Refractory Intracranial Hypertension Research Articles

Influence of cerebrospinal fluid drainage in the first days after aneurysm rupture on the severity of early brain injury following aneurysmal subarachnoid hemorrhage

PurposeProgressive cerebral edema with refractory intracranial hypertension (ICP) requiring decompressive hemicraniectomy (DHC) is a severe manifestation of early brain injury (EBI) after aneurysmal subarachnoid hemorrhage (aSAH). The purpose of the study was to investigate whether a more pronounced cerebrospinal fluid (CSF) drainage has an influence on cerebral perfusion pressure (CPP) and the extent of EBI after aSAH.MethodsPatients with aSAH and indication for ICP-monitoring admitted to our center between 2012 and 2020 were retrospectively included. EBI was categorized based on intracranial blood burden, persistent loss of consciousness, and SEBES (Subarachnoid Hemorrhage Early Brain Edema Score) score on the third day after ictus. The draining CSF and vital signs such as ICP and CPP were documented daily.Results90 out of 324 eligible aSAH patients (28%) were included. The mean age was 54.2 ± 11.9 years. DHC was performed in 24% (22/90) of patients. Mean CSF drainage within 72 h after ictus was 168.5 ± 78.5 ml. A higher CSF drainage within 72 h after ictus correlated with a less severe EBI and a less frequent need for DHC (r=-0.33, p = 0.001) and with a higher mean CPP on day 3 after ictus (r = 0.2351, p = 0.02).ConclusionA more pronounced CSF drainage in the first 3 days of aSAH was associated with higher CPP and a less severe course of EBI and required less frequently a DHC. These results support the hypothesis that an early and pronounced CSF drainage may facilitate blood clearance and positively influence the course of EBI.

Venous Manometry Insights: Diagnostic Criteria Utility and Clinical Correlation in Patients with Refractory Idiopathic Intracranial Hypertension (S20.003)

Venous Manometry Insights: Diagnostic Criteria Utility and Clinical Correlation in Patients with Refractory Idiopathic Intracranial Hypertension (S20.003)

Reasons for Discontinuation of Medical Management in Refractory Idiopathic Intracranial Hypertension (P3-12.007)

Reasons for Discontinuation of Medical Management in Refractory Idiopathic Intracranial Hypertension (P3-12.007)

Endovascular stenting for cerebral venous sinus stenosis secondary to meningioma invasion.

Symptomatic intracranial hypertension (IH) due to venous outflow obstruction secondary to dural venous sinus (DVS) tumoral invasion affects up to 3% of intracranial meningioma patients. The literature regarding endovascular therapies of such patients is limited to a few case reports and a recent single-centre case series. We describe our single-centre experience of endovascular therapy in patients with clinically symptomatic IH secondary to DVS meningioma invasion. We performed a retrospective review of clinical and radiological data of all patients with refractory IH and meningiomas invading the DVS who were referred for possible DVS venoplasty and stenting. Seven endovascular procedures in six female patients were done. Presumed secondarily induced lateral transverse sinus stenosis was also stented in four patients as part of the primary intervention. All patients experienced complete symptomatic resolution at 6-month follow-up. Five patients had no symptom recurrence over a mean follow-up period of 3.5 years. One patient with multiple meningiomas developed recurrent IH 2 years following stenting secondary to in-stent tumour re-invasion. This was re-stented with consequent 6 months post-retreatment symptomatic relief at the time of writing. No procedure-related complications occurred. In the setting of DVS stenosis secondary to meningioma invasion, endovascular therapy is a safe and successful therapeutic option with promising mid-term results. The procedure should be considered in cases where complete surgical tumour resection is unlikely or carries a significant risk. If present, secondarily induced stenoses at the lateral ends of the transverse sinuses should also be considered for treatment.

Quantitative Pupillometry for Intracranial Pressure (ICP) Monitoring in Traumatic Brain Injury: A Scoping Review.

The neurological examination has remained key for the detection of worsening in neurocritical care patients, particularly after traumatic brain injury (TBI). New-onset, unreactive anisocoria frequently occurs in such situations, triggering aggressive diagnostic and therapeutic measures to address life-threatening elevations in intracranial pressure (ICP). As such, the field needs objective, unbiased, portable, and reliable methods for quickly assessing such pupillary changes. In this area, quantitative pupillometry (QP) proves promising, leveraging the analysis of different pupillary variables to indirectly estimate ICP. Thus, this scoping review seeks to describe the existing evidence for the use of QP in estimating ICP in adult patients with TBI as compared with invasive methods, which are considered the standard practice. This review was conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews, with a main search of PubMed and EMBASE. The search was limited to studies of adult patients with TBI published in any language between 2012 and 2022. Eight studies were included for analysis, with the vast majority being prospective studies conducted in high-income countries. Among QP variables, serial rather than isolated measurements of neurologic pupillary index, constriction velocity, and maximal constriction velocity demonstrated the best correlation with invasive ICP measurement values, particularly in predicting refractory intracranial hypertension. Neurologic pupillary index and ICP also showed an inverse relationship when trends were simultaneously compared. As such, QP, when used repetitively, seems to be a promising tool for noninvasive ICP monitoring in patients with TBI, especially when used in conjunction with other clinical and neuromonitoring data.

The use of tier three therapies in acute brain injured patients

BACKGROUND In patients with acute brain injury (ABI) and refractory intracranial hypertension, the so-called ‘tier three therapies’ (TTT) (hypothermia, metabolic suppression with barbiturates, and decompressive craniectomy) may be used. OBJECTIVE We aimed to describe the incidence of use of TTT, and to assess their effect on outcome. DESIGN A secondary analysis of the ENIO observational study. SETTING Seventy-three intensive care units (ICUs) in 18 countries worldwide between June 2018 and November 2020. PATIENTS One thousand five hundred and twelve adult patients admitted to an intensive care unit (ICU) with ABI were included and categorised according to use or not of one or more TTT. RESULTS Three hundred and ninety-six patients (26.2%) received at least one TTT during the ICU stay. Five patients (0.3%) received all three TTT. TTT patients were younger (P < 0.0001), less likely to have a preinjury history of hypertension (P = 0.0008), and less frequently anisocoric within 24 h from ICU admission (P < 0.0001) than those with no tier three therapy. TTT were used less frequently in high-income countries than in upper income and lower middle-income countries (no TTT in 78% of patients in high-income countries, in 60.6% of patients in upper middle-income countries, and in 56.6% of patients in lower middle-income countries; P < 0.0001). TTT were more frequent in patients with traumatic brain injury (TBI) compared with other types of ABI and in patients with invasive intracranial pressure (ICP) monitoring (P < 0.0001). TTT use was associated with a higher incidence of ventilator-associated pneumonia (P < 0.0001), need for tracheostomy (P = 0.0194), and prolonged ICU length of stay (LOS; P < 0.0001) but not with increased ICU or hospital mortality (P = 0.999). CONCLUSION Patients with ABI are frequently managed using at least one TTT. Their use varies according to a country's economic resources, the type of ABI, and ICP monitoring and is associated with a higher risk of complications but not with ICU or hospital mortality.

In Reply to the Letter to the Editor Regarding “Cerebrospinal Fluid Diversion for Refractory Intracranial Hypertension in Traumatic Brain Injury: A Single Center Experience”

In Reply to the Letter to the Editor Regarding “Cerebrospinal Fluid Diversion for Refractory Intracranial Hypertension in Traumatic Brain Injury: A Single Center Experience”

Letter to the Editor Regarding “Cerebrospinal Fluid Diversion for Refractory Intracranial Hypertension in Traumatic Brain Injury: A Single Center Experience”

Letter to the Editor Regarding “Cerebrospinal Fluid Diversion for Refractory Intracranial Hypertension in Traumatic Brain Injury: A Single Center Experience”

Hyperemia in head injury: can transcranial doppler help to personalize therapies for intracranial hypertension?

An increase in cerebral blood flow is frequent after traumatic brain injury (TBI) and can lead to brain swelling and refractory intracranial hypertension. We hypothesized that Transcranial EcoDoppler (TCD) monitoring could be useful to detect the cause of intracranial hypertension in these patients. Our main objective was to investigate if the increase of velocity in the middle cerebral artery (MCA) on TCD could be associated with intracranial hypertension. We retrospectively studied TBI patients consecutively monitored with TCD. Hyperemia was defined as MCA mean velocity higher than 80 cm/s. Intracranial hypertension was considered when hyperosmolar therapy, hyperventilation, or deep sedation was used. We found hyperemia in 40 patients out of 118 (33.9%). On average, it started at day 2.1 ± 0.9 from admission and significantly increased (MCA velocity at day 1: 74 ± 25 cm/s vs. 109 ± 36 cm/s at day 4; p < 0.001). Intracranial hypertension was significantly associated with hyperemia, occurring in 92.5% of hyperemic and 51.3% of non-hyperemic patients (p < 0.001). Moreover, we found that hyperemia preceded severe intracranial hypertension (p < 0.0001). In a logistic regression model, hyperemia was the only variable significantly correlated with intracranial hypertension (OR 10.64; p < 0.001). Hyperemia was frequent in our population of TBI patients and preceded intracranial hypertension. TCD monitoring, if performed on a daily regular basis, can be a useful method to detect this phenomenon and to guide the therapy. It could be a tool for a cause-oriented therapy of intracranial hypertension.

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.

Erratum: Decompressive Laparotomy as a Treatment Option for Refractory Intracranial Hypertension in Patients With Traumatic Brain Injury: A Systematic Review

Erratum: Decompressive Laparotomy as a Treatment Option for Refractory Intracranial Hypertension in Patients With Traumatic Brain Injury: A Systematic Review

1128 Outcomes of Early and Late Decompressive Craniectomies in Contrast to Standard Medical Management in Patients with Traumatic Brain Injury with Refractory Intracranial Hypertension: Systematic Review and Meta-Analysis Study

Abstract Aim The meta-analysis explored the effectiveness of early and late decompressive craniectomies versus medical management in patients with refractory intracranial hypertension after sustaining traumatic brain injury. The clinical outcomes analysed were grouped into 2 categories: favourable (good recovery and moderate disability) and unfavourable outcomes (death, vegetative state, and severe disability). Intracranial pressure has been measured post-randomisation in the studies included. Method Google Scholar, Cochrane and Medline search engines were utilised for data collection ranging from 1999 until present. The searched keywords encompassed: decompressive craniectomy, refractory intracranial hypertension, medical management, and traumatic brain injury. Thereafter, the data was uploaded to Review Manager for statistical analysis. Results Of the 122 articles, 10 randomized controlled trials were included in the meta-analysis. The analysis yielded that relative risk (RR) of overall mortality in decompressive craniectomy group vs medical management is 0.58 95% CI [0.41, 0.81] (P = 0.001). The standardised mean difference (SMD) for intracranial pressure is -2.59 95% CI [-3.72, -1.46] (P &amp;lt; 0.00001) between the two groups. The odds ratio considering favourable outcomes (Glasgow Outcome Scale) for patients undergoing surgery vs medical care is 1.02 95% [0.57, 1.82] (P = 0.95). Conclusions This meta-analysis demonstrates that decompressive craniectomy significantly reduces the overall mortality and intracranial pressure in patients with TBI and refractory intracranial hypertension versus medical management. Decompressive craniectomy has a greater potential to treat TBI patients with refractory intracranial hypertension than medical care alone however more randomised clinical trials are needed to ascertain the effectiveness of the superiority of these treatments in the future research.

417 Factors Associated with the Development of Post-Traumatic Hydrocephalus Following a Decompressive Craniectomy: A Single Centre Experience

Abstract Introduction A decompressive craniectomy (DC) is a surgical procedure sometimes utilised to manage refractory intracranial hypertension following severe traumatic brain injury (sTBI). Previous studies have established a relationship between DC and post-traumatic hydrocephalus (PTH). This study aimed to identify the factors responsible for developing shunt-amenable post-traumatic hydrocephalus in patients who underwent DC following sTBI. Method A review of a prospectively collected database of all patients admitted with severe TBI in a tertiary neurosurgical centre in northwest England between January 2012 and May 2022 was performed. Post-traumatic hydrocephalus was defined as evidence of progressive ventricular dilatation, clinical deterioration, and/or the eventual need for CSF diversion (i.e. a ventriculoperitoneal shunt). Statistical analysis was carried out using IBM SPSS vs 28.0.1. Results 65 patients met the eligibility criteria and were included in the study. The mean age of the PTH group was 31.38+/-14.67, while the mean age of the non-PTH group was slightly higher at 39.96 +/- 14.85. No statistically significant difference was observed between the two groups' mechanisms of traumatic injury (MOI) (P = 0.945). Of the predictors investigated, cerebellar hematoma (and contusions) was significantly associated with post-traumatic hydrocephalus (p = 0.006). Conclusions This study concludes that cerebellar hematoma (and contusions) are associated with developing post-traumatic hydrocephalus in patients undergoing decompressive craniectomy.

Computed tomography-guided stereotactic surgery in the management of brain lesions: A single-center experience.

The present study presents our experience with computed tomography (CT)-guided stereotactic surgery in managing deep-seated brain lesions and provides a background in the expanding fields of morphological stereotactic neurosurgery. We conducted this retrospective cohort study on 80 patients managed at the Department of Neurosurgery, Zagazig University Hospitals, Zagazig, Egypt, between January 2019 to January 2021. We targeted patients with morphological stereotactic surgeries performed as the primary management modality of their treatment. A total of 80 patients, with a mean age of 44.3 years, were included in the study. The stereotactic targets were supratentorial in 71 patients (88.75%), infratentorial in seven patients (8.75%), and both supraand infratentorial in two patients (2.5%). The lesions showed enhancements with IV contrast in 55 patients (68.75%). Stereotactic procedures were performed under local anesthesia in 64 patients and general anesthesia in 16 patients. Of the 80 stereotactic procedures, 52 were biopsies (65%). We observed a significant improvement in the postoperative Karnofsky performance score compared to the postoperative score (63.4 ± 19.8 vs. 56.7 ± 15.4, P = 0.001). The level of agreement between clinical, radiological, and final pathological diagnosis was assessed; it was complete in 47.5% of the patients. The postprocedural CT scan demonstrated intracranial hemorrhage in five patients (6.25%); four (5%) were silent with no neurological complications. This study provided evidence that the stereotactic procedure is easy to perform, accurate in targeting the lesion, and spares patients from undergoing major surgical procedures. Stereotactic applications of spontaneous intracerebral hemorrhage, deep-seated abscesses, encysted tumors, or medically refractory benign intracranial hypertension can improve the outcome even in medically high-risk patients.

Decompressive Laparotomy as a Treatment Option for Refractory Intracranial Hypertension in Patients With Traumatic Brain Injury: A Systematic Review

Background: Researchers investigated the role of decompressive laparotomy as a novel technique to improve the outcome of refractory intracranial hypertension in patients with severe Traumatic brain injury (TBI). In this paper, we conduct a systematic review of the literature and discuss the existing information on the role of decompressive laparotomy in patients with severe TBI. Methods: A search for RCT, not RCT, prospective and retrospective cohort studies will be carried out through electronic databases. The strategy comprised topic headings (MeSH) such as "Decompressive laparotomy," "traumatic brain damage," "Neurocritical care," and "intracranial hypertension," as well as text words related to Booleans terms. The following data were retrieved individually and separately: mortality, functional independence (modified Rankin scale 0 to 2, or Glasgow Prognostic Scale with a score of 4 or above), and intracranial pressure value before and after Decompressive laparotomy. Results: Following a thorough text review, ten articles were examined for confidentiality, one of which is a narrative review, two of which did not cover traumatic brain injury and one of which included thoracic and neck trauma, and six of which were included for qualitative and quantitative analysis. Among the six trials considered, 46 patients with TBI and intracranial hypertension were evaluated and treated with hyperosmolar treatment and/or Decompressive Craniectomy with Decompressive laparotomy. The Glasgow Outcome Scale was used to evaluate neurological prognosis and functional competence. Conclusions: According to the findings, 8% of the patients were in a chronic vegetative state, 37.93% had severe disability, 33.45% had moderate disability, and the majority (64.3%) were able to return to work with limitations. The remaining 20.6% had mild disability or good functional recovery.

Herpetic Meningoencephalitis Occurring After Decompressive Craniectomy in Severe Head Trauma

Viral meningoencephalitis in general and herpes in particular is an extremely rare complication after neurosurgery. We report the case of a 26-year-old patient, admitted for management of a severe head injury with refractory intracranial hypertension who underwent decompressive craniectomy which was complicated by herpetic meningoencephalitis treated with aciclovir for 21 days with a successful outcome at 12 months.

Abstract Number ‐ 146: Re‐stenting Following Recurrence after Venous Sinus Stenosis Stenting for Idiopathic Intracranial Hypertension

Introduction Venous sinus stenosis (VSS) stenting in medically refractory Idiopathic Intracranial Hypertension (IIH) patients has emerged as an effective treatment with low rates of failure and recurrence. However, the best treatment strategy following recurrence of symptoms in previously stented patients with initial response is unclear and frequently leads to shunt placement. We investigated the role of re‐stenting in patients with recurrence after prior successful stenting. Methods This is a retrospective review of a prospectively maintained IIH registry. Inclusion criteria included patients with confirmed IIH and angiographically demonstrable VSS who underwent interventions from 2012–2022. Patients were divided into those who underwent a single stenting procedure (Group S) and those who underwent placement of an additional stent due to recurrence of clinical symptoms and angiographic stenosis (Group R). All re‐stenting was performed in adjacent or remote regions of stenosis. Bivariate analyses were utilized to compare clinical outcomes. Results 86 patients were included with a median age of 33 [IQR 26‐39] and 94% were females. Group S (79/86) and Group R (7/86) had similar baseline characteristics. There was similar improvement in post‐stenting opening pressure (22.4±6.7 vs. 25.2±4.6 cm H2O, p = 0.35, Group S vs. Group R), change in opening pressure (11.6±10.4 vs. 5.3±12.2 cm H2O, p = 0.20, Group S vs. Group R) and resolution of tinnitus (91.8 vs. 80%, p = 0.28, Group S vs. Group R). Headache improvement was higher in Group S at 6 weeks, but similar at 6 months (92.8 vs. 60%, p = 0.02 and 88.2 vs. 80%, p = 0.59, Group S vs. Group R). Group S also had higher improvement in visual disturbances at 6 months (93.8 vs. 60%, p = 0.01, Group S vs. Group R), but similar improvement in papilledema (92.2 vs 100%, p = 0.68, Group S vs. Group R). None of the re‐stented patients required VPS rescue. Conclusions VSS re‐stenting in IIH patients with recurrence after initial stenting is feasible with similar efficacy in reducing intracranial pressure and symptoms.

Barbiturate coma treatment in children with refractory intracranial hypertension due to traumatic brain injury; is it useful?

In pediatric severe Traumatic Brain Injury (TBI) the appearance of refractory intracranial hypertension is related to an unfavourable prognosis. Severe TBI (ECG &lt;8) is present in 60% of polytrauma children and is associated with high morbidity and mortality. The monitoring of intracranial pressure (ICP) and the treatment of intracranial hypertension have been subjects of attention in neurotrauma for years in the evidence-based guidelines currently being a topic of discussion. Currently the guides based on evidenceshowing acceptance of some guidelines for the management of intracranial hypertension, within the most accepted of sedatives/analgesics, hyperosmolar agents (hypertonic saline solution HTS and mannitol) and barbiturates, although the level of evidence of these recommendations is insufficient to standardize such management in the centers of attention.

Transorbital Ultrasonography Used to Detect Papilledema, in a Patient With Intracranial Hypertension

Intracranial hypertension (IH) is an important cause of secondary brain injury, and it is often associated with poor outcomes; due to that monitoring of intracranial pressure (ICP) is essential for the management of neurocritical patients. Although invasive methods have been the gold standard for ICP monitoring, recent non-invasive ultrasonography techniques have been used to estimate ICP. Among the most used methods are the measurement of the diameter of the optic nerve sheath and transorbital ultrasonography to evaluate papilledema. This presented case is of a patient with refractory IH due to subarachnoid hemorrhage, measured through an intraventricular catheter. A transorbital sonogram was performed and showed the presence of papilledema.

Factors associated with post traumatic hydrocephalus following decompressive craniectomy: A single-center experience.

A decompressive craniectomy (DC) is a surgical procedure sometimes utilized to manage refractory intracranial hypertension following severe traumatic brain injury (sTBI). The previous studies have established a relationship between DC and post traumatic hydrocephalus (PTH). This study aimed to identify the factors responsible for developing shunt-amenable PTH in patients who underwent DC following sTBI. A review of a prospectively collected database of all patients admitted with severe TBI in a tertiary neurosurgical center in North-west England between January 2012 and May 2022 was performed. PTH was defined as evidence of progressive ventricular dilatation, clinical deterioration, and/or the eventual need for cerebrospinal fluid diversion (i.e., a ventriculoperitoneal shunt). Statistical analysis was carried out using IBM SPSS versus 28.0.1. Sixty-five patients met the eligibility criteria and were included in the study. The mean age of the PTH group was 31.38 ± 14.67, while the mean age of the non-PTH group was slightly higher at 39.96 ± 14.85. No statistically significant difference was observed between the two groups' mechanisms of traumatic injury (P = 0.945). Of the predictors investigated, cerebellar hematoma (and contusions) was significantly associated with PTH (P = 0.006). This study concludes that cerebellar hematoma (and contusions) are associated with developing PTH in patients undergoing DC.