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Robba C, Cardim D, Donnelly J, Bertuccio A, Bacigaluppi S, Bragazzi N, Cabella B, Liu X, Matta B, Lattuada M, Czosnyka M. Effects of pneumoperitoneum and Trendelenburg position on intracranial pressure assessed using different non-invasive methods. Br J Anaesth 2018; 117:783-791. [PMID: 27956677 DOI: 10.1093/bja/aew356] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The laparoscopic approach is becoming increasingly frequent for many different surgical procedures. However, the combination of pneumoperitoneum and Trendelenburg positioning associated with this approach may increase the patient's risk for elevated intracranial pressure (ICP). Given that the gold standard for the measurement of ICP is invasive, little is known about the effect of these common procedures on ICP. METHODS We prospectively studied 40 patients without any history of cerebral disease who were undergoing laparoscopic procedures. Three different methods were used for non-invasive estimation of ICP: ultrasonography of the optic nerve sheath diameter (ONSD); transcranial Doppler-based (TCD) pulsatility index (ICPPI); and a method based on the diastolic component of the TCD cerebral blood flow velocity (ICPFVd). The ONSD and TCD were measured immediately after induction of general anaesthesia, after pneumoperitoneum insufflation, after Trendelenburg positioning, and again at the end of the procedure. RESULTS The ONSD, ICPFVd, and ICPPI increased significantly after the combination of pneumoperitoneum insufflation and Trendelenburg positioning. The ICPFVd showed an area under the curve of 0.80 [95% confidence interval (CI) 0.70-0.90] to distinguish the stage associated with the application of pneumoperitoneum and Trendelenburg position; ONSD and ICPPI showed an area under the curve of 0.75 (95% CI 0.65-0.86) and 0.70 (95% CI 0.58-0.81), respectively. CONCLUSIONS The concomitance of pneumoperitoneum and the Trendelenburg position can increase ICP as estimated with non-invasive methods. In high-risk patients undergoing laparoscopic procedures, non-invasive ICP monitoring through a combination of ONSD ultrasonography and TCD-derived ICPFVd could be a valid option to assess the risk of increased ICP.
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Affiliation(s)
- C Robba
- Neurosciences Critical Care Unit, Box 1, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK .,Department of Anaesthesiology, Mura delle Cappuccine 16, 16100 Galliera Hospital, Genoa, Italy
| | - D Cardim
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Hills Road, Cambridge CB2 0QQ, UK
| | - J Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Hills Road, Cambridge CB2 0QQ, UK
| | - A Bertuccio
- Division of Neurosurgery, Department of Clinical Neurosciences, St George's Hospital, University of London, London, UK
| | - S Bacigaluppi
- Department of Neurosurgery, Galliera Hospital, Mura delle Cappuccine 16, 16100 University of Genoa, Genoa, Italy
| | - N Bragazzi
- School of Public Health, Department of Health Sciences (DISSAL), Via Antonio Pastore 1, University of Genoa, Genoa 16132, Italy
| | - B Cabella
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Hills Road, Cambridge CB2 0QQ, UK
| | - X Liu
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Hills Road, Cambridge CB2 0QQ, UK
| | - B Matta
- Neurosciences Critical Care Unit, Box 1, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - M Lattuada
- Department of Anaesthesiology, Mura delle Cappuccine 16, 16100 Galliera Hospital, Genoa, Italy
| | - M Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Hills Road, Cambridge CB2 0QQ, UK
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Robba C, Bacigaluppi S, Cardim D, Donnelly J, Bertuccio A, Czosnyka M. Non-invasive assessment of intracranial pressure. Acta Neurol Scand 2016; 134:4-21. [PMID: 26515159 DOI: 10.1111/ane.12527] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2015] [Indexed: 11/29/2022]
Abstract
Monitoring of intracranial pressure (ICP) is invaluable in the management of neurosurgical and neurological critically ill patients. Invasive measurement of ventricular or parenchymal pressure is considered the gold standard for accurate measurement of ICP but is not always possible due to certain risks. Therefore, the availability of accurate methods to non-invasively estimate ICP has the potential to improve the management of these vulnerable patients. This review provides a comparative description of different methods for non-invasive ICP measurement. Current methods are based on changes associated with increased ICP, both morphological (assessed with magnetic resonance, computed tomography, ultrasound, and fundoscopy) and physiological (assessed with transcranial and ophthalmic Doppler, tympanometry, near-infrared spectroscopy, electroencephalography, visual-evoked potentials, and otoacoustic emissions assessment). At present, none of the non-invasive techniques alone seem suitable as a substitute for invasive monitoring. However, following the present analysis and considerations upon each technique, we propose a possible flowchart based on the combination of non-invasive techniques including those characterizing morphologic changes (e.g., repetitive US measurements of ONSD) and those characterizing physiological changes (e.g., continuous TCD). Such an integrated approach, which still needs to be validated in clinical practice, could aid in deciding whether to place an invasive monitor, or how to titrate therapy when invasive ICP measurement is contraindicated or unavailable.
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Affiliation(s)
- C. Robba
- Neurosciences Critical Care Unit; Addenbrooke's Hospital; Cambridge United Kingdom
- Brain Physics Lab; Division of Neurosurgery; Department of Clinical Neurosciences; University of Cambridge; United Kingdom
| | - S. Bacigaluppi
- Department of Neurosurgery; Galliera Hospital; Genova Italy
| | - D. Cardim
- Brain Physics Lab; Division of Neurosurgery; Department of Clinical Neurosciences; University of Cambridge; United Kingdom
| | - J. Donnelly
- Brain Physics Lab; Division of Neurosurgery; Department of Clinical Neurosciences; University of Cambridge; United Kingdom
| | - A. Bertuccio
- Department of Neurosurgery; S. George's Hospital; University of London; United Kingdom
| | - M. Czosnyka
- Brain Physics Lab; Division of Neurosurgery; Department of Clinical Neurosciences; University of Cambridge; United Kingdom
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Robba C, Bacigaluppi S, Cardim D, Donnelly J, Sekhon MS, Aries MJ, Mancardi G, Booth A, Bragazzi NL, Czosnyka M, Matta B. Intraoperative non invasive intracranial pressure monitoring during pneumoperitoneum: a case report and a review of the published cases and case report series. J Clin Monit Comput 2015; 30:527-38. [PMID: 26342642 DOI: 10.1007/s10877-015-9765-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [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: 04/22/2015] [Accepted: 09/01/2015] [Indexed: 11/30/2022]
Abstract
Non-invasive measurement of ICP (nICP) can be warranted in patients at risk for developing increased ICP during pneumoperitoneum (PP). Our aim was to assess available data on the application of nICP monitoring during these procedures and to present a patient assessed with an innovative combination of noninvasive tools. Literature review of nICP assessment during PP did not find any studies comparing different methods intraprocedurally and only few studies of any nICP monitoring were available: transcranial Doppler (TCD) studies used the pulsatility index (PI) as an estimator of ICP and failed to detect a significant ICP increase during PP, whereas two out of three optic nerve sheath diameter (ONSD) studies detected a statistically significant ICP increase. In the case study, we describe a 52 year old man with a high grade thalamic glioma who underwent urgent laparoscopic cholecystectomy. Considering the high intraoperative risk of developing intracranial hypertension, he was monitored through parallel ONSD ultrasound measurement and TCD derived formulae (flow velocity diastolic formula, FVdnICP, and PI). ONSD and FVdnICP methods indicated a significant ICP increase during PP, whereas PI was not significantly increased. Our experience, combined with the literature review, seems to suggest that PI might not detect ICP changes in this context, however we indicate a possible interest of nICP monitoring during PP by means of ONSD and of TCD derived FVdNICP, especially for patients at risk for increased ICP.
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Affiliation(s)
- C Robba
- Neurosciences Critical Care Unit, Cambridge University Hospitals NHS Foundation Trust, Box 1, Hills Road, Cambridge, CB2 0QQ, UK.
| | - S Bacigaluppi
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - D Cardim
- Department of Neurosurgery, Galliera Hospital, University of Genoa, Genoa, Italy
| | - J Donnelly
- Department of Neurosurgery, Galliera Hospital, University of Genoa, Genoa, Italy
| | - M S Sekhon
- Department of Medicine, Division of Critical Care Medicine, Vancouver General Hospital, Vancouver, Canada
| | - M J Aries
- Department of Critical Care, University of Groningen, Groningen, The Netherlands
| | - G Mancardi
- Section of Neurology, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - A Booth
- Neurosciences Critical Care Unit, Cambridge University Hospitals NHS Foundation Trust, Box 1, Hills Road, Cambridge, CB2 0QQ, UK
| | - N L Bragazzi
- Department of Health Sciences (DISSAL), School of Public Health, University of Genoa, Genoa, Italy
| | - M Czosnyka
- Department of Neurosurgery, Galliera Hospital, University of Genoa, Genoa, Italy
| | - B Matta
- Neurosciences Critical Care Unit, Cambridge University Hospitals NHS Foundation Trust, Box 1, Hills Road, Cambridge, CB2 0QQ, UK
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Fontanella M, Bacigaluppi S. Treatment of cerebral cavernous malformations: where do we stand? J Neurosurg Sci 2015; 59:199-200. [PMID: 25971231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- M Fontanella
- Department of Neurosurgery, Spedali Civili di Brescia University of Brescia, Brescia, Italy -
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Cigoli MS, De Benedetti S, Marocchi A, Bacigaluppi S, Primignani P, Gesu G, Citterio A, Tassi L, Mecarelli O, Pulitano P, Penco S. A Novel MGC4607/CCM2 Gene Mutation Associated with Cerebral Spinal and Cutaneous Cavernous Angiomas. J Mol Neurosci 2015; 56:602-7. [PMID: 25869611 DOI: 10.1007/s12031-015-0555-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 03/24/2015] [Indexed: 10/23/2022]
Abstract
Cerebral cavernous malformations (CCMs) are vascular abnormalities that may cause seizures, headaches, intracerebral hemorrhages, and focal neurological deficits; they can also be clinically silent and occur as a sporadic or an autosomal dominant condition. Three genes have been identified as causing familial CCM: KRIT1/CCM1, MGC4607/CCM2, and PDCD10/CCM3, mapping, respectively, on chromosomes 7q, 7p, and 3q. Here, we report an Italian family affected by CCM due to a MGC4607 gene mutation, on exon 4. All the affected subjects suffered from seizures, and some of them underwent surgery for removal of a cavernous angioma. Brain MRI showed multiple lesions consistent with CCMs in all patients. Spinal and cutaneous cavernous angiomas were present too. This report underlines the need for a careful interdisciplinarity among neurologists, neuroradiologists, neurosurgeons, geneticists, ophthalmologists, and dermatologists for a total evaluation of the different manifestations of familial CCM. This points out that only referral centers are organized to offer a multidisciplinary management of this disease.
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Affiliation(s)
- M S Cigoli
- Department of Laboratory Medicine - Medical Genetics Unit, Niguarda Ca' Granda Hospital, Milano, Italy
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Bergomi R, Panciani PP, Bogna A, Fazio M, Spanu F, Bacigaluppi S, Fontanella MM. Minimally invasive transforaminal interbody fusion: a single center experience. J Neurosurg Sci 2014; 58:29-33. [PMID: 25371945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Fontanella MM, Fazio M, Francione A, Bacigaluppi S, Griva F, Visocchi M, Panciani PP, Bergomi R, Spena G. Pre-symptomatic cervical myelopathy: should we operate or should we observe? What is the chance of spinal cord injury from an accident? J Neurosurg Sci 2014; 58:15-22. [PMID: 25371943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Bacigaluppi S, Retta SF, Pileggi S, Fontanella M, Goitre L, Tassi L, La Camera A, Citterio A, Patrosso MC, Tredici G, Penco S. Genetic and cellular basis of cerebral cavernous malformations: implications for clinical management. Clin Genet 2013; 83:7-14. [DOI: 10.1111/j.1399-0004.2012.01892.x] [Citation(s) in RCA: 26] [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] [Indexed: 01/13/2023]
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Bacigaluppi S, Bacigaluppi M, Tredici G. Solitary demyelinating plaques mimicking brain tumors: A tricky similarity. J Postgrad Med 2010; 56:254-6. [DOI: 10.4103/0022-3859.70928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Bacigaluppi S, Rusconi R, Rampini P, Annoni F, Zavanone ML, Carnelli V, Gaini SM. Vertebral artery dissection in a child. Is “spontaneous” still an appropriate definition? Neurol Sci 2006; 27:364-8. [PMID: 17122949 DOI: 10.1007/s10072-006-0712-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2006] [Accepted: 09/19/2006] [Indexed: 11/28/2022]
Abstract
Though a rare cause of stroke in the general population, in almost one quarter of young patients affected by stroke cervical artery dissection (CAD) is the underlying cause. Among these cases "spontaneous" dissections, intended as non-traumatic, represent about 34% of posterior circulation arterial dissection in patients aged less than 18 years. We here describe the case of a seven-year-old boy who developed a spontaneous vertebral artery dissection (VAD) leading to occipito-mesial, thalamo-capsular and cerebellar infarction. Once a traumatic origin was excluded, clinical history and laboratory findings were further analysed: fever associated with tonsillitis during the previous week, raised inflammatory indices, a throat culture positive for beta haemolysing Streptococcus group A and high titres of streptococcal antibodies were found. This case suggests that patients with CAD referred as spontaneous deserve extensive analysis. Subjects presenting with a dissection and an underlying infection are likely to have a hyperinflammatory response (although further experience is needed). In these patients immediate start of antibiotic therapy, treatment with anti-inflammatory drugs and further a lifelong prophylaxis with antibiotics before any invasive procedure are strongly recommended.
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Affiliation(s)
- S Bacigaluppi
- Department of Neurosurgery, Università degli Studi di Milano, Ospedale Policlinico, Mangiagalli e Regina Elena, Fondazione I.R.C.C.S., Via Sforza 35, I-20122 Milan, Italy.
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Piccinelli M, Boccardi E, Bacigaluppi S, Venezani A, Ene-lordache B, Remuzzi A, Antiga L. Computational geometric analysis of cerebral aneurysms and their parent vasculature from CRA. J Biomech 2006. [DOI: 10.1016/s0021-9290(06)84468-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Veneziani A, Boccardi E, Antiga L, Piccinelli M, Secchi P, Vantini S, Passerini T, De Luca M, Bacigaluppi S. Statistical and numerical investigations of cerebral aneurysms' morphology and haemodynamics. J Biomech 2006. [DOI: 10.1016/s0021-9290(06)84124-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Piccinelli M, Boccardi E, Bacigaluppi S, Venezani A, Ene-lordache B, Remuzzi A, Antiga L. Influence of siphon bends on the flow patterns of the internal carotid artery: implications for the study of aneurysm development. J Biomech 2006. [DOI: 10.1016/s0021-9290(06)84762-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Riva M, Bacigaluppi S, Galli C, Citterio A, Collice M. Primary leptomeningeal gliomatosis: case report and review of the literature. Neurol Sci 2005; 26:129-34. [PMID: 15995830 DOI: 10.1007/s10072-005-0446-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2004] [Accepted: 03/31/2005] [Indexed: 10/25/2022]
Abstract
A 62-year-old woman developed dysphasia, signs of intracranial hypertension and seizures. An MRI scan evidenced extra-axial contrast enhancement in the absence of mass lesions. CSF analysis was negative for malignant cytology and viral or bacterial microbiology. In the absence of other evidence, considering the acute clinical onset and MRI picture, a viral encephalitis was suspected and antiviral therapy was started, however, with no effect. Death occurred three weeks after presentation because of acute brain swelling. Autopsy revealed leptomeningeal gliomatosis and diffuse parenchymal infiltration at the cerebellar and left temporal lobe. Primary leptomeningeal gliomatosis (PLMG) is a rare event. The reported case and the reviewed literature evidence that clinical signs at presentation are non-specific, CSF negative findings are common, the diagnosis is always delayed and the prognosis dismal.
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Affiliation(s)
- M Riva
- Department of Neurosciences, Niguarda Ca'Granda Hospital, Piazza Ospedale Maggiore 3, I-20162 Milan, Italy.
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Abstract
The surgical treatment of intracerebral hemorrhage (ICH) is one of the most controversial areas of neurosurgery. Randomized trials are inconclusive due to the small number of patients enrolled or because performed in pre CT era. We analyze the 232 patients admitted to the Niguarda Hospital of Milano, Italy, for ICH during the period January 2001-December 2002. Sixty patients were operated: 29 had secondary haemorrhage, and 30 a primary one. The strategy followed in these patients is presented. The series suggests that indication to surgery is a complex process including several factors that have to be all considered in each patient.
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Affiliation(s)
- M Collice
- U. O. di Neurochirurgia, Ospedale Niguarda Ca'Granda, Milan, Italy.
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