The influence of hemodialysis on intracranial pressure waveform in patients with chronic kidney disease: an observational study

ABSTRACT BACKGROUND: Among the complications related to chronic kidney disease (CKD), those of a neurological nature stand out, and for a better quality of life for patients, the diagnosis and treatment of these complications is fundamental. OBJECTIVES: This study aimed to assess the effect of hemodialysis on intracranial pressure waveform (ICPw) in patients with chronic kidney disease undergoing hemodialysis and those who are not yet undergoing substitutive therapy. DESIGN AND SETTING: An observational study was conducted in two stages at a kidney replacement therapy center in Brazil. The first was a longitudinal study and the second was a cross-sectional study. METHODS: Forty-two patients on hemodialysis were included in the first stage of the study. In the second stage, 226 participants were included. Of these, 186 were individuals with chronic kidney disease (who were not undergoing substitutive therapy), and 40 did not have the disease (control group). The participants' intracranial compliance was assessed using the non-invasive Brain4care method, and the results were compared between the groups. RESULTS: There was a significant difference between the hemodialysis and non-hemodialysis groups, with the former having better ICPw conditions. CONCLUSIONS: Hemodialysis influenced the improvement in ICPw, probably due to the decrease in the patients' extra-and intracellular volumes. Furthermore, ICPw monitoring can be a new parameter to consider when defining the moment to start substitutive therapy.

Age as a predictive factor for reduced intracranial compliance in patients with headache / Idade como fator preditor de complacência intracraniana reduzida em pacientes com cefaleia

Abstract Background Increased intracranial pressure (ICP) consists of a set of signs and symptoms related to changes in intracranial compliance (ICC) and ICP. Objective This study presents a retrospective analysis of patients who underwent non-invasive monitoring of ICC based on complaints of headache, correlating decreased brain compliance and increased intracranial pressure. Methods Noninvasive ICC monitoring was performed using a Brain4care device, which contains a strain gauge and a recorder connected to a mechanical device that touches the scalp surface in the frontoparietal area lateral to the sagittal suture. This tool monitors the ICP by identifying small changes in skull measurements that are caused by pressure variations, i.e., skull deformation is associated with the detection of changes in mean ICP. A clinical evaluation of 32 patients with complaints of headache occurred from the analysis of their medical records. Results Of the 32 patients initially chosen, it was possible to complete the analysis of 18 due to the availability of data in the medical records. From the non-invasive monitoring of the ICC, the following data were collected: time-to-peak, P2/P1 ratio, age, and gender. From the statistical analysis of age and P2/P1 ratio, it was noted that as age increases, ICC tends to decrease regardless of sex (p < 0.05). Conclusion This study concluded that there is a correlation between changes in intracranial compliance and headache complaints in outpatients. There was also a relationship between age and decreased intracranial compliance but without a specific pain pattern.

Resumo Antecedentes O aumento da pressão intracraniana (PIC) consiste em um conjunto de sinais e sintomas relacionados a mudanças na complacência intracraniana (CIC) e na PIC. Objetivo Este estudo apresenta uma análise retrospectiva de pacientes que foram submetidos ao monitoramento não invasivo da CIC com base em queixas de cefaleia, correlacionando a diminuição da complacência cerebral e o aumento da pressão intracraniana. Métodos O monitoramento não invasivo da CIC foi realizado utilizando um dispositivo Brain4Care, que contém um medidor de tensão e um gravador conectado a um dispositivo mecânico que toca a superfície do couro cabeludo na área frontoparietal lateral à sutura sagital. Esta ferramenta monitora a PIC identificando pequenas alterações nas medidas do crânio que são causadas por variações de pressão, ou seja, a deformação do crânio está associada à detecção de alterações na PIC média. Uma avaliação clínica de 32 pacientes com queixas de cefaleia ocorreu a partir da análise de seus prontuários médicos. Resultados Dos 32 pacientes inicialmente escolhidos, foi possível concluir a análise de 18 devido à disponibilidade de dados nos prontuários médicos. A partir do monitoramento não invasivo da CIC, foram coletados os seguintes dados: time-to-peak, relação P2/P1, idade e sexo. Da análise estatística de idade e relação P2/P1, observou-se que à medida em que a idade aumenta, a CIC tende a diminuir independentemente do sexo (p < 0,05). Conclusão Este estudo concluiu que existe uma correlação entre as mudanças na CIC e a queixa de cefaleia em pacientes ambulatoriais. Houve também uma relação entre idade e diminuição da CIC, mas sem um padrão de dor específico.

Relationship between prehospital clinical status intracranial pressure and outcomes in pediatric patients with severe head trauma

Introduction: The prehospital phase of the management of pediatric severe traumatic brain injury may have a direct influence on the results. Objective: To evaluate the influence of prehospital variables on intracranial pressure and the results in pediatric patients with severe TBI. Method: A descriptive study of 41 pediatric patients who were admitted to the medical emergency department and later admitted to the pediatric intensive care unit due to severe head trauma was carried out between January 2003 and December 2018. Results: children aged 5-17 years predominate, and the highest number of cases were received between 0-3h at the neurotrauma center. Of the 41 cases, 27 arrived with a non-expedited airway and hypoxia was verified upon arrival by pulse oximetry. A correlation was observed between arterial hypotension on admission and elevated intracranial pressure in 9 of 15 children (60%) and in the deceased (40%). Discussion: Clinical conditions, oxygenation, arterial hypotension, and treatment in the prehospital phase may influence the state of intracranial pressure and other intracranial variables in pediatric patients with severe head injury.

Introducción: La fase prehospitalaria del manejo del traumatismo craneoencefálico grave pediátrico puede tener una influencia directa en los resultados. Objetivo: Evaluar la influencia de variables prehospitalarias sobre la presión intracraneal y los resultados en pacientes pediátricos con TCE grave. Metodología: Se realizó un estudio descriptivo de 41 pacientes pediátricos que ingresaron al servicio de urgencias médicas y posteriormente ingresaron a la unidad de cuidados intensivos pediátricos por traumatismo craneoencefálico severo entre enero de 2003 y diciembre de 2018. Resultados: predominan los niños de 5 a 17 años, y el mayor número de casos se recibieron entre las 0-3h en el centro de neurotrauma. De los 41 casos, 27 llegaron con vía aérea no acelerada y se verificó hipoxia al llegar mediante oximetría de pulso. Se observó correlación entre hipotensión arterial al ingreso y presión intracraneal elevada en 9 de 15 niños (60%) y en los fallecidos (40%). Discusión: Las condiciones clínicas, la oxigenación, la hipotensión arterial y el tratamiento en la fase prehospitalaria pueden influir en el estado de la presión intracraneal y otras variables intracraneales en pacientes pediátricos con traumatismo craneoencefálico grave.

Ecografía de nervio óptico para estimar hipertensión intracraneal en pacientes adultos con neurotrauma

Introducción: El neurotrauma es una condición que puede dar paso a una hipertensión intracraneana, situación que es muy grave. Los métodos diagnósticos de elección son los invasivos, aun así, los no invasivos y entre ellos la ecografía del nervio óptico, ofrecen muchísimas ventajas. Objetivo: Describir elementos esenciales de la ecografía de nervio óptico como método para diagnosticar hipertensión intracraneal en pacientes adultos con neurotrauma. Métodos: Se hizo una revisión de la literatura más reciente sin restricción lingüística o geográfica en las bases de datos PubMed y SciELO, se usaron términos afines al tema del artículo y se realizó una valoración crítica sobre la bibliografía consultada. Resultados: La literatura disponible sobre la ecografía del nervio óptico en la determinación de la hipertensión intracraneal es abundante y la mayoría apunta a sus beneficios como método no invasivo. La principal debilidad del mismo es que no es capaz de dar un valor exacto y esto se debe a que el valor normal del diámetro de la vaina del nervio óptico por cada persona puede variar significativamente. La proporción directa entre el diámetro de la vaina del nervio óptico y la presión intracraneal es un hecho que ningún autor intenta invalidar. Conclusiones: La ecografía del nervio óptico es un método seguro, accesible económicamente, no invasivo, fácil de usar y con un valor predictivo confiable para determinar la hipertensión intracraneal.

Introduction: Neurotrauma is a condition that can lead to intracranial hypertension, which is a very serious situation. The diagnostic methods of choice are the invasive ones, even so, the non-invasive ones offer many advantages, the ultrasound of the optic nerve is among them. Objective: To describe essential elements of optic nerve ultrasound as a method to diagnose intracranial hypertension in adult patients with neurotrauma. Methods: A review of the most recent literature was made without linguistic or geographical restrictions in databases such as PubMed and SciELO, terms related to the theme of the manuscript were used. A critical assessment of the consulted bibliography was made. Results: The available literature on optic nerve ultrasound in the determination of intracranial hypertension is abundant and most points to the benefits as a non-invasive method. However, its main weakness lies in the fact that it is not capable of giving an exact value, due to the fact that the normal value of the diameter of the optic nerve sheath for each person can vary significantly. The direct relationship between optic nerve sheath diameter and intracranial pressure is a fact that no author attempts to invalidate. Conclusions: Optic nerve ultrasound is a safe, affordable, non-invasive, easy-to-use method with a reliable predictive value to determine intracranial hypertension.

The use of noninvasive measurements of intracranial pressure in patients with traumatic brain injury: a narrative review / Avaliação não invasiva da pressão intracraniana em pacientes com traumatismo cranioencefálico: uma revisão narrativa

Abstract Background The most frequent cause of death in neurosurgical patients is due to the increase in intracranial pressure (ICP); consequently, adequate monitoring of this parameter is extremely important. Objectives In this study, we aimed to analyze the accuracy of noninvasive measurement methods for intracranial hypertension (IH) in patients with traumatic brain injury (TBI). Methods The data were obtained from the PubMed database, using the following terms: intracranial pressure, noninvasive, monitoring, assessment, and measurement. The selected articles date from 1980 to 2021, all of which were observational studies or clinical trials, in English and specifying ICP measurement in TBI. At the end of the selection, 21 articles were included in this review. Results The optic nerve sheath diameter (ONSD), pupillometry, transcranial doppler (TCD), multimodal combination, brain compliance using ICP waveform (ICPW), HeadSense, and Visual flash evoked pressure (FVEP) were analyzed. Pupillometry was not found to correlate with ICP, while HeadSense monitor and the FVEP method appear to have good correlation, but sensitivity and specificity data are not available. The ONSD and TCD methods showed good-to-moderate accuracy on invasive ICP values and potential to detect IH in most studies. Furthermore, multimodal combination may reduce the error possibility related to each technique. Finally, ICPW showed good accuracy to ICP values, but this analysis included TBI and non-TBI patients in the same sample. Conclusions Noninvasive ICP monitoring methods may be used in the near future to guide TBI patients' management.

Resumo Antecedentes A causa mais frequente de morte em pacientes neurocirúrgicos é devido ao aumento da pressão intracraniana (PIC); consequentemente, o monitoramento adequado desse parâmetro é de extrema importância. Objetivos Avaliar na literatura científica os principais métodos não invasivos de medida da PIC em pacientes com traumatismo cranioencefálico (TCE). Métodos Os dados foram obtidos na base de dados PubMed, utilizando os seguintes termos: pressão intracraniana, não invasivo, monitoramento, avaliação e medida, resultando em 147 artigos. Os artigos selecionados datam de 1980 a 2021, sendo todos estudos observacionais ou ensaios clínicos, em inglês e especificando a medida da pressão intracraniana em traumatismo cranioencefálico. Ao final da seleção, 21 artigos foram incluídos nesta revisão. Resultados Foram analisados os seguintes métodos: diâmetro da bainha do nervo óptico (ONSD), pupilometria, doppler transcraniano (TCD), combinação multimodal, complacência cerebral por meio da análise de ondas intracerebrais (ICPW), HeadSense e visual evocado por flashes de luz (FVEP). A pupilometria não se correlacionou com os valores de PIC, enquanto que o monitor HeadSense e o método FVEP parecem ter uma boa correlação, mas os dados de sensibilidade e especificidade desses métodos não estão disponíveis. Os métodos ONSD e TCD mostraram acurácia de boa a moderada quanto aos valores de IPCi, além de bom potencial para detectar hipertensão intracraniana. Ademais, a combinação multimodal pode reduzir a possibilidade de erro relacionado a cada técnica. Por fim, o ICPW apresentou boa acurácia quanto aos valores de ICPi, mas, no estudo analisado, foram incluídos pacientes com e sem TCE em uma mesma amostra. Conclusões Métodos não invasivos de medição da PIC podem atuar no futuro no manejo de pacientes com TCE como uma potencial ferramenta de triagem para TCE grave e para a detecção de hipertensão intracraniana.

Comparison between the parietal foramina observed in samples of African and European population groups / Comparación entre los forámenes parietales observados en muestras de grupos de población africanos y europeos

SUMMARY: Parietal foramina of the human skull act as a passageway for emissary veins, connecting the superior sagittal sinus to the veins of the scalp. This passageway can lead to the spread of infection from the scalp to the dural venous sinuses, but may also assist in relieving intracranial pressure. However, variation in the prevalence of parietal foramina has been noted among population groups. This observational and descriptive study aimed to determine the incidence, size and location of parietal foramina by using osteological specimens of 252 African skulls from the Sefako Makgatho Health Sciences University, South Africa and 95 European skulls from the University of Leipzig, Germany. Parietal foramina were significantly more common in the African sample (61.9 %) compared to the European sample (55.8 %). Moreover, the Central European sample displayed more unilateral foramina (29.5 %), while the African sample exhibited more bilateral foramina (40.8 %). The diameter of the parietal foramen average 1.98 mm and 1.88 mm for the European and African samples, respectively. In this study, a median foramen on the sagittal suture was observed in 14 of the overall skull caps (4 %). This study demonstrated that parietal foramina are more prevalent than anticipated in both population groups. Findings of this study, indicating an increased prevalence, and the subsequent possibility of more emissary veins encountered, can be used to improve the understanding of the variations in the prevalence and clinical implications of the parietal foramen among various population groups located world-wide.

Los forámenes parietales del cráneo humano actúan como una vía para las venas emisarias, conectando el seno sagital superior con las venas del cuero cabelludo. Este pasaje puede conducir a la propagación de infecciones desde el epicráneo (calva) hasta los senos venosos durales, pero también puede ayudar a aliviar la presión intracraneal. Sin embargo, se ha observado una variación en la prevalencia de los forámenes parietales entre los grupos de población. Este estudio observacional y descriptivo tuvo como objetivo determinar la incidencia, el tamaño y la ubicación de los forámenes parietales mediante el uso de muestras osteológicas de 252 cráneos africanos de la Universidad de Ciencias de la Salud Sefako Makgatho, Sudáfrica, y 95 cráneos europeos de la Universidad de Leipzig, Alemania. Los forámenes parietales fueron significativamente más comunes en la muestra africana (61,9 %) en comparación con la muestra europea (55,8 %). Además, la muestra centroeuropea mostró más forámenes unilaterales (29,5 %), mientras que la muestra africana mostró más forámenes bilaterales (40,8 %). El diámetro del foramen parietal promedió 1,98 mm y 1,88 mm para las muestras europeas y africanas, respectivamente. En este estudio, se observó un foramen medio en la sutura sagital en 14 de los cráneos en general (4 %). El estudio demostró que los forámenes parietales son más frecuentes de lo previsto en ambos grupos de población. Los hallazgos de este estudio, que indican una mayor prevalencia y la subsiguiente posibilidad de que se encuentren más venas emisarias, pueden ser útiles para mejorar la comprensión de las variaciones en la prevalencia y las implicaciones clínicas del foramen parietal entre varios grupos de población ubicados en el mundo.

Time course of hemispheric cerebral volume after decompressive craniectomy in malignant middle cerebral artery stroke / Evolução temporal do volume hemisférico cerebral após craniectomia descompressiva em infarto maligno de artéria cerebral média

Abstract Background Brain edema is the leading cause of death in patients with malignant middle cerebral artery (MCA) infarction. Midline shift (MLS) has been used as a monohemispheric brain edema marker in several studies; however, it does not precisely measure brain edema. It is now possible to directly measure hemisphere brain volume. Knowledge about the time course of brain edema after malignant middle cerebral artery infarction may contribute to the condition's management. Objective Therefore, our goal was to evaluate the course of brain edema in patients with malignant MCA infarction treated with decompressive craniectomy (DC) using hemispheric volumetric measurements. Methods Patients were selected consecutively from a single tertiary hospital between 2013 and 2019. All patients were diagnosed with malignant middle cerebral artery infarction and underwent a decompressive craniectomy (DC) to treat the ischemic event. All computed tomography (CT) exams performed during the clinical care of these patients were analyzed, and the whole ischemic hemisphere volume was calculated for each CT scan. Results We analyzed 43 patients (197 CT exams). Patients' mean age at DC was 51.72 [range: 42-68] years. The mean time between the ischemic ictus and DC was 41.88 (range: 6-77) hours. The mean time between the ischemic event and the peak of hemisphere volume was 168.84 (95% confidence interval [142.08, 195.59]) hours. Conclusion In conclusion, the peak of cerebral edema in malignant MCA infarction after DC occurred on the 7th day (168.84 h) after stroke symptoms onset. Further studies evaluating therapies for brain edema even after DC should be investigated.

Resumo Antecedentes O edema cerebral é a principal causa de morte em pacientes com infarto maligno de artéria cerebral média. O desvio da linha média tem sido utilizado como marcador de edema cerebral mono-hemisférico em alguns estudos; porém, ele não mede de forma precisa o edema cerebral. Atualmente é possível mensurar diretamente o volume do hemisfério cerebral. O conhecimento sobre a evolução temporal do edema cerebral após infartos malignos da artéria cerebral média pode contribuir para o cuidado clínico desta condição. Objetivo Nosso objetivo é avaliar o edema hemisférico ao longo do tempo, em pacientes com infarto maligno da artéria cerebral média, tratados com craniectomia descompressiva. Métodos Os pacientes foram selecionados de forma consecutiva, em um hospital terciário, entre 2013 e 2019. Todos os pacientes apresentavam diagnóstico de infarto maligno de artéria cerebral média e foram submetidos a craniectomia descompressiva. Todas as tomografias computadorizadas de crânio destes pacientes foram analizadas, e o volume do hemisfério cerebral infartado foi mensurado. Resultados Analisamos 43 pacientes (197 tomografias de crânio). A idade média dos pacientes na craniectomia descompressiva foi 51,72 (42-68) anos. O tempo médio entre o ictus e a craniectomia descompressiva foi 41,88 (6-77) horas. O tempo médio entre o ictus e o pico do volume hemisférico foi 168,84 (142,08-195,59) horas. Conclusão O pico do volume cerebral em pacientes com infarto maligno de artéria cerebral média submetidos a craniectomia descompressiva ocorreu no 7o dia (168,84 horas) após o infarto. Mais estudos avaliando terapêuticas direcionadas ao edema cerebral seriam úteis neste contexto.

Non-Invasive Study of Intracranial Pressure in Pre- and Post-Chemotherapy Patients for the Treatment of Breast Neoplasia

Introduction: Breast cancer is the most common type among women and brings to them significant organic changes. A new intracranial pressure monitorization method consists of an external system of sensors that detects micrometric deformations on the cranial bones and transmits, in real-time, electrical signals that are visualized on a monitor. Objective: To identify changes in intracranial pressure due to chemotherapy connections through non-invasive methodology. Methods: The present study was conducted at Hospital Santa Casa de Misericordia in the city of Ponta Grossa, PR, Brazil in 2017. The variables P2/P1 ratio (ICP morphological evaluation), laboratory parameters, comorbidities, and clinical aspects of the volunteers were evaluated. The vascular toxicity of chemotherapy often causes endothelial dysfunction, resulting in a loss of vasodilation effects and suppresses anti-inflammatory and vascular repair functions. Results: The values of the P2/P1 ratio before and after chemotherapy were also compared between groups. A statistically significant difference was observed in the pre chemotherapy P2/P1 values compared to the post-chemotherapy values. Conclusion: Variations in ICP may occur in cancer patients. Further studies are necessary to evaluate if this change may contribute to the chemotherapy side effects occurrence.

Application value of ventricular intracranial pressure monitoring in the treatment of unilateral temporal lobe cerebral contusion / 中华创伤杂志

Objective:To explore the application value of ventricular intracranial pressure monitoring (V-ICPM) in the treatment of unilateral temporal lobe cerebral contusion.Methods:A retrospective cohort study was conducted to analyze the clinical data of 295 patients with unilateral temporal lobe cerebral contusion admitted to 904th Hospital of PLA Joint Support Force from January 2014 to August 2021, including 172 males and 123 females; aged 14-78 years [(46.3±14.7)years]. V-ICPM was used in 136 patients (V-ICPM group), who received surgical or non-surgical treatment according to the monitoring, while not in 159 patients (non-V-ICPM group), who received routine surgery or non-surgical treatment. The two groups were compared in terms of the rates of intracranial hematoma clearance by craniotomy, decompressive craniectomy (DC) and dehydration and osmotic therapy during hospitalization, use time of 20% mass fraction of mannitol and 30 g/L hypertonic salt, displacement rate of brain midline structure of head CT≥10 mm after discharge, rate of intracranial infection, hydrocephalus and epilepsy, and Glasgow Outcome Scale (GOS) at 6 months after discharge.Results:All patients were followed up for 6-12 months [(8.9±2.1)months]. During hospitalization, the rate of intracranial hematoma clearance by craniotomy and the rate of DC in V-ICPM group were 35.3% (48/136) and 8.1% (11/136), lower than 47.2% (75/159) and 22.0% (35/159) in non-V-ICPM group ( P<0.05 or 0.01). There was no significant difference between the two groups in the rate of dehydration and osmotic therapy or the use time of mannitol (all P>0.05). The use time of hypertonic salt in V-ICPM group was (7.2±2.5)days, more than (4.1±1.8)days in non-V-ICPM group ( P<0.05). After discharge, the displacement rate of brain midline structure of head CT in V-ICPM group was 29.4% (40/136), lower than 42.8% (68/159) in non-V-ICPM group ( P<0.05). There was no significant difference between the two groups in the rate of intracranial infection, hydrocephalus and epilepsy (all P>0.05). Six months after discharge, the good rate of GOS in V-ICPM group was 91.2% (124/136), significantly better than 81.8% (130/159) in non-V-ICPM group ( P<0.05). Conclusion:For unilateral temporal lobe cerebral contusion, V-ICPM is associated with reduced rate of craniotomy exploration and DC, decreased incidence of complications and improved prognosis of the patients in spite of longer use time of hypertonic salt.

Best evidence summary of intracranial pressure management in patients with hemorrhagic stroke / 中国实用护理杂志

Objective:To search, select and integrate the available evidence for the intracranial pressure management in patients with hemorrhagic stroke, to provide evidence-based references for clinical practice.Methods:According to the "6S" pyramid model, all literature on the management of intracranial pressure in patients with hemorrhagic stroke was retrieved from the websites and database including UpToDate, BMJ Best Practice, Cochrane Library, PubMed, Embase, relevant guideline net works and association websites as well as National stroke database,Yimaitong, CBM, CNKI, Wanfang Data, VIP and other databases, including Clinical decision-making, guidelines, evidence collection, systematic evaluation, expert consensus and evidence-related original research. The search time limit was from the establishment of the database to June 10, 2022. Two researchers independently evaluated the literature quality. The qualified literature was extracted.Results:A total of 19 pieces of literature were included, including 3 clinical decision-making, 5 guidelines, 3 systematic reviews, 4 expert consensuses, 3 randomized controlled studies and 1 case series study. Finally, 23 pieces of best evidence were summarized, involving 5 aspects such as assessment and monitoring, management goals, management scheme, treatment selection and methods, risk management.Conclusions:Active intracranial pressure management can improve the prognosis of patients with hemorrhagic stroke. It is recommended that health care professionals should select evidence in combination with specific clinical situations and formulate individualized intracranial pressure management programs.

Occurrence of hypopituitarism after severe craniocerebral trauma and its predictors / 中华内分泌外科杂志

Objective:To investigate the occurrence and predictors of hypopituitarism after traumatic brain injury (TBI) .Methods:A prospective study was conducted on 185 patients with severe TBI in the Emergency Department of the First Hospital of Shanxi Medical University from Jan. 2020 to May. 2022, of whom 108 were male and 77 were female; age ranged from 18 to 79 years, mean (51.32±9.34) years. Pituitary function was assessed within 3-7 d after the onset of TBI, and the occurrence of hypopituitarism after severe TBI was counted. 41 cases in the hypopituitarism group, 26 males and 15 females, aged (52.76±9.83) years, were divided into the hypopituitarism group (hypopituitarism occurred) and the non-hypopituitarism group (hypopituitarism did not occur) according to whether hypopituitarism occurred. In the non-decompensated group, there were 144 cases, 82 males and 62 females, aged (50.91±9.27) years. The clinical data of the decompensated and non-decompensated groups were compared, and the factors influencing the occurrence of hypopituitarism were analysed, and a logistic prediction model was constructed based on the relevant influencing factors. The value of this model in predicting the occurrence of hypopituitarism after severe TBI was evaluated by using the receiver operating characteristic (ROC) curve.Results:The prevalence of hypopituitarism in the 185 patients with severe TBI in this study was 22.16%; the Glasgow coma scale (GCS) score on admission was lower in the decompensated group than in the non-decompensated group [ (6.36±1.04) vs (7.48±0.59) ], the percentage of hyperbaric oxygen therapy was lower than in the non-decompensated group (21.95% vs 49.31%) , the percentage of intracranial pressure (82.93% vs 49.31%) , midline displacement ≥5 mm (78.05% vs 29.86%) , skull base fracture (34.15% vs. 17.36%) , diffuse cerebral edema (19.51% vs 4.17%) , and serum brain derived neurophic factor (BDNF) . Brain derived neurophic factor (BDNF) was higher than that in the non-reduced group [ (6.35±1.29) ng/ml vs (4.51±1.06) ng/ml], and neuronal-specific enolase (NSE) was higher than that in the non-reduced group [ (33.06±5.42) μg/L vs (23.15±4.97) μg/L]. (4.97) μg/L]. Vascular epithelial growth factor (VEGF) was higher than that in the non-reduced group [ (312.07±24.35) pg/ml vs (226.80±20.96) pg/ml], tumor necrosis factor-α (TNF-α) was higher than that in the non-reduced group [ (281.24±38.91) ng/L vs (186.91) pg/ml], and tumor necrosis factor-α (TNF-α) was higher than that in the non-reduced group (186.55±35.72) ng/L (all P<0.05) . Increased intracranial pressure, midline displacement ≥5 mm, diffuse cerebral edema, serum BDNF, NSE, VEGF, and TNF-α levels were all independent risk factors for the development of hypopituitarism after severe TBI, with admission GCS score and hyperbaric oxygen therapy as protective factors ( P<0.05) ; a logistic prediction model was constructed based on the influencing factors as: Logit ( P) = 5.264-0.880×admission GCS score + 1.618×increased intracranial pressure + 1.941×midline displacement ≥5 mm + 1.289×diffuse cerebral edema+1.306×BDNF+1.426×NSE+1.781×VEGF+1.615×TNF-α-0.758×hyperbaric oxygen therapy; the model predicted the occurrence of severe TBI after the area under the curve (AUC) of hypopituitarism was 0.930 (95% CI 0.883-0.962) , with a predictive sensitivity and specificity of 90.24% and 89.19%, respectively. Conclusions:The incidence of hypopituitarism is higher after severe TBI. Increased intracranial pressure, midline displacement ≥5 mm, diffuse cerebral edema, serum BDNF, NSE, VEGF and TNF-α levels are all used as predictors of hypopituitarism.

Contribución de los hallazgos tomográficos al diagnóstico de la hipertensión intracraneal en el traumatismo craneoencefálico grave

Introducción: El traumatismo craneoencefálico es responsable de más de 500 000 visitas a departamentos de urgencias, 95 000 hospitalizaciones y 7 000 muertes en la población infantil. La monitorización clínica se apoya en técnicas imagenológicas, entre otras. Objetivo: Relacionar los hallazgos tomográficos encontrados, a través de la clasificación de Marshall al ingreso y diámetro de la vaina del nervio óptico y su asociación con la presión intracraneal y con los resultados en el paciente pediátrico con traumatismo craneoencefálico grave. Métodos: Estudio descriptivo prospectivo con todos los pacientes pediátricos aquejados de traumatismo craneoencefálico grave entre enero de 2003 y diciembre de 2017. Resultados: De los 41 casos, se encontró relación entre los niveles de presión intracraneal y el grado de luxación de la línea media >10 mm en 10 enfermos (62,5 %) y con el diámetro de la vaina del nervio óptico (>5,5 mm) por tomografía de cráneo en 12 (75,0 %), igualmente existió relación entre esas dos variables con los resultados a los 6 meses de evolución. Conclusiones: La utilización de la tomografía de cráneo simple como herramienta para la determinación de variables utilizadas en el monitoreo no invasivo de la presión intracraneal como son la clasificación tomográfica de Marshall, la luxación de la línea media y la medición del diámetro de la vaina del nervio óptico, permite identificar incrementos de la presión intracraneal. Esto pudiera utilizarse para el tratamiento intensivo de los pacientes pediátricos con traumatismo cráneo encefálico grave, sin necesidad de la utilización de monitoreo invasivo en ellos.

Introduction: Traumatic brain injury is responsible for more than 500,000 visits to the emergency services, 95,000 hospitalizations and 7,000 deaths in children. Clinical monitoring is based on imaging techniques, among others. Objective: To relate the tomographic findings found, through Marshall's classification at the entrance and diameter of the optic nerve sheath and its association with intracranial pressure and with the results in the pediatric patient with severe head trauma. Methods: Prospective descriptive study with all pediatric patients suffering from severe head trauma between January 2003 and December 2017. Results: Of the 41 cases, a relationship was found between the levels of intracranial pressure and the degree of dislocation of the midline >10 mm in 10 patients (62.5%) and with the diameter of the optic nerve sheath (>5.5 mm) by skull tomography in 12 (75.0%); there was also a relationship between these two variables with the results at 6 months of evolution. Conclusions: The use of simple tomography of the skull as a tool for the determination of variables used in the non-invasive monitoring of intracranial pressure such as Marshall tomographic classification, midline dislocation and measurement of the diameter of the optic nerve sheath, allows to identify increases in intracranial pressure. This could be used for the intensive treatment of pediatric patients with severe head trauma, without the need for invasive monitoring in them.

Ultrasonografía del diámetro de la vaina del nervio óptico en paciente con meningoencefalitis complicada / Ultrasonography of the optic nerve sheath diameter in patient with complicated meningoencephalitis

RESUMEN La ultrasonografía del diámetro de la vaina del nervio óptico es un método no invasivo para monitorizar la presión intracraneal. Se ha utilizado en múltiples patologías neurocríticas, incluyendo la infección complicada del sistema nervioso central. Se presenta el caso de una paciente femenina de 47 años, quien ingresó en la Unidad de Cuidados Intensivos luego de presentar progresión al estado comatoso secundario a cuadro de meningoencefalitis bacteriana. Al ingreso se constata midriasis bilateral arreactiva, ausencia parcial de reflejos del tallo encefálico y bradicardia. Ante la sospecha clínica de hipertensión intracraneal, se indica ultrasonografía del diámetro de la vaina del nervio óptico en plano axial. Se realizaron tres mediciones para cada ojo, mostrando un valor de 6,3, 6,6 y 6,00 mm en ojo derecho, y 6,8, 6,6 y 6,8 mm en el izquierdo (promedio biocular: 6,5 mm). Con esta medición se complementó el diagnóstico sospechado. Esta técnica representa un proceder seguro y no invasivo. Su uso completa los datos recogidos en el examen clínico. El punto de corte universalmente aceptado para el diagnóstico es de 5,0 mm o más para un valor de presión intracraneal > 20 mmHg.

ABSTRACT The optic nerve sheath ultrasonography is a non-invasive method for monitoring intracranial pressure. It has been used in multiple neurocritical pathologies, including the complicated infection of the central nervous system. The case of a 47-year-old female patient is presented; she was admitted to the Intensive Care Unit after presenting progression to comatose state secondary to bacterial meningoencephalitis. On admission, bilateral arreactive mydriasis, partial absence of brainstem reflexes and bradycardia are confirmed. Given the clinical suspicion of intracranial hypertension, ultrasonography of the optic nerve sheath diameter in the axial plane is indicated. Three measurements were made for each eye, showing a value of 6.3, 6.6 and 6.00 in the right eye, and 6.8, 6.6 and 6.8 in the left one (biocular average: 6.5 mm). With this measurement the suspected diagnosis was completed. This technique represents a secure and non-invasive procedure. Its use completes the data collected in the clinical examination. The universally accepted cut-off point for diagnosis is 5.0 mm or more for an intracranial pressure value of > 20 mmHg.

Ecografía Doppler transcraneal para estimar la presión intracraneal y presión de perfusión cerebral en pacientes pediátricos neurocríticos

RESUMEN La ecografía Doppler transcraneal es un método no invasivo que permite una adecuada monitorización de los diferentes parámetros que ayudan a definir conductas para los médicos intensivistas, sin embargo, su utilización no está generalizada entre las comunidades médicas que atienden niños con afecciones neurocríticas. Es propósito de los autores, actualizar el tema en estudio y presentar su experiencia en población pediátrica. Las indicaciones de este método provienen de investigaciones en pacientes adultos, se necesitan estudios multicéntricos en diferentes contextos clínicos para poder establecer esta técnica como un método de diagnóstico confiable en pacientes pediátricos. Concluimos que utilizar el Doppler transcraneal como prueba auxiliar en la estimación de la presión intracraneal y presión de perfusión cerebral, proporciona adoptar recursos terapéuticos frente al paciente lo más acertados posibles y brinda la posibilidad de hacer un seguimiento y evaluación de los tratamientos a pie de cama de forma mínimamente invasiva.

ABSTRACT Transcranial Doppler ultrasound is a non-invasive method that allows adequate monitoring of the different parameters that help define behaviors for intensivist physicians ; however, its use is not widespread among the medical communities that care for children with neurocritical conditions. It is the purpose of the authors to update the topic under study and present their experience with pediatric populations. The indications for this method come from research in adult patients . Multicenter studies in different clinical contexts are needed to establish this technique as a reliable diagnostic method in pediatric patients. We conclude that using transcranial Doppler as an auxiliary test in the estimation of intracranial pressure and cerebral perfusion pressure, provides the implementation of therapeutic resources in front of the patient as accurate as possible and offers the possibility of monitoring and evaluating bedside treatments in a minimally invasive way.

Relationship between dialysis quality and brain compliance in patients with end-stage renal disease (ESRD): a cross-sectional study

ABSTRACT BACKGROUND: The high number of patients with end-stage kidney disease (ESRD) on hemodialysis makes it necessary to conduct studies aimed at improving their quality of life. OBJECTIVES: To evaluate brain compliance, using the Brain4care method for intracranial pressure (ICP) monitoring, among patients with ESRD before and at the end of the hemodialysis session, and to correlate ICP with the dialysis quality index (Kt/V). DESIGN AND SETTING: Cross-sectional study conducted at a renal replacement therapy center in Brazil. METHODS: Sixty volunteers who were undergoing hemodialysis three times a week were included in this study. Brain compliance was assessed before and after hemodialysis using the noninvasive Brain4care method and intracranial pressure wave morphology was analyzed. RESULTS: Among these 60 ESRD volunteers, 17 (28%) presented altered brain compliance before hemodialysis. After hemodialysis, 12 (20%) exhibited normalization of brain compliance. Moreover, 10 (83%) of the 12 patients whose post-dialysis brain compliance became normalized were seen to present good-quality dialysis, as confirmed by Kt/V > 1.2. CONCLUSIONS: It can be suggested that changes to cerebral compliance in individuals with ESRD occur frequently and that a good-quality hemodialysis session (Kt/V > 1.2) may be effective for normalizing the patient's cerebral compliance.

Evaluation of cerebral hemodynamics by transcranial Doppler ultrasonography and its correlation with intracranial pressure in an animal model of intracranial hypertension / Avaliação da hemodinâmica encefálica utilizando Doppler transcraniano e sua correlação com a pressão intracraniana em um modelo animal de hipertensão intracraniana

ABSTRACT Background: Transcranial Doppler has been tested in the evaluation of cerebral hemodynamics as a non-invasive assessment of intracranial pressure (ICP), but there is controversy in the literature about its actual benefit and usefulness in this situation. Objective: To investigate cerebral blood flow assessed by Doppler technique and correlate with the variations of the ICP in the acute phase of intracranial hypertension in an animal model. Methods: An experimental animal model of intracranial hypertension was used. The experiment consisted of two groups of animals in which intracranial balloons were implanted and inflated with 4 mL (A) and 7 mL (B) for controlled simulation of different volumes of hematoma. The values of ICP and Doppler parameters (systolic [FVs], diastolic [FVd], and mean [FVm] cerebral blood flow velocities and pulsatility index [PI]) were collected during the entire procedure (before and during hematoma simulations and venous hypertonic saline infusion intervention). Comparisons between Doppler parameters and ICP monitoring were performed. Results: Twenty pigs were studied, 10 in group A and 10 in group B. A significant correlation between PI and ICP was obtained, especially shortly after abrupt elevation of ICP. There was no correlation between ICP and FVs, FVd or FVm separately. There was also no significant change in ICP after intravenous infusion of hypertonic saline solution. Conclusions: These results demonstrate the potential of PI as a parameter for the evaluation of patients with suspected ICP elevation.

RESUMO Antecedentes: O Doppler transcraniano (DTC) é uma técnica não invasiva para a avaliação da hemodinâmica cerebral, porém existem controvérsias na literatura sobre sua aplicabilidade preditiva em situações de elevada pressão intracraniana (PIC). Objetivo: Investigar o fluxo sanguíneo cerebral pelo DTC e correlacioná-lo com as variações da PIC na fase aguda da hipertensão intracraniana em modelo animal. Métodos: Dois grupos de animais (suínos) foram submetidos a hipertensão intracraniana secundária à indução de diferentes volumes de hematoma, por meio da insuflação de balão intracraniano controlado com 4 e 7 mL de solução salina fisiológica (grupos A e B, respectivamente). Em seguida, administrou-se infusão venosa de solução salina hipertônica (SSH 3%). Foram coletados os valores dos parâmetros de PIC e DTC (velocidade sistólica [FVs], diastólica [FVd] e média [FVm] do fluxo sanguíneo cerebral), bem como o índice de pulsatilidade (IP). Comparações entre os parâmetros do DTC e o monitoramento da PIC foram realizadas. Resultados: Vinte porcos foram estudados, dez no grupo A e dez no grupo B. Correlação significativa entre IP e PIC foi obtida, principalmente logo após a elevação abrupta da PIC. Não houve correlação entre PIC e FVs, FVd ou FVm separadamente. Também não houve alteração significativa na PIC após a infusão de SSH. Conclusões: Esses resultados demonstram o potencial do IP como um bom parâmetro para a avaliação de pacientes com suspeita de elevação da PIC.

Actualización en el tratamiento del síndrome de hipertensión intracraneana / Update on the management of intracranial hypertension syndrome

Elevated intracranial pressure (ICP) is a devastating complication, with great impact on neurological status and high morbidity and mortality. Intracranial hypertension (ICH) has multiple etiologies. The natural history of this condition can lead to brain death. The successful management of patients with elevated ICP (> 20-25 mmHg) requires fast and timely recognition, judicious use of invasive monitoring and therapies aimed to reversing its underlying cause. Therefore, it must be managed as a neurological emergency. The objective of this review is to present in a friendly way the diagnostic approach and the management of ICH, focused on general practitioners.

Effects of different doses of dexmedetomidine on intracranial pressure in patients undergoing gynecological laparoscopic surgery / 中国药房

OBJECTIVE To investigate the effects of different doses of dexmedetomidine on intracranial pressure in patients undergoing gynecological laparoscopic surgery. METHODS Ninety patients undergoing selective gynecological laparoscopic surgery in trendelenburg position were divided into low-dose experimental group （group D 1），high-dose experimental group （group D 2） and control group （group C ）according to random number table ，with 30 cases in each group. Group D 1 and group D 2 received continuous intravenous infusion of dexmedetomidine 1.0 μ g/kg for 10 min for induction of anesthesia ，and then continued intravenous infusion at the rate of 0.4 μg（/ kg·h）and 0.6 μg（/ kg·h）respectively. Group C was continuously pumped with the constant volume of Sodium chloride injection. Three groups stopped pumping 30 minutes before the end of the operation. The heart rate（HR）and mean arterial pressure （MAP）were recorded when entering the room （T0），10 min after intravenous pump of dexmedetomidine（T1），10 min（T2），30 min（T3），60 min（T4）after pneumoperitoneum ，10 min after pneumoperitoneum was closed to restore the supine position （T5）. At the same time ，optic nerve sheath diameter （ONSD）in both eyes was measured by ultrasound，and the occurrence of intraoperative bradycardia and the use of atropine were recorded. RESULTS There was no statistical significance in ONSD ，HR or MAP among 3 groups at T 0（P＞0.05）. Compared with T 0，ONSD of 3 groups were decreased significantly at T 1（except for group C ）；ONSD of 3 groups were increased significantly at T 2-T5，while MAP and HR were all decreased significantly （P＜0.05）. HR of group D 2 was decreased significantly at T 1（P＜0.05）. Compared with group C ， ONSD and HR of group D 1 and D 2 were all decreased significantly at T 1-T5（P＜0.05）. Compared with group C ，the number of patients with bradycardia and those who used atropine in group D 1 and D 2 were increased significantly （P＜0.05）. CONCLUSIONS Continuous pumping of dexmedetomidine during gynecologic laparoscopic surgery can reduce the increase of intracranial pressure in patients ；compared with pumping rate of 0.6 μg（/ kg·h），the change of patient ’s HR tends to be more stable with a pumping rate of 0.4 μg（/ kg·h）.

Continuous monitoring of intracranial pressure and partial oxygen pressure of brain tissue in patients with severe traumatic brain injury after standard decompressive craniectomy and microscopic hematoma removal / 中国综合临床

Objective:To investigate the effect of continuous intracranial pressure (ICP) and brain oxygen partial pressure (PbtO 2) monitoring and guiding treatment after the application of standard large bone flap decompression and microhematoma removal in patients with severe traumatic brain injury (TBI). Methods:A retrospective analysis was done of 41 patients with TBI in Department of Neurosurgery in the Inner Mongolia People's Hospital from January 2018 to May 2020. Patients with Glasgow coma scale (GCS)<8 points were treatesd with microscopical removal of hematoma and contusion brain tissue and standard large bone flap decompression. Intraoperative intracranial pressure and brain tissue oxygen partial pressure monitoring probes were placed. Postoperatively, continuous intracranial pressure monitoring and partial oxygen pressure monitoring of brain tissue were performed, and target-based treatment under ICP and PbtO 2 monitoring was performed. According to the Glasgow Outcome (GOS) score after six months, patients were divided into a good outcome group (4-5 scores) and a poor outcome group (1-3 scores). There were 26 cases in good prognosis group and 15 cases in poor prognosis group. Linear regression analysis was used to further evaluate the relationship between PbtO 2, ICP and GOS score. The measurement data of normal distribution were compared by independent sample t-test. The counting data were expressed in cases (%), and the comparison between groups was adopted χ 2 inspection. The general linear bivariate Pearson correlation test was used. Results:The mean value of PbtO 2 (17.42±5.34) mmHg in the poor prognosis group was lower than that in the good prognosis group (24.65±5.61) mmHg, with statistical significance ( t=4.04, P<0.001). The mean value of ICP (22.32±3.45) mmHg in the poor prognosis group was higher than that (17.32±3.23) mmHg in the good prognosis group, with statistical significance ( t=4.15, P<0.001). Using PbtO 2 and ICP as independent variables and GOS score after 6 months as dependent variable, a regression equation was established ( Y=4.040 X+7.497; Y=-2.549 X+28.63). The mean value of PbtO 2 was positively correlated with GOS scores after 6 months in patients with severe head injury ( r=0.75, P<0.001). The mean value of ICP was negatively correlated with the prognosis of patients with severe head injury ( r=-0.87, P<0.001). Conclusion:The treatment guided by ICP combined with PbtO 2 monitoring is valuable in improving the prognosis of patients with severe traumatic brain injury after standard decompressive craniectomy, and may improve the prognosis 6 months after the injury.

Clinical efficacy of gradual decompression in the treatment of severe traumatic brain injury and its effects on the improvement of intracranial pressure / 中国基层医药

Objective:To investigate the clinical efficacy of gradual decompression in the treatment of severe traumatic brain injury and its effects on the improvement of intracranial pressure.Methods:The clinical data of 120 patients with severe traumatic brain injury who received treatment in the General Hospital of Taiyuan Iron and Steel (Group) Co., Ltd. from January 2015 to January 2020 were retrospectively analyzed. The included patients were divided into decompressive craniectomy group (control group, n = 64) and gradual decompression group ( n = 56). Intracranial pressure was compared between the two groups at different time points (before surgery, during the surgery, immediately after surgery, 3 and 6 months after surgery). The patient's self-care ability, coma degree, and neurological deficits pre-surgery and 6 months after surgery were evaluated in each group. The incidence of complications throughout the surgery and within 6 months after surgery was calculated to evaluate the quality of life. Results:There was no significant difference in intracranial pressure pre-surgery between the two groups ( P > 0.05). Intracranial pressure in the gradual decompression group was (30.74 ± 2.51) mmHg, (25.11 ± 2.06) mmHg, (21.34 ± 2.01) mmHg, and (16.74 ± 1.54) mmHg respectively during the surgery, immediately after surgery, and 3 and 6 months after surgery, which was significantly lower than that in the control group [(34.31 ± 3.06) mmHg, (30.64 ± 2.57) mmHg, (26.33 ± 2.35) mmHg, (22.64 ± 1.95) mmHg, t = 12.88, 19.03, 12.40, 18.20, all P < 0.001]. There were no significant differences in scores of the Modified Barthel Index (MBI), the Glasgow Coma Scale (GCS), the National Institutes of Health Stroke Scale (NIHSS) pre-surgery between the two groups (all P > 0.05). At 6 months after surgery, the MBI and GCS scores increased and the NIHSS score decreased in each group. There were significant differences in the NIHSS, MBI, and GCS scores between the two groups ( t = 7.61, 6.26, 13.07, all P < 0.001). During the surgery and 6 months after surgery, the incidences of cerebral infarction, delayed cerebral hematoma, and acute encephalocele were significantly lower in the gradual decompression group than in the control group ( χ2 = 4.23, 4.35, 4.83, all P < 0.05). The Generic Quality of Life Inventory-74 Questionnaire scores in environment, psychological health, social relationship, and psychological health domains were significantly higher in the gradual decompression group than in the control group ( t = 8.16, 9.80, 8.68, 7.76, all P < 0.001) Conclusion:This study is the first to analyze the feasibility of gradual decompression for the treatment of severe traumatic brain injury in terms of intracranial pressure, quality of life, and short- and medium-term complications. Findings from this study confirm that gradual decompression can effectively lower intracranial pressure of patients with severe traumatic brain injury, improve neurological function, reduce complications, and improve patients' self-care ability and quality of life.