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Karamian A, Seifi A, Lucke-Wold B. Comparing the effects of mannitol and hypertonic saline in severe traumatic brain injury patients with elevated intracranial pressure: a systematic review and meta-analysis. Neurol Res 2024:1-10. [PMID: 38825027 DOI: 10.1080/01616412.2024.2360862] [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: 03/07/2024] [Accepted: 05/23/2024] [Indexed: 06/04/2024]
Abstract
OBJECTIVES Controlling elevated intracranial pressure following brain injury with hyperosmolar agents is one of the mainstay treatments in traumatic brain injury patients. In this study, we compared the effects of hypertonic saline (HS) and mannitol in reducing increased intracranial pressure. METHODS A total of 637 patients from 15 studies were included in our meta-analysis. The primary outcomes were mortality, the length of stay in the hospital and ICU, and the Glasgow Outcome Scale at follow-up. RESULTS The mortality in the mannitol group was not statistically different compared to the HS group (RR = 1.55; 95% CI = [0.98, 2.47], p = 0.06). The length of stay in the ICU was significantly shorter in the HS group (MD = 1.18, 95% CI = [0.44, 1.92], p < 0.01). In terms of favorable neurological outcomes, there was no significant difference between the two agents (RR = 0.92, 95% CI = [0.11, 7.96], p = 0.94). The duration of the effect was shorter in the mannitol group than in the HS group (MD = -0.67, 95% CI = [-1.00, -0.33], p < 0.01). DISCUSSION The results showed that HS and mannitol had similar effects in reducing ICP. Although the HS was associated with a longer duration of effect and shorter ICU stay, other secondary outcomes including mortality rate and favorable neurological outcomes were similar between the two drugs. In conclusion, considering the condition of each patient individually, HS could be a reasonable option than mannitol to reduce ICP in TBI patients.
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Affiliation(s)
- Armin Karamian
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Seifi
- Department of Neurosurgery, University of Texas Health, San Antonio, TX, USA
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Baeg SI, Lee K, Jeon J, Jang HR. Management for Electrolytes Disturbances during Continuous Renal Replacement Therapy. Electrolyte Blood Press 2022; 20:64-75. [PMID: 36688209 PMCID: PMC9827043 DOI: 10.5049/ebp.2022.20.2.64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/18/2022] [Accepted: 12/19/2022] [Indexed: 01/05/2023] Open
Abstract
Despite the lack of proven superiority in mortality compared to intermittent hemodialysis, continuous renal replacement therapy (CRRT) is the preferred renal replacement therapy modality for critically ill patients with acute kidney injury (AKI) due to better hemodynamic stability and steady correction of electrolytes disturbances and volume overload. Multiple and complex electrolyte disorders in patients with AKI can be managed effectively with CRRT because controlled and predictable correction is feasible. Thus, CRRT has an advantage with safety over conventional hemodialysis, especially in patients with both renal dysfunction and electrolyte disorder that require a sophisticated treatment with avoidance of rapid correction. On the contrary, CRRT can potentially lead to paradoxical disturbance of electrolytes such as hypokalemia or hypophosphatemia, especially in patients under high dose or prolonged duration of CRRT treatment. These electrolytes related complications can be prevented with close monitoring followed by the appropriate use of CRRT fluids. Although there is a lack of solid evidence and standardized guideline for CRRT prescriptions, optimal management of various electrolyte disturbances can be achieved with individualized and tailored dialysate and replacement fluid prescriptions. Several commercially available CRRT solutions with varying compositions provide flexibility to manage electrolyte disorders and maintain the stability of electrolyte. In this review, we discuss various prescription methods to manage common electrolyte imbalances as well as preventative strategies to maintain electrolyte homeostasis during CRRT providing detailed protocols used in our center. This review may contribute to future research that can lead to the development of clinical practice guidelines.
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Affiliation(s)
- Song In Baeg
- Division of Nephrology, Department of Internal Medicine, Myongji Hospital, Hanyang University Medical Center, Goyang, Republic of Korea
| | - Kyungho Lee
- Division of Nephrology, Department of Medicine, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Junseok Jeon
- Division of Nephrology, Department of Medicine, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Hye Ryoun Jang
- Division of Nephrology, Department of Medicine, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
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Lachance BB, Chang W, Motta M, Parikh G, Podell J, Badjatia N, Simard JM, Schwartzbauer GT, Morris NA. Verticalization for Refractory Intracranial Hypertension: A Case Series. Neurocrit Care 2021; 36:463-470. [PMID: 34405321 DOI: 10.1007/s12028-021-01323-z] [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: 05/19/2021] [Accepted: 07/26/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Severe intracranial hypertension is strongly associated with mortality. Guidelines recommend medical management involving sedation, hyperosmotic agents, barbiturates, hypothermia, and surgical intervention. When these interventions are maximized or are contraindicated, refractory intracranial hypertension poses risk for herniation and death. We describe a novel intervention of verticalization for treating intracranial hypertension refractory to aggressive medical treatment. METHODS This study was a single-center retrospective review of six cases of refractory intracranial hypertension in a tertiary care center. All patients were treated with a standard-of-care algorithm for lowering intracranial pressure (ICP) yet maintained an ICP greater than 20 mmHg. They were then treated with verticalization for at least 24 h. We compared the median ICP, the number of ICP spikes greater than 20 mmHg, and the percentage of ICP values greater than 20 mmHg in the 24 h before verticalization vs. after verticalization. We assessed the use of hyperosmotic therapies and any changes in the mean arterial pressure and cerebral perfusion pressure related with the intervention. RESULTS Five patients were admitted with subarachnoid hemorrhage and one with intracerebral hemorrhage. All patients had ICP monitoring by external ventricular drain. The median opening pressure was 30 mmHg (25th-75th interquartile range 22.5-30 mmHg). All patients demonstrated a reduction in ICP after verticalization, with a significant decrease in the median ICP (12 vs. 8 mmHg; p < 0.001), the number of ICP spikes (12 vs. 2; p < 0.01), and the percentage of ICP values greater than 20 mmHg (50% vs. 8.3%; p < 0.01). There was a decrease in total medical interventions after verticalization (79 vs. 41; p = 0.05) and a lower total therapy intensity level score after verticalization. The most common adverse effects included asymptomatic bradycardia (n = 3) and pressure wounds (n = 4). CONCLUSIONS Verticalization is an effective noninvasive intervention for lowering ICP in intracranial hypertension that is refractory to aggressive standard management and warrants further study.
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Affiliation(s)
- Brittany Bolduc Lachance
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA.
| | - WanTsu Chang
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Melissa Motta
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Gunjan Parikh
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Jamie Podell
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Neeraj Badjatia
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Gary T Schwartzbauer
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Nicholas A Morris
- Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
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4
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Yessayan LT, Szamosfalvi B, Rosner MH. Management of dysnatremias with continuous renal replacement therapy. Semin Dial 2021; 34:472-479. [PMID: 34218456 DOI: 10.1111/sdi.12983] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/17/2021] [Accepted: 04/05/2021] [Indexed: 11/28/2022]
Abstract
Disorders of serum sodium concentration are common in critically ill patients who may have concomitant acute kidney injury, chronic kidney disease, or end-stage kidney disease. Many of these patients may require customized serum sodium level management with dialysis which, if not strictly controlled, can lead to significant complications. Thus, controlled correction of the serum sodium level is necessary to avoid the development of osmotic demyelination syndrome in hyponatremic patients and dialysis disequilibrium syndrome in hypernatremic patients. Continuous renal replacement therapy offers unique benefits through the ability to slowly and safely correct dysnatremias that can be tailored to specific patient needs and should be considered in select patients.
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Affiliation(s)
- Lenar T Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Balazs Szamosfalvi
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Mitchell H Rosner
- Division of Nephrology, Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
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5
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Bergmans SF, Schober P, Schwarte LA, Loer SA, Bossers SM. Prehospital fluid administration in patients with severe traumatic brain injury: A systematic review and meta-analysis. Injury 2020; 51:2356-2367. [PMID: 32888722 DOI: 10.1016/j.injury.2020.08.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/22/2020] [Accepted: 08/24/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Prehospital management of severe traumatic brain injury (TBI) focuses on preventing secondary brain injury. Therefore, hypotension should be prevented, or if present, should be promptly treated in order to maintain optimal cerebral perfusion pressure. Fluid resuscitation is a traditional mainstay in the prehospital treatment of hypotension, however, the choice of fluid type that is to be administered in the prehospital setting is the subject of an on-going debate. This systematic review and meta-analysis was therefore performed to assess the effect of different fluid types on outcome in patients with severe TBI. METHODS PubMed, Embase and Web of Science were searched for articles up to March 2020. Studies comparing two or more prehospital administered fluid types with suspected or confirmed severe TBI were deemed eligible for inclusion. Studied outcomes were mortality and (extended) Glasgow Outcome Scale (GOS). The meta-analysis tested for differences in survival between hypertonic saline (HTS) and normotonic crystalloids (i.e. normal saline or Lactated Ringer's) and between hypertonic saline with dextran (HSD) and normotonic crystalloids. The systematic review is registered in the PROSPERO register with number CRD42020140423. RESULTS This literature search yielded a total of 519 articles, of which 12 were included in the systematic review and 6 were included in the meta-analysis. Eleven studies found no statistically significant difference in survival between patients treated with different fluid types (e.g. normal saline and hypertonic saline). All studies assessing neurological outcome, measured through (extended) GOS, found no statistically significant difference between different fluid types. Meta-analysis showed no better survival for patients treated with HSD, when compared to normotonic crystalloids (overall RR 0.99, 95% CI 0.93-1.06). Moreover, HTS compared to normotonic crystalloids does not result in a better survival (overall RR 1.04, 95% CI 0.97-1.12). CONCLUSIONS This systematic review and meta-analysis did not demonstrate a survival or neurological benefit for one specific fluid type administered in the prehospital setting.
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Affiliation(s)
- S F Bergmans
- Department Anaesthesiology, Amsterdam University Medical Centre, De Boelelaan 1117, 1081, Amsterdam, the Netherlands.
| | - P Schober
- Department Anaesthesiology, Amsterdam University Medical Centre, De Boelelaan 1117, 1081, Amsterdam, the Netherlands; Helicopter Emergency Medical Service "Lifeliner 1", Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - L A Schwarte
- Department Anaesthesiology, Amsterdam University Medical Centre, De Boelelaan 1117, 1081, Amsterdam, the Netherlands; Helicopter Emergency Medical Service "Lifeliner 1", Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - S A Loer
- Department Anaesthesiology, Amsterdam University Medical Centre, De Boelelaan 1117, 1081, Amsterdam, the Netherlands
| | - S M Bossers
- Department Anaesthesiology, Amsterdam University Medical Centre, De Boelelaan 1117, 1081, Amsterdam, the Netherlands
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6
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Lutters B, Koehler PJ, Wijdicks EF. Worth Their Salt: One Hundred Years of Hyperosmolar Therapy. Eur Neurol 2020; 83:536-541. [PMID: 32866954 DOI: 10.1159/000510183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 07/10/2020] [Indexed: 11/19/2022]
Abstract
In this article, we commemorate the centenary of the discovery and clinical implementation of hyperosmolar therapy for the treatment of increased intracranial pressure (ICP). Following the pioneering work of anatomists Weed and McKibben in 1919, the use of hypertonic solutions was soon adopted into clinical practice, even though the preferred hypertonic agent, route of administration, and ideas regarding the physiological mechanism by which it reduced ICP diverged. These divergent conceptions and practices have continued to surround the use of hyperosmolar therapy into present times.
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Affiliation(s)
- Bart Lutters
- Julius Center, Medical Humanities, University Medical Center Utrecht, Utrecht, The Netherlands,
| | - Peter J Koehler
- Faculty of Health, Medicine & Life Sciences, Maastricht University, Maastricht, The Netherlands
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Donovan J, Rohlwink UK, Tucker EW, Hiep NTT, Thwaites GE, Figaji AA. Checklists to guide the supportive and critical care of tuberculous meningitis. Wellcome Open Res 2020. [PMID: 31984242 DOI: 10.12688/wellcomeopenres.15512.1] [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: 01/13/2023] Open
Abstract
The assessment and management of tuberculous meningitis (TBM) is often complex, yet no standardised approach exists, and evidence for the clinical care of patients, including those with critical illness, is limited. The roles of proformas and checklists are increasing in medicine; proformas provide a framework for a thorough approach to patient care, whereas checklists offer a priority-based approach that may be applied to deteriorating patients in time-critical situations. We aimed to develop a comprehensive assessment proforma and an accompanying 'priorities' checklist for patients with TBM, with the overriding goal being to improve patient outcomes. The proforma outlines what should be asked, checked, or tested at initial evaluation and daily inpatient review to assist supportive clinical care for patients, with an adapted list for patients in critical care. It is accompanied by a supporting document describing why these points are relevant to TBM. Our priorities checklist offers a useful and easy reminder of important issues to review during a time-critical period of acute patient deterioration. The benefit of these documents to patient outcomes would require investigation; however, we hope they will promote standardisation of patient assessment and care, particularly of critically unwell individuals, in whom morbidity and mortality remains unacceptably high.
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Affiliation(s)
- Joseph Donovan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ursula K Rohlwink
- Neuroscience Institute and Division of Neurosurgery, University of Cape Town, Cape Town, 7700, South Africa
| | - Elizabeth W Tucker
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA.,Division of Pediatric Critical Care, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Nguyen Thi Thu Hiep
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Anthony A Figaji
- Neuroscience Institute and Division of Neurosurgery, University of Cape Town, Cape Town, 7700, South Africa
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8
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Ong C, Hutch M, Barra M, Kim A, Zafar S, Smirnakis S. Effects of Osmotic Therapy on Pupil Reactivity: Quantification Using Pupillometry in Critically Ill Neurologic Patients. Neurocrit Care 2020; 30:307-315. [PMID: 30298336 DOI: 10.1007/s12028-018-0620-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Osmotic therapy is a critical component of medical management for cerebral edema. While up to 90% of neurointensivists report using these treatments, few quantitative clinical measurements guide optimal timing, dose, or administration frequency. Its use is frequently triggered by a qualitative assessment of neurologic deterioration and/or pupil size, and anecdotally appears to improve pupil asymmetry suggestive of uncal herniation. However, subjective pupil assessment has poor reliability, making it difficult to detect or track subtle changes. We hypothesized that osmotic therapy reproducibly improves quantitative pupil metrics. METHODS We included patients at two centers who had recorded quantitative pupil measurements within 2 h before and after either 20% mannitol or 23.4% hypertonic saline in the neurosciences intensive care unit. The primary outcome was the Neurologic Pupil Index (NPi), a composite metric ranging from 0 to 5 in which > 3 is considered normal. Secondary outcomes included pupil size, percent change, constriction and dilation velocity, and latency. Results were analyzed with Wilcoxon signed-rank tests, Chi-square and multi-level linear regression to control for other edema-reducing interventions. RESULTS Out of 72 admissions (403 paired pupil observations), NPi significantly differed within 2 h of osmotic therapy when controlling for other commonly used interventions in our whole cohort (β = 0.08, p = 0.0168). The effect was most pronounced (β = 0.57) in patients with abnormal NPi prior to intervention (p = 0.0235). CONCLUSIONS Pupil reactivity significantly improves after osmotic therapy in a heterogenous critically ill population when controlling for various other interventions. Future work is necessary to determine dose-dependent effects and clinical utility.
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Affiliation(s)
- C Ong
- Boston University School of Medicine, Boston, USA.
- Brigham and Women's Hospital, Boston, USA.
- Harvard Medical School, Boston, USA.
| | - M Hutch
- Boston University School of Medicine, Boston, USA
| | - M Barra
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - A Kim
- Brigham and Women's Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - S Zafar
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - S Smirnakis
- Brigham and Women's Hospital, Boston, USA
- Harvard Medical School, Boston, USA
- Jamaica Plain VA Hospital, Boston, USA
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9
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Donovan J, Rohlwink UK, Tucker EW, Hiep NTT, Thwaites GE, Figaji AA. Checklists to guide the supportive and critical care of tuberculous meningitis. Wellcome Open Res 2019; 4:163. [PMID: 31984242 PMCID: PMC6964359 DOI: 10.12688/wellcomeopenres.15512.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2019] [Indexed: 12/21/2022] Open
Abstract
The assessment and management of tuberculous meningitis (TBM) is often complex, yet no standardised approach exists, and evidence for the clinical care of patients, including those with critical illness, is limited. The roles of proformas and checklists are increasing in medicine; proformas provide a framework for a thorough approach to patient care, whereas checklists offer a priority-based approach that may be applied to deteriorating patients in time-critical situations. We aimed to develop a comprehensive assessment proforma and an accompanying 'priorities' checklist for patients with TBM, with the overriding goal being to improve patient outcomes. The proforma outlines what should be asked, checked, or tested at initial evaluation and daily inpatient review to assist supportive clinical care for patients, with an adapted list for patients in critical care. It is accompanied by a supporting document describing why these points are relevant to TBM. Our priorities checklist offers a useful and easy reminder of important issues to review during a time-critical period of acute patient deterioration. The benefit of these documents to patient outcomes would require investigation; however, we hope they will promote standardisation of patient assessment and care, particularly of critically unwell individuals, in whom morbidity and mortality remains unacceptably high.
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Affiliation(s)
- Joseph Donovan
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ursula K. Rohlwink
- Neuroscience Institute and Division of Neurosurgery, University of Cape Town, Cape Town, 7700, South Africa
| | - Elizabeth W. Tucker
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
- Division of Pediatric Critical Care, Johns Hopkins All Children’s Hospital, St. Petersburg, FL, USA
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Nguyen Thi Thu Hiep
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
| | - Guy E. Thwaites
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Anthony A. Figaji
- Neuroscience Institute and Division of Neurosurgery, University of Cape Town, Cape Town, 7700, South Africa
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10
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Contemporary Management of Increased Intraoperative Intracranial Pressure: Evidence-Based Anesthetic and Surgical Review. World Neurosurg 2019; 129:120-129. [PMID: 31158533 DOI: 10.1016/j.wneu.2019.05.224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 05/26/2019] [Accepted: 05/27/2019] [Indexed: 12/29/2022]
Abstract
Increased intracranial pressure (ICP) is frequently encountered in the neurosurgical setting. A multitude of tactics exists to reduce ICP, ranging from patient position and medications to cerebrospinal fluid diversion and surgical decompression. A vast amount of literature has been published regarding ICP management in the critical care setting, but studies specifically tailored toward the management of intraoperative acute increases in ICP or brain bulk are lacking. Compartmentalizing the intracranial space into blood, brain tissue, and cerebrospinal fluid and understanding the numerous techniques available to affect these individual compartments can guide the surgical team to quickly identify increased brain bulk and respond appropriately. Rapidly instituting measures for brain relaxation in the operating room is essential in optimizing patient outcomes. Knowledge of the efficacy, rapidity, feasibility, and risks of the various available interventions can aid the team to properly tailor their approach to each individual patient. In this article, we present the first evidence-based review of intraoperative management of ICP and brain bulk.
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11
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Glykys J, Duquette E, Rahmati N, Duquette K, Staley KJ. Mannitol decreases neocortical epileptiform activity during early brain development via cotransport of chloride and water. Neurobiol Dis 2019; 125:163-175. [PMID: 30711483 DOI: 10.1016/j.nbd.2019.01.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 01/28/2019] [Accepted: 01/30/2019] [Indexed: 12/31/2022] Open
Abstract
Seizures and brain injury lead to water and Cl- accumulation in neurons. The increase in intraneuronal Cl- concentration ([Cl-]i) depolarizes the GABAA reversal potential (EGABA) and worsens seizure activity. Neocortical neuronal membranes have a low water permeability due to the lack of aquaporins necessary to move free water. Instead, neurons use cotransport of ions including Cl- to move water. Thus, increasing the extracellular osmolarity during seizures should result in an outward movement of water and salt, reducing [Cl-]i and improving GABAA receptor-mediated inhibition. We tested the effects of hyperosmotic therapy with a clinically relevant dose of mannitol (20 mM) on epileptiform activity, spontaneous multiunit activity, spontaneous inhibitory post-synaptic currents (sIPSCs), [Cl-]i, and neuronal volume in layer IV/V of the developing neocortex of C57BL/6 and Clomeleon mice. Using electrophysiological techniques and multiphoton imaging in acute brain slices (post-natal day 7-12) and organotypic neocortical slice cultures (post-natal day 14), we observed that mannitol: 1) decreased epileptiform activity, 2) decreased neuronal volume and [Cl-]i through CCCs, 3) decreased spontaneous multi-unit activity frequency but not amplitude, and 4) restored the anticonvulsant efficacy of the GABAA receptor modulator diazepam. Increasing extracellular osmolarity by 20 mOsm with hypertonic saline did not decrease epileptiform activity. We conclude that an increase in extracellular osmolarity by mannitol mediates the efflux of [Cl-]i and water through CCCs, which results in a decrease in epileptiform activity and enhances benzodiazepine actions in the developing neocortex in vitro. Novel treatments aimed to decrease neuronal volume may concomitantly decrease [Cl-]i and improve seizure control.
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Affiliation(s)
- J Glykys
- Department of Neurology, Massachusetts General Hospital, Boston 02114, United States; Harvard Medical School, Boston, MA 02115, United States.
| | - E Duquette
- Department of Neurology, Massachusetts General Hospital, Boston 02114, United States
| | - N Rahmati
- Department of Neurology, Massachusetts General Hospital, Boston 02114, United States; Harvard Medical School, Boston, MA 02115, United States
| | - K Duquette
- Department of Neurology, Massachusetts General Hospital, Boston 02114, United States; Northeastern University, Boston 02115, United States
| | - K J Staley
- Department of Neurology, Massachusetts General Hospital, Boston 02114, United States; Harvard Medical School, Boston, MA 02115, United States
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12
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Decompressive Hemicraniectomy in Elderly Patients With Space-Occupying Infarction (DECAP): A Prospective Observational Study. Neurocrit Care 2018; 31:97-106. [DOI: 10.1007/s12028-018-0660-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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13
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Hernández-Palazón J, Fuentes-García D, Doménech-Asensi P, Burguillos-López S, García-Ferreira J, Falcón-Araña L, Piqueras-Pérez C. A dose-response relationship study of hypertonic saline on brain relaxation during supratentorial brain tumour craniotomy. Br J Neurosurg 2018; 32:619-627. [PMID: 30260251 DOI: 10.1080/02688697.2018.1508640] [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
Background: A prospective, randomized, double-blind study was designed to assess differences in brain relaxation between 2 doses of 3% HS during elective supratentorial brain tumour surgery.Methods: 60 patients undergoing supratentorial craniotomy for tumour resection were enrolled to receive either 3 mL/kg (group L) or 5 mL/kg (group H) of 3% HS administered at skin incision. Brain relaxation was assessed after dura opening on a scale ranging 1-4 (1 = perfectly relaxed, 2 = satisfactorily relaxed, 3 = firm brain, 4 = bulging brain). Hemodynamic variables and laboratory values (blood gases, osmolarity, haematocrit, and lactate) were collected before HS infusion and 30, 120 and 360 min after it. Presence of midline shift, postoperative complications, PCU and hospital stay, and mortality after 30 days were also recorded.Results: There was no difference in brain relaxation, with 2.0 (1.0-3.0) and 2.0 (1.0-2.3) (P = 0.535) for patients in groups L and H, respectively. If adjusted for the presence of midline shift, 50% of patients had adequate brain relaxation scores (grades 1 and 2) in group L and 61% in group H (OR 0.64, CI = 0.16-2.49, P = 0.515). No significant differences in perioperative outcome, mortality and length of PCU and hospital stay were observed.Conclusion: 3 mL/kg of 3% HS result in similar brain relaxation scores as 5 mL/kg in patients undergoing craniotomy for supratentorial brain tumour. This study reveals that both high and low doses of 3% HS may be less effective on intraoperative brain relaxation in patients with midline shift.
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Affiliation(s)
| | - Diego Fuentes-García
- Department of Anaesthesia, Hospital Universitario "Virgen de la Arrixaca", Murcia, Spain
| | - Paloma Doménech-Asensi
- Department of Anaesthesia, Hospital Universitario "Virgen de la Arrixaca", Murcia, Spain
| | | | | | - Luis Falcón-Araña
- Department of Anaesthesia, Hospital Universitario "Virgen de la Arrixaca", Murcia, Spain
| | - Claudio Piqueras-Pérez
- Department of Neurosurgery, Hospital Universitario "Virgen de la Arrixaca", Murcia, Spain
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14
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Oernbo EK, Lykke K, Steffensen AB, Töllner K, Kruuse C, Rath MF, Löscher W, MacAulay N. Cerebral influx of Na + and Cl - as the osmotherapy-mediated rebound response in rats. Fluids Barriers CNS 2018; 15:27. [PMID: 30249273 PMCID: PMC6154956 DOI: 10.1186/s12987-018-0111-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 08/19/2018] [Indexed: 02/01/2023] Open
Abstract
Background Cerebral edema can cause life-threatening increase in intracranial pressure. Besides surgical craniectomy performed in severe cases, osmotherapy may be employed to lower the intracranial pressure by osmotic extraction of cerebral fluid upon intravenous infusion of mannitol or NaCl. A so-called rebound effect can, however, hinder continuous reduction in cerebral fluid by yet unresolved mechanisms. Methods We determined the brain water and electrolyte content in healthy rats treated with osmotherapy. Osmotherapy (elevated plasma osmolarity) was mediated by intraperitoneal injection of NaCl or mannitol with inclusion of pharmacological inhibitors of selected ion-transporters present at the capillary lumen or choroidal membranes. Brain barrier integrity was determined by fluorescence detection following intravenous delivery of Na+-fluorescein. Results NaCl was slightly more efficient than mannitol as an osmotic agent. The brain water loss was only ~ 60% of that predicted from ideal osmotic behavior, which could be accounted for by cerebral Na+ and Cl− accumulation. This electrolyte accumulation represented the majority of the rebound response, which was unaffected by the employed pharmacological agents. The brain barriers remained intact during the elevated plasma osmolarity. Conclusions A brain volume regulatory response occurs during osmotherapy, leading to the rebound response. This response involves brain accumulation of Na+ and Cl− and takes place by unresolved molecular mechanisms that do not include the common ion-transporting mechanisms located in the capillary endothelium at the blood–brain barrier and in the choroid plexus epithelium at the blood–CSF barrier. Future identification of these ion-transporting routes could provide a pharmacological target to prevent the rebound effect associated with the widely used osmotherapy.
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Affiliation(s)
- Eva Kjer Oernbo
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Lykke
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark.,AJVaccines, Copenhagen, Denmark
| | | | - Kathrin Töllner
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Hannover, Germany.,Center for Systems Neuroscience, Hannover, Germany
| | - Christina Kruuse
- Neurovascular Research Unit, Department of Neurology, Herlev Gentofte Hospital, University of Copenhagen, Herlev, Copenhagen, Denmark
| | | | - Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Hannover, Germany.,Center for Systems Neuroscience, Hannover, Germany
| | - Nanna MacAulay
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark. .,Department of Neuroscience, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, 2200, Copenhagen, Denmark.
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15
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Sorby-Adams AJ, Marcoionni AM, Dempsey ER, Woenig JA, Turner RJ. The Role of Neurogenic Inflammation in Blood-Brain Barrier Disruption and Development of Cerebral Oedema Following Acute Central Nervous System (CNS) Injury. Int J Mol Sci 2017; 18:E1788. [PMID: 28817088 PMCID: PMC5578176 DOI: 10.3390/ijms18081788] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 08/07/2017] [Accepted: 08/15/2017] [Indexed: 12/13/2022] Open
Abstract
Acute central nervous system (CNS) injury, encompassing traumatic brain injury (TBI) and stroke, accounts for a significant burden of morbidity and mortality worldwide, largely attributable to the development of cerebral oedema and elevated intracranial pressure (ICP). Despite this, clinical treatments are limited and new therapies are urgently required to improve patient outcomes and survival. Originally characterised in peripheral tissues, such as the skin and lungs as a neurally-elicited inflammatory process that contributes to increased microvascular permeability and tissue swelling, neurogenic inflammation has now been described in acute injury to the brain where it may play a key role in the secondary injury cascades that evolve following both TBI and stroke. In particular, release of the neuropeptides substance P (SP) and calcitonin gene-related peptide (CGRP) appear to be critically involved. In particular, increased SP expression is observed in perivascular tissue following acute CNS injury, with the magnitude of SP release being related to both the frequency and degree of the insult. SP release is associated with profound blood-brain barrier disruption and the subsequent development of vasogenic oedema, as well as neuronal injury and poor functional outcomes. Inhibition of SP through use of a neurokinin 1 (NK1) antagonist is highly beneficial following both TBI and ischaemic stroke in pre-clinical models. The role of CGRP is more unclear, especially with respect to TBI, with both elevations and reductions in CGRP levels reported following trauma. However, a beneficial role has been delineated in stroke, given its potent vasodilatory effects. Thus, modulating neuropeptides represents a novel therapeutic target in the treatment of cerebral oedema following acute CNS injury.
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Affiliation(s)
- Annabel J Sorby-Adams
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide SA 5005, Australia.
| | - Amanda M Marcoionni
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide SA 5005, Australia.
| | - Eden R Dempsey
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide SA 5005, Australia.
| | - Joshua A Woenig
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide SA 5005, Australia.
| | - Renée J Turner
- Adelaide Medical School and Adelaide Centre for Neuroscience Research, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide SA 5005, Australia.
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16
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Bach L, Dries DJ. Management of Traumatic Intracranial Hypertension: Old Questions With New Answers. Air Med J 2017; 36:156-159. [PMID: 28739231 DOI: 10.1016/j.amj.2017.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 05/17/2017] [Indexed: 06/07/2023]
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17
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Ji N, Weng D, Liu C, Gu Z, Chen S, Guo Y, Fan Z, Wang X, Chen J, Zhao Y, Zhou J, Wang J, Ma D, Li N. Adenovirus-mediated delivery of herpes simplex virus thymidine kinase administration improves outcome of recurrent high-grade glioma. Oncotarget 2016; 7:4369-78. [PMID: 26716896 PMCID: PMC4826211 DOI: 10.18632/oncotarget.6737] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 11/26/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND This randomized, open-label, multicenter, phase II clinical trial was conducted to assess the anti-tumor efficacy and safety of replication-deficient adenovirus mutant thymidine kinase (ADV-TK) in combination with ganciclovir administration in patients with recurrent high-grade glioma (HGG). PATIENTS AND METHODS 53 patients with recurrent HGG were randomly allocated to receive intra-arterial cerebral infusion of ADV-TK or conventional treatments. The primary end point was 6-month progression-free survival (PFS-6). Secondary end points included progression-free survival (PFS), overall survival (OS), safety, and clinical benefit. This trial is registered with Clinicaltrials.gov, NCT00870181. RESULTS In ADV-TK group, PFS-6 was 54.5%, the median PFS was 29.6 weeks, the median OS was 45.4 weeks, and better survivals were achieved when compared with control group. The one-year PFS and OS were 22.7% and 44.6% in ADV-TK group respectively, and clinical benefit was 68.2%. There are 2 patients alive for more than 4 years without progression in ADV-TK group. In the subgroup of glioblastoma received ADV-TK, PFS-6 was 71.4%, median PFS was 34.9 weeks, median OS was 45.7 weeks respectively, much better than those in control group. The one-year PFS and OS were 35.7% and 50.0% in ADV-TK group respectively. ADV-TK/ganciclovir gene therapy was well tolerated, and no treatment-related severe adverse events were noted. CONCLUSION Our study demonstrated a notable improvement of PFS-6, PFS and OS in ADV-TK treated group, and the efficacy and safety appear to be comparable to other reported treatments used for recurrent HGG. ADV-TK gene therapy is therefore a valuable therapeutic option for recurrent HGG.
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Affiliation(s)
- Nan Ji
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P.R. China.,Beijing Key Laboratory of Brian Tumor, Beijing, P.R. China
| | - Danhui Weng
- Tongji Hospital Affiliated with Tongji Medical College of Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Cang Liu
- Beijing Friendship Hospital, Capital Medical University, Beijing, P.R. China
| | - Zheng Gu
- Beijing Chao-Yang Hospital, Capital Medical University, Beijing, P.R. China
| | - Shizhang Chen
- Beijing YouAn Hospital, Capital Medical University, Beijing, P.R. China
| | - Ying Guo
- Beijing YouAn Hospital, Capital Medical University, Beijing, P.R. China
| | - Zhong Fan
- Beijing YouAn Hospital, Capital Medical University, Beijing, P.R. China
| | - Xiao Wang
- Beijing YouAn Hospital, Capital Medical University, Beijing, P.R. China
| | - Jianfei Chen
- Beijing YouAn Hospital, Capital Medical University, Beijing, P.R. China
| | - Yanyan Zhao
- Beijing YouAn Hospital, Capital Medical University, Beijing, P.R. China
| | - Jianfeng Zhou
- Tongji Hospital Affiliated with Tongji Medical College of Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Jisheng Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P.R. China.,Beijing Key Laboratory of Brian Tumor, Beijing, P.R. China
| | - Ding Ma
- Tongji Hospital Affiliated with Tongji Medical College of Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Ning Li
- Beijing YouAn Hospital, Capital Medical University, Beijing, P.R. China
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18
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Bonaventure PL, Lauzier F, Turgeon AF. Managing critically ill patients with severe traumatic brain injury: How should we season the recipe? Can J Anaesth 2016; 63:647-51. [PMID: 27044396 DOI: 10.1007/s12630-016-0635-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 03/02/2016] [Accepted: 03/17/2016] [Indexed: 10/22/2022] Open
Affiliation(s)
- Paule Lessard Bonaventure
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec - Université Laval, Québec City, QC, Canada.,Division of Neurosurgery, Department of Neurological Sciences, CHU de Québec - Université Laval, Hôpital de l'Enfant-Jésus, Québec City, QC, Canada
| | - François Lauzier
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec - Université Laval, Québec City, QC, Canada.,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, CHU de Québec - Université Laval, Hôpital de l'Enfant-Jésus, Québec City, QC, Canada
| | - Alexis F Turgeon
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec - Université Laval, Québec City, QC, Canada. .,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, CHU de Québec - Université Laval, Hôpital de l'Enfant-Jésus, Québec City, QC, Canada.
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19
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Abstract
OPINION STATEMENT Cerebral edema (i.e., "brain swelling") is a common complication following intracerebral hemorrhage (ICH) and is associated with worse clinical outcomes. Perihematomal edema (PHE) accumulates during the first 72 h after hemorrhage, and during this period, patients are at risk of clinical deterioration due to the resulting tissue shifts and brain herniation. First-line medical therapies for patients symptomatic of PHE include osmotic agents, such as mannitol in low- or high-dose bolus form, or boluses of hypertonic saline (HTS) at varied concentrations with or without subsequent continuous infusion. Decompressive craniectomy may be required for symptomatic edema refractory to osmotherapy. Other strategies that reduce PHE such as hypothermia and minimally invasive surgery have shown promise in pilot studies and are currently being evaluated in larger clinical trials. Ongoing basic, translational, and clinical research seek to better elucidate the pathophysiology of PHE to identify novel strategies to prevent edema formation as a next major advance in the treatment of ICH.
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20
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Esquenazi Y, Lo VP, Lee K. Critical Care Management of Cerebral Edema in Brain Tumors. J Intensive Care Med 2015; 32:15-24. [PMID: 26647408 DOI: 10.1177/0885066615619618] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 10/05/2015] [Accepted: 11/06/2015] [Indexed: 12/21/2022]
Abstract
Cerebral edema associated with brain tumors is extremely common and can occur in both primary and metastatic tumors. The edema surrounding brain tumors results from leakage of plasma across the vessel wall into the parenchyma secondary to disruption of the blood-brain barrier. The clinical signs of brain tumor edema depend on the location of the tumor as well as the extent of the edema, which often exceeds the mass effect induced by the tumor itself. Uncontrolled cerebral edema may result in increased intracranial pressure and acute herniation syndromes that can result in permanent neurological dysfunction and potentially fatal herniation. Treatment strategies for elevated intracranial pressure consist of general measures, medical interventions, and surgery. Alhough the definitive treatment for the edema may ultimately be surgical resection of the tumor, the impact of the critical care management cannot be underestimated and thus patients must be vigilantly monitored in the intensive care unit. In this review, we discuss the pathology, pathophysiology, and clinical features of patients presenting with cerebral edema. Imaging findings and treatment modalities used in the intensive care unit are also discussed.
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Affiliation(s)
- Yoshua Esquenazi
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Victor P Lo
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Kiwon Lee
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, USA
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21
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Phang I, Werndle MC, Saadoun S, Varsos G, Czosnyka M, Zoumprouli A, Papadopoulos MC. Expansion duroplasty improves intraspinal pressure, spinal cord perfusion pressure, and vascular pressure reactivity index in patients with traumatic spinal cord injury: injured spinal cord pressure evaluation study. J Neurotrauma 2015; 32:865-74. [PMID: 25705999 PMCID: PMC4492612 DOI: 10.1089/neu.2014.3668] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
We recently showed that, after traumatic spinal cord injury (TSCI), laminectomy does not improve intraspinal pressure (ISP), spinal cord perfusion pressure (SCPP), or the vascular pressure reactivity index (sPRx) at the injury site sufficiently because of dural compression. This is an open label, prospective trial comparing combined bony and dural decompression versus laminectomy. Twenty-one patients with acute severe TSCI had re-alignment of the fracture and surgical fixation; 11 had laminectomy alone (laminectomy group) and 10 had laminectomy and duroplasty (laminectomy+duroplasty group). Primary outcomes were magnetic resonance imaging evidence of spinal cord decompression (increase in intradural space, cerebrospinal fluid around the injured cord) and spinal cord physiology (ISP, SCPP, sPRx). The laminectomy and laminectomy+duroplasty groups were well matched. Compared with the laminectomy group, the laminectomy+duroplasty group had greater increase in intradural space at the injury site and more effective decompression of the injured cord. In the laminectomy+duroplasty group, ISP was lower, SCPP higher, and sPRx lower, (i.e., improved vascular pressure reactivity), compared with the laminectomy group. Laminectomy+duroplasty caused cerebrospinal fluid leak that settled with lumbar drain in one patient and pseudomeningocele that resolved completely in five patients. We conclude that, after TSCI, laminectomy+duroplasty improves spinal cord radiological and physiological parameters more effectively than laminectomy alone.
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Affiliation(s)
- Isaac Phang
- 1 Academic Neurosurgery Unit, St. George's University of London , United Kingdom
| | - Melissa C Werndle
- 1 Academic Neurosurgery Unit, St. George's University of London , United Kingdom
| | - Samira Saadoun
- 1 Academic Neurosurgery Unit, St. George's University of London , United Kingdom
| | - Georgios Varsos
- 2 Department of Clinical Neurosciences, University of Cambridge , Cambridge, United Kingdom
| | - Marek Czosnyka
- 2 Department of Clinical Neurosciences, University of Cambridge , Cambridge, United Kingdom
| | - Argyro Zoumprouli
- 3 Department of Anaesthesia, St. George's Hospital , London, United Kingdom
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