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Fotakopoulos G, Siasios I, Gatos C, Georgakopoulou VE, Trakas N, Sklapani P, Fountas KN. Acute intracranial hemorrhage during the installation of the LICOX microdialysis system: A case report. MEDICINE INTERNATIONAL 2024; 4:39. [PMID: 38827950 PMCID: PMC11140294 DOI: 10.3892/mi.2024.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/02/2024] [Indexed: 06/05/2024]
Abstract
Neuro-monitoring is widely employed for the evaluation of intubated patients in the intensive care unit with stroke, severe head trauma, subarachnoid hemorrhage and/or hepatic encephalopathy. The present study reports the case of a patient with acute intracranial hemorrhage following the insertion of neuromonitoring catheters, which required surgical management. The patient was a 14-year-old male who sustained a severe traumatic brain injury and underwent a right-sided hemicraniectomy. During the installation of the neuromonitoring catheters, an acute hemorrhage was noted with a rapidly elevating intracranial pressure. A craniotomy was performed to identify and coagulate the injured cortical vessel. As demonstrated herein, the thorough evaluation of the clotting profile of the patient, a meticulous surgical technique and obtaining a post-insertion computed tomography scan may minimize the risk of any neuromonitoring-associated hemorrhagic complications.
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Affiliation(s)
- George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | - Ioannis Siasios
- Department of Neurosurgery, Papageorgiou Hospital, 56429 Thessaloniki, Greece
| | - Charalampos Gatos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | | | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Pagona Sklapani
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
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Stein KY, Froese L, Gomez A, Sainbhi AS, Vakitbilir N, Ibrahim Y, Zeiler FA. Intracranial Pressure Monitoring and Treatment Thresholds in Acute Neural Injury: A Narrative Review of the Historical Achievements, Current State, and Future Perspectives. Neurotrauma Rep 2023; 4:478-494. [PMID: 37636334 PMCID: PMC10457629 DOI: 10.1089/neur.2023.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
Since its introduction in the 1960s, intracranial pressure (ICP) monitoring has become an indispensable tool in neurocritical care practice and a key component of the management of moderate/severe traumatic brain injury (TBI). The primary utility of ICP monitoring is to guide therapeutic interventions aimed at maintaining physiological ICP and preventing intracranial hypertension. The rationale for such ICP maintenance is to prevent secondary brain injury arising from brain herniation and inadequate cerebral blood flow. There exists a large body of evidence indicating that elevated ICP is associated with mortality and that aggressive ICP control protocols improve outcomes in severe TBI patients. Therefore, current management guidelines recommend a cerebral perfusion pressure (CPP) target range of 60-70 mm Hg and an ICP threshold of >20 or >22 mm Hg, beyond which therapeutic intervention should be initiated. Though our ability to achieve these thresholds has drastically improved over the past decades, there has been little to no change in the mortality and morbidity associated with moderate-severe TBI. This is a result of the "one treatment fits all" dogma of current guideline-based care that fails to take individual phenotype into account. The way forward in moderate-severe TBI care is through the development of continuously derived individualized ICP thresholds. This narrative review covers the topic of ICP monitoring in TBI care, including historical context/achievements, current monitoring technologies and indications, treatment methods, associations with patient outcome and multi-modal cerebral physiology, present controversies surrounding treatment thresholds, and future perspectives on personalized approaches to ICP-directed therapy.
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Affiliation(s)
- Kevin Y. Stein
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Logan Froese
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nuray Vakitbilir
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Younis Ibrahim
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Frederick A. Zeiler
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Basha AK, Mahmoud MA, Al Ashwal MI, Aglan O, ElShawady SB, Abdel-Latif AM, Elsayed AM, AbdelGhany W. Management of Severe Traumatic Brain Injury: A Single Institution Experience in a Middle-Income Country. Front Surg 2021; 8:690723. [PMID: 34746219 PMCID: PMC8570277 DOI: 10.3389/fsurg.2021.690723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 09/13/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Severe traumatic brain injury (TBI) is a major public health problem usually resulting in mortality or severe disabling morbidities of the victims. Intracranial pressure (ICP) monitoring is recently recognized as an imperative modality in the management of severe TBI, whereas growing evidence, based on randomized controlled trials (RCTs), suggests that ICP monitoring does not affect the outcome when compared with clinical and radiological data-based management. Also, ICP monitoring carries a considerable risk of intracranial infection that cannot be overlooked. The aim of this study is to assess the different aspects of our current local institutional management of severe TBI using non-invasive ICP monitoring for a potential need to change our management strategy. Methods: We retrospectively reviewed our data of TBI from June 2019 through January 2020. Patients with severe TBI were identified. Their demographics, Glasgow coma score (GCS) at presentation, treatments received, and imaging data were extracted from the charts. Glasgow outcome scale extended (GOS-E) at 6 months was also assessed for the patients. Results: Twenty patients with severe TBI were identified on chart review. Ten patients received only medical treatment measures to lower the ICP, whereas the other 10 patients had additional surgical interventions. In one patient, a ventriculostomy tube was inserted to monitor ICP and to drain cerebrospinal fluid (CSF). This was complicated by ventriculostomy-associated infection (VAI) and the tube was removed. In our cohort, the total mortality rate was 40%. The average GOS-E for the survivor patients managed without ICP monitoring based on the clinical and radiological data was 6.2 at 6 months follow-up. The 6-month overall good outcome, based on GOS-E, was 33.3%. Conclusion: Although recent guidelines advocate for the use of ICP monitoring in the management of severe TBI, they remain underutilized in our practice due to many factors. External ventricular drains were mainly used to drain CSF; however, the higher rates of VAIs in our institution compared with the literature-reported rates are not in favor of the use of ICP monitoring. We recommend doing a comparative study between our current practice using clinical-and radiological-based management and subdural or intraparenchymal bolts. More structured RCTs are needed to validate these findings in our setting.
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Affiliation(s)
| | | | | | - Osama Aglan
- Neurosurgery Department, Ain Shams University, Cairo, Egypt
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Bjornson A, Henderson D, Lawrence E, McMullan J, Ushewokunze S. The Sensor Reservoir-does it change management? Acta Neurochir (Wien) 2021; 163:1087-1095. [PMID: 33587185 DOI: 10.1007/s00701-021-04729-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND The Miethke Sensor Reservoir sits within a ventriculoperitoneal shunt system to give a reading of the pressure within the shunt. This information can guide the management of hydrocephalus patients who present frequently with headaches. METHODS We reviewed a cohort of 12 patients who underwent implantation of a Sensor Reservoir to assess how the management of their symptoms changed over a 4-year period. RESULTS When comparing the group before the Sensor Reservoir and after the Sensor Reservoir insertion, there was a 75% reduction in number of CT head scans (P<0.05), 100% reduction in episodes of ICP monitoring (P<0.05), 55% reduction in number of X-ray shunt series, and a 50% reduction in acute presentation to hospital with shunt-related symptoms. The number of clinic attendances increased by 44%. In addition, cost analysis showed a saving of £6952 per patients over the 2-year period following Sensor Reservoir insertion as a result of reduced admissions and investigations. Complications were seen in 3 patients-two patients developed shunt-related infections, and 1 patient underwent shunt revision due to a proximal shunt obstruction. Seventy-five percent of patients showed an improvement in their symptoms at the end of the 4-year period. CONCLUSION Implantation of a Sensor Reservoir in shunt patients with chronic headaches can reduce the number of investigations and hospital admissions and guide management resulting in a clinical improvement.
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Anania P, Battaglini D, Miller JP, Balestrino A, Prior A, D'Andrea A, Badaloni F, Pelosi P, Robba C, Zona G, Fiaschi P. Escalation therapy in severe traumatic brain injury: how long is intracranial pressure monitoring necessary? Neurosurg Rev 2020; 44:2415-2423. [PMID: 33215367 PMCID: PMC7676754 DOI: 10.1007/s10143-020-01438-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/29/2020] [Accepted: 11/11/2020] [Indexed: 11/24/2022]
Abstract
Traumatic brain injury frequently causes an elevation of intracranial pressure (ICP) that could lead to reduction of cerebral perfusion pressure and cause brain ischemia. Invasive ICP monitoring is recommended by international guidelines, in order to reduce the incidence of secondary brain injury; although rare, the complications related to ICP probes could be dependent on the duration of monitoring. The aim of this manuscript is to clarify the appropriate timing for removal and management of invasive ICP monitoring, in order to reduce the risk of related complications and guarantee adequate cerebral autoregulatory control. There is no universal consensus concerning the duration of invasive ICP monitoring and its related complications, although the pertinent literature seems to show that the longer is the monitoring maintenance, the higher is the risk of technical issues. Besides, upon 72 h of normal ICP values or less than 72 h if the first computed tomography scan is normal (none or minimal signs of injury) and the neurological exam is available (allowing to observe variations and possible occurrence of new-onset pathological response), the removal of invasive ICP monitoring can be justified. The availability of non-invasive monitoring systems should be considered to follow up patients' clinical course after invasive ICP probe removal or for substituting the invasive monitoring in case of contraindication to its placement. Recently, optic nerve sheath diameter and straight sinus systolic flow velocity evaluation through ultrasound methods showed a good correlation with ICP values, demonstrating their potential role in place of invasive monitoring or in the early weaning phase from the invasive ICP monitoring.
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Affiliation(s)
- Pasquale Anania
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
| | - Denise Battaglini
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Medicine, University of Barcelona, Barcelona, Spain
| | - John P Miller
- Louisiana State University, Health Sciences University, New Orleans, LA, USA
| | - Alberto Balestrino
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Alessandro Prior
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Alessandro D'Andrea
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Filippo Badaloni
- Division of Neurosurgery, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Genoa, Italy
| | - Gianluigi Zona
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal And Children (DINOGMI), University of Genoa, Genoa, Italy
| | - Pietro Fiaschi
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal And Children (DINOGMI), University of Genoa, Genoa, Italy
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Abstract
Telemetric intracranial pressure (ICP) monitoring is a new method of measuring ICP which eliminates some of the shortcomings of previous methods. However, there are limited data on specific characteristics, including the advantages and disadvantages of this method. The main aim of this study was to demonstrate the indications, benefits, and complications of telemetric ICP monitoring. PubMed, MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for relevant studies without language or date restriction in May 2019. Human studies in which telemetric ICP monitoring was the main subject of the study were included. Our initial search resulted in 1650 articles from which 50 studies were included. There were no randomized controlled trials. The majority of the studies were case reports or case series (68%). The most common aim of studies was testing of the device (52%), and monitoring the disease progression or recovery (46%). The most common indications for telemetric ICP monitoring in these studies were testing cerebrospinal fluid shunt function (46%), ICP control after the procedure (36%), and diagnosing intracranial hypertension (22%) and hydrocephalus (12%). In total, 1423 brain disease patients had been monitored in studies. The possibility of long-term ICP monitoring as the main benefit was reported in 38 (76%) studies. The associated complication rate was 7.1%. Despite the increasing application of telemetric monitoring devices, studies to evaluate specific characteristics of this method have been infrequent and inadequate. Future research using a higher level of scientific methods is needed to evaluate advantage and disadvantages.
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Sturges BK, Dickinson PJ, Tripp LD, Udaltsova I, LeCouteur RA. Intracranial pressure monitoring in normal dogs using subdural and intraparenchymal miniature strain-gauge transducers. J Vet Intern Med 2018; 33:708-716. [PMID: 30575120 PMCID: PMC6430958 DOI: 10.1111/jvim.15333] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 08/24/2018] [Accepted: 09/05/2018] [Indexed: 12/25/2022] Open
Abstract
Background Monitoring of intracranial pressure (ICP) is a critical component in the management of intracranial hypertension. Safety, efficacy, and optimal location of microsensor devices have not been defined in dogs. Hypothesis/Objective Assessment of ICP using a microsensor transducer is feasible in anesthetized and conscious animals and is independent of transducer location. Intraparenchymal transducer placement is associated with more adverse effects. Animals Seven adult, bred‐for‐research dogs. Methods In a prospective investigational study, microsensor ICP transducers were inserted into subdural and intraparenchymal locations at defined rostral or caudal locations within the rostrotentorial compartment under general anesthesia. Mean arterial pressure and ICP were measured continuously during physiological maneuvers, and for 20 hours after anesthesia. Results Baseline mean ± SD values for ICP and cerebral perfusion pressure were 7.2 ± 2.3 and 78.9 ± 7.6 mm Hg, respectively. Catheter position did not have a significant effect on ICP measurements. There was significant variation from baseline ICP accompanying physiological maneuvers (P < .001) and with normal activities, especially with changes in head position (P < .001). Pathological sequelae were more evident after intraparenchymal versus subdural placement. Conclusions and Clinical Importance Use of a microsensor ICP transducer was technically straightforward and provided ICP measurements within previously reported reference ranges. Results support the use of an accessible dorsal location and subdural positioning. Transient fluctuations in ICP are normal events in conscious dogs and large variations associated with head position should be accounted for when evaluating animals with intracranial hypertension.
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Affiliation(s)
- Beverly K Sturges
- Departments of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, California
| | - Peter J Dickinson
- Departments of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, California
| | - Linda D Tripp
- Office of Research, University of California-Davis, Davis, California
| | - Irina Udaltsova
- Population, Health and Reproduction, School of Veterinary Medicine, University of California-Davis, Davis, California
| | - Richard A LeCouteur
- Departments of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, California
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Jackson S, Weingart J, Nduom EK, Harfi TT, George RT, McAreavey D, Ye X, Anders NM, Peer C, Figg WD, Gilbert M, Rudek MA, Grossman SA. The effect of an adenosine A 2A agonist on intra-tumoral concentrations of temozolomide in patients with recurrent glioblastoma. Fluids Barriers CNS 2018; 15:2. [PMID: 29332604 PMCID: PMC5767971 DOI: 10.1186/s12987-017-0088-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/26/2017] [Indexed: 01/29/2023] Open
Abstract
Background The blood–brain barrier (BBB) severely limits the entry of systemically administered drugs including chemotherapy to the brain. In rodents, regadenoson activation of adenosine A2A receptors causes transient BBB disruption and increased drug concentrations in normal brain. This study was conducted to evaluate if activation of A2A receptors would increase intra-tumoral temozolomide concentrations in patients with glioblastoma. Methods Patients scheduled for a clinically indicated surgery for recurrent glioblastoma were eligible. Microdialysis catheters (MDC) were placed intraoperatively, and the positions were documented radiographically. On post-operative day #1, patients received oral temozolomide (150 mg/m2). On day #2, 60 min after oral temozolomide, patients received one intravenous dose of regadenoson (0.4 mg). Blood and MDC samples were collected to determine temozolomide concentrations. Results Six patients were enrolled. Five patients had no complications from the MDC placement or regadenoson and had successful collection of blood and dialysate samples. The mean plasma AUC was 16.4 ± 1.4 h µg/ml for temozolomide alone and 16.6 ± 2.87 h µg/ml with addition of regadenoson. The mean dialysate AUC was 2.9 ± 1.2 h µg/ml with temozolomide alone and 3.0 ± 1.7 h µg/ml with regadenoson. The mean brain:plasma AUC ratio was 18.0 ± 7.8 and 19.1 ± 10.7% for temozolomide alone and with regadenoson respectively. Peak concentration and Tmax in brain were not significantly different. Conclusions Although previously shown to be efficacious in rodents to increase varied size agents to cross the BBB, our data suggest that regadenoson does not increase temozolomide concentrations in brain. Further studies exploring alternative doses and schedules are needed; as transiently disrupting the BBB to facilitate drug entry is of critical importance in neuro-oncology. Electronic supplementary material The online version of this article (10.1186/s12987-017-0088-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sadhana Jackson
- Brain Cancer Program, Johns Hopkins University, David H. Koch Cancer Research Building II, 1550 Orleans Street, Room 1M16, Baltimore, MD, 21287, USA. .,Neuro-Oncology Branch, NCI/NIH, 9030 Old Georgetown Rd, Building 82, Bethesda, MD, 20892, USA.
| | - Jon Weingart
- School of Medicine, Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, 21287, USA
| | - Edjah K Nduom
- Surgical Neurology Branch, NINDS/NIH, 10 Center Drive, 3D20, Bethesda, MD, 20814, USA
| | - Thura T Harfi
- David Heart & Lung Research Institute, The Ohio State University, 374 12th Avenue, Suite 200, Columbus, OH, 43210, USA
| | - Richard T George
- Heart and Vascular Institute, Johns Hopkins University, 600 N. Wolfe Street, Sheikh Zayed Tower, Baltimore, MD, 21287, USA
| | - Dorothea McAreavey
- Critical Care Medicine Department, Nuclear Cardiology Section, NIH Clinical Center, 10 Center Drive, Bethesda, MD, 20892, USA
| | - Xiaobu Ye
- School of Medicine, Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, 21287, USA
| | - Nicole M Anders
- Cancer Chemical and Structural Biology and Analytical Pharmacology Core Laboratory, Johns Hopkins University, Bunting-Blaustein Cancer Research Building I, 1650 Orleans Street, CRB1 Room 1M52, Baltimore, MD, 21231, USA
| | - Cody Peer
- Clinical Pharmacology, NCI/NIH, 10 Center Drive, 5A01, Bethesda, MD, 20814, USA
| | - William D Figg
- Clinical Pharmacology, NCI/NIH, 10 Center Drive, 5A01, Bethesda, MD, 20814, USA
| | - Mark Gilbert
- Neuro-Oncology Branch, NCI/NIH, 9030 Old Georgetown Rd, Building 82, Bethesda, MD, 20892, USA
| | - Michelle A Rudek
- Cancer Chemical and Structural Biology and Analytical Pharmacology Core Laboratory, Johns Hopkins University, Bunting-Blaustein Cancer Research Building I, 1650 Orleans Street, CRB1 Room 1M52, Baltimore, MD, 21231, USA
| | - Stuart A Grossman
- Brain Cancer Program, Johns Hopkins University, David H. Koch Cancer Research Building II, 1550 Orleans Street, Room 1M16, Baltimore, MD, 21287, USA
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Zeiler FA, Ziesmann MT, Goeres P, Unger B, Park J, Karakitsos D, Blaivas M, Vergis A, Gillman LM. A unique method for estimating the reliability learning curve of optic nerve sheath diameter ultrasound measurement. Crit Ultrasound J 2016; 8:9. [PMID: 27501699 PMCID: PMC4977242 DOI: 10.1186/s13089-016-0044-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 07/27/2016] [Indexed: 11/14/2022] Open
Abstract
Background Optic nerve sheath diameter (ONSD) measurement using ultrasound has been proposed as a rapid, non-invasive, point of care technique to estimate intra-cranial pressure (ICP). Ultrasonic measurement of the optic nerve sheath can be quite challenging and there is limited literature surrounding learning curves for this technique. We attempted to develop a method to estimate the reliability learning curve for ONSD measurement utilizing a unique definition of reliability: a plateau in within-subject variability with unchanged between-subject variability. Methods As part of a previously published study, a single operator measured the ONSD in 120 healthy volunteers over a 6-month period. Utilizing the assumption that the four measurements made on each subject during this study should be equal, the relationship of within-subject variance was described using a quadratic-plateau model as assessed by segmental polynomial (knot) regression. Results Segmental polynomial (knot) regression revealed a plateau in within-subject variance after the 21st subject. However, there was no difference in overall mean values [3.69 vs 3.68 mm (p = 0.884)] or between-subject variance [14.49 vs 11.92 (p = 0.54)] above or below this cutoff. Conclusions This study suggests a significant finite learning curve associated with ONSD measurements. It also offers a unique method of calculating the learning curve associated with ONSD measurement.
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Affiliation(s)
- Frederick A Zeiler
- Departments of Surgery, University of Manitoba, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada
| | - Markus T Ziesmann
- Departments of Surgery, University of Manitoba, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada
| | - Patrick Goeres
- Undergraduate Medical Education, University of Manitoba, Winnipeg, MB, Canada
| | - Bertram Unger
- Medical Education, University of Manitoba, Winnipeg, MB, Canada
| | - Jason Park
- Departments of Surgery, University of Manitoba, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada
| | - Dimitrios Karakitsos
- Departments of Internal Medicine, University of South Carolina, School of Medicine, Columbia, SC, USA
| | - Michael Blaivas
- Departments of Internal Medicine and Emergency Medicine, University of South Carolina, School of Medicine, Columbia, SC, USA
| | - Ashley Vergis
- Departments of Surgery, University of Manitoba, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada
| | - Lawrence M Gillman
- Departments of Surgery, University of Manitoba, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada.
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Dey M, Stadnik A, Riad F, Zhang L, McBee N, Kase C, Carhuapoma JR, Ram M, Lane K, Ostapkovich N, Aldrich F, Aldrich C, Jallo J, Butcher K, Snider R, Hanley D, Ziai W, Awad IA. Bleeding and infection with external ventricular drainage: a systematic review in comparison with adjudicated adverse events in the ongoing Clot Lysis Evaluating Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR-III IHV) trial. Neurosurgery 2015; 76:291-300; discussion 301. [PMID: 25635887 PMCID: PMC4333009 DOI: 10.1227/neu.0000000000000624] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Retrospective series report varied rates of bleeding and infection with external ventricular drainage (EVD). There have been no prospective studies of these risks with systematic surveillance, threshold definitions, or independent adjudication. OBJECTIVE To analyze the rate of complications in the ongoing Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR III) trial, providing a comparison with a systematic review of complications of EVD in the literature. METHODS Patients were prospectively enrolled in the CLEAR III trial after placement of an EVD for obstructive intraventricular hemorrhage and randomized to receive recombinant tissue-type plasminogen activator or placebo. We counted any detected new hemorrhage (catheter tract hemorrhage or any other distant hemorrhage) on computed tomography scan within 30 days from the randomization. Meta-analysis of published series of EVD placement was compiled with STATA software. RESULTS Growing or unstable hemorrhage was reported as a cause of exclusion from the trial in 74 of 5707 cases (1.3%) screened for CLEAR III. The first 250 patients enrolled have completed adjudication of adverse events. Forty-two subjects (16.8%) experienced ≥1 new bleeds or expansions, and 6 of 250 subjects (2.4%) suffered symptomatic hemorrhages. Eleven cases (4.4%) had culture-proven bacterial meningitis or ventriculitis. CONCLUSION Risks of bleeding and infection in the ongoing CLEAR III trial are comparable to those previously reported in EVD case series. In the present study, rates of new bleeds and bacterial meningitis/ventriculitis are very low despite multiple daily injections, blood in the ventricles, the use of thrombolysis in half the cases, and generalization to >60 trial sites.
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Affiliation(s)
- Mahua Dey
- ‡Section of Neurosurgery and Neurovascular Surgery Program, Division of Biological Sciences and the Pritzker School of Medicine, University of Chicago, Chicago, Illinois; §Pritzker School of Medicine, University of Chicago, Chicago, Illinois; ¶Johns Hopkins Medicine, Baltimore, Maryland; ‖Boston Medical Center, Boston, Massachusetts; #Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; **University of Maryland, Baltimore, Maryland; ‡‡Thomas Jefferson University, Philadelphia, Pennsylvania; §§University of Alberta, Edmonton, Alberta, Canada; ¶¶Stanford University, Stanford, California
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Kim JE, Ko SB, Kang HS, Seo DH, Park SQ, Sheen SH, Park HS, Kang SD, Kim JM, Oh CW, Hong KS, Yu KH, Heo JH, Kwon SU, Bae HJ, Lee BC, Yoon BW, Park IS, Rha JH. Clinical practice guidelines for the medical and surgical management of primary intracerebral hemorrhage in Korea. J Korean Neurosurg Soc 2014; 56:175-87. [PMID: 25368758 PMCID: PMC4217052 DOI: 10.3340/jkns.2014.56.3.175] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 07/15/2014] [Accepted: 09/06/2014] [Indexed: 12/03/2022] Open
Abstract
The purpose of this clinical practice guideline (CPG) is to provide current and comprehensive recommendations for the medical and surgical management of primary intracerebral hemorrhage (ICH). Since the release of the first Korean CPGs for stroke, evidence has been accumulated in the management of ICH, such as intracranial pressure control and minimally invasive surgery, and it needs to be reflected in the updated version. The Quality Control Committee at the Korean Society of cerebrovascular Surgeons and the Writing Group at the Clinical Research Center for Stroke (CRCS) systematically reviewed relevant literature and major published guidelines between June 2007 and June 2013. Based on the published evidence, recommendations were synthesized, and the level of evidence and the grade of the recommendation were determined using the methods adapted from CRCS. A draft guideline was scrutinized by expert peer reviewers and also discussed at an expert consensus meeting until final agreement was achieved. CPGs based on scientific evidence are presented for the medical and surgical management of patients presenting with primary ICH. This CPG describes the current pertinent recommendations and suggests Korean recommendations for the medical and surgical management of a patient with primary ICH.
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Affiliation(s)
- Jeong Eun Kim
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-Bae Ko
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Dae-Hee Seo
- Department of Neurosurgery, Good Morning Hospital, Pyeongtaek, Korea
| | - Sukh-Que Park
- Department of Neurosurgery, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Seung Hun Sheen
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Hyun Sun Park
- Department of Neurosurgery, Inha University College of Medicine, Incheon, Korea
| | - Sung Don Kang
- Department of Neurosurgery, Wonkwang University School of Medicine, Iksan, Korea
| | - Jae Min Kim
- Department of Neurosurgery, Hanyang University College of Medicine, Guri, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Keun-Sik Hong
- Department of Neurology, Inje University College of Medicine, Goyang, Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University College of Medicine, Anyang, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Sun-Uck Kwon
- Department of Neurology, University of Ulsan College of Medicine, Seoul, Koera
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University College of Medicine, Anyang, Korea
| | - Byung-Woo Yoon
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
| | - In Sung Park
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Incheon, Korea
| | - Joung-Ho Rha
- Department of Neurology, Inha University College of Medicine, Incheon, Korea
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Naik BI, Keeley EC, Gress DR, Zuo Z. Case scenario: a patient on dual antiplatelet therapy with an intracranial hemorrhage after percutaneous coronary intervention. Anesthesiology 2014; 121:644-53. [PMID: 24950163 PMCID: PMC4165792 DOI: 10.1097/aln.0000000000000350] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Bhiken I Naik
- From the Department of Anesthesiology (B.I.N., Z.Z.), Division of Cardiovascular Medicine (E.C.K.), Department of Neurology (D.R.G.), University of Virginia, Charlottesville, Virginia
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13
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Shin DS, Hwang SC, Kim BT, Jeong JH, Im SB, Shin WH. Serial Brain CT Scans in Severe Head Injury without Intracranial Pressure Monitoring. Korean J Neurotrauma 2014; 10:26-30. [PMID: 27169029 PMCID: PMC4852589 DOI: 10.13004/kjnt.2014.10.1.26] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 04/20/2014] [Accepted: 04/21/2014] [Indexed: 11/15/2022] Open
Abstract
Objective The intracranial pathologies after head trauma should be usually progressed. It is clearly visualized in the non-invasive brain CT. The invasive monitor such as intracranial pressure (ICP) monitoring may be accompanied with the complications. This study aims whether the patients with severe head injury could be managed with serial CT scans. Methods The medical records of 113 patients with severe head injury in the prospectively enrolled trauma bank were retrospectively analyzed. After the emergency care, all the patients were admitted to the intensive care unit for the aggressive medical managements. Repeat brain CT scans were routinely taken at 6 hours and 48 hours after the trauma. ICP monitoring was restrictively applied for the uncertain intracranial pressure based on the CT. The surgical intervention and the mortality rate were analyzed. Results Immediate surgical intervention after the initial CT scan was done in 47 patients. Among the initially non-surgical patients, 59 patients were managed with the serial CT scans and 7 with the ICP monitoring. Surgical interventions underwent eventually for 10 patients in the initially non-surgical patients; 1 in the ICP monitoring and 9 in the serial CT. The mortality rate was 23.7% in the serial brain CT and 28.6% in the ICP monitoring. There was no statistical difference between two groups in the aspect of mortality (p=0.33). Conclusion Serial CT scans in time could be a good way to monitor the intracranial progression in the severe head injury and reduce the implantation of an invasive ICP probe.
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Affiliation(s)
- Dong-Seong Shin
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Sun-Chul Hwang
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Bum-Tae Kim
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Je Hoon Jeong
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Soo-Bin Im
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Won-Han Shin
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
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Jackson DA, Patel AV, Darracott RM, Hanel RA, Freeman WD, Hanley DF. Safety of intraventricular hemorrhage (IVH) thrombolysis based on CT localization of external ventricular drain (EVD) fenestrations and analysis of EVD tract hemorrhage. Neurocrit Care 2013; 19:103-10. [PMID: 22544476 PMCID: PMC3785325 DOI: 10.1007/s12028-012-9713-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The purpose of the study is to review the CT findings associated with ventriculostomy placement in regards to the safety of an EVD plus recombinant tissue plasminogen activator (rt-PA) for IVH. METHODS A retrospective review was conducted for patients receiving intraventricular rt-PA for IVH from January 2004 to September 2009. Safety was assessed by the presence of EVD tract hemorrhage by CT at baseline after EVD placement, worsening hemorrhage after rt-PA, and CSF infection. IVH volumetrics were assessed by the Le Roux score and outcomes by Glasgow Outcome Scale and modified Rankin Scale. RESULTS Twenty-seven patients received rt-PA for IVH. Median dose was 2 mg (range 0.3-8) and a median of two doses (range 1-17) were given. Worsening EVD catheter tract hemorrhage after rt-PA was 46.7 %, with a significantly higher incidence of worsening tract hemorrhage seen with incorrectly placed EVDs (p = 0.04). IVH hematoma burden decreased by a median Le Roux score of 10 (range 3-16) prior to rt-PA to 4 (range 0-16) after rt-PA. There were no central nervous system bacterial infections. CONCLUSION Intraventricular rt-PA appears to be relatively safe especially when all EVD fenestrations are within the ventricle and reduces IVH burden similar to other studies. We describe a CT-based EVD tract hemorrhage grading scale to evaluate EVD tract hemorrhage before and after thrombolysis, and a bone-window technique to evaluate EVD fenestrations prior to IVH thrombolysis. Further research is needed evaluating these imaging techniques in regard to intraventricular thrombolytic safety and EVD tract hemorrhage.
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Affiliation(s)
| | - Alden V. Patel
- Department of Pharmacy, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - William D. Freeman
- Departments of Neurology and Critical Care, Mayo Clinic, 4500, San Pablo Road, Jacksonville, FL 32224, USA
| | - Daniel F. Hanley
- Departments of Neurology, Neurosurgery, and Anesthesiology & Critical Care Medicine, The Johns Hopkins University, Baltimore, MD, USA
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15
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Eide PK, Bakken A. The baseline pressure of intracranial pressure (ICP) sensors can be altered by electrostatic discharges. Biomed Eng Online 2011; 10:75. [PMID: 21859487 PMCID: PMC3180435 DOI: 10.1186/1475-925x-10-75] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 08/22/2011] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The monitoring of intracranial pressure (ICP) has a crucial role in the surveillance of patients with brain injury. During long-term monitoring of ICP, we have seen spontaneous shifts in baseline pressure (ICP sensor zero point), which are of technical and not physiological origin. The aim of the present study was to explore whether or not baseline pressures of ICP sensors can be affected by electrostatics discharges (ESD's), when ESD's are delivered at clinically relevant magnitudes. METHODS We performed bench-testing of a set of commercial ICP sensors. In our experimental setup, the ICP sensor was placed in a container with 0.9% NaCl solution. A test person was charged 0.5-10 kV, and then delivered ESD's to the sensor by touching a metal rod that was located in the container. The continuous pressure signals were recorded continuously before/after the ESD's, and the pressure readings were stored digitally using a computerized system RESULTS A total of 57 sensors were tested, including 25 Codman ICP sensors and 32 Raumedic sensors. When charging the test person in the range 0.5-10 kV, typically ESD's in the range 0.5-5 kV peak pulse were delivered to the ICP sensor. Alterations in baseline pressure ≥ 2 mmHg was seen in 24 of 25 (96%) Codman sensors and in 17 of 32 (53%) Raumedic sensors. Lasting changes in baseline pressure > 10 mmHg that in the clinical setting would affect patient management, were seen frequently for both sensor types. The changes in baseline pressure were either characterized by sudden shifts or gradual drifts in baseline pressure. CONCLUSIONS The baseline pressures of commercial solid ICP sensors can be altered by ESD's at discharge magnitudes that are clinically relevant. Shifts in baseline pressure change the ICP levels visualised to the physician on the monitor screen, and thereby reveal wrong ICP values, which likely represent a severe risk to the patient.
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Affiliation(s)
- Per K Eide
- Department of Neurosurgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
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16
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Morgenstern LB, Hemphill JC, Anderson C, Becker K, Broderick JP, Connolly ES, Greenberg SM, Huang JN, MacDonald RL, Messé SR, Mitchell PH, Selim M, Tamargo RJ. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2010; 41:2108-29. [PMID: 20651276 DOI: 10.1161/str.0b013e3181ec611b] [Citation(s) in RCA: 993] [Impact Index Per Article: 70.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage. METHODS A formal literature search of MEDLINE was performed. Data were synthesized with the use of evidence tables. Writing committee members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Statements Oversight Committee and Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years' time. RESULTS Evidence-based guidelines are presented for the care of patients presenting with intracerebral hemorrhage. The focus was subdivided into diagnosis, hemostasis, blood pressure management, inpatient and nursing management, preventing medical comorbidities, surgical treatment, outcome prediction, rehabilitation, prevention of recurrence, and future considerations. CONCLUSIONS Intracerebral hemorrhage is a serious medical condition for which outcome can be impacted by early, aggressive care. The guidelines offer a framework for goal-directed treatment of the patient with intracerebral hemorrhage.
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Diagnosis influences response of cerebral near infrared spectroscopy to intracranial hypertension in children. Pediatr Crit Care Med 2010; 11:514-22. [PMID: 19935441 PMCID: PMC3675803 DOI: 10.1097/pcc.0b013e3181c51cf1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe cerebral regional oxygen saturation measured by near infrared spectroscopy in the setting of normal and increased intracranial pressure in children to evaluate the association between cerebral regional oxygen saturation and intracranial pressure in comparison with other clinical variables. DESIGN Prospective observational cohort study. SETTING Two academic tertiary care centers' pediatric intensive care units. PATIENTS Thirty patients with intracranial pressure and near infrared spectroscopy monitoring (median age, 11.5 yrs; interquartile range, 5.2-13 yrs) for a range of neurologic diagnoses, including brain tumor, trauma, intracerebral hemorrhage, and hydrocephalus. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Temporally correlated cerebral regional oxygen saturation with hematologic (hematocrit), biochemical (pH), and physiological (intracranial pressure, mean arterial pressure, cerebral perfusion pressure, temperature, heart rate, pulse oximetry and end-tidal carbon dioxide) variables. Cerebral regional oxygen saturation during episodes of increased intracranial pressure was lower than with normal intracranial pressure (mean +/- sd intracranial pressure >20 = 71% +/- 13% vs. intracranial pressure <20 = 75% +/- 10%), although the mean difference (-4%) is small compared with variability in the measurement. Neither isolated values nor change in cerebral regional oxygen saturation were significantly associated with intracranial pressure or cerebral perfusion pressure in the overall population. Isolated values and change in end-tidal CO2 were significantly correlated with cerebral regional oxygen saturation and change in cerebral regional oxygen saturation (all p < 0.01). In exploratory analyses, the diagnostic group significantly modified the effect of intracranial hypertension on regional oxygen saturation: regional oxygen saturation decreased during intracranial hypertension in patients with brain tumors (p = .05) and hydrocephalus (p < .001) but increased during intracranial hypertension in those with intracranial hemorrhage (p < .001). CONCLUSIONS These data suggest that cerebral regional oxygen saturation is lower with intracranial hypertension. However, the relationship between cerebral regional oxygen saturation and intracranial pressure is strongly influenced by diagnosis.
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Moon HH, Kim JH, Kang HI, Moon BG, Lee SJ, Kim JS. Brain Injuries during Intraoperative Ventriculostomy in the Aneurysmal Subarachnoid Hemorrhage Patients. J Korean Neurosurg Soc 2009; 46:215-20. [PMID: 19844621 DOI: 10.3340/jkns.2009.46.3.215] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2009] [Revised: 07/20/2009] [Accepted: 08/18/2009] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Intraoperative ventriculostomy is widely adopted to make the slack brain. However, there are few reports about hemorrhagic or parenchymal injuries after ventriculostomy. We tried to analyze and investigate the incidence of these complications in a consecutive series of patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS From September 2006 to June 2007, 43 patients underwent surgical clipping for aneurysmal SAH at our hospital. Among 43 patients, we investigated hemorrhagic or parenchymal injuries after intraoperative ventriculostomy using postoperative computed tomographic scan in 26 patients. After standard pterional craniotomy, ventriculostomy catheter was inserted perpendicular to the cortical surface along the bisectional imaginary line from Paine's point. RESULTS Hemorrhagic injuries were detected in 12 of 26 patients (46.2%). Mean systolic blood pressure during anesthesia was with in statistically significant parameter related to hemorrhage (p = 0.006). On the other hand, parenchymal injuries were detected in 11 of 26 patients (42.3%). Female and the amount of infused mannitol during anesthesia showed statistically significant parameters related to parenchymal injury (p = 0.005, 0.04, respectively). However, there were no ventriculostomy-related severe complications. CONCLUSION In our series, hemorrhagic or parenchymal injuries after intraoperative ventriculostomy occurred more commonly than previously reported series in aneurysmal SAH patients. Although the clinical outcomes of complications are generally favorable, neurosurgeon must keep in mind the frequent occurrence of brain injury after intraoperative ventriculostomy in the acute stage of aneurysmal SAH.
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Affiliation(s)
- Hyung Ho Moon
- Department of Neurosurgery, Eulji University, Nowon Eulji Hospital, Seoul, Korea
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19
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Placement of external ventricular drains and intracranial pressure monitors by neurointensivists. Neurocrit Care 2009; 10:241-7. [PMID: 18449808 DOI: 10.1007/s12028-008-9097-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION External ventricular drains (EVDs) and intracranial pressure (ICP) monitors are widely used in the Neurological Critical Care Unit (NCCU) to measure ICP and divert cerebrospinal fluid (CSF). EVDs and ICP monitors have historically been placed by neurosurgeons; however, with recent staffing of NCCUs by neurointensivists, a growing number of EVDs and ICP monitors are being placed by these specialists. RESULTS Limited data are available concerning the safety or feasibility of such placements by neurointensivists. We present our experience with EVD and ICP monitor placement by a neurointensivist in the NCCU. A retrospective chart review of 29 patients with EVD placement and 7 patients with ICP monitors--all placed by a single neurointensivist--was conducted for patients admitted to the NCCU from August 2005 to January 2008. DISCUSSION These findings were compared to published outcomes from neurosurgeon placements. All 29 patients with EVDs remained infection-free, with CSF pleocytosis occurring in one patient (3.4%). All 7 patients receiving ICP monitors remained free from infection. Complications after drain placement occurred in 20.7% (n = 6) of patients, with all six complications being EVD tract hematoma measuring less than 5 cm(3). CONCLUSION Patients receiving ICP monitors had no complications. These complication rates are comparable to published rates, which suggest that placement of EVDs and ICP monitors by neurointensivists may be safe and effective. However, small sample size (n = 36) prohibits definitive safety and efficacy conclusions. For this reason, further research analyzing a larger patient sample is warranted.
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Hemorrhagic complications of ventriculostomy placement: a meta-analysis. Neurocrit Care 2009; 10:253-6. [PMID: 19224404 DOI: 10.1007/s12028-009-9193-0] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Accepted: 01/21/2009] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The reported intracerebral hemorrhage rate due to ventriculostomy placement varies widely. As studies emerge regarding alternative techniques of ventriculostomy placement, and placement by non-neurosurgeons, further definition of the true intracerebral hemorrhage rate associated with ventriculostomy is warranted. We performed a meta-analysis of the existing literature to further elucidate the incidence of intracerebral hemorrhage due to ventriculostomy. METHODS We performed an extensive literature search using Ovid MEDLINE and PubMed for relevant studies published after 1970. Only studies with more than 25 ventriculostomy procedures were included. Data were extracted regarding number of hemorrhages, clinically significant hemorrhages, and the use of routine post-ventriculostomy CT scanning. We performed subgroup analyses based on the use of routine post-ventriculostomy CT scanning. Chi-squared test was used to determine statistical significance. RESULTS Overall, 102 hemorrhagic complications from 1,790 ventriculostomies were reported, a hemorrhage rate of 5.7%. Of the 102 hemorrhages, 11 were clinically significant (clinically significant hemorrhage rate = 0.61%). In studies that used routine post-placement CT scans, the hemorrhage rate was 10.06%, compared to a hemorrhage rate of 1.53% in studies in which routine CT scans were not performed (P < 0.001). Eight clinically significant hemorrhages (0.91%) were identified in the studies utilizing routine post-procedural CT scanning, compared to three clinically significant hemorrhages (0.33%) in studies without routine CT scans (P = 0.113). CONCLUSION The overall hemorrhage risk associated with ventriculostomy placement based on the existing literature is 5.7%. Clinically significant hemorrhage due to ventriculostomy is less than 1%. Modifications of technique that might reduce hemorrhage risk, and the utility of routine post-procedural CT scanning, merit further investigation.
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Saladino A, White JB, Wijdicks EFM, Lanzino G. Malplacement of ventricular catheters by neurosurgeons: a single institution experience. Neurocrit Care 2009; 10:248-52. [PMID: 18923816 DOI: 10.1007/s12028-008-9154-z] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2008] [Accepted: 09/20/2008] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The placement of cerebrospinal fluid (CSF) diversion devices requires an appropriate technical expertise associated with proper surgical training in order to minimize undue complications. This study sought to review a single institution's experience with placement of external ventricular drains (EVD) and ventriculoperitoneal (VP) shunts as performed by neurosurgeons with procedure-specific training. METHODS A retrospective database review was conducted for all patients who underwent intraventricular CSF diversion over a 5-year period from March 2003 to February 2008. Included in the analysis were ventriculostomy procedures that included EVDs, VP shunts, and ventriculoatrial shunts. RESULTS A total of 138 patients underwent 212 ventriculostomy procedures. Seventy-one (51%) patients were male and sixty-seven (49%) were female. The median age was 50.1 years. A ventriculostomy-related hemorrhage was identified in 15 (7.1%) patients-4 of whom developed new symptoms. Twenty-six (12.3%) ventriculostomy catheters were malplaced as determined from post-procedural imaging. Ventriculostomy-related infections were identified in 7 (3.3%) patients, 4 of whom had EVDs and 3 of whom had VP shunts. CONCLUSION The placement of intraventricular catheters by neurosurgeons remains a relatively safe and effective procedure that is associated with infrequent rates of symptomatic hemorrhage and infection.
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Affiliation(s)
- Andrea Saladino
- Department of Neurologic Surgery, The Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA
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Mauritz W, Janciak I, Wilbacher I, Rusnak M. Severe traumatic brain injury in Austria IV: intensive care management. Wien Klin Wochenschr 2007; 119:46-55. [PMID: 17318750 DOI: 10.1007/s00508-006-0763-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The goal of this paper is to describe the ICU management of severe traumatic brain injury (TBI) in Austria. PATIENTS AND METHODS Data sets from 415 patients included by 5 Austrian hospitals were available. The analysis focused on complications and outcomes of intensive care, monitoring of intracranial pressure (ICP), efficacy of interventions to control ICP, management of hemodynamics and cerebral perfusion pressure (CPP), ventilation, and effects of hyperglycaemia. RESULTS Overall ICU mortality was 30.8%; 90-day mortality was 35.7%. Final outcome was favorable in 33%, unfavorable in 51%, and in 16% the final outcome was unknown. An ICP monitoring device was used in 64%; most patients received intraparenchymal sensors (77%). Events associated with mortality > 50% were CPP < 50 mm Hg for > 12 hours/day, ICP > 25 mm Hg for > 12 hours/day, and MAP < 70 mm Hg for > 18 hours/day. The use of ICP monitoring was associated with significantly reduced ICU mortality. Interventions that may have improved the outcome included the use of barbiturates (short-term), hypertonic saline, moderate hyperventilation (33 < pCO2 < 37; p < 0.001 vs. aggressive hyper-and normoventilation), and normothermia. Hyperglycaemia was associated with poor outcome. CONCLUSIONS Our study showed that ICU management of patients with severe TBI mostly follows international guidelines, and that outcome was comparable to or even better than that reported by other authors. Low CPP was associated with poor outcome, and was more often due to low MAP than to elevated ICP. The use of barbiturates and hypertonic saline was more common than expected. CPP should be maintained > 50 mm Hg, the use of catecholamines, fluid loading, barbiturates (short-term), moderate hyperventilation, hypertonic saline, and insulin may improve outcome after severe TBI.
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Affiliation(s)
- Walter Mauritz
- Department of Anaesthesia and Critical Care Medicine, Trauma Hospital Lorenz Boehler, INRO (International Neurotrauma Research Organisation) Medical Advisory Board, Vienna, Austria.
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