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Kung SS, Chien SY, Liao FF, Yang YH, Hsieh KP. The prescribing patterns and effectiveness of sedatives and analgesics for severe traumatic brain injury patients in Taiwan. J Crit Care 2025; 88:155094. [PMID: 40286488 DOI: 10.1016/j.jcrc.2025.155094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2025] [Revised: 04/02/2025] [Accepted: 04/13/2025] [Indexed: 04/29/2025]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major global health challenge associated with high mortality and morbidity. Secondary brain injury caused by disrupted intracranial pressure (ICP) regulation often necessitates sedation; however, guidelines lack specificity for TBI management. METHODS This study analyzed sedation and analgesia prescribing patterns and their outcomes in severe TBI patients in Taiwan using National Health Insurance Research Database data (2012-2019). Severe TBI patients intubated during intensive care unit (ICU) hospitalization were included. The primary outcome was 30-day all-cause mortality, with sensitivity analyses for 14-day mortality and 30-day all-cause mortality excluding deaths within 3 days. Inverse probability of treatment weighting (IPTW) was applied to balance patient characteristics across groups. Mortality rates across groups were evaluated using Kaplan-Meier survival analysis. At the same time, the Cox proportional hazards model simultaneously assessed the impact of various risk factors, such as age and comorbidities, on mortality. RESULTS Among 6030 patients, sedation and analgesia patterns varied, with midazolam combined with opioids being the most common regimen. Compared to the reference group (sedatives with opioids), the risk of death was highest in the no-prescription group (HR = 2.73, 95 % CI = 2.60-2.86), followed by the sedation-only group (HR = 1.58, 95 % CI = 1.50-1.66) and the opioids-only group (HR = 1.49, 95 % CI = 1.42-1.57; all p < 0.0001). Sensitivity analyses confirmed consistent trends. CONCLUSIONS These findings underscore the importance of optimizing sedation practices and enhancing awareness to improve outcomes for severe TBI patients.
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Affiliation(s)
- Sui-Sum Kung
- Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shao-Yun Chien
- School of Pharmacy, College of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Pharmacy, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Fen-Fen Liao
- Department of Pharmacy, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Yi-Hsin Yang
- National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan
| | - Kun-Pin Hsieh
- School of Pharmacy, College of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Pharmacy, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
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2
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Steindl A, Zach C, Berchtold L, Grisold A, Gatterbauer B, Eckert F, Bago-Horvath Z, Hainfellner JA, Exner R, Fitzal F, Pfeiler G, Singer CF, Widhalm G, Bartsch R, Preusser M, Berghoff AS. Prognostic relevance of the neurological symptom burden in brain metastases from breast cancer. Br J Cancer 2025; 132:733-743. [PMID: 40025253 PMCID: PMC11997164 DOI: 10.1038/s41416-025-02967-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 12/18/2024] [Accepted: 02/20/2025] [Indexed: 03/04/2025] Open
Abstract
BACKGROUND Existing prognostic models for breast cancer (BC) brain metastases (BM) overlook neurological symptoms. Thus, we explored the incidence and prognostic relevance of neurological symptoms in a real-world cohort of BC patients with BM. METHODS The Vienna Brain Metastasis Registry identified BC patients with BM between 1992 and 2020, categorised by subtype: hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-), HER2 overexpressing (HER2+), and triple-negative (TN). RESULTS A total of 716 patients with BM from BC were included. In total, 80% (573/716) of the patients presented with neurological symptoms at BM diagnosis. Across all BC subtypes, asymptomatic patients presented with a significantly longer median OS from diagnosis of BM compared to symptomatic patients (p < 0.05; log-rank test; HR+ BC 29 vs. 9 months; HER2+ BC 24 vs. 12 months; TN 12 vs. 6 months). In multivariate analysis with the BC-specific Graded Prognostic Assessment (Breast-GPA: HR:1.4; 95% CI:1.3-1.5; p < 0.001), the presence of neurological symptoms at diagnosis (HR:1.6; 95% CI: 1.4-1.9; p < 0.001) presented as independently associated with OS from time of BM diagnosis, respectively. CONCLUSIONS Neurological burden at BM diagnosis independently predicts survival in BC patients. Our findings emphasise incorporating the symptom status in the prognostic evaluation and reassessing BM screening in high-risk patients during prospective clinical trials.
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Affiliation(s)
- Ariane Steindl
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Personalized Immunotherapy, Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Clara Zach
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Luzia Berchtold
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
- Institute of Medical Statistics, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Anna Grisold
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna, Vienna, Austria
| | | | - Franziska Eckert
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | | | - Johannes A Hainfellner
- Division of Neuropathology and Neurochemistry, Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Ruth Exner
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Florian Fitzal
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Georg Pfeiler
- Department of Obstetrics and Gynecology, and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Christian F Singer
- Department of Obstetrics and Gynecology, and Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Georg Widhalm
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Rupert Bartsch
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Matthias Preusser
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Personalized Immunotherapy, Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Anna S Berghoff
- Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
- Christian Doppler Laboratory for Personalized Immunotherapy, Division of Oncology, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
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3
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Caschera L, Fiore G, Nava S, Criscuolo S, Lo Russo FM, Casale S, Conte G, Platania G, Costa A, Carrabba G, Locatelli M, Triulzi FM. Diabetic ketoacidosis with central nervous system involvement: Conventional and advanced magnetic resonance neuroimaging findings. Neuroradiol J 2025; 38:247-250. [PMID: 38654625 PMCID: PMC11571342 DOI: 10.1177/19714009241248745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
Diabetic ketoacidosis (DKA) is a serious complication in children with diabetes mellitus type 1 (DM1). In rare and severe cases DKA may be complicated by cerebral edema, central brain herniation and cerebral infarctions. We present the magnetic resonance imaging findings in a child with DKA and central nervous system involvement; diffusion tensor imaging (DTI) and functional MRI (fMRI) were performed to assess the white matter integrity of sensory pathways and cortical sensory processing. Conventional imaging showed bilateral uncal herniation, effacement of the perimesencephalic cisterns, wide ischemic lesions in the posterior cerebral artery (PCA) territories, sagging brainstem and Duret's hemorrhage consistent with signs of central brain herniation and intracranial hypertension. Advanced MRI showed a possible left-sided cortical reorganization for sensory function, with underlying left cortico-talamic and cortico-spinal pathways less severely impaired. Knowledge of the full framework in these conditions is of vital importance for timely patient management; advanced neuroimaging techniques may be considered as prognostic indicators in those cases with extensive involvement of eloquent brain areas.
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Affiliation(s)
- Luca Caschera
- Neuroradiology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Italy
| | - Giorgio Fiore
- Unit of Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Italy
- Unit of Oncology and Hemato-Oncology, University of Milan, Italy
| | - Simone Nava
- Neuroradiology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Italy
| | | | - Francesco M Lo Russo
- Neuroradiology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Italy
| | - Silvia Casale
- Neuroradiology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Italy
| | - Giorgio Conte
- Neuroradiology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Italy
| | - Giulia Platania
- Neuroradiology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Italy
| | - Antonella Costa
- Neuroradiology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Italy
| | - Giorgio Carrabba
- Unit of Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Italy
| | - Marco Locatelli
- Unit of Neurosurgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Italy
- “Aldo Ravelli” Research Center for Neurotechnology and Experimental Brain Therapeutics, University of Milan, Italy
| | - Fabio Maria Triulzi
- Neuroradiology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Italy
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
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4
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Weant KA, Gregory H. Updates on the Use of Osmotherapy in the Emergency Department. Adv Emerg Nurs J 2025; 47:96-102. [PMID: 40106783 DOI: 10.1097/tme.0000000000000559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2025]
Abstract
Elevated intracranial pressure (ICP) is a critical condition associated with significant morbidity and mortality, requiring prompt and effective management. Mannitol and hypertonic saline (HTS) are the two most widely used hyperosmolar agents in clinical practice for ICP reduction, each with distinct pharmacologic properties, efficacy profiles, and safety considerations. This review aims to provide a comprehensive assessment of the mechanisms, clinical efficacy, safety, practical considerations, and guideline recommendations associated with the use of mannitol and HTS for the management of elevated ICP. Current available data does not clearly support one hyperosmolar agent over another and both agents are considered equivalent. Consensus recommendations vary, but the most recent recommendations seem to support the use of HTS over mannitol, mostly due to potential pharmacodynamic advantages that have been shown in smaller investigations. Further research is warranted to refine dosing strategies, clarify administration concerns, and address knowledge gaps in comparative efficacy and safety.
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Affiliation(s)
- Kyle A Weant
- Author Affiliations: Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, University of South Carolina, Columbia, South Carolina (Dr Weant); and Department of Pharmacy, University of North Carolina Health, Chapel Hill, North Carolina (Dr Gregory)
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5
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Robbins B, Almassalkhi L, Baum R, Blackburn M, Davis J, Edwards L, Hile G, Olney W, Weant K, Metts E. Pharmacotherapy adjuncts for traumatic brain injury: A narrative review of evidence and considerations in the emergency department. Am J Emerg Med 2025; 89:78-84. [PMID: 39705854 DOI: 10.1016/j.ajem.2024.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Revised: 11/14/2024] [Accepted: 12/02/2024] [Indexed: 12/23/2024] Open
Abstract
Traumatic Brain Injury (TBI) remains a significant global health concern with significant impact on morbidity and mortality. This narrative review explores adjunctive pharmacologic agents to be employed by emergency medicine clinicians during Advanced Trauma Life Support (ATLS) in patients presenting with a TBI. Pharmacologic agents are commonly employed for the management of rapid sequence intubation and post-intubation analgosedation, hemodynamics, intracranial pressure, coagulopathy, seizure prophylaxis, and infection. This narrative review discusses current evidence and controversies to optimize adjunct pharmacotherapies during the acute management of TBI within the emergency department.
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Affiliation(s)
- Blake Robbins
- University of Kentucky HealthCare, 800 Rose Street, Lexington, KY, 40536, USA.
| | - Lars Almassalkhi
- Atrium Health Wake Forest Baptist, 1 Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Regan Baum
- University of Kentucky HealthCare, 800 Rose Street, Lexington, KY, 40536, USA
| | - Matthew Blackburn
- University of Kentucky HealthCare, 800 Rose Street, Lexington, KY, 40536, USA
| | - Jason Davis
- University of Kentucky HealthCare, 800 Rose Street, Lexington, KY, 40536, USA
| | - Lindsey Edwards
- University of Kentucky HealthCare, 800 Rose Street, Lexington, KY, 40536, USA
| | - Garrett Hile
- University of Kentucky HealthCare, 800 Rose Street, Lexington, KY, 40536, USA
| | - William Olney
- University of Kentucky HealthCare, 800 Rose Street, Lexington, KY, 40536, USA
| | - Kyle Weant
- University of South Carolina College of Pharmacy, 715 Sumter St, Columbia, SC, 29208, USA
| | - Elise Metts
- University of Kentucky HealthCare, 800 Rose Street, Lexington, KY, 40536, USA
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Nair SS, Guo A, Boen J, Aggarwal A, Chahal O, Tandon A, Patel M, Sankararaman S, Durr NJ, Azad TD, Pirracchio R, Stevens RD. A deep learning approach for generating intracranial pressure waveforms from extracranial signals routinely measured in the intensive care unit. Comput Biol Med 2024; 177:108677. [PMID: 38833800 DOI: 10.1016/j.compbiomed.2024.108677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 05/27/2024] [Accepted: 05/28/2024] [Indexed: 06/06/2024]
Abstract
Intracranial pressure (ICP) is commonly monitored to guide treatment in patients with serious brain disorders such as traumatic brain injury and stroke. Established methods to assess ICP are resource intensive and highly invasive. We hypothesized that ICP waveforms can be computed noninvasively from three extracranial physiological waveforms routinely acquired in the Intensive Care Unit (ICU): arterial blood pressure (ABP), photoplethysmography (PPG), and electrocardiography (ECG). We evaluated over 600 h of high-frequency (125 Hz) simultaneously acquired ICP, ABP, ECG, and PPG waveform data in 10 patients admitted to the ICU with critical brain disorders. The data were segmented in non-overlapping 10-s windows, and ABP, ECG, and PPG waveforms were used to train deep learning (DL) models to re-create concurrent ICP. The predictive performance of six different DL models was evaluated in single- and multi-patient iterations. The mean average error (MAE) ± SD of the best-performing models was 1.34 ± 0.59 mmHg in the single-patient and 5.10 ± 0.11 mmHg in the multi-patient analysis. Ablation analysis was conducted to compare contributions from single physiologic sources and demonstrated statistically indistinguishable performances across the top DL models for each waveform (MAE±SD 6.33 ± 0.73, 6.65 ± 0.96, and 7.30 ± 1.28 mmHg, respectively, for ECG, PPG, and ABP; p = 0.42). Results support the preliminary feasibility and accuracy of DL-enabled continuous noninvasive ICP waveform computation using extracranial physiological waveforms. With refinement and further validation, this method could represent a safer and more accessible alternative to invasive ICP, enabling assessment and treatment in low-resource settings.
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Affiliation(s)
- Shiker S Nair
- Department of Biomedical Engineering, Johns Hopkins University Whiting School of Engineering, Baltimore, MD, USA.
| | - Alina Guo
- Department of Biomedical Engineering, Johns Hopkins University Whiting School of Engineering, Baltimore, MD, USA
| | - Joseph Boen
- Department of Biomedical Engineering, Johns Hopkins University Whiting School of Engineering, Baltimore, MD, USA
| | - Ataes Aggarwal
- Department of Biomedical Engineering, Johns Hopkins University Whiting School of Engineering, Baltimore, MD, USA
| | - Ojas Chahal
- Department of Biomedical Engineering, Johns Hopkins University Whiting School of Engineering, Baltimore, MD, USA
| | - Arushi Tandon
- Department of Biomedical Engineering, Johns Hopkins University Whiting School of Engineering, Baltimore, MD, USA
| | - Meer Patel
- Department of Biomedical Engineering, Johns Hopkins University Whiting School of Engineering, Baltimore, MD, USA
| | - Sreenidhi Sankararaman
- Department of Biomedical Engineering, Johns Hopkins University Whiting School of Engineering, Baltimore, MD, USA
| | - Nicholas J Durr
- Department of Biomedical Engineering, Johns Hopkins University Whiting School of Engineering, Baltimore, MD, USA
| | - Tej D Azad
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Romain Pirracchio
- Department of Anesthesia and Perioperative Care, UCSF, San Francisco, USA
| | - Robert D Stevens
- Department of Biomedical Engineering, Johns Hopkins University Whiting School of Engineering, Baltimore, MD, USA; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, USA.
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7
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Scala I, Miccoli M, Pafundi PC, Rizzo PA, Vitali F, Bellavia S, Giovanni JD, Colò F, Marca GD, Guglielmi V, Brunetti V, Broccolini A, Di Iorio R, Monforte M, Calabresi P, Frisullo G. Automated Pupillometry Is Able to Discriminate Patients with Acute Stroke from Healthy Subjects: An Observational, Cross-Sectional Study. Brain Sci 2024; 14:616. [PMID: 38928617 PMCID: PMC11202086 DOI: 10.3390/brainsci14060616] [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: 06/03/2024] [Revised: 06/18/2024] [Accepted: 06/19/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Automated pupillometry (AP) is a handheld, non-invasive tool that is able to assess pupillary light reflex dynamics and is useful for the detection of intracranial hypertension. Limited evidence is available on acute ischemic stroke (AIS) patients. The primary objective was to evaluate the ability of AP to discriminate AIS patients from healthy subjects (HS). Secondly, we aimed to compute a predictive score for AIS diagnosis based on clinical, demographic, and AP variables. METHODS We included 200 consecutive patients admitted to a comprehensive stroke center who underwent AP assessment through NPi-200 (NeurOptics®) within 72 h of stroke onset and 200 HS. The mean values of AP parameters and the absolute differences between the AP parameters of the two eyes were considered in the analyses. Predictors of stroke diagnosis were identified through univariate and multivariate logistic regressions; we then computed a nomogram based on each variable's β coefficient. Finally, we developed a web app capable of displaying the probability of stroke diagnosis based on the predictive algorithm. RESULTS A high percentage of pupil constriction (CH, p < 0.001), a low constriction velocity (CV, p = 0.002), and high differences between these two parameters (p = 0.036 and p = 0.004, respectively) were independent predictors of AIS. The highest contribution in the predictive score was provided by CH, the Neurological Pupil Index, CV, and CV absolute difference, disclosing the important role of AP in the discrimination of stroke patients. CONCLUSIONS The results of our study suggest that AP parameters, and in particular, those concerning pupillary constriction, may be useful for the early diagnosis of AIS.
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Affiliation(s)
- Irene Scala
- Department of Neuroscience, Catholic University of Sacred Heart, 00168 Rome, Italy; (I.S.); (M.M.); (P.A.R.); (F.V.); (S.B.); (J.D.G.); (F.C.); (G.D.M.); (V.B.); (A.B.); (P.C.)
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (V.G.); (R.D.I.); (M.M.)
| | - Massimo Miccoli
- Department of Neuroscience, Catholic University of Sacred Heart, 00168 Rome, Italy; (I.S.); (M.M.); (P.A.R.); (F.V.); (S.B.); (J.D.G.); (F.C.); (G.D.M.); (V.B.); (A.B.); (P.C.)
| | - Pia Clara Pafundi
- Facility of Epidemiology and Biostatistics, Gemelli Generator, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy;
| | - Pier Andrea Rizzo
- Department of Neuroscience, Catholic University of Sacred Heart, 00168 Rome, Italy; (I.S.); (M.M.); (P.A.R.); (F.V.); (S.B.); (J.D.G.); (F.C.); (G.D.M.); (V.B.); (A.B.); (P.C.)
| | - Francesca Vitali
- Department of Neuroscience, Catholic University of Sacred Heart, 00168 Rome, Italy; (I.S.); (M.M.); (P.A.R.); (F.V.); (S.B.); (J.D.G.); (F.C.); (G.D.M.); (V.B.); (A.B.); (P.C.)
| | - Simone Bellavia
- Department of Neuroscience, Catholic University of Sacred Heart, 00168 Rome, Italy; (I.S.); (M.M.); (P.A.R.); (F.V.); (S.B.); (J.D.G.); (F.C.); (G.D.M.); (V.B.); (A.B.); (P.C.)
| | - Jacopo Di Giovanni
- Department of Neuroscience, Catholic University of Sacred Heart, 00168 Rome, Italy; (I.S.); (M.M.); (P.A.R.); (F.V.); (S.B.); (J.D.G.); (F.C.); (G.D.M.); (V.B.); (A.B.); (P.C.)
| | - Francesca Colò
- Department of Neuroscience, Catholic University of Sacred Heart, 00168 Rome, Italy; (I.S.); (M.M.); (P.A.R.); (F.V.); (S.B.); (J.D.G.); (F.C.); (G.D.M.); (V.B.); (A.B.); (P.C.)
| | - Giacomo Della Marca
- Department of Neuroscience, Catholic University of Sacred Heart, 00168 Rome, Italy; (I.S.); (M.M.); (P.A.R.); (F.V.); (S.B.); (J.D.G.); (F.C.); (G.D.M.); (V.B.); (A.B.); (P.C.)
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (V.G.); (R.D.I.); (M.M.)
| | - Valeria Guglielmi
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (V.G.); (R.D.I.); (M.M.)
| | - Valerio Brunetti
- Department of Neuroscience, Catholic University of Sacred Heart, 00168 Rome, Italy; (I.S.); (M.M.); (P.A.R.); (F.V.); (S.B.); (J.D.G.); (F.C.); (G.D.M.); (V.B.); (A.B.); (P.C.)
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (V.G.); (R.D.I.); (M.M.)
| | - Aldobrando Broccolini
- Department of Neuroscience, Catholic University of Sacred Heart, 00168 Rome, Italy; (I.S.); (M.M.); (P.A.R.); (F.V.); (S.B.); (J.D.G.); (F.C.); (G.D.M.); (V.B.); (A.B.); (P.C.)
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (V.G.); (R.D.I.); (M.M.)
| | - Riccardo Di Iorio
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (V.G.); (R.D.I.); (M.M.)
| | - Mauro Monforte
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (V.G.); (R.D.I.); (M.M.)
| | - Paolo Calabresi
- Department of Neuroscience, Catholic University of Sacred Heart, 00168 Rome, Italy; (I.S.); (M.M.); (P.A.R.); (F.V.); (S.B.); (J.D.G.); (F.C.); (G.D.M.); (V.B.); (A.B.); (P.C.)
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (V.G.); (R.D.I.); (M.M.)
| | - Giovanni Frisullo
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (V.G.); (R.D.I.); (M.M.)
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8
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Beck J, Bolina JK, Boyd LH. Acute liver failure. JAAPA 2024; 37:22-27. [PMID: 38595172 DOI: 10.1097/01.jaa.0000000000000001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
ABSTRACT Acute liver failure, commonly caused by acetaminophen overdose, is associated with numerous systemic complications including cerebral edema, hypotension, acute kidney injury, and infection. Management is primarily supportive, with an emphasis on excellent neurocritical care. Although some antidotes and targeted treatments exist, the only definitive treatment remains orthotopic liver transplant.
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Affiliation(s)
- James Beck
- At Emory University Hospital in Atlanta, Ga., James Beck practices in critical care, Jasleen K. Bolina is a clinical pharmacy specialist in critical care, and Lisa H. Boyd is lead advanced practice provider in critical care. The authors have disclosed no potential conflicts of interest, financial or otherwise
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9
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Juskys R, Vilcinis R, Piliponis L, Tamasauskas A. Degree of basal cisterns compression predicting mortality and functional outcome after craniotomy and primary decompressive craniectomy in acute subdural hematoma population. Acta Neurochir (Wien) 2023; 165:4013-4020. [PMID: 37878128 DOI: 10.1007/s00701-023-05845-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/09/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVES The compression of basal cisterns on CT is one of the signs of intracranial hypertension in TBI population. This study evaluates the relationship between the degree of basal cisterns effacement and outcomes in aSDH population. METHODS The study includes prospectively collected data from 290 patients who underwent osteoplastic craniotomy (OC) or primary decompressive craniectomy (pDC) for aSDH from 2016 to 2021. Univariate and multivariate regression analyses were performed to evaluate the association of baseline characteristics and extent of basal cisterns compression on pre-operative and post-operative CT scans with the outcomes at the time of discharge. Outcomes were dichotomized into mortality (and unfavourable (GOS 1-3 vs GOS 4-5). The degree of cisternal compression was evaluated using the cisternal effacement score of perimesencephalic and quadrigeminal cisternal components. Critical thresholds associated with the outcomes were calculated. RESULTS Age and pre-/post-operative degree of cisternal compression were the strongest independent predictors of intrahospital mortality in a whole sample and separately in OC and pDC subgroups. The unfavourable outcome was independently predicted by age, pre-/post-operative status of cisternal compression and initial GCS. Critical thresholds associated with the mortality and poor functional outcome were, respectively, age ≥ 70 (OR 3.14 [CI 95% 1.82-5.46], p < 0.001) and ≥ 67 (OR 3.87 [CI 95% 2.33-6.54], p < 0.001), pre-operative cisternal effacement score ≥ 9 (OR 6.39 [CI 95% 3.62-11.53], p < 0.001) and ≥ 7 (OR 4.93 [CI 95% 2.96-8.38], p < 0.001), post-operative cisternal effacement score ≥ 6 (OR 20.6 [CI 95% 10.08-45.10], p < 0.001) and ≥ 3 (OR 7.47 [CI 95% 3.87-15.73], p < 0.001) and initial GCS ≤ 8 (OR 0.24 [CI 95% 0.13-0.43], p < 0.001 and OR 0.12 [CI 95% 0.07-0.21], p < 0.001). CONCLUSIONS After adjusting for baseline characteristics, age and degree of cisternal compression remained the independent predictors of mortality, whereas unfavourable outcomes were associated with age, cisternal obliteration and GCS on presentation.
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Affiliation(s)
- R Juskys
- Department of Neurosurgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - R Vilcinis
- Department of Neurosurgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - L Piliponis
- Department of Neurosurgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
- Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
| | - A Tamasauskas
- Neuroscience Institute, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
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10
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Falconi S, Demopoulos A, Collins R, Garza J, Nagy L. Outcomes of Pediatric Traumatic Brain Injury Patients Presenting with or Developing Cerebral Herniation. World Neurosurg 2023; 177:e700-e709. [PMID: 37406799 DOI: 10.1016/j.wneu.2023.06.125] [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: 03/21/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) is the leading cause of mortality and morbidity in children. Previous studies evaluated outcomes of adult patients; however, few assessed outcomes of pediatric TBI patients presenting with herniation. This study investigated outcome data in pediatric patients presenting with TBI and cerebral herniation and the interventional strategies used for each patient in a rural community. METHODS A dual-institution retrospective review of 50 pediatric patients presenting with TBI and cerebral herniation from January 2011 to December 2020 was conducted. Mechanism of injury; herniation based on radiology findings; admission, presurgery, and postsurgery Glasgow Coma Scale scores; intracranial pressure values; discharge Glasgow Outcome Scale scores; length of stay; intensive care unit length of stay; procedures performed; and 30-day mortality/morbidity were collected for each patient. RESULTS Although a nonsurgical approach led to better outcomes (29.4% vs. 48.4% mortality rate), early intervention with decompressive craniectomy improved morbidity in patients with severe TBI and cerebral herniation. Male patients presenting with TBI complicated by herniation were more likely to have a fatal outcome compared with female patients (51.6% vs. 26.3%). Behavior and age at injury may play a role in these differences. CONCLUSIONS TBI remains a serious concern in the pediatric population with no clear guidelines on the optimal treatment. This study highlights the advantage of integrating more aggressive surgical intervention, such as decompressive craniectomy, in rural communities earlier in the hospital course. Future studies should explore additional factors that could contribute to outcomes in this patient population.
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Affiliation(s)
- Sirin Falconi
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA.
| | - Alex Demopoulos
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Reagan Collins
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - John Garza
- Department of Mathematics, The University of Texas Permian Basin, Odessa, Texas, USA
| | - Laszlo Nagy
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
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11
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Chopra P, Singh M, Singh A, Masi A, Yurkofsky J, Zaita B, Kaur G. Perioperative Management of Spontaneous Intracranial Hemorrhage in a Patient With Hemophilia A in a Resource Limited Country. Cureus 2023; 15:e43485. [PMID: 37711951 PMCID: PMC10499499 DOI: 10.7759/cureus.43485] [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] [Accepted: 08/13/2023] [Indexed: 09/16/2023] Open
Abstract
Intracranial hemorrhage (ICH) is a serious complication of hemophilia A with high morbidity and mortality. The management of such cases is complicated by nonspecific and often delayed presentation, increased frequency of rebleeding, low awareness regarding clotting factor replacement, and debate regarding the efficacy of surgical interventions. We report a case of an 18-year-old male patient with hemophilia A, who first presented to the emergency department in India in a comatose state. Neuroimaging revealed subdural hematoma with midline shift and uncal herniation. The patient was successfully managed with perioperative cryoprecipitate and factor VIII replacement, tiered intracranial pressure lowering strategies, and early decompressive craniectomy with clot evacuation. In India, there are no standardized guidelines for screening and routine care for hereditary diseases like hemophilia. In a resource-deficient country, management was complicated by the limited availability of factor VIII in the emergent setting, as well as the inability to obtain serial factor levels in the postoperative period. We hope that this article helps to guide the management of ICH and hemophilia in resource-limited countries.
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Affiliation(s)
- Puneet Chopra
- Critical Care, Satguru Partap Singh (SPS) Hospital, Ludhiana, IND
| | - Manraj Singh
- Basic Biomedical Sciences, Dayanand Medical College and Hospital, Ludhiana, IND
| | | | - Athena Masi
- Basic Biomedical Sciences, Touro College of Osteopathic Medicine, Middletown, USA
| | - Judith Yurkofsky
- Basic Biomedical Sciences, Touro College of Osteopathic Medicine, Middletown, USA
| | - Brittany Zaita
- Basic Biomedical Sciences, Touro College of Osteopathic Medicine, Middletown, USA
| | - Gurjinder Kaur
- Basic Biomedical Sciences, Touro College of Osteopathic Medicine, Middletown, USA
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12
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Lam MSH, Luoma AMV, Reddy U. Acute perioperative neurological emergencies. Int Anesthesiol Clin 2023; 61:53-63. [PMID: 37249171 DOI: 10.1097/aia.0000000000000404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Michelle S H Lam
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Astri M V Luoma
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, UK
| | - Ugan Reddy
- Department of Neuroanaesthesia and Neurocritical Care, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, UK
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13
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Lui AK, Lin F, Uddin A, Nolan B, Clare K, Nguyen T, Spirollari E, Feldstein E, Bornovski Y, Dominguez J, Coritsidis G, Gandhi CD, Al-Mufti F. A double-hit: End-stage renal disease patients suffer worse outcomes in intracerebral hemorrhage. Brain Circ 2023; 9:172-177. [PMID: 38020947 PMCID: PMC10679629 DOI: 10.4103/bc.bc_24_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/05/2023] [Accepted: 06/13/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) carries significant morbidity and mortality. Previous single-center retrospective analysis suggests that end-stage renal disease (ESRD) is a risk factor for severe ICH and worse outcomes. This investigation aims to examine the impact of ESRD on ICH severity, complications, and outcomes using a multicenter national database. METHODS The International Classification of Disease, Ninth and Tenth Revision Clinical Modification codes were used to query the National Inpatient Sample for patients with ICH and ESRD between 2010 and 2019. Primary endpoints were the functional outcome, length of stay (LOS), and in-hospital mortality. Multivariate variable regression models and a propensity-score matched analysis were established to analyze patient outcomes associated with baseline patient characteristics. RESULTS We identified 211,266 patients with ICH, and among them, 7,864 (3.77%) patients had a concurrent diagnosis of ESRD. Patients with ESRD were younger (60.85 vs. 67.64, P < 0.01) and demonstrated increased ICH severity (0.78 vs. 0.77, P < 0.01). ESRD patients experienced higher rates of sepsis (15.9% vs. 6.15%, P < 0.01), acute myocardial infarction (8.05% vs. 3.65%, P < 0.01), and cardiac arrest (5.94% vs. 2.4%, P < 0.01). In addition, ESRD predicted poor discharge disposition (odds ratio [OR]: 2.385, 95% confidence interval [CI]: 2.227-2.555, P < 0.01), longer hospital LOS (OR: 1.629, 95% CI: 1.553-1.709, P < 0.01), and in-hospital mortality (OR: 2.786, 95% CI: 2.647-2.932, P < 0.01). CONCLUSIONS This study utilizes a multicenter database to analyze the effect of ESRD on ICH outcomes. ESRD is a significant predictor of poor functional outcomes, in-hospital mortality, and prolonged stay in the ICH population.
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Affiliation(s)
- Aiden K. Lui
- School of Medicine at New York Medical College, Valhalla, New York USA
| | - Fangyi Lin
- School of Medicine at New York Medical College, Valhalla, New York USA
| | - Anaz Uddin
- School of Medicine at New York Medical College, Valhalla, New York USA
| | - Bridget Nolan
- School of Medicine at New York Medical College, Valhalla, New York USA
- Brain and Spine Institute at Westchester Medical Center, Valhalla, New York USA
| | - Kevin Clare
- School of Medicine at New York Medical College, Valhalla, New York USA
- Brain and Spine Institute at Westchester Medical Center, Valhalla, New York USA
| | - Terry Nguyen
- School of Medicine at New York Medical College, Valhalla, New York USA
| | - Eris Spirollari
- School of Medicine at New York Medical College, Valhalla, New York USA
| | - Eric Feldstein
- Brain and Spine Institute at Westchester Medical Center, Valhalla, New York USA
| | - Yarden Bornovski
- Brain and Spine Institute at Westchester Medical Center, Valhalla, New York USA
| | - Jose Dominguez
- Brain and Spine Institute at Westchester Medical Center, Valhalla, New York USA
| | - George Coritsidis
- Department of Nephrology at Westchester Medical Center, Valhalla, New York USA
| | - Chirag D. Gandhi
- School of Medicine at New York Medical College, Valhalla, New York USA
- Brain and Spine Institute at Westchester Medical Center, Valhalla, New York USA
| | - Fawaz Al-Mufti
- School of Medicine at New York Medical College, Valhalla, New York USA
- Brain and Spine Institute at Westchester Medical Center, Valhalla, New York USA
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14
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Didsbury M, See EJ, Cheng DR, Kausman J, Quinlan C. Correcting Hypernatremia in Children. Clin J Am Soc Nephrol 2023; 18:306-314. [PMID: 36888887 PMCID: PMC10103237 DOI: 10.2215/cjn.0000000000000077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 01/03/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND In children with hypernatremia, current clinical guidelines recommend a reduction in serum sodium of 0.5 mmol/L per hour or less to avoid complications of cerebral edema. However, no large-scale studies have been conducted in the pediatric setting to inform this recommendation. Therefore, this study aimed to report the association between the rate of correction of hypernatremia, neurological outcomes, and all-cause mortality in children. METHODS A retrospective cohort study was conducted from 2016 to 2019 at a quaternary pediatric center in Melbourne, Victoria, Australia. All children with at least one serum sodium level ≥150 mmol/L were identified through interrogation of the hospital's electronic medical record. Medical notes, neuroimaging reports, and electroencephalogram results were reviewed for evidence of seizures and/or cerebral edema. The peak serum sodium level was identified and correction rates over the first 24 hours and overall were calculated. Unadjusted and multivariable analyses were used to examine the association between the rate of sodium correction and neurological complications, the requirement for neurological investigation, and death. RESULTS There were 402 episodes of hypernatremia among 358 children over the 3-year study period. Of these, 179 were community-acquired and 223 developed during admission. A total of 28 patients (7%) died during admission. Mortality was higher in children with hospital-acquired hypernatremia, as was the frequency of intensive care unit admission and hospital length of stay. Rapid correction (>0.5 mmol/L per hour) occurred in 200 children and was not associated with greater neurological investigation or mortality. Length of stay was longer in children who received slow correction (<0.5 mmol/L per hour). CONCLUSIONS Our study did not find any evidence that rapid sodium correction was associated with greater neurological investigation, cerebral edema, seizures, or mortality; however, slow correction was associated with a longer hospital length of stay.
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Affiliation(s)
- Madeleine Didsbury
- Department of Nephrology, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Centre for Health Analytics The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Emily J. See
- Department of Nephrology, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Centre for Health Analytics The Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia
- School of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Daryl R. Cheng
- Centre for Health Analytics The Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of General Medicine and EMR Team, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Joshua Kausman
- Department of Nephrology, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Centre for Health Analytics The Royal Children's Hospital, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Catherine Quinlan
- Department of Nephrology, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Centre for Health Analytics The Royal Children's Hospital, Melbourne, Victoria, Australia
- School of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
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15
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Neurologic Complications in Patients With Left Ventricular Assist Devices. Can J Cardiol 2023; 39:210-221. [PMID: 36400374 PMCID: PMC9905352 DOI: 10.1016/j.cjca.2022.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/10/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Left ventricular assist device (LVAD) use has revolutionised the care of patients with advanced heart failure, allowing more patients to survive until heart transplantation and providing improved quality for patients unable to undergo transplantation. Despite these benefits, improvements in device technology, and better clinical care and experience, LVADs are associated with neurologic complications. This review provides information on the incidence, risk factors, and management of neurologic complications among LVAD patients. Although scant guidelines exist for the evaluation and management of neurologic complications in LVAD patients, a high index of suspicion can prompt early detection of neurologic complications which may improve overall neurologic outcomes. A better understanding of the implications of continuous circulatory flow on systemic and cerebral vasculature is necessary to reduce the common occurrence of neurologic complications in this population.
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16
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Her J, Merbl Y, Gerken K, Kim M, Hofmeister E, Bacek LM, Kuo KW, Yanke AB. Relationship between admission vitals and brain herniation in 32 cats: a retrospective study. J Feline Med Surg 2022; 24:770-778. [PMID: 34612748 PMCID: PMC10812265 DOI: 10.1177/1098612x211048639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The aim of the study was to evaluate whether any admission vitals correlated with the presence of brain herniation diagnosed via MRI in cats presenting with neurologic signs. METHODS Medical records at two veterinary university referral centers were reviewed to identify cats that underwent brain MRI between 2010 and 2019. A control group of cats with intracranial lesions without concurrent brain herniation was analyzed for comparison. Data relating to signalment, vitals on admission, abnormalities observed on initial neurologic examination, underlying etiology, advanced imaging findings and outcome were reviewed. A Modified Glasgow Coma Scale (MGCS) score was determined retrospectively based on initial neurologic examination. Logistic regressions were performed to investigate the relationship between each risk factor and the odds of brain herniation as diagnosed on MRI. RESULTS Thirty-two cats with brain herniation and 44 cats with abnormal brain MRI without evidence of herniation (as a control group) based on MRI findings were included. Cats with intracranial neoplasia vs other diagnoses were found to be at increased risk of herniation (odds ratio [OR] 4.8, 95% confidence interval [CI] 1.8-13.8; P = 0.001). The odds of herniation increased with age (OR 1.1, 95% CI 1.01-1.2; P = 0.031). Cats with herniation had a significantly lower level of consciousness in their MGCS score (P <0.0001) than cats without herniation. There was no significant difference in either motor activity or brainstem reflexes between the groups (P >0.05). CONCLUSIONS AND RELEVANCE Admission heart rate and blood pressure were not associated with brain herniation. Cats with herniation were presented with a significantly lower level of consciousness in their MGCS score; however, this clinical feature cannot be directly attributable to and predictive of herniation. Older cats with intracranial neoplasia are more likely to have brain herniation.
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Affiliation(s)
- Jiwoong Her
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL, USA
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
| | - Yael Merbl
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Washington State University, Pullman, WA, USA
| | - Katherine Gerken
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL, USA
| | - Minjeong Kim
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL, USA
| | - Erik Hofmeister
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL, USA
| | | | - Kendon W Kuo
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL, USA
| | - Amy B Yanke
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL, USA
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17
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Lui A, Kumar KK, Grant GA. Management of Severe Traumatic Brain Injury in Pediatric Patients. FRONTIERS IN TOXICOLOGY 2022; 4:910972. [PMID: 35812167 PMCID: PMC9263560 DOI: 10.3389/ftox.2022.910972] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/10/2022] [Indexed: 11/23/2022] Open
Abstract
The optimal management of severe traumatic brain injury (TBI) in the pediatric population has not been well studied. There are a limited number of research articles studying the management of TBI in children. Given the prevalence of severe TBI in the pediatric population, it is crucial to develop a reference TBI management plan for this vulnerable population. In this review, we seek to delineate the differences between severe TBI management in adults and children. Additionally, we also discuss the known molecular pathogenesis of TBI. A better understanding of the pathophysiology of TBI will inform clinical management and development of therapeutics. Finally, we propose a clinical algorithm for the management and treatment of severe TBI in children using published data.
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Affiliation(s)
- Austin Lui
- Touro University College of Osteopathic Medicine, Vallejo, CA, United States
| | - Kevin K. Kumar
- Department of Neurosurgery, Stanford University, Stanford, CA, United States
- Division of Pediatric Neurosurgery, Lucile Packard Children’s Hospital, Palo Alto, CA, United States
| | - Gerald A. Grant
- Department of Neurosurgery, Stanford University, Stanford, CA, United States
- Division of Pediatric Neurosurgery, Lucile Packard Children’s Hospital, Palo Alto, CA, United States
- Department of Neurosurgery, Duke University, Durham, NC, United States
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18
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Squires JE, Alonso EM, Ibrahim SH, Kasper V, Kehar M, Martinez M, Squires RH. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper on the Diagnosis and Management of Pediatric Acute Liver Failure. J Pediatr Gastroenterol Nutr 2022; 74:138-158. [PMID: 34347674 DOI: 10.1097/mpg.0000000000003268] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
ABSTRACT Pediatric acute liver failure (PALF) is a rare, rapidly progressive clinical syndrome with significant morbidity and mortality. The phenotype of PALF manifests as abrupt onset liver dysfunction, which can be brought via disparate etiology. Management is reliant upon intensive clinical care and support, often provided by the collaborative efforts of hepatologists, critical care specialists, and liver transplant surgeons. The construction of an age-based diagnostic approach, the identification of a potential underlying cause, and the prompt implementation of appropriate therapy can be lifesaving; however, the dynamic and rapidly progressive nature of PALF also demands that diagnostic inquiries be paired with monitoring strategies for the recognition and treatment of common complications of PALF. Although liver transplantation can provide a potential life-saving therapeutic option, the ability to confidently determine the certainness that liver transplant is needed for an individual child has been hampered by a lack of adequately tested clinical decision support tools and accurate predictive models. Given the accelerated progress in understanding PALF, we will provide clinical guidance to pediatric gastroenterologists and other pediatric providers caring for children with PALF by presenting the most recent advances in diagnosis, management, pathophysiology, and associated outcomes.
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Affiliation(s)
- James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Estella M Alonso
- Department Pediatric Hepatology, Ann and Robert H Lurie Children's Hospital, Chicago, Illinois, USA
| | - Samar H Ibrahim
- Department of Pediatrics, Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Vania Kasper
- Division of Pediatric Gastroenterology, Nutrition and Liver Diseases, Hasbro Children's Hospital, Providence, RI
| | - Mohit Kehar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Mercedes Martinez
- Department of Pediatrics, Vagelos College of Physician and Surgeons, Columbia University, New York, NY
| | - Robert H Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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19
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Kircher CE, Adeoye O. Prehospital and Emergency Department Care of the Patient With Acute Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00052-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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20
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Navarro JC, Kofke WA. Perioperative Management of Acute Central Nervous System Injury. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00024-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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21
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Carpenter K, Iwanaga J, Aysenne A, Dumont AS, Bui CJ, Tubbs RS. An anatomical model for studying cerebellar tonsillar herniation related to raised intracranial pressure. Clin Anat 2021; 35:251-255. [PMID: 34913515 DOI: 10.1002/ca.23827] [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: 11/17/2021] [Accepted: 11/29/2021] [Indexed: 11/06/2022]
Abstract
Brain herniation is one of the most feared complications of many neurological pathologies. However, current understanding of the mechanisms behind brain herniation syndromes is poor. By investigating the correlations between raised intracranial pressure (ICP) and herniation of the cerebellar tonsils, we hope to develop a model that can be used to study intracranial fluid dynamics and its effects on brain tissue. This will facilitate evaluation of patients with elevated ICP and development of novel treatments including surgical approaches for decompressing the posterior cranial fossa and upper cervical spine. A standard suboccipital surgical approach was used to expose the foramen magnum and observe movements of the cerebellar tonsils in fresh cadavers. A urinary Foley catheter balloon in the parietal extradural space was used to simulate a mass effect while ICP was monitored. The baseline anatomy differed widely among the cadaver specimens. However, and overall, we found that as ICP rises, the cerebellar tonsils descend through the foramen magnum at a rate of 0.3 mm per 1 mmHg increase in ICP. A mean descent of 6.2 mm was observed for a mean ICP increase of 17 mmHg. In this cadaveric study, we present a method and model for exploring brain herniation syndromes in the context of ICP changes. This could allow for further models to study the effects of other neuropathologies on the cerebellar tonsils, including posterior cranial fossa mass lesions and cerebellar hemorrhage.
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Affiliation(s)
- Kennedy Carpenter
- Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, Louisiana, USA
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Aimee Aysenne
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Aaron S Dumont
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - C J Bui
- Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, Louisiana, USA
| | - R Shane Tubbs
- Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, Louisiana, USA.,Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA.,Department of Anatomical Sciences, St. George's University, St. George's, Grenada.,Department of Structural & Cellular Biology, Tulane University School of Medicine, New Orleans, Louisiana, USA.,Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
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Andrade RDAP, Oshiro HE, Miyazaki CK, Hayashi CY, de Morais MA, Brunelli R, Carmo JP. A Nanometer Resolution Wearable Wireless Medical Device for Non Invasive Intracranial Pressure Monitoring. IEEE SENSORS JOURNAL 2021; 21:22270-22284. [DOI: 10.1109/jsen.2021.3090648] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2025]
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23
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Her J, Yanke AB, Gerken K, Yoon J, Peters AA, Hofmeister E, Bacek LM, Kuo KW. Retrospective evaluation of the relationship between admission variables and brain herniation in dogs (2010-2019): 54 cases. J Vet Emerg Crit Care (San Antonio) 2021; 32:50-57. [PMID: 34608750 DOI: 10.1111/vec.13147] [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: 10/20/2019] [Revised: 06/09/2020] [Accepted: 07/21/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To document the admission systolic blood pressure (SBP), heart rate (HR), and modified Glasgow coma scale (MGCS) score in dogs with and without brain herniation and to determine their relationship with brain herniation. DESIGN Retrospective study between 2010 and 2019. SETTING University veterinary teaching hospital. ANIMALS Fifty-four client-owned dogs with brain herniation and 40 client-owned dogs as a control group, as determined on magnetic resonance imaging. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS SBP, HR, MGCS score, and outcome were extracted from medical records. MGCS score was retrospectively calculated based on initial neurological examination in dogs with adequate available information. Dogs with brain herniation had a significantly higher SBP (P = 0.0078), greater SBP-HR difference (P = 0.0006), and lower MGCS score (P < 0.0001) compared to control dogs. A cutoff value of an SBP ≥ 178 mm Hg, SBP-HR ≥ 60, and MGCS score ≤ 14 each provides a specificity of 90%-98%. A combination of an SBP > 140 mm Hg and HR < 80/min provided 24% sensitivity and 100% specificity to diagnose dogs with brain herniation (P < 0.0001). CONCLUSIONS A high SBP, a greater difference between SBP and HR, a combination of higher SBP and lower HR, and a low MGCS score were associated with brain herniation in dogs presenting with neurological signs upon admission. Early recognition of these abnormalities may help veterinarians to suspect brain herniation and determine timely treatment.
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Affiliation(s)
- Jiwoong Her
- Department of Clinical Sciences, Auburn University College of Veterinary Medicine, Auburn, Alabama, USA
| | - Amy B Yanke
- Department of Clinical Sciences, Auburn University College of Veterinary Medicine, Auburn, Alabama, USA
| | - Katherine Gerken
- Department of Clinical Sciences, Auburn University College of Veterinary Medicine, Auburn, Alabama, USA
| | - Jin Yoon
- Veterinary Surgical Centers, Vienna, Virginia, USA
| | | | - Erik Hofmeister
- Department of Clinical Sciences, Auburn University College of Veterinary Medicine, Auburn, Alabama, USA
| | | | - Kendon W Kuo
- Department of Clinical Sciences, Auburn University College of Veterinary Medicine, Auburn, Alabama, USA
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24
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Gamblin A, Fredrickson VL, Hollon TC, Salzman KL, Couldwell WT. Idiopathic chronic temporal lobe herniation with associated epilepsy. Acta Neurochir (Wien) 2021; 163:2805-2808. [PMID: 34292392 DOI: 10.1007/s00701-021-04926-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/18/2021] [Indexed: 11/30/2022]
Abstract
Herniation of parahippocampal gyrus is usually caused by pressure differentials intracranially, and herniation without known risk factors is extremely rare. We describe a patient with a long history of seizures and a remote status epilepticus event. On magnetic resonance imaging, a presumed left temporal lobe tumor was observed. On neurosurgical consultation, the lesion was identified as a chronic mesial temporal lobe herniation. The patient lacked history that would suggest risk of cerebral herniation. Accurately identifying the patient's chronic temporal lobe herniation radiographically likely saved this patient from unnecessary surgery or biopsy and allowed the patient to receive appropriate conservative care.
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Affiliation(s)
- Austin Gamblin
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Vance L Fredrickson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Todd C Hollon
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Karen L Salzman
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA.
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25
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Moscardini-Martelli J, Ponce-Gomez JA, Alcocer-Barradas V, Romano-Feinholz S, Padilla-Quiroz P, Zazueta MO, Ortega-Porcayo LA. Upward transtentorial herniation: A new role for endoscopic third ventriculostomy. Surg Neurol Int 2021; 12:334. [PMID: 34345475 PMCID: PMC8326076 DOI: 10.25259/sni_140_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/27/2021] [Indexed: 11/22/2022] Open
Abstract
Background: The placement of external ventricular drainage (EVD) to treat hydrocephalus secondary to a cerebellar stroke is controversial because it has been associated to upward transtentorial herniation (UTH). This case illustrates the effectiveness of endoscopic third ventriculostomy (ETV) after the ascending herniation has occurred. Case Description: A 50-year-old man had a cerebellar stroke with hemorrhagic transformation, tonsillar herniation, and non-communicating obstructive hydrocephalus. Considering that the patient was anticoagulated and thrombocytopenic, an EVD was placed initially, followed by clinical deterioration and UTH. We performed a suboccipital craniectomy immediately after clinical worsening, but the patient did not show clinical or radiological improvement. On the 5th day, we did an ETV, which reverses the upward herniation and hydrocephalus. The patient improved progressively with good neurological recovery. Conclusion: ETV is an effective and safe procedure for obstructive hydrocephalus. The successful resolution of the patient’s upward herniation after the ETV offers a potential option to treat UTH and advocates further research in this area.
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Affiliation(s)
| | - Juan Antonio Ponce-Gomez
- Neurological Center, Centro Médico ABC.,Department of Neurological Surgery, Hospital Ángeles Pedregal.,Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez"
| | - Victor Alcocer-Barradas
- Department of Neurological Surgery, Hospital Ángeles Pedregal.,Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez"
| | | | | | - Marcela Osuna Zazueta
- Neurological Center, Centro Médico ABC.,Department of Neurological Surgery, Hospital Ángeles Pedregal
| | - Luis Alberto Ortega-Porcayo
- Department of Medicine, Faculty of Health Sciences, Universidad Anáhuac.,Neurological Center, Centro Médico ABC.,Department of Neurological Surgery, Hospital Ángeles Pedregal
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26
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Rynkowski CB, Basso LS, Kolias AG, Bianchin MM. Long-Term Outcome After Decompressive Craniectomy in a Developing Country. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 131:87-90. [PMID: 33839825 DOI: 10.1007/978-3-030-59436-7_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Decompressive craniectomy (DC) may reduce mortality but might increase the number of survivors in a vegetative state. In this study, we assessed the long-term functional outcome of patients undergoing DC in a middle-income country. METHODS This was a prospective observational study of patients undergoing DC at a single tertiary hospital in southern Brazil between January 2015 and December 2018. RESULTS Of the 125 patients who were included in this study, 57.6% (72/125) had a traumatic brain injury (TBI), 21.6% (27/125) had a stroke, 19.2% (24/125) had a cerebral hemorrhage (intracerebral or subarachnoid hemorrhage), and 0.8% (1/125) had a cerebral abscess. The mean age was 45.18 ± 19.6 years, and 71% of the patients were men. The mean initial Glasgow Coma Scale (GCS) score was 7.8 ± 3.6. The in-hospital mortality rate was 44.8% (56/125). Of the survivors, 50.7% (35/69) had a favorable outcome 6 months after DC. After multivariate analysis, a lower initial GCS score (7.5 ± 3.6 versus 8.8 ± 3.5, P = 0.007) and older age (49.7 ± 18.9 versus 33.3 ± 16.2 years, P = 0.0001) were associated with an unfavorable outcome. CONCLUSION Six months after DC, almost half of the patients who survive have a favorable outcome.
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Affiliation(s)
- Carla B Rynkowski
- Adult Critical Care Unit, Hospital Cristo Redentor, Porto Alegre, Brazil.
| | | | - Angelos G Kolias
- Neurosurgical Division, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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27
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Noureldine MHA, Hartnett S, Zavadskiy G, Pressman E, Kim JK, Davis D, Ciesla D, Bull B, Agazzi S. Predicting neurosurgical clearance in the polytrauma patient with concomitant traumatic brain injury. J Clin Neurosci 2021; 89:51-55. [PMID: 34119294 DOI: 10.1016/j.jocn.2021.04.023] [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: 09/09/2020] [Revised: 03/02/2021] [Accepted: 04/16/2021] [Indexed: 10/21/2022]
Abstract
The goal of this study is to develop a model based on previously used prognostic predictors in traumatic brain injury (TBI) patients with polytrauma, which will facilitate the decision-making of whether to clear these patients for non-cranial surgery. Data of eligible patients was obtained from a trauma database at a Level I trauma and academic tertiary referral center in the United States. The number of days seen by the neurosurgical service prior to clearance, injury severity score (ISS), post-trauma day 0 (PTD 0) of Glasgow Coma Score (GCS), intracranial pressure (ICP) score and computed tomography (CT) score, as well as the changes in GCS, ICP score and CT score between PTD 0 and day of clearance were the variables used in developing the model. The Neurosurgical Clearance Model (NCM) was developed using data from 50 patients included in the study. Patients were cleared by neurosurgeons 1.6 days later than it would appear possible based on a retrospective review of the patients' clinical conditions. A single model equation was developed, the ultimate result of which is a clearance probability value. The best cutoff clearance probability value was found to be 0.584 (or 58.4%) using Receiver Operator Characteristic curve analysis. Our data suggests that neurosurgeons are risk-averse in clearing polytrauma patients for non-cranial surgery. This pilot NCM, if reproduced and validated by other groups and in larger prospective studies, may become a useful tool to assist clinicians in this often-difficult decision-making process.
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Affiliation(s)
| | - Sara Hartnett
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Gleb Zavadskiy
- Muma College of Business, University of South Florida, Tampa, FL, USA
| | - Elliot Pressman
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Joon Kyung Kim
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Donald Davis
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of South Florida, Tampa, FL, USA
| | - David Ciesla
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Brooke Bull
- Division of Trauma and Acute Care Surgery, Department of Surgery, Tampa General Hospital, Tampa, FL, USA
| | - Siviero Agazzi
- Department of Surgery, University of South Florida, Tampa, FL, USA
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28
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Shope C, Alshareef M, Larrew T, Bolling C, Reagan J, Yazdani M, Spampinato M, Eskandari R. Utility of a pediatric fast magnetic resonance imaging protocol as surveillance scanning for traumatic brain injury. J Neurosurg Pediatr 2021; 27:475-481. [PMID: 33545669 DOI: 10.3171/2020.8.peds20496] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 08/19/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is a prevalent pediatric pathology in the modern emergency department. Computed tomography (CT) is utilized for detection of TBI and can result in cumulatively high radiation exposure. Recently, a fast brain magnetic resonance imaging (fbMRI) protocol has been employed for rapid imaging of hydrocephalus in pediatric patients. The authors investigate the utility of a modified trauma-focused fbMRI (t-fbMRI) protocol as an alternative to surveillance CT in the setting of acute TBI in pediatric patients, thus reducing radiation exposure while improving diagnostic yield. METHODS A retrospective review was performed at the authors' institution for all pediatric patients who had undergone t-fbMRI within 72 hours of an initial CT scan, using a 1.5- or 3-T MR scanner for trauma indications. Forty patients met the study inclusion criteria. The authors performed a comparison of findings on the reads of CT and fbMRI, and a board-certified neuroradiologist conducted an independent review of both modalities. RESULTS T-fbMRI outperformed CT in specificity, sensitivity, and negative predictive value for all injury pathologies measured, except for skull fractures. T-fbMRI demonstrated a sensitivity of 100% in the detection of extraaxial bleed, intraventricular hemorrhage, and subarachnoid hemorrhage and had a sensitivity of 78% or greater for epidural hematoma, subdural hematoma, and intraparenchymal hemorrhage. T-fbMRI yielded a specificity of 100% for all types of intracranial hemorrhages, with a corresponding negative predictive value that exceeded that for CT. CONCLUSIONS In pediatric populations, the t-fbMRI protocol provides a valid alternative to CT in the surveillance of TBI and intracranial hemorrhage. Although not as sensitive in the detection of isolated skull fractures, t-fbMRI can be used to monitor pathologies implicated in TBI patients while minimizing radiation exposure from traditional surveillance imaging.
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Affiliation(s)
- Chelsea Shope
- 1College of Medicine, Medical University of South Carolina; and
| | | | | | - Christopher Bolling
- 3Radiology, Medical University of South Carolina, Charleston, South Carolina
| | - Justin Reagan
- 3Radiology, Medical University of South Carolina, Charleston, South Carolina
| | - Milad Yazdani
- 3Radiology, Medical University of South Carolina, Charleston, South Carolina
| | - Maria Spampinato
- 3Radiology, Medical University of South Carolina, Charleston, South Carolina
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29
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Takahashi CE, Virmani D, Chung DY, Ong C, Cervantes-Arslanian AM. Blunt and Penetrating Severe Traumatic Brain Injury. Neurol Clin 2021; 39:443-469. [PMID: 33896528 DOI: 10.1016/j.ncl.2021.02.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Severe traumatic brain injury is a common problem. Current practices focus on the importance of early resuscitation, transfer to high-volume centers, and provider expertise across multiple specialties. In the emergency department, patients should receive urgent intracranial imaging and consideration for tranexamic acid. Close observation in the intensive care unit environment helps identify problems, such as seizure, intracranial pressure crisis, and injury progression. In addition to traditional neurologic examination, patients benefit from use of intracranial monitors. Monitors gather physiologic data on intracranial and cerebral perfusion pressures to help guide therapy. Brain tissue oxygenation monitoring and cerebromicrodialysis show promise in studies.
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Affiliation(s)
- Courtney E Takahashi
- Department of Neurology, Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA.
| | - Deepti Virmani
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
| | - David Y Chung
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA; Division of Neurocritical Care, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA; Neurovascular Research Unit, Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Charlene Ong
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
| | - Anna M Cervantes-Arslanian
- Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
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30
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Musick S, Alberico A. Neurologic Assessment of the Neurocritical Care Patient. Front Neurol 2021; 12:588989. [PMID: 33828517 PMCID: PMC8019734 DOI: 10.3389/fneur.2021.588989] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 03/02/2021] [Indexed: 11/30/2022] Open
Abstract
Sedation is a ubiquitous practice in ICUs and NCCUs. It has the benefit of reducing cerebral energy demands, but also precludes an accurate neurologic assessment. Because of this, sedation is intermittently stopped for the purposes of a neurologic assessment, which is termed a neurologic wake-up test (NWT). NWTs are considered to be the gold-standard in continued assessment of brain-injured patients under sedation. NWTs also produce an acute stress response that is accompanied by elevations in blood pressure, respiratory rate, heart rate, and ICP. Utilization of cerebral microdialysis and brain tissue oxygen monitoring in small cohorts of brain-injured patients suggests that this is not mirrored by alterations in cerebral metabolism, and seldom affects oxygenation. The hard contraindications for the NWT are preexisting intracranial hypertension, barbiturate treatment, status epilepticus, and hyperthermia. However, hemodynamic instability, sedative use for primary ICP control, and sedative use for severe agitation or respiratory distress are considered significant safety concerns. Despite ubiquitous recommendation, it is not clear if additional clinically relevant information is gleaned through its use, especially with the contemporaneous utilization of multimodality monitoring. Various monitoring modalities provide unique and pertinent information about neurologic function, however, their role in improving patient outcomes and guiding treatment plans has not been fully elucidated. There is a paucity of information pertaining to the optimal frequency of NWTs, and if it differs based on type of injury. Only one concrete recommendation was found in the literature, exemplifying the uncertainty surrounding its utility. The most common sedative used and recommended is propofol because of its rapid onset, short duration, and reduction of cerebral energy requirements. Dexmedetomidine may be employed to facilitate serial NWTs, and should always be used in the non-intubated patient or if propofol infusion syndrome (PRIS) develops. Midazolam is not recommended due to tissue accumulation and residual sedation confounding a reliable NWT. Thus, NWTs are well-tolerated in selected patients and remain recommended as the gold-standard for continued neuromonitoring. Predicated upon one expert panel, they should be performed at least one time per day. Propofol or dexmedetomidine are the main sedative choices, both enabling a rapid awakening and consistent NWT.
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Affiliation(s)
- Shane Musick
- Department of Neurosurgery, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, United States
| | - Anthony Alberico
- Department of Neurosurgery, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, United States
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31
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Tunthanathip T, Duangsuwan J, Wattanakitrungroj N, Tongman S, Phuenpathom N. Clinical Nomogram Predicting Intracranial Injury in Pediatric Traumatic Brain Injury. J Pediatr Neurosci 2021; 15:409-415. [PMID: 33936306 PMCID: PMC8078639 DOI: 10.4103/jpn.jpn_11_20] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/12/2020] [Accepted: 03/28/2020] [Indexed: 01/12/2023] Open
Abstract
Background: There are differences in injured mechanisms among pediatric traumatic brain injury (TBI) in developing countries. This study aimed to develop and validate clinical nomogram for predicting intracranial injury in pediatric TBI that will be implicated in balancing the unnecessary investigation in the general practice. Materials and Methods: The retrospective study was conducted in all patients who were younger than 15 years old and underwent computed tomography (CT) of the brain after TBI in southern Thailand. Injured mechanisms and clinical characteristics were identified and analyzed with binary logistic regression for predicting intracranial injury. Using random sampling without replacement, the total data was split into nomogram developing dataset (80%) and testing dataset (20%). Therefore, a nomogram was constructed and applied via the web-based application from the developing dataset. Using testing dataset, validation as binary classifiers was performed by various probabilities levels. Results: A total of 900 victims were enrolled. The mean age was 87.2 (standard deviation [SD] 57.4) months, and 65.3% of all patients injured were from road traffic accidents. The rate of positive findings in CT of the brain was 32.8%. A nomogram was developed from the significant variables, including age groups, road traffic accidents, loss of consciousness, scalp hematoma/laceration, motor weakness, signs of basilar skull fraction, low Glasgow Coma Scale score, and pupillary light reflex. Therefore, a nomogram was developed from 80% of data and was validated from 20% of data. The accuracy, sensitivity, specificity, positive, and negative predictive values of the nomogram were 0.83, 0.42, 1.00, 1.00, and 0.81 at a cutoff value of 0.5 probability. Conclusion: This study provides a clinical nomogram that will be applied to making decisions in general practice as a diagnostic tool from high specificity.
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Affiliation(s)
- Thara Tunthanathip
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Jarunee Duangsuwan
- Department of Computer Science, Faculty of Science, Prince of Songkla University, Hat Yai, Thailand
| | - Niwan Wattanakitrungroj
- Department of Computer Science, Faculty of Science, Prince of Songkla University, Hat Yai, Thailand
| | - Sasiporn Tongman
- Department of Biotechnology, Faculty of Science and Technology, Thammasat University (Rangsit Campus), Khlong Luang, Thailand
| | - Nakornchai Phuenpathom
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
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Abstract
The neurological intensive care unit plays an integral role in the management of cerebrovascular disease in the acute and perioperative period. Understanding the use of intracranial pressure (ICP) monitoring and how to apply the appropriate intervention for ICP elevation to ensure adequate cerebral perfusion is the foundation of neurocritical care. Careful management of the interplay between cerebral and systemic physiology, particularly in disorders of cerebral autoregulation, is critical in preventing secondary brain injury. Finally, understanding the cerebral pathophysiology of the underlying injured brain in acute stroke, subarachnoid hemorrhage, and arterial stenosis can help to guide the optimal use of interventional endovascular procedures in these disease states.
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Affiliation(s)
- Vineeta Singh
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States.
| | - Roger Cheng
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
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33
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Kalisvaart ACJ, Wilkinson CM, Gu S, Kung TFC, Yager J, Winship IR, van Landeghem FKH, Colbourne F. An update to the Monro-Kellie doctrine to reflect tissue compliance after severe ischemic and hemorrhagic stroke. Sci Rep 2020; 10:22013. [PMID: 33328490 PMCID: PMC7745016 DOI: 10.1038/s41598-020-78880-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/01/2020] [Indexed: 02/06/2023] Open
Abstract
High intracranial pressure (ICP) can impede cerebral blood flow resulting in secondary injury or death following severe stroke. Compensatory mechanisms include reduced cerebral blood and cerebrospinal fluid volumes, but these often fail to prevent raised ICP. Serendipitous observations in intracerebral hemorrhage (ICH) suggest that neurons far removed from a hematoma may shrink as an ICP compliance mechanism. Here, we sought to critically test this observation. We tracked the timing of distal tissue shrinkage (e.g. CA1) after collagenase-induced striatal ICH in rat; cell volume and density alterations (42% volume reduction, 34% density increase; p < 0.0001) were highest day one post-stroke, and rebounded over a week across brain regions. Similar effects were seen in the filament model of middle cerebral artery occlusion (22% volume reduction, 22% density increase; p ≤ 0.007), but not with the Vannucci-Rice model of hypoxic-ischemic encephalopathy (2.5% volume increase, 14% density increase; p ≥ 0.05). Concerningly, this 'tissue compliance' appears to cause sub-lethal damage, as revealed by electron microscopy after ICH. Our data challenge the long-held assumption that 'healthy' brain tissue outside the injured area maintains its volume. Given the magnitude of these effects, we posit that 'tissue compliance' is an important mechanism invoked after severe strokes.
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Affiliation(s)
- Anna C J Kalisvaart
- Department of Psychology, Faculty of Science, University of Alberta, Edmonton, AB, Canada
| | - Cassandra M Wilkinson
- Department of Psychology, Faculty of Science, University of Alberta, Edmonton, AB, Canada
| | - Sherry Gu
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
| | - Tiffany F C Kung
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
| | - Jerome Yager
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Ian R Winship
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
- Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Frank K H van Landeghem
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
- Department of Laboratory Medicine and Pathology, University of Alberta Hospital, Edmonton, Canada
| | - Frederick Colbourne
- Department of Psychology, Faculty of Science, University of Alberta, Edmonton, AB, Canada.
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada.
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Riveros Gilardi B, Muñoz López JI, Hernández Villegas AC, Garay Mora JA, Rico Rodríguez OC, Chávez Appendini R, De la Mora Malváez M, Higuera Calleja JA. Types of Cerebral Herniation and Their Imaging Features. Radiographics 2020; 39:1598-1610. [PMID: 31589570 DOI: 10.1148/rg.2019190018] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cerebral herniation, defined as a shift of cerebral tissue from its normal location into an adjacent space, is a life-threatening condition that requires prompt diagnosis. The imaging spectrum can range from subtle changes to clear displacement of brain structures. For radiologists, it is fundamental to be familiar with the different imaging findings of the various subtypes of brain herniation. Brain herniation syndromes are commonly classified on the basis of their location as intracranial and extracranial hernias. Intracranial hernias can be further divided into three types: (a) subfalcine hernia; (b) transtentorial hernia, which can be ascending or descending (lateral and central); and (c) tonsillar hernia. Brain herniation may produce brain damage, compress cranial nerves and vessels causing hemorrhage or ischemia, or obstruct the normal circulation of cerebrospinal fluid, producing hydrocephalus. Owing to its location, each type of hernia may be associated with a specific neurologic syndrome. Knowledge of the clinical manifestations ensures a focused imaging analysis. To make an accurate diagnosis, the authors suggest a six-key-point approach: comprehensive analysis of a detailed history of the patient and results of clinical examination, knowledge of anatomic landmarks, direction of mass effect, recognition of displaced structures, presence of indirect radiologic findings, and possible complications. CT and MRI are the imaging modalities of choice used for establishing a correct diagnosis and guiding therapeutic decisions. They also have important prognostic implications. The preferred imaging modality is CT: the acquisition time is shorter and it is less expensive and more widely available. Patients with brain herniation are generally in critical clinical condition. Making a prompt diagnosis is fundamental for the patient's safety.©RSNA, 2019.
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Affiliation(s)
- Berta Riveros Gilardi
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Mexico City, Mexico 14080 (B.R.G., A.C.H.V., J.A.G.M., O.C.R.R., R.C.A., M.D.L.M.M., J.A.H.C.); and Department of Neuroradiology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico (J.I.M.L.)
| | - José Ignacio Muñoz López
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Mexico City, Mexico 14080 (B.R.G., A.C.H.V., J.A.G.M., O.C.R.R., R.C.A., M.D.L.M.M., J.A.H.C.); and Department of Neuroradiology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico (J.I.M.L.)
| | - Antonio Carlos Hernández Villegas
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Mexico City, Mexico 14080 (B.R.G., A.C.H.V., J.A.G.M., O.C.R.R., R.C.A., M.D.L.M.M., J.A.H.C.); and Department of Neuroradiology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico (J.I.M.L.)
| | - Juan Alberto Garay Mora
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Mexico City, Mexico 14080 (B.R.G., A.C.H.V., J.A.G.M., O.C.R.R., R.C.A., M.D.L.M.M., J.A.H.C.); and Department of Neuroradiology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico (J.I.M.L.)
| | - Oralia Cristina Rico Rodríguez
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Mexico City, Mexico 14080 (B.R.G., A.C.H.V., J.A.G.M., O.C.R.R., R.C.A., M.D.L.M.M., J.A.H.C.); and Department of Neuroradiology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico (J.I.M.L.)
| | - Roberto Chávez Appendini
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Mexico City, Mexico 14080 (B.R.G., A.C.H.V., J.A.G.M., O.C.R.R., R.C.A., M.D.L.M.M., J.A.H.C.); and Department of Neuroradiology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico (J.I.M.L.)
| | - Marianne De la Mora Malváez
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Mexico City, Mexico 14080 (B.R.G., A.C.H.V., J.A.G.M., O.C.R.R., R.C.A., M.D.L.M.M., J.A.H.C.); and Department of Neuroradiology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico (J.I.M.L.)
| | - Jesús Antonio Higuera Calleja
- From the Department of Radiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Mexico City, Mexico 14080 (B.R.G., A.C.H.V., J.A.G.M., O.C.R.R., R.C.A., M.D.L.M.M., J.A.H.C.); and Department of Neuroradiology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico (J.I.M.L.)
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Joubert C, Mathais Q, Faivre A, Dagain A. Post-traumatic central non-pupil-sparing oculomotor palsy: a case report. Acta Neurol Belg 2020; 120:765-767. [PMID: 32048229 DOI: 10.1007/s13760-020-01293-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 01/30/2020] [Indexed: 11/26/2022]
Affiliation(s)
- C Joubert
- Department of Neurosurgery, Sainte Anne Military Hospital, 2 Boulevard Sainte Anne, BP 600, 83000, Toulon, France.
| | - Q Mathais
- Intensive Care Unit, Sainte Anne Military Hospital, Toulon, France
| | - A Faivre
- Department of Neurology, Sainte Anne Military Hospital, Toulon, France
| | - A Dagain
- Department of Neurosurgery, Sainte Anne Military Hospital, 2 Boulevard Sainte Anne, BP 600, 83000, Toulon, France
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McCann ME, Lee JK, Inder T. Beyond Anesthesia Toxicity: Anesthetic Considerations to Lessen the Risk of Neonatal Neurological Injury. Anesth Analg 2020; 129:1354-1364. [PMID: 31517675 DOI: 10.1213/ane.0000000000004271] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Infants who undergo surgical procedures in the first few months of life are at a higher risk of death or subsequent neurodevelopmental abnormalities. Although the pathogenesis of these outcomes is multifactorial, an understanding of the nature and pathogenesis of brain injury in these infants may assist the anesthesiologist in consideration of their day-to-day practice to minimize such risks. This review will summarize the main types of brain injury in preterm and term infants and their key pathways. In addition, the review will address key potential pathogenic pathways that may be modifiable including intraoperative hypotension, hypocapnia, hyperoxia or hypoxia, hypoglycemia, and hyperthermia. Each of these conditions may increase the risk of perioperative neurological injury, but their long-term ramifications are unclear.
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Affiliation(s)
- Mary Ellen McCann
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology, Johns Hopkins University, Baltimore, Maryland
| | - Terrie Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Williams V, Bansal A, Jayashree M, Ismail J, Aggarwal A, Gupta SK, Singhi S, Singhi P, Baranwal AK, Nallasamy K. Decompressive craniectomy in pediatric non-traumatic intracranial hypertension: a single center experience. Br J Neurosurg 2020; 34:258-263. [PMID: 32186205 DOI: 10.1080/02688697.2020.1740648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Purpose: To study the clinical profile and predictors of outcome in children undergoing decompressive craniectomy (DC) for non-traumatic intracranial hypertension (ICH).Materials and methods: Mixed observational study of children, aged 1 month-12 years, who underwent DC for non-traumatic ICH in a tertiary care pediatric intensive care unit from 2012 to 2017. Data on clinical profile and outcome were retrieved retrospectively and survivors were assessed prospectively. The primary outcome was neurological outcome using Glasgow Outcome Scale-Extended (GOS-E) at minimum 6 months' post-discharge. GOS-E of 1-4 were classified as a poor and 5-8 as a good outcome.Results: Thirty children, median (IQR) age of 6.5 (2, 50) months, underwent DC; of which 26 (86.7%) were boys. Altered sensorium (n = 26, 86.7%), seizures (n = 25, 83.3%), pallor (n = 19, 63.3%) and anisocoria (n = 14, 46.7%) were common signs and symptoms. Median (IQR) Glasgow Coma Scale at admission was 9 (6,11). Commonest etiology was intracranial bleed (n = 24; 80%). Median (IQR) time to DC was 24 (24,72) h. Eight (26.7%) children died; 2 during PICU stay and 6 during follow-up. Neurological sequelae at discharge (n = 28) were seizures (n = 25; 89.2%) and hemiparesis (n = 16; 57.1%). Twenty-one children were followed-up at median (IQR) duration of 12 (6,54) months. Good neurological outcome was seen in 14/29 (48.2%) and hemiparesis in 10/21 (47.6%) patients. On regression analysis, anisocoria at admission was an independent predictor of poor outcome [OR 7.33; 95%CI: 1.38-38.87; p = 0.019].Conclusions: DC is beneficial in children with non-traumatic ICH due to a focal pathology and midline shift. Evidence on indications and timing of DC in NTC is still evolving.
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Affiliation(s)
- Vijai Williams
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Arun Bansal
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Muralidharan Jayashree
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Javed Ismail
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashish Aggarwal
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - S K Gupta
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sunit Singhi
- Pediatrics, Medanta, The Medicity, Gurugram, India
| | | | - Arun Kumar Baranwal
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Karthi Nallasamy
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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da Silva Bento P, Santiago AD, Vendrame Saes LS, Erbs Pessoa JL, Ockner Silva TL, Schirmer J, de Aguiar Roza B. Loss of Potential Donors Due to Hemodynamic Maintenance. Transplant Proc 2020; 52:1226-1230. [PMID: 32192745 DOI: 10.1016/j.transproceed.2020.02.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/11/2020] [Accepted: 02/13/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Statistics indicate low utilization of potential donors, where only about one-third are converted into actual donors. In this context, it is plausible to argue that many potential donors are not hemodynamically stable for harvesting multiple organs since the procedures for maintaining parameters of stability may not be a priority in all critical care units in the country. Thus, it is necessary to identify losses of potential donors due to hemodynamic maintenance since reversing this situation enable minimizing mortality on waiting lists. METHODS This was a retrospective quantitative study, based on information sent to Notification, Organ Procurement, and Distribution Centers by reporting hospitals in the state of São Paulo, using the Death Information Form regarding the specifics of each death registered in their intensive care units and emergency rooms. RESULTS Hemodynamic instability contributed to a loss of 537 potential donors, corresponding to 61.9% of failures to obtain potentially transplantable organs. CONCLUSION Of the 33,175 cases of death reported, 867 fulfilled the criteria to be possible and potential donors (ie, patients diagnosed with brain death). Among these cases, 38.1% fulfilled Criterion 3 (ie, they were hemodynamically stable and in ideal organ donation condition). Therefore, this study concludes that losses due to maintenance occurred in 537 brain dead patients. This finding highlights the importance of investing in the development of competencies of professionals who work in critical care units to increase the number of multiple organ and tissue donors and reduce waiting lists.
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Affiliation(s)
| | - Alessandra Duarte Santiago
- Intra-Hospital Commission of Organ and Tissue Donation for Transplant, Hospital São Paulo, São Paulo, Brazil
| | | | | | | | - Janine Schirmer
- Clinical and Surgical Nursing Department, Paulista Nursing School, Federal University of São Paulo, São Paulo, Brazil
| | - Bartira de Aguiar Roza
- Clinical and Surgical Nursing Department, Paulista Nursing School, Federal University of São Paulo, São Paulo, Brazil
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Wang J, Fang Y, Ramesh S, Zakaria A, Putman MT, Dinescu D, Paik J, Geocadin RG, Tahsili-Fahadan P, Altaweel LR. Intraosseous Administration of 23.4% NaCl for Treatment of Intracranial Hypertension. Neurocrit Care 2020; 30:364-371. [PMID: 30397844 DOI: 10.1007/s12028-018-0637-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND/OBJECTIVE Prompt treatment of acute intracranial hypertension is vital to preserving neurological function and frequently includes administration of 23.4% NaCl. However, 23.4% NaCl administration requires central venous catheterization that can delay treatment. Intraosseous catheterization is an alternative route of venous access that may result in more rapid administration of 23.4% NaCl. METHODS Single-center retrospective analysis of 76 consecutive patients, between January 2015 and January 2018, with clinical signs of intracranial hypertension received 23.4% NaCl through either central venous catheter or intraosseous access. RESULTS Intraosseous cannulation was successful on the first attempt in 97% of patients. No immediate untoward effects were seen with intraosseous cannulation. Time to treatment with 23.4% NaCl was significantly shorter in patients with intraosseous access compared to central venous catheter (p < 0.0001). CONCLUSIONS Intraosseous cannulation resulted in more rapid administration of 23.4% NaCl with no immediate serious complications. Further investigations to identify the clinical benefits and safety of hypertonic medication administration via intraosseous cannulation are warranted.
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Affiliation(s)
- Jing Wang
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Yun Fang
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Subhashini Ramesh
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Asma Zakaria
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Maryann T Putman
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Dan Dinescu
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - James Paik
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA
| | - Romergryko G Geocadin
- Neurocritical Care Unit Division, Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Pouya Tahsili-Fahadan
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA.,Neurocritical Care Unit Division, Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Laith R Altaweel
- Neuroscience Intensive Care Unit, Medical Critical Care Service, Department of Medicine, INOVA Fairfax Hospital, 3300 Gallows Rd, Falls Church, VA, 22042, USA. .,Neuroscience Research, Neuroscience and Spine Institute, INOVA Fairfax Hospital, Falls Church, VA, USA.
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Rubiano AM, Vera DS, Montenegro JH, Carney N, Clavijo A, Carreño JN, Gutierrez O, Mejia J, Ciro JD, Barrios ND, Soto AR, Tejada PA, Zerpa MC, Gomez A, Navarrete N, Echeverry O, Umaña M, Restrepo CM, Castillo JL, Sanabria OA, Bravo MP, Gomez CM, Godoy DA, Orjuela GD, Arias AA, Echeverri RA, Paranos J. Recommendations of the Colombian Consensus Committee for the Management of Traumatic Brain Injury in Prehospital, Emergency Department, Surgery, and Intensive Care (Beyond One Option for Treatment of Traumatic Brain Injury: A Stratified Protocol [BOOTStraP]). J Neurosci Rural Pract 2020; 11:7-22. [PMID: 32140001 PMCID: PMC7055642 DOI: 10.1055/s-0040-1701370] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Traumatic brain injury (TBI) is a global public health problem. In Colombia, it is estimated that 70% of deaths from violence and 90% of deaths from road traffic accidents are TBI related. In the year 2014, the Ministry of Health of Colombia funded the development of a clinical practice guideline (CPG) for the diagnosis and treatment of adult patients with severe TBI. A critical barrier to the widespread implementation was identified-that is, the lack of a specific protocol that spans various levels of resources and complexity across the four treatment phases. The objective of this article is to present the process and recommendations for the management of patients with TBI in various resource environments, across the treatment phases of prehospital care, emergency department (ED), surgery, and intensive care unit. Methods Using the Delphi methodology, a consensus of 20 experts in emergency medicine, neurosurgery, prehospital care, and intensive care nationwide developed recommendations based on 13 questions for the management of patients with TBI in Colombia. Discussion It is estimated that 80% of the global population live in developing economies where access to resources required for optimum treatment is limited. There is limitation for applications of CPGs recommendations in areas where there is low availability or absence of resources for integral care. Development of mixed methods consensus, including evidence review and expertise points of good clinical practices can fill gaps in application of CPGs. BOOTStraP (Beyond One Option for Treatment of Traumatic Brain Injury: A Stratified Protocol) is intended to be a practical handbook for care providers to use to treat TBI patients with whatever resources are available. Results Stratification of recommendations for interventions according to the availability of the resources on different stages of integral care is a proposed method for filling gaps in actual evidence, to organize a better strategy for interventions in different real-life scenarios. We develop 10 algorithms of management for building TBI protocols based on expert consensus to articulate treatment options in prehospital care, EDs, neurological surgery, and intensive care, independent of the level of availability of resources for care.
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Affiliation(s)
- Andres M. Rubiano
- NIHR Global Health Research Group in Neurotrauma, University of Cambridge, UK/Neurosciences Institute, Universidad El Bosque, Bogotá, Colombia/Meditech Foundation, Cali, Colombia
| | - David S. Vera
- MEDITECH Foundation, Universidad El Bosque, Bogota, Colombia
| | | | - Nancy Carney
- School of Medicine, Oregon Health & Science University, Portland, Oregon, United States
| | - Angelica Clavijo
- INUB MEDITECH, Universidad El Bosque, Clinical Research, Bogotá, Colombia
| | - Jose N. Carreño
- Department of Intensive Care, Fundación Santa Fé University Hospital, Bogotá, Colombia
| | - Oscar Gutierrez
- Neurosurgery Service, Hospital Occidente de Kennedy, Bogotá, Colombia
| | - Jorge Mejia
- Department of Intensive Care, Valle de Lili Foundation, Cali, Colombia
| | - Juan D. Ciro
- Intensive Care Service, Las Américas Clinic, Medellín, Colombia
| | - Ninel D. Barrios
- Intensive Care Service, Clínica General del Norte, Barranquilla, Colombia
| | - Alvaro R. Soto
- Neurosurgery Service, San Antonio Departamental Hospital, Pitalito-Huila, Colombia
| | - Paola A. Tejada
- Institute of Neurosciences, Universidad El Bosque, Clinical Research, Bogotá, Colombia
| | - Maria C. Zerpa
- Intensive Care Service, Clínica Del Norte, Cúcuta, Colombia
| | - Alejandro Gomez
- Prehospital Care Program, Adventist University, Medellín, Colombia
| | | | | | | | | | | | | | - Maria P. Bravo
- Faculty of Medicine, Universidad Surcolombiana, Neiva, Colombia
| | - Claudia M. Gomez
- Neurosurgery Service, Urabá Clinic, Apartadó-Antioquia, Colombia
| | - Daniel A. Godoy
- Intensive Care Service, Sanatorium Pasteur, Catamarca, Argentina
| | | | | | | | - Jorge Paranos
- Neurosurgery and Intensive Care Service, Santa Casa da Misericórdia Hospital in São João del-Rei, São João del-Rei, Minas Gerais, Brazil
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Venkatasubba Rao CP, Bershad EM, Calvillo E, Maldonado N, Damani R, Mandayam S, Suarez JI. Real-time Noninvasive Monitoring of Intracranial Fluid Shifts During Dialysis Using Volumetric Integral Phase-Shift Spectroscopy (VIPS): A Proof-of-Concept Study. Neurocrit Care 2019; 28:117-126. [PMID: 28547320 DOI: 10.1007/s12028-017-0409-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cerebral edema, which is associated with increased intracranial fluid, is often a complication of many acute neurological conditions. There is currently no accepted method for real-time monitoring of intracranial fluid volume at the bedside. We evaluated a novel noninvasive technique called "Volumetric Integral Phase-shift Spectroscopy (VIPS)" for detecting intracranial fluid shifts during hemodialysis. METHODS Subjects receiving scheduled hemodialysis for end-stage renal disease and without a history of major neurological conditions were enrolled. VIPS monitoring was performed during hemodialysis. Serum osmolarity, electrolytes, and cognitive function with mini-mental state examination (MMSE) were assessed. RESULTS Twenty-one monitoring sessions from 14 subjects (4 women), mean group age 50 (SD 12.6), were analyzed. The serum osmolarity decreased by a mean of 6.4 mOsm/L (SD 6.6) from pre- to post-dialysis and correlated with an increase in the VIPS edema index (E-Dex) of 9.7% (SD 12.9) (Pearson's correlation r = 0.46, p = 0.037). Of the individual determinants of serum osmolarity, changes in serum sodium level correlated best with the VIPS edema index (Pearson's correlation, r = 0.46, p = 0.034). MMSE scores did not change from pre- to post-dialysis. CONCLUSIONS We detected an increase in the VIPS edema index during hemodialysis that correlated with decreased serum osmolarity, mainly reflected by changes in serum sodium suggesting shifts in intracranial fluids.
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Affiliation(s)
- Chethan P Venkatasubba Rao
- Department of Neurology, Section of Vascular Neurology and Neurocritical Care, Baylor College of Medicine, One Baylor Plaza, MS, NB 122, Houston, TX, 77030, USA.
| | - Eric M Bershad
- Department of Neurology, Section of Vascular Neurology and Neurocritical Care, Baylor College of Medicine, One Baylor Plaza, MS, NB 122, Houston, TX, 77030, USA
| | - Eusebia Calvillo
- Department of Neurology, Section of Vascular Neurology and Neurocritical Care, Baylor College of Medicine, One Baylor Plaza, MS, NB 122, Houston, TX, 77030, USA
| | - Nelson Maldonado
- Department of Neurology, Section of Vascular Neurology and Neurocritical Care, Baylor College of Medicine, One Baylor Plaza, MS, NB 122, Houston, TX, 77030, USA
| | - Rahul Damani
- Department of Neurology, Section of Vascular Neurology and Neurocritical Care, Baylor College of Medicine, One Baylor Plaza, MS, NB 122, Houston, TX, 77030, USA
| | - Sreedhar Mandayam
- Department of Nephrology, Baylor College of Medicine, Houston, TX, USA
| | - Jose I Suarez
- Department of Neurology, Section of Vascular Neurology and Neurocritical Care, Baylor College of Medicine, One Baylor Plaza, MS, NB 122, Houston, TX, 77030, USA
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Chau CYC, Craven CL, Rubiano AM, Adams H, Tülü S, Czosnyka M, Servadei F, Ercole A, Hutchinson PJ, Kolias AG. The Evolution of the Role of External Ventricular Drainage in Traumatic Brain Injury. J Clin Med 2019; 8:E1422. [PMID: 31509945 PMCID: PMC6780113 DOI: 10.3390/jcm8091422] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 09/05/2019] [Accepted: 09/05/2019] [Indexed: 02/06/2023] Open
Abstract
External ventricular drains (EVDs) are commonly used in neurosurgery in different conditions but frequently in the management of traumatic brain injury (TBI) to monitor and/or control intracranial pressure (ICP) by diverting cerebrospinal fluid (CSF). Their clinical effectiveness, when used as a therapeutic ICP-lowering procedure in contemporary practice, remains unclear. No consensus has been reached regarding the drainage strategy and optimal timing of insertion. We review the literature on EVDs in the setting of TBI, discussing its clinical indications, surgical technique, complications, clinical outcomes, and economic considerations.
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Affiliation(s)
- Charlene Y C Chau
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
| | - Claudia L Craven
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N3BG, UK
| | - Andres M Rubiano
- Neurosciences Institute, INUB-MEDITECH Research Group, El Bosque University, 113033 Bogotá, Colombia
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB20QQ, UK
| | - Hadie Adams
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
| | - Selma Tülü
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
- Department of Neurosurgery, Innsbruck Medical University, 6020 Innsbruck, Austria
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
| | - Franco Servadei
- Department of Neurosurgery, Humanitas University and Research Hospital, 20090 Milan, Italy
| | - Ari Ercole
- Division of Anaesthesia, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB20QQ, UK
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge CB20QQ, UK.
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge CB20QQ, UK.
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Abstract
PURPOSE OF REVIEW This article reviews the management of cerebral edema, elevated intracranial pressure (ICP), and cerebral herniation syndromes in neurocritical care. RECENT FINDINGS While corticosteroids may be effective in reducing vasogenic edema around brain tumors, they are contraindicated in traumatic cerebral edema. Mannitol and hypertonic saline use should be tailored to patient characteristics including intravascular volume status. In patients with traumatic brain injury who are comatose, elevated ICP should be managed with an algorithmic, multitiered treatment protocol to maintain an ICP of 22 mm Hg or less. Third-line ICP treatments include anesthetic agents, induced hypothermia, and decompressive craniectomy. Recent clinical trials have demonstrated that induced hypothermia and decompressive craniectomy are ineffective as early neuroprotective strategies and should be reserved for third-line management of refractory ICP elevation in severe traumatic brain injury. Monitoring for cerebral herniation should include bedside pupillometry in supratentorial space-occupying lesions and recognition of upward herniation in patients with posterior fossa lesions. SUMMARY Although elevated ICP, cerebral edema, and cerebral herniation are interrelated, treatments should be based on the distinct pathophysiologic process. Focal lesions resulting in brain compression are primarily managed with surgical decompression, whereas global or multifocal brain injury requires a treatment protocol that includes medical and surgical interventions.
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Cold Atmospheric Plasma as an Adjunct to Immunotherapy for Glioblastoma Multiforme. World Neurosurg 2019; 130:369-376. [PMID: 31284051 DOI: 10.1016/j.wneu.2019.06.209] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 06/26/2019] [Accepted: 06/27/2019] [Indexed: 11/22/2022]
Abstract
Glioblastoma multiforme (GBM) is the most common and aggressive form of brain cancer in adults. GBM carries a dismal prognosis because of its proliferative, invasive, and angiogenic capabilities and because of its ability to downregulate the immune system. Immune-based therapies under investigation for GBM have been unsuccessful in vivo because of this downregulation. Cold atmospheric plasma (CAP) is a high-energy state of matter that can be applied directly or indirectly to tumor tissue to serve as an adjunct to immunotherapy in the treatment of GBM because it upregulates the immune system by the induction of reactive oxygen species. CAP has the potential to improve the efficacy of existing and investigative immunotherapies for GBM.
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Abstract
Raised intracranial pressure (rICP) syndrome is seen in various pathologies. Appropriate and systematic management is important for favourable patient outcome. This review describes the stepwise approach to control the raised ICP in a tiered manner, with increasing aggressiveness. The role of ICP measurement in the assessment of cerebral autoregulation and individualised management is discussed. Although a large amount of research has been undertaken for the management of raised ICP, there still remain unanswered questions. This review tries to put together the best evidence in a succinct manner. HOW TO CITE THIS ARTICLE Tripathy S, Ahmad SR. Raised Intracranial Pressure Syndrome: A Stepwise Approach. Indian J Crit Care Med 2019;23(Suppl 2):S129-S135.
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Affiliation(s)
- Swagata Tripathy
- Department of Anesthesia and Intensive Care, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Suma Rabab Ahmad
- Department of Anesthesia and Intensive Care, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 748] [Impact Index Per Article: 124.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.
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Affiliation(s)
- Donat R. Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic
- Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005 Hradec Kralove, Czech Republic
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003 Hradec Kralove, Czech Republic
- Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS B3H 2Y9 Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Beverley J. Hunt
- King’s College and Departments of Haematology and Pathology, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000 Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924 Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181 Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
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Abstract
Pediatric acute liver failure (PALF) is a dynamic, life-threatening condition of disparate etiology. Management of PALF is dependent on intensive collaborative clinical care and support. Proper recognition and treatment of common complications of liver failure are critical to optimizing outcomes. In parallel, investigations to identify underlying cause and the implementation of timely, appropriate treatment can be life-saving. Predicting patient outcome in the era of liver transplantation has been unfulfilling and better predictive models must be developed for proper stewardship of the limited resource of organ availability.
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Affiliation(s)
- James E Squires
- Department of Pediatric Gastroenterology and Hepatology, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
| | - Patrick McKiernan
- Department of Pediatric Gastroenterology and Hepatology, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
| | - Robert H Squires
- Department of Pediatric Gastroenterology and Hepatology, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
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Fitzpatrick S, Leach P. Neurosurgical aspects of abusive head trauma management in children: a review for the training neurosurgeon. Br J Neurosurg 2018; 33:47-50. [PMID: 30353746 DOI: 10.1080/02688697.2018.1529295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The management of head trauma in children from suspected abuse is multidisciplinary. The primary role of neurosurgeons is to manage the acute clinical situation. They also have a secondary role in assisting others to determine the cause of the injury and prevent recurrences. This article aims to guide the trainee neurosurgeon on management of this patient group according to current literature.
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Affiliation(s)
- S Fitzpatrick
- a College of Medicine, University of Cardiff , Wales , UK
| | - P Leach
- b Department of Paediatric Neurosurgery , University Hospital of Wales , Cardiff , UK
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Clinical characteristics of acute encephalopathy with acute brain swelling: A peculiar type of acute encephalopathy. Brain Dev 2018; 40:792-798. [PMID: 29885875 DOI: 10.1016/j.braindev.2018.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 05/10/2018] [Accepted: 05/10/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Acute encephalopathy has been observed with acute brain swelling (ABS) that is characterized by rapid progression to whole-brain swelling. The objective of this study was to describe the clinical characteristics of ABS. METHODS We encountered four patients with ABS and retrospectively investigated their clinical data with a medical chart review. RESULTS Three patients had seizure clustering or status epilepticus in the clinical course. Signs of elevated intracranial pressure (ICP) appeared 3-9 h after the first convulsive attack in three patients. In all patients, signs of brainstem involvement appeared 1-8 h after signs of elevated ICP. Mild hyponatremia that progressed after signs of elevated ICP appeared was noted in three patients. Brain CT revealed mild brain swelling in the initial phase, which rapidly progressed to whole-brain swelling. No focal abnormalities were detected on brain MRI in one patient. Continuous electroencephalography was initially normal, but in two patients, high-amplitude slow waves appeared with rapid changes before signs of brainstem involvement. Although recovery was achieved without sequelae in two patients, outcome was fatal for the other two. CONCLUSIONS The pathogenesis of ABS has yet to be clarified, but clinical features in our patients are not consistent with any established subtypes of acute encephalopathy. Therefore, we believe that ABS should be recognized as a new type of acute encephalopathy.
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Kim DH, Jun JS, Kim R. Measurement of the Optic Nerve Sheath Diameter with Magnetic Resonance Imaging and Its Association with Eyeball Diameter in Healthy Adults. J Clin Neurol 2018; 14:345-350. [PMID: 29856162 PMCID: PMC6032005 DOI: 10.3988/jcn.2018.14.3.345] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 03/10/2018] [Accepted: 03/13/2018] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND AND PURPOSE The optic nerve sheath diameter (ONSD) is an indirect marker of the intracranial pressure, but the normal range of ONSD as measured using magnetic resonance imaging (MRI) and its associations with clinical parameters and the eyeball transverse diameter (ETD) remain unclear. METHODS We included 314 healthy adults who underwent brain MRI examinations for health screening between June 2014 and September 2017. The ONSD and ETD of each eye were calculated using time-of-flight magnetic resonance angiography. Linear regression analyses were performed to assess the relationships between ONSD and variables including age, sex, height, weight, body mass index (BMI), mean arterial blood pressure (MABP), intraocular pressure (IOP), and ETD. We further investigated a normative value for the ONSD/ETD ratio and its associated factors. RESULTS The mean ONSD and ETD were 4.71 mm [95% confidence interval (CI), 4.66-4.75 mm] and 21.24 mm (95% CI, 21.13-21.35 mm), respectively. Multiple linear regression analysis showed that ONSD was only associated with ETD (p<0.001), with it being independent of age, sex, height, weight, BMI, MABP, and IOP. The ONSD/ETD ratio had a mean value of 0.22 (95% CI, 0.22-0.22), and was not correlated with age, sex, height, weight, BMI, MABP, or IOP. CONCLUSIONS This study determined the normative value of MRI-based ONSD in healthy Korean adults. There was a strong correlation between the ETD and ONSD, which can be presented as the ONSD/ETD ratio. This parameter needs to be investigated further in disease populations.
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Affiliation(s)
- Dong Hwan Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Sun Jun
- Department of Neurology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Ryul Kim
- Department of Neurology, Aerospace Medical Center, Korea Air Force, Cheongju, Korea.
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