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Martínez-Palacios K, Vásquez-García S, Fariyike OA, Robba C, Rubiano AM. Non-Invasive Methods for Intracranial Pressure Monitoring in Traumatic Brain Injury Using Transcranial Doppler: A Scoping Review. J Neurotrauma 2024; 41:1282-1298. [PMID: 37861291 DOI: 10.1089/neu.2023.0001] [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] [Indexed: 10/21/2023] Open
Abstract
Intracranial pressure (ICP) monitoring is necessary for managing patients with traumatic brain injury (TBI). Although gold-standard methods include intraventricular or intraparenchymal transducers, these systems cannot be used in patients with coagulopathies or in those who are at high risk of catheter-related infections, nor can they be used in resource-constrained settings. Therefore, a non-invasive modality that is more widely available, cost effective, and safe would have tremendous impact. Among such non-invasive choices, transcranial Doppler (TCD) provides indirect ICP estimates through waveform analysis of cerebral hemodynamic changes. The objective of this scoping review is to describe the existing evidence for the use of TCD-derived methods in estimating ICP in adult TBI patients as compared with gold-standard invasive methods. This review was conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews, with a main search of PubMed and Embase. The search was limited to studies conducted in adult TBI patients published in any language between 2012 and 2022. Twenty-two studies were included for analysis, with most being prospective studies conducted in high-income countries. TCD-derived non-invasive ICP (nICP) methods are either mathematical or non-mathematical, with the former having slightly better correlation with invasive methods, especially when using time-trending ICP dynamics over one-time estimated values. Nevertheless, mathematical methods are associated with greater cost and complexity in their application. Formula-based methods showed promise in excluding elevated ICP, exhibiting a high negative predictive value. Therefore, TCD-derived methods could be useful in assessing ICP changes instead of absolute ICP values for high-risk patients, especially in low-resource settings.
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Affiliation(s)
- Karol Martínez-Palacios
- Neuroscience Institute, Universidad El Bosque, Bogotá, Colombia
- MEDITECH Foundation, Cali, Colombia
| | - Sebastián Vásquez-García
- MEDITECH Foundation, Cali, Colombia
- Neurology Department, Universidad del Rosario, Bogotá, Colombia
| | - Olubunmi A Fariyike
- MEDITECH Foundation, Cali, Colombia
- Faculty of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Chiara Robba
- Department of Anesthesia and Intensive Care, Policlinico San Martino, Genova, Italy
| | - Andrés M Rubiano
- Neuroscience Institute, Universidad El Bosque, Bogotá, Colombia
- MEDITECH Foundation, Cali, Colombia
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Frontera JA, Fang T, Grayson K, Lalchan R, Dickstein L, Hussain MS, Kahn DE, Lord AS, Mazzuchin D, Melmed KR, Rutledge C, Zhou T, Lewis A. Poor Accuracy of Manually Derived Head Computed Tomography Parameters in Predicting Intracranial Hypertension After Nontraumatic Intracranial Hemorrhage. Neurocrit Care 2023; 39:677-689. [PMID: 36577900 DOI: 10.1007/s12028-022-01662-5] [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: 09/20/2022] [Accepted: 12/08/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND The utility of head computed tomography (CT) in predicting elevated intracranial pressure (ICP) is known to be limited in traumatic brain injury; however, few data exist in patients with spontaneous intracranial hemorrhage. METHODS We conducted a retrospective review of prospectively collected data in patients with nontraumatic intracranial hemorrhage (subarachnoid hemorrhage [SAH] or intraparenchymal hemorrhage [IPH]) who underwent external ventricular drain (EVD) placement. Head CT scans performed immediately prior to EVD placement were quantitatively reviewed for features suggestive of elevated ICP, including temporal horn diameter, bicaudate index, basal cistern effacement, midline shift, and global cerebral edema. The modified Fisher score (mFS), intraventricular hemorrhage score, and IPH volume were also measured, as applicable. We calculated the accuracy, positive predictive value (PPV), and negative predictive value (NPV) of these radiographic features for the coprimary outcomes of elevated ICP (> 20 mm Hg) at the time of EVD placement and at any time during the hospital stay. Multivariable backward stepwise logistic regression analysis was performed to identify significant radiographic factors associated with elevated ICP. RESULTS Of 608 patients with intracranial hemorrhages enrolled during the study time frame, 243 (40%) received an EVD and 165 (n = 107 SAH, n = 58 IPH) had a preplacement head CT scan available for rating. Elevated opening pressure and elevated ICP during hospitalization were recorded in 48 of 152 (29%) and 103 of 165 (62%), respectively. The presence of ≥ 1 radiographic feature had only 32% accuracy for identifying elevated opening pressure (PPV 30%, NPV 58%, area under the curve [AUC] 0.537, 95% asymptotic confidence interval [CI] 0.436-0.637, P = 0.466) and 59% accuracy for predicting elevated ICP during hospitalization (PPV 63%, NPV 40%, AUC 0.514, 95% asymptotic CI 0.391-0.638, P = 0.820). There was no significant association between the number of radiographic features and ICP elevation. Head CT scans without any features suggestive of elevated ICP occurred in 25 of 165 (15%) patients. However, 10 of 25 (40%) of these patients had elevated opening pressure, and 15 of 25 (60%) had elevated ICP during their hospital stay. In multivariable models, mFS (adjusted odds ratio [aOR] 1.36, 95% CI 1.10-1.68) and global cerebral edema (aOR 2.93, 95% CI 1.27-6.75) were significantly associated with elevated ICP; however, their accuracies were only 69% and 60%, respectively. All other individual radiographic features had accuracies between 38 and 58% for identifying intracranial hypertension. CONCLUSIONS More than 50% of patients with spontaneous intracranial hemorrhage without radiographic features suggestive of elevated ICP actually had ICP > 20 mm Hg during EVD placement or their hospital stay. Morphological head CT findings were only 32% and 59% accurate in identifying elevated opening pressure and ICP elevation during hospitalization, respectively.
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Affiliation(s)
- Jennifer A Frontera
- Department of Neurology, New York University School of Medicine, 150 55th St., Brooklyn, New York, NY, USA.
- Department of Neurosurgery, Mount Sinai School of Medicine, New York, NY, USA.
- Cerebrovascular Center of the Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Taolin Fang
- Department of Neurology, New York University School of Medicine, 150 55th St., Brooklyn, New York, NY, USA
| | - Kammi Grayson
- Department of Neurology, New York University School of Medicine, 150 55th St., Brooklyn, New York, NY, USA
| | - Rebecca Lalchan
- Department of Neurology, New York University School of Medicine, 150 55th St., Brooklyn, New York, NY, USA
| | - Leah Dickstein
- Department of Neurology, New York University School of Medicine, 150 55th St., Brooklyn, New York, NY, USA
- Department of Neurosurgery, New York University School of Medicine, New York, NY, USA
| | - M Shazam Hussain
- Cerebrovascular Center of the Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - D Ethan Kahn
- Department of Neurology, New York University School of Medicine, 150 55th St., Brooklyn, New York, NY, USA
| | - Aaron S Lord
- Department of Neurology, New York University School of Medicine, 150 55th St., Brooklyn, New York, NY, USA
| | - Daniel Mazzuchin
- Department of Neurosurgery, New York University School of Medicine, New York, NY, USA
| | - Kara R Melmed
- Department of Neurology, New York University School of Medicine, 150 55th St., Brooklyn, New York, NY, USA
- Department of Neurosurgery, New York University School of Medicine, New York, NY, USA
| | - Caleb Rutledge
- Department of Neurosurgery, New York University School of Medicine, New York, NY, USA
| | - Ting Zhou
- Department of Neurology, New York University School of Medicine, 150 55th St., Brooklyn, New York, NY, USA
| | - Ariane Lewis
- Department of Neurology, New York University School of Medicine, 150 55th St., Brooklyn, New York, NY, USA
- Department of Neurosurgery, New York University School of Medicine, New York, NY, USA
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Link C, D`Haese TM, Frigieri G, Brasil S, Vellosa JCR, Welling L. Intracranial compliance and volumetry in patients with traumatic brain injury. Surg Neurol Int 2023; 14:246. [PMID: 37560593 PMCID: PMC10408625 DOI: 10.25259/sni_314_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/27/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Cerebral edema (CE) and intracranial hypertension (IHT) are complications of numerous neurological pathologies. However, the study of CE and noninvasive methods to predict IHT remains rudimentary. This study aims to identify in traumatic brain injury (TBI) patients the relationship between the volume of the lateral ventricles and the parameters of the noninvasive intracranial pressure waveform (nICPW). METHODS This is an analytical, descriptive, and cross-sectional study with nonsurgical TBI patients. The monitoring of nICPW was performed with a mechanical strain gauge, and the volumetry of the lateral ventricles was calculated using the free 3D Slicer software, both during the acute phase of the injury. The linear model of fixed and random mixed effects with Gamma was used to calculate the influence of nICPW parameters (P2/P1 and time-to-peak [TTP]) values on volumetry. RESULTS Considering only the fixed effects of the sample, there was P = 0.727 (95% CI [-0.653; 0.364]) for the relationship between P2/P1 and volumetry and 0.727 (95% CI [-1.657; 1.305]) for TTP and volumetry. Considering the fixed and random effects, there was P = 8.5e-10 (95% CI [-0.759; 0.355]) for the relationship between P2/P1 and volumetry and 8.5e-10 (95% CI [-2.001; 0.274]) for TTP and volumetry. CONCLUSION The present study with TBI patients found association between nICPW parameters and the volume of the lateral ventricles in the 1st days after injury.
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Affiliation(s)
- Caroline Link
- Department of Neurology, Clinics Hospital Complex of the Federal University of Paraná, Curitiba, Brazil
| | - Thomas Markus D`Haese
- Department of Intensive care, State University of Ponta Grossa, Ponta Grossa, Brazil
| | - Gustavo Frigieri
- Braincare Desenvolvimento e Inovação Tecnológica SA - Brain4care, São Carlos, Brazil
| | - Sérgio Brasil
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - Leonardo Welling
- Neurological Surgery, State University of Ponta Grossa, Ponta Grossa, Brazil
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Shim Y, Kim J, Kim HS, Oh J, Lee S, Ha EJ. Intracranial Pressure Monitoring for Acute Brain Injured Patients: When, How, What Should We Monitor. Korean J Neurotrauma 2023; 19:149-161. [PMID: 37431379 PMCID: PMC10329885 DOI: 10.13004/kjnt.2023.19.e32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/13/2023] [Accepted: 06/16/2023] [Indexed: 07/12/2023] Open
Abstract
While there is no level I recommendation for intracranial pressure (ICP) monitoring, it is typically indicated for patients with severe traumatic brain injury (TBI) with a Glasgow Coma Scale (GCS) score of 3-8 (class II). Even for moderate TBI patients with GCS 9-12, ICP monitoring should be considered for risk of increased ICP. The impact of ICP monitoring on patient outcomes is still not well-established, but recent studies reported a reduction of early mortality (class III) in TBI patients. There is no standard protocol for the application of ICP monitoring. In cases where cerebrospinal fluid drainage is required, an external ventricular drain is commonly used. In other cases, parenchymal ICP monitoring devices are generally employed. Subdural or non-invasive forms are not suitable for ICP monitoring. The mean value of ICP is the parameter recommended for observation in many guidelines. In TBI, values above 22 mmHg are associated with increased mortality. However, recent studies proposed various parameters including cumulative time with ICP above 20 mmHg (pressure-time dose), pressure reactivity index, ICP waveform characteristics (pulse amplitude of ICP, mean ICP wave amplitude), and the compensatory reserve of the brain (reserve-amplitude-pressure), which are useful in predicting patient outcomes and guiding treatment. Further research is required for validation of these parameters compared to simple ICP monitoring.
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Affiliation(s)
- Youngbo Shim
- Department of Critical Care Medicine, Kangbuk Samsung Hospital, Seoul, Korea
| | - Jungook Kim
- Gachon University Gil Hospital Regional Trauma Center, Gachon, Korea
| | - Hye Seon Kim
- Department of Neurosurgery, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University, Incheon, Korea
| | - Jiwoong Oh
- Departments of Neurological Surgery and Critical Care Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seungioo Lee
- Departments of Neurological Surgery and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Pelah AI, Zakrzewska A, Calviello LA, Forcht Dagi T, Czosnyka Z, Czosnyka M. Accuracy of Intracranial Pressure Monitoring-Single Centre Observational Study and Literature Review. SENSORS (BASEL, SWITZERLAND) 2023; 23:3397. [PMID: 37050457 PMCID: PMC10098789 DOI: 10.3390/s23073397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/06/2023] [Accepted: 03/09/2023] [Indexed: 06/19/2023]
Abstract
Intracranial hypertension and adequacy of brain blood flow are primary concerns following traumatic brain injury. Intracranial pressure (ICP) monitoring is a critical diagnostic tool in neurocritical care. However, all ICP sensors, irrespective of design, are subject to systematic and random measurement inaccuracies that can affect patient care if overlooked or disregarded. The wide choice of sensors available to surgeons raises questions about performance and suitability for treatment. This observational study offers a critical review of the clinical and experimental assessment of ICP sensor accuracy and comments on the relationship between actual clinical performance, bench testing, and manufacturer specifications. Critically, on this basis, the study offers guidelines for the selection of ICP monitoring technologies, an important clinical decision. To complement this, a literature review on important ICP monitoring considerations was included. This study utilises illustrative clinical and laboratory material from 1200 TBI patients (collected from 1992 to 2019) to present several important points regarding the accuracy of in vivo implementation of contemporary ICP transducers. In addition, a thorough literature search was performed, with sources dating from 1960 to 2021. Sources considered to be relevant matched the keywords: "intraparenchymal ICP sensors", "fiberoptic ICP sensors", "piezoelectric strain gauge sensors", "external ventricular drains", "CSF reference pressure", "ICP zero drift", and "ICP measurement accuracy". Based on single centre observations and the 76 sources reviewed in this paper, this material reports an overall anticipated measurement accuracy for intraparenchymal transducers of around ± 6.0 mm Hg with an average zero drift of <2.0 mm Hg. Precise ICP monitoring is a key tenet of neurocritical care, and accounting for zero drift is vital. Intraparenchymal piezoelectric strain gauge sensors are commonly implanted to monitor ICP. Laboratory bench testing results can differ from in vivo observations, revealing the shortcomings of current ICP sensors.
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Affiliation(s)
- Adam I. Pelah
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Agnieszka Zakrzewska
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Leanne A. Calviello
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Teodoro Forcht Dagi
- Neurosurgery, Mayo School of Medicine and Science, Rochester, MN 55905, USA
- School of Medicine, Dentistry & Biomedical Sciences, Queen’s University Belfast, Belfast BT7 1NN, UK
| | - Zofia Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge CB2 0QQ, UK
- Institute of Electronic Systems, Warsaw University of Technology, 00-65 Warszawa, Poland
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Brodsky MC, Aul BJ, Daniels DJ, El-Dairi M. Escape from Prism. Surv Ophthalmol 2022; 68:556-561. [PMID: 35181281 DOI: 10.1016/j.survophthal.2022.02.003] [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: 01/24/2022] [Revised: 02/07/2022] [Accepted: 02/11/2022] [Indexed: 10/19/2022]
Abstract
A 14-year-old boy with a history of shunted congenital hydrocephalus began having headaches with nausea and vomiting after transcontinental flights. He gradually developed horizontal diplopia indicative of mild bilateral sixth nerve palsy, without papilledema or ventriculomegaly. Intracranial pressure monitoring showed no signs of elevation. After he subsequently developed papilledema, surgical exploration showed shunt malfunction, and shunt replacement produced rapid resolution of symptoms. This case demonstrates the importance of relying on clinical history and neuro-ophthalmologic examination in patients with hydrocephalus and suspected shunt failure, even when objective confirmatory evidence of intracranial pressure elevation is lacking.
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Affiliation(s)
- Michael C Brodsky
- Department of Departments of Ophthalmology and Neurology, Mayo Clinic, Rochester, Minnesota.
| | - Bryce J Aul
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
| | - David J Daniels
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
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Intracranial pressure monitoring in posterior fossa lesions-systematic review and meta-analysis. Neurosurg Rev 2022; 45:1933-1939. [PMID: 35118578 PMCID: PMC9160102 DOI: 10.1007/s10143-022-01746-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/25/2022] [Accepted: 01/27/2022] [Indexed: 11/13/2022]
Abstract
Elevated intracranial pressure (ICP) with reduced cerebral perfusion pressure is a well-known cause of secondary brain injury. Previously, there have been some reports describing different supra- and infratentorial ICP measurements depending on the location of the mass effect. Therefore, we aimed to perform a systematic review and meta-analysis to clarify the issue of optimal ICP monitoring in the infratentorial mass lesion. A literature search of electronic databases (PUBMED, EMBASE) was performed from January 1969 until February 2021 according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. Two assessors are independently screened for eligible studies reporting the use of simultaneous ICP monitoring in the supra- and infratentorial compartments. For quality assessment of those studies, the New Castle Ottawa Scale was used. The primary outcome was to evaluate the value of supra- and infratentorial ICP measurement, and the secondary outcome was to determine the time threshold until equalization of both values. Current evidence surrounding infratentorial ICP measurement was found to be low to very low quality according to New Castle Ottawa Scale. Eight studies were included in the systematic review, four of them containing human subjects encompassing 27 patients with infratentorial pathology. The pooled data demonstrated significantly higher infratentorial ICP values than supratentorial ICP values 12 h after onset (p < 0.05, 95% CI 3.82–5.38) up to 24 h after onset (p < 0.05; CI 1.14–3.98). After 48–72 h, both ICP measurements equilibrated showing no significant difference. Further, four studies containing 26 pigs and eight dogs showed a simultaneous increase of supra- and infratentorial ICP value according to the increase of supratentorial mass volume; however, there was a significant difference towards lower ICP in the infratentorial compartment compared to the supratentorial compartment. The transtentorial gradient leads to a significant discrepancy between supra- and infratentorial ICP monitoring. Therefore, infratentorial ICP monitoring is warranted in case of posterior fossa lesions for at least 48 h.
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Gavryushin AV, Oshorov AV, Savin IA. [Invasive intracranial pressure monitoring in posterior cranial fossa after neurosurgery: an exclusive option or a necessity?]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:71-79. [PMID: 35412715 DOI: 10.17116/neiro20228602171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
UNLABELLED Posterior cranial fossa (PCF) surgery is associated with the risk of increased intracranial pressure (ICP) under tentorium. The last one can lead to severe brainstem syndromes and postoperative complications. The currently recommended method for ICP control with a supratentorial parenchymal sensor or CSF pressure measurement through an external ventricular drainage is ineffective. Indeed, these methods do not show the true situation in the PCF. OBJECTIVE To determine the feasibility of ICP sensor insertion into cerebellar parenchyma for PCF edema after neurosurgery. MATERIAL AND METHODS We retrospectively analyzed literature data (15 references) and 3 patients after ICP sensor insertion into cerebellar parenchyma for ICP control in PCF. CONCLUSION ICP sensor insertion into cerebellar parenchyma is indicated for infratentorial postoperative edema.
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Affiliation(s)
| | - A V Oshorov
- Burdenko Neurosurgical Center, Moscow, Russia
| | - I A Savin
- Burdenko Neurosurgical Center, Moscow, Russia
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Natile M, Simonet O, Vallot F, De Kock M. Ultrasound measurement of the optic nerve sheath diameter in traumatic brain injury: a narrative review. ACTA ANAESTHESIOLOGICA BELGICA 2021. [DOI: 10.56126/72.4.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background : Raised intracranial pressure (ICP) needs to be investigated in various situations, especially in traumatic brain injury (TBI). Ultra-sonographic (US) measurement of the optic nerve sheath diameter (ONSD) is a promising noninvasive tool for assessing elevated ICP.
Objectives : This narrative review aimed to explain the history of and indications forUS measurement of ONSD. We focused on the detection of elevated ICP after TBI and discussed the possible improvements in detection methods.
Conclusions : US measurement of ONSD in TBI cases provides a qualitative but no quantitative assessment of ICP. Current studies usually calculate their own optimum cutoff value for detecting raised ICP based on the balance between sensitivity and specificity of the method when compared with invasive methods. There is no universally accepted threshold. We did not find any paper focusing on the prognosis of patients benefiting from it when compared with usual care. Another limitation is the lack of standardization. US measurement of ONSD cannot be used as the sole technique to detect elevated ICP and monitor its evolution, but it can be a useful tool in a multimodal protocol and it might help to determine the prognosis of patients in various situations.
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10
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Marini CP, McNelis J, Petrone P. Multimodality Monitoring and Goal-Directed Therapy for the Treatment of Patients with Severe Traumatic Brain Injury: A Review for the General and Trauma Surgeon. Curr Probl Surg 2021; 59:101070. [DOI: 10.1016/j.cpsurg.2021.101070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/04/2021] [Indexed: 11/28/2022]
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Marini CP, McNelis J, Petrone P. In Brief. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2021.101071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Donaldson L, Margolin E. Absence of papilledema in large intracranial tumours. J Neurol Sci 2021; 428:117604. [PMID: 34384969 DOI: 10.1016/j.jns.2021.117604] [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: 05/26/2021] [Revised: 07/07/2021] [Accepted: 08/01/2021] [Indexed: 10/20/2022]
Abstract
Papilledema refers to optic disc edema occurring secondary to raised intracranial pressure. In patients with intracranial tumours, tumour size might be the expected predictor of whether or not papilledema will develop, however, this is not the case in clinical practice. We report a series of 5 patients with large intracranial tumours and no evidence of papilledema and discuss the potential factors which may contribute to the lack of optic disc edema in these cases. Development of papilledema depends on both the presence of elevated intracranial pressure and transmission of elevated pressure to the subarachnoid space within the optic nerve sheath and to the optic nerve itself. We discuss how intracranial tumours may influence the physiology of the surrounding tissues, cerebrospinal fluid dynamics and cerebral venous outflow and how individual anatomic variations, particularly within the optic nerve sheath and optic canal, likely play a role in development of papilledema.
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Affiliation(s)
- Laura Donaldson
- University of Toronto, Department of Ophthalmology and Vision Sciences, Toronto, Ontario, Canada
| | - Edward Margolin
- University of Toronto, Department of Ophthalmology and Vision Sciences, Toronto, Ontario, Canada; University of Toronto, Department of Medicine, Division of Neurology, Toronto, Ontario, Canada.
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Godoy DA, Badenes R, Murillo-Cabezas F. Ten physiological commandments for severe head injury. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:280-292. [PMID: 34140125 DOI: 10.1016/j.redare.2020.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 09/07/2020] [Indexed: 06/12/2023]
Abstract
Advances in multiparametric brain monitoring have allowed us to deepen our knowledge of the physiopathology of head injury and how it can be treated using the therapies available today. It is essential to understand and interpret a series of basic physiological and physiopathological principles that, on the one hand, provide an adequate metabolic environment to prevent worsening of the primary brain injury and favour its recovery, and on the other hand, allow therapeutic resources to be individually adapted to the specific needs of the patient. Based on these notions, this article presents a decalogue of the physiological objectives to be achieved in brain injury, together with a series of diagnostic and therapeutic recommendations for achieving these goals. We emphasise the importance of considering and analysing the physiological variables involved in the transport of oxygen to the brain, such as cardiac output and arterial oxygen content, together with their conditioning factors and possible alterations. Special attention is paid to the basic elements of physiological neuroprotection, and we describe the multiple causes of cerebral hypoxia, how to approach them, and how to correct them. We also examine the increase in intracranial pressure as a physiopathological element, focussing on the significance of thoracic and abdominal pressure in the interpretation of intracranial pressure. Treatment of intracranial pressure should be based on a step-wise model, the first stage of which should be based on a physiopathological reflection combined with information on the tomographic lesions rather than on rigid numerical values.
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Affiliation(s)
- D A Godoy
- Unidad de Cuidados Neurointensivos, Sanatorio Pasteur, Catamarca, Argentina; Unidad de Terapia Intensiva, Hospital San Juan Bautista, Catamarca, Argentina.
| | - R Badenes
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Valencia, Valencia, Spain; Departamento de Cirugía, Universitat de València, Valencia, Spain; Instituto de Investigación Sanitaria de Valencia (INCLIVA), Valencia, Spain
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Mohney N, Alkhatib O, Koch S, O'Phelan K, Merenda A. What is the Role of Hyperosmolar Therapy in Hemispheric Stroke Patients? Neurocrit Care 2021; 32:609-619. [PMID: 31342452 DOI: 10.1007/s12028-019-00782-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The role of hyperosmolar therapy (HT) in large hemispheric ischemic or hemorrhagic strokes remains a controversial issue. Past and current stroke guidelines state that it represents a reasonable therapeutic measure for patients with either neurological deterioration or intracranial pressure (ICP) elevations documented by ICP monitoring. However, the lack of evidence for a clear effect of this therapy on radiological tissue shifts and clinical outcomes produces uncertainty with respect to the appropriateness of its implementation and duration in the context of radiological mass effect without clinical correlates of neurological decline or documented elevated ICP. In addition, limited data suggest a theoretical potential for harm from the prophylactic and protracted use of HT in the setting of large hemispheric lesions. HT exerts effects on parenchymal volume, cerebral blood volume and cerebral perfusion pressure which may ameliorate global ICP elevation and cerebral blood flow; nevertheless, it also holds theoretical potential for aggravating tissue shifts promoted by significant interhemispheric ICP gradients that may arise in the setting of a large unilateral supratentorial mass lesion. The purpose of this article is to review the literature in order to shed light on the effects of HT on brain tissue shifts and clinical outcome in the context of large hemispheric strokes, as well as elucidate when HT should be initiated and when it should be avoided.
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Affiliation(s)
- Nathan Mohney
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
- Department of Neurosurgery, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Omar Alkhatib
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
- Department of Neurosurgery, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Sebastian Koch
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
- Department of Neurosurgery, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Kristine O'Phelan
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
- Department of Neurosurgery, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Amedeo Merenda
- Department of Neurology, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA.
- Department of Neurosurgery, University of Miami Health System, 1120 NW 14th Street, Miami, FL, 33136, USA.
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15
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Godoy DA, Badenes R, Murillo-Cabezas F. Ten physiological commandments for severe head injury. ACTA ACUST UNITED AC 2021; 68:280-292. [PMID: 33487456 DOI: 10.1016/j.redar.2020.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 09/05/2020] [Accepted: 09/07/2020] [Indexed: 11/17/2022]
Abstract
Advances in multiparametric brain monitoring have allowed us to deepen our knowledge of the physiopathology of head injury and how it can be treated using the therapies available today. It is essential to understand and interpret a series of basic physiological and physiopathological principles that, on the one hand, provide an adequate metabolic environment to prevent worsening of the primary brain injury and favour its recovery, and on the other hand, allow therapeutic resources to be individually adapted to the specific needs of the patient. Based on these notions, this article presents a decalogue of the physiological objectives to be achieved in brain injury, together with a series of diagnostic and therapeutic recommendations for achieving these goals. We emphasise the importance of considering and analysing the physiological variables involved in the transport of oxygen to the brain, such as cardiac output and arterial oxygen content, together with their conditioning factors and possible alterations. Special attention is paid to the basic elements of physiological neuroprotection, and we describe the multiple causes of cerebral hypoxia, how to approach them, and how to correct them. We also examine the increase in intracranial pressure as a physiopathological element, focussing on the significance of thoracic and abdominal pressure in the interpretation of intracranial pressure. Treatment of intracranial pressure should be based on a step-wise model, the first stage of which should be based on a physiopathological reflection combined with information on the tomographic lesions rather than on rigid numerical values.
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Affiliation(s)
- D A Godoy
- Unidad de Cuidados Neurointensivos, Sanatorio Pasteur, Catamarca, Argentina; Unidad de Terapia Intensiva, Hospital San Juan Bautista, Catamarca, Argentina.
| | - R Badenes
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Valencia, Valencia, España; Departamento de Cirugía, Universitat de València, Valencia, España; Instituto de Investigación Sanitaria de Valencia (INCLIVA), Valencia, España
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16
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Mismatch between Tissue Partial Oxygen Pressure and Near-Infrared Spectroscopy Neuromonitoring of Tissue Respiration in Acute Brain Trauma: The Rationale for Implementing a Multimodal Monitoring Strategy. Int J Mol Sci 2021; 22:ijms22031122. [PMID: 33498736 PMCID: PMC7865258 DOI: 10.3390/ijms22031122] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 12/21/2022] Open
Abstract
The brain tissue partial oxygen pressure (PbtO2) and near-infrared spectroscopy (NIRS) neuromonitoring are frequently compared in the management of acute moderate and severe traumatic brain injury patients; however, the relationship between their respective output parameters flows from the complex pathogenesis of tissue respiration after brain trauma. NIRS neuromonitoring overcomes certain limitations related to the heterogeneity of the pathology across the brain that cannot be adequately addressed by local-sample invasive neuromonitoring (e.g., PbtO2 neuromonitoring, microdialysis), and it allows clinicians to assess parameters that cannot otherwise be scanned. The anatomical co-registration of an NIRS signal with axial imaging (e.g., computerized tomography scan) enhances the optical signal, which can be changed by the anatomy of the lesions and the significance of the radiological assessment. These arguments led us to conclude that rather than aiming to substitute PbtO2 with tissue saturation, multiple types of NIRS should be included via multimodal systemic- and neuro-monitoring, whose values then are incorporated into biosignatures linked to patient status and prognosis. Discussion on the abnormalities in tissue respiration due to brain trauma and how they affect the PbtO2 and NIRS neuromonitoring is given.
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17
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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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18
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Forcione M, Yakoub KM, Chiarelli AM, Perpetuini D, Merla A, Sun R, Sawosz P, Belli A, Davies DJ. Dynamic contrast-enhanced near-infrared spectroscopy using indocyanine green on moderate and severe traumatic brain injury: a prospective observational study. Quant Imaging Med Surg 2020; 10:2085-2097. [PMID: 33139989 PMCID: PMC7547258 DOI: 10.21037/qims-20-742] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/08/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND The care given to moderate and severe traumatic brain injury (TBI) patients may be hampered by the inability to tailor their treatments according to their neurological status. Contrast-enhanced near-infrared spectroscopy (NIRS) with indocyanine green (ICG) could be a suitable neuromonitoring tool. METHODS Monitoring the effective attenuation coefficients (EAC), we compared the ICG kinetics between five TBI and five extracranial trauma patients, following a venous-injection of 5 mL of 1 mg/mL ICG, using two commercially available NIRS devices. RESULTS A significantly slower passage of the dye through the brain of the TBI group was observed in two parameters related to the first ICG inflow into the brain (P=0.04; P=0.01). This is likely related to the reduction of cerebral perfusion following TBI. Significant changes in ICG optical properties minutes after injection (P=0.04) were registered. The acquisition of valid optical data in a clinical environment was challenging. CONCLUSIONS Future research should analyze abnormalities in the ICG kinetic following brain trauma, test how these values can enhance care in TBI, and adapt the current optical devices to clinical settings. Also, studies on the pattern in changes of ICG optical properties after venous injection can improve the accuracy of the values detected.
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Affiliation(s)
- Mario Forcione
- University Hospitals Birmingham NHS Foundation Trust, National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre (NIHR-SRMRC), Mindelsohn Way, Birmingham, UK
- University of Birmingham, Neuroscience & Ophthalmology Research Group, Institute of Inflammation & Ageing, College of Medical and Dental Sciences, Edgbaston, Birmingham, UK
| | - Kamal Makram Yakoub
- University Hospitals Birmingham NHS Foundation Trust, National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre (NIHR-SRMRC), Mindelsohn Way, Birmingham, UK
| | - Antonio Maria Chiarelli
- University G. D’Annunzio of Chieti-Pescara, Institute for Advanced Biomedical Technologies, Department of Neuroscience, Imaging and Clinical Sciences, Chieti, Italy
| | - David Perpetuini
- University G. D’Annunzio of Chieti-Pescara, Institute for Advanced Biomedical Technologies, Department of Neuroscience, Imaging and Clinical Sciences, Chieti, Italy
| | - Arcangelo Merla
- University G. D’Annunzio of Chieti-Pescara, Institute for Advanced Biomedical Technologies, Department of Neuroscience, Imaging and Clinical Sciences, Chieti, Italy
| | - Rosa Sun
- University Hospitals Birmingham NHS Foundation Trust, National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre (NIHR-SRMRC), Mindelsohn Way, Birmingham, UK
| | - Piotr Sawosz
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Trojdena 4, Warsaw, Poland
| | - Antonio Belli
- University Hospitals Birmingham NHS Foundation Trust, National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre (NIHR-SRMRC), Mindelsohn Way, Birmingham, UK
- University of Birmingham, Neuroscience & Ophthalmology Research Group, Institute of Inflammation & Ageing, College of Medical and Dental Sciences, Edgbaston, Birmingham, UK
| | - David James Davies
- University Hospitals Birmingham NHS Foundation Trust, National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre (NIHR-SRMRC), Mindelsohn Way, Birmingham, UK
- University of Birmingham, Neuroscience & Ophthalmology Research Group, Institute of Inflammation & Ageing, College of Medical and Dental Sciences, Edgbaston, Birmingham, UK
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19
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Rovegno M, Vera M, Ruiz A, Benítez C. Current concepts in acute liver failure. Ann Hepatol 2020; 18:543-552. [PMID: 31126880 DOI: 10.1016/j.aohep.2019.04.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 03/29/2019] [Accepted: 04/02/2019] [Indexed: 02/04/2023]
Abstract
Acute liver failure (ALF) is a severe condition secondary to a myriad of causes associated with poor outcomes. The prompt diagnosis and identification of the aetiology allow the administration of specific treatments plus supportive strategies and to define the overall prognosis, the probability of developing complications and the need for liver transplantation. Pivotal issues are adequate monitoring and the institution of prophylactic strategies to reduce the risk of complications, such as progressive liver failure, cerebral oedema, renal failure, coagulopathies or infections. In this article, we review the main aspects of ALF, including the definition, diagnosis and complications. Also, we describe the standard-of-care strategies and recent advances in the treatment of ALF. Finally, we include our experience of care patients with ALF.
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Affiliation(s)
- Maximiliano Rovegno
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
| | - Magdalena Vera
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
| | - Alex Ruiz
- Unidad de Gastroenterología, Instituto de Medicina, Escuela de Medicina, Universidad Austral de Chile, Chile
| | - Carlos Benítez
- Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile.
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20
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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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21
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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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22
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Nourallah B, Menon DK, Zeiler FA. Midline Shift is Unrelated to Subjective Pupillary Reactivity Assessment on Admission in Moderate and Severe Traumatic Brain Injury. Neurocrit Care 2019; 29:203-213. [PMID: 29619661 PMCID: PMC6208863 DOI: 10.1007/s12028-018-0526-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background This study aims to determine the relationship between pupillary reactivity, midline shift and basal cistern effacement on brain computed tomography (CT) in moderate-to-severe traumatic brain injury (TBI). All are important diagnostic and prognostic measures, but their relationship is unclear. Methods A total of 204 patients with moderate-to-severe TBI, documented pupillary reactivity, and archived neuroimaging were included. Extent of midline shift and basal cistern effacement were extracted from admission brain CT. Mean midline shift was calculated for each ordinal category of pupillary reactivity and basal cistern effacement. Sequential Chi-square analysis was used to calculate a threshold midline shift for pupillary abnormalities and basal cistern effacement. Univariable and multiple logistic regression analyses were performed. Results Pupils were bilaterally reactive in 163 patients, unilaterally reactive in 24, and bilaterally unreactive in 17, with mean midline shift (mm) of 1.96, 3.75, and 2.56, respectively (p = 0.14). Basal cisterns were normal in 118 patients, compressed in 45, and absent in 41, with mean midline shift (mm) of 0.64, 2.97, and 5.93, respectively (p < 0.001). Sequential Chi-square analysis identified a threshold for abnormal pupils at a midline shift of 7–7.25 mm (p = 0.032), compressed basal cisterns at 2 mm (p < 0.001), and completely effaced basal cisterns at 7.5 mm (p < 0.001). Logistic regression revealed no association between midline shift and pupillary reactivity. With effaced basal cisterns, the odds ratio for normal pupils was 0.22 (95% CI 0.08–0.56; p = 0.0016) and for at least one unreactive pupil was 0.061 (95% CI 0.012–0.24; p < 0.001). Basal cistern effacement strongly predicted midline shift (OR 1.27; 95% CI 1.17–1.40; p < 0.001). Conclusions Basal cistern effacement alone is associated with pupillary reactivity and is closely associated with midline shift. It may represent a uniquely useful neuroimaging marker to guide intervention in traumatic brain injury.
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Affiliation(s)
- Basil Nourallah
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Frederick A Zeiler
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, R3A 1R9, Canada.,Clinician Investigator Program, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
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23
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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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24
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Nag DS, Sahu S, Swain A, Kant S. Intracranial pressure monitoring: Gold standard and recent innovations. World J Clin Cases 2019; 7:1535-1553. [PMID: 31367614 PMCID: PMC6658373 DOI: 10.12998/wjcc.v7.i13.1535] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/11/2019] [Accepted: 05/23/2019] [Indexed: 02/05/2023] Open
Abstract
Intracranial pressure monitoring (ICP) is based on the doctrine proposed by Monroe and Kellie centuries ago. With the advancement of technology and science, various invasive and non-invasive modalities of monitoring ICP continue to be developed. An ideal monitor to track ICP should be easy to use, accurate, reliable, reproducible, inexpensive and should not be associated with infection or haemorrhagic complications. Although the transducers connected to the extra ventricular drainage continue to be Gold Standard, its association with the likelihood of infection and haemorrhage have led to the search for alternate non-invasive methods of monitoring ICP. While Camino transducers, Strain gauge micro transducer based ICP monitoring devices and the Spiegelberg ICP monitor are the emerging technology in invasive ICP monitoring, optic nerve sheath diameter measurement, venous opthalmodynamometry, tympanic membrane displacement, tissue resonance analysis, tonometry, acoustoelasticity, distortion-product oto-acoustic emissions, trans cranial doppler, electro encephalogram, near infra-red spectroscopy, pupillometry, anterior fontanelle pressure monitoring, skull elasticity, jugular bulb monitoring, visual evoked response and radiological based assessment of ICP are the non-invasive methods which are assessed against the gold standard.
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Affiliation(s)
- Deb Sanjay Nag
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
| | - Seelora Sahu
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
| | - Amlan Swain
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
| | - Shashi Kant
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
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25
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Bor-Seng-Shu E, de-Lima-Oliveira M, Nogueira RC, Almeida KJ, Paschoal EHA, Paschoal FM. Decompressive Craniectomy for Traumatic Brain Injury: Postoperative TCD Cerebral Hemodynamic Evaluation. Front Neurol 2019; 10:354. [PMID: 31031689 PMCID: PMC6473100 DOI: 10.3389/fneur.2019.00354] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 03/22/2019] [Indexed: 12/31/2022] Open
Abstract
Background: There are no studies describing the cerebral hemodynamic patterns that can occur in traumatic brain injury (TBI) patients following decompressive craniectomy (DC). Such data have potentially clinical importance for guiding the treatment. The objective of this study was to investigate the postoperative cerebral hemodynamic patterns, using transcranial Doppler (TCD) ultrasonography, in patients who underwent DC. The relationship between the cerebral circulatory patterns and the patients' outcome was also analyzed. Methods: Nineteen TBI patients with uncontrolled brain swelling were prospectively studied. Cerebral blood circulation was evaluated by TCD ultrasonography. Patients and their cerebral hemispheres were categorized based on TCD-hemodynamic patterns. The data were correlated with neurological status, midline shift on CT scan, and Glasgow outcome scale scores at 6 months after injury. Results: Different cerebral hemodynamic patterns were observed. One patient (5.3%) presented with cerebral oligoemia, 4 patients (21%) with cerebral hyperemia, and 3 patients (15.8%) with cerebral vasospasm. One patient (5.3%) had hyperemia in one cerebral hemisphere and vasospasm in the other hemisphere. Ten patients (52.6%) had nonspecific circulatory pattern. Abnormal TCD-circulatory patterns were found in 9 patients (47.4%). There was no association between TCD-cerebral hemodynamic findings and outcome. Conclusion: There is a wide heterogeneity of postoperative cerebral hemodynamic findings among TBI patients who underwent DC, including hemodynamic heterogeneity between their cerebral hemispheres. DC was proved to be effective for the treatment of cerebral oligoemia. Our data support the concept of heterogeneous nature of the pathophysiology of the TBI and suggest that DC as the sole treatment modality is insufficient.
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Affiliation(s)
- Edson Bor-Seng-Shu
- Laboratory for Neurosonology and Cerebral Hemodynamics, Division of Neurological Surgery, Hospital das Clinicas, São Paulo University Medical School, São Paulo, Brazil
| | - Marcelo de-Lima-Oliveira
- Laboratory for Neurosonology and Cerebral Hemodynamics, Division of Neurological Surgery, Hospital das Clinicas, São Paulo University Medical School, São Paulo, Brazil
| | - Ricardo Carvalho Nogueira
- Laboratory for Neurosonology and Cerebral Hemodynamics, Division of Neurological Surgery, Hospital das Clinicas, São Paulo University Medical School, São Paulo, Brazil
| | - Kelson James Almeida
- Department of Neurology, Federal University of Piauí Medical School, Teresina, Brazil
| | | | - Fernando Mendes Paschoal
- Laboratory for Neurosonology and Cerebral Hemodynamics, Division of Neurological Surgery, Hospital das Clinicas, São Paulo University Medical School, São Paulo, Brazil.,Department of Neurology, Federal University of Pará Medical School, São Paulo, Brazil
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26
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Cardim D, Robba C, Schmidt B, Donnelly J, Schmidt EA, Bohdanowicz M, Smielewski P, Czosnyka M. Midline shift in patients with closed traumatic brain injury may be driven by cerebral perfusion pressure not intracranial pressure. J Neurosurg Sci 2019; 65:383-390. [PMID: 30724053 DOI: 10.23736/s0390-5616.19.04604-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND In traumatic brain injury (TBI), swelling may disturb the potentially uniform pressure distribution in the brain, producing sustained intercompartmental pressure gradients which may associate with midline shift. The presence of pressure gradients is often neglected since bilateral invasive intracranial pressure (ICP) monitoring is not usually considered because of risks and high costs. We evaluated the presence of interhemispheric pressure gradients using bilateral transcranial Doppler (TCD) as means for non-invasive ICP (nICP) monitoring in TBI patients presenting midline shift. METHODS From a retrospective cohort of 97 TBI patients with arterial blood pressure (ABP), ICP and bilateral TCD monitoring, 24 presented unilateral lesion and midline shift confirmed by computer tomography. nICP and non-invasive cerebral perfusion pressure (nCPP) on the left and right brain hemispheres were retrospectively calculated using a mathematical model associating TCD-derived cerebral blood flow velocity and ABP. RESULTS The nCPP difference was correlated with midline shift (R=-0.34, p<.01) showing a tendency to record higher CPP at the side of expansion. Accordingly, nICP at the side of expansion was significantly lower in comparison to the compressed side (18.86 [±5.71] mmHg (mean ± standard deviation) versus 20.30 [±6.78] mmHg for expansion and compressed sides, respectively). Subsequently, nCPP was greater on the side of brain expansion (79.48±7.84, 78.03±8.93 mmHg [p<.01], for expansion and compressed sides, respectively). CONCLUSIONS TCD-based interhemispheric nCPP difference showed significant correlation with midline shift. Cerebral perfusion pressure was greater on the side of brain expansion, acting as the driving force to shift brain structures.
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Affiliation(s)
- Danilo Cardim
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Chiara Robba
- Neurosciences Critical Care Unit, Addenbrooke's Hospital, Cambridge University NHS Foundation Trust, Cambridge, UK - .,Department of Neuroscience, University of Genoa, Genoa, Italy
| | - Bernhard Schmidt
- Department of Neurology, University Hospital Chemnitz, Chemnitz, Germany
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Eric A Schmidt
- Service de Neurochirurgie, Hôpital Universitaire Toulouse-Purpan, Toulouse, France
| | - Michal Bohdanowicz
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
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27
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Petkus V, Preiksaitis A, Krakauskaite S, Bartusis L, Chomskis R, Hamarat Y, Zubaviciute E, Vosylius S, Rocka S, Ragauskas A. Non-invasive Cerebrovascular Autoregulation Assessment Using the Volumetric Reactivity Index: Prospective Study. Neurocrit Care 2019; 30:42-50. [PMID: 29951960 DOI: 10.1007/s12028-018-0569-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND This prospective study of an innovative non-invasive ultrasonic cerebrovascular autoregulation (CA) monitoring method is based on real-time measurements of intracranial blood volume (IBV) reactions following changes in arterial blood pressure. In this study, we aimed to determine the clinical applicability of a non-invasive CA monitoring method by performing a prospective comparative clinical study of simultaneous invasive and non-invasive CA monitoring on intensive care patients. METHODS CA was monitored in 61 patients with severe traumatic brain injuries invasively by calculating the pressure reactivity index (PRx) and non-invasively by calculating the volumetric reactivity index (VRx) simultaneously. The PRx was calculated as a moving correlation coefficient between intracranial pressure and arterial blood pressure slow waves. The VRx was calculated as a moving correlation coefficient between arterial blood pressure and non-invasively-measured IBV slow waves. RESULTS A linear regression between VRx and PRx averaged per patients' monitoring session showed a significant correlation (r = 0.843, p < 0.001; 95% confidence interval 0.751 - 0.903). The standard deviation of the difference between VRx and PRx was 0.192; bias was - 0.065. CONCLUSIONS This prospective clinical study of the non-invasive ultrasonic volumetric reactivity index VRx monitoring, based on ultrasonic time-of-flight measurements of IBV dynamics, showed significant coincidence of non-invasive VRx index with invasive PRx index. The ultrasonic time-of-flight method reflects blood volume changes inside the acoustic path, which crosses both hemispheres of the brain. This method does not reflect locally and invasively-recorded intracranial pressure slow waves, but the autoregulatory reactions of both hemispheres of the brain. Therefore, VRx can be used as a non-invasive cerebrovascular autoregulation index in the same way as PRx and can also provide information about the CA status encompassing all intracranial hemodynamics.
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Affiliation(s)
- Vytautas Petkus
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania.
| | - Aidanas Preiksaitis
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania.,Department of Neurology, Academy of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania.,Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Department of Neurosurgery, Republic Vilnius University Hospital, Vilnius, Lithuania
| | - Solventa Krakauskaite
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Laimonas Bartusis
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Romanas Chomskis
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Yasin Hamarat
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Erika Zubaviciute
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Department of Neurosurgery, Republic Vilnius University Hospital, Vilnius, Lithuania
| | - Saulius Vosylius
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Department of Neurosurgery, Republic Vilnius University Hospital, Vilnius, Lithuania
| | - Saulius Rocka
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Department of Neurosurgery, Republic Vilnius University Hospital, Vilnius, Lithuania
| | - Arminas Ragauskas
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
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Cardim D, Griesdale DE, Ainslie PN, Robba C, Calviello L, Czosnyka M, Smielewski P, Sekhon MS. A comparison of non-invasive versus invasive measures of intracranial pressure in hypoxic ischaemic brain injury after cardiac arrest. Resuscitation 2019; 137:221-228. [PMID: 30629992 DOI: 10.1016/j.resuscitation.2019.01.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/23/2018] [Accepted: 01/02/2019] [Indexed: 10/27/2022]
Abstract
AIM Increased intracranial pressure (ICP) in hypoxic ischaemic brain injury (HIBI) can cause secondary ischaemic brain injury and culminate in brain death. Invasive ICP monitoring is limited by associated risks in HIBI patients. We sought to evaluate the agreement between invasive ICP measurements and non-invasive estimators of ICP (nICP) in HIBI patients. METHODS Eligible consecutive adult (age>18) cardiac arrest patients with HIBI were included as part of a single centre prospective interventional study. Invasive ICP monitoring and nICP measurements were undertaken using: a) transcranial Doppler ultrasonography (TCD), b) optic nerve sheet diameter ultrasound (ONSD) and c) jugular venous bulb pressure (JVP). Multiple measurements applied in linear mixed-effects models were considered to obtain the correlation coefficient between ICP and nICP as well as their predictive abilities to detect intracranial hypertension (ICP≥20mm Hg). RESULTS Eleven patients were included (median age of 47 [range 20-71], 8 males and 3 females). There was a linear relationship between ICP and nICP with ONSD (R=0.53 [p<0.0001]), JVP (R=0.38 [p<0.001]) and TCD (R=0.30 [p<0.01]). The ability to predict intracranial hypertension was highest for ONSD and TCD (area under the receiver operating curve (AUC)=0.96 [95% CI: 0.90-1.00] and AUC=0.91 [95% CI: 0.83-1.00], respectively). JVP presented the weakest prediction ability (AUC=0.75 [95% CI: 0.56-0.94]). CONCLUSIONS ONSD and TCD methods demonstrated agreement with invasively-monitored ICP, suggesting their potential roles in the detection of intracranial hypertension in HIBI after cardiac arrest.
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Affiliation(s)
- Danilo Cardim
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, The University of British Columbia, Vancouver, BC, Canada,.
| | - Donald E Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, The University of British Columbia, Vancouver, BC, Canada,; Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, The University of British Columbia, Vancouver, BC, Canada,; Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, The University of British Columbia, Vancouver, BC, Canada
| | - Philip N Ainslie
- Department of Health and Exercise Sciences, The University of British Columbia - Okanagan, Kelowna, BC, Canada
| | - Chiara Robba
- Anaesthesia and Intensive Care, IRCCS San Martino, Genova, Italy
| | - Leanne Calviello
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, United Kingdom; Institute of Electronic Systems, Warsaw University of Technology, Poland
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, United Kingdom
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, The University of British Columbia, Vancouver, BC, Canada
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29
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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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30
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Narasimhan S, Weis JA, González HFJ, Thompson RC, Miga MI. In vivo modeling of interstitial pressure in a porcine model: approximation of poroelastic properties and effects of enhanced anatomical structure modeling. J Med Imaging (Bellingham) 2018; 5:045002. [PMID: 30840744 DOI: 10.1117/1.jmi.5.4.045002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 11/02/2018] [Indexed: 12/13/2022] Open
Abstract
The purpose of this investigation is to test whether a poroelastic model with enhanced structure can capture in vivo interstitial pressure dynamics in a brain undergoing mock surgical loads. Using interstitial pressure data from a porcine study, we use an inverse model to reconstruct material properties in an effort to capture these in vivo brain tissue dynamics. Four distinct models for the reconstruction of parameters are investigated (full anatomical condition description, condition without dural septa description, condition without ventricle boundary description, and the conventional fully saturated model). These models are systematic in their development to isolate the influence of three model characteristics: the dural septa, the treatment of the ventricles, and the treatment of the brain as a saturated media. This study demonstrates that to capture appropriate pressure compartmentalization, interstitial pressure gradients, pressure transient effects, and deformations within the brain, the proposed boundary conditions and structural enhancement coupled with a heterogeneous description invoking partial saturation are needed in a biphasic poroelastic model. These findings suggest that with enhanced anatomical modeling and appropriate model assumptions, poroelastic models can be used to capture quite complex brain deformations and interstitial pressure dynamics.
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Affiliation(s)
- Saramati Narasimhan
- Vanderbilt University, Department of Biomedical Engineering, Nashville, Tennessee, United States
| | - Jared A Weis
- Wake Forest School of Medicine, Department of Biomedical Engineering, Winston-Salem, North Carolina, United States
| | - Hernán F J González
- Vanderbilt University, Department of Biomedical Engineering, Nashville, Tennessee, United States
| | - Reid C Thompson
- Vanderbilt University Medical Center, Department of Neurological Surgery, Nashville, Tennessee, United States
| | - Michael I Miga
- Vanderbilt University, Department of Biomedical Engineering, Nashville, Tennessee, United States
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31
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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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32
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Herklots MW, Moudrous W, Oldenbeuving A, Roks G, Mourtzoukos S, Schoonman GG, Ganslandt O. Prospective Evaluation of Noninvasive HeadSense Intracranial Pressure Monitor in Traumatic Brain Injury Patients Undergoing Invasive Intracranial Pressure Monitoring. World Neurosurg 2017; 106:557-562. [PMID: 28712896 DOI: 10.1016/j.wneu.2017.07.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/04/2017] [Accepted: 07/06/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Martin W Herklots
- Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands.
| | - Walid Moudrous
- Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands
| | - Annemarie Oldenbeuving
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands
| | - Gerwin Roks
- Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands
| | | | - Guus G Schoonman
- Department of Neurology, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands
| | - Oliver Ganslandt
- Department of Neurosurgery, Stuttgart Hospital, Stuttgart, Germany
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33
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Nordström CH, Koskinen LO, Olivecrona M. Aspects on the Physiological and Biochemical Foundations of Neurocritical Care. Front Neurol 2017; 8:274. [PMID: 28674514 PMCID: PMC5474476 DOI: 10.3389/fneur.2017.00274] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 05/29/2017] [Indexed: 12/25/2022] Open
Abstract
Neurocritical care (NCC) is a branch of intensive care medicine characterized by specific physiological and biochemical monitoring techniques necessary for identifying cerebral adverse events and for evaluating specific therapies. Information is primarily obtained from physiological variables related to intracranial pressure (ICP) and cerebral blood flow (CBF) and from physiological and biochemical variables related to cerebral energy metabolism. Non-surgical therapies developed for treating increased ICP are based on knowledge regarding transport of water across the intact and injured blood-brain barrier (BBB) and the regulation of CBF. Brain volume is strictly controlled as the BBB permeability to crystalloids is very low restricting net transport of water across the capillary wall. Cerebral pressure autoregulation prevents changes in intracranial blood volume and intracapillary hydrostatic pressure at variations in arterial blood pressure. Information regarding cerebral oxidative metabolism is obtained from measurements of brain tissue oxygen tension (PbtO2) and biochemical data obtained from intracerebral microdialysis. As interstitial lactate/pyruvate (LP) ratio instantaneously reflects shifts in intracellular cytoplasmatic redox state, it is an important indicator of compromised cerebral oxidative metabolism. The combined information obtained from PbtO2, LP ratio, and the pattern of biochemical variables reveals whether impaired oxidative metabolism is due to insufficient perfusion (ischemia) or mitochondrial dysfunction. Intracerebral microdialysis and PbtO2 give information from a very small volume of tissue. Accordingly, clinical interpretation of the data must be based on information of the probe location in relation to focal brain damage. Attempts to evaluate global cerebral energy state from microdialysis of intraventricular fluid and from the LP ratio of the draining venous blood have recently been presented. To be of clinical relevance, the information from all monitoring techniques should be presented bedside online. Accordingly, in the future, the chemical variables obtained from microdialysis will probably be analyzed by biochemical sensors.
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Affiliation(s)
| | - Lars-Owe Koskinen
- Department of Clinical Neuroscience, Division of Neurosurgery, Umeå University, Umeå, Sweden
| | - Magnus Olivecrona
- Faculty of Health and Medicine, Department of Anesthesia and Intensive Care, Section for Neurosurgery Örebro University Hospital, Örebro University, Örebro, Sweden
- Department for Medical Sciences, Örebro University, Örebro, Sweden
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Vidal-Jorge M, Sánchez-Guerrero A, Mur-Bonet G, Castro L, Rădoi A, Riveiro M, Fernández-Prado N, Baena J, Poca MA, Sahuquillo J. Does Normobaric Hyperoxia Cause Oxidative Stress in the Injured Brain? A Microdialysis Study Using 8-Iso-Prostaglandin F2α as a Biomarker. J Neurotrauma 2017; 34:2731-2742. [PMID: 28323516 DOI: 10.1089/neu.2017.4992] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Significant controversy exists regarding the potential clinical benefit of normobaric hyperoxia (NBO) in patients with traumatic brain injury (TBI). This study consisted of two aims: 1) to assess whether NBO improves brain oxygenation and metabolism and 2) to determine whether this therapy may increase the risk of oxidative stress (OxS), using 8-iso-Prostaglandin F2α (PGF2α) as a biomarker. Thirty-one patients with a median admission Glasgow Coma Scale score of 4 (min: 3, max: 12) were monitored with cerebral microdialysis and brain tissue oxygen sensors and treated with fraction of inspired oxygen (FiO2) of 1.0 for 4 h. Patients were divided into two groups according to the area monitored by the probes: normal injured brain and traumatic penumbra/traumatic core. NBO maintained for 4 h did not induce OxS in patients without preOxS at baseline, except in one case. However, for patients in whom OxS was detected at baseline, NBO induced a significant increase in 8-iso-PGF2α. The results of our study showed that NBO did not change energy metabolism in the whole group of patients. In the five patients with brain lactate concentration ([Lac]brain) > 3.5 mmol/L at baseline, NBO induced a marked reduction in both [Lac]brain and lactate-to-pyruvate ratio. Although these differences were not statistically significant, together with the results of our previous study, they suggest that TBI patients would benefit from receiving NBO when they show indications of disturbed brain metabolism. These findings, in combination with increasing evidence that TBI metabolic crises are common without brain ischemia, open new possibilities for the use of this accessible therapeutic strategy in TBI patients.
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Affiliation(s)
- Marian Vidal-Jorge
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Angela Sánchez-Guerrero
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Gemma Mur-Bonet
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Lidia Castro
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Andreea Rădoi
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain
| | - Marilyn Riveiro
- 2 Neurotraumatology Intensive Care Unit, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Natalia Fernández-Prado
- 2 Neurotraumatology Intensive Care Unit, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jacinto Baena
- 2 Neurotraumatology Intensive Care Unit, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria-Antonia Poca
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain .,3 Department of Neurosurgery, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Sahuquillo
- 1 Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR) , Barcelona, Spain .,3 Department of Neurosurgery, Vall d'Hebron University Hospital , Universitat Autònoma de Barcelona, Barcelona, Spain
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[Intensive care treatment after aneurysmal subarachnoid hemorrhage]. Anaesthesist 2017; 65:951-970. [PMID: 27900416 DOI: 10.1007/s00101-016-0242-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a devastating disease and nearly one third of patients die in the acute phase. Due to the bleeding event, a hyperactive sympathetic nervous system and an uncontrolled inflammatory response have a profound local and systemic impact on other organ functions. Neuroendocrinological disorders and cardiopulmonary morbidity are dominant. Despite a decrease in hospital mortality for high volume centers, a high proportion of survivors suffer from neurological deficits. Knowledge of the pathophysiology of vasospasms in the later stages of the disease has increased. Anti-inflammatory treatment does not improve the outcome. Nimodipine prophylaxis in the first 96 h after SAH seems to be the only intervention which has been proven to be advantageous in studies; however, nearly every second survivor of SAH suffers from some neurological deficits and more than one third of survivors report depressive episodes or symptoms of posttraumatic stress disorder.
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36
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Abstract
Management of patients with aneurysmal subarachnoid hemorrhage focuses on prevention of rebleeding by early treatment of the aneurysm, as well as detection and management of neurologic and medical complications. Early detection of delayed cerebral ischemia and management of modifiable contributing causes such as vasospasm take a central role, with the goal of preventing irreversible cerebral injury. In efforts to prevent delayed cerebral ischemia, multimodality monitoring has emerged as a promising tool in detecting subclinical physiologic changes before infarction occurs. However, there has been much variability in the utilization of this technology. Recent consensus guidelines discuss the role of multimodality monitoring in acute brain injury. In this review, we evaluate these guidelines and the utility of each modality of multimodality monitoring in aneurysmal subarachnoid hemorrhage.
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37
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Hirzallah MI, Choi HA. The Monitoring of Brain Edema and Intracranial Hypertension. JOURNAL OF NEUROCRITICAL CARE 2016. [DOI: 10.18700/jnc.160093] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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38
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Mahdavi ZK, Olson DM, Figueroa SA. Association Patterns of Simultaneous Intraventricular and Intraparenchymal Intracranial Pressure Measurements. Neurosurgery 2016; 79:561-7. [DOI: 10.1227/neu.0000000000001265] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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39
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Phang I, Papadopoulos MC. Intraspinal Pressure Monitoring in a Patient with Spinal Cord Injury Reveals Different Intradural Compartments: Injured Spinal Cord Pressure Evaluation (ISCoPE) Study. Neurocrit Care 2016; 23:414-8. [PMID: 26136148 DOI: 10.1007/s12028-015-0153-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND We recently described a technique for monitoring intraspinal pressure (ISP) after traumatic spinal cord injury (TSCI). This is analogous to intracranial pressure monitoring after brain injury. We showed that, after severe TSCI, ISP at the injury site is elevated as the swollen cord is compressed against the dura. METHODS In a patient with complete thoracic TSCI, we sequentially monitored subdural ISP above the injury, at the injury site, and below the injury intraoperatively. Postoperatively, we simultaneously monitored subdural ISP and intraparenchymal ISP at the injury site and compared the two ISP signals as well as their Fast Fourier Transform spectra. RESULTS Subdural ISP recorded from the injury site was higher than subdural ISP recorded from above or below the injury site by more than 10 mmHg. The subdural and intraparenchymal ISP signals recorded from the injury site had comparable amplitudes and Fast Fourier Transform spectra. Intraparenchymal pulse pressure was twofold larger than subdural pulse pressure. CONCLUSION After severe TSCI, three intradural compartments form (space above injury, injury site, space below injury) with different ISPs. At the level of maximum spinal cord swelling (injury site), subdural ISP is comparable to intraparenchymal ISP.
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Affiliation(s)
- Isaac Phang
- Academic Neurosurgery Unit, St George's University of London, Room 0.136 Jenner Wing, Cranmer Terrace, Tooting, London, SW17 0RE, UK
| | - Marios C Papadopoulos
- Academic Neurosurgery Unit, St George's University of London, Room 0.136 Jenner Wing, Cranmer Terrace, Tooting, London, SW17 0RE, UK.
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40
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Abstract
Increased intracranial pressure (ICP) is a pathologic state common to a variety of serious neurologic conditions, all of which are characterized by the addition of volume to the intracranial vault. Hence all ICP therapies are directed toward reducing intracranial volume. Elevated ICP can lead to brain damage or death by two principle mechanisms: (1) global hypoxic-ischemic injury, which results from reduction of cerebral perfusion pressure (CPP) and cerebral blood flow, and (2) mechanical compression, displacement, and herniation of brain tissue, which results from mass effect associated with compartmentalized ICP gradients. In unmonitored patients with acute neurologic deterioration, head elevation (30 degrees), hyperventilation (pCO2 26-30 mmHg), and mannitol (1.0-1.5 g/kg) can lower ICP within minutes. Fluid-coupled ventricular catheters and intraparenchymal pressure transducers are the most accurate and reliable devices for measuring ICP in the intensive care unit (ICU) setting. In a monitored patient, treatment of critical ICP elevation (>20 mmHg) should proceed in the following steps: (1) consideration of repeat computed tomography (CT) scanning or consideration of definitive neurosurgical intervention, (2) intravenous sedation to attain a quiet, motionless state, (3) optimization of CPP to levels between 70 and 110 mmHg, (4) osmotherapy with mannitol or hypertonic saline, (5) hyperventilation (pCO2 26-30 mmHg), (6) high-dose pentobarbital therapy, and (7) systemic cooling to attain moderate hypothermia (32-33°C). Placement of an ICP monitor and use of a stepwise treatment algorithm are both essential for managing ICP effectively in the ICU setting.
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Affiliation(s)
- Stephan A. Mayer
- Division of Critical Care Neurology, Departments of Neurology, Neurosurgery, College of Physicians and Surgeons, Columbia University, New York, NY,
| | - Ji Y. Chong
- Division of Critical Care Neurology, Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY
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Seule M, Sikorski C, Sakowitz O, von Campe G, Santos E, Orakcioglu B, Unterberg A, Keller E. Evaluation of a New Brain Tissue Probe for Intracranial Pressure, Temperature, and Cerebral Blood Flow Monitoring in Patients with Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2016; 25:193-200. [DOI: 10.1007/s12028-016-0284-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
The challenges posed by acute brain injury (ABI) involve the management of the initial insult in addition to downstream inflammation, edema, and ischemia that can result in secondary brain injury (SBI). SBI is often subclinical, but can be detected through physiologic changes. These changes serve as a surrogate for tissue injury/cell death and are captured by parameters measured by various monitors that measure intracranial pressure (ICP), cerebral blood flow (CBF), brain tissue oxygenation (PbtO2), cerebral metabolism, and electrocortical activity. In the ideal setting, multimodality monitoring (MMM) integrates these neurological monitoring parameters with traditional hemodynamic monitoring and the physical exam, presenting the information needed to clinicians who can intervene before irreversible damage occurs. There are now consensus guidelines on the utilization of MMM, and there continue to be new advances and questions regarding its use. In this review, we examine these recommendations, recent evidence for MMM, and future directions for MMM.
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Affiliation(s)
- David Roh
- Department of Neurology and Neurocritical Care, Columbia University, 177 Fort Washington Ave, New York, NY 10032, USA
| | - Soojin Park
- Department of Neurology and Neurocritical Care, Columbia University, 177 Fort Washington Ave, New York, NY 10032, USA
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Latin American consensus on the use of transcranial Doppler in the diagnosis of brain death. Rev Bras Ter Intensiva 2016; 26:240-52. [PMID: 25295818 PMCID: PMC4188460 DOI: 10.5935/0103-507x.20140035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 03/17/2014] [Indexed: 12/13/2022] Open
Abstract
Transcranial Doppler evaluates cerebral hemodynamics in patients with brain injury and is a useful technical tool in diagnosing cerebral circulatory arrest, usually present in the brain-dead patient. This Latin American Consensus was formed by a group of 26 physicians experienced in the use of transcranial Doppler in the context of brain death. The purpose of this agreement was to make recommendations regarding the indications, technique, and interpretation of the study of transcranial ultrasonography in patients with a clinical diagnosis of brain death or in the patient whose clinical diagnosis presents difficulties; a working group was formed to enable further knowledge and to strengthen ties between Latin American physicians working on the same topic. A review of the literature, concepts,and experiences were exchanged in two meetings and via the Internet. Questions about pathophysiology, equipment, techniques, findings, common problems, and the interpretation of transcranial Doppler in the context of brain death were answered. The basic consensus statements are the following: cerebral circulatory arrest is the final stage in the evolution of progressive intracranial hypertension, which is visualized with transcranial Doppler as a "pattern of cerebral circulatory arrest". The following are accepted as the standard of cerebral circulatory arrest: reverberant pattern, systolic spikes, and absence of previously demonstrated flow. Ultrasonography should be used - in acceptable hemodynamic conditions - in the anterior circulation bilaterally (middle cerebral artery) and in the posterior (basilar artery) territory. If no ultrasonographic images are found in any or all of these vessels, their proximal arteries are acceptable to be studied to look for a a pattern of cerebral circulatory arrest.
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Characterisation of Supra- and Infratentorial ICP Profiles. ACTA NEUROCHIRURGICA SUPPLEMENT 2016; 122:37-40. [DOI: 10.1007/978-3-319-22533-3_7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Advances in Intracranial Pressure Monitoring and Its Significance in Managing Traumatic Brain Injury. Int J Mol Sci 2015; 16:28979-97. [PMID: 26690122 PMCID: PMC4691093 DOI: 10.3390/ijms161226146] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 11/24/2015] [Accepted: 11/24/2015] [Indexed: 12/11/2022] Open
Abstract
Intracranial pressure (ICP) measurements are essential in evaluation and treatment of neurological disorders such as subarachnoid and intracerebral hemorrhage, ischemic stroke, hydrocephalus, meningitis/encephalitis, and traumatic brain injury (TBI). The techniques of ICP monitoring have evolved from invasive to non-invasive-with both limitations and advantages. Some limitations of the invasive methods include short-term monitoring, risk of infection, restricted mobility of the subject, etc. The invasiveness of a method limits the frequency of ICP evaluation in neurological conditions like hydrocephalus, thus hampering the long-term care of patients with compromised ICP. Thus, there has been substantial interest in developing noninvasive techniques for assessment of ICP. Several approaches were reported, although none seem to provide a complete solution due to inaccuracy. ICP measurements are fundamental for immediate care of TBI patients in the acute stages of severe TBI injury. In severe TBI, elevated ICP is associated with mortality or poor clinical outcome. ICP monitoring in conjunction with other neurological monitoring can aid in understanding the pathophysiology of brain damage. This review article presents: (a) the significance of ICP monitoring; (b) ICP monitoring methods (invasive and non-invasive); and (c) the role of ICP monitoring in the management of brain damage, especially TBI.
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Accuracy of intracranial pressure monitoring: systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:420. [PMID: 26627204 PMCID: PMC4667503 DOI: 10.1186/s13054-015-1137-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 11/11/2015] [Indexed: 11/16/2022]
Abstract
Introduction Intracranial pressure (ICP) measurement is used to tailor interventions and to assist in formulating the prognosis for traumatic brain injury patients. Accurate data are therefore essential. The aim of this study was to verify the accuracy of ICP monitoring systems on the basis of a literature review. Methods A PubMed search was conducted from 1982 to 2014, plus additional references from the selected papers. Accuracy was defined as the degree of correspondence between the pressure read by the catheter and a reference “real” ICP measurement. Studies comparing simultaneous readings from at least two catheters were included. Drift was defined as the loss of accuracy over the monitoring period. Meta-analyses of data from the studies were used to estimate the overall mean difference between simultaneous ICP measurements and their variability. Individual studies were weighted using both a fixed and a random effects model. Results Of 163 articles screened, 83 compared two intracranial catheters: 64 reported accuracy and 37 drift (some reported both). Of these, 10 and 17, respectively, fulfilled the inclusion criteria for accuracy and zero drift analysis. The combined mean differences between probes were 1.5 mmHg (95 % confidence interval (CI) 0.7–2.3) with the random effects model and 1.6 mmHg (95 % CI 1.3–1.9) with the fixed effects model. The reported mean drift over a long observation period was 0.75 mmHg. No relation was found with the duration of monitoring or differences between various probes. Conclusions This study confirms that the average error between ICP measures is clinically negligible. The random effects model, however, indicates that a high percentage of readings may vary over a wide range, with clinical implications both for future comparison studies and for daily care.
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Mahdavi Z, Pierre-Louis N, Ho TT, Figueroa SA, Olson DM. Advances in cerebral monitoring for the patient with traumatic brain injury. Crit Care Nurs Clin North Am 2015; 27:213-23. [PMID: 25981724 DOI: 10.1016/j.cnc.2015.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A brief overview of the most common invasive and noninvasive monitoring tools collectively referred to using the term "multimodal monitoring" is provided. Caring for the critically ill patient with traumatic brain injury requires careful monitoring to prevent or reduce secondary brain injury. Concurrent to the growth of the subspecialty of neurocritical care, there has been a concerted effort to discover novel mechanisms to monitor the physiology of brain injury. The past 2 decades have witnessed an exponential growth in neurologic monitoring in terms of intracranial pressure, blood flow, metabolism, oxygenation, advanced neuroimaging, and electrophysiology.
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Affiliation(s)
- Zakraus Mahdavi
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Naregnia Pierre-Louis
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Thuy-Tien Ho
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Stephen A Figueroa
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - DaiWai M Olson
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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Kukreti V, Mohseni-Bod H, Drake J. Management of raised intracranial pressure in children with traumatic brain injury. J Pediatr Neurosci 2015; 9:207-15. [PMID: 25624921 PMCID: PMC4302538 DOI: 10.4103/1817-1745.147572] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Increased intracranial pressure (ICP) is associated with worse outcome after traumatic brain injury (TBI). The current guidelines and management strategies are aimed at maintaining adequate cerebral perfusion pressure and treating elevated ICP. Despite controversies, ICP monitoring is important particularly after severe TBI to guide treatment and in developed countries is accepted as a standard of care. We provide a narrative review of the recent evidence for the use of ICP monitoring and management of ICP in pediatric TBI.
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Affiliation(s)
- Vinay Kukreti
- Department of Neurocritical Care, Children's National Medical Center, Washington, D.C., USA
| | - Hadi Mohseni-Bod
- Department of Pediatric Critical Care, The Hospital for Sick Children, University of Toronto, Canada
| | - James Drake
- Department of Neurosurgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
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Rodríguez-Boto G, Rivero-Garvía M, Gutiérrez-González R, Márquez-Rivas J. Basic concepts about brain pathophysiology and intracranial pressure monitoring. NEUROLOGÍA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.nrleng.2012.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Rodríguez-Boto G, Rivero-Garvía M, Gutiérrez-González R, Márquez-Rivas J. Conceptos básicos sobre la fisiopatología cerebral y la monitorización de la presión intracraneal. Neurologia 2015; 30:16-22. [DOI: 10.1016/j.nrl.2012.09.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 09/06/2012] [Accepted: 09/14/2012] [Indexed: 11/29/2022] Open
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