Intracranial Hypertension In Patients Research Articles

Management of intracranial hypertension in patients with severe traumatic brain injury: Pay attention to the oxygen level

Management of intracranial hypertension in patients with severe traumatic brain injury: Pay attention to the oxygen level

Lumbar puncture rapidly improves olfaction in patients with idiopathic intracranial hypertension: A cohort study.

A lumbar puncture constitutes an important diagnostic procedure in the evaluation of idiopathic intracranial hypertension. Chronic overflow of cerebrospinal fluid into the sheaths of the olfactory nerves appears to be related to olfactory impairment in these patients. Here, we asked whether cerebrospinal fluid drainage in idiopathic intracranial hypertension patients improves olfactory function. Fourteen idiopathic intracranial hypertension patients and 14 neurologic control patients were investigated before and after lumbar puncture using the extended Sniffin' Sticks procedure. We assessed odor threshold, discrimination, and identification. In idiopathic intracranial hypertension patients, cerebrospinal fluid was drained until cerebrospinal fluid pressure had normalized. In addition, a third group of 14 healthy controls participated in the two smell tests at similar intervals. Relative to healthy controls, threshold, discrimination, and identification composite scores before lumbar puncture were significantly lower in idiopathic intracranial hypertension patients and also in neurologic controls. Following lumbar puncture, threshold, discrimination, and identification scores for neurologic controls remained unchanged whereas idiopathic intracranial hypertension patients showed robust improvement on the composite score as well as on all three subscores (all changes: p < 0.003), quickly regaining olfactory function in the normal range. Cerebrospinal fluid opening pressure was significantly correlated with improvement in threshold, discrimination, and identification score upon cerebrospinal fluid drainage (r = 0.609, p = 0.021). Olfactory impairment is an important, yet underappreciated, clinical feature of idiopathic intracranial hypertension. Lowering of increased intracranial pressure improves hyposmia. Our findings shed new light on the pathophysiology of cerebrospinal fluid circulation in idiopathic intracranial hypertension.

Cerebrospinal fluid dynamics modulation by diet and cytokines in rats

BackgroundIdiopathic intracranial hypertension (IIH) is a neurological disorder characterised by raised cerebrospinal fluid (CSF) pressure in the absence of any intracranial pathology. IIH mainly affects women with obesity between the ages of 15 and 45. Two possible mechanisms that could explain the increased CSF pressure in IIH are excessive CSF production by the choroid plexus (CP) epithelium or impaired CSF drainage from the brain. However, the molecular mechanisms controlling these mechanisms in IIH remain to be determined.MethodsIn vivo ventriculo-cisternal perfusion (VCP) and variable rate infusion (VRI) techniques were used to assess changes in rates of CSF secretion and resistance to CSF drainage in female and male Wistar rats fed either a control (C) or high-fat (HF) diet (under anaesthesia with 20 μl/100 g medetomidine, 50 μl/100 g ketamine i.p). In addition, CSF secretion and drainage were assessed in female rats following treatment with inflammatory mediators known to be elevated in the CSF of IIH patients: C–C motif chemokine ligand 2 (CCL2), interleukin (IL)-17 (IL-17), IL-6, IL-1β, tumour necrosis factor-α (TNF-α), as well as glucocorticoid hydrocortisone (HC).ResultsFemale rats fed the HF diet had greater CSF secretion compared to those on control diet (3.18 ± 0.12 μl/min HF, 1.49 ± 0.15 μl/min control). Increased CSF secretion was seen in both groups following HC treatment (by 132% in controls and 114% in HF) but only in control rats following TNF-α treatment (137% increase). The resistance to CSF drainage was not different between control and HF fed female rats (6.13 ± 0.44 mmH2O min/μl controls, and 7.09 ± 0.26 mmH2O min/μl HF). and when treated with CCL2, both groups displayed an increase in resistance to CSF drainage of 141% (controls) and 139% (HF) indicating lower levels of CSF drainage.ConclusionsWeight loss and therapies targeting HC, TNF-α and CCL2, whether separately or in combination, may be beneficial to modulate rates of CSF secretion and/or resistance to CSF drainage pathways, both factors likely contributing to the raised intracranial pressure (ICP) observed in female IIH patients with obesity.

Intracranial hypertension in patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis.

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating and life-threatening condition with high mortality and morbidity. Even though there is an association with intracranial pressure (ICP) raise and aSAH, there is a lack of recommendations regarding the indications for ICP monitoring in patients with aSAH. Defining what patients are at a higher risk to develop intracranial hypertension and its role in the functional outcome and mortality in patients with aSAH will be the purpose of the following systematic review and meta-analysis. The primary endpoint is to determine the prevalence and impact on mortality of ICP in patients with aSAH. Secondary endpoints aim to describe the variables related to the development of ICP and the relationship between traumatic and aneurysmal etiology of intracranial hypertension. PubMed, Embase, Central Cochrane Registry of Controlled Trials, and research meeting abstracts were searched up to August 2019 for studies that performed ICP monitoring, assessed the prevalence of intracranial hypertension and the mortality, in adults. Newcastle Ottawa scale (NOS) was used to assess study quality. The statistical analysis was performed using the Mantel-Haenszel methodology for the prevalence and mortality of intracranial hypertension for reasons with a randomized effect analysis model. Heterogeneity was assessed by I2. A total of 110 bibliographic citations were identified, 20 were considered potentially eligible, and after a review of the full text, 12 studies were considered eligible and 5 met the inclusion criteria for this review. One study obtained 7 points in the NOS, another obtained 6 points, and the rest obtained 5 points. Five studies were chosen for the final analysis, involving 793 patients. The rate of intracranial hypertension secondary to aSAH was 70.69% (95% CI 56.79-82.84%) showing high heterogeneity (I2 = 92.48%, p = < 0.0001). The results of the meta-analysis of mortality rate associated with intracranial hypertension after aSAH found a total of four studies, which involved 385 patients. The mortality rate was 30.3% (95% CI: 14.79-48.57%). Heterogeneity was statistically significant (I2 = 90.36%; p value for heterogeneity < 0.001). We found that in several studies, they reported that a high degree of clinical severity scale (Hunt and Hess or WNFS) and tomographic (Fisher) were significantly correlated with the increase in ICP above 20mmHg (P < 0.05). The interpretation of the results could be underestimated for the design heterogeneity of the included studies. New protocols establishing the indications for ICP monitoring in aSAH are needed. Given the high heterogeneity of the studies included, we cannot provide clinical recommendations regarding this issue.

Neuroimaging findings in patients with idiopathic intracranial hypertension and cerebral venous thrombosis, and their association with clinical features

ABSTRACTObjective: To investigate the frequency of neuroimaging findings of intracranial hypertension in patients with idiopathic intracranial hypertension (IIH) and cerebral venous thrombosis (CVT). We also aimed to compare these findings in two patient groups and investigate the association of these findings with some clinical parameters.Methods: Patients with IIH and CVT admitted to the neurology, neuro-ophthalmology outpatient clinics, and emergency services between 2017 and 2019 were enrolled in this study. The presence of eight previously defined neuroimaging signs of intracranial hypertension were evaluated on MRIs. The values of total MRI scores were formed to use in the analyses investigating the association between neuroimaging findings and clinical parameters.Results: Twenty-three patients with proven IIH and seven patients with CVT with signs of intracranial hypertension were included in this study. Body mass index (BMI) values were higher in the IIH group than in the CVT group (31.0/25.9; p = 0.022). There were no differences in terms of gender distribution, age, ortotal MRI scores between the patient groups. The most common neuroimaging parameters found in the IIH group were the following: increased peri-optic cerebrospinal fluid (CSF) (n = 20) and optic nerve tortuosity (n = 12). There were no significant correlations between values of total MRI scores, lumbar puncture opening pressure, and BMI.Conclusion: Neuroimaging findings are useful tools with high diagnostic sensitivity in IIH. The most sensitive finding was increased peri-optic CSF. The utility of these neuroimaging correlates and their potential significance as solely diagnostic markers in IIH should be investigated in future large-scale studies.

EVENTS ASSOCIATED WITH THE OCCURRENCE OF INTRACRANIAL HYPERTENSION IN PEDIATRIC PATIENTS WITH SEVERE CRANIOENCEPHALIC TRAUMA AND MONITORING OF INTRACRANIAL PRESSURE.

ABSTRACTObjective:To determine the events associated with the occurrence of intracranial hypertension (ICH) in pediatric patients with severe cranioencephalic trauma.Methods:This was a prospective cohort study of patients 18 years old and younger with cranioencephalic trauma, scores below nine on the Glasgow Coma Scale, and intracranial pressure monitoring. They were admitted between September, 2005 and March, 2014 into a Pediatric Intensive Care Unit. ICH was defined as an episode of intracranial pressure above 20 mmHg for more than five minutes that needed treatment.Results:A total of 198 children and adolescents were included in the study, of which 70.2% were males and there was a median age of nine years old. ICH occurred in 135 (68.2%) patients and maximum intracranial pressure was 36.3 mmHg, with a median of 34 mmHg. A total of 133 (97.8%) patients with ICH received sedation and analgesia for treatment of the condition, 108 (79.4%) received neuromuscular blockers, 7 (5.2%) had cerebrospinal fluid drainage, 105 (77.2%) received mannitol, 96 (70.6%) received hyperventilation, 64 (47.1%) received 3% saline solution, 20 (14.7%) received barbiturates, and 43 (31.9%) underwent a decompressive craniectomy. The events associated with the occurrence of ICH were tomographic findings at the time of admission of diffuse or hemispheric swelling (edema plus engorgement). The odds ratio for ICH in patients with Marshall III (diffuse swelling) tomography was 14 (95%CI 2.8–113; p<0.003), and for those with Marshall IV (hemispherical swelling) was 24.9 (95%CI 2.4–676, p<0.018). Mortality was 22.2%.Conclusions:Pediatric patients with severe cranioencephalic trauma and tomographic alterations of Marshall III and IV presented a high chance of developing ICH.

Relationship of Optic Nerve Sheath Diameter and Intracranial Hypertension in Patients with Traumatic Brain Injury.

Background:to study the association between optic nerve sheath diameter (ONSD) and intracranial pressure (ICP) in patients with moderate-to-severe brain injury.Patients and Methods:A retrospective cohort study of traumatic brain injury (TBI) patients was conducted between 2010 and 2014. Data were analyzed and compared according to the ICP monitoring cutoff values. Outcomes included intracranial hypertension (ICH) and mortality.Results:A total of 167 patients with a mean age of 33 ± 14 years, of them 96 had ICP monitored. ICP values correlated with ONSD measurement (r = 0.21, P = 0.04). Patients who developed ICH were more likely to have higher mean ONSD (P = 0.01) and subarachnoid hemorrhage (SAH) (P = 0.004). Receiver operating curve for ONSD showed a cutoff value of 5.6 mm to detect ICH with sensitivity 72.2% and specificity 50%. Age and ICP were independent predictors of inhospital mortality in multivariate model. Another model with same covariates showed ONSD and SAH to be independent predictors of ICH. Simple linear regression showed a significant association of ONSD with increased ICP (β = 0.21, 95% confidence interval 0.25–5.08, P = 0.03).Conclusions:ONSD is a simple noninvasive measurement on initial CT in patients with TBI that could be a surrogate for ICP monitoring. However, further studies are warranted.

Western Trauma Association critical decisions in trauma: Management of intracranial hypertension in patients with severe traumatic brain injuries.

Western Trauma Association critical decisions in trauma: Management of intracranial hypertension in patients with severe traumatic brain injuries.

Oligoclonal bands and levels of interleukin 4, interleukin 10, and tumor necrosis factor alpha in idiopathic intracranial hypertension Egyptian patients

BackgroundIdiopathic intracranial hypertension (IIH) is a neurological disorder of unknown pathophysiology with many proposed theories that involve CSF dynamics but recently, involvement of inflammatory and autoimmune processes has been postulated.ObjectivesTo investigate presence of oligoclonal bands (OCB) in cerebrospinal fluid (CSF) and serum cytokine level in patients with IIH.MethodsThis study was conducted on 27 IIH female patients and 21 age- and sex-matched control groups. Patient and control groups were subjected to measurement of interleukin-4 (IL-4), IL-10, and tumor necrosis factor α (TNF-α) levels in serum, and CSF oligoclonal bands was measured in the IIH patient group. Body mass index (BMI) was measured to both patients and control.ResultsSerum levels of IL-4, IL-10, and TNF alpha were significantly higher in IIH patients than controls (p < 0.001); 22% of IIH patients had positive OCB in CSF. There was a statistically significant difference regarding TNF-α level in OCB-positive and OCB-negative patients being higher in positive patients. No statistically significant correlation was found between serum levels of IL-4, IL-10, TNF-α, and BMI.ConclusionAutoimmune inflammatory process may play a role in pathophysiology of IIH.

Men Are from Mars, Idiopathic Intracranial Hypertension Is from Venous: The Role of Venous Sinus Stenosis and Stenting in Idiopathic Intracranial Hypertension.

Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, is a disease primarily affecting obese women of child-bearing age, typically presenting with positional headaches, diplopia from abducens nerve palsies, pulse-synchronous tinnitus, and visual disturbances related to papilledema, including transient visual obscurations, blurry vision, and visual field defects. Controversy remains regarding the pathophysiology of IIH. Elevated intracranial pressure in IIH is thought to be the result of a dysregulation of cerebrospinal fluid (CSF) dynamics, through excessive secretion, reduced drainage, or both. Passive CSF drainage through the arachnoid granulations depends on a pressure gradient between the subarachnoid space and the cerebral venous system, such that elevations in cerebral venous pressure lead to impaired CSF drainage. Dural venous sinus stenosis (DVSS) at the junction of the transverse and sigmoid sinuses, leading to local venous hypertension and a secondary reduction in CSF drainage through the arachnoid granulations, is increasingly recognized as an important component of the pathophysiology of IIH. A growing number of studies have demonstrated a role for stenting of DVSS as an alternative to CSF shunting and optic nerve sheath fenestration in medically refractory IIH patients with vision loss or debilitating symptoms.

Cerebrospinal fluid opening pressure: The effect of body mass index and body composition

ObjectivesIdiopathic intracranial hypertension (IIH) is strongly related to obesity. The relationship between intracranial pressure, body mass index (BMI), percentage body fat and distribution of body fat in non-IIH patients remains less clear. The aim of this study was to examine the relationship between intracranial pressure and body type in non-IIH patients. Patients and MethodsLumbar puncture manometry was used to measure cerebrospinal fluid opening pressure (CSFOP). BMI, in addition to neck, waist and hip circumferences were calculated. Air displacement plethysmography (BODPOD) was used to assess body composition. ResultsData was collected from 100 subjects. 11 subjects with conditions known to cause raised intracranial pressure were excluded from analysis. According to Pearson correlation factors displaying a significant relationship with CSFOP included: BMI (R = 0.635, p < 0.0001); waist circumference (R = 0.498, p < 0.0001), hip circumference (R = 0.513, p < 0.0001) and percentage body fat (R = 0.435, p < 0.001). Multivariate analysis indicated that BMI was the only independent factor which predicted CSFOP. Sub-analysis according to gender indicated that BMI was predictive in females and percentage body fat was predictive in males. We did not identify any differences in BMI, percentage body fat or distribution of body fat in 7 IIH patients and 7 wt-matched non-IIH patients. ConclusionBMI and percentage body fat both positively correlated with CSFOP, but BMI was more predictive in women and percentage body fat was more predictive in men. We did not find a relationship between distribution of body fat and CSFOP.

Non-invasive prediction of intracranial hypertension in patients with craniosynostosis using computed tomography

ObjectiveThis study aimed to verify that children with craniosynostosis could be diagnosed with intracranial hypertension prior to surgery. We planned to use a computed tomography (CT)-based technique that can predict preoperatively the presence of intracranial hypertension. MethodsThe study group included consecutive children with craniosynostosis, with 27 patients who were to undergo surgery between 2008 and 2018. The control group included 90 children who underwent CT for a minor reason. The craniosynostosis children underwent CT prior to surgery. The inner and outer cranial circumferences and area were automatically measured from scan data. The circularity (which determines skull inner shape and area) and the C-ratio (the ratio of the inner/outer circumferences) were calculated. ResultsBoth the circularity and the C-ratio in the craniosynostosis group were low significantly, indicating more complex skull inner surface than the controls and thus more severe digital impression. When analyzed for age group, the both values were significantly lower in the <3 group than in the controls. The circularity and C-ratio indicated more severe digital impression and thus possible intracranial hypertension. ConclusionOur novel evaluation for intracranial hypertension in craniosynostosis is less invasive procedure than conventional method and useful for screening or regular follow-up.

Optic Nerve Sheath Diameter with Intracranial Hypertension in Patients with Traumatic Head Injury

Journal of the American College of Surgeons 229(4):p S191, October 2019. | DOI: 10.1016/j.jamcollsurg.2019.08.421

支架置入与球囊扩张治疗特发性颅内高压伴静脉窦狭窄的疗效比较 Stenting Versus Balloon Angioplasty in Idiopathic Intracranial Hypertension Patients with Venous Sinus Stenosis

支架置入与球囊扩张治疗特发性颅内高压伴静脉窦狭窄的疗效比较 Stenting Versus Balloon Angioplasty in Idiopathic Intracranial Hypertension Patients with Venous Sinus Stenosis

Early Osmotherapy in Severe Traumatic Brain Injury: An International Multicenter Study.

The optimal osmotic agent to treat intracranial hypertension in patients with severe traumatic brain injury (TBI) remains uncertain. We aimed to test whether the choice of mannitol or hypertonic saline (HTS) as early (first 96 h) osmotherapy in these patients might be associated with a difference in mortality. We retrospectively analyzed data from 2015 from 14 tertiary intensive care units (ICUs) in Australia, UK, and Europe treating severe TBI patients with intracranial pressure (ICP) monitoring and compared mortality in those who received mannitol only versus HTS only. We performed multi-variable analysis adjusting for site and illness severity (Injury Severity Score, extended IMPACT score, and mean ICP over the first 96 h) using Cox proportional hazards regression. We collected data on 262 patients and compared patients who received early osmotherapy with mannitol alone (n = 46) with those who received HTS alone (n = 46). Mannitol patients were older (median age, 49.2 (19.2) vs. 40.5 (16.8) years; p = 0.02), with higher Injury Severity Scores (42 (15.9) vs. 32.1 [11.3]; p = 0.001), and IMPACT-TBI predicted 6-month mortality (34.5% [23-46] vs. 25% [13-38]; p = 0.02), but had similar APACHE-II scores, and mean and maximum ICPs over the first 96 h. The unadjusted hazard ratio for in-hospital mortality in patients receiving only mannitol was 3.35 (95% confidence interval [CI], 1.60-7.03; p = 0.001). After adjustment for key mortality predictors, the hazard ratio for in-hospital mortality in patients receiving only mannitol was 2.64 (95% CI, 0.96-7.30; p = 0.06). The choice of early osmotherapy in severe TBI patients may affect survival, or simply reflect clinician beliefs about their different roles, and warrants controlled investigation.

Quantitative d-dimer level and anticoagulant therapy in idiopathic intracranial hypertension

BackgroundIdiopathic intracranial hypertension (IIH) is a syndrome characterized by elevated intracranial pressure (ICP) of unknown etiologyAim of the workThe aim of this research is to study the quantitative d-dimer level and the role of anticoagulant therapy in absence of occlusive sinus thrombosis in patients with IIH.MethodologyTwenty-four patients with IIH according to the modified Dandy criteria were enrolled. Headache impact test (HIT6), ophthalmological assessment including Frisen classification for papilledema, visual acuity, visual field, and visual evoked potentials were performed to the patients. Serum quantitative d-dimer level was measured using the enzyme-linked immunosorbent assay (ELISA) technique for the patients and for 24 healthy matched controls. Patients were divided into two groups: group (1) received acetazolamide and low molecular weight heparin (LMWH) in a prophylactic dose for 2 weeks while group (2) received acetazolamide only. Both groups continued on acetazolamide for 6 months. We followed the patients after 1 and 6 months later through the HIT6 test and the ophthalmological assessment.Resultsd-dimer level was statistically higher among the cases compared to the controls. Also, a statistically significant improvement was recorded in the ophthalmological assessment after 6 months among both groups; more evident in group (1).ConclusionThe elevated d-dimer level and the visual improvement in IIH patients receiving LMWH added to acetazolamide suggest the presence of an underlying unrecognized non-occlusive venous cerebral microthrombi impeding the cerebrospinal fluid (CSF) drainage.Trial registrationClinicalTrials,gov on 22/5/2019, NCT03963336.

Clinical analysis of 36 cases of idiopathic intracranial hypertension complicated with iron deficiency anemia

Objective: To investigate the clinical features, imaging findings and prognosis of idiopathic intracranial hypertension (IIH) patients complicated with iron deficiency anemia (IDA). Methods: A total of 307 cases of IIH patients hospitalized in Beijing Tongren Hospital were retrospectively screened between January 1, 2011 and February 28, 2018. There were 49 anemia cases (15.96%) and 45 IDA cases (14.66%), respectively. Finally, 36 IDA patients were enrolled. The clinical characteristics, imaging findings, treatment and prognosis of these patients were analyzed. Results: IIH combined with IDA was more common in women of childbearing age (34/36). There were 30 obese and overweight cases (83.33%), with multiple subacute or chronic course of disease. The visual symptoms in the early IIH patients were first diagnosed in the Department of Ophthalmology. The first symptom was headache with/without visual symptoms (27 cases (75%)). Head MRI detected empty sella or partial empty sella, and 2 cases of venous sinus thrombosis were found in DSA examination. Of the 34 female patients, 24 had simple menometrorrhagia or menstrual disorder. All patients were given methyl acetate to reduce the intracranial pressure and iron therapy. Five patients received low molecular weight heparin-warfarin sequential treatment, 5 cases underwent gynecologic surgery and 2 male cases received hemorrhoid operation. There were 7 cases underwent lumbar cisterna-peritoneal shunt for visual impairment. During the follow-up, intracranial pressure decreased and visual function of patients improved significantly. Conclusions: IIH is frequently found in obese or overweight women at childbearing age and IDA may be an important cause of IIH. IIH can cause serious irreversible visual impairment. Therefore, early identification and active treatment should be performed. Correction of anemia can significantly improve the clinical symptoms of IIH. Operation should be employed for IIH patients with poor visual function or rapid progress, in order to reduce intracranial pressure and improve prognosis as soon as possible.

Magnetic Resonance Imaging of Idiopathic Intracranial Hypertension: Before and After Treatment.

This study aimed to identify the reversibility of MRI findings indicative of increased intracranial hypertension in idiopathic intracranial hypertension (IIH) patients after treatment. This retrospective, observational study included demographic and clinical data from 10 patients with IIH and 10 controls. Brain MRI findings in IIH patients were recorded twice: once when patients had papilledema and again after resolution of papilledema. Neuroradiologists graded MRI findings in both groups based on an imaging grading scale. After resolution of papilledema, all patients showed improvement in 2 or more of the MRI characteristics of IIH. This was especially the case for the height of the midsagittal pituitary gland and optic nerve sheath thickness (ONST), which were significantly different in all pairwise group comparisons. Sellar configuration, globe configuration, and horizontal orbital optic nerve tortuosity were different between the IIH pre-treatment group and controls, but not between controls and the IIH post-treatment group. We found no difference in optic nerve head hyperintensity or optic nerve thickness among the 3 groups. We demonstrated that several morphometric MRI characteristics in IIH are reversible to a certain extent after treatment. Enlarged subarachnoid spaces filled with cerebrospinal fluid seem to remain reduced, and the ONST and height of the pituitary gland are not fully normalized after treatment.

Longitudinal analysis of optic nerve edema, retinal nerve fiber layer thickness, and visual field mean deviation in pediatric patients with intracranial hypertension

Optic nerve edema (ONE), retinal nerve fiber layer (RNFL) thickening, and increased visual field mean deviation (VFMD) comprise several of the significant ophthalmic findings in intracranial hypertension (IH) patients. RNFL thickness is strongly correlated with ONE at baseline, and improves with medical management in adults. Similarly, VFMD shows improvement with appropriate therapy. As monitoring response to therapy can be challenging in some children, this study aims to describe the longitudinal differences in these parameters in pediatric patients.

The relationship between optic canal size and severity of papilledema in children with intracranial hypertension

Bony optic canal size has been proposed to affect the dynamics of cerebrospinal fluid pressure from the cranium to the subarachnoid space within the optic nerve sheath. This may contribute to variations in clinically observed optic nerve edema (ONE) in patients with intracranial hypertension (IH). The purpose of this study was to determine if a relationship exists between optic canal size and the grade of clinically observed ONE in pediatric IH patients.