Traumatic brain injury and haemorrhagic complications after intracranial pressure monitoring

Ultrasound detected increase in optic disk height to identify elevated intracranial pressure: a systematic review

BACKGROUND

Elevated intracranial pressure (eICP) is a serious medical emergency that requires prompt identification and monitoring. The current gold standards of eICP detection require patient transportation, radiation, and can be invasive. Ocular ultrasound has emerged as a rapid, non-invasive, bedside tool to measure correlates of eICP. This systematic review seeks to explore the utility of ultrasound detected optic disc elevation (ODE) as an ultrasonographic finding of eICP and to study its sensitivity and specificity as a marker of eICP.

METHODS

This systematic review followed the preferred reporting items for systematic reviews and meta-analyses guidelines. We systematically searched PubMed, EMBASE, and Cochrane Central for English articles published before April 2023; yielding 1,919 total citations. After eliminating duplicates, and screening the records, we identified 29 articles that addressed ultrasonographically detected ODE.

RESULTS

The 29 articles included a total of 1249 adult and pediatric participants. In patients with papilledema, the mean ODE ranged between 0.6 mm and 1.2 mm. Proposed cutoff values for ODE ranged between 0.3 mm and 1 mm. The majority of studies reported a sensitivity between 70 and 90%, and specificity ranged from 69 to 100%, with a majority of studies reporting a specificity of 100%.

CONCLUSIONS

ODE and ultrasonographic characteristics of the optic disc may aid in differentiating papilledema from other conditions. Further research on ODE elevation and its correlation with other ultrasonographic signs is warranted as a means to increase the diagnostic accuracy of ultrasound in the setting of eICP.

Nonepileptic Electroencephalographic Correlates of Episodic Increases in Intracranial Pressure

PURPOSE

Continuous EEG can potentially be used as real-time brain telemetry for the early detection of neurologic decline. Scant literature on EEG changes related to elevated intracranial pressure (ICP) limits its use in this context.

METHODS

Retrospective, observational case series of patients in whom we noted EEG changes correlating with a clinical concern for elevated ICP, measured or unmeasured.

RESULTS

We noted EEG changes of varying severity and duration correlating with either measured or unmeasured clinical concern for elevated ICP. In two patients with recurrent transient unresponsiveness (presumed from plateau waves), generalized rhythmic delta activity and attenuation of fast activity occurred 30 minutes before a clinical change. Elevated ICP in two patients, one related to progressive mass effect from infarctions, and the other to dialysis, correlated with generalized slowing and attenuation of fast activity up to 24 hours before clinical deterioration, leading to diffuse suppression. Two patients with intraventricular hemorrhage had cyclic patterns at ∼1 per minute and ∼6 per minute (similar frequency to described frequency of Lundberg B and C waves, respectively).

CONCLUSIONS

Cyclic patterns and varying degrees of slowing and attenuation often preceded clinical deterioration associated with intracranial hypertension. Future systematic studies of EEG changes in this setting will facilitate early and noninvasive detection of elevated ICP.

Intersubject assessment of implantable antenna performance for intracranial pressure monitoring

This work focuses on the assessment of an implantable antenna performance designed for Intracranial Pressure (ICP) monitoring applications. A simplified three-layer canonical model, exclusively designed for antenna tuning inside anatomical human head, is evaluated. Inter-subject variability is studied using four different human head anatomical models which are part of the Virtual Family by Foundation for Research on Information Technologies in Society (IT'IS) and have been extensively used in the literature. Simulations are performed within MedRadio band, which is worldwide available, and has been allocated exclusively for medical applications. The results highlight the suitability of the proposed simplified model for antenna fine-tuning. Moreover, no significant detuning effects are observed among the anatomical models, as the antenna maintain sits resonance, radiation and safety performance.

Effects and Clinical Characteristics of Intracranial Pressure Monitoring-Targeted Management for Subsets of Traumatic Brain Injury: An Observational Multicenter Study

OBJECTIVES

To evaluate the efficacy of traumatic brain injury management guided by intracranial pressure monitoring and to explore the specific subgroups for which intracranial pressure monitoring might be significantly associated with improved outcomes based on a classification of the various traumatic brain injury pathophysiologies using the clinical features and CT scans.

DESIGN

Retrospective observational multicenter study.

SETTING

Twenty-two hospitals (16 level I trauma centers and six level II trauma centers) in nine provinces in China.

PATIENTS

Moderate or severe traumatic brain injury patients who were more than 14 years old.

INTERVENTIONS

Intracranial pressure monitoring.

MEASUREMENTS AND MAIN RESULTS

All data were collected by physicians from medical records. The 6-month mortality and favorable outcome were assessed with the Glasgow Outcome Scale Extended score. An intracranial pressure monitor was inserted into 838 patients (58.1%). The mean duration of intracranial pressure monitoring was 4.44 ± 3.65 days. The significant predictors of intracranial pressure monitoring included the mechanism of injury, a Glasgow Coma Scale score of 9-12 at admission that dropped to a score of 3-8 within 24 hours after injury, a Marshall CT classification of III-IV, the presence of a major extracranial injury, subdural hematoma, intraparenchymal lesions, trauma center level, and intracranial pressure monitoring utilization of hospital. The intracranial pressure monitoring and no intracranial pressure monitoring groups did not significantly differ in terms of complications. For the total sample, the placement of intracranial pressure monitoring was not associated with either 6-month mortality (16.9% vs 20.5%; p = 0.086) or 6-month unfavorable outcome (49.4% vs 45.8%; p = 0.175). For patients with a Glasgow Coma Scale score of 3-8 at admission, intracranial pressure monitoring was also not significantly associated with 6-month mortality (20.9% vs 26.0%; p = 0.053) or an unfavorable outcome (56.9% vs 55.5%; p = 0.646). Multivariate logistic regression analyses showed that intracranial pressure monitoring resulted in a significantly lower 6-month mortality for patients who had a Glasgow Coma Scale score of 3-5 at admission (adjusted odds ratio, 0.57; 95% CI, 0.36-0.90; adjusted p = 0.016), those who had a Glasgow Coma Scale score of 9-12 at admission that dropped to 3-8 within 24 hours after injury (adjusted odds ratio, 0.28; 95% CI, 0.08-0.96; adjusted p = 0.043), and those who had a probability of death at 6 months greater than 0.6 (adjusted odds ratio, 0.55; 95% CI, 0.32-0.94; adjusted p = 0.029).

CONCLUSIONS

There were multiple differences between the intracranial pressure monitoring and no intracranial pressure monitoring groups regarding patient characteristics, injury severity, characteristics of CT scan, and hospital type. Intracranial pressure monitoring in conjunction with intracranial pressure-targeted therapies is significantly associated with lower mortality in some special traumatic brain injury subgroups. The prospective randomized controlled trials specifically investigating these subgroups will be required to further characterize the effects of intracranial pressure monitoring on behavioral outcomes in patients with traumatic brain injury.

Intracranial pseudoaneurysm after intracranial pressure monitor placement

Traumatic intracranial pseudoaneurysms are a rare but severe complication following arterial injury. Pseudoaneurysm formation can occur secondary to blunt or penetrating trauma or iatrogenic injury. We report a case of traumatic pseudoaneurysm secondary to placement of an intracranial pressure (ICP) monitor. A 27-year-old man was involved in a motorcycle accident resulting in multiple intracranial hemorrhages. The patient underwent craniectomy and placement of an ICP monitor. 17 days later he developed dilation of his left pupil, with imaging demonstrating a new hemorrhage in the vicinity of the previous ICP monitor. A cerebral angiogram confirmed a left-sided distal M4 pseudoaneurysm which was treated by n-butyl cyanoacrylate embolization. Intracranial pseudoaneurysm formation following neurosurgical procedures is uncommon. Delayed intracranial hemorrhage in a region of prior intracranial manipulation, even following a procedure as 'routine' as placement of an ICP monitor, should raise the suspicion for this rare but potentially lethal complication.

Intracranial pseudoaneurysm after intracranial pressure monitor placement

Traumatic intracranial pseudoaneurysms are a rare but severe complication following arterial injury. Pseudoaneurysm formation can occur secondary to blunt or penetrating trauma or iatrogenic injury. We report a case of traumatic pseudoaneurysm secondary to placement of an intracranial pressure (ICP) monitor. A 27-year-old man was involved in a motorcycle accident resulting in multiple intracranial hemorrhages. The patient underwent craniectomy and placement of an ICP monitor. 17 days later he developed dilation of his left pupil, with imaging demonstrating a new hemorrhage in the vicinity of the previous ICP monitor. A cerebral angiogram confirmed a left-sided distal M4 pseudoaneurysm which was treated by n-butyl cyanoacrylate embolization. Intracranial pseudoaneurysm formation following neurosurgical procedures is uncommon. Delayed intracranial hemorrhage in a region of prior intracranial manipulation, even following a procedure as 'routine' as placement of an ICP monitor, should raise the suspicion for this rare but potentially lethal complication.

Decreased risk of secondary brain herniation with intracranial pressure monitoring in patients with haemorrhagic stroke

BACKGROUND

Intracranial-pressure (ICP) monitoring is considered standard care for severe traumatic brain injury and is used frequently, but the efficacy of treatment based on monitoring in patients with hemorrhagic stroke has not been rigorously assessed. In this study, we investigated the clinical value of ICP monitoring in patients with hemorrhagic stroke.

METHODS

We conducted a randomized, unblinded, controlled trial in which 90 patients with hemorrhagic stroke were randomly assigned to ICP monitoring or a control group. The primary outcome was a composite of incidence rate of hematoma enlargement and secondary brain herniation. The secondary outcome was neurological status assessed using the Glasgow Outcome Scale scores at 6 months post-onset. Characteristics of the patients at baseline and outcome measurements were also compared between the two groups.

RESULTS

There was no significant between-group difference in the incidence of hematoma enlargement (control group, 38.6% vs. ICP monitoring group, 32.6%; P > 0.05). The incidence rate of secondary brain herniation in the ICP monitoring group was significantly lower compared with the control group (10.9% vs. 20.5%, P = 0.04). Six-month mortality was 6.5% in the ICP group and 9.1% in the control group (P < 0.05), and neurological outcome was better in the ICP group compared with the control group (P < 0.05).

CONCLUSION

The dynamic ICP value may be more sensitive and effective in preventing secondary brain herniation in patients with hemorrhagic stroke compared with guidance directed by clinical signs and radiological indicators.

Relationship between intracranial pressure monitoring and outcomes in severe traumatic brain injury patients

Intracranial pressure (ICP) monitoring is recommended in patients with a severe traumatic brain injury (TBI) and an abnormal computed tomography (CT) scan. However, there is contradicting evidence about whether ICP monitoring improves outcome. The purpose of this study was to examine the relationship between ICP monitoring and outcomes in patients with severe TBI. From February 2001 to December 2008, a total of 477 consecutive adult (> or =18 years) patients with severe TBI were included retrospectively in the study. Patients who underwent ICP monitoring (n=52) were compared with those who did not (n=425). The primary outcome was hospital mortality. Secondary outcomes were ICU mortality, mechanical ventilation duration, the need for tracheostomy, and ICU and hospital length of stay (LOS). After adjustment for multiple potential confounding factors, ICP monitoring was not associated with significant difference in hospital or ICU mortality (odds ratio [OR] = 1.71, 95% confidence interval [CI] = 0.79 to 3.70, P = 0.17; OR = 1.01, 95% CI = 0.41 to 2.45, P = 0.99, respectively). ICP monitoring was associated with a significant increase in mechanical ventilation duration (coefficient = 5.66, 95% CI = 3.45 to 7.88, P < 0.0001), need for tracheostomy (OR = 2.02, 95% CI = 1.02 to 4.03, P = 0.04), and ICU LOS (coefficient = 5.62, 95% CI = 3.27 to 7.98, P < 0.0001), with no significant difference in hospital LOS (coefficient = 8.32, 95% CI = -82.6 to 99.25, P = 0.86). Stratified by the Glasgow Coma Scale score, ICP monitoring was associated with a significant increase in hospital mortality in the group of patients with Glasgow Coma Scale 7 to 8 (adjusted OR = 12.89, 95% CI = 3.14 to 52.95, P = 0.0004). In patients with severe TBI, ICP monitoring was not associated with reduced hospital mortality, however with a significant increase in mechanical ventilation duration, need for tracheostomy, and ICU LOS.

Continuous ventricular cerebrospinal fluid drainage with intracranial pressure monitoring for management of posttraumatic diffuse brain swelling

BACKGROUND: Ventricular drainage has played an important role in the management of traumatic brain-injured patients. The aim of the present study was describe outcomes in a series of 57 patients with diffuse brain swelling underwent to intracranial pressure (ICP) monitoring. METHOD: Fifty-eight patients with diffuse posttraumatic brain swelling, were evaluated prospectively. The Glasgow Coma Scale (GCS) scores of patients varied from 4 to 12. Patients groups divided according to GCS and age. Patient neurological assessment was classified as favorable, unfavorable, and death. RESULTS: Mechanisms of injury were vehicle accidents in 72.4% and falls in 15.6%. 54% of patients had GCS scores between 6 and 8. There were no statistical differences, regarding outcome, between groups separated by age. In the adults group (n=47), 44.7% evolved favorably. CONCLUSION: Our results indicate a poor prognosis in patients with brain swelling. We believe that continuous ventricular CSF drainage with ICP monitoring is a simple method as an adjunct in the management of these patients.

Does ICP monitoring make a difference in neurocritical care? Eur J Anaesthesiol. 2008;42:87-93. [PMID: 18289423 DOI: 10.1017/s0265021507003237]

Raised intracranial pressure and low cerebral perfusion pressure are associated with ischaemia and poor outcome after brain injury. Therefore, many management protocols target these variables. However, there are no randomized controlled trials that have demonstrated the effectiveness of intracranial pressure-guided care in severely head-injured patients. Observational studies of such therapy have yielded inconsistent results, ranging from decreased mortality to no effect or increased morbidity or mortality. A recent cohort study supports the notion that the possible benefits of intracranial pressure monitoring after traumatic brain injury are small - if present - and would exceed a number needed for the treatment of 16. Furthermore, intracranial pressure monitoring and aggressive management of intracranial pressure and cerebral perfusion pressure have been associated with increased lengths of stay in the neurocritical care unit, conceivable costs and possibly an increased rate of complications. Against this background, there is sufficient clinical equipoise to warrant an adequately powered randomized controlled trial to compare intracranial pressure-guided care with supportive critical care without intracranial pressure monitoring in patients with severe traumatic brain injury. However, the realization of such a trial is likely to be problematic for a number of reasons, not least of which the firmly held biases of many clinicians.

The Camino intracranial pressure device in clinical practice. Assessment in a 1000 cases

BACKGROUND

Intracranial pressure (ICP) monitoring has become standard in the management of neurocritical patients. A variety of monitoring techniques and devices are available, each offering advantages and disadvantages. Analysis of large populations has never been performed.

PATIENTS AND METHODS

A prospective study was designed to evaluate the Camino fiberoptic intraparenchymal cerebral pressure monitor for complications and accuracy.

RESULTS

Between 1992-2004 one thousand consecutive patients had a fiberoptic ICP monitor placed. The most frequent indication for monitoring was severe head injury (697 cases). The average duration of ICP monitoring was 184.6 +/- 94.3 hours; the range was 16-581 hours. Zero drift (range, -17 to 21 mm Hg; mean 7.3 +/- 5.1) was recorded after the devices were removed from 624 patients. Mechanical complications such as: breakage of the optical fiber (n = 17); dislocations of the fixation screw (n = 15) or the probe (n = 13); and failure of ICP recording for unknown reasons (n = 4) were found in 49 Camino devices.

CONCLUSIONS

The Camino ICP sensor remains one of the most popular ICP monitoring devices for use in critical neurosurgical patients. The system offers reliable ICP measurements in an acceptable percentage of device complications and the advantage of in vivo recalibration. The incidence of technical complications was low and similar to others devices.