Increased Intracranial Pressure Monitoring Research Articles

The effect of passive leg raising test on intracranial pressure and cerebral autoregulation in brain injured patients: a physiological observational study

BackgroundThe use of the passive leg raising (PLR) is limited in acute brain injury (ABI) patients with increased intracranial pressure (ICP) since the postural change of the head may impact on ICP and cerebral autoregulation. However, the PLR use may prevent a positive daily fluid balance, which had been recently associated to worse neurological outcomes. We therefore studied early and delayed effects of PLR on the cerebral autoregulation of patients recovering from ABI.Materials and methodsThis is a Prospective, observational, single-center study conducted in critically ill patients admitted with stable ABI and receiving invasive ICP monitoring, multimodal neuromonitoring and continuous hemodynamic monitoring. The fluid challenge consisted of 500 mL of crystalloid over 10 min; fluid responsiveness was defined as cardiac index increase ≥ 10%. Comparisons between different variables at baseline and after PLR were made by paired Wilcoxon signed-rank test. The correlation coefficients between hemodynamic and neuromonitoring variables were assessed using Spearman’s rank test.ResultsWe studied 23 patients [12 patients (52.2%) were fluid responders]. The PLR significantly increased ICP [from 13.7 (8.3–16.4) to 15.4 (12.0–19.2) mmHg; p < 0.001], cerebral perfusion pressure (CPP) [from 51.1 (47.4–55.6) to 56.4 (49.6–61.5) mmHg; p < 0.001] and the pressure reactivity index (PRx) [from 0.12 (0.01–0.24) to 0.43 (0.34–0.46) mmHg; p < 0.001]. Regarding Near Infrared Spectroscopy (NIRS)-derived parameters, PLR significantly increased the arterial component of regional cerebral oxygen saturation (O2Hbi) [from 1.8 (0.8–3.7) to 4.3 (2.5–5.6) μM cm; p < 0.001], the deoxygenated hemoglobin (HHbi) [from 1.6 (0.2–2.9) to 2.7 (1.4–4.0) μM cm; p = 0.007] and total hemoglobin (cHbi) [from 3.6 (1.9–5.3) to 7.8 (5.2–10.3): p < 0.001]. In all the patients who had altered autoregulation after PLR, these changes persisted ten minutes afterwards. After the PLR, we observed a significant correlation between MAP and CPP and PRx.ConclusionsIn ABI patient with stable ICP, PLR test increased ICP, but mostly within safety values and thresholds. Despite this, cerebral autoregulation was importantly impaired, and this persisted up to 10 min after the end of the maneuvre. Our results discourage the use of PLR test in ABI even when ICP is stable.

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.

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.

Effects of intubation technique on intracranial pressure: a cadaveric study.

Patients are at risk of increased intracranial pressure (ICP) during manipulation for endotracheal intubation. The aim of this cadaveric study was to quantify this relationship. Five fresh frozen adult cadaveric heads were used. The internal carotid artery (ICA) and internal jugular vein (IJV) were dissected bilaterally. All vessels were occluded on the right side. To mimic central venous pressures, the left IJV was cannulated and filled with water to maintain a pressure of approximately 7 cm H2O. The ICA cannula was attached to an oscillating water pump. Next, an ICP monitor was placed. Normophysiological volumes of water were infused to maintain normal ICP. Baseline ICP and IJV pressures were recorded. The heads were then placed in the sniffing position and in neutral position for nasal intubation, and finally an oral endotracheal tube was placed using standard head/neck maneuvers. The ICP was recorded. Mean baseline ICP was 13 mmHg (range 4-18 mmHg) and mean IJV pressure was 6 cm H2O. In the sniffing position, ICP increased in all specimens by a mean of 5 mmHg. In the neutral position, after intubation, the ICP increased in all specimens by a mean of 3 mmHg. Nasal intubation resulted in an increase in four of the five specimens. The mean increase in ICP with this maneuver was 2 mmHg. We present a cadaveric model of ICP measurement during neck manipulation using intracranial fluid dynamics. The ICP increased consistently. Following clinical studies, physicians involved in intubating patients with concern for raised ICP should change the technique to avoid complications.

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.

Application of Intracranial Pressure-Directed Therapy on Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage

ObjectiveElevated ICP is a well-recognized phenomenon in aneurysmal subarachnoid hemorrhage (aSAH) that has been demonstrated to lead to poor outcomes. Delayed cerebral ischemia (DCI) is the most important reason for a poor clinical outcome after a subarachnoid hemorrhage. DCI is understood as a multifactorial process that evolves over time, largely caused by the sequelae of increased intracranial pressure (ICP). The study aimed to assess how to better define the association between ICP and DCI, and whether rational ICP management can improve the outcome of aSAH patients.MethodsWe prospectively reviewed patients diagnosed with aSAH and received microsurgery clipping at our department from December 2019 to January 2021. Subdural ICP monitoring devices were kept to monitor the ICP. The ICP values were recorded every 1-h epochs. ICP -guided dehydration treatments were routinely performed to control the ICP level of patients after surgery. To evaluate whether the subdural ICP-directed management improved the prognosis of the aSAH patients, we compared the outcome data of the patients in our cohort with those treated at another ward of our hospital at the same period.ResultsIn total, 144 consecutive aSAH patients received microsurgery clipping at our department, 68 of whom underwent ICP monitoring. A total of 11,424 1-h ICP measurements were recorded for the included patients (1.30 years of recordings). Of 68 patients with ICP monitoring, 27 (27/68, 39.7%) patients developed DCI. Univariate analysis showed that higher Hunt-Hess grade (OR 2.138, 95% CI 1.025–4.459, p = 0.043), higher preoperative modified Rankin Scale score (OR 1.534, 95% CI 1.033–2.276, p = 0.034), and the max ICP value of each day value >28.5 mmHg (OR 4.442, 95% CI 1.509–13.082, p = 0.007) were associated with DCI. Also, patients with ICP-directed treatment showed a significantly lower DCI incidence than patients without ICP monitoring.ConclusionOur study suggests that I less than 15 mmHg possibly constitute normal values and that 28.5 mmHg is the ICP threshold most strongly associated with the occurrence of DCI in aSAH patients. Patients who received the ICP-directed treatment presented a lower incidence of DCI. Our findings provide a basis for the recommendation of ICP-directed treatment after aSAH.Trial Registration NumberNCT04785976.

Abnormal Intracranial Pulse Pressure Amplitude Despite Normalized Static Intracranial Pressure in Idiopathic Intracranial Hypertension Refractory to Conservative Medical Therapy.

Idiopathic intracranial hypertension (IIH) incorporates symptoms and signs of increased intracranial pressure (ICP) and is diagnosed by increased lumbar cerebrospinal fluid pressure. However, our knowledge about the characteristics of ICP abnormality, e.g., changes in pulsatile versus static ICP, remains scarce. This study questioned how overnight pulsatile ICP (mean ICP wave amplitude, MWA) associates with static ICP (mean ICP) in IIH patients who were refractory to conservative medical treatment. The material included 80 consecutive IIH patients undergoing ICP monitoring prior to shunt, as part of work-up for failed conservative medical therapy. In this group, the overnight mean ICP was normalized in 52/80 patients, but with abnormal overnight MWA in 45 of the 52 patients. Even though there was a positive correlation between MWA and mean ICP at group level and within individual ICP recordings, the levels of MWA were abnormal in a high proportion of patients despite normalized mean ICP. Taken together, the present results disclosed lasting abnormal pulsatile ICP despite normalized static ICP in IIH patients refractory to conservative medical therapy, which may reflect the underlying pathophysiology. It is tentatively suggested that abnormal pulsatile ICP in IIH may reflect alterations at the glia–neurovascular interface, resulting in impaired astrocytic pulsation absorber mechanisms.

Automated Pupillometry as a Triage and Assessment Tool in Patients with Traumatic Brain Injury

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in young adults. Automated infrared pupillometry (AIP) has shown promising results in predicting neural damage in aneurysmal subarachnoid hemorrhage and ischemic stroke. We aimed to explore potential uses of AIP in triaging patients with TBI. We hypothesized that a brain injury severe enough to require an intervention would show Neurologic Pupil Index (NPI) changes. We conducted a prospective pilot study at a level-1 trauma center between November 2019 and February 2020. AIP readings of consecutive patients seen in the emergency department with blunt TBI and abnormal imaging findings on computed tomography were recorded by the assessing neurosurgery resident. The relationship between NPI and surgical intervention was studied. Thirty-six patients were enrolled, 9 of whom received an intervention. NPI was dichotomized into normal (≥3) versus abnormal (<3) and was predictive of intervention (Fisher exact test; P < 0.0001). Six of the 9 patients had a Glasgow Coma Scale (GCS) score ≤8 and imaging signs of increased intracranial pressure (ICP) and underwent craniectomy (n= 4) or ICP monitor placement (n= 2) and had an abnormal NPI. Three patients underwent ICP monitor placement for GCS score ≤8 in accordance with TBI guidelines despite minimal imaging findings and had a normal NPI. The GCS score of these patients improved within 24 hours, requiring ICP monitor removal. NPI was normal in all patients who did not require intervention. AIP could be useful in triaging comatose patients after blunt TBI. An NPI ≥3 may be reassuring in patients with no signs of mass effect or increased ICP.

Relationship between Increased Intracranial Pressure and Mastoid Effusion.

ObjectiveThis study aimed to assess the relationship between increased intracranial pressure (ICP) and mastoid effusions (ME). MethodsBetween January 2015 and October 2018, patients who underwent intracranial surgery and had ICP monitoring catheters placed were enrolled. ICP was recorded hourly for at least 3 days. ME was determined by the emergence of opacification in mastoid air cells on follow-up brain imaging. C-reactive protein (CRP) levels, presence of endotracheal tube (ETT) and nasogastric tube (NGT), duration of intensive care unit (ICU) stay, duration of mechanical ventilator application, diagnosis, surgical modalities, and presence of sinusitis were recorded. Each factor’s effect on the occurrence of ME was analyzed by binary logistic regression analyses. To analyze the independent effects of ICP as a predictor of ME a multivariable logistic regression analysis was performed. ResultsTotal of 61 (53%) out of 115 patients had ME. Among the patients who had unilateral brain lesions, 94% of subject (43/50) revealed the ipsilateral development of ME. ME developed at a mean of 11.1±6.2 days. The variables including mean ICP, peak ICP, age, trauma, CRP, ICU stays, application of mechanical ventilators and presence of ETT and NGT showed statistically significant difference between ME groups and non-ME groups in univariate analysis. Sex and the occurrence of sinusitis did not differ between two groups. Adding the ICP variables significantly improved the prediction of ME in multivariable logistic regression analysis. ConclusionWhile multiple factors affect ME, this study demonstrates that ICP and ME are probably related. Further studies are needed to determine the mechanistic relationship between ICP and middle ear pressure.

A new novel method for assessing intracranial pressure using non-invasive fundus images: a pilot study

Arteriole and venule diameter ratio (A/V-ratio) can be measured using fundus photography. In this pilot study, we correlated changes in the intracranial pressure with the diameter of vessels of the retina. We investigated whether increased intracranial pressure (ICP) was reflected in a measurable and quantifiable distention of the venule diameter, leading to a decreased A/V-ratio. This was demonstrated by assessment of the A/V-ratio in patients already undergoing conventional ICP monitoring with a cerebral intraparenchymal pressure monitor. Our method shows a correlation between A/V ratio and ICP and suggests an easily obtainable and usable point-of-care (POC), non-invasive method to estimate the intracranial pressure without the necessity of mydriatic drugs. Furthermore, the sensitivity/specificity analysis with a cut-off of < 0.8015 A/V-ratio, showed a sensitivity of 94% [85–98%] and a specificity of 50% [34–66%] with a positive likelihood ratio of 9.0. This means that in a clinical setting there is a 94% chance of correctly identifying individuals with ICP ≥ 20 mmHg.

Intracranial pressure monitoring for malignant stroke: It is too soon to call it off.

Malignant cerebral infarction (MCI) is a large middle cerebral artery infarction. MCI frequently results in increased intracranial pressure (ICP) because of its extent of the infarction. MCI management focuses on lowering ICP, but monitoring ICP has not been a standard of care. Studies have found insignificant clinical value in monitoring ICP because of doubtful correlations between ICP values and clinical findings. However, this conclusion is largely based on unilateral ICP measurements. Bilateral ICP measurements and differentials accompanying clinical findings are needed to draw a concrete conclusion on the usage of ICP monitoring in MCI management.

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.

Role of Orbital Ultrasound in the Assessment of Clinically Detected Papilledema.

Background:Increased intracranial pressure (ICP) is frequently seen, and it is considered a serious problem that needs a careful assessment and management, especially by easy and least invasive modalities.Objective:The objective of the study is to assess the optic nerve sheath diameter (ONSD) using transorbital ultrasound (US) as a marker and indicator for diagnosing raised intracranial pressure.Patients and Methods:It is a prospective study that was carried out in Neurology and/or Ophthalmology Clinics, Baghdad Teaching Hospital in the Medical City Complex during the period from June 2016 to May 2017; in this study, 40 patients seeking medical help for other causes were considered to be a control group and the other 40 patients who were complaining of raised ICP symptoms and suggested of having optic disc swelling by ophthalmoscopy examination. All the patients and the control group were examined by transorbital US to measure the ONSD, and then, only the patients with symptoms of raised intracranial underwent a lumbar puncture (LP).Results:Pearson's correlation test was used, demonstrating a very significant correlation between the ultrasonographic ONSD and the measurements of LP (R > 0.9) and (P < 0.001). Transorbital US yielded high sensitivity (91.6%) with modest specificity (75%) and high accuracy (90.0%) of ONSD was considered the normal the cutoff value of (5 mm) obtained from the control group. The US also showed the crescent sign and the optic disc bulging with lower sensitivity than the ONSD (61.1% and 41.6%, respectively) but with very high specificity (100%) for both.Conclusion:ONSD by transorbital ultrasonography is highly accurate, easily performed, and noninvasive procedure for the detection of raised ICP. Routine daily monitoring of ONSD could be of help in intensive care units when invasive ICP monitoring is not available or contraindicated; it also has a good role in early recognition of intracranial hypertension.

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.

ICP MONITOR PLACEMENT STEPWISE EARLY DECOMPRESSIVE CRANIECTOMY FOR THE MANAGEMENT OF SEVERE TBI PATIENTS: A CASE REPORT

Introduction. Increased intracranial pressure (ICP) is a secondary event that mostly occurs following traumatic brain injury (TBI) and it correlates with poor outcome of the patients. Several studies have suggested that early decompressive craniectomy (DC; within 48 hours after injury) is recommended for severe TBI patients requiring removal of intracranial hemorrhage and early DC was able to reduce the complications of TBI caused by increased ICP. However, even early DC has been performed, increased ICP may still progress due to massive brain edema. Methods. We herein report a case report of patient admitted with severe TBI and intracranial hemorrhage. The patients were underwent DC and ICP monitor placement after the removal of the intracranial hemorrhage. During postoperative observation in ICU, the CSF of the patients was gradually drained if the ICP was over 15mmHg. Results. The ICP right after performed early DC was 30 cmH2O (22 mmHg). One day after surgery, the hemodynamic of the patient was stable and the GCS was 2X5 with the ICP of the patient was about 18 cmH2O. On day 2-5, patient was hemodynamically stable with improved GCS (3X5) and decreased of ICP (around 13-15 cmH2O). On day 6, the ICP monitor was removed and the patient discharged on day 19 after fully recovered. Conclusion. The placement of ICP monitor and the application of gradual release of CSF after DC might be helpful to reduce increased ICP in severe TBI patients, and thus reducing the morbidity and mortality.&#x0D; &#x0D; Keywords: Traumatic brain injury, intracranial pressure monitor, decompressive craniectomy

ICP MONITOR PLACEMENT STEPWISE EARLY DECOMPRESSIVE CRANIECTOMY FOR THE MANAGEMENT OF SEVERE TBI PATIENTS: A CASE REPORT

Introduction. Increased intracranial pressure (ICP) is a secondary event that mostly occurs following traumatic brain injury (TBI) and it correlates with poor outcome of the patients. Several studies have suggested that early decompressive craniectomy (DC; within 48 hours after injury) is recommended for severe TBI patients requiring removal of intracranial hemorrhage and early DC was able to reduce the complications of TBI caused by increased ICP. However, even early DC has been performed, increased ICP may still progress due to massive brain edema. Methods. We herein report a case report of patient admitted with severe TBI and intracranial hemorrhage. The patients were underwent DC and ICP monitor placement after the removal of the intracranial hemorrhage. During postoperative observation in ICU, the CSF of the patients was gradually drained if the ICP was over 15mmHg. Results. The ICP right after performed early DC was 30 cmH2O (22 mmHg). One day after surgery, the hemodynamic of the patient was stable and the GCS was 2X5 with the ICP of the patient was about 18 cmH2O. On day 2-5, patient was hemodynamically stable with improved GCS (3X5) and decreased of ICP (around 13-15 cmH2O). On day 6, the ICP monitor was removed and the patient discharged on day 19 after fully recovered. Conclusion. The placement of ICP monitor and the application of gradual release of CSF after DC might be helpful to reduce increased ICP in severe TBI patients, and thus reducing the morbidity and mortality. Keywords: Traumatic brain injury, intracranial pressure monitor, decompressive craniectomy

Cerebral microvascular abnormalities in patients with idiopathic intracranial hypertension

AimIdiopathic intracranial hypertension (IIH) is characterized by symptoms indicative of increased intracranial pressure (ICP), such as headache and visual impairment. We have previously reported that brain biopsies from IIH patients show patchy astrogliosis and increased expression of the water channel aquaporin-4 (AQP4) at perivascular astrocytic endfeet. MethodsThe present study was undertaken to investigate for ultrastructural changes of the cerebral capillaries in individuals with IIH. We examined by electron microscopy (EM) biopsies from the cortical parenchyma of 10 IIH patients and 8 reference subjects (patients, not healthy individuals), in whom tissue was retrieved from other elective and necessary brain surgeries (epilepsy, tumors or vascular diseases). IIH patients were diagnosed on the basis of typical clinical symptoms and abnormal intracranial pressure wave amplitudes during overnight ICP monitoring. ResultsAll 10 IIH patients underwent shunt surgery followed by favorable clinical outcome. EM revealed abnormal pericyte processes in IIH. The basement membrane (BM) showed more frequently evidence of degeneration in IIH, but neither the BM dimensions nor the pericyte coverage differed between IIH and reference tissue. The BM thickness increased significantly with increasing age. Reference individuals were older than IIH cases; observations may to some extent be age-related. ConclusionThe present study disclosed marked changes of the cerebral cortical capillaries in IIH patients, suggesting that microvascular alterations are involved in the evolvement of IIH.

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.