Uncontrollable Intracranial Pressure Research Articles

Acute evacuation of 54 intracerebral hematomas (aICH) during the microsurgical clipping of a ruptured middle cerebral artery bifurcation aneurysm—illustration of the individual clinical courses and outcomes with a serial brain CT/MRI panel until 12 months

PurposeIn aneurysmal intracerebral hemorrhage (aICH), our review showed the lack of the patient’s individual (i) timeline panels and (ii) serial brain CT/MRI slice panels through the aICH evacuation and neurointensive care until the final brain tissue outcome.MethodsOur retrospective cohort consists of 54 consecutive aICH patients from a defined population who acutely underwent the clipping of a middle cerebral artery bifurcation saccular aneurysm (Mbif sIA) with the aICH evacuation at Kuopio University Hospital (KUH) from 2010 to 2019. We constructed the patient’s individual timeline panels since the emergency call and serial brain CT/MRI slice panels through the aICH evacuation and neurointensive care until the final brain tissue outcome. The patients were indicated by numbers (1.–54.) in the pseudonymized panels, tables, results, and discussion.ResultsThe aICH volumes on KUH admission (median 46 cm3) plotted against the time from the emergency call to the evacuation (median 8 hours) associated significantly with the rebleeds (n=25) and the deaths (n=12). The serial CT/MRI slice panels illustrated the aICHs, intraventricular hemorrhages (aIVHs), residuals after the aICH evacuations, perihematomal edema (PHE), delayed cerebral injury (DCI), and in the 42 survivors, the clinical outcome (mRS) and the brain tissue outcome.ConclusionsRegarding aICH evacuations, serial brain CT/MRI panels present more information than words, figures, and graphs. Re-bleeds associated with larger aICH volumes and worse outcomes. Swift logistics until the sIA occlusion with aICH evacuation is required, also in duty hours and weekends. Intraoperative CT is needed to illustrate the degree of aICH evacuation. PHE may evoke uncontrollable intracranial pressure (ICP) in spite of the acute aICH volume reduction.

Hypertonic Saline Versus Other Intracranial-Pressure-Lowering Agents for Patients with Acute Traumatic Brain Injury: A Systematic Review and Meta-analysis.

Acute traumatic brain injury (TBI) is a major cause of mortality and disability worldwide. Intracranial pressure (ICP)-lowering is a critical management priority in patients with moderate to severe acute TBI. We aimed to evaluate the clinical efficacy and safety of hypertonic saline (HTS) versus other ICP-lowering agents in patients with TBI. We conducted a systematic search from 2000 onward for randomized controlled trials (RCTs) comparing HTS vs. other ICP-lowering agents in patients with TBI of all ages. The primary outcome was the Glasgow Outcome Scale (GOS) score at 6months (PROSPERO CRD42022324370). Ten RCTs (760 patients) were included. Six RCTs were included in the quantitative analysis. There was no evidence of an effect of HTS on the GOS score (favorable vs. unfavorable) compared with other agents (risk ratio [RR] 0.82, 95% confidence interval [CI] 0.48-1.40; n = 406; 2 RCTs). There was no evidence of an effect of HTS on all-cause mortality (RR 0.96, 95% CI 0.60-1.55; n = 486; 5 RCTs) or total length of stay (RR 2.36, 95% CI - 0.53 to 5.25; n = 89; 3 RCTs). HTS was associated with adverse hypernatremia compared with other agents (RR 2.13, 95% CI 1.09-4.17; n = 386; 2 RCTs). The point estimate favored a reduction in uncontrolled ICP with HTS, but this was not statistically significant (RR 0.52, 95% CI 0.26-1.04; n = 423; 3 RCTs). Most included RCTs were at unclear or high risk of bias because of lack of blinding, incomplete outcome data, and selective reporting. We found no evidence of an effect of HTS on clinically important outcomes and that HTS is associated with adverse hypernatremia. The included evidence was of low to very low certainty, but ongoing RCTs may help to the reduce this uncertainty. In addition, heterogeneity in GOS score reporting reflects the need for a standardized TBI core outcome set.

Augmentation of Supratemporal Hollowing With Silicone Block During Autologous Cranioplasty After Decompressive Craniectomy With Additional Temporalis Resection.

Decompressive craniectomy is a potentially life-saving neurosurgical procedure. In cases of insufficient decompression, uncontrolled intracranial pressure even after sufficient decompression, or when the intracranial pressure is increased due to external factors such as intramuscular hematoma in the temporal muscle, additional temporalis resection may be necessary. However, the hollowing of the supratemporal fossa that occurs after additional temporalis resection can create a major cosmetic problem. Several alternatives are available to fill the hollowing of the supratemporal fossa during cranial reconstruction, but each has a disadvantage, whether it is expensive or difficult to shape for bilateral symmetry. The author solved the cosmetic problem by using a properly carved silicone block to fill the supratemporal fossa while conducting cranioplasty, and here reports it with a literature review.

Ventriculoperitoneal Shunt for CNS Metastasis in Breast Cancer: Clinical Outcomes Based on Intrinsic Subtype

BackgroundLeptomeningeal metastasis (LM) is associated with a grave prognosis in breast cancer (BC) and can be controlled with a ventriculoperitoneal shunt (VPS). Information regarding LM and VPS based on intrinsic subtype is limited; thus, we investigated the clinical outcomes of BC treated with VPS. Patients and MethodsThe present retrospective study comprised 70 patients diagnosed with LM who received a VPS. The patients were divided into 4 groups based on BC subtype: hormone receptor (HR)+/human epidermal growth factor receptor 2 (HER2)−, HR+/HER2+, HR−/HER2+, and triple negative BC (TNBC). ResultsThe most common indications for VPS were uncontrolled intracranial pressure (57.1%) and uncontrolled headache (55.7%), which improved in 54 (77.1%) of 70 patients after VPS. The median overall survival (OS) after brain or LM and overall survival after VPS were 7.6 and 2.3 months, respectively. Anti-HER2 treatment was a significant prognostic factor for better OS after brain or LM based on multivariate analysis (hazard ratio, 0.15; 95% confidence interval, 0.04-0.57; P = .005), whereas TNBC was correlated with shorter OS after central nervous system metastasis (hazard ratio, 2.82; 95% confidence interval, 1.46-5.48; P = .002). ConclusionsThere were significant differences in clinical outcome based on the intrinsic subtype of patients with BC with LM who received a VPS. Anti-HER2 treatment in patients with HER2+ BC was associated with better survival in patients with metastatic BC with VPS insertion compared with those without. Survival of metastatic BC with VPS remained poor, especially in the TNBC subgroup.

Hypertonic saline versus other intracranial pressure-lowering agents for people with acute traumatic brain injury.

Hypertonic saline versus other intracranial pressure-lowering agents for people with acute traumatic brain injury.

Subcutaneous bone flap storage after emergency craniectomy: cost-effectiveness and rate of resorption.

OBJECTIVEDecompressive craniectomy is used for uncontrolled intracranial pressure in traumatic brain injury and malignant hemispheric stroke. Subcutaneous preservation of the autologous bone flap in the abdomen is a simple, portable technique but has largely been abandoned due to perceived concerns of resorption. The authors sought to characterize their experience with subcutaneous preservation of the bone flap and cranioplasty.METHODSThe authors performed a retrospective single-institution review of subcutaneous preservation of the autologous bone flap after decompressive craniectomy from 2005 to 2015. The primary outcome was clinically significant bone resorption, defined as requiring a complete mesh implant at the time of cranioplasty, or delayed revision. The outcome also combined cases with any minor bone resorption to determine predictors of this outcome. Logistic regression modeling was used to determine the risk factors for predicting resorption. A cost comparison analysis was also used via the 2-sided t-test to compare the cost of cranioplasty using an autologous bone flap with standard custom implant costs.RESULTSA total of 193 patients with craniectomy were identified, 108 of whom received a cranioplasty. The mean time to cranioplasty was 104.31 days. Severe resorption occurred in 10 cases (9.26%): 4 were clinically significant (2 early and 2 late) and 6 demonstrated type II (severe) necrosis on CT, but did not require revision. Early resorption of any kind (mild or severe) occurred in 28 (25.93%) of 108 cases. Of the 108 patients, 26 (24.07%) required supplemental cranioplasty material. Late resorption of any kind (mild or severe) occurred in 6 (5.88%) of 102 cases. Of these, a clinically noticeable but nonoperative deformity was noted in 4 (3.92%) and minor (type I) necrosis on CT in 37 (37%) of 100. Bivariate analysis identified fragmentation of bone (OR 3.90, 95% CI 1.03-14.8), shunt-dependent hydrocephalus (OR 7.97, 95% CI 1.57-40.46), and presence of post-cranioplasty drain (OR 9.39, 95% CI 1.14-1000) to be significant risk factors for bone resorption. A binary logistic regression optimized using Fisher's scoring determined the optimal multivariable combination of factors. Fragmentation of bone (OR 5.84, 95% CI 1.38-28.78), diabetes (OR 7.61, 95% CI 1.37-44.56), and shunt-dependent hydrocephalus (OR 9.35, 95% CI 1.64-56.21) were found to be most predictive of resorption, with a C value of 0.78. Infections occurred in the subcutaneous pocket in 5 (2.60%) of the 193 cases and after cranioplasty in 10 (9.26%) of the 108 who underwent cranioplasty. The average cost of cranioplasty with autologous bone was $2156.28 ± $1144.60 (n = 15), and of a custom implant was $35,118.60 ± $2067.51 (3 different sizes; p < 0.0001).CONCLUSIONSCraniectomy with autologous bone cranioplasty using subcutaneous pocket storage is safe and compares favorably to cryopreservation in terms of resorption and favorably to a custom synthetic implant in terms of cost. While randomized data are required to definitively prove the superiority of one method, subcutaneous preservation has enough practical advantages with low risk to warrant routine use for most patients.

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.

Relationship between Intracranial Pressure or Cerebral Perfusion Pressure and Prognosis in Patients with Severe Traumatic Brain Injury Treated with Mild Hypothermia

Aims: The purpose of this study was to predict the clinical course by intracranial pressure (ICP) or cerebral perfusion pressure (CPP) in the acute phase and prognosis in patients with severe head trauma who underwent therapeutic mild hypothermia (HT). Methods: A consecutive 143 patients treated with HT for intracranial hypertension (ICH) in two trauma centers were included in this study. The pressure measured after computed tomography scanning was defined as the initial ICP or CPP. Outcome was assessed at 6 months according to the Glasgow Outcome Scale. ROC analysis was performed to clarify the threshold value of ICP/CPP predictive of ICP uncontrollable by HT. Results: The cutoff value of ICP for uncontrollable ICP obtained from ROC analysis was 32.5 mmHg (sensitivity: 0.545, specificity: 0.875), and that for CPP was 56.5 mmHg (sensitivity: 0.813, specificity: 0.663). Fifty-three (96.4%) of 55 patients whose initial ICP was greater than 32.5 mmHg and 67 (95.7%) of 70 patients whose initial CPP was less than 56.5 mmHg had developed uncontrollable ICP. Conclusion: The cutoff values predictive of ICP uncontrollable by HT from ROC analysis were 32.5 mmHg for ICP and 56.5 mmHg for CPP. For those patients with initial ICP greater than the cutoff value or an initial CPP less than the cutoff value, it may be harmful to prolong HT. The knowledge obtained from this study may be useful for considering the treatment strategy for severe traumatic brain injury.

The Combined Use of Cardiac Output and Intracranial Pressure Monitoring to Maintain Optimal Cerebral Perfusion Pressure and Minimize Complications for Severe Traumatic Brain Injury.

ObjectiveTo show the effect of dual monitoring including cardiac output (CO) and intracranial pressure (ICP) monitoring for severe traumatic brain injury (TBI) patiens. We hypothesized that meticulous treatment using dual monitoring is effective to sustain maintain minimal intensive care unit (ICU) complications and maintain optimal ICP and cerebral perfusion pressure (CPP) for severe TBI patiens.MethodsWe included severe TBI, below Glasgow Coma Scale (GCS) 8 and head abbreviation injury scale (AIS) >4 and performed decompressive craniectomy at trauma ICU of our hospital. We collected the demographic data, head AIS, injury severity score (ISS), initial GCS, ICU stay, sedation duration, fluid therapy related complications, Glasgow Outcome Scale (GOS) at 3 months and variable parameters of ICP and CO monitor.ResultsThirty patients with severe TBI were initially selected. Thirteen patients were excluded because 10 patients had fixed pupillary reflexes and 3 patients had uncontrolled ICP due to severe brain edema. Overall 17 patients had head AIS 5 except 2 patients and 10 patients (58.8%) had multiple traumas as mean ISS 29.1. Overall complication rate of the patients was 64.7%. Among the parameters of CO monitoring, high stroke volume variation is associated with fluid therapy related complications (p=0.043) and low cardiac contractibility is associated with these complications (p=0.009) statistically.ConclusionCombined use of CO and ICP monitors in severe TBI patients who could be necessary to decompressive craniectomy and postoperative sedation is good alternative methods to maintain an adequate ICP and CPP and reduce fluid therapy related complications during postoperative ICU care.

Barbiturates for acute traumatic brain injury

Raised intracranial pressure (ICP) is an important complication of severe brain injury, and is associated with high mortality. Barbiturates are believed to reduce ICP by suppressing cerebral metabolism, thus reducing cerebral metabolic demands and cerebral blood volume. However, barbiturates also reduce blood pressure and may, therefore, adversely effect cerebral perfusion pressure. To assess the effects of barbiturates in reducing mortality, disability and raised ICP in people with acute traumatic brain injury. To quantify any side effects resulting from the use of barbiturates. The following electronic databases were searched on 26 September 2012: CENTRAL (The Cochrane Library), MEDLINE (Ovid SP), PubMed, EMBASE (Ovid SP), PsycINFO (Ovid SP), PsycEXTRA (Ovid SP), ISI Web of Science: Science Citation Index and Conference Proceedings Citation Index-Science. Searching was not restricted by date, language or publication status. We also searched the reference lists of the included trials and review articles. We contacted researchers for information on ongoing studies. Randomised controlled trials of one or more of the barbiturate class of drugs, where study participants had clinically diagnosed acute traumatic brain injury of any severity. Two review authors screened the search results, extracted data and assessed the risk of bias in the trials. Data from seven trials involving 341 people are included in this review.For barbiturates versus no barbiturate, the pooled risk ratio (RR) of death from three trials was 1.09 (95% confidence interval (CI) 0.81 to 1.47). Death or disability, measured using the Glasgow Outcome Scale was assessed in two trials, the RR with barbiturates was 1.15 (95% CI 0.81 to 1.64). Two trials examined the effect of barbiturate therapy on ICP. In one, a smaller proportion of patients in the barbiturate group had uncontrolled ICP (68% versus 83%); the RR for uncontrolled ICP was 0.81 (95% CI 0.62 to 1.06). In the other, mean ICP was also lower in the barbiturate group. Barbiturate therapy results in an increased occurrence of hypotension (RR 1.80; 95% CI 1.19 to 2.70). For every four patients treated, one developed clinically significant hypotension. Mean body temperature was significantly lower in the barbiturate group.In one study of pentobarbital versus mannitol there was no difference in death between the two study groups (RR 1.21; 95% CI 0.75 to 1.94). Pentobarbital was less effective than mannitol for control of raised ICP (RR 1.75; 95% CI 1.05 to 2.92).In one study the RR of death with pentobarbital versus thiopental was 1.78 (95% CI 1.03 to 3.08) in favour of thiopental. Fewer people had uncontrollable ICP with thiopental (RR 1.64; 95% CI 1.03 to 2.60). There was no significant difference in the effects of pentobarbital versus thiopental for death or disability, measured using the Glasgow Outcome Scale (RR 1.31; 95% CI 0.88 to 1.94), or hypotension (RR 0.95; 95% CI 0.81 to 1.12). There is no evidence that barbiturate therapy in patients with acute severe head injury improves outcome. Barbiturate therapy results in a fall in blood pressure in one in four patients. This hypotensive effect will offset any ICP lowering effect on cerebral perfusion pressure.

Role of quantitative CSF microscopy to predict culture status and outcome in HIV-associated cryptococcal meningitis in a Brazilian cohort

This retrospective study aimed to evaluate the clinical, laboratory, and quantitative cerebrospinal fluid (CSF) cryptococcal cell counts for associations with in-hospital outcomes of HIV-infected patients with cryptococcal meningitis. Ninety-eight HIV-infected adult patients with CSF culture-proven cryptococcal meningitis were admitted between January 2006 and June 2008 at a referral center in Sao Paulo, Brazil. Cryptococcal meningitis was the first AIDS-defining illness in 69%, of whom 97% (95/98) had known prior HIV infection. The median CD4+ T-cell count was 39 cells/μL (interquartile range 17–87 cells/μL). Prior antiretroviral therapy was reported in 50%. Failure to sterilize the CSF by 7–14 days was associated with baseline fungal burden of ≥10 yeasts/μL by quantitative CSF microscopy (odds ratio [OR] = 15.3, 95% confidence interval [CI] 4.1–56.7; P < 0.001) and positive blood cultures (OR = 11.5, 95% CI 1.2–109; P = 0.034). At 7–14 days, ≥10 yeasts/μL CSF was associated with positive CSF cultures in 98% versus 36% with <10 yeasts/μL CSF (P < 0.001). In-hospital mortality was 30% and was associated with symptoms duration for >14 days, altered mental status (P < 0.001), CSF white blood cell counts <5 cells/μL (P = 0.027), intracranial hypertension (P = 0.011), viral loads >50,000 copies/mL (P = 0.036), ≥10 yeasts/μL CSF at 7–14 days (P = 0.038), and intracranial pressure >50 cmH20 at 7–14 days (P = 0.007). In conclusion, most patients were aware of their HIV status. Fungal burden of ≥10 yeasts/μL by quantitative CSF microscopy predicted current CSF culture status and may be useful to customize the induction therapy. High uncontrolled intracranial pressure was associated with mortality.

Intracranial pressure and hypothermia

Although the neuroprotective potential of hypothermia is well known and has been established experimentally, its clinical use is limited to selected indications [1], as large trials have yielded disappointing results [2]. This has been mainly attributed to the side effects of hypothermia in critically ill patients and problems with rewarming. Intracranial hypertension is a major problem in neurocritical care and particularly in patients with subarachnoid hemorrhage (SAH) and traumatic brain injury (TBI), causing death if uncontrolled. As trials on prophylactic hypothermia, for example, for TBI have not been successful in improving outcome, its routine use can currently not be recommended. However, there are many literature reports demonstrating enormous efficacy of hypothermia to reduce elevated intracranial pressure (ICP). Mechanisms of action are thought to be the reduction of metabolism and perfusion and the reduction of edema besides others. Studies have indicated that therapeutic efficacy is sufficient for ICP control at mild hypothermia of 35°C, thus minimizing detrimental effects. In desperate clinical situations hypothermia is used to control intracranial hypertension both for TBI and SAH, but it has recently been applied only as a last resort. Other second-tier therapies and surgical maneuvers like decompressive craniectomy have been popularized instead, although their efficacy is still questioned as well. The knowledge and experience with therapeutic hypothermia has advanced in recent years and the problems of side effects and most importantly rewarming can be better addressed [3]. The latter has been a tremendous problem in patients with uncontrollable ICP, as despite its initial efficacy ICP problems recurred, if hypothermia was stopped prematurely. This goes in line with a recent metaanalysis that stressed the importance of prolonged hypothermia (48 hours to 5 days) and of slow rewarming (<1°C/4 hours). As a consequence the Eurotherm3235Trial was initiated to investigate the effect of hypothermia particularly for intracranial pressure reduction [4]. It has to be awaited whether this will foster the use of hypothermia to treat elevated ICP or whether we will stick with the policy of controlled normothermia.

Chapter 11. Barbiturates

Chapter 11. Barbiturates

Chapter 4. Threshold for treatment of intracranial hypertension

Chapter 4. Threshold for treatment of intracranial hypertension

Chapter 8. Hyperosmolar therapy

Chapter 8. Hyperosmolar therapy

Severe traumatic brain injury in children—a single center experience regarding therapy and long-term outcome

The impact of intracranial pressure (ICP), decompressive craniectomy (DC), extent of ICP therapy, and extracranial complications on long-term outcome in a single-center pediatric patient population with severe traumatic brain injury (TBI) is examined. Data of pediatric (≤16 years) TBI patients were retrospectively reviewed using a prospectively acquired database on neurosurgical interventions between April 1996 and March 2007 at the Charité Berlin. The patients' records, neuroimages, admission Glasgow Coma Scale (GCS) score, the time to craniectomy for hematoma evacuation/DC, and the extent of ICP therapy were reviewed. Twelve-month and long-term outcome was evaluated (Glasgow Outcome Scale). Fifty-three pediatric TBI patients [mean age 8.41 (0-16) years] were studied. Patients were categorized into two groups, with DC (n = 14) and without DC (n = 39). DC was performed 3 ± 3.98 median, quartiles 2 (0-3.75) days post-trauma. In the majority of children (n = 9; 64%), surgical decompression was performed early within 2 days post-trauma. (0.8 ± 0.9 days). The DC group tended to be older (median age 12 vs. 7 years, p = 0.052), had a lower GCS (3 vs. 6.5, p < 0.01), and had a 3-fold longer stay on the ICU (20 vs. 6.5 days, p < 0.03) compared to the conservatively treated group. Mean follow-up duration (n = 30) was 5.2 ± 2.4 years (range 1-10.5). At the most recent follow-up examination, 92% of survivors had returned to school. Though initial GCS was worse in pediatric TBI patients who underwent decompressive craniectomy compared to the conservatively treated patients, long-term outcome was comparable. In children, decompressive craniectomy might be favored early in the management of uncontrollable ICP.

Impact of Decompressive Craniectomy on Functional Outcome After Severe Traumatic Brain Injury

The beneficial effect of decompressive craniectomy (DC) in the treatment of traumatic brain injury (TBI) remains controversial. In many centers, it is used as a salvage procedure for uncontrollable intracranial pressure (ICP). It is our contention that DC represents a viable early option for head trauma patients. The purpose of this study was to evaluate the efficacy of DC on functional outcome after severe TBI in the largest single institutional series reported in the literature. Patients with severe TBI (Abbreviated Injury Score 4-5) treated with DC for the management of increased ICP during 6-year period were identified from the trauma registry. Functional outcome was measured 1 year to 6 years postinjury using the Glasgow Outcome Score Extended (GOSE) via telephone interview and classified as good (GOSE 5-8) or poor (GOSE 1-4, including death). Outcomes were compared using Wilcoxon rank-sum and chi2 tests where appropriate. One hundred and seventy-one patients were identified: 137 (80%) men and 34 (20%) women. Overall mortality (all in-hospital) was 32% (head-related = 22%). Of the 117 survivors, follow-up was obtained in all but 6 (95%). Good outcome was achieved in 96 patients (56% overall, 82% of survivors). Those with good outcome were younger (26 years vs. 43 years, p = 0.0028) and experienced a greater change in predecompression to postdecompression ICP (ICP reduced by 23 mm Hg vs. 10 mm Hg, p < 0.0001). Not surprisingly, unchanged ICP (predecompression to postdecompression) was associated with poor outcome (p = 0.0031). There was no difference in immediate predecompression ICP between survivors versus nonsurvivors. However, immediate predecompression Glasgow Coma Score was significantly higher in survivors compared with nonsurvivors (7 vs. 5, p < 0.0001). DC resulted in good functional outcome in >50% of patients with severe TBI. The greatest benefit was observed in younger patients with a demonstrable reduction in ICP after decompression. The prospect of improved functional outcome offered by this procedure in the treatment of severe TBI warrants prospective investigation.

Brain cytokine flux in acute liver failure and its relationship with intracranial hypertension

In acute liver failure (ALF), it is unclear whether the systemic inflammatory response associated with intracranial hypertension is related to brain cytokine production. To determine the relationship of brain cytokine production with severity of intracranial hypertension in ALF patients. We studied 16 patients with ALF. All patients were mechanically ventilated and cerebral blood flow measured using the Kety-Schmidt technique and intracranial pressure (ICP) measured with a Camino subdural catheter. We sampled blood from an artery and a reverse jugular catheter to measure proinflammatory cytokines (TNF-alpha, IL-6 and IL-1beta) and ammonia. Additionally, in 3 patients, serial samples were obtained over a 72 h period. In ALF patients a good correlation between arterial pro-inflammatory cytokines and ICP (r (2) = 0.34, 0.50 and 0.52; for IL-6, IL-1beta and TNF-alpha respectively) was observed. There was a positive cerebral cytokine 'flux' (production), in ALF patients with uncontrolled ICP. Plasma ammonia between groups was not statistically significant. In the ALF patients studied longitudinally, brain proinflammatory cytokine production was associated with uncontrolled ICP. Our results provide novel data supporting brain production of cytokines in patients with uncontrolled intracranial hypertension indicating activation of the inflammatory cascade in the brain. Also, the appearance of these cytokines in the jugular bulb catheter may indicate a compromised blood brain barrier at this late stage.

Bridging hyperacute liver failure by ABO-incompatible auxiliary partial orthotopic liver transplantation

Uncontrollable intracranial pressure elevation in hyperacute liver failure often proves fatal if no suitable liver for transplantation is found in due time. Both ABO-compatible and auxiliary partial orthotopic liver transplantation have been described to control such scenario. However, each method is associated with downsides in terms of immunobiology, organ availability and effects on the overall waiting list.

Outcome following decompressive craniectomy for malignant swelling due to severe head injury

The aim of this study was to assess outcome following decompressive craniectomy for malignant brain swelling due to closed traumatic brain injury (TBI). During a 48-month period (March 2000-March 2004), 50 of 967 consecutive patients with closed TBI experienced diffuse brain swelling and underwent decompressive craniectomy, without removal of clots or contusion, to control intracranial pressure (ICP) or to reverse dangerous brain shifts. Diffuse injury was demonstrated in 44 patients, an evacuated mass lesion in four in whom decompressive craniectomy had been performed as a separate procedure, and a nonevacuated mass lesion in two. Decompressive craniectomy was performed urgently in 10 patients before ICP monitoring; in 40 patients the procedure was performed after ICP had become unresponsive to conventional medical management as outlined in the American Association of Neurological Surgeons guidelines. Survivors were followed up for at least 3 months posttreatment to determine their Glasgow Outcome Scale (GOS) score. Decompressive craniectomy lowered ICP to less than 20 mm Hg in 85% of patients. In the 40 patients who had undergone ICP monitoring before decompression, ICP decreased from a mean of 23.9 to 14.4 mm Hg (p < 0.001). Fourteen of 50 patients died, and 16 either remained in a vegetative state (seven patients) or were severely disabled (nine patients). Twenty patients had a good outcome (GOS Score 4-5). Among 30-day survivors, good outcome occurred in 17, 67, and 67% of patients with postresuscitation Glasgow Coma Scale scores of 3 to 5, 6 to 8, and 9 to 15, respectively (p < 0.05). Outcome was unaffected by abnormal pupillary response to light, timing of decompressive craniectomy, brain shift as demonstrated on computerized tomography scanning, and patient age, possibly because of the small number of patients in each of the subsets. Complications included hydrocephalus (five patients), hemorrhagic swelling ipsilateral to the craniectomy site (eight patients), and subdural hygroma (25 patients). Decompressive craniectomy was associated with a better-than-expected functional outcome in patients with medically uncontrollable ICP and/or brain herniation, compared with outcomes in other control cohorts reported on in the literature.