Control Of Intracranial Hypertension Research Articles

Development of a Novel Device for Decompressive Craniectomy: An Experimental and Cadaveric Study and Preliminary Clinical Application.

Decompressive craniectomy is an intervention of established efficacy in patients with intractable cerebral edema. To evaluate a new device used in alternative to decompressive craniectomy. This device is designed to perform an augmentative craniotomy by keeping the bone flap elevated using specific cranial suspension titanium plates and giving the brain enough room to swell. We tested the mechanical characteristics of the cranial brackets on dried skulls, on 3D-printed skull models, and on a preserved cadaver head. The resistance of the device was examined through dynamometric testing, and the feasibility of the surgical technique, including the suspension of the bone flap and the skin closure, was investigated on the cadaveric model. A preliminary clinical series of 2 patients is also reported. The laboratory tests have shown that this system allows an adequate expansion of the intracranial volume and it could withstand a force up to 637 ± 13 N in the synthetic model and up to 658 ± 9 N in the human skull without dislocation or failure of the brackets nor fractures of the bone ridges. Preliminary application in the clinical setting has shown that augmentative craniotomy is effective in the control of intracranial hypertension and could reduce the costs and complications associated with the classical decompressive craniectomy technique. Preliminary laboratory and clinical results show augmentative craniotomy to be a promising, alternative technique to decompressive craniectomy. Further clinical studies will be needed to validate its efficacy.

Historical aspects of the problem of surgical treatment of hemorrhagic stroke. The role of intracranial pressure in the choice of treatment tactics (review of literature)

This article provides a literature review of the past 60 years, conducted using keywords through the PubMed Internet resource, dedicated to the methods of surgical treatment of hemorrhagic stroke. The existing published results of clinical studies do not allow us to draw unambiguous conclusions about the superiority of conservative or neurosurgical treatment in relation to the functional recovery of patients. There is a statistical significance of the advantages of surgery based on the prevention of dislocation syndrome, control of intracranial hypertension, and prevention or at least reduction of the effect of blood and its degradation products on the surrounding healthy tissue. However, large randomized controlled trials have failed to demonstrate this benefit in terms of mortality or functional outcome.There are two main areas of hemorrhagic stroke surgery – open surgery and minimally invasive methods. The practice of open surgery is associated with high trauma rates, as well as with certain risks and complications. However, craniotomy is a lifesaving measure in critical situations with signs of persistent increased intracranial pressure leading to neurological impairment. The ability to control intracranial pressure provides a chance for the choice of more optimal tactics of surgical treatment.Today, the gold standard for intracranial pressure monitoring is the installation of invasive intraventricular or intraparenchymal transducers. The method is appreciated for its accuracy, however, there are a number of disadvantages in the form of the possibility of hemorrhagic and infectious complications, as well as the high cost of the sensor itself, which limits its routine use. The inability to measure intracranial pressure before surgery causes an unreasonable expansion of indications for choosing an open method of surgery, which reduces the possibility of a better functional outcome.All of these points make it urgent to search for a non-invasive method for measuring intracranial pressure, which would contribute to the timely choice of a surgical method without the danger of worsening the clinical outcome.

Treatment of intraventricular hemorrhage in infants

Intraventricular hemorrhage (IVH) is a disorder of the central nervous system, which is most frequently diagnosed in newborns. The disorder occurrence and development are related to the gestation age and weight of a newborn. IVH arises in 30 % of newborns with weight under 1500 g and develops on the 2 nd — 3 rd day after birth. Fifty-five percent of newborns present a neurological deficit following IVH, 30 % of patients with IVH have a permanent disability in early childhood and 70 % — at a different age. Premature newborns with IVH of III–IV grade have a high risk of developing posthemorrhagic hydrocephalus (PHH), cerebral palsy and mental disturbances. Literature review and analysis of the world major medical databases (MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, PubMed) of etiology, pathogenesis, treatment of IVH in infants illustrate advantages and limitations of the various methods for the control of intracranial hypertension associated with IVH and PHH. Gold standard and method of permanent control of intracranial hypertension — ventriculoperitoneal shunting frequently requires temporary control of the intracranial pressure and has limitations in this category of patients. Considering that there is no the only correct way of treatment of IVH and PHH, and recognizing disadvantages for each method of temporary and permanent draining of the CSF, the interventions should focus on the early clearing of the CSF pathways. Among proposed techniques, neuroendoscopic lavage is worthy of special attention, because it is associated with a lower rate of infectious complications and need in subsequent neurosurgical interventions according to the research results. Considering the pathogenesis of PHH development and treatment results, techniques of neuroendoscopic lavage need to be further researched and implemented in the list of neurosurgical procedures for the children with IVH in Ukraine.

Expert consensus on the diagnosis and treatment of cryptococcal meningitis

Cryptococcal meningitis is a common and refractory central nervous system infection, with high rates of mortality and disability. The experts of the Society of Infectious Diseases of Chinese Medical Association have reached this consensus after a thorough discussion. Based on the current situation of cryptococcal meningitis in China, the management of cryptococcal meningitis includes 6 aspects: introduction, microorganism identification, clinical manifestations and diagnosis, principles of antifungal therapy, treatment of refractory and recurrent meningitis, treatment of intracranial hypertension. There is not a separate consensus on human immunodeficiency virus (HIV) infection in patients with cryptococcal meningitis. This article focuses on different antifungal regimens and reducing intracranial pressure by reference to Infectious Disease Society of America (IDSA) guidelines. The importance of early diagnosis, combined long-term antifungal therapy, control of intracranial hypertension are emphasized.

La cryptococcose au cours de l’infection à VIH

Cryptococcosis is a cosmopolitan fungal serious condition due to an encapsulated yeast Cryptococcus neoformans. This is the systemic fungal infection the most common in HIV infection. This yeast is present in the environment and its main entrance in the body is the respiratory tract. Its gravity is linked to its tropism for the central nervous system. It generally affects subjects with severe deficit of cellular immunity and in particular, patients living with HIV. The diagnosis of neuromeningeal cryptococcosis is based on the detection of encapsulated yeasts at microscopic examination of cerebrospinal fluid, the detection of capsular polysaccharide antigen in serum or cerebrospinal fluid, but especially on the culture. A staging is always essential. The prognosis is severe. The control of intracranial hypertension is a major element of prognosis.

Spontaneous cerebrospinal fluid leak repair: A five‐year prospective evaluation

Mounting evidence indicates the majority of spontaneous cerebrospinal fluid (CSF) leaks are associated with intracranial hypertension. The objectives of the current study were to assess outcomes regarding spontaneous CSF leaks focusing on premorbid factors, surgical technique, and management of intracranial pressure. Prospective cohort. Prospective evaluation of patients with spontaneous CSF leaks was performed. Data regarding demographics, nature of presentation, body mass index (BMI), location and size of defect, intracranial pressure, clinical follow-up, and complications were collected. Over 5 years, 46 patients (average age, 51 years) with 56 spontaneous CSF leaks were treated by a single otolaryngologist. Twenty-one subjects presented with recurrence of their CSF leak following previous endoscopic and/or open approaches by other physicians. Obesity was present in 78% of individuals (average BMI, 35.6). Fifty-two CSF leaks (93%) were successfully repaired at first attempt. With secondary repair, all CSF leaks were closed at last clinical follow-up (average, 93 weeks). Three patients developed late failures (>2 months), with one recurrence at a distinct location from the primary site at 8 months postprocedure (associated with ventriculoperitoneal shunt failure). Opening pressures via lumbar puncture averaged 24.3 ± 8.3 cm H2 0, which increased significantly to 32.3 ± 9.0 cm H2 0 (P < .0001) following closure of the skull base defect(s). Management of intracranial hypertension included acetazolamide (n = 23) or permanent CSF diversion (n = 19, including five revisions of failed preexisting shunts). Although spontaneous CSF leaks have the highest recurrence rate of any etiology, prospective evaluation demonstrates high success rates with control of intracranial hypertension.

Monitoring and prediction of intracranial hypertension in pediatric traumatic brain injury

Control of intracranial hypertension (ICH) in patients with traumatic brain injury (TBI) is standard care. However, predicting risk for ICH is essential to balance risks and benefits of intracranial pressure (ICP) monitoring. Current recommendations for ICP monitoring in pediatric trauma patients are extrapolated from adult studies. This retrospective study evaluated 299 children admitted to Primary Children's Medical Center with moderate to severe TBI. ICP monitors were used in 120. Demographic, injury, and admission computed tomography (CT) scan characteristics were compared with determine factors associated with monitoring among those with less severe head CT findings. Among all monitored patients, clinical and radiographic features were compared for early ICH defined as any sustained ICP ≥20 mm Hg in the first 24 hours. Factors independently associated with monitoring children with Marshall I or II scores included presence of intraventricular hemorrhage (odds ratio [OR], 21.4; 95% confidence interval [CI], 4.0-114.7) and greater injury severity scores (ISS) (OR, 9.5 [95% CI, 2.9-31.1] for ISS 21 to 29 and OR, 14.3 [95% CI, 4.3-50.5] for ISS >29 compared with ISS <21). Among those with a normal head CT, 9 of 68 had an ICP monitor placed because of the inability to localize pain. Of these, 78% (7 of 9) had early ICH. Among monitored patients radiologic and clinical features of injury severity were not useful to distinguish risk for early ICH. Among children with severe TBI, a normal head CT does not exclude ICH. Need for ICP monitoring should be determined by depth of coma in addition to radiographic imaging.

A comparison of hinge craniotomy and decompressive craniectomy for the treatment of malignant intracranial hypertension: early clinical and radiographic analysis

Hinge craniotomy (HC) has recently been described as an alternative to decompressive craniectomy (DC). Although HC may obviate the need for cranial reconstruction, an analysis comparing HC to DC has not yet been published. A retrospective review was conducted of 50 patients who underwent cranial decompression (20 with HC, 30 with DC). Baseline demographics, neurological examination results, and underlying pathology were reviewed. Clinical outcome was assessed by length of ventilatory support, length of intensive care unit stay, and survival at discharge. Control of intracranial hypertension was assessed by average daily intracranial pressure (ICP) for the duration of ICP monitoring and an ICP therapeutic intensity index. Radiographic outcomes were assessed by comparing preoperative and postoperative CT scans for: 1) Rotterdam score; 2) postoperative volume of cerebral expansion; 3) presence of uncal herniation; 4) intracerebral hemorrhage; and 5) extraaxial hematoma. Postoperative CT scans were analyzed for the size of the craniotomy/craniectomy and magnitude of extracranial herniation. No significant differences were identified in baseline demographics, neurological examination results, or Rotterdam score between the HC and DC groups. Both HC and DC resulted in adequate control of ICP, as reflected in the average ICP for each group of patients (HC = 12.0 +/- 5.6 mm Hg, DC = 12.7 +/- 4.4 mm Hg; p > 0.05) at the same average therapeutic intensity index (HC = 1.2 +/- 0.3, DC = 1.2 +/- 0.4; p > 0.05). The need for reoperation (3 [15%] of 20 patients in the HC group, 3 [10%] of 30 patients in the DC group; p > 0.05), hospital survival (15 [75%] of 20 in the HC group, 21 [70%] of 30 in the DC group; p > 0.05), and mean duration of both mechanical ventilation (9.0 +/- 7.2 days in the HC group, 11.7 +/- 12.0 days in the DC group; p > 0.05) and intensive care unit stay (11.6 +/- 7.7 days in the HC group, 15.6 +/- 15.3 days in the DC group; p > 0.05) were similar. The difference in operative time for the two procedures was not statistically significant (130.4 +/- 71.9 minutes in the HC group, 124.9 +/- 63.3 minutes in the DC group; p > 0.05). The size of the cranial defect was comparable between the 2 groups. Postoperative imaging characteristics, including Rotterdam score, also did not differ significantly. Although a smaller volume of cerebral expansion was associated with HC (77.5 +/- 54.1 ml) than DC (105.1 +/- 65.1 ml), this difference was not statistically significant. Hinge craniotomy appears to be at least as good as DC in providing postoperative ICP control and results in equivalent early clinical outcomes.

Update in the treatment of traumatic brain injury

This review focuses on recent advances in the treatment of traumatic brain injury (TBI) during 2004 and 2005. Injured brain is a very heterogeneous structure, significantly evolving over time. Implementation of multimodal neuromonitoring will certainly provide more insights into pathophysiology of TBI. More studies are needed to determine how to best incorporate these new parameters into effective management protocols. Based on current literature, corticosteroids should not be indicated for the treatment of TBI. Avoidance or immediate treatment of secondary insults remains a mainstream of clinical care for patients with TBI. It seems that the therapy should focus on control of intracranial hypertension, and values of cerebral perfusion pressure around 60 mm Hg appear to correlate with favorable outcome in most patients. Hypertonic saline may become a preferred osmotherapeutic agent in severely head-injured patients, especially those with refractory intracranial hypertension. Benefit and indications for performing a decompressive craniectomy remain to be determined. Overall, individualized treatment respecting actual status of a patient's intra- and extracranial homeostasis should be the key principle of our current therapeutic approach toward severely head-injured patients.

Cryptococcose

The capsulated yeast Cryptococcus neoformans is responsible for cryptococcosis. The main clinical feature is a disseminated meningo-encephalitis that occurs mostly in patients with cellular immune defects, especially those infected by the human immunodeficiency virus (HIV). The severity of the brain involvement determines the prognosis with an approximately 20 % mortality rate despite adequate antifungal treatment and highly active antiretroviral therapy. The diagnosis in based on microscopic examination showing encapsulated yeasts, on the detection of cryptococcal capsular polysaccharide in serum or cerebrospinal fluid, and especially on a positive culture. An extensive workup is mandatory in all cases. The classical regimen for cryptococcal meningitis and several extrameningeal cryptococcosis combines an induction and consolidation phases with amphotericin B + flucytosine, and fluconazole, respectively for a minimum of 8 weeks, followed by a maintenance phase with fluconazole which duration varies upon the immune status of the patient. The control of intracranial hypertension is a major factor influencing the prognosis of cryptococcal meningoencephalitis. The timing of the introduction of antiretroviral drugs should be discussed for patients for whom cryptococcosis reveals the HIV infection.

Chapter 13. The use of barbiturates in the control of intracranial hypertension in severe pediatric traumatic brain injury

Small studies of high-dose barbiturate therapy suggest that barbiturates are effective in lowering intracranial pressure in selected cases of refractory intracranial hypertension in children with severe traumatic brain injury.

Chapter 13. The use of barbiturates in the control of intracranial hypertension in severe pediatric traumatic brain injury

Chapter 13. The use of barbiturates in the control of intracranial hypertension in severe pediatric traumatic brain injury

Chapter 13. The use of barbiturates in the control of intracranial hypertension in severe pediatric traumatic brain injury

Chapter 13. The use of barbiturates in the control of intracranial hypertension in severe pediatric traumatic brain injury

Hypothermia related changes in electrocortical activity at stepwise increase of intracranial pressure in piglets

Recent experimental studies have demonstrated that mild hypothermia can be effective in the control of intracranial hypertension. However, investigations to analyze the effects of hypothermia on changes in brain oxygen metabolism and electrocortical activity caused by increased intracranial pressure (ICP) are lacking. We examined the effects of mild hypothermia on electrocorticogram (ECoG) in combination with measurement of regional cerebral blood flow (CBF) and estimation of brain oxygen metabolism during stepwise increase of ICP. For this purpose thirteen female piglets (14 days old, 4-5 kg b.w.) were anaesthetized and mechanically ventilated. An epidural balloon was gradually inflated in order to increase ICP to 25 mmHg, 35 mmHg and 45 mmHg every 30 minutes at adjusted mean arterial blood pressures (MAP). This procedure resulted in gradual cerebral perfusion pressure (CPP) reduction of about 70%, 50%, and 30% of baseline [baseline CPP: normothermia (NT) 80+/-3 mmHg; hypothermia (HT) 84+/-3 mmHg]. Control animals were maintained in a normothermic state (38.6+/-0.2 degrees C). HT animals were surface cooled and maintained at 31.9+/-0.1 degrees C. ECoG, regional CBF, cerebral oxygen delivery (cDO2) and the cerebral metabolic rate of oxygen (CMRO2) were estimated during the normothermic period, after hypothermic stabilization, and after the gradual CPP reductions. The baseline ECoG showed the typical delta-dominated frequency pattern for isoflurane anaesthesia. At the hypothermic level, a frequency shift was seen from delta activity towards the higher frequencies (theta- and alpha activity) and the total spectral power was significantly reduced (56+/-17% from baseline, p < 0.05). the cortical CBF decreased markedly to 67+/-10% (p < 0.05), whereas the medulla oblongata blood flow increased slightly. During controlled increase of ICP by regional mass expansion from epidural balloon inflation, we found at mild and moderate stages of ICP increase (25 and 35 mmHg) only minimal changes in the ECoG in hypothermic animals compared to the hypothermic baseline, whereas the ECoG in normothermic animals showed a marked decrease in frequency, amplitude and total spectral power. We conclude that mild hypothermia produces an arousal-like ECoG activity with marked frequency shift to alpha activity and a change from high to low voltage activity. Furthermore, the hypothermic brain showed a preserved neuronal function at moderate stages of ICP. Obviously, hypothermia improves the functional tolerance of the brain to impaired oxygen supply.

Effect of Mild Hypothermia on Uncontrollable Intracranial Hypertension after Severe Head Injury

Recent experimental studies have demonstrated that mild hypothermia at about 34 degrees C can be effective in the control of intracranial hypertension. A randomized controlled study of mild hypothermia was carried out in 33 severely head-injured patients. All patients fulfilled the following criteria: 1) persistent intracranial pressure (ICP) greater than 20 mm Hg despite fluid restriction, hyperventilation, and high-dose barbiturate therapy; 2) an ICP lower than the mean arterial blood pressure; and 3) a Glasgow Coma Scale score of 8 or less. The patients were divided into two groups: one received mild hypothermia (16 patients) and one served as a control group (17 patients). Mild hypothermia significantly reduced the ICP and increased the cerebral perfusion pressure. Eight patients (50%) in the hypothermia group and three (18%) in the control group survived (p < 0.05), while five (31%) in the hypothermia group and 12 (71%) in the control group died of uncontrollable intracranial hypertension (p < 0.05). In five patients in the hypothermia group, cerebral blood flow was measured by the hydrogen clearance method and arteriojugular venous oxygen difference was evaluated before and during mild hypothermia. Mild hypothermia significantly decreased the cerebral blood flow, arteriojugular venous oxygen difference, and cerebral metabolic rate of oxygen (p < 0.01). The results of this preliminary investigation suggest that mild hypothermia is a safe and effective method to control traumatic intracranial hypertension and to improve mortality and morbidity rates.

Severe Head Trauma: Pathophysiology and Management

Acute traumatic brain injury is a leading cause of morbidity and mortality. Intensive management is aimed at early evacuation of intracranial mass lesions, control of intracranial hypertension, and prevention of medical complications.

Perioperative Management of Intracranial Catastrophes

The management and evaluation of neurosurgical intracranial catastrophes require a multidisciplinary approach to optimize outcome. Intracranial pathology must be rapidly evaluated. Clinically, the patient's mental status, the degree and extent of focal neurologic deficits, and the dynamic nature of any changes in clinical status are assessed. The CT scan is invaluable for diagnosing and monitoring the progress and extent of intracranial pathology. Medical therapy for the control of intracranial hypertension must be undertaken simultaneously. This begins with provision of an adequate, protected airway and support of cardiopulmonary function. Specific measures to control intracranial hypertension include hyperventilation, osmotherapy, CSF removal, seizure control, autonomic control, sedation (primarily thiopental), muscle relaxation, mild hypothermia, and, if indicated, steroids. The goal of intraoperative management is physiologic support of systemic and cerebral hemodynamics. There should be a smooth transition from the discovery of the patient in extremis through the period of medical stabilization, operative intervention, and ultimate delivery of the patient to the intensive care facility for extended treatment.

Efficacy of Induced Barbiturate Coma in Control of Intracranial Hypertension

Efficacy of Induced Barbiturate Coma in Control of Intracranial Hypertension

Silent duodenal perforation

Iatrogenic barbiturate coma for the control of intracranial hypertension is a relatively new addition to the neurosurgeon's therapeutic armamentarium. Although initial studies are quite promising, the induction of coma, especially for prolonged periods (ranging from days to weeks), is a major therapeutic endeavor which requires sophisticated monitoring of both neurological and physiological function. A multidisciplinary approach prevents many possible complications of this form of therapy and facilitates treatment when untoward physiological complications do occur. The following case report illustrates one such complication.

Experimental effects of steroids and steroid withdrawal on cerebrospinal fluid absorption.

The authors studied the effects on cerebrospinal fluid (CSF) absorption of chronic administration and acute withdrawal of steroids in dogs. CSF absorption was measured by determining the amount of isotope (indium 111DTPA) recovered over a 4-hour period after injection into the cisterna magna. Resistance to CSF absorption was estimated by determining rates of low of Ringer's lactate infusion into the cisterna magna over a range of pressure gradients between CSF and sagittal sinus. Steroid withdrawal was associated with a marked reduction in CSF absorption and an increase in resistance to CSF flow. Dogs on steroids also showed reduced CSF absorption although the reduction was not statistically significant when compared with controls. The results are discussed in terms of possible mechanisms of action of steroids on CSF absorption, the etiology of the benign intracranial hypertension syndrome and the use of steroids and in the control of intracranial hypertension.