Insertion Of Intracranial Pressure Monitor Research Articles

Perceived Utility of Intracranial Pressure Monitoring in Traumatic Brain Injury: A Seattle International Brain Injury Consensus Conference Consensus-Based Analysis and Recommendations.

Intracranial pressure (ICP) monitoring is widely practiced, but the indications are incompletely developed, and guidelines are poorly followed. To study the monitoring practices of an established expert panel (the clinical working group from the Seattle International Brain Injury Consensus Conference effort) to examine the match between monitoring guidelines and their clinical decision-making and offer guidance for clinicians considering monitor insertion. We polled the 42 Seattle International Brain Injury Consensus Conference panel members' ICP monitoring decisions for virtual patients, using matrices of presenting signs (Glasgow Coma Scale [GCS] total or GCS motor, pupillary examination, and computed tomography diagnosis). Monitor insertion decisions were yes, no, or unsure (traffic light approach). We analyzed their responses for weighting of the presenting signs in decision-making using univariate regression. Heatmaps constructed from the choices of 41 panel members revealed wider ICP monitor use than predicted by guidelines. Clinical examination (GCS) was by far the most important characteristic and differed from guidelines in being nonlinear. The modified Marshall computed tomography classification was second and pupils third. We constructed a heatmap and listed the main clinical determinants representing 80% ICP monitor insertion consensus for our recommendations. Candidacy for ICP monitoring exceeds published indicators for monitor insertion, suggesting the clinical perception that the value of ICP data is greater than simply detecting and monitoring severe intracranial hypertension. Monitor insertion heatmaps are offered as potential guidance for ICP monitor insertion and to stimulate research into what actually drives monitor insertion in unconstrained, real-world conditions.

E-bike-related cranial injuries in pediatric population.

E-bikes are being used increasingly by all age groups. Children riding e-bikes often do not use safety equipment such as helmets, and are at increased risk for injuries requiring neurosurgery. The most common type of injury among pediatric e-bikers is head and neck trauma. We describe our experience treating cranial injuries. Data regarding children (< 18years old) with e-bike-related cranial injuries were collected retrospectively from two tertiary centers. Twenty patients were included. Seventeen were e-bike users, and three were hit as pedestrians. The average age at admission was 11.3 ± 4.85 (range 1.5-17) years old. All 17 e-bike users did not wear a helmet. Seventeen of the 20 (85%) suffered from skull fractures (70% involving the frontal bone), nine involving more than one region. Six patients (30%) had intracerebral contusions, 3 (15%) an epidural hematoma, and 6 (30%) a subdural hematoma. Three patients (15%) underwent surgery, two of them for depressed skull fracture reduction, and one for insertion of intracranial pressure monitor. One patient died (5%); 1 (5%) had a Glasgow Outcome Scale (GOS) of 3, 5 (25%) had a GOS of 2, and 13 (65%) were discharged without any neurological deficit (GOS 1). E-bikes may inflict various cranial injuries, including fractures and intracranial bleeds, and may lead to significant morbidity and mortality. Education of children to use protective gear, wide exposure of younger adolescents to traffic laws, and limiting the use of e-bikes to older children, are all necessary actions.

Decompressive craniectomy for herpes simplex encephalitis complicated by frank intracerebral hemorrhage: a case report and review of the literature

BackgroundHerpes simplex encephalitis is the most common type of sporadic encephalitis worldwide. Frank intracerebral hemorrhage complicating the disease course in herpes simplex encephalitis patients is rare, especially cases where surgical decompression is necessary. Here, we report a previously healthy female with herpes simplex encephalitis who underwent surgical decompression due to temporal lobe hemorrhage.Case presentationA previously healthy 34-year-old Korean female presented with fever, myalgia and severe headache. Brain MRI showed a high T2 signal intensity change and diffuse swelling of the right temporal lobe. Polymerase chain reaction testing of the cerebrospinal fluid confirmed the presence of herpes simplex virus 1. The patient was admitted for close observation and intravenous acyclovir. On hospital day 3, she had a sudden onset of vomiting and severe headache. Brain CT showed frank temporal lobe hemorrhage. Despite aggressive medical treatment, she became increasingly drowsy. Ultimately, she underwent emergency right decompressive craniectomy, expansile duraplasty and intracranial pressure monitor insertion. The patient recovered fully without any neurological deficits or neuropsychological problems. She was discharged after completion of 2 weeks of acyclovir and returned 2 months later for cranioplasty.ConclusionsPatients with severe herpes simplex encephalitis complicated by intracerebral hemorrhage or malignant cerebral edema should undergo aggressive medical treatment. Surgical decompression should also be actively considered in these severe cases to prevent further neurological deterioration.

A clinical prediction model for raised intracranial pressure in patients with traumatic brain injuries.

Intracranial hypertension is believed to contribute to secondary brain insult in traumatically brain injured patients. Currently, the diagnosis of intracranial hypertension requires intracranial monitoring or advanced imaging. Unfortunately, prehospital transport times can be prolonged, delaying time to the initial radiographic assessment. The aim of this study was to identify clinical variables associated with raised intracranial pressure (ICP) prior to the completion of neuroimaging. We performed a retrospective cohort study of head injured patients over a 3-year period. Patients were labeled as having increased ICP if they had a single reading of ICP greater than 20 mm Hg within 1 hour of ICP monitor insertion or computed tomography findings suggestive of raised ICP. Patient and clinical characteristics were analyzed using stepwise multivariable logistic regression with ICP as the dependent variable. Of 701 head injured patients identified, 580 patients met inclusion criteria. Mean age was 48.65 ± 21 years, 73.3% were male. The mean Injury Severity Score was 22.71 ± 12.38, and the mean Abbreviated Injury Scale for body region head was 3.34 ± 1.06. Overall mortality was 14.7%. Only 46 (7.9%) patients had an ICP monitor inserted; however, a total of 107 (18%) patients met the definition of raised ICP. The mortality rate for patients with raised ICP was 50.4%. Independent predictors of raised ICP were as follows: age, older than 55 years (odds ratio [OR], 2.26; 95% confidence interval [CI], 1.35-3.76), pupillary fixation (OR, 5.76; 95% CI, 3.16-10.50), signs of significant head trauma (OR, 2.431; 95% CI, 1.39-4.26), and need for intubation (OR, 3.589; 95% CI, 2.10-6.14). This study identified four independent variables associated with raised ICP and incorporated these findings into a preliminary risk assessment scale that can be implemented at the bedside to identify patients at significant risk of raised ICP. Future work is needed to prospectively validate these findings prior to clinical implementation. Prognostic, Epidemiological, level III.

Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury.

Increased intracranial pressure (ICP) in patients with traumatic brain injury (TBI) is associated with a higher mortality rate and poor outcome. Mannitol and hypertonic saline (HTS) have both been used to treat high ICP, but it is unclear which one is more effective. Here, the authors compare the effect of mannitol versus HTS on lowering the cumulative and daily ICP burdens after severe TBI. The Brain Trauma Foundation TBI-trac New York State database was used for this retrospective study. Patients with severe TBI and intracranial hypertension who received only 1 type of hyperosmotic agent, mannitol or HTS, were included. Patients in the 2 groups were individually matched for Glasgow Coma Scale score (GCS), pupillary reactivity, craniotomy, occurrence of hypotension on Day 1, and the day of ICP monitor insertion. Patients with missing or erroneous data were excluded. Cumulative and daily ICP burdens were used as primary outcome measures. The cumulative ICP burden was defined as the total number of days with an ICP of > 25 mm Hg, expressed as a percentage of the total number of days of ICP monitoring. The daily ICP burden was calculated as the mean daily duration of an ICP of > 25 mm Hg, expressed as the number of hours per day. The numbers of intensive care unit (ICU) days, numbers of days with ICP monitoring, and 2-week mortality rates were also compared between the groups. A 2-sample t-test or chi-square test was used to compare independent samples. The Wilcoxon signed-rank or Cochran-Mantel-Haenszel test was used for comparing matched samples. A total of 35 patients who received only HTS and 477 who received only mannitol after severe TBI were identified. Eight patients in the HTS group were excluded because of erroneous or missing data, and 2 other patients did not have matches in the mannitol group. The remaining 25 patients were matched 1:1. Twenty-four patients received 3% HTS, and 1 received 23.4% HTS as bolus therapy. All 25 patients in the mannitol group received 20% mannitol. The mean cumulative ICP burden (15.52% [HTS] vs 36.5% [mannitol]; p = 0.003) and the mean (± SD) daily ICP burden (0.3 ± 0.6 hours/day [HTS] vs 1.3 ± 1.3 hours/day [mannitol]; p = 0.001) were significantly lower in the HTS group. The mean (± SD) number of ICU days was significantly lower in the HTS group than in the mannitol group (8.5 ± 2.1 vs 9.8 ± 0.6, respectively; p = 0.004), whereas there was no difference in the numbers of days of ICP monitoring (p = 0.09). There were no significant differences between the cumulative median doses of HTS and mannitol (p = 0.19). The 2-week mortality rate was lower in the HTS group, but the difference was not statistically significant (p = 0.56). HTS given as bolus therapy was more effective than mannitol in lowering the cumulative and daily ICP burdens after severe TBI. Patients in the HTS group had significantly lower number of ICU days. The 2-week mortality rates were not statistically different between the 2 groups.

Intracranial Pressure Is Still Number 1 Despite BEST:TRIP Study

s not question contrary, the d group were acranial hyperference was in e ICP-directed xamination in tensity and the eatment in the for patients in est value from roach for TBI P monitoring analysis of the reatment. this scans, longer We congratulate Chesnut et al. on their work, which great commitment and perseverance in conducting under very difficult circumstances (3). However, we authors overinterpret their results by not adequately several variables that are important in the manage traumatic brain injury (TBI). Misinterpretation of health care workers and/or policymakers could lead clusions about our current treatment practice in seve role of intracranial pressure (ICP)–directed treatmen Central to their approach is that Chesnut et al whether the guidelines-based protocol . . . significa the outcome” of severe TBI. The authors state that ICP-directed treatment arm were treated according lines for the management of severe traumatic brain details of this protocol are outlined in the supplement ment that the authors “strongly suggest using thes whenever available and/or possible.” However, excep ence to ICPmonitoring, neither the results in the actua additional data given in the supplement prove or eve nificant guideline adherence. Key components of the ommendations are, in addition to ICPmonitoring, th arterial hypotension and severe hyperventilation, ea support,maintenance of cerebral perfusionpressure of steroids. The authors do not provide data on any for ICP monitor insertion, CPP, and hyperventilatio cerebral perfusion pressure (CPP), they report a high patients with low CPP values; 86% of patients experi at some point, and the mean duration of low CPP wa which is rather high. Because CPP is tightly linked to (CPP MAP ICP), this suggests that arterial hy have been present in some of these patients. Severe h to CO2 values below 30 mm Hg was used in up to 16 The high use of barbiturates in the ICP treatment g concern because this is potentially associated with ar sion. Advanced TBI centers in North America and Eu avoid the use of barbiturates and also avoid severe hy No data are given on seizure activity, hemodynamic any laboratory values.Nutritional support seems to have b

RURAL NEUROTRAUMA IN AUSTRALIA: IMPLICATIONS FOR SURGICAL TRAINING

Australia's vast size and small population preclude a neurosurgical service in most rural areas. Thus, general surgeons often initially manage rural neurotrauma. This study aimed to define the neurotrauma surgical caseload in rural Australia and to examine the level of training and confidence of rural surgeons for neurotrauma management. A questionnaire was sent to all Australian members of the Division of Rural Surgery of the Royal Australasian College of Surgeons. Responses were grouped by distance from a neurosurgical centre and analysed using one-way anova. The response rate was 91%, and 161 rural surgeons were included. In total, 90 surgeons carried out approximately 600 procedures for neurotrauma in 5 years. The number of procedures per surgeon increased with distance from a neurosurgical centre (P < 0.0001), as did pre-transport delays (P < 0.001). Combined pre-transport and transport time was at least 2 h for 84% of surgeons. The majority (75% or more) of rural surgeons accessed hospitals with necessary basic infrastructure, including 24-h computed tomography scan, emergency department, and intensive care unit. There was no association between distance from a neurosurgical centre and level of neurosurgical training. Only 28% of rural surgeons had neurosurgery training more advanced than resident level. However, confidence with management of cranial trauma increased significantly with distance. More distant surgeons felt more confident with computed tomography reading (P = 0.02); burr hole (P = 0.02); craniotomy (P = 0.03) and intracranial pressure monitor insertion (P < 0.0001). A significant volume of neurotrauma is managed surgically in rural Australia as dictated by distance. However, neurotrauma training of rural surgeons has occurred on an ad hoc basis, with those most exposed and most distant developing some confidence. Evidence for specific adequate training is lacking, but this study suggests that it is necessary.