed: 05/10/2023] Open
Abstract
Given the complexity of cerebral pathology in patients with acute brain injury, various neuromonitoring strategies have been developed to better appreciate physiologic relationships and potentially harmful derangements. There is ample evidence that bundling several neuromonitoring devices, termed "multimodal monitoring," is more beneficial compared to monitoring individual parameters as each may capture different and complementary aspects of cerebral physiology to provide a comprehensive picture that can help guide management. Furthermore, each modality has specific strengths and limitations that depend largely on spatiotemporal characteristics and complexity of the signal acquired. In this review we focus on the common clinical neuromonitoring techniques including intracranial pressure, brain tissue oxygenation, transcranial doppler and near-infrared spectroscopy with a focus on how each modality can also provide useful information about cerebral autoregulation capacity. Finally, we discuss the current evidence in using these modalities to support clinical decision making as well as potential insights into the future of advanced cerebral homeostatic assessments including neurovascular coupling.
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Affiliation(s)
- Jeffrey R. Vitt
- Department of Neurological Surgery, UC Davis Medical Center, Sacramento, CA, United States
- Department of Neurology, UC Davis Medical Center, Sacramento, CA, United States
| | - Nicholas E. Loper
- Department of Neurological Surgery, UC Davis Medical Center, Sacramento, CA, United States
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States
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Abstract
OBJECTIVES Critically ill patients are at high risk of acute brain injury. Bedside multimodality neuromonitoring techniques can provide a direct assessment of physiologic interactions between systemic derangements and intracranial processes and offer the potential for early detection of neurologic deterioration before clinically manifest signs occur. Neuromonitoring provides measurable parameters of new or evolving brain injury that can be used as a target for investigating various therapeutic interventions, monitoring treatment responses, and testing clinical paradigms that could reduce secondary brain injury and improve clinical outcomes. Further investigations may also reveal neuromonitoring markers that can assist in neuroprognostication. We provide an up-to-date summary of clinical applications, risks, benefits, and challenges of various invasive and noninvasive neuromonitoring modalities. DATA SOURCES English articles were retrieved using pertinent search terms related to invasive and noninvasive neuromonitoring techniques in PubMed and CINAHL. STUDY SELECTION Original research, review articles, commentaries, and guidelines. DATA EXTRACTION Syntheses of data retrieved from relevant publications are summarized into a narrative review. DATA SYNTHESIS A cascade of cerebral and systemic pathophysiological processes can compound neuronal damage in critically ill patients. Numerous neuromonitoring modalities and their clinical applications have been investigated in critically ill patients that monitor a range of neurologic physiologic processes, including clinical neurologic assessments, electrophysiology tests, cerebral blood flow, substrate delivery, substrate utilization, and cellular metabolism. Most studies in neuromonitoring have focused on traumatic brain injury, with a paucity of data on other clinical types of acute brain injury. We provide a concise summary of the most commonly used invasive and noninvasive neuromonitoring techniques, their associated risks, their bedside clinical application, and the implications of common findings to guide evaluation and management of critically ill patients. CONCLUSIONS Neuromonitoring techniques provide an essential tool to facilitate early detection and treatment of acute brain injury in critical care. Awareness of the nuances of their use and clinical applications can empower the intensive care team with tools to potentially reduce the burden of neurologic morbidity in critically ill patients.
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Affiliation(s)
- Swarna Rajagopalan
- Department of Neurology, Cooper Medical School of Rowan University, Camden, NJ
| | - Aarti Sarwal
- Department of Neurology, Atrium Wake Forest School of Medicine, Winston-Salem, NC
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12
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Sharma R, Tsikvadze M, Peel J, Howard L, Kapoor N, Freeman WD. Multimodal monitoring: practical recommendations (dos and don'ts) in challenging situations and uncertainty. Front Neurol 2023; 14:1135406. [PMID: 37206910 PMCID: PMC10188941 DOI: 10.3389/fneur.2023.1135406] [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: 12/31/2022] [Accepted: 04/06/2023] [Indexed: 05/21/2023] Open
Abstract
With the advancements in modern medicine, new methods are being developed to monitor patients in the intensive care unit. Different modalities evaluate different aspects of the patient's physiology and clinical status. The complexity of these modalities often restricts their use to the realm of clinical research, thereby limiting their use in the real world. Understanding their salient features and their limitations can aid physicians in interpreting the concomitant information provided by multiple modalities to make informed decisions that may affect clinical care and outcomes. Here, we present a review of the commonly used methods in the neurological intensive care unit with practical recommendations for their use.
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Affiliation(s)
- Rohan Sharma
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
- *Correspondence: Rohan Sharma
| | - Mariam Tsikvadze
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Jeffrey Peel
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Levi Howard
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Nidhi Kapoor
- Department of Neurology, Baptist Medical Center, Jacksonville, FL, United States
| | - William D. Freeman
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
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13
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Tabassum S, Ruesch A, Acharya D, Yang J, Relander FAJ, Scammon B, Wolf MS, Rakkar J, Clark RSB, McDowell MM, Kainerstorfer JM. Clinical translation of noninvasive intracranial pressure sensing with diffuse correlation spectroscopy. J Neurosurg 2022:1-10. [PMID: 36683191 DOI: 10.3171/2022.9.jns221203] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 09/20/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Intracranial pressure (ICP) is an important therapeutic target in many critical neuropathologies. The current tools for ICP measurements are invasive; hence, these are only selectively applied in critical cases where the benefits surpass the risks. To address the need for low-risk ICP monitoring, the authors developed a noninvasive alternative. METHODS The authors recently demonstrated noninvasive quantification of ICP in an animal model by using morphological analysis of microvascular cerebral blood flow (CBF) measured with diffuse correlation spectroscopy (DCS). The current prospective observational study expanded on this preclinical study by translating the method to pediatric patients. Here, the CBF features, along with mean arterial pressure (MAP) and heart rate (HR) data, were used to build a random decision forest, machine learning model for estimation of ICP; the results of this model were compared with those of invasive monitoring. RESULTS Fifteen patients (mean age ± SD [range] 9.8 ± 5.1 [0.3-17.5] years; median age [interquartile range] 11 [7.4] years; 10 males and 5 females) who underwent invasive neuromonitoring for any purpose were enrolled. Estimated ICP (ICPest) very closely matched invasive ICP (ICPinv), with a root mean square error (RMSE) of 1.01 mm Hg and 95% limit of agreement of ≤ 1.99 mm Hg for ICPinv 0.01-41.25 mm Hg. When the ICP range (ICPinv 0.01-29.05 mm Hg) was narrowed on the basis of the sample population, both RMSE and limit of agreement improved to 0.81 mm Hg and ≤ 1.6 mm Hg, respectively. In addition, 0.3% of the test samples for ICPinv ≤ 20 mm Hg and 5.4% of the test samples for ICPinv > 20 mm Hg had a limit of agreement > 5 mm Hg, which may be considered the acceptable limit of agreement for clinical validity of ICP sensing. For the narrower case, 0.1% of test samples for ICPinv ≤ 20 mm Hg and 1.1% of the test samples for ICPinv > 20 mm Hg had a limit of agreement > 5 mm Hg. Although the CBF features were crucial, the best prediction accuracy was achieved when these features were combined with MAP and HR data. Lastly, preliminary leave-one-out analysis showed model accuracy with an RMSE of 6 mm Hg and limit of agreement of ≤ 7 mm Hg. CONCLUSIONS The authors have shown that DCS may enable ICP monitoring with additional clinical validation. The lower risk of such monitoring would allow ICP to be estimated for a wide spectrum of indications, thereby both reducing the use of invasive monitors and increasing the types of patients who may benefit from ICP-directed therapies.
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Affiliation(s)
- Syeda Tabassum
- 1Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh
| | - Alexander Ruesch
- 1Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh.,4Neuroscience Institute, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Deepshikha Acharya
- 1Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh
| | - Jason Yang
- 1Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh
| | - Filip A J Relander
- 1Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh
| | - Bradley Scammon
- 1Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh
| | - Michael S Wolf
- 2Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh
| | - Jaskaran Rakkar
- 2Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh
| | - Robert S B Clark
- 2Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh
| | - Michael M McDowell
- 3Division of Neurological Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh; and
| | - Jana M Kainerstorfer
- 1Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh.,4Neuroscience Institute, Carnegie Mellon University, Pittsburgh, Pennsylvania
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14
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de Moraes FM, Rocha E, Barros FCD, Freitas FGR, Miranda M, Valiente RA, de Andrade JBC, Neto FEAC, Silva GS. Waveform Morphology as a Surrogate for ICP Monitoring: A Comparison Between an Invasive and a Noninvasive Method. Neurocrit Care 2022; 37:219-227. [PMID: 35332426 PMCID: PMC8947812 DOI: 10.1007/s12028-022-01477-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 02/22/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although the placement of an intraventricular catheter remains the gold standard technique for measuring intracranial pressure (ICP), the method has several limitations. Therefore, noninvasive alternatives to ICP (ICPni) measurement are of great interest. The main objective of this study was to compare the correlation and agreement of wave morphology between ICP (standard intraventricular ICP monitoring) and a new ICPni monitor in patients admitted with stroke. The second objective was to estimate the discrimination of the noninvasive method to detect intracranial hypertension. METHODS We prospectively collected data of adults admitted to an intensive care unit with subarachnoid hemorrhage, intracerebral hemorrhage, or ischemic stroke in whom an invasive ICP monitor was placed. Measurements were simultaneously collected from two parameters [time-to-peak (TTP) and the ratio regarding the second and first peak of the ICP wave (P2/P1 ratio)] of ICP and ICPni wave morphology monitors (Brain4care). Intracranial hypertension was defined as an invasively measured sustained ICP > 20 mm Hg for at least 5 min. RESULTS We studied 18 patients (subarachnoid hemorrhage = 14; intracerebral hemorrhage = 3; ischemic stroke = 1) on 60 occasions with a median age of 52 ± 14.3 years. A total of 197,400 waves (2495 min) from both ICP (standard ICP monitoring) and the ICPni monitor were sliced into 1-min-long segments, and we determined TTP and the P2/P1 ratio from the mean pulse. The median invasively measured ICP was 13 (9.8-16.2) mm Hg, and intracranial hypertension was present on 18 occasions (30%). The correlation and agreement between invasive and noninvasive methods for wave morphology were strong for the P2/P1 ratio and moderate for TTP using categoric (κ agreement 88.1% and 71.3%, respectively) and continuous (intraclass correlation coefficient 0.831 and 0.584, respectively) measures. There was a moderate but significant correlation with the mean ICP value (P2/P1 ratio r = 0.427; TTP r = 0.353; p < 0.001 for all) between noninvasive and invasive techniques. The areas under the curve to estimate intracranial hypertension were 0.786 [95% confidence interval (CI) 0.72-0.93] for the P2/P1 ratio and 0.694 (95% CI 0.60-0.74) for TTP. CONCLUSIONS The new ICPni wave morphology monitor showed a good agreement with the standard invasive method and an acceptable discriminatory power to detect intracranial hypertension. Clinical trial registration Trial registration: NCT05121155.
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Affiliation(s)
| | - Eva Rocha
- Neurology and Neurosurgery Department, Federal University of São Paulo, São Paulo, Brazil
| | | | | | - Maramelia Miranda
- Neurology and Neurosurgery Department, Federal University of São Paulo, São Paulo, Brazil
| | - Raul Alberto Valiente
- Neurology and Neurosurgery Department, Federal University of São Paulo, São Paulo, Brazil
| | | | | | - Gisele Sampaio Silva
- Neurology and Neurosurgery Department, Federal University of São Paulo, São Paulo, Brazil
- Hospital Israelita Albert Einstein, São Paulo, Brazil
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15
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Doron O, Zadka Y, Barnea O, Rosenthal G. Interactions of brain, blood, and CSF: a novel mathematical model of cerebral edema. Fluids Barriers CNS 2021; 18:42. [PMID: 34530863 PMCID: PMC8447530 DOI: 10.1186/s12987-021-00274-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/20/2021] [Indexed: 12/02/2022] Open
Abstract
Background Previous models of intracranial pressure (ICP) dynamics have not included flow of cerebral interstitial fluid (ISF) and changes in resistance to its flow when brain swelling occurs. We sought to develop a mathematical model that incorporates resistance to the bulk flow of cerebral ISF to better simulate the physiological changes that occur in pathologies in which brain swelling predominates and to assess the model’s ability to depict changes in cerebral physiology associated with cerebral edema. Methods We developed a lumped parameter model which includes a representation of cerebral ISF flow within brain tissue and its interactions with CSF flow and cerebral blood flow (CBF). The model is based on an electrical analog circuit with four intracranial compartments: the (1) subarachnoid space, (2) brain, (3) ventricles, (4) cerebral vasculature and the extracranial spinal thecal sac. We determined changes in pressure and volume within cerebral compartments at steady-state and simulated physiological perturbations including rapid injection of fluid into the intracranial space, hyperventilation, and hypoventilation. We simulated changes in resistance to flow or absorption of CSF and cerebral ISF to model hydrocephalus, cerebral edema, and to simulate disruption of the blood–brain barrier (BBB). Results The model accurately replicates well-accepted features of intracranial physiology including the exponential-like pressure–volume curve with rapid fluid injection, increased ICP pulse pressure with rising ICP, hydrocephalus resulting from increased resistance to CSF outflow, and changes associated with hyperventilation and hypoventilation. Importantly, modeling cerebral edema with increased resistance to cerebral ISF flow mimics key features of brain swelling including elevated ICP, increased brain volume, markedly reduced ventricular volume, and a contracted subarachnoid space. Similarly, a decreased resistance to flow of fluid across the BBB leads to an exponential-like rise in ICP and ventricular collapse. Conclusions The model accurately depicts the complex interactions that occur between pressure, volume, and resistances to flow in the different intracranial compartments under specific pathophysiological conditions. In modelling resistance to bulk flow of cerebral ISF, it may serve as a platform for improved modelling of cerebral edema and blood–brain barrier disruption that occur following brain injury.
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Affiliation(s)
- Omer Doron
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Kiryat Hadassah, 91120, Jerusalem, Israel.,Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Yuliya Zadka
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Ofer Barnea
- Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Guy Rosenthal
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Kiryat Hadassah, 91120, Jerusalem, Israel.
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16
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Spectral Cerebral Blood Volume Accounting for Noninvasive Estimation of Changes in Cerebral Perfusion Pressure in Patients with Traumatic Brain Injury. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021. [PMID: 33839844 DOI: 10.1007/978-3-030-59436-7_38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
We present the application of a new method for non-invasive cerebral perfusion pressure estimation (spectral nCPP or nCPPs) accounting for changes in transcranial Doppler-derived pulsatile cerebral blood volume. Primarily, we analysed cases in which CPP was changing (delta [∆],magnitude of changes]): (1) rise during vasopressor-induced augmentation of ABP (N = 16); and (2) spontaneous changes in intracranial pressure (ICP) during plateau waves (N = 14). Secondarily, we assessed nCPPs in a larger cohort in which CPP presented a wider range of values. The average correlation in the time domain between CPP and nCPPs for patients undergoing an induced rise in arterial blood pressure (ABP) was 0.95 ± 0.07. For the greater traumatic brain injury (TBI) cohort, this correlation was 0.63 ± 0.37. ∆ correlations between mean values of CPP and nCPPs were 0.73 (p = 0.002) and 0.78 (p < 0.001) respectively for induced rise in ABP and ICP plateau wave cohorts. The area under the curve (AUC) for ∆CPP was of 0.71 with a 95% confidence interval of 0.54-0.88. To detect low CPP, AUC was 0.817 with a 95% confidence interval of 0.79-0.85. nCPPs can reliably identify changes in direct CPP across time and the magnitude of these changes in absolute values. The ability to detect changes in CPP is reasonable but stronger for detecting low CPP, ≤70 mmHg.
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17
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Beidler PG, Novokhodko A, Prolo LM, Browd S, Lutz BR. Fluidic Considerations of Measuring Intracranial Pressure Using an Open External Ventricular Drain. Cureus 2021; 13:e15324. [PMID: 34221772 PMCID: PMC8239198 DOI: 10.7759/cureus.15324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Measurement of intracranial pressure (ICP) during cerebrospinal fluid (CSF) drainage with an external ventricular drain (EVD) typically requires stopping the flow during measurement. However, there may be benefits to simultaneous ICP measurement and CSF drainage. Several studies have evaluated whether accurate ICP measurements can be obtained while the EVD is open. They report differing outcomes when it comes to error, and hypothesize several sources of error. This study presents an investigation into the fluidic sources of error for ICP measurement with concurrent drainage in an EVD. Our experiments and analytical model both show that the error in pressure measurement increases linearly with flow rate and is not clinically significant, regardless of drip chamber height. At physiologically relevant flow rates (40 mL/hr) and ICP set points (13.6 - 31.3 cmH2O or 10 - 23 mmHg), our model predicts an underestimation of 0.767 cmH2O (0.56 mmHg) with no observed data point showing error greater than 1.09 cmH2O (0.8 mmHg) in our experiment. We extrapolate our model to predict a realistic worst-case clinical scenario where we expect to see a mean maximum error of 1.06 cmH2O (0.78 mmHg) arising from fluidic effects within the drainage system for the most resistive catheter. Compared to other sources of error in current ICP monitoring, error in pressure measurement due to drainage flow is small and does not prohibit clinical use. However, other effects such as ventricular collapse or catheter obstruction could affect ICP measurement under continuous drainage and are not investigated in this study.
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Affiliation(s)
| | - Alexander Novokhodko
- Bioengineering, University of Washington, Seattle, USA.,Mechanical Engineering, University of Washington, Seattle, USA
| | - Laura M Prolo
- Neurosurgery, Stanford University School of Medicine, Stanford, USA.,Surgical Services, VA Palo Alto Health Care System, Palo Alto, USA
| | - Samuel Browd
- Neurosurgery, Seattle Children's Hospital, Seattle, USA.,Bioengineering, University of Washington, Seattle, USA.,Neurological Surgery, University of Washington, Seattle, USA
| | - Barry R Lutz
- Bioengineering, University of Washington, Seattle, USA
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18
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Sallam A, Abdelaal Ahmed Mahmoud M Alkhatip A, Kamel MG, Hamza MK, Yassin HM, Hosny H, Younis MI, Ramadan E, Algameel HZ, Abdelhaq M, Abdelkader M, Mills KE, Mohamed H. The Diagnostic Accuracy of Noninvasive Methods to Measure the Intracranial Pressure: A Systematic Review and Meta-analysis. Anesth Analg 2021; 132:686-695. [PMID: 32991330 DOI: 10.1213/ane.0000000000005189] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Although invasive monitoring is the standard method for intracranial pressure (ICP) measurement, it is not without potential for serious complications. Noninvasive methods have been proposed as alternatives to invasive ICP monitoring. The study aimed to investigate the diagnostic accuracy of the currently available noninvasive methods for intracranial hypertension (ICH) monitoring. METHODS We searched 5 databases for articles evaluating the diagnostic accuracy of noninvasive methods in diagnosing ICH in PubMed, Institute of Science Index, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and Embase. The quantitative analysis was conducted if there were at least 2 studies evaluating a specific method. The accuracy measures included the sensitivity, specificity, likelihood ratios, and diagnostic odds ratio. RESULTS We included 134 articles. Ultrasonographic optic nerve sheath diameter (US ONSD) had high diagnostic accuracy (estimated sensitivity of 90%; 95% confidence interval [CI], 87-92, estimated specificity of 88%; 95% CI, 84-91) while the magnetic resonance imaging (MRI) ONSD had estimated sensitivity of 77%; 95% CI, 64-87 and estimated specificity of 89%; 95% CI, 84-93, and computed tomography (CT) ONSD had estimated sensitivity of 93%; 95% CI, 90-96 and estimated specificity of 79%; 95% CI, 56-92. All MRI signs had a very high estimated specificity ranging from 90% to 99% but a low estimated sensitivity except for sinus stenosis which had high estimated sensitivity as well as specificity (90%; 95% CI, 75-96 and 96%; 95% CI, 91-99, respectively). Among the physical examination signs, pupillary dilation had a high estimated specificity (86%; 95% CI, 76-93). Other diagnostic tests to be considered included pulsatility index, papilledema, transcranial Doppler, compression or absence of basal cisterns, and ≥10 mm midline shift. Setting the cutoff value of ICH to ≥20 mm Hg instead of values <20 mm Hg was associated with higher sensitivity. Moreover, if the delay between invasive and noninvasive methods was within 1 hour, the MRI ONSD and papilledema had a significantly higher diagnostic accuracy compared to the >1 hour subgroup. CONCLUSIONS Our study showed several promising tools for diagnosing ICH. Moreover, we demonstrated that using multiple, readily available, noninvasive methods is better than depending on a single sign such as physical examination or CT alone.
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Affiliation(s)
- Amr Sallam
- From the Department of Anaesthesia, Beaumont Hospital, Dublin, Ireland.,Department of Anaesthesia, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Ahmed Abdelaal Ahmed Mahmoud M Alkhatip
- Department of Anaesthesia, Birmingham Children's Hospital, Birmingham, United Kingdom.,Department of Anaesthesia, Beni-Suef University Hospital and Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | | | | | - Hany Mahmoud Yassin
- Department of Anesthesia, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Hisham Hosny
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt.,Department of Anaesthesia, Essex Cardiothoracic Center, Basildon and Thurrock University Hospital, Basildon, United Kingdom
| | - Mohamed I Younis
- Department of Anaesthesia, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Eslam Ramadan
- From the Department of Anaesthesia, Beaumont Hospital, Dublin, Ireland.,Department of Anaesthesia, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Haytham Zien Algameel
- Department of Anaesthesia, Aberdeen Royal Infirmary Hospital, Aberdeen, United Kingdom
| | - Mohamed Abdelhaq
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Abdelkader
- Department of Anaesthesia, Beni-Suef University Hospital and Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Kerry E Mills
- Department of Science and Technology, University of Canberra, Canberra, ACT, Australia
| | - Hassan Mohamed
- Department of Anaesthesia, Faculty of Medicine, Cairo University, Cairo, Egypt.,Department of Anaesthesia and Intensive Care, Cork University Hospital, Cork, Ireland
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19
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Lucinskas P, Deimantavicius M, Bartusis L, Zakelis R, Misiulis E, Dziugys A, Hamarat Y. Human ophthalmic artery as a sensor for non-invasive intracranial pressure monitoring: numerical modeling and in vivo pilot study. Sci Rep 2021; 11:4736. [PMID: 33637806 PMCID: PMC7910574 DOI: 10.1038/s41598-021-83777-x] [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: 09/15/2020] [Accepted: 02/05/2021] [Indexed: 01/31/2023] Open
Abstract
Intracranial pressure (ICP) monitoring is important in managing neurosurgical, neurological, and ophthalmological patients with open-angle glaucoma. Non-invasive two-depth transcranial Doppler (TCD) technique is used in a novel method for ICP snapshot measurement that has been previously investigated prospectively, and the results showed clinically acceptable accuracy and precision. The aim of this study was to investigate possibility of using the ophthalmic artery (OA) as a pressure sensor for continuous ICP monitoring. First, numerical modeling was done to investigate the possibility, and then a pilot clinical study was conducted to compare two-depth TCD-based non-invasive ICP monitoring data with readings from an invasive Codman ICP microsensor from patients with severe traumatic brain injury. The numerical modeling showed that the systematic error of non-invasive ICP monitoring was < 1.0 mmHg after eliminating the intraorbital and blood pressure gradient. In a clinical study, a total of 1928 paired data points were collected, and the extreme data points of measured differences between invasive and non-invasive ICP were - 3.94 and 4.68 mmHg (95% CI - 2.55 to 2.72). The total mean and SD were 0.086 ± 1.34 mmHg, and the correlation coefficient was 0.94. The results show that the OA can be used as a linear natural pressure sensor and that it could potentially be possible to monitor the ICP for up to 1 h without recalibration.
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Affiliation(s)
- Paulius Lucinskas
- grid.6901.e0000 0001 1091 4533Health Telematics Science Institute, Kaunas University of Technology, K. Barsausko Str. 59-A556, 51423 Kaunas, Lithuania
| | - Mantas Deimantavicius
- grid.6901.e0000 0001 1091 4533Health Telematics Science Institute, Kaunas University of Technology, K. Barsausko Str. 59-A556, 51423 Kaunas, Lithuania
| | - Laimonas Bartusis
- grid.6901.e0000 0001 1091 4533Health Telematics Science Institute, Kaunas University of Technology, K. Barsausko Str. 59-A556, 51423 Kaunas, Lithuania
| | - Rolandas Zakelis
- grid.6901.e0000 0001 1091 4533Health Telematics Science Institute, Kaunas University of Technology, K. Barsausko Str. 59-A556, 51423 Kaunas, Lithuania
| | - Edgaras Misiulis
- grid.20653.320000 0001 2228 249XLaboratory of Combustion Processes, Lithuanian Energy Institute, Breslaujos Str. 3, 44403 Kaunas, Lithuania
| | - Algis Dziugys
- grid.20653.320000 0001 2228 249XLaboratory of Combustion Processes, Lithuanian Energy Institute, Breslaujos Str. 3, 44403 Kaunas, Lithuania
| | - Yasin Hamarat
- grid.6901.e0000 0001 1091 4533Health Telematics Science Institute, Kaunas University of Technology, K. Barsausko Str. 59-A556, 51423 Kaunas, Lithuania
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20
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Åkerlund CAI, Donnelly J, Zeiler FA, Helbok R, Holst A, Cabeleira M, Güiza F, Meyfroidt G, Czosnyka M, Smielewski P, Stocchetti N, Ercole A, Nelson DW. Impact of duration and magnitude of raised intracranial pressure on outcome after severe traumatic brain injury: A CENTER-TBI high-resolution group study. PLoS One 2020; 15:e0243427. [PMID: 33315872 PMCID: PMC7735618 DOI: 10.1371/journal.pone.0243427] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 11/21/2020] [Indexed: 12/19/2022] Open
Abstract
Magnitude of intracranial pressure (ICP) elevations and their duration have been associated with worse outcomes in patients with traumatic brain injuries (TBI), however published thresholds for injury vary and uncertainty about these levels has received relatively little attention. In this study, we have analyzed high-resolution ICP monitoring data in 227 adult patients in the CENTER-TBI dataset. Our aim was to identify thresholds of ICP intensity and duration associated with worse outcome, and to evaluate the uncertainty in any such thresholds. We present ICP intensity and duration plots to visualize the relationship between ICP events and outcome. We also introduced a novel bootstrap technique to evaluate uncertainty of the equipoise line. We found that an intensity threshold of 18 ± 4 mmHg (2 standard deviations) was associated with worse outcomes in this cohort. In contrast, the uncertainty in what duration is associated with harm was larger, and safe durations were found to be population dependent. The pressure and time dose (PTD) was also calculated as area under the curve above thresholds of ICP. A relationship between PTD and mortality could be established, as well as for unfavourable outcome. This relationship remained valid for mortality but not unfavourable outcome after adjusting for IMPACT core variables and maximum therapy intensity level. Importantly, during periods of impaired autoregulation (defined as pressure reactivity index (PRx)>0.3) ICP events were associated with worse outcomes for nearly all durations and ICP levels in this cohort and there was a stronger relationship between outcome and PTD. Whilst caution should be exercised in ascribing causation in observational analyses, these results suggest intracranial hypertension is poorly tolerated in the presence of impaired autoregulation. ICP level guidelines may need to be revised in the future taking into account cerebrovascular autoregulation status considered jointly with ICP levels.
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Affiliation(s)
- Cecilia AI Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
- School of Computer Science and Communication, KTH Royal Institute of Technology, Stockholm, Sweden
- * E-mail:
| | - Joseph Donnelly
- Clinical Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Frederick A. Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Raimund Helbok
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Innsbruck, Austria
| | - Anders Holst
- School of Computer Science and Communication, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Manuel Cabeleira
- Clinical Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Fabian Güiza
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Marek Czosnyka
- Clinical Neuroscience, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technolology, Warszawa, Poland
| | - Peter Smielewski
- Clinical Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Nino Stocchetti
- Department of Pathophysiology and Transplants, University of Milan, and Neuroscience Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - David W. Nelson
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
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21
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Picard NA, Zanardi CA. Letter to the Editor. The skull as a brain shape-keeper: viscoelasticity and orthostatic intracranial pressure. J Neurosurg 2020; 133:1620-1622. [PMID: 32197245 DOI: 10.3171/2019.12.jns193367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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22
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Iwasaki KI, Ogawa Y, Kurazumi T, Imaduddin SM, Mukai C, Furukawa S, Yanagida R, Kato T, Konishi T, Shinojima A, Levine BD, Heldt T. Long-duration spaceflight alters estimated intracranial pressure and cerebral blood velocity. J Physiol 2020; 599:1067-1081. [PMID: 33103234 PMCID: PMC7894300 DOI: 10.1113/jp280318] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 10/19/2020] [Indexed: 12/20/2022] Open
Abstract
Key points During long‐duration spaceflights, some astronauts develop structural ocular changes including optic disc oedema that resemble signs of intracranial hypertension. In the present study, intracranial pressure was estimated non‐invasively (nICP) using a model‐based analysis of cerebral blood velocity and arterial blood pressure waveforms in 11 astronauts before and after long‐duration spaceflights. Our results show that group‐averaged estimates of nICP decreased significantly in nine astronauts without optic disc oedema, suggesting that the cephalad fluid shift during long‐duration spaceflight rarely increased postflight intracranial pressure. The results of the two astronauts with optic disc oedema suggest that both increases and decreases in nICP are observed post‐flight in astronauts with ocular alterations, arguing against a primary causal relationship between elevated ICP and spaceflight associated optical changes. Cerebral blood velocity increased independently of nICP and spaceflight‐associated ocular alterations. This increase may be caused by the reduced haemoglobin concentration after long‐duration spaceflight.
Abstract Persistently elevated intracranial pressure (ICP) above upright values is a suspected cause of optic disc oedema in astronauts. However, no systematic studies have evaluated changes in ICP from preflight. Therefore, ICP was estimated non‐invasively before and after spaceflight to test whether ICP would increase after long‐duration spaceflight. Cerebral blood velocity in the middle cerebral artery (MCAv) was obtained by transcranial Doppler sonography and arterial pressure in the radial artery was obtained by tonometry, in the supine and sitting positions before and after 4−12 months of spaceflight in 11 astronauts (10 males and 1 female, 46 ± 7 years old at launch). Non‐invasive ICP (nICP) was computed using a validated model‐based estimation method. Mean MCAv increased significantly after spaceflight (ANOVA, P = 0.007). Haemoglobin decreased significantly after spaceflight (14.6 ± 0.8 to 13.3 ± 0.7 g/dL, P < 0.001). A repeated measures correlation analysis indicated a negative correlation between haemoglobin and mean MCAv (r = −0.589, regression coefficient = −4.68). The nICP did not change significantly after spaceflight in the 11 astronauts. However, nICP decreased significantly by 15% in nine astronauts without optic disc oedema (P < 0.005). Only one astronaut increased nICP to relatively high levels after spaceflight. Contrary to our hypothesis, nICP did not increase after long‐duration spaceflight in the vast majority (>90%) of astronauts, suggesting that the cephalad fluid shift during spaceflight does not systematically or consistently elevate postflight ICP in astronauts. Independently of nICP and ocular alterations, the present results of mean MCAv suggest that long‐duration spaceflight may increase cerebral blood flow, possibly due to reduced haemoglobin concentration. During long‐duration spaceflights, some astronauts develop structural ocular changes including optic disc oedema that resemble signs of intracranial hypertension. In the present study, intracranial pressure was estimated non‐invasively (nICP) using a model‐based analysis of cerebral blood velocity and arterial blood pressure waveforms in 11 astronauts before and after long‐duration spaceflights. Our results show that group‐averaged estimates of nICP decreased significantly in nine astronauts without optic disc oedema, suggesting that the cephalad fluid shift during long‐duration spaceflight rarely increased postflight intracranial pressure. The results of the two astronauts with optic disc oedema suggest that both increases and decreases in nICP are observed post‐flight in astronauts with ocular alterations, arguing against a primary causal relationship between elevated ICP and spaceflight associated optical changes. Cerebral blood velocity increased independently of nICP and spaceflight‐associated ocular alterations. This increase may be caused by the reduced haemoglobin concentration after long‐duration spaceflight.
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Affiliation(s)
- Ken-Ichi Iwasaki
- Department of Social Medicine, Division of Hygiene, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Yojiro Ogawa
- Department of Social Medicine, Division of Hygiene, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Takuya Kurazumi
- Department of Social Medicine, Division of Hygiene, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Syed M Imaduddin
- Department of Electrical Engineering and Computer Science, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Chiaki Mukai
- Space Biomedical Research Group, Japan Aerospace Exploration Agency, Tsukuba-shi, Ibaraki, Japan.,Tokyo University of Science, Shinjuku-ku, Tokyo, Japan
| | - Satoshi Furukawa
- Space Biomedical Research Group, Japan Aerospace Exploration Agency, Tsukuba-shi, Ibaraki, Japan
| | - Ryo Yanagida
- Department of Social Medicine, Division of Hygiene, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Tomokazu Kato
- Department of Social Medicine, Division of Hygiene, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan
| | - Toru Konishi
- Department of Social Medicine, Division of Hygiene, Nihon University School of Medicine, Itabashi-ku, Tokyo, Japan.,Aeromedical Laboratory, Japan Air Self-Defense Force, Ministry of Defense, Sayama-shi, Saitama, Japan
| | - Ari Shinojima
- Department of Ophthalmology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Benjamin D Levine
- The Institute for Exercise and Environmental Medicine (IEEM) at Texas Health Presbyterian Hospital Dallas, Dallas, TX, USA.,Department of Medicine and Cardiology, the University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Thomas Heldt
- Department of Electrical Engineering and Computer Science, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
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23
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Svedung Wettervik T, Engquist H, Howells T, Rostami E, Hillered L, Enblad P, Lewén A. Arterial lactate in traumatic brain injury - Relation to intracranial pressure dynamics, cerebral energy metabolism and clinical outcome. J Crit Care 2020; 60:218-225. [PMID: 32882604 DOI: 10.1016/j.jcrc.2020.08.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/21/2020] [Accepted: 08/13/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE High arterial lactate is associated with disturbed systemic physiology. Lactate can also be used as alternative cerebral fuel and it is involved in regulating cerebral blood flow. This study explored the relation of endogenous arterial lactate to systemic physiology, pressure autoregulation, cerebral energy metabolism, and clinical outcome in traumatic brain injury (TBI). METHOD A retrospective study including 115 patients (consent given) with severe TBI treated in the neurointensive care unit, Uppsala university hospital, Sweden, 2008-2018. Data from cerebral microdialysis, arterial blood gases, hemodynamics and intracranial pressure were analyzed the first ten days post-injury. RESULTS Arterial lactate peaked on day 1 post-injury (mean 1.7 ± 0.7 mM) and gradually decreased. Higher arterial lactate correlated with lower age (p-value < 0.05), higher Marshall score (p-value < 0.05) and higher arterial glucose (p-value < 0.001) in a multiple regression analysis. Higher arterial lactate was associated with poor pressure autoregulation (p-value < 0.01), but not to worse cerebral energy metabolism. Higher arterial lactate was also associated with unfavorable clinical outcome (p-value < 0.05). CONCLUSIONS High endogenous arterial lactate is a biomarker of poor systemic physiology and may disturb cerebral blood flow autoregulation.
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Affiliation(s)
- Teodor Svedung Wettervik
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala SE-751 85, Sweden.
| | - Henrik Engquist
- Department of Surgical Sciences/Anesthesia and Intensive Care, Uppsala University, Uppsala SE-751 85, Sweden
| | - Timothy Howells
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala SE-751 85, Sweden
| | - Elham Rostami
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala SE-751 85, Sweden
| | - Lars Hillered
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala SE-751 85, Sweden
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala SE-751 85, Sweden
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala SE-751 85, Sweden
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24
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Jaishankar R, Fanelli A, Filippidis A, Vu T, Holsapple J, Heldt T. A Spectral Approach to Model-Based Noninvasive Intracranial Pressure Estimation. IEEE J Biomed Health Inform 2020; 24:2398-2406. [PMID: 31880569 PMCID: PMC10615348 DOI: 10.1109/jbhi.2019.2961403] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Intracranial pressure (ICP) normally ranges from 5 to 15 mmHg. Elevation in ICP is an important clinical indicator of neurological injury, and ICP is therefore monitored routinely in several neurological conditions to guide diagnosis and treatment decisions. Current measurement modalities for ICP monitoring are highly invasive, largely limiting the measurement to critically ill patients. An accurate noninvasive method to estimate ICP would dramatically expand the pool of patients that could benefit from this cranial vital sign. METHODS This article presents a spectral approach to model-based ICP estimation from arterial blood pressure (ABP) and cerebral blood flow velocity (CBFV) measurements. The model captures the relationship between the ABP, CBFV, and ICP waveforms and utilizes a second-order model of the cerebral vasculature to estimate ICP. RESULTS The estimation approach was validated on two separate clinical datasets, one recorded from thirteen pediatric patients with a total duration of around seven hours, and the other recorded from five adult patients, one hour and 48 minutes in total duration. The algorithm was shown to have an accuracy (mean error) of 0.4 mmHg and -1.5 mmHg, and a precision (standard deviation of the error) of 5.1 mmHg and 4.3 mmHg, in estimating mean ICP (range of 1.3 mmHg to 24.8 mmHg) on the pediatric and adult data, respectively. These results are comparable to previous results and within the clinically relevant range. Additionally, the accuracy and precision in estimating the pulse pressure of ICP on a beat-by-beat basis were found to be 1.3 mmHg and 2.9 mmHg respectively. CONCLUSION These contributions take a step towards realizing the goal of implementing a real-time noninvasive ICP estimation modality in a clinical setting, to enable accurate clinical-decision making while overcoming the drawbacks of the invasive ICP modalities.
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25
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Heldt T, Zoerle T, Teichmann D, Stocchetti N. Intracranial Pressure and Intracranial Elastance Monitoring in Neurocritical Care. Annu Rev Biomed Eng 2020; 21:523-549. [PMID: 31167100 DOI: 10.1146/annurev-bioeng-060418-052257] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patients with acute brain injuries tend to be physiologically unstable and at risk of rapid and potentially life-threatening decompensation due to shifts in intracranial compartment volumes and consequent intracranial hypertension. Invasive intracranial pressure (ICP) monitoring therefore remains a cornerstone of modern neurocritical care, despite the attendant risks of infection and damage to brain tissue arising from the surgical placement of a catheter or pressure transducer into the cerebrospinal fluid or brain tissue compartments. In addition to ICP monitoring, tracking of the intracranial capacity to buffer shifts in compartment volumes would help in the assessment of patient state, inform clinical decision making, and guide therapeutic interventions. We review the anatomy, physiology, and current technology relevant to clinical management of patients with acute brain injury and outline unmet clinical needs to advance patient monitoring in neurocritical care.
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Affiliation(s)
- Thomas Heldt
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA; .,Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA;
| | - Tommaso Zoerle
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; ,
| | - Daniel Teichmann
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA;
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; , .,Department of Physiopathology and Transplant Medicine, University of Milan, 20122 Milan, Italy
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26
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Fischer JB, Ghouse A, Tagliabue S, Maruccia F, Rey-Perez A, Báguena M, Cano P, Zucca R, Weigel UM, Sahuquillo J, Poca MA, Durduran T. Non-Invasive Estimation of Intracranial Pressure by Diffuse Optics: A Proof-of-Concept Study. J Neurotrauma 2020; 37:2569-2579. [PMID: 32460617 DOI: 10.1089/neu.2019.6965] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Intracranial pressure (ICP) is an important parameter to monitor in several neuropathologies. However, because current clinically accepted methods are invasive, its monitoring is limited to patients in critical conditions. On the other hand, there are other less critical conditions for which ICP monitoring could still be useful; therefore, there is a need to develop non-invasive methods. We propose a new method to estimate ICP based on the analysis of the non-invasive measurement of pulsatile, microvascular cerebral blood flow with diffuse correlation spectroscopy. This is achieved by training a recurrent neural network using only the cerebral blood flow as the input. The method is validated using a 50% split sample method using the data from a proof-of-concept study. The study involved a population of infants (n = 6) with external hydrocephalus (initially diagnosed as benign enlargement of subarachnoid spaces) as well as a population of adults (n = 6) with traumatic brain injury. The algorithm was applied to each cohort individually to obtain a model and an ICP estimate. In both diverse cohorts, the non-invasive estimation of ICP was achieved with an accuracy of <4 mm Hg and a negligible small bias. Further, we have achieved a good correlation (Pearson's correlation coefficient >0.9) and good concordance (Lin's concordance correlation coefficient >0.9) in comparison with standard clinical, invasive ICP monitoring. This preliminary work paves the way for further investigations of this tool for the non-invasive, bedside assessment of ICP.
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Affiliation(s)
- Jonas B Fischer
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels, Barcelona, Spain.,HemoPhotonics S.L., Castelldefels, Barcelona, Spain
| | - Ameer Ghouse
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels, Barcelona, Spain
| | - Susanna Tagliabue
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels, Barcelona, Spain
| | - Federica Maruccia
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels, Barcelona, Spain.,Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Anna Rey-Perez
- Neurotrauma Intensive Care Unit, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marcelino Báguena
- Neurotrauma Intensive Care Unit, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Paola Cano
- Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Riccardo Zucca
- Synthetic Perceptive, Emotive and Cognitive Systems (SPECS), Institute for Bioengineering of Catalonia (IBEC), Barcelona Institute of Science and Technology, Barcelona, Spain
| | - Udo M Weigel
- HemoPhotonics S.L., Castelldefels, Barcelona, Spain
| | - Juan Sahuquillo
- Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain.,Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria A Poca
- Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain.,Department of Neurosurgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Turgut Durduran
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels, Barcelona, Spain.,Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
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27
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Canac N, Jalaleddini K, Thorpe SG, Thibeault CM, Hamilton RB. Review: pathophysiology of intracranial hypertension and noninvasive intracranial pressure monitoring. Fluids Barriers CNS 2020; 17:40. [PMID: 32576216 PMCID: PMC7310456 DOI: 10.1186/s12987-020-00201-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 06/11/2020] [Indexed: 12/30/2022] Open
Abstract
Measurement of intracranial pressure (ICP) is crucial in the management of many neurological conditions. However, due to the invasiveness, high cost, and required expertise of available ICP monitoring techniques, many patients who could benefit from ICP monitoring do not receive it. As a result, there has been a substantial effort to explore and develop novel noninvasive ICP monitoring techniques to improve the overall clinical care of patients who may be suffering from ICP disorders. This review attempts to summarize the general pathophysiology of ICP, discuss the importance and current state of ICP monitoring, and describe the many methods that have been proposed for noninvasive ICP monitoring. These noninvasive methods can be broken down into four major categories: fluid dynamic, otic, ophthalmic, and electrophysiologic. Each category is discussed in detail along with its associated techniques and their advantages, disadvantages, and reported accuracy. A particular emphasis in this review will be dedicated to methods based on the use of transcranial Doppler ultrasound. At present, it appears that the available noninvasive methods are either not sufficiently accurate, reliable, or robust enough for widespread clinical adoption or require additional independent validation. However, several methods appear promising and through additional study and clinical validation, could eventually make their way into clinical practice.
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28
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Evensen KB, Eide PK. Measuring intracranial pressure by invasive, less invasive or non-invasive means: limitations and avenues for improvement. Fluids Barriers CNS 2020; 17:34. [PMID: 32375853 PMCID: PMC7201553 DOI: 10.1186/s12987-020-00195-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/19/2020] [Indexed: 12/20/2022] Open
Abstract
Sixty years have passed since neurosurgeon Nils Lundberg presented his thesis about intracranial pressure (ICP) monitoring, which represents a milestone for its clinical introduction. Monitoring of ICP has since become a clinical routine worldwide, and today represents a cornerstone in surveillance of patients with acute brain injury or disease, and a diagnostic of individuals with chronic neurological disease. There is, however, controversy regarding indications, clinical usefulness and the clinical role of the various ICP scores. In this paper, we critically review limitations and weaknesses with the current ICP measurement approaches for invasive, less invasive and non-invasive ICP monitoring. While risk related to the invasiveness of ICP monitoring is extensively covered in the literature, we highlight other limitations in current ICP measurement technologies, including limited ICP source signal quality control, shifts and drifts in zero pressure reference level, affecting mean ICP scores and mean ICP-derived indices. Control of the quality of the ICP source signal is particularly important for non-invasive and less invasive ICP measurements. We conclude that we need more focus on mitigation of the current limitations of today's ICP modalities if we are to improve the clinical utility of ICP monitoring.
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Affiliation(s)
- Karen Brastad Evensen
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, P.O. Box 4950, Nydalen, 0424, Oslo, Norway
- Department of Informatics, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, P.O. Box 4950, Nydalen, 0424, Oslo, Norway.
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
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29
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Alambyan V, Pace J, Sukpornchairak P, Yu X, Alnimir H, Tatton R, Chitturu G, Yarlagadda A, Ramos-Estebanez C. Imaging Guidance for Therapeutic Delivery: The Dawn of Neuroenergetics. Neurotherapeutics 2020; 17:522-538. [PMID: 32240530 PMCID: PMC7283376 DOI: 10.1007/s13311-020-00843-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Modern neurocritical care relies on ancillary diagnostic testing in the form of multimodal monitoring to address acute changes in the neurological homeostasis. Much of our armamentarium rests upon physiological and biochemical surrogates of organ or regional level metabolic activity, of which a great deal is invested at the metabolic-hemodynamic-hydrodynamic interface to rectify the traditional intermediaries of glucose consumption. Despite best efforts to detect cellular neuroenergetics, current modalities cannot appreciate the intricate coupling between astrocytes and neurons. Invasive monitoring is not without surgical complication, and noninvasive strategies do not provide an adequate spatial or temporal resolution. Without knowledge of the brain's versatile behavior in specific metabolic states (glycolytic vs oxidative), clinical practice would lag behind laboratory empiricism. Noninvasive metabolic imaging represents a new hope in delineating cellular, nigh molecular level energy exchange to guide targeted management in a diverse array of neuropathology.
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Affiliation(s)
- Vilakshan Alambyan
- Department of Neurology, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA
| | - Jonathan Pace
- Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Persen Sukpornchairak
- Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Xin Yu
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Radiology, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, Ohio, USA
| | - Hamza Alnimir
- Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ryan Tatton
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
| | - Gautham Chitturu
- Department of Arts and Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Anisha Yarlagadda
- Department of Arts and Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ciro Ramos-Estebanez
- Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA.
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30
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Jaishankar R, Fanelli A, Filippidis A, Vu T, Holsapple J, Heldt T. A Frequency-domain Approach to Noninvasive Intracranial Pressure Estimation. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2019:5055-5058. [PMID: 31946995 DOI: 10.1109/embc.2019.8857042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Intracranial pressure (ICP) is a cranial vital sign, crucial in the monitoring and treatment of several neurological injuries. The clinically accepted measurement modalities of ICP are highly invasive, carrying risks of infection and limiting the benefits of ICP measurement to a small subset of critically ill patients. This work aims to take a step towards developing an accurate noninvasive means of estimating ICP, by utilizing a model-based frequency-domain approach. The mean ICP and pulse pressures of ICP are estimated from arterial blood pressure (ABP) and cerebral blood flow velocity (CBFV) waveforms, and the estimates are validated on an adult population, comprising of around two hours of data from five patients. The algorithm was shown to have an accuracy (mean error) of -1.5 mmHg and a precision (standard deviation of the error) of 4.3 mmHg in estimating the mean ICP. These results are comparable to the previously reported errors among the currently accepted invasive measurement methods, and well within the clinically relevant range.
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31
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Pedersen SH, Lilja-Cyron A, Astrand R, Juhler M. Monitoring and Measurement of Intracranial Pressure in Pediatric Head Trauma. Front Neurol 2020; 10:1376. [PMID: 32010042 PMCID: PMC6973131 DOI: 10.3389/fneur.2019.01376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/12/2019] [Indexed: 01/09/2023] Open
Abstract
Purpose of Review: Monitoring of intracranial pressure (ICP) is an important and integrated part of the treatment algorithm for children with severe traumatic brain injury (TBI). Guidelines often recommend ICP monitoring with a treatment threshold of 20 mmHg. This focused review discusses; (1) different ICP technologies and how ICP should be monitored in pediatric patients with severe TBI, (2) existing evidence behind guideline recommendations, and (3) how we could move forward to increase knowledge about normal ICP in children to support treatment decisions. Summary: Current reference values for normal ICP in adults lie between 7 and 15 mmHg. Recent studies conducted in “pseudonormal” adults, however, suggest a normal range below this level where ICP is highly dependent on body posture and decreases to negative values in sitting and standing position. Despite obvious physiological differences between children and adults, no age or body size related reference values exist for normal ICP in children. Recent guidelines for treatment of severe TBI in pediatric patients recommend ICP monitoring to guide treatment of intracranial hypertension. Decision on ICP monitoring modalities are based on local standards, the individual case, and the clinician's choice. The recommended treatment threshold is 20 mmHg for a duration of 5 min. Both prospective and retrospective observational studies applying different thresholds and treatment strategies for intracranial hypertension were included to support this recommendation. While some studies suggest improved outcome related to ICP monitoring (lower rate of mortality and severe disability), most studies identify high ICP as a marker of worse outcome. Only one study applied age-differentiated thresholds, but this study did not evaluate the effect of these different thresholds on outcome. The quality of evidence behind ICP monitoring and treatment thresholds in severe pediatric TBI is low and treatment can potentially be improved by knowledge about normal ICP from observational studies in healthy children and cohorts of pediatric “pseudonormal” patients expected to have normal ICP. Acceptable levels of ICP − and thus also treatment thresholds—probably vary with age, disease and whether the patient has intact cerebral autoregulation. Future treatment algorithms should reflect these differences and be more personalized and dynamic.
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Affiliation(s)
| | | | - Ramona Astrand
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
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32
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Differentiate the Source and Site of Intracranial Pressure Measurements Using More Precise Nomenclature. Neurocrit Care 2020; 30:239-243. [PMID: 30251073 DOI: 10.1007/s12028-018-0613-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Intracranial pressure (ICP) monitoring is fundamental for neurocritical care patient management. For many years, ventricular and parenchymal devices have been available for this aim. The purpose of this paper is to review the published literature comparing ICP recordings via an intraventricular catheter or an intraparenchymal (brain tissue) catheter. METHODS Literature search of Medline, CINAHL, Embase, and Scopus was performed in which manuscripts discussed both ICP monitoring via an intraventricular catheter and ICP monitoring through intraparenchymal (brain tissue) catheter. Keywords and MeSH terms used include critical care, intracranial pressure, ICP, monitoring, epidural catheter, intracranial hypertension, ventriculostomy, ventricular drain, external ventricular drain, and physiologic monitoring. RESULTS Eleven articles met inclusion criteria. The published literature shows differences in simultaneously recorded ICP between the intraventricular and intraparenchymal sites. CONCLUSIONS We propose two new terms that more accurately identify the anatomical site of recording for the referenced ICP: intracranial pressure ventricular (ICP-v) and intracranial pressure brain tissue (ICP-bt). Further delineation of the conventional term "ICP" into these two new terms will clarify the difference between ICP-v and ICP-bt and their respective measurement locations.
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Abstract
PURPOSE OF REVIEW The optimal management of external ventricular drains (EVD) in the setting of acute brain injury remains controversial. Therefore, we sought to determine whether there are optimal management approaches based on the current evidence. RECENT FINDINGS We identified 2 recent retrospective studies on the management of EVDs after subarachnoid hemorrhage (SAH) which showed conflicting results. A multicenter survey revealed discordance between existing evidence from randomized trials and actual practice. A prospective study in a post-traumatic brain injury (TBI) population demonstrated the benefit of EVDs but did not determine the optimal management of the EVD itself. The recent CLEAR trials have suggested that specific positioning of the EVD in the setting of intracerebral hemorrhage with intraventricular hemorrhage may be a promising approach to improve blood clearance. Evidence on the optimal management of EVDs remains limited. Additional multicenter prospective studies are critically needed to guide approaches to the management of the EVD.
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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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Fanelli A, Vonberg FW, LaRovere KL, Walsh BK, Smith ER, Robinson S, Tasker RC, Heldt T. Fully automated, real-time, calibration-free, continuous noninvasive estimation of intracranial pressure in children. J Neurosurg Pediatr 2019; 24:509-519. [PMID: 31443086 DOI: 10.3171/2019.5.peds19178] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 05/28/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In the search for a reliable, cooperation-independent, noninvasive alternative to invasive intracranial pressure (ICP) monitoring in children, various approaches have been proposed, but at the present time none are capable of providing fully automated, real-time, calibration-free, continuous and accurate ICP estimates. The authors investigated the feasibility and validity of simultaneously monitored arterial blood pressure (ABP) and middle cerebral artery (MCA) cerebral blood flow velocity (CBFV) waveforms to derive noninvasive ICP (nICP) estimates. METHODS Invasive ICP and ABP recordings were collected from 12 pediatric and young adult patients (aged 2-25 years) undergoing such monitoring as part of routine clinical care. Additionally, simultaneous transcranial Doppler (TCD) ultrasonography-based MCA CBFV waveform measurements were performed at the bedside in dedicated data collection sessions. The ABP and MCA CBFV waveforms were analyzed in the context of a mathematical model, linking them to the cerebral vasculature's biophysical properties and ICP. The authors developed and automated a waveform preprocessing, signal-quality evaluation, and waveform-synchronization "pipeline" in order to test and objectively validate the algorithm's performance. To generate one nICP estimate, 60 beats of ABP and MCA CBFV waveform data were analyzed. Moving the 60-beat data window forward by one beat at a time (overlapping data windows) resulted in 39,480 ICP-to-nICP comparisons across a total of 44 data-collection sessions (studies). Moving the 60-beat data window forward by 60 beats at a time (nonoverlapping data windows) resulted in 722 paired ICP-to-nICP comparisons. RESULTS Greater than 80% of all nICP estimates fell within ± 7 mm Hg of the reference measurement. Overall performance in the nonoverlapping data window approach gave a mean error (bias) of 1.0 mm Hg, standard deviation of the error (precision) of 5.1 mm Hg, and root-mean-square error of 5.2 mm Hg. The associated mean and median absolute errors were 4.2 mm Hg and 3.3 mm Hg, respectively. These results were contingent on ensuring adequate ABP and CBFV signal quality and required accurate hydrostatic pressure correction of the measured ABP waveform in relation to the elevation of the external auditory meatus. Notably, the procedure had no failed attempts at data collection, and all patients had adequate TCD data from at least one hemisphere. Last, an analysis of using study-by-study averaged nICP estimates to detect a measured ICP > 15 mm Hg resulted in an area under the receiver operating characteristic curve of 0.83, with a sensitivity of 71% and specificity of 86% for a detection threshold of nICP = 15 mm Hg. CONCLUSIONS This nICP estimation algorithm, based on ABP and bedside TCD CBFV waveform measurements, performs in a manner comparable to invasive ICP monitoring. These findings open the possibility for rational, point-of-care treatment decisions in pediatric patients with suspected raised ICP undergoing intensive care.
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Affiliation(s)
- Andrea Fanelli
- 1Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge
| | - Frederick W Vonberg
- 1Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge
- 2Department of Anesthesiology, Critical Care and Pain Medicine, and
| | | | - Brian K Walsh
- 2Department of Anesthesiology, Critical Care and Pain Medicine, and
| | - Edward R Smith
- 4Neurosurgery, Boston Children's Hospital, Boston, Massachusetts; and
| | - Shenandoah Robinson
- 4Neurosurgery, Boston Children's Hospital, Boston, Massachusetts; and
- 5Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland
| | - Robert C Tasker
- 2Department of Anesthesiology, Critical Care and Pain Medicine, and
- Departments of3Neurology and
| | - Thomas Heldt
- 1Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge
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M Imaduddin S, Fanelli A, Vonberg FW, Tasker RC, Heldt T. Pseudo-Bayesian Model-Based Noninvasive Intracranial Pressure Estimation and Tracking. IEEE Trans Biomed Eng 2019; 67:1604-1615. [PMID: 31535978 DOI: 10.1109/tbme.2019.2940929] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE A noninvasive intracranial pressure (ICP) estimation method is proposed that incorporates a model-based approach within a probabilistic framework to mitigate the effects of data and modeling uncertainties. METHODS A first-order model of the cerebral vasculature relates measured arterial blood pressure (ABP) and cerebral blood flow velocity (CBFV) to ICP. The model is driven by the ABP waveform and is solved for a range of mean ICP values to predict the CBFV waveform. The resulting errors between measured and predicted CBFV are transformed into likelihoods for each candidate ICP in two steps. First, a baseline ICP estimate is established over five data windows of 20 beats by combining the likelihoods with a prior distribution of the ICP to yield an a posteriori distribution whose median is taken as the baseline ICP estimate. A single-state model of cerebral autoregulatory dynamics is then employed in subsequent data windows to track changes in the baseline by combining ICP estimates obtained with a uniform prior belief and model-predicted ICP. For each data window, the estimated model parameters are also used to determine the ICP pulse pressure. RESULTS On a dataset of thirteen pediatric patients with a variety of pathological conditions requiring invasive ICP monitoring, the method yielded for mean ICP estimation a bias (mean error) of 0.6 mmHg and a root-mean-squared error of 3.7 mmHg. CONCLUSION These performance characteristics are well within the acceptable range for clinical decision making. SIGNIFICANCE The method proposed here constitutes a significant step towards robust, continuous, patient-specific noninvasive ICP determination.
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Chau CYC, Craven CL, Rubiano AM, Adams H, Tülü S, Czosnyka M, Servadei F, Ercole A, Hutchinson PJ, Kolias AG. The Evolution of the Role of External Ventricular Drainage in Traumatic Brain Injury. J Clin Med 2019; 8:E1422. [PMID: 31509945 PMCID: PMC6780113 DOI: 10.3390/jcm8091422] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 09/05/2019] [Accepted: 09/05/2019] [Indexed: 02/06/2023] Open
Abstract
External ventricular drains (EVDs) are commonly used in neurosurgery in different conditions but frequently in the management of traumatic brain injury (TBI) to monitor and/or control intracranial pressure (ICP) by diverting cerebrospinal fluid (CSF). Their clinical effectiveness, when used as a therapeutic ICP-lowering procedure in contemporary practice, remains unclear. No consensus has been reached regarding the drainage strategy and optimal timing of insertion. We review the literature on EVDs in the setting of TBI, discussing its clinical indications, surgical technique, complications, clinical outcomes, and economic considerations.
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Affiliation(s)
- Charlene Y C Chau
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
| | - Claudia L Craven
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N3BG, UK
| | - Andres M Rubiano
- Neurosciences Institute, INUB-MEDITECH Research Group, El Bosque University, 113033 Bogotá, Colombia
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB20QQ, UK
| | - Hadie Adams
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
| | - Selma Tülü
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
- Department of Neurosurgery, Innsbruck Medical University, 6020 Innsbruck, Austria
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
| | - Franco Servadei
- Department of Neurosurgery, Humanitas University and Research Hospital, 20090 Milan, Italy
| | - Ari Ercole
- Division of Anaesthesia, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB20QQ, UK
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK.
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB20QQ, UK.
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Tirado-Caballero J, Muñoz-Nuñez A, Rocha-Romero S, Rivero-Garvía M, Gomez-González E, Marquez-Rivas J. Long-term reliability of the telemetric Neurovent-P-tel sensor: in vivo case report. J Neurosurg 2019; 131:578-581. [PMID: 30168735 DOI: 10.3171/2018.4.jns172988] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 04/02/2018] [Indexed: 02/03/2023]
Abstract
Intracranial pressure (ICP) measurements are imperative for the proper diagnosis and treatment of several neurological disorders. Telemetric sensors have shown their utility for ICP estimation in short-term monitoring in humans. However, their long-term reliability is uncertain. The authors present the case of a 37-year-old woman diagnosed with benign intracranial hypertension and obesity. The patient underwent gastric bypass surgery for ICP control. In order to monitor ICP before and after bariatric surgery, a Neurovent-P-tel sensor was implanted in the left frontal lobe. After gastric bypass, normal ICP values were recorded, and the patient's visual fields improved. However, the patient experienced incapacitating daily headaches. The authors decided to implant a Codman Microsensor ICP transducer in the right frontal lobe to assess the long-term reliability of the Neurovent-P-tel measurements. A comparison of the recordings at 24 and 48 hours showed good correlation and reliability during long-term monitoring with the Neurovent-P-tel, with minimal zero drift after 11 months of implantation.
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Affiliation(s)
- Jorge Tirado-Caballero
- 1Neurosurgery Service, Virgen del Rocío University Hospital, Seville
- 3Group of Applied Neuroscience, Biomedicine Institute of Seville, Spain
| | - Andres Muñoz-Nuñez
- 1Neurosurgery Service, Virgen del Rocío University Hospital, Seville
- 3Group of Applied Neuroscience, Biomedicine Institute of Seville, Spain
| | - Santiago Rocha-Romero
- 1Neurosurgery Service, Virgen del Rocío University Hospital, Seville
- 3Group of Applied Neuroscience, Biomedicine Institute of Seville, Spain
| | - Mónica Rivero-Garvía
- 1Neurosurgery Service, Virgen del Rocío University Hospital, Seville
- 3Group of Applied Neuroscience, Biomedicine Institute of Seville, Spain
| | - Emilio Gomez-González
- 2Group of Interdisciplinary Physics, University of Seville; and
- 3Group of Applied Neuroscience, Biomedicine Institute of Seville, Spain
| | - Javier Marquez-Rivas
- 1Neurosurgery Service, Virgen del Rocío University Hospital, Seville
- 3Group of Applied Neuroscience, Biomedicine Institute of Seville, Spain
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Reinstrup P, Unnerbäck M, Marklund N, Schalen W, Arrocha JC, Bloomfield EL, Sadegh V, Hesselgard K. Best zero level for external ICP transducer. Acta Neurochir (Wien) 2019; 161:635-642. [PMID: 30848373 PMCID: PMC6431298 DOI: 10.1007/s00701-019-03856-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 02/15/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Continuous monitoring of intracranial pressure (ICP) was introduced in the 1950s. For correct ICP recordings, the zero-reference point for the external pressure gauge must be placed next to a head anatomical structure. We evaluated different anatomical points as zero reference for the ICP device at different head positions and their relation to brain centre (BC), foramen of Monro (Monro), and brain surface. METHODS Patients referred for neuroimaging due to e.g. headache all having normal 3D MRI scans were selected. Monro, BC, Orbit(O), external auditory meatus (EAM), and orbito-meatal (OM) line were identified and projected to mid-sagittal, or axial images. Each scan was evaluated like lying supine, 45° head elevations, upright, and 45° lateral position. Distances from skin to brain surface, BC, and Monro were measured. All values are presented as mean ± SD and/or range in millimetre. For conversion to mmHg, millimetre was multiplied by 0.074. RESULTS Twenty MRI scans were examined. A zero reference at EAM or glabella was ideal at BC when head was strict supine or in the lateral position. At 45° head elevation, an overestimation of the BC-ICP by 4.8 ± 0.8 and in upright 5.6 ± 0.5 mmHg was found, and 45° lateral underestimated ICP-BC by 6.3 ± 1.0 mmHg. Monro was situated 45 ± 5 mm rostral to the mid-OM line and 24 (18-31) mm inferior and 13 (8-17) mm in front of BC. A zero-reference point aligned with the highest point of the head underestimated BC-ICP and Monro-ICP. If the ICP reading was added 5.9 or 6.3 mmHg, respectively, a deviation from BC-ICP was ≤ 1.8 mmHg and Monro-ICP was ≤ 0.9 mmHg in all head positions. CONCLUSIONS EAM and glabella are defined anatomical structures representing BC when strict supine or lateral but with 12 mmHg variation with different head positions used in clinical practice. The OM line follows Monro at head elevation, but not when the head is turned. When the highest external point on the head is used, ICP values at brain surface as well as Monro and BC are underestimated. This underestimation is fairly constant and, when corrected for, provides the most exact ICP reading.
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Affiliation(s)
- Peter Reinstrup
- Department of Intensive & Perioperative care, Skanes University Hospital, Lund, Sweden.
| | - Mårten Unnerbäck
- Department of Intensive & Perioperative Care, Skanes University Hospital, Malmö, Sweden
| | - Niklas Marklund
- Department of Clinical Sciences, Neurosurgery, Skane University Hospital, Lund, Sweden
| | - Wilhelm Schalen
- Department of Clinical Sciences, Neurosurgery, Skane University Hospital, Lund, Sweden
| | | | | | - Vahabi Sadegh
- Department of Neuro Radiology, Skanes University Hospital, Lund, Sweden
| | - Karin Hesselgard
- Department of Clinical Sciences, Neurosurgery, Skane University Hospital, Lund, Sweden
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Sturges BK, Dickinson PJ, Tripp LD, Udaltsova I, LeCouteur RA. Intracranial pressure monitoring in normal dogs using subdural and intraparenchymal miniature strain-gauge transducers. J Vet Intern Med 2018; 33:708-716. [PMID: 30575120 PMCID: PMC6430958 DOI: 10.1111/jvim.15333] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 08/24/2018] [Accepted: 09/05/2018] [Indexed: 12/25/2022] Open
Abstract
Background Monitoring of intracranial pressure (ICP) is a critical component in the management of intracranial hypertension. Safety, efficacy, and optimal location of microsensor devices have not been defined in dogs. Hypothesis/Objective Assessment of ICP using a microsensor transducer is feasible in anesthetized and conscious animals and is independent of transducer location. Intraparenchymal transducer placement is associated with more adverse effects. Animals Seven adult, bred‐for‐research dogs. Methods In a prospective investigational study, microsensor ICP transducers were inserted into subdural and intraparenchymal locations at defined rostral or caudal locations within the rostrotentorial compartment under general anesthesia. Mean arterial pressure and ICP were measured continuously during physiological maneuvers, and for 20 hours after anesthesia. Results Baseline mean ± SD values for ICP and cerebral perfusion pressure were 7.2 ± 2.3 and 78.9 ± 7.6 mm Hg, respectively. Catheter position did not have a significant effect on ICP measurements. There was significant variation from baseline ICP accompanying physiological maneuvers (P < .001) and with normal activities, especially with changes in head position (P < .001). Pathological sequelae were more evident after intraparenchymal versus subdural placement. Conclusions and Clinical Importance Use of a microsensor ICP transducer was technically straightforward and provided ICP measurements within previously reported reference ranges. Results support the use of an accessible dorsal location and subdural positioning. Transient fluctuations in ICP are normal events in conscious dogs and large variations associated with head position should be accounted for when evaluating animals with intracranial hypertension.
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Affiliation(s)
- Beverly K Sturges
- Departments of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, California
| | - Peter J Dickinson
- Departments of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, California
| | - Linda D Tripp
- Office of Research, University of California-Davis, Davis, California
| | - Irina Udaltsova
- Population, Health and Reproduction, School of Veterinary Medicine, University of California-Davis, Davis, California
| | - Richard A LeCouteur
- Departments of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, California
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Telemetry in intracranial pressure monitoring: sensor survival and drift. Acta Neurochir (Wien) 2018; 160:2137-2144. [PMID: 30267207 DOI: 10.1007/s00701-018-3691-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 09/21/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Telemetric intracranial pressure (ICP) monitoring enable long-term ICP monitoring on patients during normal day activities and may accordingly be of use during evaluation and treatment of complicated ICP disorders. However, the benefits of such equipment depend strongly on the validity of the recordings and how often the telemetric sensor needs to be re-implanted. This study investigates the clinical and technical sensor survival time and drift of the telemetric ICP sensor: Raumedic Neurovent-P-tel. METHODS Implanted telemetric ICP sensors in the period from January 2011 to December 2017 were identified, and medical records reviewed for complications, explantation reasons, and parameters relevant for determining clinical and technical sensor survival time. Explanted sensors were tested in an experimental setup to study baseline drift. RESULTS In total, implantation of 119 sensors were identified. Five sensors (4.2%) were explanted due to skin damage, three (2.5%) due to wound infection, and two (1.7%) due to ethylene oxide allergy. No other complications were observed. The median clinical sensor survival time was 208 days (95% CI 150-382). The median technical sensor survival time was 556 days (95% CI 382-605). Explanted sensors had a median baseline drift of 2.5 mmHg (IQR 2.0-5.5). CONCLUSION In most cases, the ICP sensor provides reliable measurements beyond the approved implantation time of 90 days. Thus, the sensor should not be routinely removed after this period, if ICP monitoring is still indicated. However, some sensors showed technical malfunction prior to the CE-approval, underlining that caution should always be taken when analyzing telemetric ICP curves.
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Shin J, Yan Y, Bai W, Xue Y, Gamble P, Tian L, Kandela I, Haney CR, Spees W, Lee Y, Choi M, Ko J, Ryu H, Chang JK, Pezhouh M, Kang SK, Won SM, Yu KJ, Zhao J, Lee YK, MacEwan MR, Song SK, Huang Y, Ray WZ, Rogers JA. Bioresorbable pressure sensors protected with thermally grown silicon dioxide for the monitoring of chronic diseases and healing processes. Nat Biomed Eng 2018; 3:37-46. [PMID: 30932064 DOI: 10.1038/s41551-018-0300-4] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 08/23/2018] [Indexed: 11/09/2022]
Abstract
Pressures in the intracranial, intraocular and intravascular spaces are clinically useful for the diagnosis and management of traumatic brain injury, glaucoma and hypertension, respectively. Conventional devices for measuring these pressures require surgical extraction after a relevant operational time frame. Bioresorbable sensors, by contrast, eliminate this requirement, thereby minimizing the risk of infection, decreasing the costs of care and reducing distress and pain for the patient. However, the operational lifetimes of bioresorbable pressure sensors available at present fall short of many clinical needs. Here, we present materials, device structures and fabrication procedures for bioresorbable pressure sensors with lifetimes exceeding those of previous reports by at least tenfold. We demonstrate measurement accuracies that compare favourably to those of the most sophisticated clinical standards for non-resorbable devices by monitoring intracranial pressures in rats for 25 days. Assessments of the biodistribution of the constituent materials, complete blood counts, blood chemistry and magnetic resonance imaging compatibility confirm the biodegradability and clinical utility of the device. Our findings establish routes for the design and fabrication of bioresorbable pressure monitors that meet requirements for clinical use.
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Affiliation(s)
- Jiho Shin
- Department of Chemical and Biomolecular Engineering, University of Illinois at Urbana-Champaign, Urbana, IL, USA.,Frederick Seitz Materials Research Laboratory, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Ying Yan
- Department of Neurological Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Wubin Bai
- Department of Materials Science and Engineering, Northwestern University, Evanston, IL, USA.,Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL, USA
| | - Yeguang Xue
- Department of Materials Science and Engineering, Northwestern University, Evanston, IL, USA.,Departments of Mechanical Engineering and Civil and Environmental Engineering, Northwestern University, Evanston, IL, USA
| | - Paul Gamble
- Department of Neurological Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Limei Tian
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Irawati Kandela
- Developmental Therapeutics Core, Northwestern University, Evanston, IL, USA
| | - Chad R Haney
- Center for Advanced Molecular Imaging, Northwestern University, Evanston, IL, USA
| | - William Spees
- Biomedical Magnetic Resonance Laboratory, Mallinckrodt Institute of Radiology and Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO, USA
| | - Yechan Lee
- Department of Chemical and Biomolecular Engineering, University of Illinois at Urbana-Champaign, Urbana, IL, USA.,Frederick Seitz Materials Research Laboratory, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Minseok Choi
- Department of Chemical and Biomolecular Engineering, University of Illinois at Urbana-Champaign, Urbana, IL, USA.,Frederick Seitz Materials Research Laboratory, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Jonathan Ko
- Department of Chemical and Biomolecular Engineering, University of Illinois at Urbana-Champaign, Urbana, IL, USA.,Frederick Seitz Materials Research Laboratory, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Hangyu Ryu
- Department of Chemical and Biomolecular Engineering, University of Illinois at Urbana-Champaign, Urbana, IL, USA.,Frederick Seitz Materials Research Laboratory, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Jan-Kai Chang
- Frederick Seitz Materials Research Laboratory, University of Illinois at Urbana-Champaign, Urbana, IL, USA.,Department of Materials Science and Engineering, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Maryam Pezhouh
- Northwestern Medicine, Feinberg School of Medicine, Northwestern University, Evanston, IL, USA
| | - Seung-Kyun Kang
- Department of Bio and Brain Engineering, Korea Advanced Institute of Science Technology, Daejeon, Republic of Korea
| | - Sang Min Won
- Frederick Seitz Materials Research Laboratory, University of Illinois at Urbana-Champaign, Urbana, IL, USA.,Department of Electrical and Computer Engineering, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Ki Jun Yu
- School of Electrical and Electronic Engineering, Yonsei University, Seoul, Republic of Korea
| | - Jianing Zhao
- Frederick Seitz Materials Research Laboratory, University of Illinois at Urbana-Champaign, Urbana, IL, USA.,Department of Mechanical Science and Engineering, University of Illinois at Urbana-Champaign, Urbana, IL, USA
| | - Yoon Kyeung Lee
- Department of Materials Science and Engineering, Seoul National University, Seoul, Republic of Korea
| | - Matthew R MacEwan
- Department of Neurological Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Sheng-Kwei Song
- Biomedical Magnetic Resonance Laboratory, Mallinckrodt Institute of Radiology and Hope Center for Neurological Disorders, Washington University School of Medicine, St. Louis, MO, USA
| | - Yonggang Huang
- Department of Materials Science and Engineering, Northwestern University, Evanston, IL, USA.,Departments of Mechanical Engineering and Civil and Environmental Engineering, Northwestern University, Evanston, IL, USA
| | - Wilson Z Ray
- Department of Neurological Surgery, Washington University School of Medicine, St Louis, MO, USA.
| | - John A Rogers
- Department of Materials Science and Engineering, Northwestern University, Evanston, IL, USA. .,Center for Bio-Integrated Electronics, Northwestern University, Evanston, IL, USA. .,Departments of Biomedical Engineering, Chemistry, Mechanical Engineering, Electrical Engineering and Computer Science, and Neurological Surgery, Simpson Querrey Institute for Nano/biotechnology, McCormick School of Engineering and Feinberg School of Medicine, Northwestern University, Evanston, IL, USA.
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Sanz-García A, Pérez-Romero M, Pastor J, Sola RG, Vega-Zelaya L, Monasterio F, Torrecilla C, Vega G, Pulido P, Ortega GJ. Identifying causal relationships between EEG activity and intracranial pressure changes in neurocritical care patients. J Neural Eng 2018; 15:066029. [PMID: 30181428 DOI: 10.1088/1741-2552/aadeea] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To explore and assess the relationship between electroencephalography (EEG) activity and intracranial pressure (ICP) in patients suffering from traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH) during their stay in an intensive care unit. APPROACH We performed an observational prospective cohort study of adult patients suffering from TBI or SAH. Continuous EEG-ECG was performed during ICP monitoring. In every patient, variables derived from the EEG were calculated and the Granger causality (GC) methodology was employed to assess whether, and in which direction, there is any relationship between EEG and ICP. MAIN RESULTS One-thousand fifty-five hours of continuous multimodal monitoring were analyzed in 21 patients using the GC test. During 37.88% of the analyzed time, significant GC statistic was found in the direction from the EEG activity to the ICP, with typical lags of 25-50 s between them. When recordings were adjusted by sedation-perfusion and/or bolus-and handling, these percentages hardly changed. SIGNIFICANCE Long-lasting, continuous and simultaneous EEG and ICP recordings from TBI and SAH patients provide highly rich and useful information, which has allowed for uncovering a strong relationship between both signals. The use of this relationship could lead to developing a medical device to measure ICP in a non-invasive way.
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Affiliation(s)
- Ancor Sanz-García
- Instituto de Investigación Sanitaria, Hospital de la Princesa, Madrid, Spain
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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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Abstract
Neuromonitoring plays an important role in the management of traumatic brain injury. Simultaneous assessment of cerebral hemodynamics, oxygenation, and metabolism allows an individualized approach to patient management in which therapeutic interventions intended to prevent or minimize secondary brain injury are guided by monitored changes in physiologic variables rather than generic thresholds. This narrative review describes various neuromonitoring techniques that can be used to guide the management of patients with traumatic brain injury and examines the latest evidence and expert consensus guidelines for neuromonitoring.
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Lilja-Cyron A, Kelsen J, Andresen M, Fugleholm K, Juhler M. Feasibility of Telemetric Intracranial Pressure Monitoring in the Neuro Intensive Care Unit. J Neurotrauma 2018; 35:1578-1586. [DOI: 10.1089/neu.2017.5589] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
| | - Jesper Kelsen
- Department of Orthopedic Surgery (Spine Section), Rigshospitalet, Copenhagen, Denmark
| | - Morten Andresen
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Kåre Fugleholm
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
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Helbok R, Meyfroidt G, Beer R. Intracranial pressure thresholds in severe traumatic brain injury: Con. Intensive Care Med 2018; 44:1318-1320. [DOI: 10.1007/s00134-018-5249-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 05/26/2018] [Indexed: 10/28/2022]
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Abstract
Background Transcranial Doppler (TCD) has been used to estimate ICP noninvasively (nICP); however, its accuracy varies depending on different types of intracranial hypertension. Given the high specificity of TCD to detect cerebrovascular events, this study aimed to compare four TCD-based nICP methods during plateau waves of ICP. Methods A total of 36 plateau waves were identified in 27 patients (traumatic brain injury) with TCD, ICP, and ABP simultaneous recordings. The nICP methods were based on: (1) interaction between flow velocity (FV) and ABP using a “black-box” mathematical model (nICP_BB); (2) diastolic FV (nICP_FVd); (3) critical closing pressure (nICP_CrCP), and (4) pulsatility index (nICP_PI). Analyses focused on relative changes in time domain between ICP and noninvasive estimators during plateau waves and the magnitude of changes (∆ between baseline and plateau) in real ICP and its estimators. A ROC analysis for an ICP threshold of 35 mmHg was performed. Results In time domain, nICP_PI, nICP_BB, and nICP_CrCP presented similar correlations: 0.80 ± 0.24, 0.78 ± 0.15, and 0.78 ± 0.30, respectively. nICP_FVd presented a weaker correlation (R = 0.62 ± 0.46). Correlations between ∆ICP and ∆nICP were better represented by nICP_CrCP and BB, R = 0.48, 0.44 (p < 0.05), respectively. nICP_FVdand PI presented nonsignificant ∆ correlations. ROC analysis showed moderate to good areas under the curve for all methods: nICP_BB, 0.82; nICP_FVd, 0.77; nICP_CrCP, 0.79; and nICP_PI, 0.81. Conclusions Changes of ICP in time domain during plateau waves were replicated by nICP methods with strong correlations. In addition, the methods presented high performance for detection of intracranial hypertension. However, absolute accuracy for noninvasive ICP assessment using TCD is still low and requires further improvement.
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Sauvigny T, Göttsche J, Czorlich P, Vettorazzi E, Westphal M, Regelsberger J. Intracranial pressure in patients undergoing decompressive craniectomy: new perspective on thresholds. J Neurosurg 2018; 128:819-827. [DOI: 10.3171/2016.11.jns162263] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVEDecompressive craniectomy (DC) is an established part of treatment in patients suffering from malignant infarction of the middle cerebral artery (MCA) or traumatic brain injury (TBI). However, no clear evidence for intracranial pressure (ICP)-guided therapy after DC exists. The lack of this evidence might be due to the frequently used, but simplified threshold for ICP of 20 mm Hg, which determines further therapy. Therefore, the objective of this study was to evaluate this threshold's accuracy and to investigate the course of ICP values with respect to neurological outcome.METHODSData on clinical characteristics and parameters of the ICP course on the intensive care unit were collected retrospectively in 102 patients who underwent DC between December 2007 and April 2014 at the authors' institution. The postoperative ICP course in the first 168 hours was recorded and analyzed. From these findings, ICP thresholds discriminating favorable from unfavorable outcome were calculated using conditional inference tree analysis. Additionally, survival analysis was performed using the Kaplan-Meier method. Prognostic factors were assessed via univariate analysis and multivariate logistic regression. Favorable outcome was defined as a score of 0–4 on the modified Rankin Scale.RESULTSMultivariate logistic regression revealed that anisocoria, diagnosis, and ICP values differed significantly between the outcome groups. ICP values in the favorable and unfavorable outcome groups differed significantly (p < 0.001), while the mean ICP of both groups lay below the limit of 20 mm Hg (17.5 and 11.5 mm Hg, respectively). These findings were reproduced when analyzing the underlying pathologies of TBI and MCA infarction separately. Based on these findings, optimized time-dependent threshold values were calculated and found to be between 10 and 17 mm Hg. These values significantly distinguished favorable from unfavorable outcome and predicted 30-day mortality (p < 0.001).CONCLUSIONSThis study systematically evaluated ICP levels in a long-term analysis after DC and provides new, surprisingly low, time-dependent ICP thresholds for these patients. Future trials investigating the benefit of ICP-guided therapy should take these thresholds into consideration and validate them in further patient cohorts.
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Affiliation(s)
| | | | | | - Eik Vettorazzi
- 2Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Stone JL, Bailes JE, Hassan AN, Sindelar B, Patel V, Fino J. Brainstem Monitoring in the Neurocritical Care Unit: A Rationale for Real-Time, Automated Neurophysiological Monitoring. Neurocrit Care 2017; 26:143-156. [PMID: 27484878 DOI: 10.1007/s12028-016-0298-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Patients with severe traumatic brain injury or large intracranial space-occupying lesions (spontaneous cerebral hemorrhage, infarction, or tumor) commonly present to the neurocritical care unit with an altered mental status. Many experience progressive stupor and coma from mass effects and transtentorial brain herniation compromising the ascending arousal (reticular activating) system. Yet, little progress has been made in the practicality of bedside, noninvasive, real-time, automated, neurophysiological brainstem, or cerebral hemispheric monitoring. In this critical review, we discuss the ascending arousal system, brain herniation, and shortcomings of our current management including the neurological exam, intracranial pressure monitoring, and neuroimaging. We present a rationale for the development of nurse-friendly-continuous, automated, and alarmed-evoked potential monitoring, based upon the clinical and experimental literature, advances in the prognostication of cerebral anoxia, and intraoperative neurophysiological monitoring.
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Affiliation(s)
- James L Stone
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA. .,Departments of Neurology and Neurological Surgery, University of Illinois at Chicago, Chicago, IL, USA. .,Division of Neurosurgery, Department of Surgery, Cook County Stroger Hospital, Chicago, IL, USA.
| | - Julian E Bailes
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Ahmed N Hassan
- Departments of Neurology and Neurological Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Brian Sindelar
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA.,Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Vimal Patel
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - John Fino
- Departments of Neurology and Neurological Surgery, University of Illinois at Chicago, Chicago, IL, USA
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