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Toshniwal SS, Kinkar J, Chadha Y, Khurana K, Reddy H, Kadam A, Acharya S. Navigating the Enigma: A Comprehensive Review of Idiopathic Intracranial Hypertension. Cureus 2024; 16:e56256. [PMID: 38623134 PMCID: PMC11016992 DOI: 10.7759/cureus.56256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 03/16/2024] [Indexed: 04/17/2024] Open
Abstract
An unidentified source of increased intracranial pressure is a hallmark of idiopathic intracranial hypertension (IIH), also referred to as pseudotumor cerebri. It mainly affects young, obese women, yet it can happen to anyone, regardless of age, gender, or weight. IIH presents with symptoms such as headaches, visual disturbances, and pulsatile tinnitus and can lead to severe complications, including vision loss, if left untreated. Diagnosis involves clinical evaluation, neuroimaging, and lumbar puncture, while management options include medical interventions and surgical procedures. This review provides a comprehensive overview of IIH, including its etiology, clinical presentation, epidemiology, complications, management approaches, and challenges. Increased awareness among healthcare professionals, standardized diagnostic criteria, and further research efforts are essential for improving outcomes and quality of life for individuals with IIH.
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Affiliation(s)
- Saket S Toshniwal
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Jiwan Kinkar
- Neurology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Nagpur, IND
| | - Yatika Chadha
- Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Kashish Khurana
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Harshitha Reddy
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Abhinav Kadam
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Sourya Acharya
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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Hanif S, Yousaf I, Iqbal M, Kumari U, Surani S. Brain herniation and subsequent complications following partial resection of high-grade glioma: A case report. Clin Case Rep 2024; 12:e8407. [PMID: 38173889 PMCID: PMC10762324 DOI: 10.1002/ccr3.8407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/07/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024] Open
Abstract
Key Clinical Message This case highlights the need for tailored strategies to address issues like brain herniation, subdural hygroma, and cerebrospinal fluid leak, which, if not managed promptly, can lead to long-term neurological deficits. Additionally, the role of specialized facilities in delivering highly specialized care for managing such intricate cases cannot be understated. Abstract Decompressive craniectomy-induced subdural hygroma (SDH) frequently coexists with external cerebral herniation, resulting in neurological impairments. The incidence of brain herniation through a craniectomy defect postoperatively is 25%. Brain herniation (BH), SDH, and cerebrospinal fluid leak require urgent neurosurgical management as they can lead to irreversible long-term neurological deficits. We report a case of a 42-year-old male who presented with headache and grand mal seizures. He was diagnosed with herniation of brain parenchyma through the surgical defect with a displacement of the bone flap by a heterogeneously enhancing lesion in the left parietal lobe along with SDH in the left frontoparietal region post partial resection of high-grade glioma. In this report, we discuss the pathogenesis and management strategies of brain herniation, wound infection, cerebrospinal fluid (CSF) leak, ipsilateral SDH, floating bone flap, and communicating hydrocephalus in an adult patient following partial resection of high-grade glioma. This particular case emphasizes the value of an individualized patient-centered surgical approach to minimize the risk of postoperative complications.
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Affiliation(s)
| | - Irfan Yousaf
- Shaukat Khanum Cancer Memorial HospitalLahorePakistan
| | - Maham Iqbal
- Department of medicineDow University Of Health SciencesKarachiPakistan
| | - Usha Kumari
- Dow University of Health SciencesKarachiPakistan
| | - Salim Surani
- Texas A&M UniversityCollege StationTexasUSA
- Mayo ClinicRochesterMinnesotaUSA
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Ahmed AK, Jagtiani P, Jones S. Technical Optimization of Decompressive Craniectomy for Possible Conversion to Hinge Craniotomy in Traumatic Brain Injury. Cureus 2023; 15:e39767. [PMID: 37398770 PMCID: PMC10312037 DOI: 10.7759/cureus.39767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 07/04/2023] Open
Abstract
Hinge craniotomy for the management of elevated intracranial pressure (ICP) in traumatic brain injury remains a technique not widely adopted. The hinged bone flap decreases the allowable intracranial volume expansion, which can lead to persistent post-operative elevated ICP and the need for salvage craniectomy. Herein, we describe the technical nuances in performing a decompressive craniectomy that, when optimized, allows for stronger consideration for hinge craniotomy as a definitive technique. To conclude, hinge craniotomy is a reasonable option in the setting of traumatic brain injury. Trauma neurosurgeons can consider the technical steps to optimize a decompressive craniectomy and perform hinge craniotomy when allowable.
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Affiliation(s)
| | - Pemla Jagtiani
- Medical School, State University of New York Downstate Health Sciences University, New York, USA
| | - Salazar Jones
- Neurological Surgery, Mount Sinai Hospital, New York, USA
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Muacevic A, Adler JR, Al Arab S. Pseudotumor Cerebri Postpartum: A Case Report. Cureus 2022; 14:e32893. [PMID: 36699781 PMCID: PMC9868888 DOI: 10.7759/cureus.32893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2022] [Indexed: 12/25/2022] Open
Abstract
Idiopathic intracranial hypertension (IIH), called pseudotumor cerebri, could cause postpartum headaches. Generally, this diagnosis is idiopathic and treatment is mainly medical to avoid serious complications of possible vision loss. In this paper, we report the case of a 24-year-old lady who developed a similar constellation of symptoms and was diagnosed with this condition. Postpartum, the patient demonstrated symptoms of headache and vision disturbances. Workup ruled out infectious processes and intracranial pathologies. Normal cranial magnetic resonance imaging (MRI) and high cerebrospinal fluid (CSF) pressure during lumbar puncture led to a diagnosis of IIH. Initiation of medication allowed rapid improvement of symptoms and evaded imminent morbidity. Further discussion in light of the latest findings of the literature is held after the presentation of the case. This case sheds light on the importance on importance of fundoscopy in patients demonstrating new-onset headaches especially postpartum with the absence of intracranial pathologies.
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Muacevic A, Adler JR, Soares MF, Fonseca AC. Follow-Up by Transcranial Doppler After Rupture of a Giant Intracranial Aneurysm. Cureus 2022; 14:e31951. [PMID: 36582551 PMCID: PMC9795273 DOI: 10.7759/cureus.31951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2022] [Indexed: 11/29/2022] Open
Abstract
Giant intracranial aneurysms (GIA) are rare and manifest primarily through subarachnoid hemorrhage (SAH), cerebral ischemia, or progressive symptoms of mass effect. Transcranial Doppler (TCD) can be used to monitor cerebral vasospasm after treatment of intracranial aneurysm allowing the adjustment of therapeutics and avoiding complications. The authors present a clinical case of a patient with a ruptured intracranial giant aneurysm in which TCD was essential to monitor vasospasm and intracranial hypertension (IH). A 53-year-old male was admitted due to a sudden headache and impaired consciousness, left hemiparesis, and dysarthria. Cerebral CT scan and CT angiography at admission showed a giant aneurysm of the right middle cerebral artery (MCA) with extensive and diffuse intraventricular SAH of Fisher grade IV and Hunt and Hess grade 4. Clipping, placement of an intracranial pressure sensor, and external ventricular drain (EVD) were performed on the same day, with difficulty in preserving the M2 branch and complicated by postoperative extensive right MCA ischemia. On day three of hospitalization, TCD revealed an increased pulsatility index (>1.5) with clinical deterioration leading to re-intervention for a decompressive craniectomy. On day six, a TCD follow-up was performed to monitor blood flow complications, and particularly vasospasm, showing a severe increase in middle blood flow velocity (MBFV) in the right MCA of 205 cm/s and Lindegaard Index > 6. Daily surveillance by TCD was maintained to guide clinical management since the attempt to withdraw the EVD led to clinical deterioration with subsequent worsening of vasospasm. Improvement occurred after surgery as ventriculoperitoneal shunt insertion was performed. TCD had a major role in the clinical orientation of SAH as well as in intracranial pressure management and was decisive to establish long-term treatment.
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Quig N, Shastri D, Zeitouni D, Yap E, Sasaki-Adams D. Bilateral Decompressive Hemicraniectomy for Diffuse Cerebral Edema and Medically Refractory Elevated Intracranial Pressure in Aneurysmal Subarachnoid Hemorrhage: A Case Series. Cureus 2021; 13:e18057. [PMID: 34671533 PMCID: PMC8520698 DOI: 10.7759/cureus.18057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2021] [Indexed: 11/05/2022] Open
Abstract
Decompressive hemicraniectomy (DCHC) may be indicated in the setting of subarachnoid hemorrhage (SAH) complicated by persistent elevated intracranial pressure (ICP) that is refractory to medical interventions. Outcomes can be variable as indications for surgery can include focal hematomas, infarctions, and regional or diffuse edema. Bilateral DCHC for medically refractory elevated ICP in the setting of SAH is not well described in the literature, and the viability of this option in terms of patient outcomes is unclear. We describe the cases of four patients with medically refractory ICP secondary to diffuse cerebral edema who underwent bilateral DCHC in the setting of SAH. This is a retrospective case review of four patients with aneurysmal SAH who underwent bilateral DCHC for management of diffuse global edema resulting in medically refractory ICP. We describe two patients who made impressive recoveries after bilateral DCHC and two patients who required significant continued care needs despite ICP control in all patients. Bilateral DCHC is a viable option for control of refractory elevated ICP in SAH patients who develop diffuse cerebral edema. Bilateral DCHC in this setting can be considered after exhaustion of other therapeutic options.
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Affiliation(s)
- Nathan Quig
- Department of Neurosurgery, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Darshan Shastri
- Department of Neurosurgery, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Daniel Zeitouni
- Department of Neurosurgery, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, USA
| | - Edward Yap
- Department of Neurosurgery, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Deanna Sasaki-Adams
- Department of Neurosurgery, University of North Carolina at Chapel Hill, Chapel Hill, USA
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Weidner N, Kretschmann J, Bomberg H, Antes S, Leonhardt S, Tschan C, Oertel J, Volk T, Meiser A, Groesdonk HV. Real-Time Evaluation of Optic Nerve Sheath Diameter (ONSD) in Awake, Spontaneously Breathing Patients. J Clin Med 2021; 10:3549. [PMID: 34441846 DOI: 10.3390/jcm10163549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 12/17/2022] Open
Abstract
(1) Background: Reliable ultrasonographic measurements of optic nerve sheath diameter (ONSD) to detect increased intracerebral pressure (ICP) has not been established in awake patients with continuous invasive ICP monitoring. Therefore, in this study, we included fully awake patients with and without raised ICP and correlated ONSD with continuously measured ICP values. (2) Methods: In a prospective study, intracranial pressure (ICP) was continuously measured in 25 patients with an intraparenchymatic P-tel probe. Ultrasonic measurements were carried out three times for each optic nerve in vertical and horizontal directions. ONSD measurements and ICP were correlated. Patients with ICP of 2.0–10.0 mmHg were compared with patients suffering from an ICP of 10.1–24.2 mmHg. (3) Results: In all patients, the ONSD vertical and horizontal measurement for both eyes correlated well with the ICP (Pearson R = 0.68–0.80). Both measurements yielded similar results (Bland-Altman: vertical bias: −0.09 mm, accuracy: ±0.66 mm; horizontal bias: −0.06 mm, accuracy: ±0.48 mm). For patients with an ICP of 2.0–10.0 mmHg compared to an ICP of 10.1–24.2, ROC (receiver operating characteristic) analyses showed that ONSD measurement accurately predicts elevated ICP (optimal cut-off value 5.05 mm, AUC of 0.91, sensitivity 92% and specificity 90%, p < 0.001). (4) Conclusions: Ultrasonographic measurement of ONSD in awake, spontaneously breathing patients provides a valuable method to evaluate patients with suspected increased ICP. Additionally, it provides a potential tool for rapid assessment of ICP at the bedside and to identify patients at risk for a poor neurological outcome.
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Clond MA, Koleini EA, Richardson TE, Zyck SA, Sharma V, Dhir M, Li F, Krishnamurthy S, Thomas S, Zhang X. Focal Neurologic Deficit After Epidural Catheter Removal Leads to Meningioma Diagnosis. Cureus 2021; 13:e16015. [PMID: 34336505 PMCID: PMC8319221 DOI: 10.7759/cureus.16015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 11/05/2022] Open
Abstract
We present an unusual case of a 60-year-old female who developed subtle, new-onset left upper and lower extremity weakness on day five of perioperative thoracic epidural placement. The onset of a focal neurological deficit after epidural placement usually raises suspicion for the presence of an epidural hematoma, abscess, or traumatic cord lesion. However, in this patient, brain imaging revealed a large, previously undiagnosed intracranial mass. Classically, the risk of mass-related intracranial pressure shifts leading to neurological changes is associated with spinal techniques, including diagnostic lumbar puncture, combined spinal-epidural catheter analgesia, and unintended dural puncture during epidural placement. However, based on this case and our summary of case reports in the literature, we determined that symptom onset associated with an intracranial mass may also arise after apparently uncomplicated epidural placement. Symptom onset in our case series ranged from six hours to ten days and was highly variable depending on tumor location, with reported signs and symptoms including headache, vision changes, focal deficits, or alterations of consciousness. Further studies are required to establish definitive causation between the epidural technique and changes in cerebrospinal fluid pressures leading to symptom onset. Though rare, this is a time-sensitive diagnosis that must be considered for any patient with unexplained neurological findings after neuraxial anesthesia.
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Affiliation(s)
- Morgan A Clond
- Anesthesiology, State University of New York Upstate Medical University, Syracuse, USA
| | - Evin A Koleini
- Anesthesiology, State University of New York Upstate Medical University, Syracuse, USA
| | - Timothy E Richardson
- Pathology, University of Texas Health Science Center at San Antonio, San Antonio, USA
| | - Stephanie A Zyck
- Neurosurgery, State University of New York Upstate Medical University, Syracuse, USA
| | - Vandana Sharma
- Anesthesiology and Pain, State University of New York Upstate Medical University, Syracuse, USA
| | - Mashaal Dhir
- Surgery, State University of New York Upstate Medical University, Syracuse, USA
| | - Fenghua Li
- Anesthesiology, State University of New York Upstate Medical University, Syracuse, USA
| | - Satish Krishnamurthy
- Neurosurgery, State University of New York Upstate Medical University, Syracuse, USA
| | - Sebastian Thomas
- Anesthesiology and Pain, State University of New York Upstate Medical University, Syracuse, USA
| | - Xiuli Zhang
- Anesthesiology, State University of New York Upstate Medical University, Syracuse, USA
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Abstract
We report a case of a 27-year-old obese female presenting with headache, blurry and double vision. She was found to have bilateral papilledema by an ophthalmologist and sent to the emergency department (ED). Cerebrospinal fluid (CSF) analysis showed elevated opening pressure and lymphocytic pleocytosis. Symptoms improved significantly after lumbar puncture (LP). Subsequently, polymerase chain reaction (PCR) for herpes simplex virus-2 (HSV-2) came back positive. This case represents an unusual presentation of HSV-2 meningitis, where the clinical picture was suggestive of pseudotumor cerebri or idiopathic intracranial hypertension (IIH), but CSF analysis revealed HSV-2. Papilledema and elevated intracranial pressure has not previously been described in association with HSV-2. Therefore, patients presenting with typical signs and meeting all diagnostic criteria for IIH in the presence of CSF pleocytosis may represent a distinct group of viral-induced intracranial hypertension. In these cases, an investigation of viral etiologies should be conducted.
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Affiliation(s)
- Robin Sherchan
- Internal Medicine, Northwestern Medicine McHenry Hospital, Rosalind Franklin University of Medicine and Science, McHenry, USA
| | - Jishna Shrestha
- Internal Medicine, Northwestern Medicine McHenry Hospital, Rosalind Franklin University of Medicine and Science, McHenry, USA
| | - Yetunde B Omotosho
- Internal Medicine, Northwestern Medicine McHenry Hospital, Rosalind Franklin University of Medicine and Science, McHenry, USA
| | - Nataliia Dyatlova
- Internal Medicine, Northwestern Medicine McHenry Hospital, Rosalind Franklin University of Medicine and Science, McHenry, USA
| | - Jenie S Nepomuceno
- Internal Medicine, Northwestern Medicine McHenry Hospital, Metro Infectious Disease Consultants, McHenry, USA
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Murray NM, Wolman DN, Mlynash M, Threlkeld ZD, Christensen S, Heit JJ, Harris OA, Hirsch KG. Early Head Computed Tomography Abnormalities Associated with Elevated Intracranial Pressure in Severe Traumatic Brain Injury. J Neuroimaging 2020; 31:199-208. [PMID: 33146933 DOI: 10.1111/jon.12799] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 07/17/2020] [Revised: 09/02/2020] [Accepted: 09/20/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND PURPOSE Intracranial pressure (ICP) monitoring is recommended in severe traumatic brain injury (sTBI), yet invasive monitoring has risks, and many patients do not develop elevated ICP. Tools to identify patients at risk for ICP elevation are limited. We aimed to identify early radiologic biomarkers of ICP elevation. METHODS In this retrospective study, we analyzed a prospectively enrolled cohort of patients with a sTBI at an academic level 1 trauma center. Inclusion criteria were nonpenetrating TBI, age ≥16 years, Glasgow Coma Scale (GCS) score ≤8, and presence of an ICP monitor. Two independent reviewers manually evaluated 30 prespecified features on serial head computed tomography (CTs). Patient characteristics and radiologic features were correlated with elevated ICP. The primary outcome was clinically relevant ICP elevation, defined as ICP ≥ 20 mm Hg on at least 5 or more hourly recordings during postinjury days 0-7 with concurrent administration of an ICP-lowering treatment. RESULTS Among 111 sTBI patients, the median GCS was 6 (interquartile range 3-8), and 45% had elevated ICP. Features associated with elevated ICP were younger age (every 10-year decrease, odds ratio [OR] 1.4), modified Fisher scale (mFS) score at 0-4 hours postinjury (every 1 point, OR 1.8), and combined volume of contusional hemorrhage and peri-hematoma edema (10 ml, OR 1.2) at 4-18 hours postinjury. CONCLUSIONS Younger age, mFS score, and volume of contusion are associated with ICP elevation in patients with a sTBI. Imaging features may stratify patients by their risk of subsequent ICP elevation.
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Affiliation(s)
- Nick M Murray
- Department of Neurology, Stanford University, Stanford, CA
| | - Dylan N Wolman
- Department of Radiology, Stanford University, Stanford, CA
| | | | | | | | - Jeremy J Heit
- Department of Radiology, Stanford University, Stanford, CA
| | - Odette A Harris
- Department of Neurosurgery, Stanford University, Stanford, CA
| | - Karen G Hirsch
- Department of Neurology, Stanford University, Stanford, CA
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Bateman EA, VanderEnde J, Sequeira K, MacKenzie HM. Postural neurologic deficits after decompressive craniectomy: A case series of sinking skin flap syndrome in traumatic brain injury. NeuroRehabilitation 2020; 49:663-672. [PMID: 34744055 DOI: 10.3233/nre-210160] [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] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hemicraniectomy to manage raised intracranial pressure following traumatic brain injury (TBI) has improved survival but may increase the incidence of Sinking Skin Flap Syndrome (SSFS). SSFS is a clinical syndrome in which patients with craniectomy develop objective neurologic abnormalities due to the pressure of the atmosphere on the unprotected brain, often presenting with postural headaches and neurologic deficits that localize to the craniectomy site. Previously thought to be a rare complication of craniectomy after TBI, evidence suggests SSFS is under-recognized. OBJECTIVE To describe the clinical and radiographic features leading to diagnosis and the impact of temporizing and definitive management of SSFS on outcomes in inpatients with moderate/severe TBI. METHODS Two patients' symptoms, qualitative behaviour observation, physical and cognitive outcome measures, and neuroimaging pre- and post-temporizing measures and cranioplasty are presented. RESULTS Both patients demonstrated partial improvements with temporizing measures and substantial improvements in functional, cognitive, physical, and rehabilitation outcomes from the cranioplasty and resolution of SSFS. CONCLUSIONS Rehabilitation care providers are critical to the timely diagnosis and management of SSFS, including the use of temporizing measures and advocacy for definitive treatment with cranioplasty. These cases highlight the diverse clinical presentations and importance of SSFS diagnosis to improve patient outcomes.
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Affiliation(s)
- Emma A Bateman
- Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Parkwood Institute, St Joseph's Health Care London, London, Ontario, Canada
| | - Jordan VanderEnde
- Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Parkwood Institute, St Joseph's Health Care London, London, Ontario, Canada
| | - Keith Sequeira
- Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Parkwood Institute, St Joseph's Health Care London, London, Ontario, Canada
| | - Heather M MacKenzie
- Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Parkwood Institute, St Joseph's Health Care London, London, Ontario, Canada
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12
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Lentz S, Grossman A, Koyfman A, Long B. High-Risk Airway Management in the Emergency Department: Diseases and Approaches, Part II. J Emerg Med 2020; 59:573-585. [PMID: 32591298 DOI: 10.1016/j.jemermed.2020.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 03/11/2020] [Revised: 04/30/2020] [Accepted: 05/04/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Successful airway management is critical to the practice of emergency medicine. Thus, emergency physicians must be ready to optimize and prepare for airway management in critically ill patients with a wide range of physiologic challenges. Challenges in airway management commonly encountered in the emergency department are discussed using a pearl and pitfall discussion in this second part of a 2-part series. OBJECTIVE This narrative review presents an evidence-based approach to airway and patient management during endotracheal intubation in challenging cases commonly encountered in the emergency department. DISCUSSION Adverse events during emergent airway management are common with postintubation cardiac arrest, reported in as many as 1 in 25 intubations. Many of these adverse events can be avoided by proper identification and understanding the underlying physiology, preparation, and postintubation management. Those with high-risk features including trauma, elevated intracranial pressure, upper gastrointestinal bleed, cardiac tamponade, aortic stenosis, morbid obesity, and pregnancy must be managed with airway expertise. CONCLUSIONS This narrative review discusses the pearls and pitfalls of commonly encountered physiologic high-risk intubations with a focus on the emergency clinician.
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Affiliation(s)
- Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Alexandra Grossman
- Department of Emergency Medicine, Harbor-University of California, Los Angeles Medical Center, Torrance, California
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
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13
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Singla A, Mathew PJ, Jangra K, Gupta SK, Soni SL. A Comparison of Hypertonic Saline and Mannitol on Intraoperative Brain Relaxation in Patients with Raised Intracranial Pressure during Supratentorial Tumors Resection: A Randomized Control Trial. Neurol India 2020; 68:141-145. [PMID: 32129263 DOI: 10.4103/0028-3886.279671] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction Hyperosmotic agents are used to decrease intracranial pressure (ICP). We aim to compare the effect of euvolemic solutions of 3% hypertonic saline (HTS) and 20% mannitol on intraoperative brain relaxation in patients with clinical or radiological evidence of raised ICP undergoing surgery for supratentorial tumors. Materials and Methods A. prospective double-blind study was conducted on 30 patients randomized into two equal groups. Each patient was administered 5 ml/kg of either 20% mannitol or 3% HTS over 15 minutes (min) after skin incision. Hemodynamic data, brain relaxation and serum electrolyte levels were recorded. Results Intraoperative brain relaxation was comparable between the two groups. There was a statistically significant difference in the mean arterial pressures (MAPs) between the two groups after one minutes (min) with a greater degree of decrease in blood pressure recorded in the mannitol group (P = 0.041). MAP with mannitol was significantly lower than the preinduction value after 75 min of administration of drug (P = 0.003). Urine output was significantly higher in the mannitol group (P = 0.00). Administration of HTS was associated with a transient increase in serum sodium concentrations, which was statistically significant but returned to normal within 48 h (P < 0.001). Conclusions Both mannitol and HTS provided adequate intraoperative brain relaxation. On the contrary, there was no statistically significant fall in blood pressure with HTS. Thus, we advocate the use of HTS over mannitol as it maintains better hemodynamic stability.
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Affiliation(s)
- Ankush Singla
- Department of Anaesthesia, Adesh Medical College, Bhathinda, Punjab, India
| | - Preethy J Mathew
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kiran Jangra
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil K Gupta
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shiv Lal Soni
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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14
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Oberfoell S, Murphy D, French A, Trent S, Richards D. Inter-rater Reliability of Sonographic Optic Nerve Sheath Diameter Measurements by Emergency Medicine Physicians. J Ultrasound Med 2017; 36:1579-1584. [PMID: 28370143 DOI: 10.7863/ultra.16.05055] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 10/24/2016] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To compare the degree of agreement of sonographic optic nerve sheath diameter (ONSD) measurements by ultrasound fellowship-trained and resident emergency medicine (EM) physicians. METHODS Ten ultrasound fellowship-trained EM attending physicians from multiple institutions and 51 resident EM physicians at a single residency were enrolled to measure the ONSD using a computerized ruler on five separate still-frame sonograms of adult eyes that included the retrobulbar optic nerve. Descriptive and bivariate statistics for each ultrasound image were calculated to compare median ONSD measurements among groups. Intraclass correlation coefficients (ICCs) were calculated to estimate the inter-rater reliability. RESULTS Although the median ONSD measurement of each image did not significantly differ between resident and ultrasound fellowship-trained EM physicians, we found greater variation in agreement of ONSD measurements by resident EM physicians (ICC 0.50; 95% confidence interval 0.25-0.89) than ultrasound fellowship-trained EM physicians (ICC 0.73; 95% confidence interval 0.44-0.96). CONCLUSIONS Although both resident and ultrasound fellowship-trained EM physicians showed good inter-rater reliability of ONSD measurements, variation in agreement among ultrasound fellowship-trained EM physicians may be as wide as 0.44, suggesting that even in skilled hands, ultrasound measurement of the ONSD may not be as dependable a screening tool for elevated intracranial pressure as previously suggested in the literature.
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Affiliation(s)
| | - David Murphy
- University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Andrew French
- University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Denver Health and Hospital Authority, Department of Emergency Medicine, Denver, Colorado, USA
| | - Stacy Trent
- University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Denver Health and Hospital Authority, Department of Emergency Medicine, Denver, Colorado, USA
| | - David Richards
- University of Colorado Denver School of Medicine, Aurora, Colorado, USA
- Denver Health and Hospital Authority, Department of Emergency Medicine, Denver, Colorado, USA
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15
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Abstract
Neurologic complications of cancer are common and are frequently life-threatening events. Certain neurologic emergencies occur more frequently in the cancer population, specifically elevated intracranial pressure, epidural cord compression, status epilepticus, ischemic and hemorrhagic stroke, central nervous system infection, and treatment-associated neurologic dysfunction. These emergencies require early diagnosis and prompt treatment to ensure the best possible outcome and are best managed in the intensive care unit. This article reviews the presentation, pathophysiology, and management of the most common causes of acute neurologic decompensation in the patient with cancer.
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Affiliation(s)
- Andrew L Lin
- 1 Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Edward K Avila
- 1 Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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16
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Abstract
The hydatid cyst (HC) is endemic in Mediterranean region including Syria. The central nervous system is involved in 2–3% of cases. HC in cerebellum is very rare. We report a case that presented as an emergency for high intracranial pressure and deteriorating Glascow coma scale. Close monitoring and precise surgical management using Dowling's technique resulted in very good outcome with full recovery. We highlight the need for very careful surgical treatment because cyst rupture and secondary hydatidosis due to spillage of the cyst contents can dramatically worsen the outcome. HC should be taken into consideration in countries where hydatid infestation is endemic.
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Affiliation(s)
- Fakhr Fakhouri
- Division of Neurosurgery, Department of Surgery, Aleppo University Hospital, Aleppo, Syria
| | - Abdelwahed Ghajar
- Associated Professor of Neurosurgery and Chief of Division of Neurosurgery, Department of Surgery, Aleppo University Hospital, Aleppo, Syria
| | - Nihad Mahli
- Professor of General Surgery and Chief of Department of Surgery, Aleppo University Hospital, Aleppo, Syria
| | - Nihad Shoumal
- Neurosurgery Resident, Division of Neurosurgery, Department of Surgery, Aleppo University Hospital, Aleppo, Syria
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17
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Gilad O, Shefer-Averbuch N, Garty BZ. Primary varicella infection presenting with headache and elevated intracranial pressure. J Child Neurol 2015; 30:793-5. [PMID: 24846901 DOI: 10.1177/0883073814535500] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [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: 11/10/2013] [Accepted: 04/19/2014] [Indexed: 11/17/2022]
Abstract
Primary varicella infection may be associated with neurologic complications, such as cerebritis and meningoencephalitis. Several cases of varicella infection with elevated intracranial pressure have been reported. We describe a 13-year-old immunocompetent girl who presented with a clinical picture of headaches and elevated intracranial pressure as the only manifestation of primary varicella zoster infection. The working diagnosis at first was pseudotumor cerebri based on complaints of headache of 2 weeks' duration, in addition to vomiting and papilledema, without fever or skin eruption. On lumbar puncture, opening pressure was 420 mmH2O, but mild pleocytosis and mildly elevated protein level ruled out the diagnosis of pseudotumor cerebri. Our patient had no history of previous varicella infection, and she did not receive the varicella zoster vaccine. Serology tests, done on admission and repeated 2 months later, suggested primary varicella infection. The literature on varicella infection associated with pseudotumor cerebri or elevated intracranial pressure is reviewed.
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Affiliation(s)
- Oded Gilad
- Department of Pediatrics, Schneider Children's Medical Center of Israel, Petach Tikva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noa Shefer-Averbuch
- Department of Pediatrics, Schneider Children's Medical Center of Israel, Petach Tikva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ben Zion Garty
- Department of Pediatrics, Schneider Children's Medical Center of Israel, Petach Tikva, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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