Intraoperative Intracranial Pressure Monitoring Research Articles

Intraoperative Intracranial pressure monitoring as an intraoperative guide during operations for relieving elevated intracranial pressure

Intraoperative Intracranial pressure monitoring as an intraoperative guide during operations for relieving elevated intracranial pressure

Intracranial Pressure Monitoring Location: A Pilot Study on the Validation of Subdural Site with the Intraventricular Site.

Introduction Knowledge of preoperative and intraoperative intracranial pressure (ICP) enables the neuroanesthesiologist to optimize cerebral perfusion pressure. However, ICP is rarely monitored during the intraoperative period. In this report, subdural site ICP measurement is validated with intraventricular ICP measurement, and the feasibility of subdural ICP monitoring during the intraoperative period is discussed. Materials and Methods In this prospective pilot study, ICP measurement at the subdural site was achieved with an intravenous cannula and the ventricular site with a ventricular cannula. Both were transduced using a fluid-filled pressure transducer and connected to the monitor for display of the number and the waveforms. Monitoring of intraoperative ICP using both the techniques was done in all patients recruited into the study. The correlation between the two modalities of measurement was studied by the Spearman correlation test and their limits of agreement were studied using the Bland-Altman plot. A case series describing the perioperative management based on the subdural ICP values are also described. Results Subdural ICP showed a strong correlation with intraventricular ICP ( r s = 0.93, p = 0.01). Agreement analysis using the Bland-Altman plot showed that the mean difference of ICP between the modalities was 1.44 mm Hg (95% confidence interval, -0.6 to 3.49, p = 0.122). Discussion This study validates the ICP values measured at the subdural site with the intraventricular site. Subdural site ICP monitoring can be achieved rapidly with readily available systems and helps in making intraoperative clinical decisions. Conclusion Cannula-based subdural ICP is a satisfactory alternative to intraventricular ICP monitoring in the intraoperative period.

A novel method for repeated cerebrospinal fluid sampling and long-term monitoring of intracranial pressure in rats.

Cannulation implantation into the cisterna magna is an important procedure in cerebrospinal fluid (CSF) sampling and intracranial pressure (ICP) monitoring. The disadvantages of existing techniques include the risk of brain damage, compromised muscle mobility, and the complexity of the procedures. In the present study, the authors describe a modified, simple, and reliable procedure for long-term cannulation implantation into the cisterna magna in rats. The device consists of four parts: the puncture segment, the connection segment, the fixing segment, and the external segment. Intraoperative ICP monitoring and post-operative computed tomography (CT) scans were performed, which confirmed the accuracy and safety of this method. There were no limitations on the daily activities of the rats when long-term drainage was carried out for 1 week. This new technique offers an improved method of cannulation and will be a potentially useful method for CSF sampling and ICP monitoring in neuroscience research.

Outcomes and Predictors of Outcome with Cisternostomy in the Management of Traumatic Brain Injury—A Prospective Observational Study at a Tertiary Centre

Abstract Background Traumatic brain injury (TBI) is a major cause of morbidity and mortality in young individuals. Goal of management in TBI patients is mainly focused on the secondary injury. Since the cisterns and the brain communicate, it would be possible to decrease the pressure in both these compartments by opening the cisterns to the atmospheric pressure. Objective To study the outcomes and predictors of outcome with cisternostomy in the management of TBI. Methods A single tertiary care center's prospective observational study of outcomes with cisternostomy with intraoperative intracranial pressure (ICP) monitoring. Patients were evaluated clinically and radiologically with Marshall CT score. They were categorized into mild, moderate, and severe head injury groups based on Glasgow coma scale (GCS) score. Outcomes were evaluated with Glasgow outcome scale (GOS) score. Results A total of 25 patients with TBI were enrolled in this study. They underwent cisternostomy with intraoperative ICP monitoring. They were categorized into 4 groups based on the age. In our study, mortality rate was 32%. As much as 48% had good recovery at 3 months follow-up with GOS 4 and 5. Mean ICP after cisternostomy was 6.36 ± 1.91 mm Hg. In our study, there was decrease in ICP after cisternostomy. Conclusion Age, time interval from trauma to surgery, and ICP showed prognostic importance on outcomes. Cisternostomy can efficiently decrease the ICP in the TBI patients and reduce postoperative complications.

Role of Intraoperative ICP And CPP Measurement for Predicting Surgical Outcome in Severe Traumatic Brain Injury

Abstract Introduction Traumatic brain injury (TBI) is one of the leading causes of mortality and disability worldwide, and optimizing the management of these patients is a continuing challenge. Intraoperative intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were evaluated for use as prognostic indicators after surgery for severe TBI. Although ICP and CPP monitoring is standard postsurgery treatment for TBI, very few studies have reported the use of ICP and CPP values monitored during surgery. Objectives The objectives of this study were to evaluate the use of intraoperative ICP and CPP values as prognostic indicators and as subjective guidelines for managing severe TBI. Materials and Methods All patients with severe TBI who underwent surgical decompression and ICP monitoring intraoperatively were included in our study from 2017 to 2018. We measured ICP and CPP values after creation of the first burr hole, after hematoma evacuation, and after wound closure. Results From the analysis of receiver-operated characteristic (ROC) curves, we observed that ICP initial (cutoff > 28 mm Hg) and CPP initial (cutoff < 44.5 mm Hg) are the best predictors of unfavorable outcomes. Favorable outcome (Glasgow outcome scale [GOS] 4 and 5) and unfavorable outcome (GOS 1–3) after 6 months were achieved in 64.1 and 35.8% of patients, respectively. There was significant difference between the ICP and CPP values which are measured after the first burrhole, after hematoma evacuation, and after scalp closure in both favorable and unfavorable outcomes. The highest positive Pearson’s correlation coefficient is found between GOS and ICP and CPP after first burr hole. Conclusion Monitoring ICP and CPP during surgery improves management in patients with severe TBI and provides an early prognostic indicator in such patients.

Intraoperative intracranial pressure monitoring in the pediatric craniosynostosis population.

OBJECTIVEEvaluation of increased intracranial pressure (ICP) in the pediatric craniosynostosis population based solely on ophthalmological, clinical, and radiographic data is subjective, insensitive, and inconsistent. The aim of this study was to examine the intraoperative ICP before and after craniectomy in this patient population.METHODSThe authors measured the ICP before and after craniectomy using a subdural ICP monitor in 45 children. They regulated end-tidal carbon dioxide and the monitoring site under general anesthesia to record consistent ICP readings.RESULTSThe average age of the patient population was 29 months (range 3.8-180.5 months). Thirty-seven patients (82.2%) were undergoing initial craniosynostosis procedures. All craniosynostosis procedures were categorized as one of the following: frontoorbital advancement (n = 24), frontoorbital advancement with distraction osteogenesis (n = 1), posterior vault distraction osteogenesis (n = 10), and posterior vault reconstruction (n = 10). Nineteen of 45 patients (42.2%) had syndromic or multisuture craniosynostosis. The mean postcraniectomy ICP (8.8 mm Hg, range 2-18 mm Hg) was significantly lower than the precraniectomy ICP (16.5 mm Hg, range 6-35 mm Hg) (p < 0.001). Twenty-four patients (53%) had elevated ICP prior to craniectomy, defined as ≥ 15 mm Hg. Only 4 (8.9%) children had papilledema on preoperative funduscopic examination (sensitivity 17%, specificity 100%, negative predictive value 51%, and positive predictive value 100%). There were no significant differences in elevated precraniectomy ICP based on type of craniosynostosis (syndromic/multisuture or nonsyndromic) or age at the time of surgery. Patients undergoing initial surgery in the first 12 months of life were significantly less likely to have elevated precraniectomy ICP compared with patients older than 12 months (26.3% vs 73.1%, p = 0.005).CONCLUSIONSIn this study, the authors report the largest cohort of syndromic and nonsyndromic craniosynostosis patients (n = 45) who underwent precraniectomy and postcraniectomy ICP evaluation. A craniectomy or completed craniotomy cuts for distractors effectively reduced ICP in 43/45 patients. The authors' findings support the notion that papilledema on funduscopy is a highly specific, however poorly sensitive, indicator of increased ICP, and thus is not a reliable screening method. These findings indicate that even nonsyndromic patients with craniosynostosis are at risk for increased ICP. Furthermore, patients who present prior to 12 months of age appear less likely to have elevated ICP on presentation. Further studies with other noninvasive imaging of the retina may be useful as an adjunct tool for determining elevated ICP.

The value of intraoperative intracranial pressure monitoring for predicting re-operation using salvage decompressive craniectomy after craniotomy in patients with traumatic mass lesions.

BackgroundThe risk factors of predicting the need for postoperative decompressive craniectomy due to intracranial hypertension after primary craniotomy remain unclear. This study aimed to investigate the value of intraoperative intracranial pressure (ICP) monitoring in predicting re-operation using salvage decompressive craniectomy (SDC).MethodsFrom January 2008 to October 2014, we retrospectively reviewed 284 patients with severe traumatic brain injury (STBI) who underwent craniotomy for mass lesion evacuation without intraoperative brain swelling. Intraoperative ICP was documented at the time of initial craniotomy and then again after the dura was sutured. SDC was used when postoperative ICP was continually higher than 25 mmHg for 1 h without a downward trend. Univariate and multivariate analyses were applied to both initial demographic and radiographic features to identify risk factors of SDC requirement.ResultsOf 284, 41 (14.4 %) patients who underwent SDC had a higher Initial ICP than those who didn’t (38.1 ± 9.2 vs. 29.3 ± 8.1 mmHg, P < 0.001), but there was no difference in ICP after the dura was sutured. The factors which have significant effects on SDC are higher initial ICP [odds ratio (OR): 1.100, 95 % confidence interval (CI): 1.052–1.151, P < 0.001], older age (OR: 1.039, 95 % CI: 1.002–1.077, P = 0.039), combined lesions (OR: 3.329, 95 % CI: 1.199–9.244, P = 0.021) and early hypotension (OR: 2.524, 95 % CI: 1.107–5.756, P = 0.028). The area under the curve of multivariate regression model was 0.771.ConclusionsThe incidence of re-operation using SDC after craniotomy was 14.4 %. The independent risk factors of SDC requirement are initial ICP, age, early hypotension and combined lesions.

Surgical Treatment of Severe Traumatic Brain Injury in Switzerland: Results from a Multicenter Study.

Since the introduction of modern surgical techniques and monitoring tools for the treatment of severe traumatic brain injury (TBI) in Switzerland, standardized nationwide operative procedures are still lacking. This study aimed to assess surgical management and monitoring strategies in patients admitted throughout Switzerland with severe TBI. Demographic, clinical, and radiologic data from a prospective national cohort study on severe brain-injured patients (Patient-relevant Endpoints after Brain Injury from Traumatic Accidents [PEBITA]) were collected during a 3-year period. This study evaluated patients admitted to 7 of the 11 trauma centers included in PEBITA. We retrospectively analyzed surgery-related computed tomography (CT) findings prior to and after treatment, intracranial pressure (ICP) monitoring, size and technical features of craniotomy, as well as surgical complications. ResULTS: This study included 353 of the 921 patients enrolled in PEBITA who underwent surgical treatment for severe TBI. At admission, acute subdural hematoma was the most frequent focal lesion diagnosed (n = 154 [44%]), followed by epidural hematoma (n = 96 [27%]) and intracerebral hematoma (n = 84 [24%]). A total of 198 patients (61%) presented with midline shift. Clinical deterioration in terms of Glasgow Coma Scale scores or intractable ICP values as an indication for surgical evacuation or decompression were documented in 20% and 6%, respectively. A total of 97 (27.5%) only received a catheter/probe for ICP monitoring. Surgical procedures to treat a focal lesion or decompress the cerebrum were performed in 256 patients (72.5%). Of the 290 surgical procedures (excluding ICP probe implantation), craniotomy (137 [47.2%]) or decompressive craniectomy (133 [45.9%]) were performed most frequently. The mean size of craniectomy in terms of maximal linear width on the CT axial slice was 8.4 ± 2.9 cm. Intraoperative ICP monitoring was reported in 61% of the interventions. Significant intraoperative brain swelling was documented in 50.6% of the procedures. Surgery-related complications occurred in 89 cases (32%). This study highlights the lack of standardized and systematic documentation of technical aspects of surgical treatment of patients presenting with severe TBI in Switzerland. Technical strategies such as size of craniectomy and the use of perioperative ICP measurement were not documented in a standardized manner. A prospective systematic surgical documentation system might contribute to future formulation of recommendations for the surgical treatment of patients presenting with severe TBI in Switzerland.

Intraoperative intracranial pressure and cerebral perfusion pressure for predicting surgical outcome in severe traumatic brain injury

Intraoperative intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were evaluated for use as prognostic indicators after surgery for severe traumatic brain injury (TBI), and threshold ICP and CPP values were determined to provide guidelines for patient management. This retrospective study reviewed data for 66 patients (20 females and 46 males) aged 13–83 years (average age, 48 years) who had received decompressive craniectomy and hematoma evacuation for severe TBI. The analysis of clinical characteristics included Glascow Coma Scale score, trauma mechanism, trauma severity, cerebral hemorrhage type, hematoma thickness observed on computed tomography scan, Glasgow Outcome Scale score, and mortality. Patients whose treatment included ICP monitoring had significantly better prognosis (p < 0.001) and significantly lower mortality (p = 0.016) compared to those who did not receive ICP monitoring. At all three major steps of the procedure, i.e., creation of the burr hole, evacuation of the hematoma, and closing of the wound, intraoperative ICP and CPP values significantly differed. The ICP and CPP values were also significantly associated with surgical outcome in the severe TBI patients. Between hematoma evacuation and wound closure, ICP and CPP values differed by 6.8 ± 4.5 and 6.5 ± 4.6 mmHg, respectively (mean difference, 6 mmHg). Intraoperative thresholds were 14 mmHg for ICP and 56mmH for CPP. Monitoring ICP and CPP during surgery improves management of severe TBI patients and provides an early prognostic indicator. During surgery for severe TBI, early detection of increased ICP is also crucial for enabling sufficiently early treatment to improve surgical outcome. However, further study is needed to determine the optimal intraoperative ICP and CPP thresholds before their use as subjective guidelines for managing severe TBI patients.

Intraoperative monitoring of intracranial pressure in treating severe traumatic brain injury patients

Objective To explore the value of intraoperative continuous monitoring of intracranial pressure(ICP) in the treatment of patients with severe traumatic brain injury (sTBI).Methods ICP results of fifty - eight cases with sTBI were analyzed retrospectively from March 2008 to March 2010.According to the prognosis,patients were divided into two groups,the good group ( GOS 4 ～ 5 ) and poor group( GOS 1 ～3),and the intraoperative ICP fluctuation,surgical procedures and prognosis between two groups were analyzed and compared. Results The mean ICP of initial,bone removed and bone closed phase between the two groups,and the ICP fluctuation between each phase have statistical significance ( P ＜0.01 ). Conclusion Intraoperative ICP monitoring contributes to identify problems timely,guide treatment and assess prognosis,and plays an important clinical value in the treatment of sTBI patients. Key words: Intraoperative ICP; Severe traumatic brain injury; Monitoring

Acute Cranial Decompression in Meckel-Gruber Syndrome and Slit-Ventricle Syndrome With Craniocephalic Disproportion

Slit-ventricle syndrome (SVS) is characterized by headaches associated with subnormal ventricular size in patients with shunt-treated hydrocephalus. It commonly occurs in children who have had shunts placed at an early age and is diagnosed when computed tomography scans are carried out to investigate suspected shunt obstruction with an accompanying rise in intracranial pressure (ICP). Overdrainage of cerebrospinal fluid may additionally result in craniocephalic disproportion, potentially by dampening the normal expansile pulsations of the dura against the skull, which leads to craniostenosis. Management is controversial because many strategies have only short-term benefit, and surgical intervention is understandably often seen as a last resort.We present a case of a child with SVS and craniocephalic disproportion who was treated with urgent cranial expansion due to rising ICP. Intraoperative ICP monitoring demonstrates a rapid and sustained drop in ICP, and the patient made an uneventful return to his premorbid condition. We conclude that cranial vault expansion should be considered as an effective treatment for postshunt craniocephalic disproportion in patients with SVS.

Standardized induction of subarachnoid hemorrhage in mice by intracranial pressure monitoring

Background and purposeSubarachnoid hemorrhage (SAH) is the subtype of stroke with the most unfavorable outcome but the least well investigated molecular pathophysiology. Among others, not sufficiently well standardized in vivo models suitable for the use with transgenic animals may be responsible for this situation. Therefore the aim of the current study was to detect suitable intra-operative parameters for the controlled and standardized induction of SAH in mice and to characterize the long-term functional and histopathological outcome of mice subjected to this procedure. MethodsExperimental study in mice using the intraluminal Circle of Willis perforation (CWp) model of SAH. ResultsSAH induced a sharp increase of intracranial pressure (ICP) from 5.1±1.2 to 78.5±9.3mmHg (mean±SD; p<0.05), a concomitant drop of cerebral blood flow (rCBF) by 81±4% (p<0.05), and a significant Cushing reflex response (p<0.05). rCBF measurements alone could not reliably detect SAH. SAH resulted in significant brain edema formation (brain water content increase at 72h: 2.9±0.9%; p<0.05), loss of hippocampal neurons (CA1: −56%, CA2: −55%; CA3: −72%; 7 days; p<0.05), severe neurological dysfunction over 7 days, and a mortality of 30%. ConclusionsOur results indicate that CWp in mice can be standardized by intra-operative ICP monitoring. CWp leads to prolonged intracranial hypertension, selective neuronal cell death in the hippocampus, and severe neurological dysfunction. CWp in mice with ICP monitoring may therefore become a valuable tool for future investigations of the molecular pathophysiology of SAH.

A new expandable cannula system for endoscopic evacuation of intraparenchymal hemorrhages

The authors describe a newly developed expandable cannula to enable a more efficient use of an endoscope in removing intraparenchymal spontaneous hypertensive intracerebral hematomas. The cannula is introduced like a conventional brain cannula, using neuronavigation techniques to reach the targeted hematoma accurately, and, once deployed, conventional microsurgical techniques are used under direct endoscopic visualization. This method was used in 6 patients, and, based on the results of intraoperative intracranial pressure monitoring and postoperative CT scanning, the authors were able to achieve good hematoma removal. They found that by using the expandable cannula, efficient endoscopic surgery in the brain parenchyma was possible.

Laparoscopic Procedures in Adults With Ventriculoperitoneal Shunts

Until recently, the presence of a ventriculoperitoneal shunt (VPS) was considered an absolute contraindication to laparoscopy. In some cases, intraabdominal insufflation causes a rapid, sustained increase in intracranial pressure (ICP). Such intracranial hypertension may result in hindbrain herniation. To prevent this, the use of lower abdominal pressures, intraoperative ICP monitoring, intraoperative ventricular drainage, and distal shunt catheter clamping/externalization has been reported in some studies. However, other studies show that laparoscopy is safe even without VPS catheter clamping and with only routine anesthetic monitoring. Moreover, the risk of retrograde failure of the valve system has been shown to be minimal even with intraabdominal pressures as high as 80 mm Hg. We report how we managed a hydrocephalic adult with a VPS shunt undergoing laparoscopic cholecystectomy in the hope that our experience contributes to the successful management of such patients in the future.

Laparoscopic surgery in children with ventriculoperitoneal shunts: Effect of pneumoperitoneum on intracranial pressure—preliminary experience

Objectives We monitored changes in intracranial pressure (ICP) in 2 children with myelodysplasia undergoing laparoscopic bladder autoaugmentation. Both children had ventriculoperitoneal shunts (VPS) secondary to Arnold-Chiari malformations (type II). Methods ICP was monitored through a 23-gauge needle placed into the shunt reservoir and connected to a pressure transducer and drainage system. Intraoperative mean arterial pressure, end-tidal CO 2 (ETCO 2), ICP, abdominal pressure, and cerebral perfusion pressures were all monitored. Results Both children demonstrated rapid onset and sustained increases in ICP of greater than 12 mm Hg above baseline to a maximum pressure of 25 mm Hg. The average cerebrospinal fluid removed from each patient was 30 cc, thereby lowering ICP with no adverse neurologic sequela. The pCO 2 remained constant throughout the procedures, as measured by ETCO 2. Conclusions We believe that intracranial hypertension (IH) results from a “Valsalva-like” phenomenon, which causes cerebral vascular engorgement. In addition, the pneumoperitoneum may increase the resistance to outflow through the distal peritoneal catheter, causing a partial or complete shunt obstruction. Untreated IH may result in adverse neurologic sequelae from brain herniation in these children with hindbrain anomalies and potentially altered brain compliance. We believe it is prudent to perform intraoperative ICP monitoring in this subgroup of patients undergoing laparoscopic surgery and that IH should be treated by ventricular drainage.