Elevated Increased Intracranial Pressure Research Articles

Derivation, external and clinical validation of a deep learning approach for detecting intracranial hypertension

Increased intracranial pressure (ICP) ≥15 mmHg is associated with adverse neurological outcomes, but needs invasive intracranial monitoring. Using the publicly available MIMIC-III Waveform Database (2000–2013) from Boston, we developed an artificial intelligence-derived biomarker for elevated ICP (aICP) for adult patients. aICP uses routinely collected extracranial waveform data as input, reducing the need for invasive monitoring. We externally validated aICP with an independent dataset from the Mount Sinai Hospital (2020–2022) in New York City. The AUROC, accuracy, sensitivity, and specificity on the external validation dataset were 0.80 (95% CI, 0.80–0.80), 73.8% (95% CI, 72.0–75.6%), 73.5% (95% CI 72.5–74.5%), and 73.0% (95% CI, 72.0–74.0%), respectively. We also present an exploratory analysis showing aICP predictions are associated with clinical phenotypes. A ten-percentile increment was associated with brain malignancy (OR = 1.68; 95% CI, 1.09-2.60), intracerebral hemorrhage (OR = 1.18; 95% CI, 1.07–1.32), and craniotomy (OR = 1.43; 95% CI, 1.12–1.84; P < 0.05 for all).

Intraoperative Intracranial Pressure Changes in Children With Craniosynostosis Undergoing Endoscopic-Assisted Strip Craniectomy.

Craniosynostosis can lead to progressive cranial and skull base deformities and can be associated with increased intracranial pressure (ICP), ophthalmological manifestations, behavioral changes, and developmental delay. Most published data on the incidence of elevated ICP include older children undergoing open surgical correction. Endoscopic-assisted release of fused sutures with postoperative helmet therapy is an established method for managing craniosynostosis presenting at an early age; however, the immediate effect of this approach on ICP in a young cohort has not been previously reported. Prospective data on 52 children undergoing endoscopic-assisted release of stenosed cranial sutures were included. Individuals were excluded if they underwent open correction or had previous cranial surgery. Individuals underwent a standardized endoscopic approach for each suture type. ICP was measured using an intraparenchymal sensor both before creation of the neosuture and after complete release of the stenosed suture. An ICP reading of >10 mm Hg was considered elevated. The mean age was 5.3 months, range 1 to 32 months, and 94% was younger than 12 months. The mean opening pressure was 12.7 mm Hg, and the mean closing pressure was 2.9 mm Hg. Opening ICP ≥10 mm Hg was present in 58%, ≥15 mm Hg was present in 31%, and ≥20 mm Hg was present in 23%. No patient had an ICP above 10 mm Hg at closing. The mean percentage change in ICP among all craniosynostosis cases was a 64% decrease. Optic disk swelling was identified in 28 children preoperatively and improved in 22 children at follow-up. Elevated ICP may occur in infants with craniosynostosis at higher rates than previously reported. Endoscopic-assisted craniectomy has an immediate effect on lowering ICP and improving postoperative ophthalmological findings.

Outcomes of Repeat Surgery in Pediatric Severe Traumatic Brain Injury: An Analysis from Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial

BackgroundEarly operative intervention, craniotomy (CO), and/or craniectomy (DC) are occasionally warranted in severe traumatic brain injury (TBI). Persistent increased intracranial pressure (ICP) or accumulation of intracranial hematoma post-surgery can result in higher mortality and morbidity. There is a gap in information regarding the outcome of repeat surgery (RS) in pediatric patients with severe TBI. MethodsAn observational cohort study titled Approaches and Decisions in Acute Pediatric Trial (ADAPT) of severe TBI data was obtained from the Federal Interagency Traumatic Brain Injury Research (FITBIR) Informatics System. All pediatric patients who underwent CO or DC, survived more than 44 hours and were found to have persistent elevated ICP >20 for two consecutive hours were included in the study. The purpose of the study was to find the outcomes of RS in pediatric severe TBI. Propensity based matching was used to find the outcomes. The primary outcome was 60-day mortality. ResultsOut of 1000 total patients enrolled in the ADAPT trial, 160 patients qualified for this study. Propensity score matching created 13 pairs of patients. There were no significant differences found between the groups who had RS vs. those who did not have repeat surgery (NRS). There were no significant differences found between the groups regarding 60-day mortality, median hospital days, median ICU days, and 6-month favorable outcome on Glasgow Outcome Scale Extended (GOS-E) score. ConclusionThere was no difference in mortality between patients who underwent a second surgery and patients who did not have to undergo a second surgery.

Supracerebellar infratentorial resection of a torcular lesion causing fulminant intracranial hypertension: illustrative case.

Venous sinus stenosis has been implicated in intracranial hypertension and can lead to papilledema and blindness. The authors report the unique case of a cerebellar transtentorial lesion resulting in venous sinus stenosis in the torcula and bilateral transverse sinuses that underwent resection. A 5-year-old male presented with subacute vision loss and bilateral papilledema. Imaging demonstrated a lesion causing mass effect on the torcula/transverse sinuses and findings of increased intracranial pressure (ICP). A lumbar puncture confirmed elevated pressure, and the patient underwent bilateral optic nerve sheath fenestration. Cerebral angiography and venous manometry showed elevated venous sinus pressures suggestive of venous hypertension. The patient underwent a craniotomy and supracerebellar/infratentorial approach. A stalk emanating from the cerebellum through the tentorium was identified and divided. Postoperative magnetic resonance imaging showed decreased lesion size and improved sinus patency. Papilledema resolved and other findings of elevated ICP improved. Pathology was consistent with atrophic cerebellar cortex. Serial imaging over 6 months demonstrated progressive decrease in the lesion with concurrent improvements in sinus patency. Although uncommon, symptoms of intracranial hypertension in patients with venous sinus lesions should prompt additional workup ranging from dedicated venous imaging to assessments of ICP and venous manometry.

Intracranial Pressure, Autoregulation, and Cerebral Perfusion in Infants With Nonsyndromic Craniosynostosis at the Time of Surgical Correction

BACKGROUND AND OBJECTIVE: Although an increased intracranial pressure (ICP) is a known problem in children with syndromic craniosynostosis, it remains unclear whether elevated ICP and impaired cerebral perfusion exist in nonsyndromic synostosis and should be defined as targets of primary treatment. This study aimed to investigate ICP, cerebral autoregulation (CAR), and brain perfusion in infants with nonsyndromic craniosynostosis at first surgical intervention. METHODS: Forty-three infants were prospectively included. The patients underwent perioperative measurement of mean arterial blood pressure, ICP, and brain perfusion before and after cranial vault decompression. Physiological parameters with possible influences on ICP and autoregulation/brain perfusion were standardized for age. CAR was assessed by the pressure reactivity index (PRx), calculated using the mean arterial blood pressure and ICP. RESULTS: Biparietal decompression was performed in 29 infants with sagittal synostosis (mean age, 6.1 ± 1.3 months). Fronto-orbital advancement was performed in 10 and 4 infants with metopic and unilateral coronal synostosis, respectively (mean age, 11.6 ± 2.1 months). An elevated ICP (&gt;15 mm Hg) was found in 20 of 26 sagittal (mean, 21.7 ± 4.4 mm Hg), 2 of 8 metopic (mean, 17.1 ± 0.4 mm Hg), and 2 of 4 unilateral coronal synostosis cases (mean, 18.9 ± 2.5 mm Hg). Initial ICP was higher in sagittal synostosis than in metopic/coronal synostosis (P = .002). The postdecompression ICP was significantly reduced in sagittal synostosis cases (P &lt; .001). The relative cerebral blood flow and blood flow velocity significantly increased after decompression. Impaired CAR was found in infants with a mean ICP &gt;12 mm Hg (PRx, 0.26 ± 0.32), as compared with those with a mean ICP ≤ 12 mm Hg (PRx, −0.37 ± 0.07, P = .001). CONCLUSION: Contrary to common belief, an elevated ICP and significantly impaired CAR can exist early in single suture synostosis, particularly sagittal synostosis. Because an influence of raised ICP on long-term cognitive development is known in other diseases, we suggest that preventing increased ICP during the phase of maximal brain development may be a goal for decompressive surgery, at least for sagittal synostosis cases.

Link between both infratentorial and supratentorial intracranial pressure burdens and final outcome in patients with infratentorial brain injury.

Increased intracranial pressure (ICP) is most likely not being transmitted uniformly within the cranium. The ICP profiles in the supra- and infratentorial compartments remain largely unclear. Increased ICP in the cerebellum, however, is insufficiently captured by supratentorial ICP (ICPsup) monitoring due to compartmentalization through the tentorium. The authors hypothesized that additional infratentorial ICP (ICPinf) monitoring can be clinically valuable in selected patients. The aims of this study were to demonstrate the safety and feasibility of ICPinf monitoring and to investigate the influence of the ICPinf on clinical outcome in a real-world setting. Fifteen consecutive patients with posterior fossa (PF) lesions requiring surgery and anticipated prolonged neurointensive care between June 2019 and December 2021 were included. Simultaneous ICPsup and ICPinf were recorded. ICP burden was defined as a 15-minute interval with a mean ICP > 22 mm Hg. The Glasgow Outcome Scale score was assessed after 3 months. The mean ICPinf was substantially higher compared with ICPsup throughout the entire period of ICP recording (16.08 ± 4.44 vs 10.74 ± 3.6 mm Hg, p < 0.01). ICPinf was significantly higher in patients with unfavorable outcome when compared with those with favorable outcome (mean 17.2 ± 4.1 vs 11.4 ± 3.5 mm Hg, p < 0.05). Patients with unfavorable outcome showed significantly higher ICPinf burden compared with those with favorable outcome (mean 40.6 ± 43.8 vs 0.3 ± 0.4 hours, p < 0.05). Neither absolute ICPsup nor ICPsup burden was significantly associated with unfavorable outcome (p = 0.13). No monitoring-associated complications occurred. Supplementary ICPinf monitoring is safe and reliable. There is a significant transtentorial pressure gradient within the cranium showing elevated ICPs in the PF. Elevated ICP levels in the PF were strongly associated with unfavorable neurological outcome irrespective of ICPsup values.

Modelling idiopathic intracranial hypertension in rats: contributions of high fat diet and testosterone to intracranial pressure and cerebrospinal fluid production

BackgroundIdiopathic intracranial hypertension (IIH) is a condition characterized by increased intracranial pressure (ICP), impaired vision, and headache. Most cases of IIH occur in obese women of childbearing age, though age, BMI, and female sex do not encompass all aspects of IIH pathophysiology. Systemic metabolic dysregulation has been identified in IIH with a profile of androgen excess. However, the mechanistic coupling between obesity/hormonal perturbations and cerebrospinal fluid dynamics remains unresolved.MethodsFemale Wistar rats were either fed a high fat diet (HFD) for 21 weeks or exposed to adjuvant testosterone treatment for 28 days to recapitulate IIH causal drivers. Cerebrospinal fluid (CSF) and blood testosterone levels were determined with mass spectrometry, ICP and CSF dynamics with in vivo experimentation, and the choroid plexus function revealed with transcriptomics and ex vivo isotope-based flux assays.ResultsHFD-fed rats presented with increased ICP (65%), which was accompanied by increased CSF outflow resistance (50%) without altered CSF secretion rate or choroid plexus gene expression. Chronic adjuvant testosterone treatment of lean rats caused elevated ICP (55%) and CSF secretion rate (85%), in association with increased activity of the choroid plexus Na+,K+,2Cl− cotransporter, NKCC1.ConclusionsHFD-induced ICP elevation in experimental rats occurred with decreased CSF drainage capacity. Adjuvant testosterone, mimicking the androgen excess observed in female IIH patients, elevated the CSF secretion rate and thus ICP. Obesity-induced androgen dysregulation may thus contribute to the disease mechanism of IIH.

Early Signs of Elevated Intracranial Pressure on Computed Tomography Correlate With Measured Intracranial Pressure in the Intensive Care Unit and Six-Month Outcome After Moderate to Severe Traumatic Brain Injury.

Traumatic brain injury (TBI) is a leading cause of death and disability in the United States. Early triage and treatment after TBI have been shown to improve outcome. Identifying patients at risk for increased intracranial pressure (ICP) via baseline computed tomography (CT) , however, has not been validated previously in a prospective dataset. We hypothesized that acute CT findings of elevated ICP, combined with direct ICP measurement, hold prognostic value in terms of six-month patient outcome after TBI. Data were obtained from the Progesterone for Traumatic Brain Injury, Experimental Clinical Treatment (ProTECTIII) multi-center clinical trial. Baseline CT scans for 881 participants were individually reviewed by a blinded central neuroradiologist. Five signs of elevated ICP were measured (sulcal obliteration, lateral ventricle compression, third ventricle compression, midline shift, and herniation). Associations between signs of increased ICP and outcomes (six-month functional outcome and death) were assessed. Secondary analyses of 354 patients with recorded ICP monitoring data available explored the relationships between hemorrhage phenotype/anatomic location, sustained ICP ≥20 mm Hg, and surgical intervention(s). Univariate and multi-variate logistic/linear regressions were performed; p < 0.05 is defined as statistically significant. Imaging characteristics associated with ICP in this cohort include sulcal obliteration (p = 0.029) and third ventricular compression (p = 0.039). Univariate regression analyses indicated that increasing combinations of the five defined signs of elevated ICP were associated with death, poor functional outcome, and time to death. There was also an increased likelihood of death if patients required craniotomy (odds ratio [OR] = 4.318, 95% confidence interval [1.330-16.030]) or hemicraniectomy (OR = 2.993 [1.109-8.482]). On multi-variate regression analyses, hemorrhage location was associated with death (posterior fossa, OR = 3.208 [1.120-9.188] and basal ganglia, OR = 3.079 [1.178-8.077]). Volume of hemorrhage >30 cc was also associated with increased death, OR = 3.702 [1.575-8.956]). The proportion of patient hours with sustained ICP ≥20 mm Hg, and maximum ICP ≥20 mm Hg were also directly correlated with increased death (OR = 6 4.99 [7.731-635.51]; and OR = 1.025 [1.004-1.047]), but not with functional outcome. Poor functional outcome was predicted by concurrent presence of all five radiographic signs of elevated ICP (OR = 4.44 [1.514-14.183]) and presence of frontal lobe (OR = 2.951 [1.265-7.067]), subarachnoid (OR = 2.231 [1.067-4.717]), or intraventricular (OR = 2.249 [1.159-4.508]) hemorrhage. Time to death was modulated by total patient days of elevated ICP ≥20 mm Hg (effect size = 3.424 [1.500, 5.439]) in the first two weeks of hospitalization. Sulcal obliteration and third ventricular compression, radiographic signs of elevated ICP, were significantly associated with measurements of ICP ≥20 mm Hg. These radiographic biomarkers were significantly associated with patient outcome. There is potential utility of ICP-related imaging variables in triage and prognostication for patients after moderate-severe TBI.

Cerebral perfusion pressure optimization for the regulation of brain edema and intracranial pressure

Background: Increased intracranial pressure (ICP) is a pathological condition associated with severe neurological conditions in patients with acute brain injuries. Managing increased ICP based on optimal cerebral perfusion pressure (CPP) is crucial for improving outcomes.Current Concepts: Cerebral autoregulation, the intrinsic ability to maintain stable cerebral blood flow across a wide range of CPP, is impaired in several brain injuries. CPP, the difference between the mean arterial pressure and the ICP, is a critical factor in maintaining cerebral blood flow. Therefore, optimal CPP is important in managing patients with acute brain injuries. In addition, monitoring cerebral autoregulation and its response to pathological derangements can help diagnose, manage, and predict acute brain injury outcomes. Goal-directed therapy using cerebral autoregulation is beneficial in managing patients with ICP elevation. If blood pressure is excessively low in a patient with elevated intracranial pressure, a treatment to increase blood pressure should be considered as a first step, called optimizing cerebral perfusion pressure. However, if CPP is excessively high in a patient with elevated ICP, a treatment to lower CPP by controlling blood pressure to an appropriate level to prevent worsening of edema due to hyperperfusion should be considered.Discussion and Conclusion: Monitoring cerebral autoregulation to guide optimal management of increased ICP based on optimal CPP may be helpful in goal-directed therapy and improving prognosis among patients with acute brain injuries.

Hypertonic saline for traumatic brain injury: a systematic review and meta-analysis

BackgroundTraumatic brain injury (TBI) causes mortality and long-term disability among young adults and imposes a notable cost on the healthcare system. In addition to the first physical hit, secondary injury, which is associated with increased intracranial pressure (ICP), is defined as biochemical, cellular, and physiological changes after the physical injury. Mannitol and Hypertonic saline (HTS) are the treatment bases for elevated ICP in TBI. This systematic review and meta-analysis evaluates the effectiveness of HTS in the management of patients with TBI.MethodsThis study was conducted following the Joanna Briggs Institute (JBI) methods and PRISMA statement. A systematic search was performed through six databases in February 2022, to find studies that evaluated the effects of HTS, on increased ICP. Meta-analysis was performed using comprehensive meta-analysis (CMA).ResultsOut of 1321 results, 8 studies were included in the systematic review, and 3 of them were included in the quantitative synthesis. The results of the meta-analysis reached a 35.9% (95% CI 15.0–56.9) reduction in ICP in TBI patients receiving HTS, with no significant risk of publication bias (t-value = 0.38, df = 2, p-value = 0.73). The most common source of bias in our included studies was the transparency of blinding methods for both patients and outcome assessors.ConclusionHTS can significantly reduce the ICP, which may prevent secondary injury. Also, based on the available evidence, HTS has relatively similar efficacy to Mannitol, which is considered the gold standard therapy for TBI, in boosting patients' neurological condition and reducing mortality rates.

Optic Nerve Sheath Diameter Ultrasound: A Non-Invasive Approach to Evaluate Increased Intracranial Pressure in Critically Ill Pediatric Patients.

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.

Abstract 9724: Variance of the Intracranial Pressure Over Time and Relationship With Neurologic Prognosis in Cardiac Arrest Survivors Who Underwent Targeted Temperature Management

Introduction: Increased intracranial pressure (ICP) is one of the most serious post-cardiac arrest (CA) complications, and is associated with poor outcomes. However, only a few studies have described the changes in ICP over time according to neurologic outcomes during targeted temperature management (TTM) after CA. We aimed to investigate the changes in the ICP over time and neurologic prognosis in out-of-hospital cardiac arrest (OHCA) survivors who received TTM. Methods: This retrospective single-center study included OHCA survivors who underwent TTM between May 2018 and December 2020. ICP was measured immediately after the return of spontaneous circulation (ROSC) (Day 1), and after 24 h (Day 2), 48 h (Day 3), and 72 h (Day 4) by connecting a lumbar drain. The neurologic outcome was determined 3 months after the ROSC, and the Cerebral Performance Category (CPC) was dichotomized into good (CPC 1-2) and poor (CPC 3-5) outcomes. Results: We included 91 patients (males, 67; 74%); of whom 51 (56%) had a poor outcome. The ICP was significantly higher in the poor outcome group at each time point, except for Day 4. Moreover, the peak ICP levels were also higher in the poor outcome group (17.0 vs. 14.8; P = 0.002). The change in ICP levels was highest between Day 2 and Day 3 in the good outcome group, but between Day 1 and Day 2 in the poor outcome group. However, there was no difference in the total ICP change between the poor and good outcome groups (3.00 vs 3.09; P = 0.52). Using receiver operating characteristic analyses, the optimal cutoff values of the ICP levels for the prediction of poor outcomes were determined as: day 1, &gt; 11.8; day 2, &gt; 14.0; day 3, &gt; 15.0; and day 4, &gt; 14.8. Conclusions: All OHCA survivors who received TTM had an elevated ICP, regardless of the neurologic prognosis. However, peak ICP levels and the change in the ICP level on the first day after the ROSC was significantly higher in the poor outcome group. A prospective, multi-center study is required to confirm these results.

Ultrasound assessment of optic nerve sheath diameter for evaluation of elevated intracranial pressure in patient with head trauma: A comparative study with CT head

Purpose: Increased intracranial pressure (ICP) is complication of traumatic brain injury. Early detection of raised ICP is helpful in timely treatment. Bed side ultrasound of optic nerve sheath is easier for detection of raised intracranial pressure by measuring its diameter. Our aim was to determine whether bedside ultrasound measurement of optic nerve sheath diameter (ONSD) can accurately predict raised intracranial pressure in head injury patients and to calculation of validity of test. Methods and Materials: Total 150 patients with head injury was first examined by ultrasound. The ONSD was measured 3 mm behind the globe perpendicular to long axis of globe in both eyes than mean binocular ONSD was calculated. Diameter more than 5 mm was considered abnormal. CT scan was performed in all patients and result was considered positive for elevated ICP if mid line shift, effacement of sulci, ventricles and cisterns are seen. Results: Out of total 150 patients 61 was female and 89 was male, age was ranging from 23-61 years. 30 patients showed mean binocular ONSD >5mm by ultrasound out of them 26 patients showed positive signs of raised intracranial pressure on CT. Sensitivity and negative predictive value of ultrasound to detect raised ICP was 100%, Specificity was 96.7 % and negative predictive value was 86.6 %. Conclusions: Ultrasound can be used as bed side screening tool to detect raised ICP in ICU patients and head trauma patients especially in hospital with high patient flow in emergency department.

Acute Paradoxical Herniation: A Case Report

AbstractDecompressive craniectomy is used to relieve acute increased intracranial pressure (ICP) when medical therapy has failed. Paradoxical herniation is a rare complication that occurs when the pressure of the intracranial contents falls abnormally below the atmospheric pressure. Symptoms often include neurological deficits, the etiology of which is often mistaken for elevated ICP. This diagnosis requires quick recognition, and treatment requires a change from ICP reduction therapies to those that increase the ICP, and ultimately cranioplasty.

Utility of Point-of-Care Ultrasound in the Diagnosis of Idiopathic Intracranial Hypertension in the Emergency Department.

Emergency physicians are frequently required to identify and triage patients with increased intracranial pressure (ICP). Idiopathic intracranial hypertension (IIH) is a possible cause that must be considered. Its prognosis depends on prompt recognition and treatment, and progression of the disease can lead to permanent vision loss and considerable morbidity. Point-of-care ultrasound can rapidly identify elevated ICP. Measurements of the optic nerve sheath diameter (ONSD) and optic disc elevation (ODE) can act as surrogates for ICP. We describe five cases in which ultrasound was used to identify increased ICP and aid clinical decision-making. In several of the cases, ultrasound was used to confirm a suspicion for IIH and initiate therapy while awaiting the results of a more time-consuming and technically challenging test, such as lumbar puncture or optical coherence tomography. One of the patients was pregnant, and sonographic evidence of elevated ICP helped avoid exposing the patient to unnecessary radiation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ultrasound is a quick and versatile tool for screening patients with neurologic symptoms, and when integrated into the proper clinical context, can reduce the use of more invasive tests. It can be particularly useful in patients with pathology that may not show abnormalities on computed tomography scan or in whom lumbar puncture is technically difficult, making patients at risk for IIH well-suited to examination by ultrasound. We use a cutoff of 5mm for ONSD and 0.6mm for ODE, though there are no universally agreed on cutoff values.

Prevalence of elevated intracranial pressure in patients with classical trigeminal neuralgia with overweight and obesity

Background: There is a clear association between obesity and Idiopathic Intracranial Hypertension (IIH), a syndrome characterized by increased Intracranial Pressure (ICP). The clinical manifestations of IHH include headache and visual/oculomotor disorders due to the involvement of abducens nerve. Thus far, it has not been widely studied whether affectations by ICP elevation could involve other cranial nerves such as the trigeminal nerve.Objective: The aim of this study is to analyze the prevalence of elevated ICP in patients with BMI ≥ 25 that suffer vascular compression of the trigeminal nerve. Methods: A case series including 19 patients evaluated during a period of 8 months with BMI ≥ 25 and a clinical diagnosis of classic trigeminal neuralgia (TN) who underwent Microvascular Decompression (MVD) surgery is reported. Patients with TN presenting another cause of intracranial hypertension were excluded. The ICP was determined just before MVD surgery by introducing an enteral tube through a 2 mm incision in the dura and measuring the level reached by the CSF. Results: In our series, 42.1% of patients suffered overweight (n = 8), 47.3% grade I obesity (n = 9) and 10.5% grade II obesity (n = 2). The ICP was elevated in 47.4% of patients. Conclusion: IHH is an obesity-related disorder. Patients with BMI ≥ 25 and TN show a high prevalence of ICP. It is important to consider that an obese patient may present high ICP during and after MVD surger

Prevalence of elevated intracranial pressure in patients with classical trigeminal neuralgia with overweight and obesity

Background: There is a clear association between obesity and Idiopathic Intracranial Hypertension (IIH), a syndrome characterized by increased Intracranial Pressure (ICP). The clinical manifestations of IHH include headache and visual/oculomotor disorders due to the involvement of abducens nerve. Thus far, it has not been widely studied whether affectations by ICP elevation could involve other cranial nerves such as the trigeminal nerve.Objective: The aim of this study is to analyze the prevalence of elevated ICP in patients with BMI ≥ 25 that suffer vascular compression of the trigeminal nerve. Methods: A case series including 19 patients evaluated during a period of 8 months with BMI ≥ 25 and a clinical diagnosis of classic trigeminal neuralgia (TN) who underwent Microvascular Decompression (MVD) surgery is reported. Patients with TN presenting another cause of intracranial hypertension were excluded. The ICP was determined just before MVD surgery by introducing an enteral tube through a 2 mm incision in the dura and measuring the level reached by the CSF. Results: In our series, 42.1% of patients suffered overweight (n = 8), 47.3% grade I obesity (n = 9) and 10.5% grade II obesity (n = 2). The ICP was elevated in 47.4% of patients. Conclusion: IHH is an obesity-related disorder. Patients with BMI ≥ 25 and TN show a high prevalence of ICP. It is important to consider that an obese patient may present high ICP during and after MVD surger

Effect of 5 different cervical collars on optic nerve sheath diameter

Utilizing cervical collars is a common practice in emergency departments. Multiple studies have been conducted on the utility of this practice, but few have looked into the negative effects of cervical collar (C-collar) use. The authors of this study were concerned that cervical collars could be leading to varying degrees of venous compression. Venous compression leads to increased intracranial pressure (ICP) due to improper vascular drainage. Further, numerous studies in the literature have shown that an elevated ICP is associated with mortality and poor neurologic outcomes.

Hypertonic saline versus other intracranial pressure-lowering agents for people with acute traumatic brain injury.

Increased intracranial pressure (ICP) has been shown to be strongly associated with poor neurological outcomes and mortality for patients with acute traumatic brain injury (TBI). Currently, most efforts to treat these injuries focus on controlling the ICP. Hypertonic saline (HTS) is a hyperosmolar therapy that is used in traumatic brain injury to reduce intracranial pressure. The effectiveness of HTS compared with other ICP-lowering agents in the management of acute TBI is still debated, both in the short and the long term. To assess the comparative efficacy and safety of hypertonic saline versus other ICP-lowering agents in the management of acute TBI. We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library, PubMed, Embase Classic+Embase (OvidSP), ISI Web of Science: Science Citation Index and Conference Proceedings Citation Index-Science, as well as trials registers, on 11 December 2019. We supplemented these searches using four major Chinese databases on 19 September 2018. We also checked bibliographies, and contacted study authors to identify additional studies. We sought to identify all randomised controlled trials (RCTs) of HTS versus other intracranial pressure-lowering agents for people with acute TBI of any severity. We excluded cross-over trials as incompatible with assessing long term outcomes. Two review authors independently screened search results to identify potentially eligible trials and extracted data using a standard data extraction form. Outcome measures included: mortality at end of follow-up (all-cause); death or disability (as measured by the Glasgow Outcome Scale (GOS)); uncontrolled ICP (defined as failure to decrease the ICP to target and/or requiring additional intervention); and adverse events (AEs) (e.g. rebound phenomena; pulmonary oedema; acute renal failure during treatment). Six trials, involving data from 295 people, met the inclusion criteria. The majority of participants (89%) had a diagnosis of severe TBI. We had concerns about particular domains of risk of bias in each trial, as physicians were not reliably blinded to allocation, two trials contained participants with conditions other than TBI and in one trial, there were concerns about missing data for important outcomes. The original protocol was available for only one study and other trials (where registered) were registered retrospectively. Meta-analysis for both the primary outcome (mortality at final follow up) and for 'poor outcome' as per conventionally dichotomised GOS criteria, was only possible for two studies. Synthesis of long-term outcomes was inhibited by the fact that two ceased data collection within two hours of a single bolus dose of an ICP-lowering agent and one at discharge from ICU. Only three studies collected data after release from hospital. Due to variation in modes of drug administration, follow-up times, and ways of reporting changes in ICP, as well as no uniform definition of 'uncontrolled ICP', we did not perform meta-analysis for this outcome and report results narratively, by individual trial. Trials tended to report both treatments to be effective in reducing elevated ICP but that HTS had increased benefits, usually adding that pretreatment factors need to be considered (e.g. serum sodium and both system and brain hemodynamics). No trial provided data for our other outcomes of interest. Evidence for all outcomes is considered very low, as assessed by GRADE. All conclusions were downgraded due to imprecision (small sample size), indirectness (due to choice of measurement and/or selection of patients without TBI), and in some cases, risk of bias and inconsistency. Only one of the included trials reported data on adverse effects (AEs) - a rebound phenomenon, which was present only in the comparator group (mannitol). No data were reported on pulmonary oedema or acute renal failure during treatment. On the whole, investigators do not seem to have rigorously sought to collect data on AEs. This review set out to find trials comparing HTS to a potential range of other ICP-lowering agents, but only identified trials comparing it with mannitol or mannitol in combination with glycerol. Based on limited data, there is weak evidence to suggest that HTS is no better than mannitol in efficacy and safety in the long-term management of acute TBI. Future research should be comprised of large, multi-site trials, prospectively registered, reported in accordance with current best practice. Issues such as the type of TBI suffered by participants and concentration of infusion and length of time over which the infusion is given should be investigated.

Abstract 334: Point-Of-Care Ultrasound in the Assessment of Optic Nerve Sheath Diameter After Out-Of-Hospital Cardiac Arrest

Introduction: Hypoxic-ischemic injury from cardiac arrest may cause cerebral edema, leading to increased intracranial pressure (ICP) and brain tissue damage. Optic nerve sheath diameter (ONSD) is associated with elevated ICP. Limited clinical studies have reported ONSD changes in the early post-resuscitation time frame. We sought to evaluate the utility of bedside ocular ultrasound measurements in the assessment of post-cardiac arrest brain injury. Methods: We studied adult out-of-hospital cardiac arrests treated at an urban academic ED and achieving return of spontaneous circulation (ROSC) between May 2018 to May 2019. We included witnessed and unwitnessed arrest as well as shockable and non-shockable rhythms. After ROSC, trained emergency physicians performed bedside ultrasonographic assessment of bilateral ONSD at 1, 6, 24, 48, and 72 hours using an ocular preset on a 15MHz linear probe. ONSD measurements at these time frames were compared between groups stratified by rhythm type and neurological outcome. Cerebral performance category (CPC) was measured at 72 hours and at discharge. Results: Out of 48 eligible patients, 15 were excluded from the study due to lack of consent or available ultrasound images. We included 33 patients, of which 11 were female and 22 were male, with a median age of 57 (IQR 20). There were 19 with an initial rhythm of asystole or pulseless electrical activity (PEA), 9 with ventricular fibrillation arrests, and 5 with an unclear rhythm. At 1 hour, patients with CPC 1-2 had smaller ONSD compared to patients with CPC 3-5 (5.5mm vs 6.1mm, p=0.03). At 72 hour, patients with CPC score of 1-2 had an average reduction in ONSD of 1.6mm verses 0.29mm increase in patients with CPC 3-5. Despite small sample size, a trend towards higher ONSD were seen in patients with non-shockable vs shockable rhythm. Females were also consistently found to have smaller ONSD measurements in all time periods compared to males. Conclusions: This is the first study in the USA to perform analysis using ONSD measurements in cardiac arrest patients. Preliminary analysis of this on-going pilot revealed a greater improvement in ONSD diameters in patients with a favorable neurological outcome. OSND may have utility in prognostication of the post-arrest state.