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Ferreira FM, Lino BT, Giannetti AV. Ultrasonographic evaluation of optic nerve sheath diameter in patients severe traumatic brain injury: a comparison with intraparenchymal pressure monitoring. Neurosurg Rev 2025; 48:47. [PMID: 39810071 DOI: 10.1007/s10143-025-03202-z] [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: 08/13/2024] [Revised: 11/27/2024] [Accepted: 01/04/2025] [Indexed: 01/16/2025]
Abstract
OBJECTIVE Increased intracranial pressure (ICP) can worsen the clinical condition of traumatic brain injury (TBI) patients. One non-invasive and easily bedside-performed technique to estimate ICP is ultrasonographic measurement of optic nerve sheath diameter (ONSD). This study aimed to analyze ONSD and correlate it with ICP values obtained by intraparenchymal monitoring to establish the ONSD threshold value for elevated ICP and reference range of ONSD in severe TBI patients. METHODS Forty severe TBI patients (Glasgow Coma Scale Score ≤ 8) were included. Ultrasonographic measurement of ONSD was performed and compared with intraparenchymal ICP monitoring to assess their association and determine the ONSD threshold value. Exclusion criteria included individuals under eighteen years old, penetrating TBI, or direct ocular trauma. RESULTS Fifty-three ONSD measurements were conducted in all patients. The mean ONSD value in the group with intracranial pressure < 20 mmHg was 5.4 mm ± 1.0, while in the group with intracranial pressure ≥ 20 mmHg, it was 6.4 mm ± 0.7 (p = 0.0026). A positive and statistically significant correlation, albeit weak (r = 0.33), was observed between ultrasonographic measurement of ONSD and intraparenchymal ICP monitoring. The statistical analysis of the ROC curve identified the best cut-off as 6.18 mm, with 77.8% sensitivity and 81.8% specificity. CONCLUSION Our results reveal a positive, albeit weak, correlation between ultrasonographic measurement of ONSD and intraparenchymal ICP monitoring, with an ONSD threshold value of 6.18 mm. Achieving only 77.8% sensitivity and considering the substantial variability between ONSD measurements (standard deviation at 1.0) might limit the reliability of ICP assessment based solely on ONSD measurements.
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Affiliation(s)
- Felipe M Ferreira
- Department of Surgery, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Breno T Lino
- Department of Ophthalmology, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Alexandre V Giannetti
- Department of Surgery, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
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Lim S, Yi Y. Efficacy and Renal Safety of Protocol-based 11.7% Hypertonic Saline Infusion Compared with 20% Mannitol in Patients with Elevated Intracranial Pressure: A Study Protocol for a Randomized Clinical Trial. Electrolyte Blood Press 2024; 22:33-39. [PMID: 39780852 PMCID: PMC11704315 DOI: 10.5049/ebp.2024.22.2.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2024] [Revised: 12/12/2024] [Accepted: 12/20/2024] [Indexed: 01/11/2025] Open
Abstract
Background Elevated intracranial pressure (ICP) is a potentially life-threatening condition requiring prompt intervention. While both mannitol and hypertonic saline (HTS) are commonly used hyperosmotic agents for treating elevated ICP, there is insufficient evidence comparing their renal safety profiles and overall effectiveness. This study protocol outlines a pragmatic randomized trial to compare protocol-based 11.7% HTS with 20% mannitol in patients with elevated ICP, focusing particularly on renal outcomes and treatment efficacy. Methods This single-center, pragmatic randomized trial will enroll 116 intensive care unit patients with elevated ICP. Participants will be randomly assigned to receive either 11.7% HTS or 20% mannitol following a schedule-based randomization approach, with HTS administration during odd-numbered months and mannitol during even-numbered months. The study will regularly monitor serum electrolytes, osmolarity, and renal function, with brain CT evaluations conducted on days 3 and 7. Comprehensive clinical assessments, including neurological evaluations and laboratory tests, will be performed at specified intervals throughout the study period. Measured Outcomes Primary outcomes include the incidence of acute kidney injury within 7 days according to KDIGO guidelines, requirement for mechanical ventilation, development of pulmonary edema, and significant fluid retention. Secondary outcomes encompass ICU and hospital length of stay, 30- and 90-day mortality rates, and neurological outcomes assessed by Glasgow Coma Scale scores at days 7 and 30. The study hypothesizes that protocol-based HTS administration will demonstrate a lower incidence of acute kidney injury and related complications while maintaining comparable efficacy in managing elevated ICP. Conclusion This study aims to provide definitive evidence regarding the relative efficacy and safety profiles of HTS compared to mannitol in managing elevated ICP. The findings will help establish clearer clinical guidelines for selecting appropriate hyperosmotic agents, potentially improving patient care outcomes and reducing treatment-related complications. This research will address a significant gap in current clinical knowledge and practice by focusing on treatment efficacy and renal safety considerations in patients with elevated ICP.
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Affiliation(s)
- Sunggyul Lim
- Division of Nephrology, Department of Internal Medicine, Dankook University Hospital, Republic of Korea
| | - Yongjin Yi
- Department of Internal Medicine, College of Medicine, Dankook University, Republic of Korea
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Sato R, Akiyama Y, Mikami T, Yamaoka A, Kamada C, Sakashita K, Takahashi Y, Kimura Y, Komatsu K, Mikuni N. Deep learning from head CT scans to predict elevated intracranial pressure. J Neuroimaging 2024; 34:742-749. [PMID: 39387348 DOI: 10.1111/jon.13241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 09/05/2024] [Accepted: 09/24/2024] [Indexed: 10/15/2024] Open
Abstract
BACKGROUND AND PURPOSE Elevated intracranial pressure (ICP) resulting from severe head injury or stroke poses a risk of secondary brain injury that requires neurosurgical intervention. However, currently available noninvasive monitoring techniques for predicting ICP are not sufficiently advanced. We aimed to develop a minimally invasive ICP prediction model using simple CT images to prevent secondary brain injury caused by elevated ICP. METHODS We used the following three methods to determine the presence or absence of elevated ICP using midbrain-level CT images: (1) a deep learning model created using the Python (PY) programming language; (2) a model based on cistern narrowing and scaling of brainstem deformities and presence of hydrocephalus, analyzed using the statistical tool Prediction One (PO); and (3) identification of ICP by senior residents (SRs). We compared the accuracy of the validation and test data using fivefold cross-validation and visualized or quantified the areas of interest in the models. RESULTS The accuracy of the validation data for the PY, PO, and SR methods was 83.68% (83.42%-85.13%), 85.71% (73.81%-88.10%), and 66.67% (55.96%-72.62%), respectively. Significant differences in accuracy were observed between the PY and SR methods. Test data accuracy was 77.27% (70.45%-77.2%), 84.09% (75.00%-85.23%), and 61.36% (56.82%-68.18%), respectively. CONCLUSIONS Overall, the outcomes suggest that these newly developed models may be valuable tools for the rapid and accurate detection of elevated ICP in clinical practice. These models can easily be applied to other sites, as a single CT image at the midbrain level can provide a highly accurate diagnosis.
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Affiliation(s)
- Ryota Sato
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Yukinori Akiyama
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Takeshi Mikami
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Ayumu Yamaoka
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Chie Kamada
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Kyoya Sakashita
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | | | - Yusuke Kimura
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Katsuya Komatsu
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Nobuhiro Mikuni
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
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Shahrom I, Mat Nayan SA, Abdullah JM, Ghani ARI, Hasnol Basri NF, Idris Z. Intracranial pressure changes in traumatic brain injury patients undergoing unilateral decompressive craniectomy with dural expansion. World Neurosurg X 2024; 24:100405. [PMID: 39399351 PMCID: PMC11470783 DOI: 10.1016/j.wnsx.2024.100405] [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: 02/03/2024] [Accepted: 09/20/2024] [Indexed: 10/15/2024] Open
Abstract
Background The aim of this study is to assess the ICP changes induced by a unilateral fronto-temporo-parietal DC with dural expansion after moderate to severe TBI. The effect of different bone flap sizes on ICP and the neurological outcomes were also evaluated after the decompressive surgery. Methods 52 TBI patients with clinical and radiological evidences of increased ICP were included in this prospective study. All patients received unilateral fronto-temporo-parietal DC with dural expansion and ventriculostomy at contralateral Kocher's point. Postoperatively, ICP values and the largest antero-posterior (AP) diameter of bone flap removed was measured, and the clinical outcomes were assessed using Extended Glasgow Outcome Scale (GOS-E) at discharge and 6 months after DC. Results The median ICP significantly decreased with an average of 56.7 % reduction from the initial opening ICP. Similar ICP changes were observed in all groups. This study also found that the large bone flap group (AP diameter >15 cm) demonstrated better postoperative ICP control as compared to the small bone flap group (AP diameter 12-15 cm), although not statistically significant. The SDH and cerebral swelling groups did better in the GOS-E at 6 months after TBI compared with cerebral contusion group. Conclusion The ICP reduction in moderate to severe TBI patients undergoing unilateral fronto-temporo-parietal DC with dural expansion occurred in accordance with decompressive steps, regardless of intracranial lesions and the surgical procedure should be performed with the bone flap size of at least 12 cm in AP diameter for adequate and sustained ICP control.
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Affiliation(s)
- Idris Shahrom
- Neurosurgery Department, Hospital Sungai Buloh, Selangor, Malaysia
- Department of Neurosciences, School of Medical Sciences, Jalan Hospital USM, 16150, Universiti Sains Malaysia, Health Campus, Kota Bharu, Kelantan, Malaysia
| | | | - Jafri Malin Abdullah
- Department of Neurosciences, School of Medical Sciences, Jalan Hospital USM, 16150, Universiti Sains Malaysia, Health Campus, Kota Bharu, Kelantan, Malaysia
- Brain and Behaviour Cluster, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150, Kota Bharu, Kelantan, Malaysia
- Department of Neurosciences & Brain Behavior Cluster, Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Health Campus, 16150, Kota Bharu, Kelantan, Malaysia
| | - Abdul Rahman Izaini Ghani
- Department of Neurosciences, School of Medical Sciences, Jalan Hospital USM, 16150, Universiti Sains Malaysia, Health Campus, Kota Bharu, Kelantan, Malaysia
- Brain and Behaviour Cluster, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150, Kota Bharu, Kelantan, Malaysia
- Department of Neurosciences & Brain Behavior Cluster, Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Health Campus, 16150, Kota Bharu, Kelantan, Malaysia
| | - Nurul Firdausi Hasnol Basri
- Acquired Brain Injury Unit, Rehabilitation Medicine Department, University of Malaya, Kuala Lumpur, Malaysia
| | - Zamzuri Idris
- Department of Neurosciences, School of Medical Sciences, Jalan Hospital USM, 16150, Universiti Sains Malaysia, Health Campus, Kota Bharu, Kelantan, Malaysia
- Brain and Behaviour Cluster, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150, Kota Bharu, Kelantan, Malaysia
- Department of Neurosciences & Brain Behavior Cluster, Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Health Campus, 16150, Kota Bharu, Kelantan, Malaysia
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Karamian A, Seifi A, Lucke-Wold B. Comparing the effects of mannitol and hypertonic saline in severe traumatic brain injury patients with elevated intracranial pressure: a systematic review and meta-analysis. Neurol Res 2024; 46:883-892. [PMID: 38825027 DOI: 10.1080/01616412.2024.2360862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 05/23/2024] [Indexed: 06/04/2024]
Abstract
OBJECTIVES Controlling elevated intracranial pressure following brain injury with hyperosmolar agents is one of the mainstay treatments in traumatic brain injury patients. In this study, we compared the effects of hypertonic saline (HS) and mannitol in reducing increased intracranial pressure. METHODS A total of 637 patients from 15 studies were included in our meta-analysis. The primary outcomes were mortality, the length of stay in the hospital and ICU, and the Glasgow Outcome Scale at follow-up. RESULTS The mortality in the mannitol group was not statistically different compared to the HS group (RR = 1.55; 95% CI = [0.98, 2.47], p = 0.06). The length of stay in the ICU was significantly shorter in the HS group (MD = 1.18, 95% CI = [0.44, 1.92], p < 0.01). In terms of favorable neurological outcomes, there was no significant difference between the two agents (RR = 0.92, 95% CI = [0.11, 7.96], p = 0.94). The duration of the effect was shorter in the mannitol group than in the HS group (MD = -0.67, 95% CI = [-1.00, -0.33], p < 0.01). DISCUSSION The results showed that HS and mannitol had similar effects in reducing ICP. Although the HS was associated with a longer duration of effect and shorter ICU stay, other secondary outcomes including mortality rate and favorable neurological outcomes were similar between the two drugs. In conclusion, considering the condition of each patient individually, HS could be a reasonable option than mannitol to reduce ICP in TBI patients.
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Affiliation(s)
- Armin Karamian
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Seifi
- Department of Neurosurgery, University of Texas Health, San Antonio, TX, USA
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Zhang Y, Zhu S, Hu Y, Guo H, Zhang J, Hua T, Zhang Z, Yang M. Correlation between early intracranial pressure and cerebral perfusion pressure with 28-day intensive care unit mortality in patients with hemorrhagic stroke. Eur Stroke J 2024; 9:648-657. [PMID: 38353230 PMCID: PMC11418543 DOI: 10.1177/23969873241232311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 01/25/2024] [Indexed: 08/23/2024] Open
Abstract
INTRODUCTION Hemorrhagic stroke may cause changes in intracranial pressure (ICP) and cerebral perfusion pressure (CPP), which may influence the prognosis of patients. The aim of this study was to investigate the relationship between early ICP, CPP, and 28-day mortality in the intensive care unit (ICU) of patients with hemorrhagic stroke. PATIENTS AND METHODS A retrospective study was performed using the Medical Information Mart for Intensive Care (MIMIC-IV) and the eICU Collaborative Research Database (eICU-CRD), including hemorrhagic stroke patients in the ICU with recorded ICP monitoring. The median values of ICP and CPP were collected for the first 24 h of the patient's monitoring. The primary outcome was 28-day ICU mortality. Multivariable Cox proportional hazards models were used to analyze the relationship between ICP, CPP, and 28-day ICU mortality. Restricted cubic regression splines were used to analyze nonlinear relationships. RESULTS The study included 837 patients with a 28-day ICU mortality rate of 19.4%. Multivariable analysis revealed a significant correlation between early ICP and 28-day ICU mortality (HR 1.08, 95% CI 1.04-1.12, p < 0.01), whereas early CPP showed no correlation with 28-day ICU mortality (HR 1.00, 95% CI 0.98-1.01, p = 0.57), with a correlation only evident when CPP < 60 mmHg (HR 1.99, 95% CI 1.14-3.48, p = 0.01). The study also identified an early ICP threshold of 16.5 mmHg. DISCUSSION AND CONCLUSION Early ICP shows a correlation with 28-day mortality in hemorrhagic stroke patients, with a potential intervention threshold of 16.5 mmHg. In contrast, early CPP showed no correlation with patient prognosis.
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Affiliation(s)
- Yang Zhang
- The Second Department of Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, P. R. China
- Laboratory of Cardiopulmonary Resuscitation and Critical Care, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, P. R. China
| | - Shuaijie Zhu
- The Second Department of Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, P. R. China
- Laboratory of Cardiopulmonary Resuscitation and Critical Care, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, P. R. China
| | - Yan Hu
- The Second Department of Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, P. R. China
- Laboratory of Cardiopulmonary Resuscitation and Critical Care, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, P. R. China
| | - Heng Guo
- The Second Department of Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, P. R. China
- Laboratory of Cardiopulmonary Resuscitation and Critical Care, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, P. R. China
| | - Jin Zhang
- The Second Department of Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, P. R. China
- Laboratory of Cardiopulmonary Resuscitation and Critical Care, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, P. R. China
| | - Tianfeng Hua
- The Second Department of Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, P. R. China
- Laboratory of Cardiopulmonary Resuscitation and Critical Care, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, P. R. China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, P. R. China
| | - Min Yang
- The Second Department of Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, P. R. China
- Laboratory of Cardiopulmonary Resuscitation and Critical Care, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, P. R. China
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Breedt DS, Harrington B, Walker IS, Gretchel A, Vlok AJ. Optic nerve sheath diameter and eyeball transverse diameter in severe head injury and its correlation with intracranial pressure. Clin Neurol Neurosurg 2024; 242:108310. [PMID: 38788542 DOI: 10.1016/j.clineuro.2024.108310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 04/23/2024] [Accepted: 04/28/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Gold standard for determining intracranial pressure (ICP), intraventricular catheter, is invasive with associated risks. Non-invasive investigations like magnetic resonance imaging and ultrasonography have demonstrated correlation between optic nerve sheath diameter (ONSD) and raised ICP. However, computed tomography (CT) is accessible and less operator-dependent. Literature shows variable results regarding correlations between ICP and ONSD on CT. The study aimed to investigate correlations between raised ICP and ONSD, eyeball transverse diameter (ETD), and ONSD/ETD ratios on CT scan(s) of severe head injuries. METHODS A retrospective review of a three-year prospectively-maintained database of severe traumatic head injuries in patients who had ICP measurements and CT scans was conducted. Glasgow Coma Score (GCS), ICP, ONSD 3 mm and 9 mm behind the globe, ETD, ONSD/ETD ratios, CT Marshall Grade, and Glasgow Outcome Score (GOS) were recorded. Statistical analysis assessed correlations between ICP and CT measurements. RESULTS Seventy-four patients were assessed; mortality rate: 36.5 %. Assault (48.6 %) and pedestrian-vehicle collisions (21.6 %) were the most common mechanisms. CT Marshall Grade correlated significantly with 3 mm and 9 mm ONSD, ONSD/ETD ratios, GCS, and GCS motor score, which correlated significantly with GOS. No significant correlation was found between ICP and ONSD, ETD or ONSD/ETD ratios. Marshall Grade was not significantly associated with ICP measurements but correlated with injury severity. CONCLUSIONS Unlike previous studies, our study not only investigated the correlation between ICP and single variables (ONSD and ETD) but also the ONSD/ETD ratios. No correlations were observed between raised ICP and ONSD, ETD or ONSD/ETD ratio on CT in neurotrauma patients.
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Affiliation(s)
- Danyca Shadé Breedt
- Division of Neurosurgery, Department of Surgical Sciences, Faculty of Medicine and Health Science, Stellenbosch University, Francie van Zijl Drive, Tygerberg, 7505, PO Box 241, Cape Town 8000, South Africa.
| | - Brad Harrington
- Division of Neurosurgery, Department of Surgical Sciences, Faculty of Medicine and Health Science, Stellenbosch University, Francie van Zijl Drive, Tygerberg, 7505, PO Box 241, Cape Town 8000, South Africa
| | - Ian Scott Walker
- Division of Neurosurgery, Department of Surgical Sciences, Faculty of Medicine and Health Science, Stellenbosch University, Francie van Zijl Drive, Tygerberg, 7505, PO Box 241, Cape Town 8000, South Africa
| | - Armin Gretchel
- Division of Neurosurgery, Department of Surgical Sciences, Faculty of Medicine and Health Science, Stellenbosch University, Francie van Zijl Drive, Tygerberg, 7505, PO Box 241, Cape Town 8000, South Africa
| | - Adriaan Johannes Vlok
- Division of Neurosurgery, Department of Surgical Sciences, Faculty of Medicine and Health Science, Stellenbosch University, Francie van Zijl Drive, Tygerberg, 7505, PO Box 241, Cape Town 8000, South Africa
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Peng C, Chi L, Chen M, Peng L, Yang F, Shao L, Bo L, Jin Z. Effect of continuous hypertonic saline infusion on clinical outcomes in patients with traumatic brain injury. Neurosurg Rev 2024; 47:78. [PMID: 38340147 DOI: 10.1007/s10143-024-02316-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/01/2024] [Accepted: 02/06/2024] [Indexed: 02/12/2024]
Abstract
Osmotic therapy has been recognized as an important treatment option for patients with traumatic brain injury (TBI). Nevertheless, the effect of hypertonic saline (HTS) remains unknown, as findings are primarily based on a large database. This study aimed to elucidate the effect of HTS on the clinical outcomes of patients with TBI admitted to the intensive care unit (ICU). We retrospectively identified patients with moderate-to-severe TBI from two public databases: Medical Information Mart for Intensive Care (MIMIC)-IV and eICU Collaborative Research Database (eICU-CRD). A marginal structural Cox model (MSCM) was used, with time-dependent variates designed to reflect exposure over time during ICU stay. Trajectory modeling based on the intracranial pressure evolution pattern allowed for the identification of subgroups. Overall, 130 (6.65%) of 1955 eligible patients underwent HTS. MSCM indicated that the HTS significantly associated with higher infection complications (e.g., urinary tract infection (HR 1.88, 95% CI 1.26-2.81, p = 0.002)) and increased ICU LOS (HR 2.02, 95% CI 1.71-2.40, p < 0.001). A protective effect of HTS on GCS was found in subgroups with medium and low intracranial pressure. Our study revealed no significant difference in mortality between patients who underwent HTS and those who did not. Increased occurrence rates of infection and electrolyte imbalance are inevitable outcomes of continuous HTS infusion. Although the study suggests slight beneficial effects, including better neurological outcomes, these results warrant further validation.
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Affiliation(s)
- Chi Peng
- Department of Health Statistics, Naval Medical University, No. 800 Xiangyin Road, Shanghai, 200433, China
| | - Lijie Chi
- Department of Vascular and Endovascular Surgery, Hainan Hospital of PLA General Hospital, Sanya, 572000, China
| | - Mengjie Chen
- Department of Otorhinolaryngology-Head and Neck Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, 200433, China
| | - Liwei Peng
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, 710038, China
| | - Fan Yang
- Institute of Pathology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University, (Army Medical University) and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Liangjing Shao
- Department of Hematology, General Hospital Eastern Theater Command of PLA, Nanjing, 210002, China
| | - Lulong Bo
- Department of Anesthesiology, The First Affiliated Hospital of Naval Medical University, No. 168, Changhai Road, Yangpu District, Shanghai, 200433, China.
| | - Zhichao Jin
- Department of Health Statistics, Naval Medical University, No. 800 Xiangyin Road, Shanghai, 200433, China.
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Tagliabue S, Kacprzak M, Serra I, Maruccia F, Fischer JB, Riveiro-Vilaboa M, Rey-Perez A, Expósito L, Lindner C, Báguena M, Durduran T, Poca MA. Transcranial, Non-Invasive Evaluation of Potential Misery Perfusion During Hyperventilation Therapy of Traumatic Brain Injury Patients. J Neurotrauma 2023; 40:2073-2086. [PMID: 37125452 PMCID: PMC10541939 DOI: 10.1089/neu.2022.0419] [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: 05/02/2023] Open
Abstract
Hyperventilation (HV) therapy uses vasoconstriction to reduce intracranial pressure (ICP) by reducing cerebral blood volume. However, as HV also lowers cerebral blood flow (CBF), it may provoke misery perfusion (MP), in which the decrease in CBF is coupled with increased oxygen extraction fraction (OEF). MP may rapidly lead to the exhaustion of brain energy metabolites, making the brain vulnerable to ischemia. MP is difficult to detect at the bedside, which is where transcranial hybrid, near-infrared spectroscopies are promising because they non-invasively measure OEF and CBF. We have tested this technology during HV (∼30 min) with bilateral, frontal lobe monitoring to assess MP in 27 sessions in 18 patients with traumatic brain injury. In this study, HV did not lead to MP at a group level (p > 0.05). However, a statistical approach yielded 89 events with a high probability of MP in 19 sessions. We have characterized each statistically significant event in detail and its possible relationship to clinical and radiological status (decompressive craniectomy and presence of a cerebral lesion), without detecting any statistically significant difference (p > 0.05). However, MP detection stresses the need for personalized, real-time assessment in future clinical trials with HV, in order to provide an optimal evaluation of the risk-benefit balance of HV. Our study provides pilot data demonstrating that bedside transcranial hybrid near-infrared spectroscopies could be utilized to assess potential MP.
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Affiliation(s)
- Susanna Tagliabue
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels, Barcelona, Spain
| | - Michał Kacprzak
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels, Barcelona, Spain
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Isabel Serra
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels, Barcelona, Spain
- Centre de Recerca Matemàtica (CRM), Bellaterra, Spain
| | - Federica Maruccia
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels, Barcelona, Spain
- Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Jonas B. Fischer
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels, Barcelona, Spain
- HemoPhotonics S.L., Castelldefels (Barcelona), Spain
| | | | - Anna Rey-Perez
- Neurotrauma Intensive Care Unit, and Vall d'Hebron University Hospital, Barcelona, Spain
| | - Lourdes Expósito
- Neurotrauma Intensive Care Unit, and Vall d'Hebron University Hospital, Barcelona, Spain
| | - Claus Lindner
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels, Barcelona, Spain
| | - Marcelino Báguena
- Neurotrauma Intensive Care Unit, and Vall d'Hebron University Hospital, Barcelona, Spain
| | - Turgut Durduran
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - María Antonia Poca
- Centre de Recerca Matemàtica (CRM), Bellaterra, Spain
- Department of Neurosurgery, Vall d'Hebron University Hospital, Barcelona, Spain
- Department of Surgery, Universidad Autònoma de Barcelona, Barcelona, Spain
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Leppert J, Ditz C, Souayah N, Behrens C, Tronnier VM, Küchler J. Limitations of prone positioning in patients with aneurysmal subarachnoid hemorrhage and concomitant respiratory failure. Clin Neurol Neurosurg 2023; 232:107878. [PMID: 37423091 DOI: 10.1016/j.clineuro.2023.107878] [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: 05/19/2023] [Revised: 06/21/2023] [Accepted: 06/25/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVE Prone positioning (PP) is an established treatment modality for respiratory failure. After aneurysmal subarachnoid hemorrhage (aSAH), PP is rarely performed considering the risk of intracranial hypertension. The aim of this study was to analyze the effects of PP on intracranial pressure (ICP), cerebral perfusion pressure (CPP) and cerebral oxygenation following aSAH. PATIENTS AND METHODS Demographic and clinical data of aSAH patients admitted over a 6-year period and treated with PP due to respiratory insufficiency were retrospectively analyzed. ICP, CPP, brain tissue oxygenation (pBrO2), respiratory parameters and ventilator settings were analyzed before and during PP. RESULTS Thirty patients receiving invasive multimodal neuromonitoring were included. Overall, 97 PP sessions were performed. Mean arterial oxygenation and pBrO2 increased significantly during PP. We found a significant increase in median ICP compared to the baseline level in supine position. No significant changes in CPP were observed. Five PP sessions had to be terminated early due to medically refractory ICP-crisis. The affected patients were younger (p = 0.02) with significantly higher baseline ICP values (p = 0.009). Baseline ICP correlates significantly (p < 0.001) with ICP 1 h (R: 0.57) and 4 h (R: 0.55) after onset of PP. CONCLUSION PP in aSAH patients with respiratory insufficiency is an effective therapeutic option improving arterial and global cerebral oxygenation without compromising CPP. The significant increase in ICP was moderate in most sessions. However, as some patients experience intolerable ICP crises during PP, continuous ICP-Monitoring is considered mandatory. Patients with elevated baseline ICP and reduced intracranial compliance should not be considered for PP.
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Affiliation(s)
- Jan Leppert
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Claudia Ditz
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany.
| | - Noura Souayah
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Carianne Behrens
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Volker M Tronnier
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Jan Küchler
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
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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: 3] [Impact Index Per Article: 1.5] [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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Moyer JD, Elouahmani S, Codorniu A, Abback PS, Jeantrelle C, Goutagny S, Gauss T, Sigaut S. External ventricular drainage for intracranial hypertension after traumatic brain injury: is it really useful? Eur J Trauma Emerg Surg 2023; 49:1227-1234. [PMID: 35169869 DOI: 10.1007/s00068-022-01903-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 01/29/2022] [Indexed: 11/03/2022]
Abstract
PURPOSES External ventricular drainage (EVD) is frequently used to control raised intracranial pressure after traumatic brain injury. However, the available evidence about its effectiveness in this context is limited. The aim of this study is to evaluate the effectiveness of EVD to control intracranial pressure and to identify the clinical and radiological factors associated with its success. METHODS For this retrospective cohort study conducted in a Level 1 traumacenter in Paris area between May 2011 and March 2019, all patients with intracranial hypertension and treated with EVD were included. EVD success was defined as an efficient and continuous control of intracranial hypertension avoiding the use of third tier therapies (therapeutic hypothermia, decompressive craniectomy, and barbiturate coma) or avoiding a decision to withdraw life sustaining treatment due to both refractory intracranial hypertension and severity of brain injury lesions. RESULTS 83 patients with EVD were included. EVD was successful in 33 patients (40%). Thirty-two patients (39%) required a decompressive craniectomy, eight patients (9%) received barbiturate coma. In ten cases (12%) refractory intracranial hypertension prompted a protocolized withdrawal of care. Complications occurred in nine patients (11%) (three cases of ventriculitis, six cases of catheter occlusion). Multivariate analysis identified no independent factors associated with EVD success. CONCLUSION In a protocol-based management for traumatic brain injury, EVD allowed intracranial pressure control and avoided third tier therapeutic measures in 40% of cases with a favorable risk-benefit ratio.
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Affiliation(s)
- Jean-Denis Moyer
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 boulevard du Général Leclerc, 92110, Clichy, France.
| | - Saida Elouahmani
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - Anais Codorniu
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - Paer-Selim Abback
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - Caroline Jeantrelle
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - Stéphane Goutagny
- Department of Neurosurgery, Assistance Publique Hôpitaux de Paris, Beaujon Hospital, Clichy, France
- Université de Paris, UFR de Médecine Paris Nord, Paris, France
| | - Tobias Gauss
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - Stéphanie Sigaut
- Department of Anesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP. Nord, 100 boulevard du Général Leclerc, 92110, Clichy, France
- Université de Paris, UFR de Médecine Paris Nord, Paris, France
- NeuroDiderot, Inserm U1141, Université de Paris, Paris, France
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Suehiro E, Tanaka T, Kawashima M, Matsuno A. Challenges in the Treatment of Severe Traumatic Brain Injury Based on Data in the Japan Neurotrauma Data Bank. Neurol Med Chir (Tokyo) 2023; 63:43-47. [PMID: 36436980 PMCID: PMC9995150 DOI: 10.2176/jns-nmc.2022-0276] [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: 11/25/2022] Open
Abstract
The Japan Neurotrauma Data Bank is a source of epidemiological data for patients with severe traumatic brain injury (TBI) and is sponsored by the Japan Society of Neurotraumatology. In this report, we examined the changes in the treatment of severe TBI in Japan based on data of the Japan Neurotrauma Data Bank. Controlling and decreasing intracranial pressure (ICP) are the primary objective of severe TBI treatment. Brain-oriented whole-body control or neurocritical care, including control of cerebral perfusion pressure, respiration, and infusion, are also increasingly considered important because cerebral tissues require oxygenation to improve the outcomes of patients with severe TBI. The introduction of neurocritical care in Japan was delayed compared with that in Western countries. However, the rate of ICP monitoring increased from 28.0% in 2009 to 36.7% in 2015 and is currently likely to be higher. Neurocritical care has also become more common, but the functional prognosis of patients has not significantly improved in Japan. Changes in the background of patients with severe TBI suggest the need for improvement of acute-phase treatment for elderly patients. Appropriate social rehabilitation from the subacute to chronic phases and introduction of cellular therapeutics are also needed for patients with TBI.
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Affiliation(s)
- Eiichi Suehiro
- Department of Neurosurgery, School of Medicine, International University of Health and Welfare
| | - Tatsuya Tanaka
- Department of Neurosurgery, School of Medicine, International University of Health and Welfare
| | - Masatou Kawashima
- Department of Neurosurgery, School of Medicine, International University of Health and Welfare
| | - Akira Matsuno
- Department of Neurosurgery, School of Medicine, International University of Health and Welfare
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Pfeifer R, Klingebiel FKL, Halvachizadeh S, Kalbas Y, Pape HC. How to Clear Polytrauma Patients for Fracture Fixation: Results of a systematic review of the literature. Injury 2023; 54:292-317. [PMID: 36404162 DOI: 10.1016/j.injury.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/03/2022] [Accepted: 11/06/2022] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Early patient assessment is relevant for surgical decision making in severely injured patients and early definitive surgery is known to be beneficial in stable patients. The aim of this systematic review is to extract parameters indicative of risk factors for adverse outcome. Moreover, we aim to improve decision making and separate patients who would benefit from early versus staged definitive surgical fixation. METHODS Following the PRISMA guidelines, a systematic review of peer-reviewed articles in English or German language published between (2000 and 2022) was performed. The primary outcome was the pathophysiological response to polytrauma including coagulopathy, shock/haemorrhage, hypothermia and soft tissue injury (trauma, brain injury, thoracic and abdominal trauma, and musculoskeletal injury) to determine the treatment strategy associated with the least amount of complications. Articles that had used quantitative parameters to distinguish between stable and unstable patients were summarized. Two authors screened articles and discrepancies were resolved by consensus. Quantitative values for relevant parameters indicative of an unstable polytrauma patient were obtained. RESULTS The initial systematic search using MeSH criteria yielded 1550 publications deemed relevant to the following topics (coagulopathy (n = 37), haemorrhage/shock (n = 7), hypothermia (n = 11), soft tissue injury (n = 24)). Thresholds for stable, borderline, unstable and in extremis conditions were defined according to the existing literature as follows: Coagulopathy; International Normalized Ratio (INR) and viscoelastic methods (VEM)/Blood/shock; lactate, systolic blood pressure and haemoglobin, hypothermia; thresholds in degrees Celsius/Soft tissue trauma: traumatic brain injury, thoracic and abdominal trauma and musculoskeletal trauma. CONCLUSION In this systematic literature review, we summarize publications by focusing on different pathways that stimulate pathophysiological cascades and remote organ damage. We propose that these parameters can be used for clinical decision making within the concept of safe definitive surgery (SDS) in the treatment of severely injured patients.
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Affiliation(s)
- Roman Pfeifer
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland.
| | | | - Sascha Halvachizadeh
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland.
| | - Yannik Kalbas
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland.
| | - Hans-Christoph Pape
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland.
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Ketofol as an Anesthetic Agent in Patients With Isolated Moderate to Severe Traumatic Brain Injury: A Prospective, Randomized Double-blind Controlled Trial. J Neurosurg Anesthesiol 2023; 35:49-55. [PMID: 36745167 DOI: 10.1097/ana.0000000000000774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 03/28/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The effects of ketofol (propofol and ketamine admixture) on systemic hemodynamics and outcomes in patients undergoing emergency decompressive craniectomy for traumatic brain injury (TBI) are unknown and explored in this study. METHODS Fifty patients with moderate/severe TBI were randomized to receive ketofol (n=25) or propofol (n=25) for induction and maintenance of anesthesia during TBI surgery. Intraoperative hemodynamic stability was assessed by continuous measurement of mean arterial pressure (MAP) and need for rescue interventions to maintain MAP within 20% of baseline. Brain relaxation scores, serum biomarker-glial fibrillary acidic protein levels, and extended Glasgow Outcome Scale (GOSE) at 30 and 90 days after discharge were also explored. RESULTS MAP was lower and hemodynamic fluctuations more frequent in patients receiving propofol compared with those receiving ketofol (P<0.05). MAP fell >20% below baseline in 22 (88%) patients receiving propofol and in 10 (40%) receiving ketofol (P=0.001), with a greater requirement for vasopressors (80% vs. 24%, respectively; P=0.02). Intraoperative brain relaxation scores and GOSE at 30 and 90 day were similar between groups. Glial fibrillary acidic protein was lower in the ketofol group (3.31±0.43 ng/mL) as compared with the propofol (3.41±0.17 ng/mL; P=0.01) group on the third postoperative day. CONCLUSION Compared with propofol, ketofol for induction and maintenance of anesthesia during decompressive surgery in patients with moderate/severe TBI was associated with improved hemodynamic stability, lower vasopressor requirement, and similar brain relaxation.
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16
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Baser B, Bolukbasi M, Uzlu D, Ozbay AD. Does MARPE therapy have effects on intracranial pressure? a clinical study. BMC Oral Health 2022; 22:450. [PMID: 36261817 PMCID: PMC9583475 DOI: 10.1186/s12903-022-02482-x] [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: 07/22/2022] [Accepted: 10/04/2022] [Indexed: 11/30/2022] Open
Abstract
Background We aimed to evaluate possible intracranial pressure (ICP) changes caused by screw activations during active microimplant-assisted rapid palatal expansion (MARPE) therapy of post-pubertal individuals by measuring the optic nerve sheath diameter (ONSD) under ultrasonography (US) guidance. Methods This study’s participants comprised 15 patients (7 males, 8 females) with posterior crossbite and a mean age of 16.7 years (14.25–20.08 years). The Maxillary Skeletal Expander (MSE) appliance was used to perform MARPE in all patients. Their vital signs (heart rate, mean arterial pressure (MAP), and peripheral oxygen saturation (SpO2)) were recorded. The ONSD was measured by US immediately before the first screw activation (T0), and the measurements were repeated 1 min (T1) and 10 min (T2) after the first activation. In the last session of active MARPE therapy, the same measurement protocol was performed as in the first activation session (T3, T4, and T5). The patients’ perceptions of pain during the screw activation were also noted at T1 and T4 using a four-category verbal rating scale (VRS-4). The significant differences among different time intervals performed with the Friedman test (for all tested variables; SpO2, MAP, Heart Rate, VRS-4 and ONSD). Spearman correlation test was used for VRS-4 and ONSD comparisons. The statistical significance level was accepted as p < 0.05. Results The ONSD values (T1 and T4) relatively increased within 1 min after screw activation but did not reach a statistically significant level (p > 0.05). There was also no significant difference between the initial (T0) and the final (T5) ONSD values during the active MARPE therapy (p > 0.05). Conclusion There is no changes or alterations in intracranial pressure in late adolescents during active MARPE therapy. Supplementary information The online version contains supplementary material available at 10.1186/s12903-022-02482-x.
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Affiliation(s)
- Baris Baser
- Department of Orthodontics, Faculty of Dentistry, Karadeniz Technical University, Trabzon, Turkey.
| | - Merve Bolukbasi
- Department of Orthodontics, Faculty of Dentistry, Karadeniz Technical University, Trabzon, Turkey
| | - Dilek Uzlu
- Department of Ophtalmology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Ahmet Duhan Ozbay
- Department of Ophtalmology, Erzurum Regional Education and Research Hospital, Erzurum, Turkey
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Castaño-Leon AM, Gomez PA, Jimenez-Roldan L, Paredes I, Munarriz PM, Perez IP, Eiriz Fernandez C, García-Pérez D, Moreno Gomez LM, Sinovas OE, Posadas GG, Lagares A. Intracranial Pressure Monitoring in Patients With Severe Traumatic Brain Injury: Extension of the Recommendations and the Effect on Outcome by Propensity Score Matching. Neurosurgery 2022; 91:437-449. [DOI: 10.1227/neu.0000000000002044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 04/04/2022] [Indexed: 11/19/2022] Open
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Eltabl MA, Ammar AS, Saif DS. Evaluating the retro-auricular incision versus reversed question mark incision and Kempe's 'T-bar' incision for decompressive hemicraniectomy. EGYPTIAN JOURNAL OF NEUROSURGERY 2022. [DOI: 10.1186/s41984-022-00155-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The proper decompression for hemicraniectomy depends on intraoperative surgical technique, so the skin incision, on the other hand, is an important variable throughout hemicraniectomy, and there are a variety of cutaneous incisions, including the Kempe T shaped, the reversed question mark and the retro-auricular incisions. We aim to compare those three types of incisions and assess their effects on the surgical outcomes regarding the skull defect size, survived beyond 1 week, post-operative complications and mortality rates.
Results
A retrospective study included 180 patients were separated into three age- and sex-matched groups according to the type of incision used for their hemicraniectomy. Data including age, sex, causes of surgery, comorbidities, the incision type, the defect area of the skull, intraoperative time and estimated blood loss were recruited for all patients. The mortality and morbidity rates at 3 months post-surgery were documented for all patients. There was a significant difference in the operative time, and the intraoperative measures of blood loss, and insignificant differences in the surviving rate after 1-week post-surgery among the three group patients. There were significant differences between the first and third patient groups compared to the second group regarding wound complications, while the first and third groups were comparable.
Conclusions
The retro-auricular incision is a safe preferable substitute for the reversed question mark and Kempe T-shaped incisions in decompressive hemicraniectomy, due to the better blood flow maintaining, lower rate of post-operative wound complications.
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Wiedermann CJ. Use of Hyperoncotic Human Albumin Solution in Severe Traumatic Brain Injury Revisited-A Narrative Review and Meta-Analysis. J Clin Med 2022; 11:jcm11092662. [PMID: 35566786 PMCID: PMC9099946 DOI: 10.3390/jcm11092662] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/07/2022] [Accepted: 05/07/2022] [Indexed: 11/16/2022] Open
Abstract
A significant proportion of patients with a severe traumatic brain injury (TBI) have hypoalbuminemia and require fluid resuscitation. Intravenous fluids can have both favorable and unfavorable consequences because of the risk of hyperhydration and hypo- or hyperosmolar conditions, which may affect the outcome of a TBI. Fluid resuscitation with human albumin solution (HAS) corrects low serum albumin levels and aids in preserving euvolemia in non-brain-injured intensive care units and in perioperative patients. However, the use of HAS for TBI remains controversial. In patients with TBI, the infusion of hypooncotic (4%) HAS was associated with adverse outcomes. The side effects of 4% HAS and the safety and efficacy of hyperoncotic (20-25%) HAS used in the Lund concept of TBI treatment need further investigation. A nonsystematic review, including a meta-analysis of controlled clinical trials, was performed to evaluate hyperoncotic HAS in TBI treatment. For the meta-analysis, the MEDLINE and EMBASE Library databases, as well as journal contents and reference lists, were searched for pertinent articles up to March 2021. Four controlled clinical studies involving 320 patients were included. The first was a randomized trial. Among 165 patients treated with hyperoncotic HAS, according to the Lund concept, 24 (14.5%) died vs. 59 out of 155 control patients (38.1%). A Lund concept intervention using hyperoncotic HAS was associated with a significantly reduced mortality (p = 0.002). Evidence of the beneficial effects of fluid management with hyperoncotic HAS on mortality in patients with TBI is at a high risk of bias. Prospective randomized controlled trials are required, which could lead to changes in clinical practice recommendations for fluid management in patients with TBI.
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Affiliation(s)
- Christian J. Wiedermann
- Institute of General Practice and Public Health, Claudiana—College of Health Professions, 39100 Bolzano, Italy;
- Department of Public Health, Medical Decision Making and HTA, University of Health Sciences, Medical Informatics and Technology, 6060 Hall in Tyrol, Austria
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Optic Nerve Sheath Diameter Ultrasound: A Non-Invasive Approach to Evaluate Increased Intracranial Pressure in Critically Ill Pediatric Patients. Diagnostics (Basel) 2022; 12:diagnostics12030767. [PMID: 35328319 PMCID: PMC8946972 DOI: 10.3390/diagnostics12030767] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/15/2022] [Accepted: 03/15/2022] [Indexed: 01/16/2023] Open
Abstract
Early diagnosis of increased intracranial pressure (ICP) is crucial for prompt diagnosis and treatment of intracranial hypertension in critically ill pediatric patients, preventing secondary brain damage and mortality. Although the placement of an external ventricular drain coupled to an external fluid-filled transducer remains the gold standard for continuous ICP monitoring, other non-invasive approaches are constantly being improved and can provide reliable estimates. The use of point-of-care ultrasound (POCUS) for the assessment of ICP has recently become widespread in pediatric emergency and critical care settings, representing a valuable extension of the physical examination. The aim of this manuscript is to review and discuss the basic principles of ultra-sound measurement of the optic nerve sheath diameter (ONSD) and summarize current evidence on its diagnostic value in pediatric patients with ICP. There is increasing evidence that POCUS measurement of the ONSD correlates with ICP, thus appearing as a useful extension of the physical examination in pediatrics, especially in emergency medicine and critical care settings for the initial non-invasive assessment of patients with suspected raised ICP. Its role could be of value even to assess the response to therapy and in the follow-up of patients with diagnosed intracranial hypertension if invasive ICP monitoring is not available. Further studies on more homogeneous and extensive study populations should be performed to establish ONSD reference ranges in the different pediatric ages and to define cut-off values in predicting elevated ICP compared to invasive ICP measurement.
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Lang E, Neuschwander A, Favé G, Abback PS, Esnault P, Geeraerts T, Harrois A, Hanouz JL, Kipnis E, Leone M, Legros V, Mellati N, Pottecher J, Hamada S, Pirracchio R. Clinical decision support for severe trauma patients: Machine learning based definition of a bundle of care for hemorrhagic shock and traumatic brain injury. J Trauma Acute Care Surg 2022; 92:135-143. [PMID: 34554136 DOI: 10.1097/ta.0000000000003401] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Deviation from guidelines is frequent in emergency situations, and this may lead to increased mortality. Probably because of time constraints, 55% is the greatest reported guidelines compliance rate in severe trauma patients. This study aimed to identify among all available recommendations a reasonable bundle of items that should be followed to optimize the outcome of hemorrhagic shocks (HSs) and severe traumatic brain injuries (TBIs). METHODS We first estimated the compliance with French and European guidelines using the data from the French TraumaBase registry. Then, we used a machine learning procedure to reduce the number of recommendations into a minimal set of items to be followed to minimize 7-day mortality. We evaluated the bundles using an external validation cohort. RESULTS This study included 5,924 trauma patients (1,414 HS and 4,955 TBI) between 2011 and August 2019 and studied compliance to 36 recommendation items. Overall compliance rate to recommendation items was 71.6% and 66.9% for HS and TBI, respectively. In HS, compliance was significantly associated with 7-day decreased mortality in univariate analysis but not in multivariate analysis (risk ratio [RR], 0.91; 95% confidence interval [CI], 0.90-1.17; p = 0.06). In TBI, compliance was significantly associated with decreased mortality in univariate and multivariate analysis (RR, 0.85; 95% CI, 0.75-0.92; p = 0.01). For HS, the bundle included 13 recommendation items. In the validation cohort, when this bundle was applied, patients were found to have a lower 7-day mortality rate (RR, 0.46; 95% CI, 0.27-0.63; p = 0.01). In TBI, the bundle included seven items. In the validation cohort, when this bundle was applied, patients had a lower 7-day mortality rate (RR, 0.55; 95% CI, 0.34-0.71; p = 0.02). DISCUSSION Using a machine-learning procedure, we were able to identify a subset of recommendations that minimizes 7-day mortality following traumatic HS and TBI. These two bundles remain to be evaluated in a prospective manner. LEVEL OF EVIDENCE Care Management, level II.
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Affiliation(s)
- Elodie Lang
- From the Department of Anesthesia and Critical Care Medicine, APHP Hopital Européen Georges Pompidou (E.L., A.N., G.F., S.H.); Department of Anesthesia and Critical Care Medicine, Hôpital Beaujon (P.S.A.), Clichy; Department of Anesthesia and Critical Care Medicine, Hia Sainte Anne (P.E.); Department of Anesthesia and Critical Care Medicine, Chu De Toulouse (T.G.), Toulouse; Department of Anesthesia and Critical Care Medicine, Chu De Bicêtre (A.H.), Le Kremlin Bicêtre France; Department of Anesthesia and Critical Care Medicine, Chu De Caen (J.-L.H.), Caen; Department of Anesthesia and Critical Care Medicine, Chu Lille (E.K.), Lille; Department of Anesthesia and Critical Care Medicine, Hopital Nord (M.L.), Marseille; Department of Anesthesia and Critical Care Medicine, Chu De Reims (V.L.), Reims; Department of Anesthesia and Critical Care Medicine, Chr Metz Thionville (N.M.), Metz; Department of Anesthesia and Critical Care Medicine, Chu Strasbourg (J.P.), Strasbourg, France; Department of Anesthesia and Critical Care Medicine, Zuckerberg San Francisco General Hospital and Trauma Center (R.P.), San Francisco, California
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Siwicka-Gieroba D, Dabrowski W. Credibility of the Neutrophil-to-Lymphocyte Count Ratio in Severe Traumatic Brain Injury. Life (Basel) 2021; 11:life11121352. [PMID: 34947883 PMCID: PMC8706648 DOI: 10.3390/life11121352] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/01/2021] [Accepted: 12/03/2021] [Indexed: 02/07/2023] Open
Abstract
Traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality worldwide. The consequences of a TBI generate the activation and accumulation of inflammatory cells. The peak number of neutrophils entering into an injured brain is observed after 24 h; however, cells infiltrate within 5 min of closed brain injury. Neutrophils release toxic molecules including free radicals, proinflammatory cytokines, and proteases that advance secondary damage. Regulatory T cells impair T cell infiltration into the central nervous system and elevate reactive astrogliosis and interferon-γ gene expression, probably inducing the process of healing. Therefore, the neutrophil-to-lymphocyte ratio (NLR) may be a low-cost, objective, and available predictor of inflammation as well as a marker of secondary injury associated with neutrophil activation. Recent studies have documented that an NLR value on admission might be effective for predicting outcome and mortality in severe brain injury patients.
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23
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Corallo F, Lo Buono V, Calabrò RS, De Cola MC. Can Cranioplasty Be Considered a Tool to Improve Cognitive Recovery Following Traumatic Brain Injury? A 5-Years Retrospective Study. J Clin Med 2021; 10:jcm10225437. [PMID: 34830718 PMCID: PMC8624554 DOI: 10.3390/jcm10225437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/17/2021] [Accepted: 11/19/2021] [Indexed: 01/19/2023] Open
Abstract
Cranioplasty (CP) is a neurosurgical intervention of skull repairing following a decompressive craniectomy. Unfortunately, the impact of cranioplasty on cognitive and motor function is still controversial. Fifteen TBI subjects aged 26–54 years with CP after decompressive craniectomy were selected in this observational retrospective study. As per routine clinical practice, a neuropsychological evaluation carried out immediately before the cranioplasty (Pre CP) and one month after the cranioplasty (T0) was used to measure changes due to CP surgery. This assessment was performed each year for 5 years after discharge in order to investigate long-term cognitive changes (T1-T5). Before cranioplasty, about 53.3% of subjects presented a mild to severe cognitive impairment and about 40.0% a normal cognition. After CP, we found a significant improvement in all neuropsychological test scores. The more significant differences in cognitive recovery were detected after four years from CP. Notably, we found significant differences between T4 and T0-T1, as well as between T5 and T0-T1-T2 in all battery tests. This retrospective study further suggests the importance of CP in the complex management of patients with TBI showing how these patients might improve their cognitive function over a long period after the surgical procedure.
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Real-Time Evaluation of Optic Nerve Sheath Diameter (ONSD) in Awake, Spontaneously Breathing Patients. J Clin Med 2021; 10:jcm10163549. [PMID: 34441846 PMCID: PMC8396942 DOI: 10.3390/jcm10163549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 12/17/2022] Open
Abstract
(1) Background: Reliable ultrasonographic measurements of optic nerve sheath diameter (ONSD) to detect increased intracerebral pressure (ICP) has not been established in awake patients with continuous invasive ICP monitoring. Therefore, in this study, we included fully awake patients with and without raised ICP and correlated ONSD with continuously measured ICP values. (2) Methods: In a prospective study, intracranial pressure (ICP) was continuously measured in 25 patients with an intraparenchymatic P-tel probe. Ultrasonic measurements were carried out three times for each optic nerve in vertical and horizontal directions. ONSD measurements and ICP were correlated. Patients with ICP of 2.0–10.0 mmHg were compared with patients suffering from an ICP of 10.1–24.2 mmHg. (3) Results: In all patients, the ONSD vertical and horizontal measurement for both eyes correlated well with the ICP (Pearson R = 0.68–0.80). Both measurements yielded similar results (Bland-Altman: vertical bias: −0.09 mm, accuracy: ±0.66 mm; horizontal bias: −0.06 mm, accuracy: ±0.48 mm). For patients with an ICP of 2.0–10.0 mmHg compared to an ICP of 10.1–24.2, ROC (receiver operating characteristic) analyses showed that ONSD measurement accurately predicts elevated ICP (optimal cut-off value 5.05 mm, AUC of 0.91, sensitivity 92% and specificity 90%, p < 0.001). (4) Conclusions: Ultrasonographic measurement of ONSD in awake, spontaneously breathing patients provides a valuable method to evaluate patients with suspected increased ICP. Additionally, it provides a potential tool for rapid assessment of ICP at the bedside and to identify patients at risk for a poor neurological outcome.
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25
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McCredie VA, Chavarría J, Baker AJ. How do we identify the crashing traumatic brain injury patient - the intensivist's view. Curr Opin Crit Care 2021; 27:320-327. [PMID: 33852501 PMCID: PMC8240643 DOI: 10.1097/mcc.0000000000000825] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Over 40% of patients with severe traumatic brain injury (TBI) show clinically significant neurological worsening within the acute admission period. This review addresses the importance of identifying the crashing TBI patient, the difficulties appreciating clinical neurological deterioration in the comatose patient and how neuromonitoring may provide continuous real-time ancillary information to detect physiologic worsening. RECENT FINDINGS The latest editions of the Brain Trauma Foundation's Guidelines omitted management algorithms for adult patients with severe TBI. Subsequently, three consensus-based management algorithms were published using a Delphi method approach to provide a bridge between the evidence-based guidelines and integration of the individual treatment modalities at the bedside. These consensus statements highlight the serious situation of critical deterioration requiring emergent evaluation and guidance on sedation holds to obtain a neurological examination while balancing the potential risks of inducing a stress response. SUMMARY One of the central tenets of neurocritical care is to detect the brain in trouble. The first and most fundamental neurological monitoring tool is the clinical exam. Ancillary neuromonitoring data may provide early physiologic biomarkers to help anticipate, prevent or halt secondary brain injury processes. Future research should seek to understand how data integration and visualization technologies may reduce the cognitive workload to improve timely detection of neurological deterioration.
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Affiliation(s)
- Victoria A. McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto
- Toronto Western Hospital, University Health Network
- Krembil Research Institute, Toronto Western Hospital
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre
| | - Javier Chavarría
- Interdepartmental Division of Critical Care Medicine, University of Toronto
| | - Andrew J. Baker
- Interdepartmental Division of Critical Care Medicine, University of Toronto
- Department of Critical Care, St. Michael's Hospital Toronto, University of Toronto
- Department of Anesthesia, Keenan Research Centre for Biomedical Science, St. Michael's Hospital Toronto, University of Toronto, Toronto, Ontario, Canada
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26
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Beidler PG, Novokhodko A, Prolo LM, Browd S, Lutz BR. Fluidic Considerations of Measuring Intracranial Pressure Using an Open External Ventricular Drain. Cureus 2021; 13:e15324. [PMID: 34221772 PMCID: PMC8239198 DOI: 10.7759/cureus.15324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Measurement of intracranial pressure (ICP) during cerebrospinal fluid (CSF) drainage with an external ventricular drain (EVD) typically requires stopping the flow during measurement. However, there may be benefits to simultaneous ICP measurement and CSF drainage. Several studies have evaluated whether accurate ICP measurements can be obtained while the EVD is open. They report differing outcomes when it comes to error, and hypothesize several sources of error. This study presents an investigation into the fluidic sources of error for ICP measurement with concurrent drainage in an EVD. Our experiments and analytical model both show that the error in pressure measurement increases linearly with flow rate and is not clinically significant, regardless of drip chamber height. At physiologically relevant flow rates (40 mL/hr) and ICP set points (13.6 - 31.3 cmH2O or 10 - 23 mmHg), our model predicts an underestimation of 0.767 cmH2O (0.56 mmHg) with no observed data point showing error greater than 1.09 cmH2O (0.8 mmHg) in our experiment. We extrapolate our model to predict a realistic worst-case clinical scenario where we expect to see a mean maximum error of 1.06 cmH2O (0.78 mmHg) arising from fluidic effects within the drainage system for the most resistive catheter. Compared to other sources of error in current ICP monitoring, error in pressure measurement due to drainage flow is small and does not prohibit clinical use. However, other effects such as ventricular collapse or catheter obstruction could affect ICP measurement under continuous drainage and are not investigated in this study.
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Affiliation(s)
| | - Alexander Novokhodko
- Bioengineering, University of Washington, Seattle, USA.,Mechanical Engineering, University of Washington, Seattle, USA
| | - Laura M Prolo
- Neurosurgery, Stanford University School of Medicine, Stanford, USA.,Surgical Services, VA Palo Alto Health Care System, Palo Alto, USA
| | - Samuel Browd
- Neurosurgery, Seattle Children's Hospital, Seattle, USA.,Bioengineering, University of Washington, Seattle, USA.,Neurological Surgery, University of Washington, Seattle, USA
| | - Barry R Lutz
- Bioengineering, University of Washington, Seattle, USA
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27
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Koo J, Lee J, Lee SH, Moon JH, Yang SY, Cho KT. Does the Size of Unilateral Decompressive Craniectomy Impact Clinical Outcomes in Patients with Intracranial Mass Effect after Severe Traumatic Brain Injury? Korean J Neurotrauma 2021; 17:3-14. [PMID: 33981638 PMCID: PMC8093026 DOI: 10.13004/kjnt.2021.17.e10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/20/2021] [Accepted: 03/18/2021] [Indexed: 11/15/2022] Open
Abstract
Objective Decompressive craniectomy (DC) is one of the treatment modalities in severe traumatic brain injury (TBI), however, there was a lack of evidence for optimal craniectomy size. The authors aimed to investigate optimal DC size and analyze clinical outcome according to craniectomy size. Methods We retrospectively reviewed the medical data of 87 patients with a space occupying lesion following TBI who underwent unilateral DC. Craniectomy size was measured by anterior-posterior (AP) diameter and surface estimate (SE). Mortality, clinical outcome, and complications were collected and analyzed according to craniectomy size. Results Nineteen patients (21.8%) died and 35 patients (40.2%) had a favorable outcome at last follow-up (a mean duration, 30.3±39.4 months; range, 0.2-132.6 months). Receiver operating curve analyses identified AP diameter more than 12.5 cm (area under the curve [AUC]=0.740; p=0.002) and SE more than 98.0 cm2 (AUC=0.752; p=0.001) as cut-off values for survival, and AP diameter more than 13.4 cm (AUC=0.650; p=0.018) and SE more than 107.3 cm2 (AUC=0.685; p=0.003) for favorable outcome. Large craniectomy resulted in a significantly lower mortality rate and a higher rate of favorable outcome than small craniectomy (p=0.005 and p=0.014, respectively). However, procedure related bleeding occurred more frequently in the large craniectomy group (p=0.044). Conclusion Unilateral DC size is associated with clinical outcome of patients with a space occupying lesion following severe TBI. Large craniectomy is needed for survival and favorable outcome.
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Affiliation(s)
- Jinhwan Koo
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jeongjun Lee
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Su Hwan Lee
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jung Hyeon Moon
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Seung-Yeob Yang
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Keun-Tae Cho
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Goyang, Korea
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28
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Rajajee V, Soroushmehr R, Williamson CA, Najarian K, Gryak J, Awad A, Ward KR, Tiba MH. Novel Algorithm for Automated Optic Nerve Sheath Diameter Measurement Using a Clustering Approach. Mil Med 2021; 186:496-501. [PMID: 32830251 DOI: 10.1093/milmed/usaa231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/09/2020] [Accepted: 08/07/2020] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Using ultrasound to measure optic nerve sheath diameter (ONSD) has been shown to be a useful modality to detect elevated intracranial pressure. However, manual assessment of ONSD by a human operator is cumbersome and prone to human errors. We aimed to develop and test an automated algorithm for ONSD measurement using ultrasound images and compare it to measurements performed by physicians. MATERIALS AND METHODS Patients were recruited from the Neurological Intensive Care Unit. Ultrasound images of the optic nerve sheath from both eyes were obtained using an ultrasound unit with an ocular preset. Images were processed by two attending physicians to calculate ONSD manually. The images were processed as well using a novel computerized algorithm that automatically analyzes ultrasound images and calculates ONSD. Algorithm-measured ONSD was compared with manually measured ONSD using multiple statistical measures. RESULTS Forty-four patients with an average/Standard Deviation (SD) intracranial pressure of 14 (9.7) mmHg were recruited and tested (with a range between 1 and 57 mmHg). A t-test showed no statistical difference between the ONSD from left and right eyes (P > 0.05). Furthermore, a paired t-test showed no significant difference between the manually and algorithm-measured ONSD with a mean difference (SD) of 0.012 (0.046) cm (P > 0.05) and percentage error of difference of 6.43% (P = 0.15). Agreement between the two operators was highly correlated (interclass correlation coefficient = 0.8, P = 0.26). Bland-Altman analysis revealed mean difference (SD) of 0.012 (0.046) (P = 0.303) and limits of agreement between -0.1 and 0.08. Receiver Operator Curve analysis yielded an area under the curve of 0.965 (P < 0.0001) with high sensitivity and specificity. CONCLUSION The automated image-analysis algorithm calculates ONSD reliably and with high precision when compared to measurements obtained by expert physicians. The algorithm may have a role in computer-aided decision support systems in acute brain injury.
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Affiliation(s)
- Venkatakrishna Rajajee
- Department of Neurological Surgery, University of Michigan, Ann Arbor, MI 48109-5338, USA.,Department of Neurology, University of Michigan, Ann Arbor, MI 48109-5316, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), Ann Arbor, MI 48109-2800, USA
| | - Reza Soroushmehr
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI 48109-2218, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), Ann Arbor, MI 48109-2800, USA
| | - Craig A Williamson
- Department of Neurological Surgery, University of Michigan, Ann Arbor, MI 48109-5338, USA.,Department of Neurology, University of Michigan, Ann Arbor, MI 48109-5316, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), Ann Arbor, MI 48109-2800, USA
| | - Kayvan Najarian
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI 48109-2218, USA.,Department of Emergency Medicine, University of Michigan, Ann Arbor, MI 48109-2800, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), Ann Arbor, MI 48109-2800, USA
| | - Jonathan Gryak
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI 48109-2218, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), Ann Arbor, MI 48109-2800, USA
| | - Abdelrahman Awad
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI 48109-2800, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), Ann Arbor, MI 48109-2800, USA
| | - Kevin R Ward
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI 48109-2800, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109-2099, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), Ann Arbor, MI 48109-2800, USA
| | - Mohamad H Tiba
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI 48109-2800, USA.,Michigan Center for Integrative Research in Critical Care (MCIRCC), Ann Arbor, MI 48109-2800, USA
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29
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Abouhashem S, Albakry A, El-Atawy S, Fawzy F, Elgammal S, Khattab O. Prediction of early mortality after primary decompressive craniectomy in patients with severe traumatic brain injury. EGYPTIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1186/s41984-020-00096-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Objectives
Traumatic brain injury (TBI) is a worldwide major health problem associated with a high rate of morbidity and mortality. Intracranial hypertension following TBI is the main but not the only cause of early mortality. Decompressive craniectomy (DC) is used to decrease the intracranial pressure (ICP) and prevent brain herniation following TBI; however, the clinical outcome after DC for patients with TBI generates continuous debate. Prediction of early mortality after DC will help in making the surgery decision.
The aim of this study is to predict early mortality after DC based on the initial clinical and radiological findings.
Methods
In this study, 104 patients with severe traumatic brain injury have been treated by decompressive craniectomy and were retrospectively analyzed. Patients were divided into two groups; group I involved 32 patients who died within 28 days while group II involved 72 patients who survived after 28 days. The relationship between initial Glasgow Coma Scale score (GCS), pupil size and reactivity, associated injuries, and radiological findings were analyzed as predictor factors for early mortality.
Results
A total of 104 patients with severe TBI have been treated by DC and were analyzed; the early mortality occurred in 32 patients, 30.77%. There is a significant difference between groups in gender, mean GCS, Marshall scale, presence of isochoric pupils, and lung injury.
After stratification, odds of early mortality increases with the lower GCS, higher Marshall scale, lung injury, and abdominal injury while male gender and the presence of isochoric pupils decrease the odds of mortality. After univariate regression, the significant impact of GCS disappears except for GCS-8 which decreases the odds of mortality in comparison to other GCS scores while higher Marshall scale, presence of isochoric pupils, and lung injury increase the odds of mortality, but most of these effects disappear after multiple regressions except for lung injury and isochoric pupils.
Conclusion
Prediction of early mortality after DC is multifactorial, but the odds of early mortality after decompressive craniectomy in severe traumatic brain injury are progressively increased with the lower GCS, higher Marshall scale, and the presence of lung or abdominal injury.
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30
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Challenges and Opportunities in Multimodal Monitoring and Data Analytics in Traumatic Brain Injury. Curr Neurol Neurosci Rep 2021; 21:6. [PMID: 33527217 PMCID: PMC7850903 DOI: 10.1007/s11910-021-01098-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW Increasingly sophisticated systems for monitoring the brain have led to an increase in the use of multimodality monitoring (MMM) to detect secondary brain injuries before irreversible damage occurs after brain trauma. This review examines the challenges and opportunities associated with MMM in this population. RECENT FINDINGS Locally and internationally, the use of MMM varies. Practical challenges include difficulties with data acquisition, curation, and harmonization with other data sources limiting collaboration. However, efforts toward integration of MMM data, advancements in data science, and the availability of cloud-based infrastructures are now affording the opportunity for MMM to advance the care of patients with brain trauma. MMM provides data to guide the precision management of patients with traumatic brain injury in real time. While challenges exist, there are exciting opportunities for MMM to live up to this promise and to drive new insights into the physiology of the brain and beyond.
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31
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Sahu S, Panda N, Swain A, Mathew P, Singla N, Gupta S, Jangra K, Bhardwaj A, Bhagat H. Optic Nerve Sheath Diameter: Correlation With Intra-Ventricular Intracranial Measurements in Predicting Dysfunctional Intracranial Compliance. Cureus 2021; 13:e13008. [PMID: 33659139 PMCID: PMC7919758 DOI: 10.7759/cureus.13008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2021] [Indexed: 11/24/2022] Open
Abstract
Background Ultrasonographic (USG) measurement of optic nerve sheath diameter (ONSD) has been proposed as a non-invasive, bedside method to detect raised intracranial pressure (ICP) in various clinical settings. We aimed to correlate the ONSD obtained from ultrasonography with the gold standard, intraventricular ICP, and to find out the cut-off point which predicts ICP accurately at different levels. Methodology A prospective double-blind study was carried out by performing ocular ultrasounds in 30 adult patients with features of intracranial hypertension. The ONSD was measured by USG intraoperatively along with direct intraventricular pressure measurement. The ONSD was compared with the intraventricular ICP and correlations were derived. The optimum cut-off of ONSD to predict ICP > 20 mm Hg, 25 mm Hg, 30 mm Hg, and 35 mm Hg was sought. Results There was a significant correlation of ONSD with ICP (r = 0.532, p = 0.002). An ONSD threshold of 5.5 mm predicted ICP > 20 mm Hg with high sensitivity (100%) and specificity (75%) (area under receiver operating characteristic [ROC] curve = 0.904, p=0.01). The optimum ONSD cut-off predicting ICP at values of 25 mm Hg, 30 mm Hg, and 35 mm Hg was 6.3 mm, 6.5 mm, and 6.7 mm, respectively. Conclusion Our study confirms the utility of optic nerve ultrasound in the diagnostic evaluation of patients with known or suspected intracranial hypertension. We recommend an ONSD cut-off of 5.5 mm for predicting ICP > 20 mm Hg.
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Affiliation(s)
- Seelora Sahu
- Anaesthesiology, Tata Main Hospital, Jamshedpur, IND
| | - Nidhi Panda
- Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Amlan Swain
- Anaesthesiology, Tata Main Hospital, Jamshedpur, IND
| | - Preethy Mathew
- Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Navneet Singla
- Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Sunil Gupta
- Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Kiran Jangra
- Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Avanish Bhardwaj
- Anaesthesiology and Critical Care, Command Hospital Airforce Bangalore, Bengaluru, IND
| | - Hemant Bhagat
- Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
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32
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Depreitere B, Citerio G, Smith M, Adelson PD, Aries MJ, Bleck TP, Bouzat P, Chesnut R, De Sloovere V, Diringer M, Dureanteau J, Ercole A, Hawryluk G, Hawthorne C, Helbok R, Klein SP, Neumann JO, Robba C, Steiner L, Stocchetti N, Taccone FS, Valadka A, Wolf S, Zeiler FA, Meyfroidt G. Cerebrovascular Autoregulation Monitoring in the Management of Adult Severe Traumatic Brain Injury: A Delphi Consensus of Clinicians. Neurocrit Care 2021; 34:731-738. [PMID: 33495910 PMCID: PMC8179892 DOI: 10.1007/s12028-020-01185-x] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/31/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Several methods have been proposed to measure cerebrovascular autoregulation (CA) in traumatic brain injury (TBI), but the lack of a gold standard and the absence of prospective clinical data on risks, impact on care and outcomes of implementation of CA-guided management lead to uncertainty. AIM To formulate statements using a Delphi consensus approach employing a group of expert clinicians, that reflect current knowledge of CA, aspects that can be implemented in TBI management and CA research priorities. METHODS A group of 25 international academic experts with clinical expertise in the management of adult severe TBI patients participated in this consensus process. Seventy-seven statements and multiple-choice questions were submitted to the group in two online surveys, followed by a face-to-face meeting and a third online survey. Participants received feedback on average scores and the rationale for resubmission or rephrasing of statements. Consensus on a statement was defined as agreement of more than 75% of participants. RESULTS Consensus amongst participants was achieved on the importance of CA status in adult severe TBI pathophysiology, the dynamic non-binary nature of CA impairment, its association with outcome and the inadvisability of employing universal and absolute cerebral perfusion pressure targets. Consensus could not be reached on the accuracy, reliability and validation of any current CA assessment method. There was also no consensus on how to implement CA information in clinical management protocols, reflecting insufficient clinical evidence. CONCLUSION The Delphi process resulted in 25 consensus statements addressing the pathophysiology of impaired CA, and its impact on cerebral perfusion pressure targets and outcome. A research agenda was proposed emphasizing the need for better validated CA assessment methods as well as the focused investigation of the application of CA-guided management in clinical care using prospective safety, feasibility and efficacy studies.
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Affiliation(s)
- B Depreitere
- Neurosurgery, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - G Citerio
- Intensive Care Medicine, School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - M Smith
- Neurocritical Care Unit, National Hospital for Neurology and Neurosurgery, University College London, London, UK
| | - P David Adelson
- Barrow Neurological Institute At Phoenix Childrens Hospital, Department of Child Health/Neurosurgery, University of Arizona College of Medicine, Tucson, AZ, USA
- Department of Neurosurgery, Mayo Clinic School of Medicine, School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ, USA
| | - M J Aries
- Department of Intensive Care, Maastricht University Medical Center, University of Maastricht, Maastricht, The Netherlands
| | - T P Bleck
- Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - P Bouzat
- Grenoble Alps Trauma Center, Department of Anesthesiology and Intensive Care Medicine, Grenoble University Hospital, Grenoble, France
| | - R Chesnut
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - V De Sloovere
- Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - M Diringer
- Department of Neurology, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO, USA
| | - J Dureanteau
- Université Paris Sud - Hôpitaux Universitaires Paris-Sud, Paris, France
| | - A Ercole
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - G Hawryluk
- Section of Neurosurgery, University of Manitoba, Winnipeg, MB, Canada
| | - C Hawthorne
- Head and Neck Anaesthesia and Neurocritical Care, Institute of Neurological Sciences, Glasgow, UK
| | - R Helbok
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - S P Klein
- Neurosurgery, University Hospital Brussels, Brussels, Belgium
| | - J O Neumann
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - C Robba
- Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genova, Italy
| | - L Steiner
- Anesthesiology, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - N Stocchetti
- Department of Physiopathology and Transplant, Milan University and Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - F S Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - A Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
| | - S Wolf
- Department of Neurosurgery, University Hospital Berlin Charité, Berlin, Germany
| | - F A Zeiler
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Canada
| | - G Meyfroidt
- Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
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Agrawal D, Raghavendran K, Zhao L, Rajajee V. A Prospective Study of Optic Nerve Ultrasound for the Detection of Elevated Intracranial Pressure in Severe Traumatic Brain Injury. Crit Care Med 2020; 48:e1278-e1285. [PMID: 33048902 PMCID: PMC7708401 DOI: 10.1097/ccm.0000000000004689] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Intracranial pressure monitoring plays a critical role in the management of severe traumatic brain injury. Our objective was to evaluate the accuracy of optic nerve sheath diameter as a noninvasive screening test for the detection of elevated intracranial pressure and prediction of intracranial pressure treatment intensity. DESIGN Prospective, blinded study of diagnostic accuracy. SETTING Neurotrauma ICU. SUBJECTS Consecutive patients with severe traumatic brain injury. INTERVENTIONS Optic nerve ultrasound was performed daily and optic nerve ultrasound measured at the point-of-care as well as remotely by an expert blinded to all patient details. Optic disc elevation was also measured. The index test was the highest remote-expert optic nerve ultrasound for the admission. The reference standard was the concurrent invasive intracranial pressure, with test-positivity set at intracranial pressure greater than 22 mm Hg. A priori the minimally acceptable sensitivity threshold was 90% with corresponding specificity 60%. We also evaluated the ability of optic nerve ultrasound to predict a therapeutic intensity level greater than 10. MEASUREMENTS AND MAIN RESULTS One hundred twenty patients were enrolled. The intraclass correlation coefficient between point of care and expert optic nerve sheath diameter after enrollment of 50 subjects was poor at 0.16 (-0.08 to 0.41) but improved to 0.87 (0.81-0.92) for the remaining subjects after remedial training. The area under the curve of the receiver operating characteristic curve of the highest expert-measured optic nerve sheath diameter to detect intracranial pressure greater than 22 mm Hg was 0.81 (0.73-0.87); area under the curve for prediction of therapeutic intensity level greater than 10 was 0.51 (0.42-0.60). Optic nerve sheath diameter greater than 0.72 demonstrated sensitivity 82% (48-98%) and specificity 79% (70-86%) for intracranial pressure greater than 22 mm Hg. The area under the curve of highest measured optic disc elevation to detect intracranial pressure greater than 22 mm Hg was 0.84 (0.76-0.90). Optic disc elevation greater than 0.04 cm attained sensitivity 90% (56-100%) and specificity 71% (61-79%). CONCLUSIONS While optic nerve sheath diameter demonstrated a modest, statistically significant correlation with intracranial pressure, a predetermined level of diagnostic accuracy to justify routine clinical use as a screening test was not achieved. Measurement of optic disc elevation appears promising for the detection of elevated intracranial pressure, however, verification from larger studies is necessary.
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Affiliation(s)
- Deepak Agrawal
- Department of Neurosurgery, JPN Apex Trauma Centre and Neurosciences Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | | | - Lili Zhao
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Venkatakrishna Rajajee
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI
- Department of Neurology, University of Michigan, Ann Arbor, MI
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Rasulo F, Piva S, Park S, Oddo M, Megjhani M, Cardim D, Matteotti I, Gandolfi L, Robba C, Taccone FS, Latronico N. The Association Between Peri-Hemorrhagic Metabolites and Cerebral Hemodynamics in Comatose Patients With Spontaneous Intracerebral Hemorrhage: An International Multicenter Pilot Study Analysis. Front Neurol 2020; 11:568536. [PMID: 33193007 PMCID: PMC7649496 DOI: 10.3389/fneur.2020.568536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 09/28/2020] [Indexed: 11/13/2022] Open
Abstract
Background and Objective: Cerebral microdialysis (CMD) enables monitoring brain tissue metabolism and risk factors for secondary brain injury such as an imbalance of consumption, altered utilization, and delivery of oxygen and glucose, frequently present following spontaneous intracerebral hemorrhage (SICH). The aim of this study was to evaluate the relationship between lactate/pyruvate ratio (LPR) with hemodynamic variables [mean arterial blood pressure (MABP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), and cerebrovascular pressure reactivity (PRx)] and metabolic variables (glutamate, glucose, and glycerol), within the cerebral peri-hemorrhagic region, with the hypothesis that there may be an association between these variables, leading to a worsening of outcome in comatose SICH patients. Methods: This is an international multicenter cohort study regarding a retrospective dataset analysis of non-consecutive comatose patients with supratentorial SICH undergoing invasive multimodality neuromonitoring admitted to neurocritical care units pertaining to three different centers. Patients with SICH were included if they had an indication for invasive ICP and CMD monitoring, were >18 years of age, and had a Glasgow Coma Scale (GCS) score of ≤8. Results: Twenty-two patients were included in the analysis. A total monitoring time of 1,558 h was analyzed, with a mean (SD) monitoring time of 70.72 h (66.25) per patient. Moreover, 21 out of the 22 patients (95%) had disturbed cerebrovascular autoregulation during the observation period. When considering a dichotomized LPR for a threshold level of 25 or 40, there was a statistically significant difference in all the measured variables (PRx, glucose, glutamate), but not glycerol. When dichotomized PRx was considered as the dependent variable, only LPR was related to autoregulation. A lower PRx was associated with a higher survival [27.9% (23.1%) vs. 56.0% (31.3%), p = 0.03]. Conclusions: According to our results, disturbed autoregulation in comatose SICH patients is common. It is correlated to deranged metabolites within the peri-hemorrhagic region of the clot and is also associated with poor outcome.
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Affiliation(s)
- Frank Rasulo
- Department of Anesthesia, Intensive Care and Emergency Medicine, Spedali Civili University Hospital of Brescia, Brescia, Italy
- *Correspondence: Frank Rasulo ; orcid.org/0000-0001-8038-569X
| | - Simone Piva
- Department of Anesthesia, Intensive Care and Emergency Medicine, Spedali Civili University Hospital of Brescia, Brescia, Italy
| | - Soojin Park
- Department of Neurocritical Care, Columbia University, Presbyterian Hospital Medical Center of New York, New York City, NY, United States
| | - Mauro Oddo
- Department of Intensive Care, Canton of Vaud University Hospital (CHUV)-Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Murad Megjhani
- Department of Neurocritical Care, Columbia University, Presbyterian Hospital Medical Center of New York, New York City, NY, United States
| | - Danilo Cardim
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Ilaria Matteotti
- Department of Anesthesia, Intensive Care and Emergency Medicine, Spedali Civili University Hospital of Brescia, Brescia, Italy
| | - Leonardo Gandolfi
- Department of Anesthesia, Intensive Care and Emergency Medicine, Spedali Civili University Hospital of Brescia, Brescia, Italy
| | - Chiara Robba
- Department of Anesthesia and Intensive Care, Ospedale Policlinico San Martino Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Genova, Italy
| | | | - Nicola Latronico
- Department of Anesthesia, Intensive Care and Emergency Medicine, Spedali Civili University Hospital of Brescia, Brescia, Italy
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Shi J, Tan L, Ye J, Hu L. Hypertonic saline and mannitol in patients with traumatic brain injury: A systematic and meta-analysis. Medicine (Baltimore) 2020; 99:e21655. [PMID: 32871879 PMCID: PMC7458171 DOI: 10.1097/md.0000000000021655] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 07/05/2020] [Accepted: 07/08/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND To compare the effects of 3% hypertonic saline solution and 20% mannitol solution on intracranial hypertension. METHODS WAN-FANGDATA, CNKI, and CQVIP databases were searched, and relevant literatures of randomized controlled trials comparing 3% hypertonic saline solution with mannitol in reducing intracranial hypertension from 2010 to October 2019 were collected. Meta-analysis was performed using RevMan software. RESULTS As a result, 10 articles that met the inclusion criteria were finally included. A total of 544 patients were enrolled in the study, 270 in the hypertonic saline group and 274 in the mannitol group. There was no significant difference in the decrease of intracranial pressure and the onset time of drug between the 2 groups after intervention (all P > .05). There was a statistically significant difference between the hypertonic saline group and the mannitol group in terms of duration of effect in reducing intracranial pressure (95% confidence interval: 0.64-1.05, Z = 8.09, P < .00001) and cerebral perfusion pressure after intervention (95% confidence interval: 0.15-0.92, Z = 2.72, P = .007). CONCLUSION Both 3% hypertonic saline and mannitol can effectively reduce intracranial pressure, but 3% hypertonic saline has a more sustained effect on intracranial pressure and can effectively increase cerebral perfusion pressure.
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Miyoshi Y, Kondo Y, Suzuki H, Fukuda T, Yasuda H, Yokobori S. Effects of hypertonic saline versus mannitol in patients with traumatic brain injury in prehospital, emergency department, and intensive care unit settings: a systematic review and meta-analysis. J Intensive Care 2020; 8:61. [PMID: 32817796 PMCID: PMC7425012 DOI: 10.1186/s40560-020-00476-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 07/28/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Intracranial pressure control has long been recognized as an important requirement for patients with severe traumatic brain injury. Hypertonic saline has drawn attention as an alternative to mannitol in this setting. The aim of this study was to assess the effects of hypertonic saline versus mannitol on clinical outcomes in patients with traumatic brain injury in prehospital, emergency department, and intensive care unit settings by systematically reviewing the literature and synthesizing the evidence from randomized controlled trials. METHODS We searched the MEDLINE database, the Cochrane Central Register of Controlled Trials, and the Igaku Chuo Zasshi (ICHUSHI) Web database with no date restrictions. We selected randomized controlled trials in which the clinical outcomes of adult patients with traumatic brain injury were compared between hypertonic saline and mannitol strategies. Two investigators independently screened the search results and conducted the data extraction. The primary outcome was all-cause mortality. The secondary outcomes were 90-day and 180-day mortality, good neurological outcomes, reduction in intracranial pressure, and serum sodium level. Random effects estimators with weights calculated by the inverse variance method were used to determine the pooled risk ratios. RESULTS A total of 125 patients from four randomized trials were included, and all the studies were conducted in the intensive care unit. Among 105 patients from three trials that evaluated the primary outcome, 50 patients were assigned to the hypertonic saline group and 55 patients were assigned to the mannitol group. During the observation period, death was observed for 16 patients in the hypertonic saline group (32.0%) and 21 patients in the mannitol group (38.2%). The risks were not significant between the two infusion strategies (pooled risk ratio, 0.82; 95% confidence interval, 0.49-1.37). There were also no significant differences between the two groups in the other secondary outcomes. However, the certainty of the evidence was rated very low for all outcomes. CONCLUSIONS Our findings revealed no significant difference in the all-cause mortality rates between patients receiving hypertonic saline or mannitol to control intracranial pressure. Further investigation is warranted because we only included a limited number of studies.
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Affiliation(s)
- Yukari Miyoshi
- Department of Emergency and Critical care Medicine, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021 Japan
| | - Yutaka Kondo
- Department of Emergency and Critical care Medicine, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021 Japan
| | - Hidetaka Suzuki
- Emergency and Critical Care Center, Japanese Red Cross Musashino Hospital, Musashino, Japan
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Nishihara, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
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Sheikh ZB, Maciel CB, Dhakar MB, Hirsch LJ, Gilmore EJ. Nonepileptic Electroencephalographic Correlates of Episodic Increases in Intracranial Pressure. J Clin Neurophysiol 2020; 39:149-158. [PMID: 32701765 DOI: 10.1097/wnp.0000000000000750] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Continuous EEG can potentially be used as real-time brain telemetry for the early detection of neurologic decline. Scant literature on EEG changes related to elevated intracranial pressure (ICP) limits its use in this context. METHODS Retrospective, observational case series of patients in whom we noted EEG changes correlating with a clinical concern for elevated ICP, measured or unmeasured. RESULTS We noted EEG changes of varying severity and duration correlating with either measured or unmeasured clinical concern for elevated ICP. In two patients with recurrent transient unresponsiveness (presumed from plateau waves), generalized rhythmic delta activity and attenuation of fast activity occurred 30 minutes before a clinical change. Elevated ICP in two patients, one related to progressive mass effect from infarctions, and the other to dialysis, correlated with generalized slowing and attenuation of fast activity up to 24 hours before clinical deterioration, leading to diffuse suppression. Two patients with intraventricular hemorrhage had cyclic patterns at ∼1 per minute and ∼6 per minute (similar frequency to described frequency of Lundberg B and C waves, respectively). CONCLUSIONS Cyclic patterns and varying degrees of slowing and attenuation often preceded clinical deterioration associated with intracranial hypertension. Future systematic studies of EEG changes in this setting will facilitate early and noninvasive detection of elevated ICP.
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Affiliation(s)
- Zubeda B Sheikh
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A.,Department of Neurology, West Virginia University School of Medicine, Morgantown, West Virginia, U.S.A
| | - Carolina B Maciel
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A.,Department of Neurology, University of Florida School of Medicine, Gainesville, Florida, U.S.A
| | - Monica B Dhakar
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A.,Department of Neurology, Epilepsy section, Emory University School of Medicine, Atlanta, Georgia, U.S.A
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Emily J Gilmore
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, U.S.A
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Wang LJ, Chen HX, Chen Y, Yu ZY, Xing YQ. Optic nerve sheath diameter ultrasonography for elevated intracranial pressure detection. Ann Clin Transl Neurol 2020; 7:865-868. [PMID: 32383326 PMCID: PMC7261744 DOI: 10.1002/acn3.51054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/13/2020] [Accepted: 04/14/2020] [Indexed: 01/06/2023] Open
Abstract
Ultrasonographically measured optic nerve sheath diameter measurement has become a common noninvasive approach for detecting elevated intracranial pressure. We present a case of aneurysmal subarachnoid hemorrhage with elevated intracranial pressure. Postoperative arachnoiditis developed, and lumbar puncture revealed low intracranial pressure. However, ultrasonography revealed a dilated optic nerve sheath, denoting elevated intracranial pressure. This was confirmed by computed tomography showing ventricular dilation. Ophthalmoscopy revealed papilledema and hemorrhage. This case study demonstrated that noninvasive bedside ultrasonographic optic nerve sheath diameter measurement can detect elevated intracranial pressure more accurately than lumbar puncture, especially in cases with intracranial infection.
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Affiliation(s)
- Li-Juan Wang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Hong-Xiu Chen
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Ying Chen
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Ze-Yang Yu
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Ying-Qi Xing
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
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Zhou J, Yang CS, Shen LJ, Lv QW, Xu QC. Usefulness of serum glucose and potassium ratio as a predictor for 30-day death among patients with severe traumatic brain injury. Clin Chim Acta 2020; 506:166-171. [PMID: 32240656 DOI: 10.1016/j.cca.2020.03.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 03/26/2020] [Accepted: 03/26/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND Serum glucose and potassium ratio (GPR) was recently found to be related to outcome of aneurysmal subarachnoid hemorrhage. This retrospectively study was to investigate the association of serum GPR with mortality in severe traumatic brain injury (sTBI). METHODS Clinical data were retrospectively reviewed of isolated sTBI patients admitted within 12 h after trauma between January 2014 and January 2019. We analyzed relationships between admission serum GPR and post-traumatic 30-day mortality in addition to admission Glasgow coma scale (GCS) scores. Discriminative ability was evaluated using area under receiver operating characteristic curve (AUC). RESULTS A total of 146 patients, of whom 37 (25.3%) died within 30 days following trauma, were included. Admission serum GPR emerged as an independent predictor for 30-day mortality (odds ratio, 5.256; 95% confidence interval (CI), 1.111-14.856) and overall survival (hazard ratio, 4.822; 95% CI, 1.157-12.870), with an AUC of 0.777 (95% CI, 0.693-0.835), which was equivalent to that of GCS scores (AUC, 0.831; 95% CI, 0.760-0.888; P = 0.179). There was a significant correlation between admission serum GPR and GCS scores (r2 = 0.293). CONCLUSIONS Serum GPR in cases of sTBI is substantially associated with trauma severity and 30-day mortality. Therefore, the potential value of serum GPR for predicting short-term mortality of sTBI patients is favorable.
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Affiliation(s)
- Jing Zhou
- Department of Neurosurgery, Shengzhou People's Hospital (The First Affiliated Hospital of Zhejiang University Shengzhou Branch), No. 666 Dangui Road, Shengzhou 312400, Zhejiang, China
| | - Chun-Song Yang
- Department of Neurosurgery, Shengzhou People's Hospital (The First Affiliated Hospital of Zhejiang University Shengzhou Branch), No. 666 Dangui Road, Shengzhou 312400, Zhejiang, China.
| | - Liang-Jun Shen
- Department of Neurosurgery, Shengzhou People's Hospital (The First Affiliated Hospital of Zhejiang University Shengzhou Branch), No. 666 Dangui Road, Shengzhou 312400, Zhejiang, China
| | - Qing-Wei Lv
- Department of Neurosurgery, Shengzhou People's Hospital (The First Affiliated Hospital of Zhejiang University Shengzhou Branch), No. 666 Dangui Road, Shengzhou 312400, Zhejiang, China
| | - Qi-Chen Xu
- Department of Neurosurgery, Shengzhou People's Hospital (The First Affiliated Hospital of Zhejiang University Shengzhou Branch), No. 666 Dangui Road, Shengzhou 312400, Zhejiang, China
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Honeybul S. Balancing the short-term benefits and long-term outcomes of decompressive craniectomy for severe traumatic brain injury. Expert Rev Neurother 2020; 20:333-340. [PMID: 32075441 DOI: 10.1080/14737175.2020.1733416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: The role of decompressive craniectomy in the management of neurological emergencies remains controversial. There is evidence available that it can reduce intracranial pressure, but it will not reverse the effects of the pathology that precipitated the neurological crisis, so there has always been concern that any reduction in mortality will result in an increase in the number of survivors with severe disability.Areas covered: The results of recent randomised controlled trials investigating the efficacy of the procedure are analyzed in order to determine the degree to which the short-term goals of reducing mortality and the long-term goals of a good functional outcome are achieved.Expert opinion: Given the results of the trials, there needs to be a change in the clinical decision-making paradigm such that decompression is reserved for patients who develop intractable intracranial hypertension and who are thought unlikely to survive without surgical intervention. In these circumstances, a more patient-centered discussion is required regarding the possibility and acceptability or otherwise of survival with severely impaired neurocognitive function.
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Affiliation(s)
- Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital and Royal Perth Hospital, Perth, Western Australia, Australia
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Assessment of intracranial pressure monitoring in patients with moderate traumatic brain injury: A retrospective cohort study. Clin Neurol Neurosurg 2020; 189:105538. [DOI: 10.1016/j.clineuro.2019.105538] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 09/13/2019] [Accepted: 09/26/2019] [Indexed: 11/17/2022]
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Grahf DC, Binz SI, Belle T, Jayaprakash N. Watching the Brain: an Overview of Neuromonitoring Systems and Their Utility in the Emergency Department. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2020. [DOI: 10.1007/s40138-020-00208-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Sahuquillo J, Dennis JA, Cochrane Injuries Group. Decompressive craniectomy for the treatment of high intracranial pressure in closed traumatic brain injury. Cochrane Database Syst Rev 2019; 12:CD003983. [PMID: 31887790 PMCID: PMC6953357 DOI: 10.1002/14651858.cd003983.pub3] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND High intracranial pressure (ICP) is the most frequent cause of death and disability after severe traumatic brain injury (TBI). It is usually treated with general maneuvers (normothermia, sedation, etc.) and a set of first-line therapeutic measures (moderate hypocapnia, mannitol, etc.). When these measures fail, second-line therapies are initiated, which include: barbiturates, hyperventilation, moderate hypothermia, or removal of a variable amount of skull bone (secondary decompressive craniectomy). OBJECTIVES To assess the effects of secondary decompressive craniectomy (DC) on outcomes of patients with severe TBI in whom conventional medical therapeutic measures have failed to control raised ICP. SEARCH METHODS The most recent search was run on 8 December 2019. We searched the Cochrane Injuries Group's Specialised Register, CENTRAL (Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic + Embase (OvidSP) and ISI Web of Science (SCI-EXPANDED & CPCI-S). We also searched trials registries and contacted experts. SELECTION CRITERIA We included randomized studies assessing patients over the age of 12 months with severe TBI who either underwent DC to control ICP refractory to conventional medical treatments or received standard care. DATA COLLECTION AND ANALYSIS We selected potentially relevant studies from the search results, and obtained study reports. Two review authors independently extracted data from included studies and assessed risk of bias. We used a random-effects model for meta-analysis. We rated the quality of the evidence according to the GRADE approach. MAIN RESULTS We included three trials (590 participants). One single-site trial included 27 children; another multicenter trial (three countries) recruited 155 adults, the third trial was conducted in 24 countries, and recruited 408 adolescents and adults. Each study compared DC combined with standard care (this could include induced barbiturate coma or cooling of the brain, or both). All trials measured outcomes up to six months after injury; one also measured outcomes at 12 and 24 months (the latter data remain unpublished). All trials were at a high risk of bias for the criterion of performance bias, as neither participants nor personnel could be blinded to these interventions. The pediatric trial was at a high risk of selection bias and stopped early; another trial was at risk of bias because of atypical inclusion criteria and a change to the primary outcome after it had started. Mortality: pooled results for three studies provided moderate quality evidence that risk of death at six months was slightly reduced with DC (RR 0.66, 95% CI 0.43 to 1.01; 3 studies, 571 participants; I2 = 38%; moderate-quality evidence), and one study also showed a clear reduction in risk of death at 12 months (RR 0.59, 95% CI 0.45 to 0.76; 1 study, 373 participants; high-quality evidence). Neurological outcome: conscious of controversy around the traditional dichotomization of the Glasgow Outcome Scale (GOS) scale, we chose to present results in three ways, in order to contextualize factors relevant to clinical/patient decision-making. First, we present results of death in combination with vegetative status, versus other outcomes. Two studies reported results at six months for 544 participants. One employed a lower ICP threshold than the other studies, and showed an increase in the risk of death/vegetative state for the DC group. The other study used a more conventional ICP threshold, and results favoured the DC group (15.7% absolute risk reduction (ARR) (95% CI 6% to 25%). The number needed to treat for one beneficial outcome (NNTB) (i.e. to avoid death or vegetative status) was seven. The pooled result for DC compared with standard care showed no clear benefit for either group (RR 0.99, 95% CI 0.46 to 2.13; 2 studies, 544 participants; I2 = 86%; low-quality evidence). One study reported data for this outcome at 12 months, when the risk for death or vegetative state was clearly reduced by DC compared with medical treatment (RR 0.68, 95% CI 0.54 to 0.86; 1 study, 373 participants; high-quality evidence). Second, we assessed the risk of an 'unfavorable outcome' evaluated on a non-traditional dichotomized GOS-Extended scale (GOS-E), that is, grouping the category 'upper severe disability' into the 'good outcome' grouping. Data were available for two studies (n = 571). Pooling indicated little difference between DC and standard care regarding the risk of an unfavorable outcome at six months following injury (RR 1.06, 95% CI 0.69 to 1.63; 544 participants); heterogeneity was high, with an I2 value of 82%. One trial reported data at 12 months and indicated a clear benefit of DC (RR 0.81, 95% CI 0.69 to 0.95; 373 participants). Third, we assessed the risk of an 'unfavorable outcome' using the (traditional) dichotomized GOS/GOS-E cutoff into 'favorable' versus 'unfavorable' results. There was little difference between DC and standard care at six months (RR 1.00, 95% CI 0.71 to 1.40; 3 studies, 571 participants; low-quality evidence), and heterogeneity was high (I2 = 78%). At 12 months one trial suggested a similar finding (RR 0.95, 95% CI 0.83 to 1.09; 1 study, 373 participants; high-quality evidence). With regard to ICP reduction, pooled results for two studies provided moderate quality evidence that DC was superior to standard care for reducing ICP within 48 hours (MD -4.66 mmHg, 95% CI -6.86 to -2.45; 2 studies, 182 participants; I2 = 0%). Data from the third study were consistent with these, but could not be pooled. Data on adverse events are difficult to interpret, as mortality and complications are high, and it can be difficult to distinguish between treatment-related adverse events and the natural evolution of the condition. In general, there was low-quality evidence that surgical patients experienced a higher risk of adverse events. AUTHORS' CONCLUSIONS Decompressive craniectomy holds promise of reduced mortality, but the effects of long-term neurological outcome remain controversial, and involve an examination of the priorities of participants and their families. Future research should focus on identifying clinical and neuroimaging characteristics to identify those patients who would survive with an acceptable quality of life; the best timing for DC; the most appropriate surgical techniques; and whether some synergistic treatments used with DC might improve patient outcomes.
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Affiliation(s)
- Juan Sahuquillo
- Vall d'Hebron University HospitalDepartment of NeurosurgeryUniversitat Autònoma de BarcelonaPaseo Vall d'Hebron 119 ‐ 129BarcelonaBarcelonaSpain08035
| | - Jane A Dennis
- University of BristolMusculoskeletal Research Unit, School of Clinical SciencesLearning and Research Building [Level 1]Southmead HospitalBristolUKBS10 5NB
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Bhaire VS, Panda N, Luthra A, Chauhan R, Rajappa D, Bhagat H. Effect of Combination of Ketamine and Propofol (Ketofol) on Cerebral Oxygenation in Neurosurgical Patients: A Randomized Double-Blinded Controlled Trial. Anesth Essays Res 2019; 13:643-648. [PMID: 32009709 PMCID: PMC6937901 DOI: 10.4103/aer.aer_119_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/25/2019] [Accepted: 09/29/2019] [Indexed: 11/25/2022] Open
Abstract
Background: The effects of ketofol (a combination of ketamine and propofol) on systemic hemodynamics and requirement of opioids/Propofol have already been studied and published. However, there is paucity in the literature on the effects of ketofol on cerebral oxygenation. This study aims to compare the effects of ketofol (ketamine + propofol [1:5]) with propofol on cerebral oxygenation using jugular venous oxygen saturation (SjVO2), in patients undergoing surgical clipping of intracranial aneurysms. Materials and Methods: A total of 40 World Federation of Neurosurgeons I and II patients were randomized into ketofol (n = 20) and propofol (n = 20) groups. Postinduction, SjVO2 catheter was inserted, and anesthesia was maintained with propofol and fentanyl in the propofol group and ketofol and fentanyl in the ketofol group. Jugular venous oxygen saturation (SjVO2) was obtained at baseline, 1 h and 2 h intraoperatively, and at 6 h after the surgery. Intraoperative hemodynamics and brain relaxation scores were also noted. Results: Entire SjVO2 values in both groups were within the normal limits. Higher SjVO2 values were observed in ketofol group compared to propofol at 1 and 2 h after starting of the drug and at 6 h after surgery (P < 0.05). In propofol group, a significant fall in SjVO2 was recorded at 2 h after beginning the drug as compared to the baseline (P = 0.001). More than 20% fall in mean arterial pressure (MAP) compared to baseline MAP was noted in 75% of patients in propofol group and 15% of patients in ketofol group (P = 0.002). In propofol group, 55% of patients required rescue drug phenylephrine to treat hypotension, whereas only 15% of patients required it in ketofol group (P = 0.02). Fentanyl requirement in ketofol group was less as compared to the propofol group (P = 0.022). Brain relaxation scores were comparable in both the study groups (P = 0.887). Conclusion: Maintenance of anesthesia with ketofol provides better cerebral oxygenation and hemodynamic stability compared to propofol in neurosurgical patients.
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Affiliation(s)
| | - Nidhi Panda
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Ankur Luthra
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Rajeev Chauhan
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Deepak Rajappa
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Hemant Bhagat
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
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Bodanapally UK, Shanmuganathan K, Parikh GY, Schwartzbauer G, Kondaveti R, Feiter TR. Quantification of Iodine Leakage on Dual-Energy CT as a Marker of Blood-Brain Barrier Permeability in Traumatic Hemorrhagic Contusions: Prediction of Surgical Intervention for Intracranial Pressure Management. AJNR Am J Neuroradiol 2019; 40:2059-2065. [PMID: 31727752 PMCID: PMC6975368 DOI: 10.3174/ajnr.a6316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/30/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Hemorrhagic contusions are associated with iodine leakage. We aimed to identify quantitative iodine-based dual-energy CT variables that correlate with the type of intracranial pressure management. MATERIALS AND METHODS Consecutive patients with contusions from May 2016 through January 2017 were retrospectively analyzed. Radiologists, blinded to the outcomes, evaluated CT variables from unenhanced admission and short-term follow-up head dual-energy CT scans obtained after contrast-enhanced whole-body CT. Treatment intensity of intracranial pressure was broadly divided into 2 groups: those managed medically and those managed surgically. Univariable analysis followed by logistic regression was used to develop a prediction model. RESULTS The study included 65 patients (50 men; median age, 48 years; Q1 to Q3, 25-65.5 years). Twenty-one patients were managed surgically (14 by CSF drainage, 7 by craniectomy). Iodine-based variables that correlated with surgical management were higher iodine concentration, pseudohematoma volume, iodine quantity in pseudohematoma, and iodine quantity in contusions. The regression model developed after inclusion of clinical variables identified 3 predictor variables: postresuscitation Glasgow Coma Scale (adjusted OR = 0.55; 95% CI, 0.38-0.79; P = .001), age (adjusted OR = 0.9; 95% CI, 0.85-0.97; P = .003), and pseudohematoma volume (adjusted OR = 2.05; 95% CI, 1.1-3.77; P = .02), which yielded an area under the curve of 0.96 in predicting surgical intracranial pressure management. The 2 predictors for craniectomy were age (adjusted OR = 0.89; 95% CI, 0.81-0.99; P = .03) and pseudohematoma volume (adjusted OR = 1.23; 95% CI, 1.03-1.45; P = .02), which yielded an area under the curve of 0.89. CONCLUSIONS Quantitative iodine-based parameters derived from follow-up dual-energy CT may predict the intensity of intracranial pressure management in patients with hemorrhagic contusions.
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Affiliation(s)
- U K Bodanapally
- From the Departments of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., T.R.F.)
| | - K Shanmuganathan
- From the Departments of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., T.R.F.)
| | | | - G Schwartzbauer
- Neurosurgery (G.S.), R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - R Kondaveti
- Kasturba Medical College (R.K.), Mangaluru, India
| | - T R Feiter
- From the Departments of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., T.R.F.)
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46
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Yu J, Park JY, Kim DH, Koh GH, Jeong W, Kim E, Hong JH, Hwang JH, Kim YK. Dexmedetomidine attenuates the increase of ultrasonographic optic nerve sheath diameter as a surrogate for intracranial pressure in patients undergoing robot-assisted laparoscopic prostatectomy: A randomized double-blind controlled trial. Medicine (Baltimore) 2019; 98:e16772. [PMID: 31415378 PMCID: PMC6831248 DOI: 10.1097/md.0000000000016772] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Pneumoperitoneum and steep Trendelenburg position during robot-assisted laparoscopic prostatectomy (RALP) can increase intracranial pressure (ICP). Dexmedetomidine, a highly selective alpha-2 adrenergic receptor agonist, can cause cerebral vasoconstriction and decrease cerebral blood flow by stimulating the postsynaptic alpha-2 adrenergic receptors on cerebral blood vessels. However, the effects of dexmedetomidine on ICP are controversial and have not been evaluated during RALP under the establishment of pneumoperitoneum in the steep Trendelenburg position. Therefore, we evaluated the effect of dexmedetomidine on optic nerve sheath diameter (ONSD) as a surrogate for assessing ICP during RALP. METHODS Patients were randomly allocated to receive dexmedetomidine (n = 63) (loading dose, 1 μg/kg for 10 minutes and continuous infusion, 0.4 μg/kg/hr) or normal saline (n = 63). The ONSD was measured at 10 minutes after induction of anesthesia in the supine position (T1), 30 minutes (T2) and 60 minutes (T3) after establishment of pneumoperitoneum in the steep Trendelenburg position, and at closing the skin in the supine position (T4). Hemodynamic and respiratory variables were measured at every time point. RESULTS ONSDs at T2, T3, and T4 were significantly smaller in the dexmedetomidine group than in the control group (5.26 ± 0.25 mm vs 5.71 ± 0.26 mm, 5.29 ± 0.24 mm vs 5.81 ± 0.23 mm, and 4.97 ± 0.24 mm vs 5.15 ± 0.28 mm, all P <.001). ONSDs at T2, T3, and T4 were significantly increased compared to T1 in both groups. Hemodynamic and respiratory variables, except heart rate, did not significantly differ between the 2 groups. The bradycardia and atropine administration were not significantly different between the 2 groups. CONCLUSION Dexmedetomidine attenuates the increase of ONSD during RALP, suggesting that intraoperative dexmedetomidine administration may effectively attenuate the ICP increase during pneumoperitoneum in the Trendelenburg position.
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Affiliation(s)
- Jihion Yu
- Department of Anesthesiology and Pain Medicine
| | | | | | - Gi-Ho Koh
- Department of Anesthesiology and Pain Medicine
| | | | - Eunkyul Kim
- Department of Anesthesiology and Pain Medicine
| | - Jun Hyuk Hong
- Departments of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Ziai WC, Thompson CB, Mayo S, Nichol M, Freeman WD, Dlugash R, Ullman N, Hao Y, Lane K, Awad I, Hanley DF, CLEAR III Investigators. Intracranial Hypertension and Cerebral Perfusion Pressure Insults in Adult Hypertensive Intraventricular Hemorrhage: Occurrence and Associations With Outcome. Crit Care Med 2019; 47:1125-1134. [PMID: 31162192 PMCID: PMC7490004 DOI: 10.1097/ccm.0000000000003848] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Elevated intracranial pressure and inadequate cerebral perfusion pressure may contribute to poor outcomes in hypertensive intraventricular hemorrhage. We characterized the occurrence of elevated intracranial pressure and low cerebral perfusion pressure in obstructive intraventricular hemorrhage requiring extraventricular drainage. DESIGN Prospective observational cohort. SETTING ICUs of 73 academic hospitals. PATIENTS Four hundred ninety-nine patients enrolled in the CLEAR III trial, a multicenter, randomized study to determine if extraventricular drainage plus intraventricular alteplase improved outcome versus extraventricular drainage plus saline. INTERVENTIONS Intracranial pressure and cerebral perfusion pressure were recorded every 4 hours, analyzed over a range of thresholds, as single readings or spans (≥ 2) of readings after adjustment for intracerebral hemorrhage severity. Impact on 30- and 180-days modified Rankin Scale scores was assessed, and receiver operating curves were analyzed to identify optimal thresholds. MEASUREMENTS AND MAIN RESULTS Of 21,954 intracranial pressure readings, median interquartile range 12 mm Hg (8-16), 9.7% were greater than 20 mm Hg and 1.8% were greater than 30 mm Hg. Proportion of intracranial pressure readings from greater than 18 to greater than 30 mm Hg and combined intracranial pressure greater than 20 plus cerebral perfusion pressure less than 70 mm Hg were associated with day-30 mortality and partially mitigated by intraventricular alteplase. Proportion of cerebral perfusion pressure readings from less than 65 to less than 90 mm Hg and intracranial pressure greater than 20 mm Hg in spans were associated with both 30-day mortality and 180-day mortality. Proportion of cerebral perfusion pressure readings from less than 65 to less than 90 mm Hg and combined intracranial pressure greater than 20 plus cerebral perfusion pressure less than 60 mm Hg were associated with poor day-30 modified Rankin Scale, whereas cerebral perfusion pressure less than 65 and less than 75 mm Hg were associated with poor day-180 modified Rankin Scale. CONCLUSIONS Elevated intracranial pressure and inadequate cerebral perfusion pressure are not infrequent during extraventricular drainage for severe intraventricular hemorrhage, and level and duration predict higher short-term mortality and long-term mortality. Burden of low cerebral perfusion pressure was also associated with poor short- and long-term outcomes and may be more significant than intracranial pressure. Adverse consequences of intracranial pressure-time burden and cerebral perfusion pressure-time burden should be tested prospectively as potential thresholds for therapeutic intervention.
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Affiliation(s)
- Wendy C. Ziai
- Departments of Neurology, Anesthesia and Critical Care Medicine, Division of Neurocritical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Carol B. Thompson
- Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - McBee Nichol
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Rachel Dlugash
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Natalie Ullman
- Departments of Neurology, Anesthesia and Critical Care Medicine, Division of Neurocritical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yi Hao
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Karen Lane
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Issam Awad
- Section of Neurosurgery and the Neurovascular Surgery Program, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Daniel F. Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD
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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: 127] [Impact Index Per Article: 21.2] [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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49
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Hutchinson PJ, Kolias AG, Tajsic T, Adeleye A, Aklilu AT, Apriawan T, Bajamal AH, Barthélemy EJ, Devi BI, Bhat D, Bulters D, Chesnut R, Citerio G, Cooper DJ, Czosnyka M, Edem I, El-Ghandour NMF, Figaji A, Fountas KN, Gallagher C, Hawryluk GWJ, Iaccarino C, Joseph M, Khan T, Laeke T, Levchenko O, Liu B, Liu W, Maas A, Manley GT, Manson P, Mazzeo AT, Menon DK, Michael DB, Muehlschlegel S, Okonkwo DO, Park KB, Rosenfeld JV, Rosseau G, Rubiano AM, Shabani HK, Stocchetti N, Timmons SD, Timofeev I, Uff C, Ullman JS, Valadka A, Waran V, Wells A, Wilson MH, Servadei F. Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury : Consensus statement. Acta Neurochir (Wien) 2019; 161:1261-1274. [PMID: 31134383 PMCID: PMC6581926 DOI: 10.1007/s00701-019-03936-y] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 04/29/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach. METHODS The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries. RESULTS The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval. CONCLUSIONS In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.
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Affiliation(s)
- 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, 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, UK
| | - Tamara Tajsic
- 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, UK
| | - Amos Adeleye
- Division of Neurological Surgery, Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Department of Neurological Surgery, University College Hospital, Ibadan, Nigeria
| | - Abenezer Tirsit Aklilu
- Neurosurgical Unit, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Tedy Apriawan
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Soetomo General Hospital, Surabaya, Indonesia
| | - Abdul Hafid Bajamal
- Department of Neurosurgery, Faculty of Medicine, Universitas Airlangga, Soetomo General Hospital, Surabaya, Indonesia
| | - Ernest J Barthélemy
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - B Indira Devi
- Department of Neurosurgery, National Institute for Mental Health and Neurosciences, Bangalore, India
| | - Dhananjaya Bhat
- Department of Neurosurgery, National Institute for Mental Health and Neurosciences, Bangalore, India
| | - Diederik Bulters
- Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
| | - Randall Chesnut
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- Neuro-Intensive Care, Department of Emergency and Intensive Care, ASST, San Gerardo Hospital, Monza, Italy
| | - D Jamie Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Idara Edem
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Kostas N Fountas
- Department of Neurosurgery, University Hospital of Larissa and University of Thessaly, Larissa, Greece
| | - Clare Gallagher
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Corrado Iaccarino
- Department of Neurosurgery, Azienda Ospedaliero Universitaria di Parma, Parma, Italy
| | - Mathew Joseph
- Department of Neurosurgery, Christian Medical College, Vellore, India
| | - Tariq Khan
- Department of Neurosurgery, North West General Hospital and Research Center, Peshawar, Pakistan
| | - Tsegazeab Laeke
- Neurosurgical Unit, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Oleg Levchenko
- Department of Neurosurgery, Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
| | - Baiyun Liu
- Department of Neurosurgery, Beijing Tiantan Medical Hospital, Capital Medical University, Beijing, China
| | - Weiming Liu
- Department of Neurosurgery, Beijing Tiantan Medical Hospital, Capital Medical University, Beijing, China
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Paul Manson
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Anna T Mazzeo
- Anesthesia and Intensive Care Unit, Department of Surgical Sciences, University of Torino, Torino, Italy
| | - David K Menon
- Division of Anaesthesia, Addenbrooke's Hospital and University of Cambridge, Cambridge, UK
| | - Daniel B Michael
- Oakland University William Beaumont School of Medicine and Michigan Head & Spine Institute, Auburn Hills, MI, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesia/Critical Care & Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kee B Park
- Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, Alfred Hospital, Melbourne, Australia
- Department of Surgery, Monash University, Melbourne, Australia
| | - Gail Rosseau
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Andres M Rubiano
- INUB/MEDITECH Research Group, El Bosque University, Bogotá, Colombia
- MEDITECH Foundation, Clinical Research, Cali, Colombia
| | - Hamisi K Shabani
- Department of Neurosurgery, Muhimbili Orthopedic-Neurosurgical Institute, Dar es Salaam, Tanzania
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
- Neuroscience Intensive Care Unit, Department of Anaesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Shelly D Timmons
- Department of Neurological Surgery, Penn State University Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ivan Timofeev
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Chris Uff
- Department of Neurosurgery, The Royal London Hospital, London, UK
- Queen Mary University of London, London, UK
| | - Jamie S Ullman
- Department of Neurosurgery, Hofstra North Shore-LIJ School of Medicine, Hempstead, NY, USA
| | - Alex Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Vicknes Waran
- Neurosurgery Division, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Adam Wells
- Department of Neurosurgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Mark H Wilson
- Imperial Neurotrauma Centre, Department of Surgery and Cancer, Imperial College, London, UK
| | - Franco Servadei
- Department of Neurosurgery, Humanitas University and Research Hospital, Milan, Italy
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50
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Gu J, Huang H, Huang Y, Sun H, Xu H. Hypertonic saline or mannitol for treating elevated intracranial pressure in traumatic brain injury: a meta-analysis of randomized controlled trials. Neurosurg Rev 2019; 42:499-509. [PMID: 29905883 DOI: 10.1007/s10143-018-0991-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 05/05/2018] [Accepted: 06/04/2018] [Indexed: 02/05/2023]
Abstract
Hyperosmolar therapy is regarded as the mainstay for treatment of elevated intracranial pressure (ICP) in traumatic brain injury (TBI). This still has been disputed as application of hypertonic saline (HS) or mannitol for treating patients with severe TBI. Thus, this meta-analysis was performed to further compare the advantages and disadvantages of mannitol with HS for treating elevated ICP after TBI. We conducted a systematic search on PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Wan Fang Data, VIP Data, SinoMed, and China National Knowledge Infrastructure (CNKI) databases. Studies were included or not based on the quality assessment by the Jadad scale and selection criteria. Twelve RCTs with 438 patients were enrolled for the meta-analysis. The comparison of HS and mannitol indicated that they were close in field of improving function outcome (RR = 1.17, 95% CI 0.89 to 1.54, p = 0.258) and reducing intracranial pressure (MD = - 0.16, 95% CI: - 0.59 to 0.27, p = 0.473) and mortality (RR = 0.78, 95% CI 0.53 to 1.16, p = 0.216). The pooled relative risk of successful ICP control was 1.06 (95% CI: 1.00 to 1.13, p = 0.044), demonstrating that HS was more effective than mannitol in ICP management. Both serum sodium (WMD = 5.30, 95% CI: 4.37 to 6.22, p < 0.001) and osmolality (WMD = 3.03, 95% CI: 0.18 to 5.88, p = 0.037) were increased after injection of hypertonic saline. The results do not lend a specific recommendation to select hypertonic saline or mannitol as a first-line for the patients with elevated ICP caused by TBI. However, for the refractory intracranial hypertension, hypertonic saline seems to be preferred.
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Affiliation(s)
- Jiajie Gu
- College of Medicine, Shantou University, Shantou, Guangdong, China
| | - Haoping Huang
- College of Medicine, Shantou University, Shantou, Guangdong, China
| | - Yuejun Huang
- Transforming Medical Center, Second Affiliated Hospital of Medical College of Shantou University, North Dongxia Rd, Shantou, 515041, Guangdong, China
| | - Haitao Sun
- Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, China
| | - Hongwu Xu
- Department of Neurosurgery, The First Affiliated Hospital of Shantou University Medical College, Changping Rd, Shantou, 515041, Guangdong, China.
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