1
|
Brasil S, de Carvalho Nogueira R, Salinet ÂSM, Yoshikawa MH, Teixeira MJ, Paiva W, Malbouisson LMS, Bor-Seng-Shu E, Panerai RB. Critical Closing Pressure and Cerebrovascular Resistance Responses to Intracranial Pressure Variations in Neurocritical Patients. Neurocrit Care 2023; 39:399-410. [PMID: 36869208 PMCID: PMC10541829 DOI: 10.1007/s12028-023-01691-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/31/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Critical closing pressure (CrCP) and resistance-area product (RAP) have been conceived as compasses to optimize cerebral perfusion pressure (CPP) and monitor cerebrovascular resistance, respectively. However, for patients with acute brain injury (ABI), the impact of intracranial pressure (ICP) variability on these variables is poorly understood. The present study evaluates the effects of a controlled ICP variation on CrCP and RAP among patients with ABI. METHODS Consecutive neurocritical patients with ICP monitoring were included along with transcranial Doppler and invasive arterial blood pressure monitoring. Internal jugular veins compression was performed for 60 s for the elevation of intracranial blood volume and ICP. Patients were separated in groups according to previous intracranial hypertension severity, with either no skull opening (Sk1), neurosurgical mass lesions evacuation, or decompressive craniectomy (DC) (patients with DC [Sk3]). RESULTS Among 98 included patients, the correlation between change (Δ) in ICP and the corresponding ΔCrCP was strong (group Sk1 r = 0.643 [p = 0.0007], group with neurosurgical mass lesions evacuation r = 0.732 [p < 0.0001], and group Sk3 r = 0.580 [p = 0.003], respectively). Patients from group Sk3 presented a significantly higher ΔRAP (p = 0.005); however, for this group, a higher response in mean arterial pressure (change in mean arterial pressure p = 0.034) was observed. Exclusively, group Sk1 disclosed reduction in ICP before internal jugular veins compression withholding. CONCLUSIONS This study elucidates that CrCP reliably changes in accordance with ICP, being useful to indicate ideal CPP in neurocritical settings. In the early days after DC, cerebrovascular resistance seems to remain elevated, despite exacerbated arterial blood pressure responses in efforts to maintain CPP stable. Patients with ABI with no need of surgical procedures appear to remain with more effective ICP compensatory mechanisms when compared with those who underwent neurosurgical interventions.
Collapse
Affiliation(s)
- Sérgio Brasil
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil.
| | - Ricardo de Carvalho Nogueira
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | - Ângela Salomão Macedo Salinet
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | - Márcia Harumy Yoshikawa
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | - Wellingson Paiva
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | | | - Edson Bor-Seng-Shu
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, School of Life Sciences, University of Leicester, Leicester, UK
- National Institute for Health and Care Research, Cardiovascular Research Centre, Glenfield Hospital, University of Leicester, Leicester, UK
| |
Collapse
|
2
|
Godoy DA, Brasil S, Iaccarino C, Paiva W, Rubiano AM. The intracranial compartmental syndrome: a proposed model for acute brain injury monitoring and management. Crit Care 2023; 27:137. [PMID: 37038236 PMCID: PMC10088257 DOI: 10.1186/s13054-023-04427-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/02/2023] [Indexed: 04/12/2023] Open
Abstract
For decades, one of the main targets in the management of severe acute brain injury (ABI) has been intracranial hypertension (IH) control. However, the determination of IH has suffered variations in its thresholds over time without clear evidence for it. Meanwhile, progress in the understanding of intracranial content (brain, blood and cerebrospinal fluid) dynamics and recent development in monitoring techniques suggest that targeting intracranial compliance (ICC) could be a more reliable approach rather than guiding actions by predetermined intracranial pressure values. It is known that ICC impairment forecasts IH, as intracranial volume may rapidly increase inside the skull, a closed bony box with derisory expansibility. Therefore, an intracranial compartmental syndrome (ICCS) can occur with deleterious brain effects, precipitating a reduction in brain perfusion, thereby inducing brain ischemia. The present perspective review aims to discuss the ICCS concept and suggest an integrative model for the combination of modern invasive and noninvasive techniques for IH and ICC assessment. The theory and logic suggest that the combination of multiple ancillary methods may enhance ICC impairment prediction, pointing proactive actions and improving patient outcomes.
Collapse
Affiliation(s)
| | - Sérgio Brasil
- Experimental Surgery Laboratory and Division of Neurological Surgery, University of São Paulo Medical School, Av. Eneas de Carvalho Aguiar 255, Sao Paulo, Brazil.
| | - Corrado Iaccarino
- Department of Biomedical, Metabolic and Neural Sciences, University Modena and Reggio Emilia, Modena, Italy
- Department of Neurosurgery, University Hospital of Modena, Modena, Italy
- Emergency Neurosurgery, AUSLRE IRCCS, Reggio Emilia, Italy
| | - Wellingson Paiva
- Experimental Surgery Laboratory and Division of Neurological Surgery, University of São Paulo Medical School, Av. Eneas de Carvalho Aguiar 255, Sao Paulo, Brazil
| | - Andres M Rubiano
- Universidad El Bosque. Bogotá, Bogotá, Colombia
- MEDITECH Foundation, Cali, Colombia
| |
Collapse
|
3
|
Paiva WS, Zippo E, Miranda C, Brasil S, Godoy DA, De Andrade AF, Neville I, Patriota GC, Domingues R, Teixeira MJ. Animal models for the study of intracranial hematomas (Review). Exp Ther Med 2022; 25:20. [PMID: 36561628 PMCID: PMC9748783 DOI: 10.3892/etm.2022.11719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/26/2022] [Indexed: 11/23/2022] Open
Abstract
Intracranial hematomas (ICH) are a frequent condition in neurosurgical and neurological practices, with several mechanisms of primary and secondary injury. Experimental research has been fundamental for the understanding of the pathophysiology implicated with ICH and the development of therapeutic interventions. To date, a variety of different animal approaches have been described that consider, for example, the ICH evolutive phase, molecular implications and hemodynamic changes. Therefore, choosing a test protocol should consider the scope of each particular study. The present review summarized investigational protocols in experimental research on the subject of ICH. With this subject, injection of autologous blood or bacterial collagenase, inflation of intracranial balloon and avulsion of cerebral vessels were the models identified. Rodents (mice) and swine were the most frequent species used. These different models allowed improvements on the understanding of intracranial hypertension establishment, neuroinflammation, immunology, brain hemodynamics and served to the development of therapeutic strategies.
Collapse
Affiliation(s)
- Wellingson Silva Paiva
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil,Medical Research Laboratory 62, Department of Neurology, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil
| | - Emanuele Zippo
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil
| | - Carolina Miranda
- Neurology Center, Samaritan Hospital, 01232010 São Paulo, Brazil
| | - Sérgio Brasil
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil,Medical Research Laboratory 62, Department of Neurology, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil,Correspondence to: Dr Sérgio Brasil, Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 255 Enéas Aguiar Street, 05403 São Paulo, Brazil
| | - Daniel Augustin Godoy
- Department of Intensive Care, Neurointensive Care Unit, Pasteur Hospital, 4700 Catamarca, Argentina
| | - Almir Ferreira De Andrade
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil,Medical Research Laboratory 62, Department of Neurology, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil
| | - Iuri Neville
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil
| | | | - Renan Domingues
- Neurology Center, Samaritan Hospital, 01232010 São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Department of Neurology, Division of Neurosurgery, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil,Medical Research Laboratory 62, Department of Neurology, School of Medicine, University of São Paulo, 05403000 São Paulo, Brazil
| |
Collapse
|
4
|
Brasil S, Solla DJF, Nogueira RDC, Jacobsen Teixeira M, Malbouisson LMS, Paiva WS. Intracranial Compliance Assessed by Intracranial Pressure Pulse Waveform. Brain Sci 2021; 11:brainsci11080971. [PMID: 34439590 PMCID: PMC8392489 DOI: 10.3390/brainsci11080971] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/06/2021] [Accepted: 07/20/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Morphological alterations in intracranial pressure (ICP) pulse waveform (ICPW) secondary to intracranial hypertension (ICP >20 mmHg) and a reduction in intracranial compliance (ICC) are well known indicators of neurological severity. The exclusive exploration of modifications in ICPW after either the loss of skull integrity or surgical procedures for intracranial hypertension resolution is not a common approach studied. The present study aimed to assess the morphological alterations in ICPW among neurocritical care patients with skull defects and decompressive craniectomy (DC) by comparing the variations in ICPW features according to elevations in mean ICP values. METHODS Patients requiring ICP monitoring because of acute brain injury were included. A continuous record of 10 min-length for the beat-by-beat analysis of ICPW was performed, with ICP elevation produced by means of ultrasound-guided manual internal jugular vein compression at the end of the record. ICPW features (peak amplitude ratio (P2/P1), time interval to pulse peak (TTP) and pulse amplitude) were counterweighed between baseline and compression periods. Results were distributed for three groups: intact skull (exclusive burr hole for ICP monitoring), craniotomy/large fractures (group 2) or DC (group 3). RESULTS 57 patients were analyzed. A total of 21 (36%) presented no skull defects, 21 (36%) belonged to group 2, whereas 15 (26%) had DC. ICP was not significantly different between groups: ±15.11 for intact, 15.33 for group 2 and ±20.81 mmHg for group 3, with ICP-induced elevation also similar between groups (p = 0.56). Significant elevation was observed for the P2/P1 ratio for groups 1 and 2, whereas a reduction was observed in group 3 (elevation of ±0.09 for groups 1 and 2, but a reduction of 0.03 for group 3, p = 0.01), and no significant results were obtained for TTP and pulse amplitudes. CONCLUSION In the present study, intracranial pressure pulse waveform analysis indicated that intracranial compliance was significantly more impaired among decompressive craniectomy patients, although ICPW indicated DC to be protective for further influences of ICP elevations over the brain. The analysis of ICPW seems to be an alternative to real-time ICC assessment.
Collapse
Affiliation(s)
- Sérgio Brasil
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 05508-070, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.S.P.)
- Correspondence:
| | - Davi Jorge Fontoura Solla
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 05508-070, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.S.P.)
| | - Ricardo de Carvalho Nogueira
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 05508-070, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.S.P.)
| | - Manoel Jacobsen Teixeira
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 05508-070, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.S.P.)
| | | | - Wellingson Silva Paiva
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 05508-070, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.S.P.)
| |
Collapse
|