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Zipfel J, Engel J, Hockel K, Heimberg E, Schuhmann MU, Neunhoeffer F. Effects of hypertonic saline on intracranial pressure and cerebral autoregulation in pediatric traumatic brain injury. J Neurosurg Pediatr 2021:1-7. [PMID: 34560657 DOI: 10.3171/2021.6.peds21143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/07/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hypertonic saline (HTS) is commonly used in children to lower intracranial pressure (ICP) after severe traumatic brain injury (sTBI). While ICP and cerebral perfusion pressure (CPP) correlate moderately to TBI outcome, indices of cerebrovascular autoregulation enhance the correlation of neuromonitoring data to neurological outcome. In this study, the authors sought to investigate the effect of HTS administration on ICP, CPP, and autoregulation in pediatric patients with sTBI. METHODS Twenty-eight pediatric patients with sTBI who were intubated and sedated were included. Blood pressure and ICP were actively managed according to the autoregulation index PRx (pressure relativity index to determine and maintain an optimal CPP [CPPopt]). In cases in which ICP was continuously > 20 mm Hg despite all other measures to decrease it, an infusion of 3% HTS was administered. The monitoring data of the first 6 hours after HTS administration were analyzed. The Glasgow Outcome Scale (GOS) score at the 3-month follow-up was used as the primary outcome measure, and patients were dichotomized into favorable (GOS score 4 or 5) and unfavorable (GOS score 1-3) groups. RESULTS The mean dose of HTS was 40 ml 3% NaCl. No significant difference in ICP and PRx was seen between groups at the HTS administration. ICP was lowered significantly in all children, with the effect lasting as long as 6 hours. The lowering of ICP was significantly greater and longer in children with a favorable outcome (p < 0.001); only this group showed significant improvement of autoregulatory capacity (p = 0.048). A newly established HTS response index clearly separated the outcome groups. CONCLUSIONS HTS significantly lowered ICP in all children after sTBI. This effect was significantly greater and longer-lasting in children with a favorable outcome. Moreover, HTS administration restored disturbed autoregulation only in the favorable outcome group. This highlights the role of a "rescuable" autoregulation regarding outcome, which might be a possible indicator of injury severity. The effect of HTS on autoregulation and other possible mechanisms should be further investigated.
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Affiliation(s)
- Julian Zipfel
- 1Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Tuebingen, Tuebingen
| | - Juliane Engel
- 2Pediatric Intensive Care Unit, University Children's Hospital of Tuebingen, Tuebingen; and
| | | | - Ellen Heimberg
- 2Pediatric Intensive Care Unit, University Children's Hospital of Tuebingen, Tuebingen; and
| | - Martin U Schuhmann
- 1Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Tuebingen, Tuebingen
| | - Felix Neunhoeffer
- 2Pediatric Intensive Care Unit, University Children's Hospital of Tuebingen, Tuebingen; and
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Skardelly M, Mönch L, Roder C, Hockel K, Tatagiba MS, Ebner FH. Survey of the management of perioperative bridging of anticoagulation and antiplatelet therapy in neurosurgery. Acta Neurochir (Wien) 2018; 160:2077-2085. [PMID: 30238395 DOI: 10.1007/s00701-018-3679-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 09/12/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND A growing number of patients on anticoagulation or antiplatelet therapy (APT) are planned for elective surgery. The management of perioperative anticoagulation and APT is challenging because it must balance the risk of thromboembolism and bleeding, and specific recommendations for the management of bridging in neurosurgical patients are lacking. We surveyed German neurosurgical centers about their management of perioperative bridging of anticoagulation and APT to provide an overview of the current bridging policy. METHOD From April to August 2016, all German neurosurgical departments were invited to participate in the survey. We used SurveyMonkey to compose ten questions and to conduct the survey, and we defined three different approaches for the perioperative management of patients on a preexisting medication: medication will be discontinued (A) with perioperative "bridging" and (B) without perioperative bridging, or (C) medication will be continued perioperatively. RESULTS Out of 141 respondents, 84 (60%) partially and 77 (55%) fully completed the questionnaire. No defined policy for the perioperative management of anticoagulation and APT was established in 60.7% (51/84) of participating centers. The perioperative management of anticoagulation and APT varied widely among different centers in all items of the questionnaire; for example, in the group of patients at high risk for thromboembolism, acetylsalicylic acid was discontinued in 22%, bridged in 35%, and continued in 35% of centers. CONCLUSIONS There is significant uncertainty regarding the management of perioperative bridging of anticoagulation and APT in neurosurgery because of a lack of prospective and limited retrospective data.
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Affiliation(s)
- Marco Skardelly
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
- Interdisciplinary Division of Neuro-Oncology, Departments of Vascular Neurology and Neurosurgery, University Hospital Tuebingen, Eberhard Karls University of Tübingen, Hertie Institute for Clinical Brain Research, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
- Neuro-Oncology Center, Comprehensive Cancer Center Tübingen, University Hospital Tuebingen, Eberhard Karls University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
| | - Lisa Mönch
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Constantin Roder
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
- Interdisciplinary Division of Neuro-Oncology, Departments of Vascular Neurology and Neurosurgery, University Hospital Tuebingen, Eberhard Karls University of Tübingen, Hertie Institute for Clinical Brain Research, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
- Neuro-Oncology Center, Comprehensive Cancer Center Tübingen, University Hospital Tuebingen, Eberhard Karls University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Konstantin Hockel
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Marcos Soares Tatagiba
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
- Interdisciplinary Division of Neuro-Oncology, Departments of Vascular Neurology and Neurosurgery, University Hospital Tuebingen, Eberhard Karls University of Tübingen, Hertie Institute for Clinical Brain Research, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
- Neuro-Oncology Center, Comprehensive Cancer Center Tübingen, University Hospital Tuebingen, Eberhard Karls University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Florian H Ebner
- Department of Neurosurgery, University Hospital Tuebingen, Eberhard Karls University Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
- Interdisciplinary Division of Neuro-Oncology, Departments of Vascular Neurology and Neurosurgery, University Hospital Tuebingen, Eberhard Karls University of Tübingen, Hertie Institute for Clinical Brain Research, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
- Neuro-Oncology Center, Comprehensive Cancer Center Tübingen, University Hospital Tuebingen, Eberhard Karls University of Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
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Nagel C, Diedler J, Gerbig I, Heimberg E, Schuhmann MU, Hockel K. State of Cerebrovascular Autoregulation Correlates with Outcome in Severe Infant/Pediatric Traumatic Brain Injury. Acta Neurochir Suppl 2017; 122:239-44. [PMID: 27165914 DOI: 10.1007/978-3-319-22533-3_48] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
OBJECTIVE It could be shown in adults with severe traumatic brain injury (TBI) that the functional status of cerebrovascular autoregulation (AR), determined by the pressure reactivity index (PRx), correlates with and even predicts outcome. We investigated PRx and its correlation with outcome in infant and pediatric TBI. Methods Ten patients (median age 2.8 years, range 1 day to 14 years) with severe TBI (Glasgow Coma Scale score <9 at presentation) underwent long-term computerized intracranial pressure (ICP) and mean arterial pressure (MAP) monitoring using dedicated software for continuous determination of cerebral perfusion pressure (CPP) and PRx. Outcome was determined at discharge and at follow-up at 6 months using the Glasgow Outcome Scale (GOS) score. RESULTS Median monitoring time was 182 h (range 22-355 h). Seven patients underwent decompressive craniectomy to control ICP during treatment in the intensive care unit. Favorable outcome (GOS 4 and 5) was reached in 4 patients, an unfavorable outcome (GOS 1-3) in 6 patients. When dichotomized to outcome, no correlation was found with ICP and CPP, but median PRx correlated well with outcome (r = -0.79, p = 0.006) and tended to be lower for GOS 4 and 5 (-0.04) than for GOS 1-3 (0.32; p = 0.067). CONCLUSION The integrity of AR seems to play the same fundamental role after TBI in the pediatric population as in adults and should be determined routinely. It carries an important prognostic value. PRx seems to be an ideal candidate parameter to guide treatment in the sense of optimizing CPP, aiming at improvement of cerebrovascular autoregulation (CPPopt concept).
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Affiliation(s)
- Carmen Nagel
- Department of Pediatric Surgery, University Hospital of Tübingen, Tübingen, Germany
| | - Jennifer Diedler
- Section of Pediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tübingen, Tübingen, Germany
| | - Ines Gerbig
- Pediatric Intensive Care Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Ellen Heimberg
- Pediatric Intensive Care Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Martin U Schuhmann
- Section of Pediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tübingen, Tübingen, Germany.
| | - Konstantin Hockel
- Section of Pediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tübingen, Tübingen, Germany
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Hockel K, Diedler J, Steiner J, Birkenhauer U, Ernemann U, Schuhmann MU. Effect of Intra-Arterial and Intravenous Nimodipine Therapy of Cerebral Vasospasm After Subarachnoid Hemorrhage on Cerebrovascular Reactivity and Oxygenation. World Neurosurg 2017; 101:372-378. [DOI: 10.1016/j.wneu.2017.02.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 01/31/2017] [Accepted: 02/02/2017] [Indexed: 10/20/2022]
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Hockel K, Diedler J, Steiner J, Birkenhauer U, Danz S, Ernemann U, Schuhmann MU. Long-Term, Continuous Intra-Arterial Nimodipine Treatment of Severe Vasospasm After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2015; 88:104-112. [PMID: 26732964 DOI: 10.1016/j.wneu.2015.11.081] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 11/23/2015] [Accepted: 11/24/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Secondary vasospasm and disturbances in cerebrovascular autoregulation are associated with the development of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. An intra-arterial application of nimodipine has been shown to increase the vessel diameter, although this effect is transient. The feasibility of long-term, continuous, intra-arterial nimodipine treatment and its effects on macrovasospasm, autoregulation parameters, and outcome were evaluated in patients with refractory severe macrovasospasm. METHODS Ten patients were included with refractory macrovasospasm despite bolus nimodipine application (n = 4) or with primary severe vasospasm (n = 6). The patients were assessed with continuous multimodal neuromonitoring (mean arterial pressure, intraceranial pressure, cerebral perfusion pressure, brain tissue oxygen tension probe), daily transcranial Doppler examinations, and computed tomography angiography/perfusion. Autoregulation indices, the pressure reactivity index, and oxygen reactivity index were calculated. Indwelling microcatheters were placed in the extracranial internal carotid arteries and 0.4 mg nimodipine was continuously infused at 50 mL/hour. RESULTS The duration of continuous, intra-arterial nimodipine ranged from 9 to 15 days. During treatment intracranial pressure remained stable, transcranial Doppler flow velocity decreased, and brain tissue oxygen tension improved by 37%. Macrovasospasm, as assessed via computed tomography angiography, had improved (n = 5) or disappeared (n = 5) at the end of treatment. Cerebrovascular autoregulation according to the pressure reactivity index and oxygen reactivity index significantly worsened during treatment. All patients showed a favorable outcome (median Glasgow Outcome Scale 5) at 3 months. CONCLUSIONS In well-selected patients with prolonged severe macrovasospasm, continuous intra-arterial nimodipine treatment can be applied as a rescue therapy with relative safety for more than 2 weeks to prevent secondary cerebral ischemia. The induced impairment of cerebrovascular autoregulation during treatment seems to have no negative effects.
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Affiliation(s)
- Konstantin Hockel
- Department of Neurosurgery, University Hospital Tübingen, University of Tübingen, Germany.
| | - Jennifer Diedler
- Department of Neurosurgery, University Hospital Tübingen, University of Tübingen, Germany
| | - Jochen Steiner
- Department of Neurosurgery, University Hospital Tübingen, University of Tübingen, Germany
| | - Ulrich Birkenhauer
- Department of Neurosurgery, University Hospital Tübingen, University of Tübingen, Germany
| | - Sören Danz
- Diagnostic and Interventional Neuroradiology, Department of Radiology, University Hospital Tübingen, University of Tübingen, Germany
| | - Ulrike Ernemann
- Diagnostic and Interventional Neuroradiology, Department of Radiology, University Hospital Tübingen, University of Tübingen, Germany
| | - Martin U Schuhmann
- Department of Neurosurgery, University Hospital Tübingen, University of Tübingen, Germany
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Hockel K, Trabold R, Schöller K, Török E, Plesnila N. Impact of anesthesia on pathophysiology and mortality following subarachnoid hemorrhage in rats. Exp Transl Stroke Med 2012; 4:5. [PMID: 22414527 PMCID: PMC3338388 DOI: 10.1186/2040-7378-4-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Accepted: 03/13/2012] [Indexed: 05/10/2023]
Abstract
BACKGROUND Anesthesia is indispensable for in vivo research but has the intrinsic potential to alter study results. The aim of the current study was to investigate the impact of three common anesthesia protocols on physiological parameters and outcome following the most common experimental model for subarachnoid hemorrhage (SAH), endovascular perforation. METHODS Sprague-Dawley rats (n = 38) were randomly assigned to (1) chloral hydrate, (2) isoflurane or (3) midazolam/medetomidine/fentanyl (MMF) anesthesia. Arterial blood gases, intracranial pressure (ICP), mean arterial blood pressure (MAP), cerebral perfusion pressure (CPP), and regional cerebral blood flow (rCBF) were monitored before and for 3 hours after SAH. Brain water content, mortality and rate of secondary bleeding were also evaluated. RESULTS Under baseline conditions isoflurane anesthesia resulted in deterioration of respiratory parameters (arterial pCO2 and pO2) and increased brain water content. After SAH, isoflurane and chloral hydrate were associated with reduced MAP, incomplete recovery of post-hemorrhagic rCBF (23 ± 13% and 87 ± 18% of baseline, respectively) and a high anesthesia-related mortality (17 and 50%, respectively). Anesthesia with MMF provided stable hemodynamics (MAP between 100-110 mmHg), high post-hemorrhagic rCBF values, and a high rate of re-bleedings (> 50%), a phenomenon often observed after SAH in humans. CONCLUSION Based on these findings we recommend anesthesia with MMF for the endovascular perforation model of SAH.
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Affiliation(s)
- Konstantin Hockel
- Laboratory of Experimental Neurosurgery, Institute for Surgical Research, Munich, Germany
| | - Raimund Trabold
- Laboratory of Experimental Neurosurgery, Institute for Surgical Research, Munich, Germany
- Department of Neurosurgery, Munich, Germany
| | - Karsten Schöller
- Laboratory of Experimental Neurosurgery, Institute for Surgical Research, Munich, Germany
- Department of Neurosurgery, Munich, Germany
| | - Elisabeth Török
- Laboratory of Experimental Neurosurgery, Institute for Surgical Research, Munich, Germany
| | - Nikolaus Plesnila
- Laboratory of Experimental Neurosurgery, Institute for Surgical Research, Munich, Germany
- Department of Neurosurgery, Munich, Germany
- Institute for Stroke and Dementia Research, University of Munich Medical Center - Grosshadern, Ludwig-Maximilians-University, Munich, Germany
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Hockel K, Schöller K, Trabold R, Nussberger J, Plesnila N. Vasopressin V(1a) receptors mediate posthemorrhagic systemic hypertension thereby determining rebleeding rate and outcome after experimental subarachnoid hemorrhage. Stroke 2011; 43:227-32. [PMID: 21998059 DOI: 10.1161/strokeaha.111.626168] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Arginine vasopressin V(1) receptors have been suggested to be involved in the pathophysiology of acute brain injury. Therefore, we aimed to determine the role of arginine vasopressin V(1) receptors after experimental subarachnoid hemorrhage (SAH). METHODS Sprague-Dawley rats subjected to SAH by endovascular puncture received either vehicle or a V(1) receptor antagonist intravenously from 1 minute before until 3 hours after SAH. Intracranial pressure, cerebral blood flow, and mean arterial blood pressure were monitored until 60 minutes after SAH. Brain water content was quantified 24 hours after SAH and neurological function and mortality were assessed daily for 7 days after hemorrhage. RESULTS In control rats, SAH induced high intracranial pressure, a brief increase in plasma arginine vasopressin, a subsequent increase in systemic blood pressure (Cushing response), a high rebleeding rate (30%), severe neurological deficits, and a 7-day mortality rate of 50%. V(1) receptor antagonist-treated animals exhibited a far less pronounced Cushing response, a less severe increase of intracranial pressure, did not exhibit rebleedings, had less severe brain edema formation and neurological deficits, and a mortality rate of only 20% (all P<0.05 versus vehicle). CONCLUSIONS Inhibition of arginine vasopressin V(1a) receptors reduces the severity of SAH and prevents rebleedings by blunting the posthemorrhagic hypertonic response (Cushing reflex), thereby reducing mortality and secondary brain damage after experimental SAH. Because the severity of the initial bleeding and rebleedings are major factors contributing to an unfavorable outcome after SAH, inhibition of V(1a) receptors may represent a novel strategy to treat SAH.
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Affiliation(s)
- Konstantin Hockel
- Department of Neurosurgery, University of Munich Medical Center–Grosshadern, Ludwig-Maximilians-University, Munich, Germany
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