Elevated Increased Intracranial Pressure Research Articles

Intracranial pressure elevations in diffuse axonal injury: association with nonhemorrhagic MR lesions in central mesencephalic structures.

Increased intracranial pressure (ICP) in patients with severe traumatic brain injury (TBI) with diffuse axonal injury (DAI) is not well defined. This study investigated the occurrence of increased ICP and whether clinical factors and lesion localization on MRI were associated with increased ICP in patients with DAI. Fifty-two patients with severe TBI (median age 24 years, range 9-61 years), who had undergone ICP monitoring and had DAI on MRI, as determined using T2*-weighted gradient echo, susceptibility-weighted imaging, and diffusion-weighted imaging (DWI) sequences, were enrolled. The proportion of good monitoring time (GMT) with ICP > 20 mm Hg during the first 120 hours postinjury was calculated and associations with clinical and MRI-related factors were evaluated using linear regression. All patients had episodes of ICP > 20 mm Hg. The mean proportion of GMT with ICP > 20 mm Hg was 5%, and 27% of the patients (14/52) spent more than 5% of GMT with ICP > 20 mm Hg. The Glasgow Coma Scale motor score at admission (p = 0.04) and lesions on DWI sequences in the substantia nigra and mesencephalic tegmentum (SN-T, p = 0.001) were associated with the proportion of GMT with ICP > 20 mm Hg. In multivariable linear regression, lesions on DWI sequences in SN-T (8% of GMT with ICP > 20 mm Hg, 95% CI 3%-13%, p = 0.004) and young age (-0.2% of GMT with ICP > 20 mm Hg, 95% CI -0.07% to -0.3%, p = 0.002) were associated with increased ICP. Increased ICP occurs in approximately one-third of patients with severe TBI who have DAI. Age and lesions on DWI sequences in the central mesencephalon (i.e., SN-T) are associated with elevated ICP. These findings suggest that MR lesion localization may aid prediction of increased ICP in patients with DAI.

Intracranial pressure and compliance in hypoxic ischemic brain injury patients after cardiac arrest

IntroductionIn hypoxic ischemic brain injury (HIBI), increased intracranial pressure (ICP) can ensue from cerebral edema stemming from cytotoxic and vasogenic mechanisms. Downstream sequelae of restricted cerebral blood flow lead to neurologic braindeath. There is limited data characterizing the temporal trends and patterns of ICP and compliance in human HIBI patients. MethodsPatients underwent invasive ICP monitoring with a parenchymal probe (Camino) and were managed with a tier-based management algorithm for elevated ICP. Data pertaining to mean arterial pressure (MAP), ICP, brain tissue oxygenation (PbtO2), end tidal carbon dioxide (ETCO2), core body temperature and RAP (moving correlation coefficient between mean ICP and its mean pulse amplitude) as a measure of intracranial compliance were recorded in the ICM + software. Data pertaining to ICP lowering interventions was also collected. ResultsTen patients were included with a median age of 47 (range 20–71) and seven were male (7/10). The mean ICP was 14 mmHg (SD 11) and time of ICP> 20 mmHg was 22% (range 0–100). The mean MAP, ETCO2 and temperature were 89 mmHg (SD 13), 31 mmHg (SD 7), 35.7 °C (SD 0.9), respectively. The mean RAP was 0.58 (SD 0.34) and time of RAP > 0.4 was 78% (range 57–97). There were no significant relationships between ETCO2 and temperature with ICP. ConclusionsIn our cohort, HIBI was characterized by normal ICP but with limited intracranial compliance. However, significant in between patient heterogeneity exists with respect to temporal patterns of intracranial pressure — volume relationships in HIBI.Trial registration: clinicaltrials.gov (NCT03609333).

A noninvasive method for the estimation of increased intracranial pressure in patients with severe traumatic brain injury using optic nerve sheath diameter measured on computed tomography head.

Background:Measurement of optic nerve sheath diameter (ONSD) using ocular ultrasonography has shown a promise in predicting increased intracranial pressure (ICP). However, this method is dependent on operator technique and equipment availability. We propose an alternative method of measuring ONSD and Marshall score grading by utilizing initial computed tomography (CT) head obtained on admission. We believe that such a technique could help predict patients requiring an invasive ICP monitor on admission.Methods:Patients were retrospectively selected from the neurosurgery database of a level II trauma center. Control patients originated from a database of nontraumatic brain injury (TBI) patients with a negative CT head and no intracranial pathology. Study subjects included patients aged 18–90 years, who sustained a severe TBI requiring placement of an ICP monitor on admission. All patients had a non-contrast CT head before the placement of an ICP monitor. Patients receiving any intervention for decreasing suspected elevated ICPs and those with any documented orbital fractures before ICP monitor placement were excluded from the study. All measurements were performed by at least of two independent assessors.Results:A total of 242 patients were reviewed, of which 204 (100 control and 104 intervention) met inclusion criteria for this study. T he average age in the control group was 49.1 ± 22.9 years old while the average age of the intervention group was 36.9 ± 15.1 years (P < 0.0001). The average Glasgow Coma Scale was 7 in the intervention group. The average ONSD of the control group was 5.73 ± 0.58 mm compared to 6.76 ± 0.83 mm in the intervention group (P < 0.0001). Linear regression analysis demonstrated a statistically significant correlation between ONSD and opening ICP (r = 0.40, P < 0.001) and peak ICP (r = 0.31, P < 0.0001). An ONSD ≥6.0 mm + Marshall score ≥3 on initial CT head demonstrated a 92.5% sensitivity, 92.6% specificity, and 96.1% positive predictive value for developing an ICP ≥20 mmHg during hospitalization.Conclusion:Utilizing ONSD in combination with Marshall score grading on initial CT head is a strong predictor of elevated ICP. These criteria can be used in future studies to develop more objective criteria to guide ICP monitor placement.

Endovascular Stenting in a Transgender Patient With Idiopathic Intracranial Hypertension

Endovascular Stenting in a Transgender Patient With Idiopathic Intracranial Hypertension

Ultrasonography Monitoring of Optic Nerve Sheath Diameter and Retinal Vessels in Patients with Cerebral Hemorrhage.

Evaluation of the diagnostic accuracy of optic nerve sheath diameter (ONSD) and Doppler indices of central retinal arteries and veins for the detection of increased intracranial pressure (ICP) in intracerebral hemorrhage (ICH) and of the usefulness of a second assessment of these variables in the monitoring of ICH. A total of 46 acute ICH patients with (group 1, n = 25) and without (group 2, n = 21) clinical and radiological computed tomography signs of raised ICP and 40 healthy controls were recruited. The median binocular ONSD and Doppler indices of retinal vessels including resistive index (RI) and retinal venous pulsation (RVP) were compared among groups, both at admission and later during ICH monitoring. Median binocular ONSD showed higher accuracy for the detection of increased ICP (sensitivity and specificity 100%), while Doppler indices were less accurate (sensitivity 48% and specificity 95% for RI; 80% and 62% for RVP). In ICH patients, ONSD was significantly elevated in group 1 both at admission (6.40 mm [interquartile range [IQR]=.70] vs. 4.70 [.40]) and at control time (6.00 [.55] vs. 4.55 [.40]; P<.01), as well as RI (.79 [.11] vs. .77 [.03] and .80 [.06] vs. .75 [.35]; P = .01). RVP was significantly increased in group 1 only at admission (3.20 cm/s [1.05] vs. 2.00 [1.55], P = .02). Median binocular ONSD evaluation showed higher accuracy for the estimation of elevated ICP compared with Doppler indices of retinal vessels. The ONSD enlargement detected in the early phase of ICH persists at control time.

Intraoperative intracranial pressure monitoring in the pediatric craniosynostosis population.

OBJECTIVEEvaluation of increased intracranial pressure (ICP) in the pediatric craniosynostosis population based solely on ophthalmological, clinical, and radiographic data is subjective, insensitive, and inconsistent. The aim of this study was to examine the intraoperative ICP before and after craniectomy in this patient population.METHODSThe authors measured the ICP before and after craniectomy using a subdural ICP monitor in 45 children. They regulated end-tidal carbon dioxide and the monitoring site under general anesthesia to record consistent ICP readings.RESULTSThe average age of the patient population was 29 months (range 3.8-180.5 months). Thirty-seven patients (82.2%) were undergoing initial craniosynostosis procedures. All craniosynostosis procedures were categorized as one of the following: frontoorbital advancement (n = 24), frontoorbital advancement with distraction osteogenesis (n = 1), posterior vault distraction osteogenesis (n = 10), and posterior vault reconstruction (n = 10). Nineteen of 45 patients (42.2%) had syndromic or multisuture craniosynostosis. The mean postcraniectomy ICP (8.8 mm Hg, range 2-18 mm Hg) was significantly lower than the precraniectomy ICP (16.5 mm Hg, range 6-35 mm Hg) (p < 0.001). Twenty-four patients (53%) had elevated ICP prior to craniectomy, defined as ≥ 15 mm Hg. Only 4 (8.9%) children had papilledema on preoperative funduscopic examination (sensitivity 17%, specificity 100%, negative predictive value 51%, and positive predictive value 100%). There were no significant differences in elevated precraniectomy ICP based on type of craniosynostosis (syndromic/multisuture or nonsyndromic) or age at the time of surgery. Patients undergoing initial surgery in the first 12 months of life were significantly less likely to have elevated precraniectomy ICP compared with patients older than 12 months (26.3% vs 73.1%, p = 0.005).CONCLUSIONSIn this study, the authors report the largest cohort of syndromic and nonsyndromic craniosynostosis patients (n = 45) who underwent precraniectomy and postcraniectomy ICP evaluation. A craniectomy or completed craniotomy cuts for distractors effectively reduced ICP in 43/45 patients. The authors' findings support the notion that papilledema on funduscopy is a highly specific, however poorly sensitive, indicator of increased ICP, and thus is not a reliable screening method. These findings indicate that even nonsyndromic patients with craniosynostosis are at risk for increased ICP. Furthermore, patients who present prior to 12 months of age appear less likely to have elevated ICP on presentation. Further studies with other noninvasive imaging of the retina may be useful as an adjunct tool for determining elevated ICP.

Transorbital ultrasound of optic nerve sheath diameter in children with raised intracranial pressure

Background : Increased intracranial pressure (ICP), also known as intracranial hypertension is defined as cerebrospinal fluid (CSF) pressure = 20 mm Hg. It is a common neurological emergency seen in children with a wide variety of underlying etiologies such as brain tumors, obstructive hydrocephalus, posttraumatic intracranial hemorrhage, meningoencephalitis, and toxic encephalitis [1,2]. If left untreated, it can produce adverse and often irreversible neurological consequences and damage the brain through compression of its structures or restriction of its blood flow. Hence, early identification of elevated ICP is critical to ensuring timely and appropriate management [3].Evaluation in critically ill patients requires complicated procedures, creating a need for rapid diagnosis and treatment of these patients along with frequent re-evaluation of raised ICP [1,4-6]. The current standard of care for diagnosing raised ICP is invasive which involves intracranial placement of a monitoring device. The ideal ICP monitor would therefore be non-invasive, portable, easy to use, cost effective and allow for continuous monitoring.There has been a longstanding quest for a reliable, non-invasive technique to assess ICP.The opportunity to make the diagnosis of raised ICP earlier using an appropriate non-invasive technique, makes the applicability of such a method broader than just neurocritical care patients. The accessible, natural bony windows in the human skull, i.e. orbit, auditory canal and AF (neonates), can potentially allow access to important information about the brain and ICP, making transorbital ultrasound measurement of the optic nerve sheath diameter (ONSD) as a surrogate marker of raised ICP [11-22]. The direct cerebrospinal fluid (CSF) connection between the peri-optic and intracranial subarachnoid spaces, makes this technique a particularly appealing option for assessing ICP [23]. The favourable acoustic properties and superficial anatomical location of the eye, make transorbital sonographic assessment of the optic nerve sheath (ONS) very suitable, futher enhancing its use. The region of the ONS located 3mm posterior to the lamina cribrosa of the retina is considered the most distensible and is recommended as the most consistent region to acquire the ONSD measurement [24]. Changes in the ONSD can be visualized using images from ultrasound, MRI and CT scans. Several studies have demonstrated a strong association between distension of the ONSD and an increase in ICP [13,14,25,26-28]. It should also be noted that, with RICP, the optic nerve diameter increases initially, later leading to papilledema, so transorbital sonography is able to show the increased ICP earlier than ophthalmoscopy. Methods : The optic nerve diameter was measured by transorbital sonography in transverse view, 3 mm posterior to the papilla in both eyes, and the mean was calculated. Two groups were examined: a control group (children with normal ICP) and a case group (increased ICP as clinically suspected and later confirmed by an alternative method). Results : In a sample of 100 children, 50 (50%) belonged to case group and 50 (50%) to control group. 68 subjects (68%) were male, and 32(32%) were female. The mean ± SD ages were 8.82 ± 4.23 years in the case group and 9.16 ± 3.86 years in the control group. The mean optic nerve diameters were 4.40 ± 0.97 mm in the case group and 2.35 ± 0.27 mm in the control group. The difference in the means was significant (P <0.05) Conclusion : Optic nerve diameter, measured by transorbital sonography, was significantly greater in patients with increased ICP compared with control group. The evaluation of the optic nerve sheath diameter is a simple non-invasive procedure, which is potentially useful in the assessment and monitoring of children suspected of having raised intracranial pressure.

Intervention for elevated intracranial pressure improves success rate after repair of spontaneous cerebrospinal fluid leaks.

Spontaneous cerebrospinal fluid (CSF) leaks are associated with increased intracranial pressure (ICP) and considered a manifestation of idiopathic intracranial hypertension. Although postoperative acetazolamide and placement of CSF shunt systems are considered valuable interventions for elevated ICP, the impact on recurrence rate remains unclear. The objective of this study was to systematically review evidence from reported literature to evaluate whether postoperative ICP management reduces recurrence rates after primary endoscopic repair. Prospective case series and systematic review. Demographics, defect location, success rates, and ICP management in spontaneous CSF leak patients were prospectively collected over 8 years. A search was also conducted in PubMed to identify studies reporting cases of spontaneous CSF rhinorrhea. Fifty-six articles with nonduplicated data were identified and combined with a prospective series of 108 patients for a total of 679 patients treated for spontaneous CSF rhinorrhea. Average age was 50.4 years with 77% female. Average body mass index was 35.8 kg/m2 . Defects were most commonly located in the sphenoid sinus (n = 334) followed by the ethmoid (n = 318) and the frontal sinus (n = 46). Successful primary repair was 92.82% in patient cohorts where ICP evaluation and intervention with acetazolamide or CSF shunt systems was performed, but was significantly decreased to 81.87% in series with no active management of elevated ICP (P < .001). Evaluation and intervention for elevated ICP in spontaneous CSF leaks is associated with significantly improved success rates following primary endoscopic repair. 4. Laryngoscope, 127:2011-2016, 2017.

Abstract WP351: No Effect of Mannitol on the Course of Perihemorrhagic Edema After Intracerebral Hemorrhage

Introduction: In patients with intracerebral hemorrhage (ICH) perihemorrhagic edema (PHE) seems to play a predictive role besides initial hematoma size, clinical status and intraventricular bleeding (IVH). PHE may exceed the initial hematoma volume by up to 600% thereby leading to increased intracranial pressure (ICP) which may cause severe clinical deterioration. EUSI and ASA guidelines recommend the use of intravenous mannitol or hypertonic saline (HS) in order to reduce elevated ICP. However, clinical data suggest that HS may be superior to mannitol in lowering ICP and clinical data concerning the effect of mannitol on PHE as a cause of elevated ICP is limited. We aimed to investigate the effect of mannitol on PHE after ICH. Methods: Patients with supratentorial spontaneous ICH treated with 20% intravenous mannitol solution (125-250ml every 6h) for 5-10 days and controls matched for ICH volume, age and IVH who did not receive any osmotic agents during the course of treatment were identified retrospectively from our institutional ICH database. PHE volume was calculated on diagnostic CT scans performed on days 1, 2-3, 4-6, 7-9 and 10-12 using a validated volumetric algorithm. Frequency of elevated ICP up to day 12 (ICP burden), modified Rankin Scale (mRS) after rehabilitation (approx. day 90) and PHE evolution were assessed as outcome variables. Results: 44 ICH patients treated with mannitol and 43 controls were included. Basic characteristics did not differ between groups (median ICH volume day 1: 32.9 mL (IQR 16.3 - 54.0) and 27.7 mL (IQR 22.4 - 37.1), p=0.786; median age 71 y (IQR 61.5 - 77) and 72 y (IQR 66 - 81), p=0.269; median PHE volume day 1: 24.3 mL (IQR 16.0 - 38.8) and 24.3 mL (IQR 17.1 - 32.1), p=0.592, respectively). In the mannitol group PHE volume exceeded to a greater extent than in controls (PHE on day 10-12: 60.1 mL (SD 33.6) vs. 36.8 mL (SD 23.2), p=0.005). Median ICP burden was higher in the mannitol group (0 (IQR 0 - 7.75) vs. 0 (IQR 0), p=0.016). Median mRS did not differ between both groups (4 (IQR 4-6) vs. 4 (IQR 3-6), p=0.321). Conclusions: We found no effect of mannitol use on the general evolution of PHE and ICP. Other underlying mechanisms may explain the short-term effect of mannitol bolus administration on ICP in patients with spontaneous supratentorial ICH.

Decompressive Hemicraniectomy in Acute Neurological Diseases

Increased intracranial pressure (ICP) secondary to severe brain injury is common. Increased ICP is commonly encountered in malignant middle cerebral artery ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage. Multiple interventions – both medical and surgical – exist to manage increased ICP. Medical management is used as first-line therapy; however it is not always effective and is associated with significant risks. Decompressive hemicraniectomy is a surgical option to reduce ICP, increase cerebral compliance, and increase cerebral blood perfusion when medical management becomes insufficient. The purpose of this review is to provide an up-to-date summary of the use of decompressive hemicraniectomy for the management of refractory elevated ICP in malignant middle cerebral artery ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage.

Perioperative Risk Assessment of Patients with Gliomatosis Cerebri

Gliomatosis cerebri is a rare diffusely infiltrating malignant glial neoplasm. Presenting symptoms include seizures, neurologic deficits, and frequently symptoms related to increased intracranial pressure (ICP). Surgical intervention, including brain biopsy, may induce worsening of these neurologic symptoms. We reviewed our database to identify prognostic and risk factors for perioperative deterioration specifically associated with elevated ICP. Between 2006 and 2014, 78 patients were treated for gliomatosis cerebri. Ten patients required perioperative emergent treatment for elevated ICP. The clinical course and outcome of these 10 patients (study group) were characterized and compared with the remaining 68 patients. The study group patients developed life-threatening symptoms of increased ICP and required urgent decompressive craniectomy (n= 5 urgent decompressive craniectomy after biopsy, n= 2 urgent decompressive craniectomy on admission) or aggressive medical therapy (n= 3). Demographic and clinical variables were similar in both groups. In patients with severe symptoms of increased ICP, enhancing tumor volume was significantly greater than in asymptomatic patients. Radiologic evidence of obliteration of the basal cisterns and herniation was more common in symptomatic patients. The proliferation index in the biopsy specimens of tumors was also significantly higher in patients with symptomatic ICP elevation. Clinical symptoms and radiologic appearance suggestive of elevated ICP at presentation, volume of contrast enhancement, and high Ki-67 proliferation index may predict the need for aggressive rapid treatment to control ICP in a small but significant subset of patients with GC. Further studies are needed to clarify the biologic basis for the unusual clinical course in these tumors.

Decompressive Hemicraniectomy in Acute Neurological Diseases.

Increased intracranial pressure (ICP) secondary to severe brain injury is common. Increased ICP is commonly encountered in malignant middle cerebral artery ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage. Multiple interventions-both medical and surgical-exist to manage increased ICP. Medical management is used as first-line therapy; however, it is not always effective and is associated with significant risks. Decompressive hemicraniectomy is a surgical option to reduce ICP, increase cerebral compliance, and increase cerebral blood perfusion when medical management becomes insufficient. The purpose of this review is to provide an up-to-date summary of the use of decompressive hemicraniectomy for the management of refractory elevated ICP in malignant middle cerebral artery ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage.

Transorbital Ultrasonographic Measurement of the Optic Nerve Sheath Diameter in Preeclampsia [24J

INTRODUCTION: Preeclampsia is ranked as the second leading cause of maternal mortality worldwide, mostly due to acute cerebral complications. The objective of this study is to estimate the frequency of increased intracranial pressure (ICP) using transorbital ultrasound among pregnant women with and without preeclampsia. METHODS: Between September and October 2014, a cross-sectional study was conducted in a tertiary care hospital in Recife, Brazil. Ultrasonographic measurements of the optic nerve sheath diameter (ONSD), using a 10–12 MHz ultrasound linear probe, were performed in two groups: preeclamptic patients and non-preeclamptic pregnant women. Fisher's exact test was used to compare categorical data established to detect increased intracranial pressure between groups. RESULTS: A total of 33 cases were included in the study: 18 women with and 15 without preeclampsia with a mean (SD) age of 27.7 (7.4) and 23.3 (7.2) years respectively. The most frequent severe features in the patients with preeclampsia were: BP ≥160/110 mm Hg (100%), headache (22.2%) and focal neurologic signs (22.2%). Signs of elevated ICP were found in 27.7% of preeclamptic women, whereas none of the healthy ones had the ONSD measurement above 5 mm (value associated to detect ICP >20 cm H2O with a sensitivity of 88% and specificity of 93%). There was a statistically significant relation between increased ICP and preeclampsia (P<.05). CONCLUSION: Ultrasonographic measurement of the ONSD is a promising tool for the assessment of increased ICP and risk stratification in patients with preeclampsia. Further studies are necessary to substantiate the value of this non-invasive technique considering the possible neurologic complications in preeclampsia.

Study of radiological findings in papilledema

Background: Early recognition of papilledema and elevated ICP is of paramount importance for ensuring restoration of vision. Papilledema, frequently occurs in the setting of increased ICP and in a variety of medical conditions, including pseudotumorcerebri, sinus thrombosis, intracerebral hemorrhage, frontal lobe neoplasms, and Chiari malformation.the primary role of imaging in the diagnosis of idiopathic intracranial hypertension (IIH) has been to exclude other conditions that can cause increased intracranial pressure (ICP) and papilledema. Material & Methods: The present study is a non randomized prospective case series being conducted in the 50 patients with disc edema/papilledema attending OPD and referred from other departments to DEPARTMENT OF OPHTHALMOLOGY, Gandhi Medical College and associated Hamidia Hospital, Bhopal from January 2013- December 2014, All patients underwent a complete medical evaluation including careful history taking, ophthalmic examination, Investigations includes MRI Scan was done in Radiology as well neurology reference was taken from Neurosurgery department, Hamidia Hospital, G.M.C. Bhopal. Result: In radiological study ICSOL is observed in 70.58% cases followed by 11.76% cases of sinusitis followed by 5.88% case each venous thrombosis,demyelination and infarction. Conclusion: Early recognition of papilledema and elevated ICP is of paramount importance for ensuring restoration of vision. Newer advanced MR imaging techniques such as fMRI and DTI may prove useful in the future to assess the potential effects of papilledema on retinal and visual pathway integrity.

Extracorporeal decarboxylation in patients with severe traumatic brain injury and ARDS enables effective control of intracranial pressure.

IntroductionAcute respiratory distress syndrome (ARDS) with concomitant impairment of oxygenation and decarboxylation represents a complex problem in patients with increased intracranial pressure (ICP). Permissive hypercapnia is not an option to obtain and maintain lung-protective ventilation in the presence of elevated ICP. Pumpless extracorporeal lung assist (pECLA) devices (iLA Membrane Ventilator; Novalung, Heilbronn, Germany) can improve decarboxylation without aggravation associated with invasive ventilation. In this pilot series, we analyzed the safety and efficacy of pECLA in patients with ARDS and elevated ICP after severe traumatic brain injury (TBI).MethodsThe medical records of ten patients (eight male, two female) with severe ARDS and severe TBI concurrently managed with external ventricular drainage in the neurointensive care unit (NICU) were retrospectively analyzed. The effect of pECLA on enabling lung-protective ventilation was evaluated using the difference between plateau pressure and positive end-expiratory pressure, defined as driving pressure (ΔP), during the 3 days preceding the implant of pECLA devices until 3 days afterward. The ICP threshold was set at 20 mmHg. To evaluate effects on ICP, the volume of daily cerebrospinal fluid (CSF) drainage needed to maintain the set ICP threshold was compared pre- and postimplant.ResultsThe ΔP values after pECLA implantation decreased from a mean 17.1 ± 0.7 cm/H2O to 11.9±0.5 cm/H2O (p = 0.011). In spite of this improved lung-protective ventilation, carbon dioxide pressure decreased from 46.6 ± 3.9 mmHg to 39.7 ± 3.5 mmHg (p = 0.005). The volume of daily CSF drainage needed to maintain ICP at 20 mmHg decreased significantly from 141.5 ± 103.5 ml to 62.2 ± 68.1 ml (p = 0.037).ConclusionsFor selected patients with concomitant severe TBI and ARDS, the application of pECLA is safe and effective. pECLA devices improve decarboxylation, thus enabling lung-protective ventilation. At the same time, potentially detrimental hypercapnia that may increase ICP is avoided. Larger prospective trials are warranted to further elucidate application of pECLA devices in NICU patients.

Accuracy of noninvasive intraocular pressure or optic nerve sheath diameter measurements for predicting elevated intracranial pressure in cryptococcal meningitis.

Cryptococcal meningitis is associated with increased intracranial pressure (ICP). Therapeutic lumbar puncture (LP) is recommended when the initial ICP is >250 mm H2O, yet the availability of manometers in Africa is limited and not always used where available. We assessed whether intraocular pressure could be a noninvasive surrogate predictor to determine when additional therapeutic LPs are necessary. Ninety-eight human immunodeficiency virus-infected Ugandans with suspected meningitis (81% Cryptococcus) had intraocular pressure measured using a handheld tonometer (n = 78) or optic nerve sheath diameter (ONSD) measured by ultrasound (n = 81). We determined the diagnostic performance of these methods for predicting ICP vs a standard manometer. The median ICP was 225 mm H2O (interquartile range [IQR], 135-405 mm H2O). The median intraocular pressure was 28 mm Hg (IQR, 22-37 mm Hg), and median ultrasound ONSD was 5.4 mm (IQR, 4.95-6.1 mm). ICP moderately correlated with intraocular pressure (ρ = 0.45, P < .001) and with ultrasound ONSD (ρ = 0.44, P < .001). There were not discrete threshold cutoff values for either tonometry or ultrasound ONSD that provided a suitable cutoff diagnostic value to predict elevated ICP (>200 mm H2O). However, risk of elevated ICP >200 mm H2O was increased with an average intraocular pressure >28 mm Hg (relative risk [RR] = 3.03; 95% confidence interval [CI], 1.55-5.92; P < .001) or an average of ONSD >5 mm (RR = 2.39; 95% CI, 1.42-4.03; P = .003). As either intraocular pressure or ONSD increased, probability of elevated ICP increased (ie, positive predictive value increased). Noninvasive intraocular pressure measurements by tonometry or ultrasound correlate with cerebrospinal fluid opening pressure, but both are a suboptimal replacement for actual ICP measurement with a manometer.

The effect of oral care on intracranial pressure in critically ill adults.

A major goal in the care of patients with neurological problems is to prevent or minimize episodes of increased intracranial pressure (ICP). Elevations in ICP in response to nursing interventions have been acknowledged since the 1960s when ICP monitoring was first introduced in the clinical setting. Until recently, few studies have specifically examined the effect of oral care on ICP, and oral care and other hygiene measures were combined or not specified, prohibiting a direct interpretation of the influence of oral care alone on ICP. The purpose of this study was to describe the relationship between routine oral care interventions and the changes in ICP specifically focusing on the effect of intensity and duration of this intervention. Twenty-three patients with a clinical condition requiring ICP monitoring were enrolled over a 12-month period. Oral care provided by neuroscience intensive care nurses was observed and videotaped. Characteristics of the intervention were documented including products used, patient positioning, and duration of the intervention. A 1-5 subjective scale was used to score intensity of oral care. Wrist actigraphy data were collected from the nurses to provide an objective measure of intensity. Patient physiologic data were collected at 12-second epochs 5 minutes before, during, and 5 minutes after oral care. The mixed-effect repeated measures analysis of variance model indicated that there was a statistically significant increase in ICP in response to oral care (p = .0031). There was, however, no clinically significant effect on ICP. This study provides evidence that oral care is safe to perform in patients in the absence of preexisting elevated ICP.

ABSTRACT 7

Background and aims: Idiopathic Increased Intracranial Hypertension (IIH), called Pseudotumor cerebri, is a common causes of progressive increased intracranial pressure (ICP) in adolescence. Optic nerve atrophy and blindness may occur if left untreated. The orbital portion of the optic nerve is surrounded by a sheath comprised of an outer layer (Dura) and an inner sheath (arachnoid) where CSF circulates. Increased ICP augments CSF pressure enlarging the optic nerve sheath diameter (ONSD). ONSD can be assessed by ultrasonography (US) with a normal size of 4–4.5 mm at adolescence. Aims: To assess if US could be a noninvasive tool to detect increased ICP in the IIH population. Methods: Prospective, blind study of patients 12–18 years of age with suspected IIH. ONSD was measured with a 13–6 MHz linear array probe prior to performing a sedated (fentanyl/propofol), recumbent, spinal tap where the opening pressure was recorded. A cut of < 20 cmH2O was considered normal. 3 ONSD measurements were performed in each eye and averaged. IRB approved study with signed informed consent. Results: 10 patients completed the study, eight had enlarged ONSD and elevated ICP, two had normal ONSD and ICP (p = 0.01).Table: No title available.Conclusions: There is direct correlation between increased ICP and ONSD. ONSD measurement with a cut off value > 4.5 mmm was associated with an increased ICP in IIH. Further studies are needed to confirm this observation.Figure

Meningoceles in Idiopathic Intracranial Hypertension

MRI abnormalities have been described in patients with increased intracranial pressure (ICP), including in those with idiopathic intracranial hypertension (IIH). Spontaneous CSF-filled outpouchings of the dura (meningoceles) and secondary CSF leaks can occur from elevated ICP in patients with IIH; however, few studies have evaluated these findings. Our objective was to evaluate the frequency of spontaneous intracranial meningoceles among IIH patients and determine their association with visual outcome. We performed a retrospective case-control study of consecutive IIH patients between 2000 and 2011 who underwent MRI that included T2-weighted imaging. Demographics, presenting symptoms, CSF opening pressure, and visual outcome were collected for the first and last evaluations. Control subjects included patients without headache or visual complaints who had normal brain MRI results. Stratified analysis was used to control for potential confounding by age, sex, race, and body mass index. We included 79 IIH patients and 76 control subjects. Meningoceles were found in 11% of IIH patients versus 0% of control subjects (p<0.003). Prominent Meckel caves without frank meningoceles were found in 9% of IIH patients versus 0% of control subjects (p<0.003). Among IIH patients, the presence of meningocele or prominent Meckel caves was not associated with demographics, symptoms, degree of papilledema, CSF opening pressure, visual acuity, or visual field defect severity. Meningoceles are significantly more common in IIH patients than in control subjects and can be considered an additional imaging sign for IIH. Meningoceles are not, however, associated with decreased CSF opening pressure or better visual outcome in IIH.

Management of raised intracranial pressure in children with traumatic brain injury.

Increased intracranial pressure (ICP) is associated with worse outcome after traumatic brain injury (TBI). The current guidelines and management strategies are aimed at maintaining adequate cerebral perfusion pressure and treating elevated ICP. Despite controversies, ICP monitoring is important particularly after severe TBI to guide treatment and in developed countries is accepted as a standard of care. We provide a narrative review of the recent evidence for the use of ICP monitoring and management of ICP in pediatric TBI.