Control Of Increased Intracranial Pressure Research Articles

Clinical Safety and Efficiency of the H-Port for Treatment of Leptomeningeal Metastasis.

To evaluate the usefulness of a cranial implantable chemoport, the H-port, as an alternative to the Ommaya reservoir for intraventricular chemotherapy/cerebrospinal fluid (CSF) access in patients with leptomeningeal metastasis (LM). One hundred fifty-two consecutive patients with a diagnosis of LM and who underwent H-port installation between 2015 and 2021 were evaluated. Adverse events associated with installation and intraventricular chemotherapy, and the rate of increased intracranial pressure (ICP) control via the port were evaluated for safety and efficacy. These indices were compared with published data of Ommaya (n=89), from our institution. Time-to-install and installation-related complications of intracranial hemorrhage (n=2) and catheter malposition (n=5) were not significantly different between the two groups. Intraventricular chemotherapy-related complications of CSF leakage occurred more frequently in the Ommaya than in the H-port group (13/89 vs. 3/152, respectively, p<0.001). Intracranial hemorrhage during chemotherapy occurred only in the Ommaya group (n=4). The CSF infection rate was not statistically different between groups (14/152 vs. 12/89, respectively). The ICP control rate according to reservoir type revealed a significantly higher ICP control rate with the H-port (40/67), compared with the Ommaya result (12/58, p<0.001). Analyzing the ICP control rate based on the CSF drainage method, continuous extraventricular drainage (implemented only with the H-port), found a significantly higher ICP control rate than with intermittent CSF drainage (33/40 vs. 6/56, respectively, p<0.0001). The H-port for intraventricular chemotherapy in patients with LM was superior for ICP control; it had equal or lower complication rates than the Ommaya reservoir.

Invasive intracranial pressure monitoring in posterior cranial fossa after neurosurgery: an exclusive option or a necessity?

To determine the feasibility of ICP sensor insertion into cerebellar parenchyma for PCF edema after neurosurgery. We retrospectively analyzed literature data (15 references) and 3 patients after ICP sensor insertion into cerebellar parenchyma for ICP control in PCF. ICP sensor insertion into cerebellar parenchyma is indicated for infratentorial postoperative edema.

Effect of Intracranial Pressure Control on Improvement of Cerebral Perfusion After Acute Subarachnoid Hemorrhage: A Comparative Angiography Study Based on Temporal Changes of Intracranial Pressure and Systemic Pressure

Increased intracranial pressure (ICP) is a well-known complication after aneurysmal subarachnoid hemorrhage (aSAH). This study focused on the different temporal changes in ICP, mean arterial pressure, and cerebral perfusion pressure at the early stage of aSAH, throughout aneurysm embolization, and their effects on improvement in angiographic perfusion patterns. Twenty-seven patients with aSAH were evaluated who underwent coiling and cerebrospinal fluid (CSF) drainage. Diagnostic angiography was performed to confirm the presence and location of the vascular lesion. The transit time of the capillary filling phase was defined as a surrogate of cerebral perfusion. Capillary filling transit times were compared before and after CSF drainage. Univariate and multivariate analyses were performed to identify associations between different physical parameters and capillary filling transit times. By univariate analysis, average capillary transit time before CSF drainage had a significant correlation with initial ICP (P= 0.0004; R2= 0.398) but not systemic pressure (mean arterial pressure or cerebral perfusion pressure). Improvement in capillary filling pattern (i.e., a decrease in angiographic capillary transit time after CSF drainage) was seen in patients with high initial ICP and correlated with ICP difference after ventricular drainage (P= 0.0001 and P < 0.0001, respectively). Using multivariate regression analysis, improved control in postprocedural ICP levels significantly correlated with angiographic evidence of improved cerebral perfusion (P= 0.0243). Decreasing ICP by CSF drainage strongly correlated with improved cerebral microcirculation after aSAH. Further development of ICP control protocols that can provide better ICP management of patients with aSAH is warranted.

Prophylactic and Therapeutic Hypothermia in Severe Traumatic Brain Injury

This review aims to synthesize knowledge on the efficacy and safety of prophylactic hypothermia (PH—cooling started shortly after trauma) and therapeutic hypothermia (TH—cooling started to treat increased intracranial pressure (ICP)) in severe traumatic brain injury (TBI). Current evidence on the use of hypothermia in severe TBI is conflicting. Recent multicenter trials on the topic have demonstrated no improvement in functional outcome or mortality in patients treated with PH. Certain patient subgroups seem to benefit from this therapy, such as individuals undergoing craniotomy. TH appears to be ineffective as a stage 2 therapy, but evidence supports its use in stage 3 ICP management. Higher risks of complications occur with hypothermia, but they can be mitigated by using milder cooling, selective brain cooling, and gradual rewarming. Short-term PH appears to be ineffective in improving outcome for severe TBI. However, PH may still be useful as a longer-duration therapy and in specific patient subgroups. In addition, optimal rate of rewarming and ideal target temperature need to be established. TH as a stage 3 ICP control therapy has only shown benefit in small trials. Higher-quality studies that shed light on these questions are required.

BMET-13CSF PROFILES AS PROGNOSTIC MARKER OR PREDICTIVE MARKER FOR INTRAVENTRICULAR CHEMOTHERAPY IN PATIENTS WITH LEPTOMENINGEAL CARCINOMATOSIS FROM SOLID CANCERS

One of difficulties in intra-CSF chemotherapy for leptomeningeal carcinomatosis (LMC) is a lack of quantitative measure for the treatment response. Previous studies evaluated CSF profiles to predict treatment response or to correlate with prognosis. However, the results were inconsistent mainly due to small number of patients and heterogeneous treatment. We analyzed 283 patients with LMC from solid cancer, who underwent intraventricular chemotherapy at National Cancer Center from 2003 to 2013. CSF parameters were cytology, cell count and protein level. Control of intracranial pressure (ICP) was reviewed as an objective indicator of symptom improvement. CSF profiles before the treatment were significantly different according to sample sites (p < 0.001) in both cell count (lumbar vs. ventricular is mean 23 ± 44 vs. 8 ± 30) and protein level (mean 124 ± 168 vs. 33 ± 66 mg/dL). Initial lumbar CSF protein level was correlated with development of increased ICP (p = 0.059), hydrocephalus (HCP) (p = 0.049), and cauda equine syndrome (CES) (p< 0.001). But, initial ventricular CSF profiles did not reflect LMC disease activity. Decrease of CSF protein level after treatment was associated with increased ICP control (p = 0.017) while cell count change or cytology conversion is not predictive. Patients with low initial protein level (≤ 50mg/dL), or cell count (≤15) show prolonged survival (p = 0.001 and 0.015, respectively). But, decrease of either protein level or cell count after the treatment and cytology response did not significantly affect the patients OS. We suggest that CSF cell count is too low to reflect disease activity or treatment response especially those from ventricle. Initial CSF protein is in accordance with LMC symptoms and the decrease of protein level after the treatment is predictive of treatment response. We need new quantitative pharmacodynamic markers for LMC treatment to improve efficacy of intraventricular chemotherapy.

Management of Increased Intracranial Pressure

After brain injury, neurologic intensive care focuses on the detection and treatment of secondary brain insults that may compound the initial injury. Increased intracranial pressure (ICP) contributes to secondary brain injury by causing brain ischemia, hypoxia, and metabolic dysfunction. Because ICP is easily measured at the bedside, it is the target of numerous pharmacologic and surgical interventions in efforts to improve brain physiology and limit secondary injury. However, ICP may not adequately reflect the metabolic health of the underlying brain tissue, particularly in cases of focal brain injury. As a result, ICP control alone may be insufficient to impact patients' long-term recovery. Further studies are needed to better understand the combination of cerebral, hemodynamic, and metabolic markers that are best utilized to ensure optimal brain and systemic recovery and overall patient outcome after brain injury.

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Introduction: Ongoing research has shown correlations between Optic Nerve Sheeth Diameter (ONSD) and increased intracranial pressure (ICP). Baseline data is lacking in the pediatric population for which to interpret an ONSD diameter that should change over time. Prior research has used arbitrary cutoff using age of 1 year. This protocol was approved and overseen by the local IRB. Methods: Eligible patients were consented for entry into the study. Patients were disqualified if there was any globe injury. 2 groups of patients were included; 1) patients with an ICP monitor in place and 2) Patient without an ICP monitor who did not have any suspicion for raised ICP due to their admitting diagnosis. Measurement of the ONSD was taken 3mm from the optic nerve insertion to the globe and measured perpendicular to the optic nerve axis. 3 measures were taken in each eye in the transverse plane and, likewise in the sagittal plane. Patients with an ICP monitor had serial measurements (1/day) and correlating ICP recorded. Patients without an ICP monitor underwent 1 set of measures. Demographic information including Age, height, weight and head circumference (HC) was also recorded. Results: Head circumference had the strongest correlation to ONSD in patients not suspected to have any intracranial pathology (r=0.579, p<0.001). Comparitively, age was also significantly correlated (r=0.382, p=0.002). Highest overall value of ONSD in control population was 4.95mm, found in one patient. Comparison to a prior trial in the same age group found 1 of 4 patients with elevated ICP in our sample that would have been classified as normal using the prior trials classification. An ANOVA analysis showed that for every 1cm increase in HC there was a correlated 0.51 mm increase in ONSD. There is a significant difference of mean ONSD between the elevated ICP group (n=4) and control group (5.41 vs 3.01, p=0.017). Conclusions: Head circumference serves as a much stronger correlation to predicted ONSD than does age. As research progresses in this field using deviation from predicted ONSD, as calculated from HC, would provide a stronger correlation than age over a patients clinical lifespan. This study is limited by few cases of measured elevated ICP, however the trend does follow the pattern shown in previous work of a positive correlation between ONSD and ICP. Further validation of this assessment tool would allow for screening this population prior to placement of an intracranial ICP monitor.

Chapter 10. Cerebrospinal fluid drainage

Chapter 10. Cerebrospinal fluid drainage

Chemoport with a non-collapsible chamber as a replacement for an Ommaya reservoir in the treatment of leptomeningeal carcinomatosis

The Ommaya reservoir for intraventricular chemotherapy of leptomeningeal carcinomatosis (LMC) patients has been reported to have some complications. We introduced a Chemoport reservoir, with a solid non-collapsible, high-profile chamber as a the replacement for the Ommaya reservoir in LMC patients. To evaluate the usefulness of Chemoport as an alternative to Ommaya for the intraventricular chemotherapy of LMC. The medical records of 155 patients (89 Ommaya and 66 Chemoport) who underwent intraventricular chemotherapy via a subgaleal reservoir were reviewed. Chemoport was secured with engraving of skull. Reservoir malfunction, including one intracranial hemorrhage (ICH) under the burr hole occurred, in six patients. During the course of therapy, cerebrospinal fluid (CSF) infection was diagnosed in 19 patients and intraventricular hemorrhage with ICH was evident in three patients of the Ommaya group. Incidence of the above-mentioned complications showed no difference between the two groups. CSF leakage under a galeal flap or through a wound edge occurred more frequently in the Ommaya group (12 patients) than in the Chemoport group (two patients) and the difference was statistically significant (p = 0.03). One-hundred and four patients showed increased intracranial pressure (ICP) and 74 of them received additional CSF drainage to control increased ICP by either intermittent CSF drainage in both groups or continuous extraventricular drainage (EVD) of CSF using designated hooked needle only in the Chemoport group. Among the factors related to the control ICP, the number of chemotherapies, type of reservoir in favor of Chemoport, and EVD showed significantly improved control of ICP (p < 0.05). Chemoport, as a reservoir for intraventricular chemotherapy, has superior ICP control at an equal or lower rate of complications compared with the Ommaya reservoir.

Keeping Patients Safe During Intrahospital Transport

Keeping Patients Safe During Intrahospital Transport

Controlled drainage of lumbar cerebrospinal fluid for the management of increased intracranial pressure in patients with subarachnoid hemorrhage

Intercranial hypertension represents a significant complication in patients with severe subarachnoid hemorrhage (SAH) from aneurysm rupture. In the acute state of SAH, increased intracranial pressure (ICP) is usually due to the direct effect of the initial hemorrhage. Over the following days, ICP may rise as a result of cerebral ischemia from developing vasospasm. Management protocols for intercranial hypertension include hyperventilation, use of mannitol ventricular cerebrospinal fluid (CSF) drainage, sedation, hypertonic saline, barbiturate coma, and decompressive surgery. In addition to these measures, we have introduced lumbar CSF drainage for the control of malignant hypertension over the last 3 years. A total of 21 patients included. All had SAH from ruptured aneurysm and underwent early surgery. Postoperative increase of ICP was treated according to a standard protocol. When all other measures had failed, lumbar CSF drainage was initiated under continuous ICP monitoring. In all patients, this resulted in an immediate decrease of ICP and an increase of cerebral perfusion pressure (CPP). Lumbar drainage was continued for a mean of 4.8 days, and without exception, resulted in lasting control of elevated ICP. In two patients with absent basal cisterns before treatment, transient herniation of the brain resulted from lumbar drainage. We conclude that controlled lumbar CSF drainage represents an effective method to control refractory intercranial hypertension in carefully selected patients.

Detection of intracochlear and intracranial pressure changes with otoacoustic emissions: a gerbil model

Increased intracranial pressure (ICP) is known to affect the phases and levels of lower-frequency distortion-product otoacoustic emissions (DPOAE) in a characteristic manner suggestive of an increase in the stiffness of the stapes system, likely in relation to an attendant increased intracochlear pressure (ICoP). DPOAEs may thus provide an easy non-invasive means of gaining access to the otherwise elusive ICoP. However, the mechanisms by which DPOAEs actually relate to ICoP are unclear and may involve changes in the stiffness of the annular ligament, stapedius muscle and even some indirect contributions of other parts of the middle ear such as the tensor tympani. A systematic study of the role of each middle-ear element on ICoP-to-DPOAE relationships as a function of frequency was undertaken in gerbils under direct control of ICP via an intracranial catheter (from 0 to 500 daPa). After the bulla was widely opened, the tendons of the stapedius and tensor tympani muscles were severed in turn. A standard electroacoustic analog model of the middle ear was used for predicting the forward and reverse middle-ear transfer-functions changes under different experimental manipulations and their consequences on DPOAEs. The observed DPOAE changes chiefly consisted in a phase-lead peaking around 2.15 kHz in closed-bulla, and 1.2 kHz in open-bulla conditions. It was proportional to ICP increase provided ICP exceeded a threshold of about 50 daPa. The profiles of DPOAE shifts matched those derived from the premise that ICoP mainly induced a change in the stiffness of the stapes system. The possible involvement of the stapedius muscle was ruled out by the absence of any effect of cutting its tendon so that the intrinsically non-linear stiffness of the annular ligament must have been the main factor. A relatively minor contribution from the tensor tympani was observed, possibly in relation to the detection of ICoP-induced displacement of the ossicular chain by neuromuscular spindles.

General Anesthesia for a Cesarean Section in a Patient with a Brain Tumor: A case report

A 28-year-old primigravida at 33 weeks gestation was referred to our hospital because of aggravation of seizures which occurred intermittently for the past 2 years. A brain magnetic resonance imaging scan taken at 33 weeks gestation showed a large brain tumor (7 5 4 cm) in the left high frontal lobe. She had a cesarean section under general anesthesia at 38 weeks and 1 day gestation. General anesthesia was induced with thiopental 250 mg, succinylcholine 75 mg and lidocaine 60 mg after a vecuronium 0.8 mg intravenous injection. The hyperventilation and mannitol used to reduce increased intracranial pressure (ICP) in this patient may be harmful and detrimental to the fetus before delivery. Achieving both ICP control and fetal well being at the same time during a cesarean section can be challenging to anesthesiologists. We report the anesthetic management of a cesarean section in a patient with a large brain tumor.

Uses and abuses of hyperventilation in severe traumatic brain injury

A critical evaluation was done about the guidelines and effects of the hyperventilation maneuver on prevention and treatment of increased intracranial pressure (ICP) that follows severe traumatic brain injury (TBI). The prophylactic use of hyperventilation should be avoided after severe TBI acute phase, unless high venous O2 values are recorded at jugular bulb blood (SjO2), or to allow time when there are evidences of neurologic deterioration with posturing. The lack of cerebrovascular response to hyperventilation to low the ICP means that the blood brain barrier (BBB) function is extensively impaired. Then, hyperventilation may be used as a screening therapeutic test in acute severe TBI, since BBB impairment is the pointer that other available clinical procedures for high ICP control (sedation, paralysis and osmotic diuretics) are not workable. A new pathogenetic hypothesis about traumatic brain edema and its therapeutic approach is presented.

Indomethacin: A review of its cerebral blood flow effects and potential use for controlling intracranial pressure in traumatic brain injury patients

Traumatic brain injury (TBI) causes about 75,000 deaths and leaves approximately 200,000 people disabled in USA each year. Brain swelling and increased intracranial pressure (ICP) contribute to this morbidity and mortality. Aggressive management protocols,including ICP control, have been shown to reduce the overall mortality from 50% to 36% following severe head injury. Despite these encouraging results, new and improved pharmacologic strategies to control ICP are required. Indomethacin (IND) is a non-steroidal anti-inflammatory agent with unique effects on cerebral blood flow physiology which may be of benefit in reducing elevated ICP in TBI patients. Data from animal models and randomized, controlled studies with pre-term infants have shown that i.v. IND produces rapid, significant reductions in cerebral blood flow (CBF). Controlled studies of I.v. IND in normal volunteers show a reduction In CBF from 26%-40%. Case series involving severe TBI patients suggest that IND i.v. boluses of 30-50mg reduce ICP by 37%-52%, reduce CBF by 22%-26%, with a modest 14% increase in cerebral perfusion pressure (CPP). Despite these encouraging results, i.v. IND should only be considered an experimental treatment for control of refractory ICP in TBI patients. Larger, well-designed randomized trials in TBI patients will provide more efficacy and safety data and delineate the effects of IND alone or in combination with other proven, effective, or experimental therapies. Once these concerns have been addressed, larger outcome studies will ultimately be needed to determine the role of IND for ICP control in TBI patients. [Neurol Res 1999; 21: 491-499]

Cerebral blood flow in patients with intracranial pressure elevation due to traumatic brain edema.

The object of this study was to determine if traumatic brain edema (BE) and increased intracranial pressure (ICP) reduce cerebral blood flow (CBF). Two groups of patients were studied, one with slight BE and ICP less than 20 mm Hg., the other with pronounced BE and ICP over 20 mm Hg. Although ICP was higher and cerebral perfusion pressure lower in pronounced edema there was only a small and non-significant reduction in CBF and no difference in cerebro-vascular resistance. Since traumatic BE does not increase resistance to blood flow through the brain, cerebral perfusion can be maintained if an adequate perfusion pressure is established. This in turn, demands the monitoring and control of ICP.