Control Of Intracranial Pressure Research Articles

A Patient With Cryptococcal Meningitis Accompanied With Acute Intracranial Hypertension Treated by Ventricular Abdominal-wall Drainage.

Intracranial hypertension is considered a common and severe complication of cryptococcal meningitis (CM), contributing to early mortality and neurological sequelae. Timely and effective control of elevated intracranial pressure is crucial for the management of CM. Herein, the authors present a case of ventricular abdominal wall drainage for CM accompanied with acute intracranial hypertension. Notably, the patient has a history of taking immunosuppressants for thoracic and abdominal diffuse lymphangiomatosis. After continuous drainage of cerebrospinal fluid combined with standardized antifungal treatment, the patient recovered well.

Safety and effectiveness of dual channels vancomycin administration in the treatment of intracranial infection after severe brain injury surgery.

To observe the clinical efficacy and safety of vancomycin intravenous drip combined with vancomycin intrathecal injection in the treatment of intracranial infection after severe brain injury surgery. From January 2020 to June 2022, 80 patients with intracranial infection after severe brain injury surgery were selected and randomly divided into 2 subgroups; there were 40 patients in each subgroup. All patients were treated with vancomycin. The control subgroup was medicated with intravenous drip, and the observation subgroup was treated through 2 channels (intravenous drip + intrathecal injection), with a course of 7 days. The clinical efficacy, intracranial pressure, infection control time, routine indexes of cerebrospinal fluid (white blood cell count [WBC], glucose content [Glu], and total protein content [Pro]) and the incidence of adverse reactions were contrasted between the 2 subgroups. Versus the control subgroup, the total effective rate in the observation subgroup was notably higher (95.00% vs 77.50%). After treatment, aiming at the intracranial pressure and infection control time, versus the control subgroup (146.20 ± 22.37) mmH2O and (9.86 ± 1.62) days, the observation subgroup were (125.43 ± 18.5) mmH2O and (7.35 ± 1.57) days respectively, which were notably lower. After treatment, versus the control subgroup, the concentrations of WBC and Pro in cerebrospinal fluid in the observation subgroup were lower, and the content of Glu was higher. There was no statistical distinction in the incidence of adverse reactions between the 2 subgroups (17.50% vs 10.00%). Two-channel administration of vancomycin can improve the clinical efficacy of internal infection after severe craniocerebral injury, reduce intracranial pressure, and cerebrospinal fluid WBC and Pro levels, and has high safety.

Clinical Impact of Standardized Interpretation and Reporting of Multimodality Neuromonitoring Data.

Evaluate the consistency and clinical impact of standardized multimodality neuromonitoring (MNM) interpretation and reporting within a system of care for patients with severe traumatic brain injury (sTBI). Retrospective, observational historical case-control study. Single-center academic level I trauma center. Standardized interpretation of MNM data summarized within daily reports. Consecutive patients with sTBI undergoing MNM were included. Historical controls were patients monitored before implementation of standardized MNM interpretation; cases were defined as patients with available MNM interpretative reports. Patient characteristics, physiologic data, and clinical outcomes were recorded, and clinical MNM reporting elements were abstracted. The primary outcome was the Glasgow Outcome Scale score 3-6 months postinjury. One hundred twenty-nine patients were included (age 42 ± 18 yr, 82% men); 45 (35%) patients were monitored before standardized MNM interpretation and reporting, and 84 (65%) patients were monitored after that. Patients undergoing standardized interpretative reporting received fewer hyperosmotic agents (3 [1-6] vs. 6 [1-8]; p = 0.04) and spent less time above an intracranial threshold of 22 mm Hg (22% ± 26% vs. 28% ± 24%; p = 0.05). The MNM interpretation cohort had a lower proportion of anesthetic days (48% [24-70%] vs. 67% [33-91%]; p = 0.02) and higher average end-tidal carbon dioxide during monitoring (34 ± 6 mm Hg vs. 32 ± 6 mm Hg; p < 0.01; d = 0.36). After controlling for injury severity, patients undergoing standardized MNM interpretation and reporting had an odds of 1.5 (95% CI, 1.37-1.59) for better outcomes. Standardized interpretation and reporting of MNM data are a novel approach to provide clinical insight and to guide individualized critical care. In patients with sTBI, independent MNM interpretation and communication to bedside clinical care teams may result in improved intracranial pressure control, fewer medical interventions, and changes in ventilatory management. In this study, the implementation of a system for management, including standardized MNM interpretation, was associated with a significant improvement in outcome.

Hinge Craniotomy for Traumatic Brain Injury: Surgical Technique

AbstractHinge craniotomy has been described as an alternative to decompressive craniectomy for the control of intracranial pressure in traumatic brain injury and stroke. In this study, the authors highlight critical steps in performing a hinge craniotomy and present a clinical case of a patient with traumatic brain injury.

Cerebral Lactate Uptake After Half-Molar Sodium Lactate Therapy in Traumatic Brain Injury: A Brief Report.

Exogenous sodium lactate has many advantages after traumatic brain injury, including intracranial pressure control and alternative energetic supply. It remains unclear, however, whether half-molar sodium lactate (HSL) is effectively incorporated in brain metabolism, which we can verify using the arteriovenous difference in lactate (AVDlac). Hence we compared the AVDlac in patients with severe traumatic brain injury receiving an equiosmolar bolus of sodium lactate or mannitol for intracranial hypertension (IH) treatment. We included 23 patients: 14 received HSL for 25 IH episodes, and nine received mannitol for 19 episodes (total of 44 IH episodes). We observed that the median variation in AVDlac was positive in the group that received HSL (Δ +0.1 [IQR -0.08-0.2] mmol/L), which suggests a net lactate uptake by the brain. On the other hand, it was negative in the group that received mannitol (Δ -0.0 [IQR -0.1 to 0.0] mmol/L), indicating a net lactate export. Finally, there were more positive AVDlac values in the group that received HSL and more negative AVDlac values in the group that received mannitol (Fisher exact p = 0.04). Our study reports the first evidence of a positive AVDlac, which corresponds to a net lactate uptake by the brain, in patients who received HSL for severe TBI. Our results constitute a bedside confirmation of the integration of lactate into the brain metabolism and pave the way for a wider dissemination of sodium lactate in the daily clinical care of patients with traumatic brain injury.

Evaluating the Status of the Injured Brain: Cerebrovascular Reserve (CVR) Is Not Equivalent to Induced Cerebrovascular Reactivity (iCVRx) and Induced Pressure Reactivity (iPRx) in Defining the Critical Cerebral Perfusion Pressure (CPP).

Methods evaluating the status of the injured brain have evolved over the past 63years since Lundberg first reported clinical measurement of intracranial pressure (ICP) to evaluate the status of the injured brain (Lundberg, Acta Psychiatr Scand Suppl. 36:1-193, 1960). Subsequent evaluation involved measurement of the autoregulatory capacity of the brain by measuring cerebral blood flow (CBF) with decreasing mean arterial pressure (MAP) to define the critical CPP where the vasodilatory capacity of the cerebral circulation is exceeded and CBF begins to fall (CPP of 50mmHg). A seminal advance was made by Marmarou (Marmarou et al., J Neurosurg. 48:332-344, 1978) who measured brain compliance by injecting a bolus of saline into the intracranial catheter while measuring the rise in intracranial pressure (ICP) otherwise known as induced pressure reactivity (iPRx). Seeking to utilise continuous measurement of iPRx in traumatic brain injury (TBI) patients with continuous monitoring of ICP, the ICP response to arterial pulsations was developed to evaluate the optimal CPP patients with raised ICP by the arterial pulsations-based iPRx. A similar approach was made with Doppler measurement of CBF with arterial pulsations for iCVRx to guide optimal CPP (CPPopt). Both iPRx and iCVRx are associated with microvascular shunts (MVS) and can accurately measure the critical CPP, whereas the CBF autoregulation curve by decreasing MAP does not. Sophisticated continuous multimodal monitoring established with ICM+ algorithms successfully identifies CPPopt for ICP control and identifies CBF dysregulation as related to outcome, but does not provide insights into the mechanisms involved in the loss of CBF autoregulation as related to increased ICP and potentially effective treatments (Froese et al., Neurocrit Care. 34:325-335, 2021).

Salt versus sugar: a systematic review assessing 3% hypertonic saline versus 20% mannitol for intracranial pressure control in severe paediatric traumatic brain injury

Salt versus sugar: a systematic review assessing 3% hypertonic saline versus 20% mannitol for intracranial pressure control in severe paediatric traumatic brain injury

Impact of ventriculo-cisternal irrigation on prevention of delayed cerebral infarction in aneurysmal subarachnoid hemorrhage: a single-center retrospective study and literature review

ObjectiveThe aim of this study was to evaluate the effectiveness of ventriculo-cisternal irrigation (VCI) in preventing vasospasms and delayed cerebral infarction (DCI) by washing out subarachnoid clots earlier after aneurysm surgery.MethodsWe retrospectively identified 340 subarachnoid hemorrhage (SAH) patients with ruptured intracranial aneurysms treated with postoperative VCI at our institution between December 2010 and January 2020. As VCI therapy, a ventricular drain/cisternal drain was placed during aneurysm surgery, and lactated Ringer’s solution was used for irrigation until day 4 of SAH, followed by intracranial pressure control at 5–10 cmH2O until day 14.ResultsThe median age was 65 years (interquartile range 52–75), with 236 female patients (69%). The World Federation of Neurosurgical Societies grade distribution was as follows: grade I or II, 175 patients (51%); grade III or IV, 84 (25%); and grade V, 81 (24%). With VCI management in all patients, total vasospasm occurred in 162 patients (48%), although the DCI incidence was low (23 patients [6.8%]). Major drainage-related complications were observed in five patients (1.5%). Early surgery, performed on SAH day 0 or 1, was identified as a preventive factor against DCI occurrence (odds ratio (OR) 0.21, 95% confidence interval (CI) 0.07–0.67; P = 0.008), while additional surgery (4.76, 1.62–13.98; P = 0.005) and dyslipidemia (3.27, 1.24–8.63; P = 0.017) were associated with DCI occurrence.ConclusionManaging vasospasms with VCI after SAH is considered a safe and effective method to prevent DCI. Early surgery after SAH may be associated with a decreased risk of DCI with VCI therapy.

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

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

Therapy Intensity Level Scale for Traumatic Brain Injury: Clinimetric Assessment on Neuro-Monitored Patients Across 52 European Intensive Care Units.

Intracranial pressure (ICP) data from traumatic brain injury (TBI) patients in the intensive care unit (ICU) cannot be interpreted appropriately without accounting for the effect of administered therapy intensity level (TIL) on ICP. A 15-point scale was originally proposed in 1987 to quantify the hourly intensity of ICP-targeted treatment. This scale was subsequently modified-through expert consensus-during the development of TBI Common Data Elements to address statistical limitations and improve usability. The latest 38-point scale (hereafter referred to as TIL) permits integrated scoring for a 24-h period and has a five-category, condensed version (TIL(Basic)) based on qualitative assessment. Here, we perform a total- and component-score analysis of TIL and TIL(Basic) to: 1) validate the scales across the wide variation in contemporary ICP management; 2) compare their performance against that of predecessors; and 3) derive guidelines for proper scale use. From the observational Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study, we extract clinical data from a prospective cohort of ICP-monitored TBI patients (n = 873) from 52 ICUs across 19 countries. We calculate daily TIL and TIL(Basic) scores (TIL24 and TIL(Basic)24, respectively) from each patient's first week of ICU stay. We also calculate summary TIL and TIL(Basic) scores by taking the first-week maximum (TILmax and TIL(Basic)max) and first-week median (TILmedian and TIL(Basic)median) of TIL24 and TIL(Basic)24 scores for each patient. We find that, across all measures of construct and criterion validity, the latest TIL scale performs significantly greater than or similarly to all alternative scales (including TIL(Basic)) and integrates the widest range of modern ICP treatments. TILmedian outperforms both TILmax and summarized ICP values in detecting refractory intracranial hypertension (RICH) during ICU stay. The RICH detection thresholds which maximize the sum of sensitivity and specificity are TILmedian ≥ 7.5 and TILmax ≥ 14. The TIL24 threshold which maximizes the sum of sensitivity and specificity in the detection of surgical ICP control is TIL24 ≥ 9. The median scores of each TIL component therapy over increasing TIL24 reflect a credible staircase approach to treatment intensity escalation, from head positioning to surgical ICP control, as well as considerable variability in the use of cerebrospinal fluid drainage and decompressive craniectomy. Since TIL(Basic)max suffers from a strong statistical ceiling effect and only covers 17% (95% confidence interval [CI]: 16-18%) of the information in TILmax, TIL(Basic) should not be used instead of TIL for rating maximum treatment intensity. TIL(Basic)24 and TIL(Basic)median can be suitable replacements for TIL24 and TILmedian, respectively (with up to 33% [95% CI: 31-35%] information coverage) when full TIL assessment is infeasible. Accordingly, we derive numerical ranges for categorising TIL24 scores into TIL(Basic)24 scores. In conclusion, our results validate TIL across a spectrum of ICP management and monitoring approaches. TIL is a more sensitive surrogate for pathophysiology than ICP and thus can be considered an intermediate outcome after TBI.

Anesthetic Management of Intraoperative Aneurysm Rupture: A Narrative Review

Intraoperative aneurysm rupture (IOAR) is a serious and potentially life-threatening complication that can occur during intracranial aneurysm surgery. Understanding the perioperative risk factor contributing to IOAR may help prevention and better handle if it occurs. The anesthesiologist should be familiar with the management of IOAR to facilitate bleeding control and improve perioperative outcome. There is controversy surrounding the management of IOAR. The main goal of management includes promptly securing for control of bleeding as well as maintaining adequate cerebral perfusion and providing neuroprotection. The purpose of the present article was to review the anesthetic management during IOAR. The authors focused on the hemodynamic and intracranial pressure control for optimizing cerebral perfusion, neuroprotection during temporary arterial occlusion, monitoring of cerebral ischemia, and recent techniques for controlling bleeding. Keywords: Intraoperative aneurysm rupture; Anesthetic management; Intracranial aneurysm; Surgical clipping

Impact of early external ventricular drainage on functional outcome after traumatic brain injury: a bicentric retrospective cohort analysis

PurposeSeveral studies have confirmed that external ventricular drain decreases intracranial pressure (ICP) after traumatic brain injury (TBI). Considering its impact on ICP control and cerebral waste metabolites clearance, timing of external ventricular drain (EVD) insertion could improve CSF drainage efficiency. The aim of the study was to evaluate the impact of early EVD versus a later one on the 3-month outcome. MethodsFor this retrospective cohort study conducted in two regional trauma-center (Caen CHU Côte de Nacre and Beaujon Hospital) between May 2011 and March 2019, all patients with intracranial hypertension following TBI and treated with EVD were included. We defined the early EVD by drainage within the 24 h of the hospital admission and the late EVD insertion by drainage beyond 24 h. A poor outcome was defined as a Glasgow Outcome Scale of one or two at 3 months. ResultsAmong the cohort of 671 patients, we analyzed 127 patients. Sixty-one (48.0%) patients had an early insertion of EVD. In the early EVD group, the mean time to insertion was 10 h versus 55 h in the late EVD group. Among the analyzed patients, 69 (54.3%) had a poor outcome including 39 (63.9%) in the early group and 30 (45.5%) in the later one. After adjustment on prognostic factors, early EVD insertion was not associated with a decrease in a poor outcome at 3-months (OR = 1.80 [0.73–4.53]). ConclusionEarly insertion of EVD (<24 h) for intracranial hypertension after TBI was not associated with improved outcome at 3 months.

Pediatric Moderate and Severe Traumatic Brain Injury: A Systematic Review of Clinical Practice Guideline Recommendations.

Traumatic brain injury (TBI) is the leading cause of death and disability in children. Many clinical practice guidelines (CPGs) have addressed pediatric TBI in the last decade but significant variability in the use of these guidelines persists. Here, we systematically review CPGs recommendations for pediatric moderate-to-severe TBI, evaluate the quality of CPGs, synthesize the quality of evidence and strength of included recommendations, and identify knowledge gaps. A systematic search was conducted in MEDLINE®, Embase, Cochrane CENTRAL, Web of Science, and Web sites of organizations publishing recommendations on pediatric injury care. We included CPGs developed in high-income countries from January 2012 to May 2023, with at least one recommendation targeting pediatric (≤ 19 years old) moderate-to-severe TBI populations. The quality of included clinical practice guidelines was assessed using the AGREE II tool. We synthesized evidence on recommendations using a matrix based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. We identified 15 CPGs of which 9 were rated moderate to high quality using AGREE II. We identified 90 recommendations, of which 40 (45%) were evidence based. Eleven of these were based on moderate to high quality evidence and were graded as moderate or strong by at least one guideline. These included transfer, imaging, intracranial pressure control, and discharge advice. We identified gaps in evidence-based recommendations for red blood cell transfusion, plasma and platelet transfusion, thromboprophylaxis, surgical antimicrobial prophylaxis, early diagnosis of hypopituitarism, and mental health mangement. Many up-to-date CPGs are available, but there is a paucity of evidence to support recommendations, highlighting the urgent need for robust clinical research in this vulnerable population. Our results may be used by clinicians to identify recommendations based on the highest level of evidence, by healthcare administrators to inform guideline implementation in clinical settings, by researchers to identify areas where robust evidence is needed, and by guideline writing groups to inform the updating of existing guidelines or the development of new ones.

Intracranial Pressure Monitoring and Treatment Thresholds in Acute Neural Injury: A Narrative Review of the Historical Achievements, Current State, and Future Perspectives.

Since its introduction in the 1960s, intracranial pressure (ICP) monitoring has become an indispensable tool in neurocritical care practice and a key component of the management of moderate/severe traumatic brain injury (TBI). The primary utility of ICP monitoring is to guide therapeutic interventions aimed at maintaining physiological ICP and preventing intracranial hypertension. The rationale for such ICP maintenance is to prevent secondary brain injury arising from brain herniation and inadequate cerebral blood flow. There exists a large body of evidence indicating that elevated ICP is associated with mortality and that aggressive ICP control protocols improve outcomes in severe TBI patients. Therefore, current management guidelines recommend a cerebral perfusion pressure (CPP) target range of 60-70 mm Hg and an ICP threshold of >20 or >22 mm Hg, beyond which therapeutic intervention should be initiated. Though our ability to achieve these thresholds has drastically improved over the past decades, there has been little to no change in the mortality and morbidity associated with moderate-severe TBI. This is a result of the "one treatment fits all" dogma of current guideline-based care that fails to take individual phenotype into account. The way forward in moderate-severe TBI care is through the development of continuously derived individualized ICP thresholds. This narrative review covers the topic of ICP monitoring in TBI care, including historical context/achievements, current monitoring technologies and indications, treatment methods, associations with patient outcome and multi-modal cerebral physiology, present controversies surrounding treatment thresholds, and future perspectives on personalized approaches to ICP-directed therapy.

Management of Aneurysmal Subarachnoid Haemorrhage and its Complications: A Clinical Guide.

Aneurysmal subarachnoid hemorrhage (aSAH) is an emergency that needs prompt diagnosis and treatment with endovascular coiling or surgical clipping of the aneurysm to prevent re-bleeding. In addition to neurologic manifestations, aSAH can cause respiratory and cardiovascular complications. The prevention of hypoxemia and hypercarbia, control of intracranial pressure, and restoration of cerebral perfusion pressure should be the primary aims of early management. Secondarily, the most important causes of persistent neurological deficits and physical dependence in aSAH are vasospasm and delayed ischemia following bleeding. During that period, a focus on the detection, prevention, and treatment of vasospasm should be the rule. Transcranial Doppler allows detection and follow-up of vasospasm, especially in severe cases. Nimodipine is the only drug that has proven efficacy for treating vasospasm. Balloon angioplasty is performed in cases of resistance to medical treatment. Along with angioplasty, intra-arterial vasodilators can be administered. New diagnostic and therapeutic advances will hopefully improve outcomes in the near future.

0902 Comparative Analysis of Sleep Apnea Patients Selected from the Stroke Unit vs Outpatient Clinic

Abstract Introduction To our knowledge, there have been studies actively looking for patients with suspected SA in the Stroke Unit (SU), but most of them were conducted using a portable polysomnography (PSG), and no study has performed Level 1 PSG (L1PSG) to date. We conducted L1PSG to the acute stroke patients selected in the SU, and conducted L1PSG to patients who visited the Neurology Outpatient Clinic (NOC) with subjective SA symptoms at the same time. By comparison, we tried to find out the SA characteristics of acute stroke patients. Methods This study was conducted on patients admitted to SU from April 1, 2021 to October 31, 2022, and patients who visited NOC during the same period and underwent L1PSG. Among patients admitted to the SU, trained night shift nurses selected patients with SA symptoms with a modified mallampati score of 3 or higher. Cases under intracranial pressure control or other interventions were excluded. Outpatients were enrolled in patients who underwent L1PSG by visiting the NOC to examine only SA. The results of the pre-sleep questionnaire and L1PSG were compared. Results Of a total of 829 stroke patients admitted to SU, 31 SU patients received L1PSG, and during the same period, 74 patients received L1PSG for SA testing at NOC. The average age of SU and NOC was 56 and 57 years, and the median BMI was 26.9 and 26.4. In the survey, the ISI (7 vs 12, p=0.04) and PSQI (5 vs 7, p=0.021) scores were statistically significantly higher in NOC patients. As a result of the L1PSG, AHI (38.8 vs 23.1, p=0.027), AHI in Supine (59.3 vs 25.6, p=0.004) and NonREM AHI (36.3 vs 20.9, p=0.027) were statistically significantly higher in SU patients. Conclusion Patients screened SA at SU overlooked their symptom and thought their sleep quality was better than that of NOC patients, but the actual AHI was higher. In particular, acute stroke patients show a large difference in AHI in supine compared to NOC, so lateral position can be recommended when absolute bed rest is needed in situations where SA is suspected in SU. More follow-up studies will be needed. Support (if any)

Cerebrospinal Fluid Diversion for Refractory Intracranial Hypertension in Traumatic Brain Injury: A Single Center Experience

Diversion of cerebrospinal fluid (CSF) is a common neurosurgical procedure for control of intracranial pressure (ICP) in the acute phase after traumatic brain injury (TBI), where medical management is insufficient. CSF can be drained via an external ventricular drain (EVD) or, in selected patients, via a lumbar (external lumbar drain [ELD]) drainage catheter. Considerable variability exists in neurosurgical practice on their use. A retrospective service evaluation was completed for patients receiving CSF diversion for ICP control after TBI, from April 2015 to August 2021. Patients were included whom fulfilled local criteria deeming them suitable for either ELD/EVD. Data were extracted from patient notes, including ICP values pre/postdrain insertion and safety data including infection or clinically/radiologically diagnosed tonsillar herniation. Forty-one patients were retrospectively identified (ELD= 30 and EVD= 11). All patients had parenchymal ICP monitoring. Both modalities affected statistically significant decreases in ICP, with relative reductions at 1, 6, and 24 hour pre/postdrainage (at 24-hour ELD P < 0.0001, EVD P < 0.01). Similar rates of ICP control failure, blockage and leak occurred in both groups. A greater proportion of patients with EVD were treated for CSF infection than with ELD. One event of clinical tonsillar herniation is reported, which may have been in part attributable to ELD overdrainage, but which did not result in adverse outcome. The data presented demonstrate that EVD and ELD can be successful in ICP control after TBI, with ELD limited to carefully selected patients with strict drainage protocols. The findings support prospective study to formally determine the relative risk-benefit profiles of CSF drainage modalities in TBI.

Orbital and Eyelid Characteristics, Strabismus, and Intracranial Pressure Control in Apert Children Treated by Endoscopic Strip Craniectomy versus Fronto-Orbital Advancement.

Twenty-five patients treated at Boston Children's Hospital met inclusion criteria for this retrospective cohort study. Primary outcomes were magnitude of palpebral fissure downslanting at 1, 3, and 5 years of age, severity of V-pattern strabismus, rectus muscle excyclorotation, and interventions to control ICP. Before craniofacial repair and through 1 year of age, none of the studied parameters differed for FOA versus ESC treated patients. Palpebral fissure downslanting became statistically greater for those treated by FOA by 3 (P < 0.001) and 5 years of age (P = 0.001). Likewise, severity of palpebral fissure downslanting correlated with severity of V-pattern strabismus at 3 (P = 0.004) and 5 (P = 0.002) years of age. Palpebral fissure downslanting and rectus muscle excyclorotation were typically coexistent (P = 0.053). Secondary interventions to control ICP were required in four of 14 patients treated by ESC (primarily FOA) and in two of 11 patients initially treated by FOA (primarily third ventriculostomy) (P = 0.661). Apert patients initially treated by ESC had less severe palpebral fissure downslanting and V-pattern strabismus, normalizing their appearance. Thirty percent initially treated by ESC required secondary FOA to control ICP.

A Roadmap for Early Management of Trauma Patients

Trauma is primarily a health hazard of the young and results in loss of precious productive years. It is the leading cause of death in young adults. Most of the health care workers are faced with management of these patients on a regular basis. The concept of ‘Platinum 10 minutes’ or an extended Platinum time of 20 minutes should be strictly adhered to optimize survival. The team of well trained first responders at the accident team should ensure that the patient receives resuscitative care during the early phase of trauma management To enhance trauma care, management has been revolutionized over the past few decades by adopting evidence based recommendations that has led to improved outcome following trauma. The main issues in the acute phase of trauma management includes securing the airway and providing optimal ventilation, fluid and blood product management, control of body temperature and intracranial pressure. A well structured trauma resuscitation approach in a step-wise manner is essential to address all issues that contribute to reduction in mortality and functional disability. An optimal pre-hospital care at the site of the trauma with efficient transfer of the patients to designated trauma centres and maintaining continuity of care has been outlined in this article without daunting the reader with intricacies of trauma care.

Sedation protocols in non-traumatic SAH (SPRINT-SAH): A cross-sectional survey among German-speaking neurointensivists.

In subarachnoid hemorrhage (SAH), titrating sedation to find a balance between wakefulness with the ability to perform valid clinical examinations on the one hand, and deep sedation to minimize secondary brain damage, on the other hand, is challenging. However, data on this topic are scarce, and current guidelines do not provide recommendations for sedation protocols in SAH. We designed a web-based, cross-sectional survey for German-speaking neurointensivists to map current standards for the indication and monitoring of sedation, duration of prolonged sedation, and biomarkers for the withdrawal of sedation. Overall, 17.4% (37/213) of neurointensivists answered the questionnaire. Most of the participants were neurologists (54.1%, 20/37) and exhibited a long-standing experience in intensive care medicine (14.9 years, SD 8.3). Among indications for prolonged sedation in SAH, the control of intracranial pressure (ICP) (94.6%) and status epilepticus (91.9%) were most significant. With regard to further complications in the course of the disease, therapy refractory ICP (45.9%, 17/37) and radiographic surrogates of elevated ICP, such as parenchymal swelling (35.1%, 13/37), were the most relevant topics for experts. Regular awakening trials were performed by 62.2% of neurointensivists (23/37). All participants used clinical examination for the therapeutic monitoring of sedation depth. A total of 83.8% of neurointensivists (31/37) used methods based on electroencephalography. As a mean duration of sedation before attempting an awakening trial in patients with unfavorable biomarkers, neurointensivists suggested 4.5 days (SD 1.8) for good-grade SAH and 5.6 days (SD 2.8) for poor-grade SAH, respectively. Many experts performed cranial imaging before the definite withdrawal of sedation [84.6% (22/26)], and 63.6% (14/22) of the participants required an absence of herniation, space-occupying lesions, or global cerebral edema. The values of ICP tolerated for definite withdrawal were smaller compared to that of awakening trials (17.3 mmHg vs. 22.1 mmHg), and patients were required to stay below the threshold value for several hours (21.3 h, SD 10.7). Despite the paucity of clear recommendations for sedation management in SAH in the pre-existing literature, we found some level of agreement indicating clinical efficacy for certain clinical practices. By mapping the current standard, this survey may help to identify controversial aspects in the clinical care of SAH and thereby streamline future research.