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1.
Celeste Dias Isabel Maia António Cerejo Georgios Varsos Peter Smielewski José-Artur Paiva Marek Czosnyka 《Neurocritical care》2014,21(1):124-132
Background
Plateau waves are common in traumatic brain injury. They constitute abrupt increases of intracranial pressure (ICP) above 40 mmHg associated with a decrease in cerebral perfusion pressure (CPP). The aim of this study was to describe plateau waves characteristics with multimodal brain monitoring in head injured patients admitted in neurocritical care.Methods
Prospective observational study in 18 multiple trauma patients with head injury admitted to Neurocritical Care Unit of Hospital Sao Joao in Porto. Multimodal systemic and brain monitoring of primary variables [heart rate, arterial blood pressure, ICP, CPP, pulse amplitude, end tidal CO2, brain temperature, brain tissue oxygenation pressure, cerebral oximetry (CO) with transcutaneous near-infrared spectroscopy and cerebral blood flow (CBF)] and secondary variables related to cerebral compensatory reserve and cerebrovascular reactivity were supported by dedicated software ICM+ (www.neurosurg.cam.ac.uk/icmplus). The compiled data were analyzed in patients who developed plateau waves.Results
In this study we identified 59 plateau waves that occurred in 44 % of the patients (8/18). During plateau waves CBF, cerebrovascular resistance, CO, and brain tissue oxygenation decreased. The duration and magnitude of plateau waves were greater in patients with working cerebrovascular reactivity. After the end of plateau wave, a hyperemic response was recorded in 64 % of cases with increase in CBF and brain oxygenation. The magnitude of hyperemia was associated with better autoregulation status and low oxygenation levels at baseline.Conclusions
Multimodal brain monitoring facilitates identification and understanding of intrinsic vascular brain phenomenon, such as plateau waves, and may help the adequate management of acute head injury at bed side. 相似文献2.
Alberto Facchini Sandra Magnoni Vittorio Civelli Fabio Triulzi Mario Nosotti Nino Stocchetti 《Neurocritical care》2013,19(3):376-380
Introduction
Posterior reversible encephalopathy syndrome (PRES) is a largely reversible disease with long-term favorable outcome. A minority of patients, however, may develop progressive cerebral edema and ischemia resulting in severe disability or death. We report a case of severe intracranial hypertension associated with PRES that was successfully treated according to intracranial pressure (ICP)- and cerebral perfusion pressure (CPP)-driven therapy.Methods
Case report.Results
A 42-year-old woman underwent bilateral lung transplantation for severe bronchiectasis. Her immunosuppressive regimen consisted of azathioprine, prednisone, and tacrolimus. She acutely developed an aggressive form of PRES that rapidly resulted in severe refractory intracranial hypertension despite discontinuation of potentially causative medications and adequate supportive therapy. Accordingly, second-tier therapies, including barbiturate infusion, were instituted and immunosuppression was switched to anti-thymocyte globulin followed by mycophenolate mofetil. Within 10 h of barbiturate administration, ICP dropped to 20 mmHg. Thiopental was administered for two days and then rapidly tapered because of severe urosepsis. Six months after discharge from the intensive care unit the patient returned to near-normal life, her only complaint being short-term amnesia.Conclusions
The decision to undertake ICP monitoring in medical conditions in which no clear recommendations exist greatly relies on physicians’ judgment. This case suggests that ICP monitoring may be considered in the setting of acute PRES among selected patients, when severe intracranial hypertension is suspected, provided that a multidisciplinary team of neurocritical care specialists is readily available. 相似文献3.
Christian Roth Andreas Ferbert Wolfgang Deinsberger Jens Kleffmann Stefanie Kästner Jana Godau Marc Schüler Michael Tryba Markus Gehling 《Neurocritical care》2014,21(2):186-191
Purpose
The objective of our trial was to obtain more comprehensive data on the risks and benefits of kinetic therapy in intensive care patients with intracerebral pathology.Methods
Standardized data of prone positioning in our NeuroIntensive Care Unit were collected from 2007 onward. A post hoc analysis of all available data was undertaken, with special consideration given to values of intracranial pressure (ICP), cerebral perfusion pressure (CPP) and oxygenation in correlation to prone (PP), or supine positioning (SP) of patients. Cases were considered eligible if kinetic therapy and ICP were documented. Prone positioning was performed in a 135° position for 8 h per treatment unit.Results
A total of 115 patients treated with prone positioning from 2007 to 2013 were identified in our medical records. Of these, 29 patients received ICP monitoring. Overall, 119 treatment units of prone positioning with a mean duration of 2.5 days per patient were performed. The mean baseline ICP in SP was 9.5 ± 5.9 mmHg and was increased significantly during PP (p < 0.0001). There was no significant difference between CPP in SP (82 ± 14.5 mmHg) compared to PP (p > 0.05). ICP values >20 mmHg occurred more often during PP than SP (p < 0.0001) and were associated with significantly more episodes of decreased CPP <70 mmHg (p < 0.0022). The mean paO2/FiO2 ratio (P/F ratio) was increased significantly in prone positioning of patients (p < 0.0001).Conclusions
The analyzed data allow a more precise understanding of changes in ICP and oxygenation during prone positioning in patients with acute brain injury and almost normal baseline ICP. Our study shows a moderate, yet significant elevation of ICP during prone positioning. However, the achieved increase of oxygenation by far exceeded the changes in ICP. It is evident that continuous monitoring of cerebral pressure is required in this patient group. 相似文献4.
Linda C. Wendell N. Stevenson Potter Julie L. Roth Stephen P. Salloway Bradford B. Thompson 《Neurocritical care》2013,19(1):111-115
Background
Eastern Equine Encephalitis (EEE) virus is an arbovirus that mostly causes asymptomatic infection in humans; however, some people can develop a neuroinvasive infection associated with a high mortality.Methods
We present a case of a patient with severe neuroinvasive EEE.Results
A 21-year-old man initially presented with headache, fever, and vomiting and was found to have a neutrophilic pleocytosis in his cerebrospinal fluid. He eventually was diagnosed with EEE, treated with high-dose methylprednisolone and intravenous immunoglobulin. His course in the NeuroIntensive Care Unit was complicated by cerebral edema and intracranial hypertension, requiring osmotherapy, pentobarbital and placement of an external ventricular device, and subclinical seizures, necessitating multiple anti-epileptic drugsConclusions
A multifaceted approach including aggressive management of cerebral edema and ICP as well as treatment with immunomodulating agents and cessation of seizures may prevent brain herniation, secondary neurologic injury and death in patients with EEE. Effective management and treatment in our patient contributed to a dramatic recovery and ultimate good outcome. 相似文献5.
Enyinna L. Nwachuku Ava M. Puccio Anita Fetzick Bobby Scruggs Yue-Fang Chang Lori A. Shutter David O. Okonkwo 《Neurocritical care》2014,20(1):49-53
Introduction
There is clinical equipoise regarding whether neurointensive care unit management of external ventricular drains (EVD) in severe traumatic brain injury (TBI) should involve an open EVD, with continuous drainage of cerebrospinal fluid (CSF), versus a closed EVD, with intermittent opening as necessary to drain CSF. In a matched cohort design, we assessed the relative impact of continuous versus intermittent CSF drainage on intracranial pressure in the management of adult severe TBI.Methods
Sixty-two severe TBI patients were assessed. Thirty-one patients managed by open EVD drainage were matched by age, sex, and injury severity (initial Glasgow Coma Scale (GCS) score) to 31 patients treated with a closed EVD drainage. Patients in the open EVD group also had a parenchymal intracranial pressure (ICP) monitor placed through an adjacent burr hole, allowing real-time recording of ICP. Hourly ICP and other pertinent data, such as length of stay in intensive care unit (LOS-ICU), Injury Severity Score, and survival status, were extracted from our prospective database.Results
With age, injury severity (initial GCS score), and neurosurgical intervention adjusted for, there was a statistically significant difference of 5.66 mmHg in mean ICP (p < 0.0001) between the open and the closed EVD groups, with the closed EVD group exhibiting greater mean ICP. ICP burden (ICP ≥ 20 mmHg) was shown to be significantly higher in the intermittent EVD group (p = 0.0002) in comparison with the continuous EVD group.Conclusion
Continuous CSF drainage via an open EVD seemed to be associated with more effective ICP control in the management of adult severe TBI. 相似文献6.
Akiyoshi Yokote Yasuo Aihara Seiichiro Eguchi Yoshikazu Okada 《Child's nervous system》2013,29(8):1363-1367
Introduction
One of the goals of cranial vault expansion performed in patients with craniosynostosis (CS) is to reduce the harmful effects associated with elevated intracranial pressure (ICP). Until now, clear guidelines on when cranial vault expansion should take place have not been established except in unacceptable cosmetic deformities.Materials and methods
This paper illustrates the potential benefit of ICP monitoring in determining the time of surgery. The ICP of six patients (ranging from 7 months to 8 years) was measured before and after surgery. For the first time, we regulated end-tidal carbon dioxide, the position and movements, the level of sedation and the monitoring site of our patients under anesthesia to report accurate ICP readings.Results
The mean pre- and postoperative ICPs were 14.7 and 4.2 mmHg, respectively. Pressure sensor was placed through a burr hole under general anesthesia and remained through all stages of recording. Though ICP monitoring has been reported before, the physiological fluctuations of ICP and patient’s condition affected results. Under our ICP monitoring protocol, the six-patient study represents a suggestion to standardize ICP measurements under certain conditions in order to improve the reproducibility of ICP monitoring and therefore establish the need for optimal timing of cranial vault expansion in pediatrics.Conclusion
Although we cannot clearly define the indications and establish normal pediatric ICP values from the result of this study because of the small number of cases and some other limitations, this is a new approach to define ICP increase as a potential indication for surgery in CS. 相似文献7.
Jennifer A. Frontera John J. Lewin III Alejandro A. Rabinstein Imo P. Aisiku Anne W. Alexandrov Aaron M. Cook Gregory J. del Zoppo Monisha A. Kumar Ellinor I. B. Peerschke Michael F. Stiefel Jeanne S Teitelbaum Katja E. Wartenberg Cindy L. Zerfoss 《Neurocritical care》2016,24(1):6-46
Background
The use of antithrombotic agents, including anticoagulants, antiplatelet agents, and thrombolytics has increased over the last decade and is expected to continue to rise. Although antithrombotic-associated intracranial hemorrhage can be devastating, rapid reversal of coagulopathy may help limit hematoma expansion and improve outcomes.Methods
The Neurocritical Care Society, in conjunction with the Society of Critical Care Medicine, organized an international, multi-institutional committee with expertise in neurocritical care, neurology, neurosurgery, stroke, hematology, hemato-pathology, emergency medicine, pharmacy, nursing, and guideline development to evaluate the literature and develop an evidence-based practice guideline. Formalized literature searches were conducted, and studies meeting the criteria established by the committee were evaluated.Results
Utilizing the GRADE methodology, the committee developed recommendations for reversal of vitamin K antagonists, direct factor Xa antagonists, direct thrombin inhibitors, unfractionated heparin, low-molecular weight heparin, heparinoids, pentasaccharides, thrombolytics, and antiplatelet agents in the setting of intracranial hemorrhage.Conclusions
This guideline provides timely, evidence-based reversal strategies to assist practitioners in the care of patients with antithrombotic-associated intracranial hemorrhage.8.
Deborah M. Stein Megan Brenner Peter F. Hu Shiming Yang Erin C. Hall Lynn G. Stansbury Jay Menaker Thomas M. Scalea 《Neurocritical care》2013,18(3):332-340
Background
We asked whether continuous intracranial pressure (ICP) monitoring data could provide objective measures of the degree and timing of intracranial hypertension (ICH) in the first week of neurotrauma critical care and whether such data could be linked to outcome.Methods
We enrolled adult (>17 years old) patients admitted to our Level I trauma center within 6 h of severe TBI. ICP data were automatically captured and ICP 5-minute means were grouped into 12-hour time periods from admission (hour 0) to >7 days (hour 180). Means, maximum, percent time (% time), and pressure-times-time dose (PTD, mmHg h) of ICP >20 mmHg and >30 mmHg were calculated for each time period.Results
From 2008 to 2010, we enrolled 191 patients. Only 2.1 % had no episodes of ICH. The timing of maximum PTD20 was relatively equally distributed across the 15 time periods. Median ICP, PTD20, %time20, and %time30 were all significantly higher in the 84–180 h time period than the 0–84 h time period. Stratified by functional outcome, those with poor functional outcome had significantly more ICH in hours 84–180. Multivariate analysis revealed that, after 84 h of monitoring, every 5 % increase in PTD20 was independently associated with 21 % higher odds of having a poor functional outcome (adjusted odds ratio = 1.21, 95 % CI 1.02–1.42, p = 0.03).Conclusions
Although early elevations in ICP occur, ICPs are the highest later in the hospital course than previously understood, and temporal patterns of ICP elevation are associated with functional outcome. Understanding this temporal nature of secondary insults has significant implications for management. 相似文献9.
James J. Riviello Jr. Jan Claassen Suzette M. LaRoche Michael R. Sperling Brian Alldredge Thomas P. Bleck Tracy Glauser Lori Shutter David M. Treiman Paul M. Vespa Rodney Bell Gretchen M. Brophy 《Neurocritical care》2013,18(2):193-200
Background
As part of the development of the Neurocritical Care Society (NCS) Status Epilepticus (SE) Guidelines, the NCS SE Writing Committee conducted an international survey of SE experts.Methods
The survey consisted of three patient vignettes (case 1, an adult; case 2, an adolescent; case 3, a child) and questions regarding treatment. The questions for each case focused on initial and sequential therapy as well as when to use continuous intravenous (cIV) therapy and for what duration. Responses were obtained from 60/120 (50%) of those surveyed.Results
This survey reveals that there is expert consensus for using intravenous lorazepam for the emergent (first-line) therapy of SE in children and adults. For urgent (second-line) therapy, the most common agents chosen were phenytoin/fosphenytoin, valproate sodium, and levetiracetam; these choices varied by the patient age in the case scenarios. Physicians who care for adult patients chose cIV therapy for RSE, especially midazolam and propofol, rather than a standard AED sooner than those who care for children; and in children, there is a reluctance to choose propofol. Pentobarbital was chosen later in the therapy for all ages.Conclusion
There is close agreement between the recently published NCS guideline for SE and this survey of experts in the treatment of SE. 相似文献10.
Aries MJ Czosnyka M Budohoski KP Kolias AG Radolovich DK Lavinio A Pickard JD Smielewski P 《Neurocritical care》2012,17(1):67-76
Background
Guidelines for the management of traumatic brain injury (TBI) call for the development of accurate methods for assessment of the relationship between cerebral perfusion pressure (CPP) and cerebral autoregulation and to determine the influence of quantitative indices of pressure autoregulation on outcome. We investigated the relationship between slow fluctuations of arterial blood pressure (ABP) and intracranial pressure (ICP) pulse amplitude (an index called PAx) using a moving correlation technique to reflect the state of cerebral vasoreactivity and compared it to the index of pressure reactivity (PRx) as a moving correlation coefficient between averaged values of ABP and ICP.Methods
A retrospective analysis of prospective 327 TBI patients (admitted on neurocritical care unit of a university hospital in the period 2003?C2009) with continuous ABP and ICP monitoring.Results
PAx was worse in patients who died compared to those who survived (?0.04?±?0.15 vs. ?0.16?±?0.15, ??2?=?28, p?0.001). In contrast to PRx, PAx was able to differentiate between fatal and non-fatal outcome in a group of 120 patients with ICP levels below 15?mmHg (?0.04?±?0.16 vs. ?0.14?±?0.16, ??2?=?6, p?=?0.01).Conclusions
PAx is a new modified index of cerebrovascular reactivity which performs equally well as established PRx in long-term monitoring in severe TBI patients, but importantly is potentially more robust at lower values of ICP. In view of establishing an autoregulation-oriented CPP therapy, continuous determination of PAx is feasible but its value has to be evaluated in a prospective controlled trail. 相似文献11.
C. M. Kowoll C. Dohmen J. Kahmann R. Dziewas I. Schirotzek O. W. Sakowitz J. Bösel 《Neurocritical care》2014,20(2):176-186
Background
Optimal management of physiological parameters in neurological/neurosurgical intensive care units (NICUs) is largely unclear as high-quality evidence is lacking. The aim of this survey was to investigate if standards exist in the use of clinical scores, systemic and cerebral monitoring and the targeting of physiology values and in what way this affects clinical management in German NICUs.Methods
National survey, on-line anonymized questionnaire. German departments stating to run a neurological, neurosurgical or interdisciplinary neurological/neurosurgical intensive care unit were identified by a web-based search of all German hospitals and contacted via email.Results
Responses from 78 German NICUs were obtained. Of 19 proposed clinical/laboratory/radiological scores only 5 were used regularly by >60 %. Bedside neuromonitoring (NM) predominantly consisted of transcranial Doppler sonography (94 %), electroencephalography (92 %) and measurement of intracranial pressure (ICP) (90 %), and was installed if patients had or were threatened by elevated ICP (86 %), had specific diseases like subarachnoid hemorrhage (51 %) or were comatose (35 %). Although mean trigger values for interventions complied with guidelines or wide-spread customs, individual trigger values varied widely, e.g., for hyperglycemia (maximum blood glucose between 120 and 250 mg/dl) or for anemia (minimum hemoglobin values between 5 and 10 g/dl).Conclusions
Although apparently aiming for standardization in neurocritical care, German NICUs show substantial differences in NM and monitoring-associated interventions. In terms of scoring and monitoring methods, German NICUs seem to be quite conservative. These survey results suggest a need of prospective and randomized interventional trials in neurocritical care to help define standards and target values. 相似文献12.
Lori Kennedy Madden Michelle Hill Teresa L. May Theresa Human Mary McKenna Guanci Judith Jacobi Melissa V. Moreda Neeraj Badjatia 《Neurocritical care》2017,27(3):468-487
Background
Targeted temperature management (TTM) is often used in neurocritical care to minimize secondary neurologic injury and improve outcomes. TTM encompasses therapeutic hypothermia, controlled normothermia, and treatment of fever. TTM is best supported by evidence from neonatal hypoxic-ischemic encephalopathy and out-of-hospital cardiac arrest, although it has also been explored in ischemic stroke, traumatic brain injury, and intracranial hemorrhage patients. Critical care clinicians using TTM must select appropriate cooling techniques, provide a reasonable rate of cooling, manage shivering, and ensure adequate patient monitoring among other challenges.Methods
The Neurocritical Care Society recruited experts in neurocritical care, nursing, and pharmacotherapy to form a writing Committee in 2015. The group generated a set of 16 clinical questions relevant to TTM using the PICO format. With the assistance of a research librarian, the Committee undertook a comprehensive literature search with no back date through November 2016 with additional references up to March 2017.Results
The Committee utilized GRADE methodology to adjudicate the quality of evidence as high, moderate, low, or very low based on their confidence that the estimate of effect approximated the true effect. They generated recommendations regarding the implementation of TTM based on this systematic review only after considering the quality of evidence, relative risks and benefits, patient values and preferences, and resource allocation.Conclusion
This guideline is intended for neurocritical care clinicians who have chosen to use TTM in patient care; it is not meant to provide guidance regarding the clinical indications for TTM itself. While there are areas of TTM practice where clear evidence guides strong recommendations, many of the recommendations are conditional, and must be contextualized to individual patient and system needs.13.
Linda C. Wendell Amir Khan Jonathan Raser Shih-Shan Lang Neil Malhotra W. Andrew Kofke Peter LeRoux Soojin Park Joshua M. Levine 《Neurocritical care》2010,13(1):113-117
Background
Ornithine transcarbamylase deficiency (OTCD) is the most common of the urea cycle disorders and results in an accumulation of ammonia and its metabolites. Excess ammonia in the brain is metabolized to glutamine, which increases intracellular osmolarity and contributes to cytotoxic edema.Methods
We report a case of a woman heterozygous for OTCD who developed acute hyperammonemic encephalopathy and increased intracranial pressure (ICP).Results
Despite hemodialysis, protein restriction, and administration of pharmacologic nitrogen scavengers, she developed progressive cerebral edema and increased ICP that was refractory to maximal medical management. She underwent a bifrontal decompressive craniectomy resulting in resolution of her intracranial hypertension.Conclusion
Aggressive multimodality management of the patient coupled with bifrontal decompressive hemicraniectomy was a life-saving measure, offering the patient a reasonable outcome. At 6 month follow-up she had moderate disability on the Glasgow Outcome Score associated with cognitive difficulties. 相似文献14.
Christian Sass Christoph Kosinski Patrick Schmidt Michael Mull Jörg Schulz Johannes Schiefer 《Neurocritical care》2013,19(1):116-118
Background
Spontaneous intracranial hypotension (SIH) is a neurologic condition with the prototypical symptom of orthostatic headache. We report a dramatic case of SIH with life-threatening bilateral hygroma and uncal herniation.Methods
Case report.Results
A 44-year-old male patient presenting with orthostatic headache and double vision was diagnosed with SIH. Diagnostic imaging showed meningeal enhancement and bilateral hygroma. A conservative treatment regime was initiated. The patient’s condition rapidly deteriorated with progressive loss of consciousness. Cranial MRI showed beginning uncal herniation. As an emergency treatment measure, an intracranial pressure (ICP) probe was inserted and intrathecal lumbal saline infusion was initiated. This led to a stabilization of ICP and allowed further diagnostics and treatment.Conclusion
Intrathecal lumbal saline infusion in combination with ICP monitoring can be a life-saving treatment option in unstable SIH patients. 相似文献15.
Hannah C. Glass Sonia L. Bonifacio Susan Peloquin Thomas Shimotake Sally Sehring Yao Sun Joseph Sullivan Elizabeth Rogers A. James Barkovich David Rowitch Donna M. Ferriero 《Neurocritical care》2010,12(3):421-429
Background
To describe the concept, implementation, patient characteristics, and preliminary outcomes of a Neonatal Neurocritical Care Service (NNCS) recently established at the University of California, San Francisco.Methods
The NNCS was developed to better address the special needs of neonates at risk for neurological injury. The service combines dedicated neurological care, specialized neonatal medical and nursing expertise, neuromonitoring, neuroimaging, neurodevelopmental care, and long-term follow up. Newborns evaluated by the NNCS between July 2008 and June 2009 were included in the analysis. Demographic data (gestational age at birth, sex, admission diagnosis, and reason for consult), outcome (mortality, length of stay), and neurophysiology and imaging resources were extracted from patient charts.Results
Over the 12-month period, 155 newborns were evaluated (approximately 25% of all admissions); of these, 51 were preterm (<36 weeks gestation) and 104 were term. Approximately half were admitted for primary medical diagnoses, such as preterm birth, congenital malformations or apnea/apparent life-threatening event (ALTE), with the remainder admitted for primary neurological problems, including perinatal asphyxia, seizures/possible seizures, or congenital cerebral malformation. The most common neurological diagnoses were hypoxic-ischemic encephalopathy (38%) and seizure (35%). Among preterm newborns, intraventricular hemorrhage grade III and periventricular hemorrhagic infarction were most common. Mortality was approximately 20% in both preterm and term populations.Conclusions
While specialized neurocritical care has improved outcomes in adult populations, longitudinal studies are needed to determine whether specialized neurocritical care services will also result in improved neurodevelopmental outcomes for newborns. 相似文献16.
Background
Bedside percutaneous tracheostomy (PT) is very commonly used for patients who require prolonged mechanical ventilation. The effect of tracheostomy on intracranial pressure (ICP) is currently a subject of controversy. The aim of our study is to clarify the relation between PT and its effect on ICP and cerebral perfusion pressure.Methods
38 patients on our intensive care unit were included prospectively in an observational study. We examined mean values of HF, SpO2, ICP, CPP, and MAP for changes over five different phases of the procedure using paired Mann?CWhitney U tests. A p value of <0.05 was considered significant. p values were Bonferroni corrected for multiple testing.Results
PT was performed on 38 patients (f?=?19, m?=?19; mean?=?56?years). Median ICP before intervention was 9?mmHg. During positioning of the patient, ICP had risen to 14, during bronchoscopy to 16, and during tracheostomy to 18?mmHg, all being significantly higher than baseline level. Monitoring of MAP showed a significant increase to 101?mmHg only during tracheostomy. SpO2 and HF did not show any significant changes. Mean duration of positioning, bronchoscopy and tracheostomy was 19, 10, and 17?min. 8 patients received osmotherapy due to a rise of ICP of more than 30?mmHg.Conclusion
PT only leads to a significant rise of ICP during the procedure. Nevertheless, therapy of ICP is necessary in some patients. From our point of view, therefore, tracheostomy should only be performed under continuous monitoring of ICP and CPP in patients with severe cerebral dysfunctions and critically elevated ICP. 相似文献17.
Mypinder S. Sekhon Paul McBeth Jie Zou Lu Qiao Leif Kolmodin William R. Henderson Steve Reynolds Donald E. G. Griesdale 《Neurocritical care》2014,21(2):245-252
Purpose
Increased intracranial pressure (ICP) is associated with worse outcomes following traumatic brain injury (TBI). Studies have confirmed that ICP is correlated with optic nerve sheath diameter (ONSD) on ultrasound. The aim of our study was to assess the independent relationship between ONSD measured using CT and mortality in a population of patients admitted with severe TBI.Methods
We conducted a retrospective cohort study of patients with a TBI requiring ICP monitoring admitted to the ICU between April 2006 and May 2012 to two neurotrauma centers. ONSD was independently measured by two physicians blinded to patient outcomes. Multivariable logistic regression modeling was used to assess an association between ONSD and hospital mortality.Results
A total of 220 patients were included in the analysis. Overall, the cohort had a mean age of 35 (SD 17) years and 171 of 220 (79 %) were male. The median admission GCS was 6 (IQR 3–8). Intra-class correlation coefficient between raters for ONSD measurements was 0.92 (95 % CI 0.90–0.94, P < 0.0001). On multivariable analysis, each 1 mm increase in ONSD was associated with a twofold increase in hospital mortality (OR 2.0, 95 % CI 1.2–3.2, P = 0.007). Using linear regression, ONSD was independently associated with increased ICP in the first 48 h after admission (β = 4.4, 95 % CI 2.5–6.3, P < 0.0001).Conclusions
In patients with TBI, ONSD measured on CT scanning was independently associated with ICP and mortality. 相似文献18.
Paredes-Andrade E Solid CA Rockswold SB Odland RM Rockswold GL 《Neurocritical care》2012,17(2):204-210
Background
Osmotherapy has been the cornerstone in the management of patients with elevated intracranial pressure (ICP) following traumatic brain injury (TBI). Several studies have demonstrated that hypertonic saline (HTS) is a safe and effective osmotherapy agent. This study evaluated the effectiveness of HTS in reducing intracranial hypertension in the presence of a wide range of serum and cerebrospinal fluid (CSF) osmolalities.Methods
Forty-two doses of 23.4% saline boluses for treatment of refractory intracranial hypertension were reviewed retrospectively. Thirty milliliters of 23.4% NaCl was infused over 15?min for intracranial hypertension, defined as ICP?>20?mmHg. The CSF and serum osmolalities from frozen stored samples were measured with an osmometer. The values of serum sodium, hourly ICP, blood urea nitrogen (BUN), and creatinine were obtained directly from the medical records.Results
The serum and CSF osmolalities correlated very closely to serum sodium (r?>?0.9, P?0.0001). The reduction in ICP from the baseline (measured from either the mean ICP or the lowest ICP measurement in the first 6?h after bolus HTS treatment) was statistically significant regardless of serum osmolality. The mean reduction from baseline to follow-up values was 8.8?mm Hg (P?0.0001). The decrease in ICP was as evident with serum osmolalities?>320 as it was at???320.Conclusion
This study demonstrates that 23.4% HTS bolus is effective for the reduction of elevated ICP in patients with severe TBI even in the presence of high serum and CSF osmolalities. 相似文献19.
Asem Salma 《Child's nervous system》2014,30(5):825-830
Objective
The theme of this paper is to outline that the genesis of normal pressure hydrocephalus (NPH) is governed by the intracranial pressure (ICP) homeostatic principle. The development of this new concept is based mainly on rethinking the well-known Monro–Kellie doctrine in the way that ICP homeostasis mechanism is not only a mechanism that works to prevent pathologically high ICP but also a mechanism that aims to protect from pathologically low ICP.Methods
The NPH-related literatures are reviewed and reinterpreted to generate a new paradigm for the cascade of pathophysiological events that leads to the genesis NPH, as well as the mechanism of clinical beneficial effects and complications of the shunting procedure.Results
According to this new paradigm, the suboptimal cerebral perfusion that is associated with the impairment of the cerebral autoregulation is the initial step in the genesis of NPH. When the overall volume of blood that circulates intracranially is diminished, a chronic low ICP with episodes of pathologically low ICP occurs. Since the cranial vault is not collapsible, those episodes of low ICP are compensated by the accumulation of cerebrospinal fluid (CSF) to keep the ICP in normal ideal range. The impairment of brain toxin-flushing mechanism because of CSF pooling combined with the already-established suboptimal cerebral perfusion leads to functional disinhibition of the cerebral cortex.Conclusion
Recognizing the importance of ICP homeostatic mechanisms in the genesis of the NPH is a simple yet novel view that could change the way we look at NP and can give a basic and fundamental theoretical frame work to achieve better understanding of NPH. 相似文献20.
Sorrentino E Diedler J Kasprowicz M Budohoski KP Haubrich C Smielewski P Outtrim JG Manktelow A Hutchinson PJ Pickard JD Menon DK Czosnyka M 《Neurocritical care》2012,16(2):258-266