Long-Term Follow-up of Patients with Post-Traumatic Refractory High Intracranial Pressure Treated with Lumbar Drainage

Drainage of cerebrospinal fluid by means of external lumbar drainage (ELD) is controversial in the adult population with traumatic brain injury. We report our experience with ELD in the treatment of post-traumatic high intracranial pressure (ICP) and the results of the long-term follow-up in these patients.

We undertook clinical evaluation of 30 patients with traumatic brain injury and high ICP treated with second-tier measures or with first-tier measures if second-tier measures were contraindicated. The study involved a retrospective review of collected data. Outcome at intensive care unit discharge and three to five years after injury were evaluated with the Glasgow Outcome Scale.

The mean age of patients was 34.9±12.5 years and 25 (83%) were male. The median (interquartile range) Glasgow Coma score was 8 (7 to 10). ICP before and one hour after ELD placement was 33.7±9.0 and 12.5±4.8 mmHg respectively, a decrease in 21.2±8.3 mmHg (P <0.0001). ELD was placed after a mean of 8.6±3.9 days. Cerebrospinal fluid drainage was maintained for a mean of 6.6±3.5 days. Four patients (13%) required ELD replacement and one patient developed a cerebrospinal fluid infection (3%). No pupillary changes were noted within 48 hours of ELD placement. Long-term outcome was favourable (good recovery or moderate disability) in 62% of the patients studied.

The use of ELD resulted in a marked decrease in ICP. These patients presented a good outcome in 62% of the cases in the long-term evaluation. Few complications related with ELD use were noted.

Correlation between brain interstitial and total serum cortisol levels in traumatic brain injury. A preliminary study

INTRODUCTION

Brain cortisol availability has never been evaluated in patients with traumatic brain injury (TBI). Cerebral microdialysis is a well-established technique for monitoring brain metabolism in neurocritically ill patients, which may be used to measure interstitial cortisol. The objective of this preliminary study was to measure brain interstitial cortisol and its correlation with total serum cortisol in patients with TBI.

METHODS

We prospectively studied 6 patients with severe TBI admitted to the Intensive Care Unit of our tertiary University Hospital in which multimodal neuromonitoring including cerebral microdialysis with a high cut-off of 100 k-Da and 20-mm long membrane was used. Serum and brain interstitial cortisol microdialysis samples were obtained every 8 h and analyzed afterwards.

RESULTS

Linear regression analysis of total serum cortisol and brain interstitial cortisol in the whole population showed a moderate correlation (R2=0.538, p<0.001, no.=118). However, intra-individual correlation showed a great variability, with correlation coefficients ranging from a R2=0.091 to R2=0.680.

CONCLUSION

Our prospective and preliminary study showed a moderate correlation of brain interstitial cortisol and total serum cortisol values in patients with diffuse TBI. However, intra-individual analysis showed a great variability. These results suggest that total serum cortisol may not reflect brain cortisol availability in half of TBI patients.

[Cerebral hemodynamics in patients with traumatic brain injury evaluated by transcranial Doppler and transcranial color coded sonography. A comparison study]

OBJECTIVE

To compare the number of vessels identified and mean velocity and pulsatility index values obtained by transcranial doppler (TCD) and transcranial color coded sonography (TCCS) in patients with traumatic brain injury (TBI).

METHODS

Thirty patients suffering from TBI admitted in our neurocritical Intensive Care Unit (ICU) were studied. We performed consecutive studies by TCD and TCCS. The number of Circle of Willis vessels insonated and the hemodynamic parameters were compared.

RESULTS

Mean age was 50 years. Twenty patients were male. By using TCCS, internal carotid artery was insonated in 95%, middle cerebral artery (MCA) in 95%, anterior cerebral artery (ACA) in 91% and posterior cerebral artery (PCA) in 92% of the studies. Using conventional TCD they were insonated in 29%, 93% 67% and 35% of the studies respectively. Mean velocity values measured by CCS and TCD in MCA were 79 cm/sec vs 59 cm/sec respectively (p< 0.0001), in ACA were 61 cm/sec vs 42 cm/sec (p< 0.0001) and in PCA were 43 cm/sec vs 33 cm/sec (p< 0.0001).

CONCLUSION

TCCS allows a high quality hemodynamic study of TBI patients admitted to the ICU. Further studies must define its impact on outcome of TBI patients.

Effect of barbiturate coma on adrenal response in patients with traumatic brain injury

INTRODUCTION

Barbiturate coma is the second tier measure recommended by guidelines to treat post-traumatic refractory intracranial pressure. Systemic hypotension is its most important side effect. Recent evidence suggests that low-dose corticosteroid therapy may be used in a subset of patients with traumatic brain injury (TBI) to avoid hypotension. We evaluated adrenal function in TBI patients undergoing barbiturate coma, as treatment of their refractory intracranial hypertension.

MATERIALS AND METHODS

We prospectively studied 40 patients with moderate to severe TBI. Group A (17 patients) were treated with barbiturate coma. Group B (23 patients) presented intracranial hypertension controlled with first tier measures, and acted as a control. Adrenal function was evaluated by using the high-dose corticotropin stimulation test within 24 h after brain injury and after barbiturate coma induction.

RESULTS

Within 24 h after TBI, adrenal function was similar in both groups. Once barbiturate coma was induced, patients in group A treated with barbiturate coma presented a higher incidence of adrenal insufficiency compared with the control group B (53% vs 22%, p=0.03). Patients treated with barbiturates, who developed adrenal impairment, required higher doses of norepinephrine to maintain cerebral perfusion pressure than patients treated with barbiturates without adrenal impairment (1.07+/-1.04 microg/kg/min vs 0.31+/-0.32 mug/kg/min, p=0.03).

CONCLUSIONS

Patients with TBI treated with barbiturate coma are at higher risk of developing adrenal insufficiency. This subset of patients presented higher requirements of vasoactive support to avoid hypotension. In these patients corticosteroid therapy may have potential therapeutic implications to treat hemodynamic instability.

Diagnóstico precoz no invasivo de la fístula carótido-cavernosa postraumática por dúplex transcraneal color. Análisis de 4 pacientes

Posttraumatic carotid-cavernous fistula (PtCCF) is an uncommon complication after cranioencephalic trauma. It is usually diagnosed with a cerebral arteriography when the clinical symptoms have already appeared. The transcranial color-coded duplex sonography (TCDS) is a non-invasive technique at the patient's bedside that permits visualization of the circle of Willis and the intracavernous segment of the internal carotid artery. The initial sonographic patterns that suggest the presence of a PtCCF by TCDS are a mosaic image in color mode, presence of arterial and venous flows mixed with high velocity and low resistances. We present our experience in the early and non-invasive diagnosis of PtCFF in an Intensive Care Unit.

[Comparison of the effectiveness of pentobarbital and thiopental in patients with refractory intracranial hypertension. Preliminary report of 20 patients]

OBJECTIVE

To assess the effectiveness of pentobarbital and thiopental to control raised intracranial pressure (ICP), refractory to first level measures, in patients with severe traumatic brain injury.

MATERIAL AND METHODS

Prospective, randomized study to compare the effectiveness between two treatments: pentobarbital and thiopental. The patients will be selected from those admitted to the Intensive Care Unit with a severe traumatic brain injury (postresuscitation Glasgow Coma Scale equal or less than 8 points) and raised ICP (ICP>20 mmHg) refractory to first level measures according to the Brain Trauma Foundation guidelines. The adverse effects of both treatments were also collected.

RESULTS

We present the results of the first 20 patients included. Ten received pentobarbital and the other ten thiopental. There were no statistically significance differences in patients'characteristics (age, sex, severity of the trauma at admission and comorbilities). There were no differences between both groups neither in the Glasgow Coma Scale at admission (thiopental six points; pentobarbital seven points; P=0.26) nor in the admission Cranial Tomography, according to the Traumatic Coma Data Bank Classification. Thiopental treatment controlled raised ICP in five cases and pentobarbital in two cases (P=0.16). Five patients in the thiopental group died and eight in the pentobarbital group (P=0.16). There were no statistically differences between both groups regarding to the presence of hypotension (P=1) or infectious complications.

CONCLUSIONS

These preliminary results indicate that thiopental could be more effective than pentobarbital in patients with refractory intracranial hypertension. These results support previous experimental findings that show that both treatments are not equal and justify to continue this study.

Jugular venous oxygen monitoring: a helpful technique in the early diagnosis of a traumatic carotid-cavernous sinus fistula

This report describes the early diagnosis of a right traumatic carotid-cavernous sinus fistula (CCSF) in a patient with head injury manifested as an acute increase in right jugular venous oxygen saturation and with no ophthalmic clinical signs. High values of jugular venous oxygen saturation must be cautiously interpreted with the clinical examination and computed tomographic findings to establish an accurate diagnosis of hyperemia with or without a CCSF.

Wedge pulmonary angiography to determine the accuracy of pulmonary wedge pressure

Wedge pulmonary angiography was done in 11 patients with acute respiratory failure, to assess the accuracy of pulmonary arterial wedge pressure (WP) as an estimation of left ventricular end-diastolic pressure (LVEDP). The pulmonary artery (PA) catheter tip was placed into a dependent position in the lungs. Although the pulmonary vein was not visualized in 7 of 11 patients, in no case was there a significant difference between WP and LVEDP. When WP is no greater than 15 mm Hg, wedge pulmonary angiography does not reflect the accuracy of WP; however, left ventricular filling pressure can be accurately estimated by WP in most of these patients.