Intracranial Pressure In Traumatic Brain Injury Research Articles

Bedside ultrasonographic evaluation of optic nerve sheath diameter for monitoring of intracranial pressure in traumatic brain injury patients: a cross sectional study in level II trauma care center in India.

Optic nerve sheath diameter (ONSD) is an emerging non-invasive, easily accessible, and possibly useful measurement for evaluating changes in intracranial pressure (ICP). The utilization of bedside ultrasonography (USG) to measure ONSD has garnered increased attention due to its portability, real-time capability, and lack of ionizing radiation. The primary aim of the study was to assess whether bedside USG-guided ONSD measurement can reliably predict increased ICP in traumatic brain injury (TBI) patients. A total of 95 patients admitted to the trauma intensive care unit was included in this cross sectional study. Patient brain computed tomography (CT) scans and Glasgow Coma Scale (GCS) scores were assessed at the time of admission. Bedside USG-guided binocular ONSD was measured and the mean ONSD was noted. Microsoft Excel was used for statistical analysis. Patients with low GCS had higher mean ONSD values (6.4±1.0 mm). A highly significant association was found among the GCS, CT results, and ONSD measurements (P<0.001). Compared to CT scans, the bedside USG ONSD had 86.42% sensitivity and 64.29% specificity for detecting elevated ICP. The positive predictive value of ONSD to identify elevated ICP was 93.33%, and its negative predictive value was 45.00%. ONSD measurement accuracy was 83.16%. Increased ICP can be accurately predicted by bedside USG measurement of ONSD and can be a valuable adjunctive tool in the management of TBI patients.

Lateral Ventricular Volume Asymmetry and Optic Nerve Sheath Diameter Predict Intracranial Pressure in Traumatic Brain Injury Patients.

Background Various noninvasive methods of intracranial pressure (ICP) measurement have been proposed. Each has unique advantages and limitations. This study was aimed at investigating the relationships between lateral ventricular asymmetry on admission computed tomography, optic nerve sheath diameter (ONSD), and ICP in traumatic brain injury (TBI) patients. Methods A prospective observational study was conducted in the patients admitted to our department between October 2018 and October 2020. 20 patients with moderate-severe TBI with a Glasgow Coma Scale of 3–12 were enrolled. Lateral ventricle volume (LVV) value measurements were conducted using ITK-SNAP software. The lateral ventricular volume ratio (LVR) was quantified by dividing the larger LVV by the smaller. Results ONSD and LVR had a good correlation with ICP. Admission LVR of >1.735 was shown to have a sensitivity of 90.9% and a specificity of 88.9% for prediction of ICP increase (AUC = 0.879; standard error = 0.091; 95% CI = 0.701 to 1.0; significance level p < 0.004). Admission ONSD of >5.55 mm was shown to have a sensitivity of 81.8% and a specificity of 88.9% for prediction of ICP increase (AUC = 0.919; standard error = 0.062; 95% CI = 0.798 to 1.0; significance level p < 0.002). Combining the ONSD and LVR, the sensitivity could be improved to 90.9% in parallel test, and the specificity could be improved to 100% in serial test. Conclusion ONSD and LVR measurements can diagnose elevated ICP in traumatic brain injury patients. ONSD combining with LVR may further improve the diagnostic evaluation.

The Impact of a Cervical Collar on Intracranial Pressure in Traumatic Brain Injury Patients: A Systematic Review and Meta-Analysis

Purpose: Although the use of a cervical collar in the prehospital setting is recommended to prevent secondary spinal cord injuries and ensure spinal immobilization, it is not known what effects this has on raising intracranial pressure (ICP) in traumatic brain injury (TBI) patients. In the absence of studies measuring ICP in the prehospital setting, the aim of this study was to systematically review the data related to ICP changes measured after presentation at the hospital in patients who had arrived wearing cervical collars. Methods: We searched Medline (PubMed), Embase, CINAHL, and Google Scholar for studies that investigated in-hospital ICP changes in TBI patients arriving at the hospital wearing collars. Titles, abstracts, and full texts were then searched for inclusion in the study. A narrative synthesis, as well as a meta-analysis, was performed. Results: Of the 1006 studies identified, only three met the inclusion/exclusion criteria. The quality of the three included studies was moderate and the risk of bias was low. All three studies used the Laerdal Stifneck collar, but all studies showed an increase in ICP after application of the collar. A further three studies that measured ICP but did not fit the systematic search were also included due to low patient numbers. A meta-analysis of the pooled data confirmed a significant increase in ICP, although between the four studies, only 77 patients were included. The meta-analysis also confirmed that after removal of the collar, there was a significant decrease in ICP. Conclusions: Our study suggests that the use of a cervical collar increases ICP in TBI and head injury patients, which may have detrimental effects. However, due to the extremely low sample size from all six studies, caution must be exercised when interpreting these data. Thus, further high-quality research is necessary to unequivocally clarify whether cervical collars should be used in patients with TBI.

P0033 / #1954: THE EFFECT OF HYPERTONIC SALINE ON INCREASED INTRACRANIAL PRESSURE IN TRAUMATIC BRAIN INJURY: PROSPECTIVE STUDY WITH NON-INVASIVE METHOD

Aims & Objectives: Transcranial Doppler (TCD) ultrasound examination is a noninvasive method for determination of intracranial pressure. The main goal of this study was to show the effectiveness of hypertonic salin infusions in reducing intracranial pressure (ICP) by using TCD ultrasound. Methods: We included all patients with mild to severe traumatic brain injury (TBI) in our intensive care unit. TCD ultrasound examinations were performed by intensivists before and after hypertonic salin infusions. We used the pulsatility index (PI) of both middle cerebral artery and optic nerve sheet diameter (ONSD) and applied the ICP equations. Results: Seventeen patients with mild to severe TBI and 12 patients in control group were included. All measurements on the TBI patients performed after a first hypertonic salin as a salvage therapy in the emergency room. The median GCSs of the patients at admission and discharge were 10 and 15 respectively. There was a significant decrease in PI after the 3rd measurement in post-hoc multiple comparisons (p=0.004). On the other hand, it was found that the decrease in ONSD became evident after the 5th measurement (p<0.0001). Eight of 17 had axonal injury findings in MRI. Two of the patients had decompressive craniectomy and none of them had died. Conclusions: The repeated hypertonic salin infusions reduce the ICP in traumatic brain injury in children and related improved GCSs. Calculation of ICP using PI and ONSD measured via TCD is a safe and fast method to determine the ICP noninvasively.

Optimal Bone Flap Size for Decompressive Craniectomy for Refractory Increased Intracranial Pressure in Traumatic Brain Injury: Taking the Patient's Head Size into Account

Decompressive craniectomy (DC) is a widely used treatment for refractory high intracranial pressure (ICP). While the Brain Trauma Foundation guidelines favor large DC, there remains a lack of consensus regarding the optimal size of DC in relationship to the patient's head size. The aim of this study is to determine the optimal size of DC to effectively control refractory ICP in traumatic brain injury and to measure that size with a method that takes into consideration the patient's head size. All cases of unilateral DC performed to control refractory increased ICP due to cerebral edema during a 7½-year period were included. Demographic and injury-related data were collected by retrospective chart review. The patients were categorized in 2 groups: 21 patients with a "small flaps" and 9 patients with a "large flap." Two groups had similar preoperative characteristics. The amount of cerebrospinal fluid drained and the doses of hyperosmolar therapy given were not different between the 2 groups. The postoperative ICP was significantly lower for the large craniectomy flap group: 13.3 mm Hg confidence interval 99% [12.7, 13.8] versus 16.9mm Hg confidence interval 99% [16.5, 17.2] (P= 0.01), and this difference was maintained for 96 hours postoperatively. Better ICP control was achieved in patients who underwent a large decompressive craniectomy (ratio >65%) when compared with smaller craniectomy sizes. The proposed method of measuring the craniectomy size, to our knowledge, is the first to take into account the patient's head size and can be easily measured intraoperatively.

Transcranial Bioimpedance Measurement as a Non-invasive Estimate of Intracranial Pressure.

We have previously demonstrated a relationship between transcranial bioimpedance (TCB) measurements and intracranial pressure (ICP) in an animal model of raised ICP. The primary objective of this study was to explore the relationship between non-invasive bioelectrical impedance measurements of the brain and skull and ICP in traumatic brain injury (TBI) patients. Included patients were adults admitted to the Neurological Intensive Care Unit with TBI and undergoing invasive ICP monitoring as part of their routine clinical care. Multi-frequency TCB measurements were performed hourly through bi-temporal electrodes. The bioimpedance parameters of Z c (impedance at the characteristic frequency) and R 0 (resistance to a direct current) were then modelled against ICP using unadjusted and adjusted linear models. One hundred and sixty-eight TCB measurements were available from ten study participants. Using an unadjusted linear modelling approach, there was no significant relationship between measured ICP and Zc or R0. The most significant relationship between ICP and TCB parameters was found by adjusting for multiple patient specific variables and using Zc and R0 normalised per patient (p < 0.0001, r 2 = 0.32). These pilot results confirm some degree of relationship between TCB parameters and invasively measured ICP. The magnitude of this relationship is small and, on the basis of the current study, TCB is unlikely to provide a clinically useful estimate of ICP in patients admitted with TBI.

Efficacy and safety of durotomy after decompressive hemicraniectomy in traumatic brain injury.

Decompressive hemicraniectomy (DH) plus duroplasty was demonstrated to be effective for treating critically elevated intracranial pressure (ICP). In order to shorten operation time and to avoid the use of autologous or heterologous material, durotomy has been introduced as an alternative to duroplasty. Only limited data is available on the effect of DH and durotomy on the increased ICP in traumatic brain injury (TBI). Therefore, we collected consecutive intraoperative ICP readings during the different steps of DH and durotomy in TBI patients. Eighteen patients with TBI and uncontrollable ICP increase (measured by either an intraparenchymal or an intraventricular ICP probe) underwent DH and durotomy. ICP readings as well as mean arterial blood pressure (MAP) and arterial PCO2 were obtained during defined stages of the operation. Surgical complications of the durotomy itself and of cranioplasty after 3months were recorded. The outcome was assessed prior to cranioplasty using the Glasgow Outcome Scale (GOS). ICP dropped significantly during surgery from a mean of 41 (±16.2) mmHg at the beginning to a mean of 11.8 (±7.5) mmHg at the end (p≤0.001). A first significant ICP-decrease to a mean of 18 (±10.8) mmHg (p≤0.001) was detected after removal of the bone flap, and a second significant ICP-decrease to a mean of 10.6 (±5.3) mmHg (p<0.001) during durotomy. The mean operation time was 115.3min (±49.6). Five patients (28%) died; seven patients (39%) had a good outcome (GOS 5). There were no relevant complications associated to durotomy. Durotomy after DH is a safe and straightforward procedure, which significantly lowers critically increased ICP in patients with TBI. Although no graft is used, dural preparation for cranioplasty at 3months is easily possible.

Targeted temperature management in traumatic brain injury.

Traumatic brain injury (TBI) is recognized as the significant cause of mortality and morbidity in the world. To reduce unfavorable outcome in TBI patients, many researches have made much efforts for the innovation of TBI treatment. With the results from several basic and clinical studies, targeted temperature management (TTM) including therapeutic hypothermia (TH) have been recognized as the candidate of neuroprotective treatment. However, their evidences are not yet proven in larger randomized controlled trials (RCTs). The main aim of this review is thus to clarify specific pathophysiology which TTM will be effective in TBI.Historically, there were several clinical trials which compare TH and normothermia. Recently, two RCTs were able to demonstrate the significant beneficial effects of TTM in one specific pathology, patients with mass evacuated lesions. These suggested that TTM might be effective especially for the ischemic-reperfusional pathophysiology of TBI, like as acute subdural hematoma which needs to be evacuated. Also, the latest preliminary report of European multicenter trial suggested the promising efficacy of reduction of intracranial pressure in TBI.Conclusively, TTM is still in the center of neuroprotective treatments in TBI. This therapy is expected to mitigate ischemic and reperfusional pathophysiology and to reduce intracranial pressure in TBI. Further results from ongoing clinical RCTs are waited.

The Ketamine Effect on ICP in Traumatic Brain Injury

Our goal was to perform a systematic review of the literature on the use of ketamine in traumatic brain injury (TBI) and its effects on intracranial pressure (ICP). All articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to November 2013), reference lists of relevant articles, and gray literature were searched. Two reviewers independently identified all manuscripts pertaining to the administration of ketamine in human TBI patients that recorded effects on ICP. Secondary outcomes of effect on cerebral perfusion pressure, mean arterial pressure, patient outcome, and adverse effects were recorded. Two reviewers independently extracted data including population characteristics and treatment characteristics. The strength of evidence was adjudicated using both the Oxford and GRADE methodology. Our search strategy produced a total 371 citations. Seven articles, six manuscripts and one meeting proceeding, were considered for the review with all utilizing ketamine, while documenting ICP in severe TBI patients. All studies were prospective studies. Five and two studies pertained to adults and pediatrics, respectively. Across all studies, of the 101 adult and 55 pediatric patients described, ICP did not increase in any of the studies during ketamine administration. Three studies reported a significant decrease in ICP with ketamine bolus. Cerebral perfusion pressure and mean blood pressure increased in two studies, leading to a decrease in vasopressors in one. No significant adverse events related to ketamine were recorded in any of the studies. Outcome data were poorly documented. There currently exists Oxford level 2b, GRADE C evidence to support that ketamine does not increase ICP in severe TBI patients that are sedated and ventilated, and in fact may lower it in selected cases.

An Overview of Published Research about the Acute Care and Rehabilitation of Traumatic Brain Injured and Spinal Cord Injured Patients

Knowledge of the breadth, nature, and volume of traumatic brain injury (TBI) and spinal cord injury (SCI) research can aid in research planning. This study aimed to provide an overview of existing TBI and SCI research to inform identification of knowledge translation (KT), systematic review (SR), and primary research opportunities. Topics and relevant articles from three large neurotrauma evidence resources were synthesized: the Global Evidence Mapping (GEM) Initiative (129 topics and 1644 articles), the Acquired Brain Injury Evidence-Based Review (ERABI; 152 topics and 732 articles), and the Spinal Cord Injury Rehabilitation Evidence (SCIRE) Project (297 topics and 1650 articles). A de-duplicated dataset of SRs, randomized controlled trials (RCTs), and other studies identified by these projects was created. In all, 145 topics were identified (66 TBI and 79 SCI), yielding 3466 research articles (1256 TBI and 2210 SCI). Topics with KT potential included cognitive therapies for TBI and prevention/management of urinary tract problems post-SCI, which accounted for 17% and 18%, respectively, of the TBI and SCI yield. Topics that may require SR included management of raised intracranial pressure in TBI, and ventilation and intermittent positive pressure interventions following SCI. Topics for which primary research may be needed included pharmacological therapies for neurological recovery post-TBI, and management of sleep-disordered breathing post-SCI. There was a larger volume of non-intervention (epidemiological) studies in SCI than in TBI. This comprehensive overview of TBI and SCI research can aid funding agencies, researchers, clinicians, and other stakeholders in prioritizing and planning TBI and SCI research.

Comparison of ultrasonographic measurement of optic nerve sheath diameter (ONSD) versus direct measurement of intracranial pressure (ICP) in traumatic brain injury patients

Aim. To compare ultrasonographic measurement of optic nerve sheath diameter (ONSD) with direct measurement of intra-cranial pressure (ICP) and evaluate the correlation between them in traumatic brain injury patients.&nbsp;Patients and methods. Twenty traumatic brain injury patients were enrolled in the study. Patients had a median Glasgow Coma Scale (GCS) score of 5. All patients underwent noninvasive measurement of ICP by ultrasonographic measurement of ONSD and invasive ICP measurement using an intraventricular catheter. We used MedCalc to analyze data.&nbsp;Results. We compared the ONSD measurement in patients with ICP less than 20 cm H2O with patients with ICP greater than 20 cm H2O. The mean ONSD for 8 patients with ICP &gt; 20 cmH2O was 7.6 +/- 0.8 mm, and for 18 patients with ICP &lt; 20 cm H2O was 5.6 +/- 0.6 mm. Student t-test&nbsp;comparison between these two groups showed a statistically significant mean difference of 1.99 (95 % CI = 1.4-2.6). The ROC curve showed that the optimal cutoff value of ONSD for predicting ICP &gt; 20 cm H2O was 6.1, with sensitivity of 100 % and specificity of 83 %. (the area under the curve was 0.98, 95 % CI = 0.825-0.990). In this study, the usually used cutoff of ONSD &gt; 5 mm gives a sensitivity of 100 %, but a specificity of only 22 %. Conclusion. Ultrasonographic measurement of ONSD correlates with direct measurement of ICP. This method has potential as a screening test for elevated ICP in traumatic brain injury.&nbsp;

Intracranial pressure monitoring for traumatic brain injury in the modern era

Intracranial pressure (ICP) has become a cornerstone of care in adult and pediatric patients with traumatic brain injury (TBI). Despite the fact that continuous monitoring of ICP in TBI was described almost 60 years ago, there are no randomized trials confirming the benefit of ICP monitoring and treatment in TBI. There is, however, a large body of clinical evidence showing that ICP monitoring influences treatment and leads to better outcomes if part of protocol-driven therapy. However, treatment of ICP has adverse effects, and there are several questions about ICP management that have yet to be definitively answered, particularly in pediatric TBI. This review examines the history and evolution of ICP monitoring, pathophysiological concepts that influence ICP interpretation, ongoing controversies, and the place of ICP monitoring in modern neurocritical care.