Intracranial Hypertension In Patients Research Articles

Evaluation of Intracranial Hypertension in Patients With Hypertensive Intracerebral Hemorrhage Using Texture Analysis.

PurposeTexture analysis based on clinical images had been widely used in neurological diseases. This study aimed to achieve depth information of computed tomography (CT) images by texture analysis and to establish a model for noninvasive evaluation of intracranial pressure (ICP) in patients with hypertensive intracerebral hemorrhage (HICH).MethodsForty-seven patients with HICH were selected. Related CT images and ICP value were collected. The morphological features of hematoma volume, midline shift, and ventriculocranial ratio were measured. Forty textural features were extracted from regions of interest. Four models were established to predict intracranial hypertension with morphological features, textural features of anterior horn, textural features of temporal lobe, and textural features of posterior horn.ResultsModel of posterior horn had the highest ability to predict intracranial hypertension (AUC = 0.90, F1 score = 0.72), followed by model of anterior horn (AUC = 0.70, F1 score = 0.53) and model of temporal lobe (AUC = 0.70, F1 score = 0.58), and model of morphological features displayed the worst performance (AUC = 0.42, F1 score = 0.38).ConclusionTexture analysis can realize interpretation of CT images in depth, which has great potential in noninvasive evaluation of intracranial hypertension.

Hypertonic lactate for the treatment of intracranial hypertension in patients with acute brain injury

Hypertonic lactate (HL) is emerging as alternative treatment of intracranial hypertension following acute brain injury (ABI), but comparative studies are limited. Here, we examined the effectiveness of HL on main cerebral and systemic physiologic variables, and further compared it to that of standard hypertonic saline (HS). Retrospective cohort analysis of ABI subjects who received sequential osmotherapy with 7.5% HS followed by HL—given at equi-osmolar (2400 mOsmol/L) and isovolumic (1.5 mL/kg) bolus doses—to reduce sustained elevations of ICP (> 20 mmHg). The effect of HL on brain (intracranial pressure [ICP], brain tissue PO2 [PbtO2], cerebral microdialysis [CMD] glucose and lactate/pyruvate ratio [LPR]) and blood (chloride, pH) variables was examined at different time-points (30, 60, 90, 120 min vs. baseline), and compared to that of HS. A total of 34 treatments among 17 consecutive subjects (13 traumatic brain injury [TBI], 4 non-TBI) were studied. Both agents significantly reduced ICP (p < 0.001, at all time-points tested): when comparing treatment effectiveness, absolute ICP decrease in mmHg and the duration of treatment effect (median time with ICP < 20 mmHg following osmotherapy 183 [108–257] vs. 150 [111–419] min) did not differ significantly between HL and HS (all p > 0.2). None of the treatment had statistically significant effects on PbtO2 and CMD biomarkers. Treatment with HL did not cause hyperchloremia and resulted in a more favourable systemic chloride balance than HS (Δ blood chloride − 1 ± 2.5 vs. + 4 ± 3 mmol/L; p < 0.001). This is the first clinical study showing that HL has comparative effectiveness than HS for the treatment of intracranial hypertension, while at the same time avoiding hyperchloremic acidosis. Both agents had no significant effect on cerebral oxygenation and metabolism.

An Observational Study on Idiopathic Intracranial Hypertension (IIH) in a Tertiary Care Hospital in Bangladesh

Background: Among the risk factors of cardiovascular diseases, hypertension is one of the major reason. Intracranial hypertension (IIH) is a pressure buildup around the brain. It can happen unexpectedly, as a result of a severe head injury, stroke, or brain abscess could be occurred. It could also be a chronic, long-term condition, known as IIH. It results in the signs and symptoms of a brain tumor. Which is also known as benign intracranial hypertension. Cerebrospinal fluid, or CSF, is the fluid that surrounds the spinal cord and brain. CSF can accumulate if too much fluid is produced or not enough is reabsorbed. This can induce symptoms similar to a brain tumor. Intracranial Hypertension can be classified into three categories, they are Acute, Chronic and Idiopathic. IIH is recognized when the increased intracranial pressure cannot be explained by any other underlying cause.Aim: The aim of the study was to observe idiopathic intracranial hypertension patients in a select tertiary care hospital of Bangladesh.Methods:This cross-sectional observational study was conducted at the Department of Neurosurgery, Sylhet M. A. G. Osmani Medical College Hospital, Sylhet, Bangladesh. The study duration was from January 2012 to December 2020. A total number of 47 participants had been recruited as study population.Results:Male: female ratio was 1:10.75, and 91% of the total participants were female. 40.43% of the participants were aged between 21-30 years. 46.81% were overweight and 34.04% were obese. Most common symptom was nausea, followed by visual impairment and double vision.Conclusion:The prevalence of Idiopathic Intracranial Hypertension is much higher among the female. Female and high BMI are significant risk factors of IIH. It is more prevalent among young adults, and results on various vision related symptoms.

Optic Nerve Sheath Diameter Detects Intracranial Hypertension in Acute Malignant Middle Cerebral Artery Infarction

ObjectivesTo evaluate optic nerve sheath diameter in the acute phase of patients with malignant ischemic middle cerebral artery stroke submitted or not to decompressive craniectomy surgery. Materials and MethodsForty patients participated in the study and were evaluated bilaterally by ultrasound on admission and at 24h, 48h and 72 h after admission. Optic nerve sheath diameter values were correlated with tomographic and/or clinical criteria compatible with severe intracranial hypertension. ResultsA Receiver Operating Characteristic curve was drawn for each eye, determining a cut-off value for severe intracranial hypertension in the right eye of 5.4 mm (sensitivity: 62%; specificity: 100%; AUC: 0.82) and in the left eye 5.4 mm (sensitivity: 76%; specificity: 84%; AUC: 0.77). In patients undergoing craniectomy, there was a decrease in the mean value of 1.04mm in the right eye (pre: 5.84 ± 0.47 mm; post: 4.80 ± 0.84 mm; p = 0.001), while in the left, it decreased around 0.86mm (pre: 5.59 ± 0.69 mm; post: 4.73 ± 0.74 mm; p = 0.003). Patients with fatal outcome showed a persistent high mean ocular nerve sheath diameter. ConclusionsMonitoring optic nerve sheath by ultrasound can be considered a reliable method for identifying severe intracranial hypertension in patients with large vessel occlusion, as well as for monitoring patients undergoing craniectomy. Additional studies will be necessary to include this parameter in craniectomy indication algorithms in the future.

Comparison of Optic Nerve Sheath Diameters Measured by Optic Ultrasonography Before and After Lumbar Puncture in Idiopathic Intracranial Hypertension Patients.

Idiopathic intracranial hypertension (IIH) symptoms include headache, blurred vision, and papilledema which may lead to permanent vision loss unless diagnosed and treated. Definitive diagnosis of IIH usually requires the measurement of intracranial pressure (ICP) via lumbar puncture (LP) which is an invasive and unwanted technique for patients. In our study, optic nerve sheath diameters (ONSD) were measured before and after lumbar puncture in IIH patients and the relationship of these measurements with ICP changes was evaluated as well as the effect of decreasing cerebrospinal fluid (CSF) pressure after a lumbar puncture on ONSD. Thus, we want to investigate whether optic nerve ultrasonography (USG) is a useful tool instead of the invasive LP for the diagnosis of IIH. A total of 25 patients who applied to the neurology clinics of Ankara Numune Training and Research Hospital between May 2014 and December 2015 and were diagnosed with IIH were included in the study. The control group consisted of 22 individuals who applied with complaints other than headaches, visual impairment or tinnitus. Optic nerve sheath diameters were measured from both eyes before and after the LP. After pre-LP measurements were taken, opening and closing CSF pressure was measured. In the control group, ONSD was measured with optic USG. Mean age of the IIH group and the control group was determined as 34.8±11.5 and 45.8±13.3 years, respectively. In the patient group, mean CSF opening pressure was 33.9±8.0 cm H2O and mean closing pressure was 18.1±4.7 cm H2O. Mean ONSD measured pre-LP was 7.1±1.0 mm in the right eye and 6.9±0.7 mm in the left eye, while mean post-LP ONSD was 6.7±0.9 mm in the right eye and 6.4±0.8 mm in the left eye. There was a statistically significant difference between ONSD values before and after the LP (p=0.006 for the right eye, p<0.001 for the left eye). In the control group, mean ONSD was 5.4±0.7 mm in the right eye and 5.5±0.6 mm in the left eye, and a statistically significant difference was found between ONSD values before and after the LP (p<0.001 for the right eye and left eye). A significant positive correlation was determined between left ONSD measurements before the LP and CSF opening pressure (r=0.501, p=0.011). In the present study, it was found that ONSD measurement by optic USG significantly displays increased ICP, and decreasing pressure via LP is rapidly reflecting ONSD measurement. Based on these findings, it is suggested that ONSD measurements by optic USG, a non-invasive method, can be used in the diagnosis and follow-up of IIH patients.

Clinical Manifestations, Neuroimaging Findings, and Treatment of Idiopathic Intracranial Hypertension in a Nepalese Tertiary Centre

Introduction: Idiopathic Intracranial Hypertension is characterized by headache, visual impairment, papilledema, and increased cerebrospinal fluid opening pressure. We aim to evaluate clinical manifestations, neuroimaging findings, and treatment of Idiopathic Intracranial Hypertension in a Nepalese tertiary center. Materials and Methods: We retrospectively included patients with the diagnosis of Idiopathic Intracranial Hypertension who were admitted to the Neurology department of Tribhuvan University Teaching Hospital from 2019 June to 2021 May and presented to the Neuro-ophthalmology outpatient clinic of the hospital for follow-up. Results: Out of 16 Idiopathic Intracranial Hypertension patients, 12(75%) patients had either headache or ocular pain. Reduced visual acuity and progressive visual loss were found in 44% of patients. Normal CSF opening pressure was found in 19%, 44% had CSF opening pressure at a range of 20-30 cm H20 and &gt; 30 cm H20 in 37.5%. 15 Idiopathic Intracranial Hypertension patients (93.7%) were subtyped as Typical and 1 patient was diagnosed as Fulminant Idiopathic Intracranial Hypertension. Acetazolamide was used for treatment in 15 patients and 1 patient needed ventriculoperitoneal shunting. 56% Seven patients (44%) had some abnormal findings: partial empty sella (44%), and tortuous optic nerve (31%), flattened posterior eyeball (31%), and hypoplastic transverse sinus (19%). Conclusions: Idiopathic Intracranial Hypertension is an uncommon diagnosis but should be suspected in patients with chronic headaches with visual impairment. In low-resource settings, proper history along with neurological and ophthalmological examinations can even detect the early features and timely referral can save the vision and disability of Idiopathic Intracranial Hypertension patients.

Recovery of Vision after Optic Nerve Sheath Fenestration in Children and Adolescents with Elevated Intracranial Pressure

To evaluate the effect of optic nerve sheath fenestration (ONSF) on the recovery of visual function in pediatric patients with optic disc swelling owing to increased intracranial pressure. Retrospective case series. Medical chart review of all pediatric patients who underwent ONSF between 2009 and 2020 at the Children's Hospital of Philadelphia. Visual function was assessed at pre and postoperative visits. The main outcome measures were visual acuity, color vision, extraocular motility, visual field mean deviation, retinal nerve fiber layer thickness measured by optical coherence tomography. Fourteen pediatric patients (10 females; mean ± SD age of 14 ± 2.6 years; range, 8.5-17.5 years) were included. Five patients underwent bilateral surgeries. Ten patients were diagnosed with idiopathic intracranial hypertension. Of the 10 idiopathic intracranial hypertension patients, 3 had a previous history of weight gain and 2 of systemic steroid treatment; these can be referred to as pseudotumor cerebri. The mean ± SD follow-up length was 16.4 ± 12.3 months. VA improved from 20/138 to 20/68 in the operated eye (P=.0003) and from 20/78 to 20/32 in the nonoperated eye (P=.02). Color vision improved in the operated eye (P=.04), extraocular motility improved in the operated and nonoperated eye (P=.002 and P=.04 respectively). Visual field mean deviation improved in the operated (-23.4 dB to -11.5 dB, P < .0001) and nonoperated eye (-19.8 dB to -6.8 dB, P=.02). Retinal nerve fiber layer thickness improved in the operated eye (349.1 to 66.2 µm; P < .0001). The postoperative improvement was observed as early as the postoperative day 1. ONSF produces a rapid and persistent vision improvement in both the operated eye and the nonoperated eye. In children and young adults with papilledema and elevated intracranial pressure causing vision loss that is severe at presentation or refractory to standard medical management, ONSF should be considered.

The role of Cushing’s reflex and the vasopressin-mediated oligoanuric response to intracranial hypertension in patients with abdominal compartment syndrome

BackgroundWe examined the link between increased intra-abdominal pressure, intracranial pressure, and vasopressin release as a potential mechanism. Intra-abdominal pressure, produced by abdominal-cavity insufflation with carbon dioxide (CO2) during laparoscopic abdominal procedures to facilitate visualization, is associated with various complications, including arterial hypertension and oliguria. MethodsMean arterial pressure, optic nerve sheath diameter, measured as a proxy for intracranial pressure, plasma vasopressin, serum and urine osmolarity, and urine output were measured 4 times during laparoscopic sleeve gastrectomy in 42 patients: before insufflation with CO2 (T0); after insufflation to 15 cm water (H2O) pressure, with 5 cm H2O positive end-expiratory pressure (T1); after positive end-expiratory pressure was raised to 10 cm H2O (T2); and after a return to the baseline state (T3). Mean values at T0 to T3 and the directional consistency of changes (increase/decrease/ unchanged) were compared among the 4 data-collection points. ResultsStatistically significant elevations (all P ≤ .001) were noted from T0 to T1 and from T0 to T2 in mean arterial pressure, optic nerve sheath diameter, and vasopressin, followed by decreases at T3. For optic nerve sheath diameter and vasopressin, the increases at T1 and T2 occurred in 98% and 100% of patients, ultimately exceeding normal levels in 88 and 97%, respectively. Conversely, urine output fell from T0 to T1 and T2 by 60.9 and 73.4%, decreasing in 88.1% of patients (all P < .001). Patients with class II obesity exhibited statistically greater increases in optic nerve sheath diameter and vasopressin, but statistically less impact on urine output, than patients with class III obesity. ConclusionIncreased mean arterial pressure, intracranial pressure, and vasopressin release appear to be intermediary steps between increased intra-abdominal pressure and oliguria. Further research is necessary to determine any causative links between these physiological changes.

A Comparison Between Pressure Wire and Microcatheter Measurements for Evaluating the Cerebral Venous Pressure Gradient.

Introduction: A pressure gradient of over 8 mm Hg across the stenosis (usually located in the transverse-sigmoid junction) is one of the criteria for cerebral venous stenting in idiopathic intracranial hypertension (IIH) patients. The possible inaccuracy of the traditional microcatheter-based pressure measurements has been discussed in previous studies. In the cardiology field, a dual-sensor pressure wire is routinely used for the evaluation of stenotic lesions. Using a pressure wire for cerebral vasculature was previously discussed in a small case series and case reports. In this study, we compared venous pressure measurements obtained using both a microcatheter and a pressure wire in patients who were candidates for stenting.Methods: A retrospective study was conducted, comparing the two methods of pressure measurements in 26 patients with venous stenosis. Altogether, 120 measurements were performed using both methods. Demographic characteristics, medical history, procedural details, medications, indications for the procedure, and complications were collected from the patient charts.Results: Based on an 8-mm Hg pressure gradient cutoff indication, 19 patients were found eligible to go through unilateral venous stenting based on catheter measurements alone. The wire results corroborated the catheter results in detecting all cases indicated for a stent. This finding implies a sensitivity equal to 100% for the wire measurements. There were no wire-related complications, demonstrating its safety.Conclusions: We conclude that the pressure wire is as safe as the microcatheter and can identify cases requiring intervention. A larger-scale study is needed to assess the measurement accuracy of the pressure wire in brain vasculature.

Intracranial Hypotension Leading to Intracranial Hypertension with Ocular Manifestations

Purpose: To report a case of a 29-year-old binocular-diplopia patient diagnosed with intracranial hypertension, caused by a subdural hematoma due to intracranial hypotension.Case summary: A 29-year-old male hypertensive patient, diagnosed 2 months previously with idiopathic intracranial hypotension, presented to an ophthalmologist with a 4-day history of binocular diplopia. Visual acuity was 1.0/0.63 (1.0) without relative afferent pupillary defects. There was bilateral papilledema, right 6th cranial nerve palsy, and blind spot enlargement in visual field examinations, suggestive of intracranial hypertension. Computer tomography of the brain identified a 2- to 3-week-old subdural hematoma, a complication of intracranial hypotension, which may have led to intracranial hypertension.Conclusion: While persistent headaches in intracranial hypertension patients progress to intracranial hypotension due to lowered cerebrospinal fluid pressures, this is the first report of intracranial hypotension progressing to intracranial hypertension.

Evaulating peripapillary vessel density ın regressed papilledema ın ıdiopathic ıntracranial hypertension patients

PurposeTo evaluate the retinal nerve fiber layer (RNFL) thickness, the ganglion cell complex (GCC) and vessel density of the radial peripapillary capillary (RPC) plexus of eyes with regressed papilledema in idiopathic intracranial hypertension (IIH) patients using optical coherence tomography angiography (OCT-A) and comparing the results with healthy controls. Materials and methodsFifty-one eyes of 31 patients diagnosed with IIH and 52 eyes of 52 healthy subjects were enrolled in this study. All patients underwent a complete ophthalmological examination and a 4.5 × 4.5 mm peripapillary OCT-A scanning. The quantitative results of the peripapillary RNFL and GCC thicknesses and vessel density of the RPC were analyzed. ResultsThe vessel density in the inferior, superior nasal, and inferior nasal sectors of the patients with IIH significantly exceeded the vessel density of the healthy controls (P = 0.008, P = 0.008, and P = 0.000, respectively). The RNFL and GCC thickness measurements were comparable in both groups. ConclusionsPatients with IIH show vascular abnormalities in the inferior nasal region, which can be detected with OCT-A. As a noninvasive imaging modality, OCT-A could provide a new perspective for understanding the pathophysiology of IIH and could also be useful in the follow-up of these patients.

Long-term telemetric intracranial pressure monitoring for diagnosis and therapy optimisation of idiopathic intracranial hypertension

BackgroundIdiopathic intracranial hypertension (IIH) is a disease which is difficult to diagnose and moreover difficult to treat. We developed a strategy for long-term telemonitoring of intracranial pressure (ICP), by incorporation of the NEUROVENT®-P-tel System, with the goal of improved diagnosis and consequent therapy of this disease. We highlight the results obtained through this approach.MethodsTwenty patients with suspected IIH who were treated in our hospital from August 2014 to October 2020 (16 females, 4 males, median age 36,6 years), were assigned to one of two ICP monitoring settings, “Home-Telemonitoring” (n = 12) and “Home-Monitoring” (n = 8). The ICP data were analysed and used conjointly with the accompanying clinical picture for establishment of IIH diagnosis, and telemonitoring was resumed for therapy optimisation of confirmed cases.ResultsThe diagnosis of IIH was confirmed in 18 of the 20 patients. Various surgical/interventional treatments were applied to the confirmed cases, including ventriculoperitoneal (VP) shunting (n = 15), stenting of the transvers venous sinus (n = 1), endoscopic third ventriculostomy (ETV) (n = 1), and ETV in combination with endoscopic laser-based coagulation of the choroid Plexus (n = 1). Optimal adjustment of the implanted shunt valves was achieved with an average valve opening pressure of 6,3 ± 2,17 cm H2O for differential valves, and of 29,8 ± 3,94 cm H2O for gravitational valves. The Home-Telemonitoring setting reduced consequent outpatient visits, compared to the Home-Monitoring setting, with an average of 3,1 visits and 4,3 visits, respectively. No complications were associated with the surgical implantation of the P-tel catheter.ConclusionThis study offers insight into the use of long-term ICP monitoring for management of IIH patients in combination with dual-valve VP shunts. The use of NEUROVENT® P-tel system and potentially other similar fully implantable ICP-monitoring devices, albeit invasive, may be justified in this complex disease. The data suggest recommending an initial adjustment of dual-valve VP-shunts of 30 and 6 cm H2O, for gravitational and differential valves, respectively. Further research is warranted to explore potential integration of this concept in IIH management guidelines.

Cerebrospinal fluid dynamics in idiopathic intracranial hypertension: a literature review and validation of contemporary findings

BackgroundIdiopathic intracranial hypertension (IIH) is a rare disease of unknown aetiology related possibly to disturbed cerebrospinal fluid (CSF) dynamics and characterised by elevated intracranial pressure (ICP) causing optic nerve atrophy if not timely treated. We studied CSF dynamics of the IIH patients based on the available literature and our well-defined cohort.MethodA literature review was performed from PubMed between 1980 and 2020 in compliance with the PRISMA guideline. Our study includes 59 patients with clinical, demographical, neuro-ophthalmological, radiological, outcome data, and lumbar CSF pressure measurements for suspicion of IIH; 39 patients had verified IIH while 20 patients did not according to Friedman’s criteria, hence referred to as symptomatic controls.ResultsThe literature review yielded 19 suitable studies; 452 IIH patients and 264 controls had undergone intraventricular or lumbar CSF pressure measurements. In our study, the mean CSF pressure, pulse amplitudes, power of respiratory waves (RESP), and the pressure constant (P0) were higher in IIH than symptomatic controls (p < 0.01). The mean CSF pressure was higher in IIH patients with psychiatric comorbidity than without (p < 0.05). In IIH patients without acetazolamide treatment, the RAP index and power of slow waves were also higher (p < 0.05). IIH patients with excess CSF around the optic nerves had lower relative pulse pressure coefficient (RPPC) and RESP than those without (p < 0.05).ConclusionsOur literature review revealed increased CSF pressure, resistance to CSF outflow and sagittal sinus pressure (SSP) as key findings in IIH. Our study confirmed significantly higher lumbar CSF pressure and increased CSF pressure waves and RAP index in IIH when excluding patients with acetazolamide treatment. In overall, the findings reflect decreased craniospinal compliance and potentially depleted cerebral autoregulation resulting from the increased CSF pressure in IIH. The increased slow waves in patients without acetazolamide may indicate issues in autoregulation, while increased P0 could reflect the increased SSP.

A national Swedish case-control study investigating incidence and factors associated with idiopathic intracranial hypertension

ObjectiveTo study the incidence of idiopathic intracranial hypertension in Sweden and to explore whether previously proposed risk factors are associated with idiopathic intracranial hypertension by investigating the odds of exposure one year prior to diagnosis in patients compared to controls.MethodsUsing Swedish health care registers and validated diagnostic algorithms, idiopathic intracranial hypertension patients diagnosed between 2000–2016 were compared with randomly selected matched controls, five from the general population and five with obesity.ResultsWe identified 902 idiopathic intracranial hypertension patients and 4510 matched individuals in each control group. Mean incidence among inhabitants ≥18 years of age was 0.71 per 100,000; rising from 0.53 in 2000–2005 to 0.95 in 2012–2016. There were increased odds for idiopathic intracranial hypertension patients compared to general population for exposure to: kidney failure (odds ratio =13.2 (4.1–42.0)), arterial hypertension (odds ratio =17.5 (10.5–29.3)), systemic lupus erythematosus (odds ratio =13.8 (4.3–44.7)), tetracyclines, sulphonamides, lithium, and corticosteroids. In obese controls, odds ratios were also significantly increased for these exposures. Hormonal contraceptive use and exposure to pregnancy did not appear to be associated factors for idiopathic intracranial hypertension development.ConclusionsThe incidence of idiopathic intracranial hypertension in Sweden is lower relative to reports from other countries but is on the rise. This case-control study confirms several previously reported risk factors associated with idiopathic intracranial hypertension.

Idiopathic intracranial hypertension - a wider spectrum than headaches and blurred vision.

The purpose of this study was to analyse less known clinical scenarios associated with idiopathic intracranial hypertension. The study involved analysis of magnetic resonance imaging signs of idiopathic intracranial hypertension in patients with spontaneous rhinoliquorrhoea (n = 7), in patients with temporal lobe epilepsy and surgically treated antero-inferior temporal lobe meningo-encephaloceles (n = 15), and in patients who developed clinical signs of idiopathic intracranial hypertension following the treatment of spontaneous intracranial hypotension (n = 7). Three of six patients with spontaneous rhinoliquorrhoea and six of 15 operated patients with temporal lobe epilepsy due to temporal lobe meningo-encephaloceles showed magnetic resonance imaging signs of idiopathic intracranial hypertension and had a body mass index >30 kg/m2. Rebound high pressure headaches and sings of idiopathic intracranial hypertension occurred in seven of 44 surgically treated spontaneous intracranial hypotension patients. Magnetic resonance imaging findings should guide the clinician to consider (idiopathic) intracranial hypertension when patients develop spontaneous rhinoliquorrhoea, temporal lobe epilepsy secondary to temporal lobe meningoencephaloceles or high pressure headaches in spontaneous intracranial hypotension. Whether idiopathic intracranial hypertension must be regarded as a differential diagnosis or as a cause, or whether there are common pathophysiological pathways that lead to signs of idiopathic intracranial hypertension in this wider spectrum of disease is the focus of further study.

Improvement of exhausted cerebral autoregulation in patients with idiopathic intracranial hypertension benefit of venous sinus stenting

Objective. To evaluate the cerebral autoregulation (CA) in idiopathic intracranial hypertension (IIH) patients with transfer function analysis, and to explore its improvement after venous sinus stenting. Approach. In total, 15 consecutive IIH patients with venous sinus stenosis and 15 controls were recruited. All the patients underwent digital subtraction angiography and venous manometry. Venous sinus stenting was performed for IIH patients with a trans-stenosis pressure gradient ≥8 mmHg. CA was assessed before and after the operation with transfer function analysis, by using the spontaneous oscillations of the cerebral blood flow velocity in the bilateral middle cerebral artery and blood pressure. Main results. Compared with controls, the autoregulatory parameters, phase shift and rate of recovery, were both significantly lower in IIH patients [(57.94° ± 23.22° versus 34.59° ± 24.15°, p < 0.001; (39.87 ± 21.95) %/s versus (20.56 ± 46.66) %/s, p = 0.045, respectively). In total, six patients with bilateral transverse or sigmoid sinus stenosis received venous sinus stenting, in whom, the phase shift significantly improved after venous sinus stenting (39.62° ± 20.26° versus 22.79° ± 19.96°, p = 0.04). Significance. The study revealed that dynamic CA was impaired in IIH patients and was improved after venous sinus stenting. CA assessment has the potential to be used for investigating the hemodynamics in IIH patients.

A One-Day Prospective National Observational Study on Sedation-Analgesia of Patients with Brain Injury in French Intensive Care Units: The SEDA-BIP-ICU (Sedation-Analgesia in Brain Injury Patient in ICU) Study.

Sedation/analgesia is a daily challenge faced by intensivists managing patients with brain injury (BI) in intensive care units (ICUs). The optimization of sedation in patients with BI presents particular challenges. A choice must be made between the potential benefit of a rapid clinical evaluation and the potential exacerbation of intracranial hypertension in patients with impaired cerebral compliance. In the ICU, a pragmatic approach to the use of sedation/analgesia, including the optimal titration, management of multiple drugs, and use of any type of brain monitor, is needed. Our research question was as follows: the aim of the study is to identify what is the current daily practice regarding sedation/analgesia in the management of patients with BI in the ICU in France? This study was composed of two parts. The first part was a descriptive survey of sedation practices and characteristics in 30 French ICUs and 27 academic hospitals specializing in care for patients with BI. This first step validates ICU participation in data collection regarding sedation-analgesia practices. The second part was a 1-day prospective cross-sectional snapshot of all characteristics and prescriptions of patients with BI. On the study day, among the 246 patients with BI, 106 (43%) had a brain monitoring device and 74 patients (30%) were sedated. Thirty-nine of the sedated patients (53%) suffered from intracranial hypertension, 14 patients (19%) suffered from agitation and delirium, and 7 patients (9%) were sedated because of respiratory failure. Fourteen patients (19%) no longer had a formal indication for sedation. In 60% of the sedated patients, the sedatives were titrated by nurses based on sedation scales. The Richmond Agitation Sedation Scale was used in 80% of the patients, and the Behavioral Pain Scale was used in 92%. The common sedatives and opioids used were midazolam (58.1%), propofol (40.5%), and sufentanil (67.5%). The cerebral monitoring devices available in the participating ICUs were transcranial Doppler ultrasound (100%), intracranial and intraventricular pressure monitoring (93.3%), and brain tissue oxygenation (60%). Cerebral monitoring by one or more monitoring devices was performed in 62% of the sedated patients. This proportion increased to 74% in the subgroup of patients with intracranial hypertension, with multimodal cerebral monitoring in 43.6%. The doses of midazolam and sufentanil were lower in sedated patients managed based on a sedation/analgesia scale. Midazolam and sufentanil are frequently used, often in combination, in French ICUs instead of alternative drugs. In our study, cerebral monitoring was performed in more than 60% of the sedated patients, although that proportion is still insufficient. Future efforts should stress the use of multiple monitoring modes and adherence to the indications for sedation to improve care of patients with BI. Our study suggests that the use of sedation and analgesia scales by nurses involved in the management of patients with BI could decrease the dosages of midazolam and sufentanil administered. Updated guidelines are needed for the management of sedation/analgesia in patients with BI.

Comparison of half-molar sodium lactate and mannitol to treat brain edema in severe traumatic brain injury: A systematic review

PurposeHypertonic fluids such as mannitol and half-molar sodium lactate are given to treat intracranial hypertension in patients with severe traumatic brain injury (TBI). In this study, sodium lactate was compared to mannitol in patients with TBI to investigate the efficacy in reducing intracranial pressure (ICP). MethodsThis study was a systematic review with literature research on articles published in any year in the databases of PubMed, ScienceDirect, Asian Journal of Neurosurgery, and Cochrane Central Register of Controlled Trials. The keywords were “half-molar sodium lactate”, “mannitol”, “cerebral edema or brain swelling”, and “severe traumatic brain injury”. The inclusion criteria were (1) studies published in English, (2) randomized control trials or retrospective/prospective studies on TBI patients, and (3) therapies including half-molar sodium lactate and mannitol and (4) sufficient data such as mean difference (MD) and risk ratio (RR). Data analysis was conducted using Review Manager 5.3. ResultsFrom 1499 studies, a total of 8 studies were eligible. Mannitol group reduced ICP of 0.65 times (MD 0.65; p = 0.64) and improved cerebral perfusion pressure of 0.61 times (MD 0.61; p = 0.88), better than the half-molar group of sodium lactate. But the half-molar group of sodium lactate maintained the mean arterial pressure level of 0.86 times, better than the mannitol group (MD 0.86; p = 0.09). ConclusionHalf-molar sodium lactate is as effective as mannitol in reducing ICP in the early phase of brain injury, superior over mannitol in an extended period. It is able to prevent intracranial hypertension and give better brain tissue perfusion as well as more stable hemodynamics. Blood osmolarity is a concern as it increases serum sodium.

The patients\u2019 perspective on the burden of idiopathic intracranial hypertension

BackgroundIdiopathic intracranial hypertension (IIH) is characterized by increased intracranial pressure without evidence of a tumor or any other underlying cause. Headache and visual disturbances are frequent complaints of IIH patients, but little is known about other symptoms. In this study, we evaluated the patients’ perspective on the burden of IIH.MethodsFor this cross-sectional study, we developed an online survey for patients with IIH containing standardized evaluations of headache (HIT-6), sleep (PROMIS Sleep Disturbance Scale) and depression (MDI) in relation to BMI, lumbar puncture opening pressure (LP OP) and treatment.ResultsBetween December 2019 and February 2020, 306 patients completed the survey. 285 (93 %) were female, mean age was 36.6 years (± 10.8), mean BMI 34.2 (± 7.3) and mean LP OP at diagnosis was 37.8 cmH2O (± 9.5). 219 (72 %) of the participants were obese (BMI ≥ 30); 251 (82 %) reported severe impacting headaches, 140 (46 %) were suffering from sleep disturbances and 169 (56 %) from depression. Higher MDI scores correlated with higher BMI and increased sleep disturbances. Patients with a normalized LP opening pressure reported less headaches, less sleep disturbances and less depression than those with a constantly elevated opening pressure.ConclusionsIn addition to headaches and visual disturbances, sleep disturbances and depression are frequent symptoms in IIH and contribute to the patients’ burden. Structured questionnaires can help to identify IIH patients’ needs and can lead to personalized and better treatment.

Cognitive performance in idiopathic intracranial hypertension and relevance of intracranial pressure.

Cognitive impairments have been reported in idiopathic intracranial hypertension; however, evidence supporting these deficits is scarce and contributing factors have not been defined. Using a case-control prospective study, we identified multiple domains of deficiency in a cohort of 66 female adult idiopathic intracranial hypertension patients. We identified significantly impaired attention networks (executive function) and sustained attention compared to a body mass index and age matched control group of 25 healthy female participants. We aimed to investigate how cognitive function changed over time and demonstrated that deficits were not permanent. Participants exhibited improvement in several domains including executive function, sustained attention and verbal short-term memory over 12-month follow-up. Improved cognition over time was associated with reduction in intracranial pressure but not body weight. We then evaluated cognition before and after a lumbar puncture with acute reduction in intracranial pressure and noted significant improvement in sustained attention to response task performance. The impact of comorbidities (headache, depression, adiposity and obstructive sleep apnoea) was also explored. We observed that body mass index and the obesity associated cytokine interleukin-6 (serum and cerebrospinal fluid) were not associated with cognitive performance. Headache severity during cognitive testing, co-morbid depression and markers of obstructive sleep apnoea were adversely associated with cognitive performance. Dysregulation of the cortisol generating enzyme 11β hydroxysteroid dehydrogenase type 1 has been observed in idiopathic intracranial hypertension. Elevated cortisol has been associated with impaired cognition. Here, we utilized liquid chromatography-tandem mass spectrometry for multi-steroid profiling in serum and cerebrospinal fluid in idiopathic intracranial hypertension patients. We noted that reduction in the serum cortisol:cortisone ratio in those undergoing bariatric surgery at 12 months was associated with improving verbal working memory. The clinical relevance of cognitive deficits was noted in their significant association with impaired reliability to perform visual field tests, the cornerstone of monitoring vision in idiopathic intracranial hypertension. Our findings propose that cognitive impairment should be accepted as a clinical manifestation of idiopathic intracranial hypertension and impairs the ability to perform visual field testing reliably. Importantly, cognitive deficits can improve over time and with reduction of intracranial pressure. Treating comorbid depression, obstructive sleep apnoea and headache could improve cognitive performance in idiopathic intracranial hypertension.