Preliminary Study on Application of Combined Monitoring of Neuroelectrophysiology-Intracranial Pressure-Cerebral Perfusion Pressure in Craniotomy for Intracranial Aneurysm Clipping: An Anatomical and Clinical Study

SUMMARY: Intracranial aneurysm is a common cerebrovascular disease with high mortality. Neurosurgical clipping for the treatment of intracranial aneurysms can easily lead to serious postoperative complications. Studies have shown that intraoperative monitoring of the degree of cerebral ischemia is extremely important to ensure the safety of operation and improve the prognosis of patients. Aim of this study was to probe the application value of combined monitoring of intraoperative neurophysiological monitoring (IONM)-intracranial pressure (ICP)-cerebral perfusion pressure (CPP) in craniotomy clipping of intracranial aneurysms. From January 2020 to December 2022, 126 patients in our hospital with intracranial aneurysms who underwent neurosurgical clipping were randomly divided into two groups. One group received IONM monitoring during neurosurgical clipping (control group, n=63), and the other group received IONM-ICP-CPP monitoring during neurosurgical clipping (monitoring group, n=63). The aneurysm clipping and new neurological deficits at 1 day after operation were compared between the two groups. Glasgow coma scale (GCS) score and national institutes of health stroke scale (NIHSS) score were compared before operation, at 1 day and 3 months after operation. Glasgow outcome scale (GOS) and modified Rankin scale (mRS) were compared at 3 months after operation. All aneurysms were clipped completely. Rate of new neurological deficit at 1 day after operation in monitoring group was 3.17 % (2/63), which was markedly lower than that in control group of 11.11 % (7/30) (P0.05). Combined monitoring of IONM-ICP-CPP can monitor the cerebral blood flow of patients in real time during neurosurgical clipping, according to the monitoring results, timely intervention measures can improve the consciousness state of patients in early postoperative period and reduce the occurrence of early postoperative neurological deficits.

El aneurisma intracraneal es una enfermedad cerebrovascular común con alta mortalidad. El clipaje neuroquirúrgico para el tratamiento de aneurismas intracraneales puede provocar complicaciones posoperatorias graves. Los estudios han demostrado que la monitorización intraoperatoria del grado de isquemia cerebral es extremadamente importante para garantizar la seguridad de la operación y mejorar el pronóstico de los pacientes. El objetivo de este estudio fue probar el valor de la aplicación de la monitorización combinada de la monitorización neurofisiológica intraoperatoria (IONM), la presión intracraneal (PIC) y la presión de perfusión cerebral (CPP) en el clipaje de craneotomía de aneurismas intracraneales. Desde enero de 2020 hasta diciembre de 2022, 126 pacientes de nuestro hospital con aneurismas intracraneales que se sometieron a clipaje neuroquirúrgico se dividieron aleatoriamente en dos grupos. Un grupo recibió monitorización IONM durante el clipaje neuroquirúrgico (grupo de control, n=63) y el otro grupo recibió monitorización IONM-ICP-CPP durante el clipaje neuroquirúrgico (grupo de monitorización, n=63). Se compararon entre los dos grupos el recorte del aneurisma y los nuevos déficits neurológicos un día después de la operación. La puntuación de la escala de coma de Glasgow (GCS) y la puntuación de la escala de accidentes cerebrovasculares de los institutos nacionales de salud (NIHSS) se compararon antes de la operación, 1 día y 3 meses después de la operación. La escala de resultados de Glasgow (GOS) y la escala de Rankin modificada (mRS) se compararon 3 meses después de la operación. Todos los aneurismas fueron cortados por completo. La tasa de nuevo déficit neurológico 1 día después de la operación en el grupo de seguimiento fue del 3,17 % (2/63), que fue notablemente inferior a la del grupo de control del 11,11 % (7/30) (P 0,05). La monitorización combinada de IONM-ICP-CPP puede controlar el flujo sanguíneo cerebral de los pacientes en tiempo real durante el corte neuroquirúrgico; de acuerdo con los resultados de la monitorización, las medidas de intervención oportunas pueden mejorar el estado de conciencia de los pacientes en el período postoperatorio temprano y reducir la aparición de problemas postoperatorios tempranos y déficits neurológicos.

Craniectomía descompresiva como alternativa terapéutica en la hipertensión intracraneal pediátrica incontrolable por traumatismo craneoencefálico grave / Decompressive craniectomy as a therapeutic alternative in uncontrollable intracranial hypertension in pediatric severe head injury

Introducción: El traumatismo craneoencefálico grave presenta una elevada incidencia en pacientes pediátricos. Es una importante causa de muerte y discapacidad. Sus causas más comunes en este grupo etario son los accidentes domésticos y de tránsito, caídas, violencia y actividades deportivas. Se realizó una revisión bibliográfica en julio y agosto de 2023 con un total de 38 bibliografías en idioma español, inglés y portugués en las bases de datos de SciElo, Elsevier, Pubmed y el motor de búsqueda Google Académico. Se consideró como criterio de selección aquella literatura publicada con mayor actualidad en concordancia con lo novedoso de esta enfermedad. Objetivo: Describir la craniectomía descompresiva como una alternativa a la hipertensión intracraneal pediátrica producida por traumatismo craneoencefálico grave. Desarrollo: Ante un traumatismo craneoencefálico grave, la presión intracraneal aumenta, lo que causa hipertensión intracraneal. Cuando esta hipertensión no se logra controlar, se convierte en refractaria, se requieren otros tratamientos más agresivos como la craniectomía descompresiva. Este procedimiento es invasivo, consiste en remover parte del cráneo para disminuir la presión dentro de la cavidad craneana. Conclusiones: Es necesario continuar los estudios de craniectomía descompresiva en el manejo de la hipertensión craneal pediátrica en la población infanto-juvenil, pues los estudios enfocados en ellos no abundan; estos constituyen una intervención de rescate. A pesar de los adelantos científicos, logros terapéuticos alcanzados y conocimientos de la hipertensión craneal pediátrica, se considera la craniectomía descompresiva como una elección terapéutica óptima, con una justa predicción y no brindarla cuando las opciones reales de éxito sean insuficientes(AU)

Introduction: Severe head trauma has a high incidence in pediatric patients. It is a major cause of death and disability. Its most common causes in this age group are domestic and traffic accidents, falls, violence and sports activities. A bibliographic review was carried out in July and August 2023 with a total of 38 bibliographies in Spanish, English and Portuguese from the SciElo, Elsevier, Pubmed databases and the Google Scholar search engine. The most recent published literature in accordance with the novelty of this disease was considered as a selection criterion. Objective: To describe decompressive craniectomy as an alternative to pediatric intracranial hypertension caused by severe head trauma. Development: In the event of severe head trauma, intracranial pressure increases, causing intracranial hypertension. When this hypertension cannot be controlled, it becomes refractory, other more aggressive treatments such as decompressive craniectomy are required. This procedure is invasive, it consists of removing part of the skull to reduce the pressure inside the cranial cavity. Conclusions: It is necessary to continue studies of decompressive craniectomy in the management of pediatric cranial hypertension in the child and adolescent population, since studies focused on them are not abundant; these constitute a rescue intervention. Despite scientific advances, therapeutic achievements and knowledge of pediatric cranial hypertension, decompressive craniectomy is considered an optimal therapeutic choice, with fair prediction and not provided when the real options for success are insufficient(AU)

Ultrasonografía del diámetro de la vaina del nervio óptico en voluntarios sanos

Fundamento: La ultrasonografía del diámetro de la vaina del nervio óptico ha sido utilizada como medidor no invasivo de la presión intracraneal. Una de las deficiencias enunciadas resulta, la no existencia de un valor estándar, que sugiera el límite entre la normalidad y la hipertensión intracraneal. Objetivo: Determinar el diámetro de la vaina del nervio óptico mediante ecografía en voluntarios sanos. Métodos: Se realizó un estudio ecológico de poblaciones múltiples en 160 voluntarios sanos que cumplieron con los criterios de inclusión. Se realizaron 3 mediciones ultrasonográficas en modo B en cada ojo, se tomó como valor final el promedio. Las variables estudiadas fueron: edad, sexo, color de la piel y diámetro de la vaina del nervio óptico. Se calculó el porcentaje, media, mediana, límite y estándar. Con un valor de referencia al 95 % del intervalo de confianza. La relación entre las variables se determinó mediante análisis de regresión logística simple con el paquete estadístico de SPSS 22.0. Resultados: El diámetro de la vaina del nervio óptico, en los sujetos, se cuantificó entre 4,62 - 4,80 mm y 4,66 - 4,83 mm para los ojos derecho e izquierdo respectivamente. Al análisis de regresión lineal simple, solo el sexo se asoció al valor del diámetro de la vaina del nervio óptico (p= 0,000). Conclusiones: En una población de voluntarios sanos el valor del diámetro de la vaina del nervio óptico fue similar a otras descripciones, con diferencias entre el sexo, lo cual sugiere tomar en consideración esta variable al hacer la medición.

Foundation: Ultrasonography of the diameter of the optic nerve sheath has been used as a non-invasive measure of intracranial pressure. One of the deficiencies stated is the non-existence of a standard value that suggests the limit between normality and intracranial hypertension. Objective: Determine the diameter of the optic nerve sheath using ultrasound in healthy volunteers. Methods: A multi-population ecological study was conducted on 160 healthy volunteers who met the inclusion criteria. Three ultrasonographic measurements were performed in B mode in each eye, the average was taken as the final value. The variables studied were: age, sex, skin color and diameter of the optic nerve sheath. The percentage, mean, median, limit and standard were calculated. With a reference value at the 95% confidence interval. The relationship between the variables was determined by simple logistic regression analysis with the SPSS 22.0 statistical package. Results: That diameter of the optic nerve sheath, in the subjects, was quantified between 4.62 - 4.80 mm and 4.66 - 4.83 mm for the right and left eyes respectively. In the simple linear regression analysis, only sex was associated with the value of the diameter of the optic nerve sheath (p= 0.000). Conclusions: In a population of healthy volunteers, the value of the diameter of the optic nerve sheath was similar to other descriptions, with differences between sex, which suggests taking this variable into consideration when making the measurement.

Advantages of intraventrilular intracranial pressure monitoring with modified paine point puncture in decompression of severe traumatic brain injury / 解放军医学杂志

Objective To explore the advantages of modified Paine point puncture for intraventricular intracranial pressure(ICP)monitoring probe implantation during decompressive craniectomy(DC)for severe traumatic brain injury.Methods The clinical data of 48 patients with severe traumatic brain injury admitted from April 2020 to April 2022 in Jiaxing Second Hospital were retrospectively collected.All patients underwent DC combined with ICP monitoring probe implantation.According to different ICP monitoring methods,they were divided into observation group(23 cases)and control group(25 cases).The observation group underwent the implantation of the intracerebroventricular ICP monitoring probe by puncture at the modified Paine point in the DC incision,while the control group underwent implantation of intracerebroventricular ICP monitoring probe by drilling of the skull through contralateral incision of DC at the Kocher point.The preoperative general data,operation time,postoperative mannitol dose and duration,ICP monitoring duration,postoperative rebleeding rate,intracranial infection rate and Glasgow outcome score(GOS)at 3 months after the operation were compared between the two groups.Results There was no statistical difference between the two groups in general data,mannitol dosage,mannitol duration and ICP monitoring duration(P>0.05).The operation time,postoperative rebleeding rate and intracranial infection rate in observation group were lower than those in control group(P<0.05).In the GOS score at 3 months after the operation,there was no statistical difference between the two groups(P>0.05).Conclusions Compared with the traditional implantation of intraventricular ICP monitoring probe through Kocher point through skull drilling with contralateral incision of DC,the implantation of intraventricular ICP monitoring probe through modified Paine point in the DC incision for severe traumatic brain injury can shorten the operation time and lower the postoperative rebleeding rate and intracranial infection rate.

Long-term mild hypothermia promotes neuroprotection by antagonizing the rebound of intracranial pressure after traumatic brain injury in rats / 天津医药

Objective To explore the optimal duration of long-term mild hypothermia(MHT)for traumatic brain injury(TBI)in rats,and observe its effect on intracranial pressure(ICP)and neurological function.Methods Forty-eight healthy adult male SD rats were divided into the normal temperature treatment(NT)group,the MHT4 h group,the MHT24 h group and the MHT48 h group by random number table method,with twelve rats in each group.The TBI model of rats was prepared by electronic controllable cortical injury device,and ICP monitoring probe was implanted.After modeling,the NT group was treated with normal temperature(37℃),and the other groups were treated with low temperature(33.0±1.0)℃for 4 h,24 h and 48 h,respectively.ICP was monitored and brain water content(BWC)was calculated after MHT treatment in each group.Blood-brain barrier permeability was determined by Evansland(EB)staining.The expression of 5-bromodeoxyuracil nucleoside(BrdU),neuronal nuclear antigen antibody(NeuN)and leukocyte differentiation antigen 86(CD86)positive cells were detected by immunofluorescence staining.The expressions of B-cell lymphoma-2(Bcl-2),Bcl-2 associated X protein(Bax),inducable nitric oxide synthase(iNOS),interleukin(IL)-10 and arginase 1(Arg-1)were detected by Western blot assay.Results Compared with the NT group,levels of BWC,ICP,EB,and CD86 positive cells,Bax and iNOS expression levels were decreased in the MHT4 h group,the MHT24 h group and the MHT48 h group,and the number of BrdU positive cells and BrdU/NeuN double-labeled positive cells were increased in hippocampus.The expression levels of Bcl-2,IL-10 and Arg-1 were increased(P＜0.01).Compared with the MHT24 h group,levels of BWC,ICP and EB,and CD86 positive cells,Bax and iNOS expression were decreased,and the number of BrdU positive cells and BrdU/NeuN double-labeled positive cells were increased in the MHT48 h group,while levels of Bcl-2,IL-10 and Arg-1 expression were increased(P＜0.01).Conclusion Long-term MHT can promote the proliferation and differentiation of neurons,inhibit apoptosis and reduce inflammation by suppressing ICP rebound,further promoting neuroprotection after TBI.

Current research status and development prospects of craniocerebral injury monitoring devices / 医疗卫生装备

The current research status and development history of craniocerebral injury monitoring devices in the world were introduced.The working principles,technical characteristics and deficiencies of invasive and noninvasive craniocerebral injury monitoring devices were analyzed,including intracranial pressure monitor,electroencephalograph and near-infrared cerebral function imager.It's pointed out multimodal monitoring and big data analysis with artificial intelligence would be the trends of craniocerebral injury monitoring devices in the future.[Chinese Medical Equipment Journal,2024,45(1):108-114]

Value of ultrasonic measurement of the ratio of optic nerve sheath diameter to eyeball transverse diameter in the diagnosis and prognosis of intracranial hypertension in patients with craniocerebral trauma / 中国医师进修杂志

Objective:To investigate the value of ultrasonic measurement of the ratio of optic nerve sheath diameter (ONSD) to eyeball transverse diameter(ETD) in the diagnosis and prognosis of intracranial hypertension in patients with craniocerebral trauma.Methods:A total of 120 patients with craniocerebral trauma treated in the Xingtai General Hospital of North China Medical and Health Group from December 2021 to January 2023 were perspectively selected, and they were divided into normal intracranial pressure group (73 cases) and intracranial hypertension group (47 cases) according to the results of intracranial pressure measurements, and the intracranial hypertension group was divided into good prognosis group (20 cases) and poor prognosis group (27 cases) according to the follow-up prognosis. The efficacy of ONSD, ETD and ONSD/ETD in intracranial hypertension diagnosis and prognosis assessment were analyzed by receiver operating characteristic (ROC) curve. Kaplan-Meier method was used to evaluate the 6-month risk of adverse prognosis of patients, and the comparison was made by Log-rank test.Results:The levels of intracranial pressure, ONSD, ONSD/ETD in the normal intracranial pressure group were lower than those in the intracranial hypertension group: (130.73 ± 23.63) mmH 2O (1 mmH 2O = 0.009 8 kPa) vs. (270.11 ± 35.78) mmH 2O, (5.47 ± 0.29) mm vs. (5.78 ± 0.44) mm, 0.246 ± 0.018 vs. 0.263 ± 0.018, there were statistical differences ( P<0.05). The scores of Glasgow Coma Scale (GCS), intracranial pressure, ONSD, ONSD/ETD in the good prognosis group were lower than those in the poor prognosis group: (5.50 ± 1.24) scores vs. (6.41 ± 1.34) scores, (256.15 ± 30.23) mmH 2O vs. (280.44 ± 36.56) mmH 2O, (5.62 ± 0.40) mm vs. (5.90 ± 0.44) mm, 0.254 ± 0.014 vs. 0.270 ± 0.017, there were statistical differences ( P<0.05). ROC curve analysis results showed that the area under the curve (AUC) of ONSD and ONSD/ETD for diagnosing intracranial hypertension in patients with craniocerebral trauma were 0.718 and 0.765, respectively, and the critical values were 5.87 mm and 0.263, respectively. The AUC of ONSD and ONSD/ETD predicting prognosis of intracranial hypertension patients was 0.677 and 0.763, respectively, and the critical values were 5.90 mm and 0.267, respectively. Grouped by the threshold of ONSD/ETD for the prognosis of intracranial hypertension (0.267), the incidence of adverse prognosis in ONSD/ETD > 0.267 group was higher than that in the ONSD/ETD≤0.267 group, there was statistical difference ( P<0.05). Conclusions:ONSD/ETD can be used as an index for diagnosis and prognosis of intracranial hypertension.

Recent advance in intracranial pressure waveform and its application in patients with severe neurological diseases / 中华神经医学杂志

Intracranial pressure (ICP) monitoring is an important way to observe the condition of patients with severe neurological diseases; at present, ICP detection mainly relies on mean ICP, but with the progress of scientific and technological means and deepened research in related fields, ICP waveforms and their related derivative indicators have attracted more and more attention from clinicians. Based on the types and morphologies of ICP waveforms and their related derivative indexes, such as pressure response index and pressure amplitude index, relationships of ICP waveforms with brain tissue compliance and brain tissue lesions, and their clinical application are reviewed to provide some references for application of ICP waveforms in patients with severe neurological diseases.

Issues related to surgical procedures of controlled decompression in the treatment of severe traumatic brain injury / 中华创伤杂志

Severe traumatic brain injury (sTBI) has a high mortality and disability rate, making it a difficult issue and hot topic in neurosurgery. Controlled decompression is an important technique in the treatment of sTBI combined with intracranial hypertension, which can reduce the ischemia-reperfusion injury to the nervous tissue and intracranial vessel and can significantly lower the incidence of complications related to decompressive craniectomy. However, the effects of the controlled decompression technique have been affected by different understandings of the technique and nonstandard surgical procedures in clinical practice. For this purpose, the authors discussed the concept of controlled decompression technique, its indications and the key problems during operation so as to standardize the surgical procedures and improve the therapeutic effects of controlled decompression technique in the treatment of sTBI.

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.

Conocimiento de enfermería en el traumatismo craneoencefálico grave y monitorización de la presión intracraneal

Introducción: El traumatismo craneoencefálico grave es una importante causa de mortalidad e incapacidades en todo el mundo, y la causa más común es el traumatismo cerrado; algunos lo consideran una "epidemia silenciosa". La monitorización de la presión intracraneal, su adecuado registro, y la correcta interpretación de los valores, permiten un diagnóstico y un tratamiento precoz, sin llegar a la hipertensión intracraneal. Objetivo: Identificar el nivel de conocimiento de enfermería en el traumatismo craneoencefálico grave y monitorización de la presión intracraneal. Métodos: Se realizó un estudio analítico observacional, descriptivo y transversal, de desarrollo tecnológico, en la Unidad de Cuidados Intensivos del Hospital Universitario Clínico Quirúrgico Comandante Faustino Pérez Hernández, en el período de enero de 2022 a julio de 2023. El universo estuvo conformado por los 62 enfermeros a los que fueron aplicados el criterio de inclusión (voluntad de participar en el estudio) y de exclusión (enfermeros de estancia transitoria). Se utilizaron la planilla de recolección de datos y un cuestionario. Resultados: El mayor porciento de los enfermeros estudiados fue asistencial a pie de cama; entre los años de experiencia prevaleció de 0-1 año, y las edades de 20-29 años. La aplicación del cuestionario exploró el estado de conocimientos en el nivel Bajo. En la etapa de diagnóstico se constató la necesidad de fortalecer los conocimientos de enfermería en el actuar del paciente con traumatismo craneoencefálico grave y monitorización de la presión intracraneal. Conclusiones: Se diagnosticó la necesidad de fortalecer los conocimientos para el afrontamiento de los cuidados con el paciente con traumatismo craneoencefálico grave.

Introduction: Severe traumatic brain injury is an important cause of mortality and disability worldwide and the most common cause is blunt trauma; some consider it a "silent epidemic." The monitoring of intracranial pressure, its adequate recording, and the correct interpretation of the values allow early diagnosis and treatment, without reaching intracranial hypertension. Objective: To identify the level of nursing knowledge on severe traumatic brain injury and intracranial pressure monitoring. Methods: An observational, descriptive and cross-sectional analytical study of technological development was carried out in the Intensive Care Unit of the Clinical Surgical University Hospital Comandante Faustino Pérez Hernandez, in the period from January 2022 to July 2023. The universe was made up of the 62 nurses to whom the inclusion criteria (the willingness to participate in the study) and exclusion criteria (temporary stay nurses) were applied. The data collection form and a questionnaire were used. Results: The highest percentage of the nurses studied provided care at the bedside; among the years of experiences prevailed from 0-1 year and ages were 20-29 years. The application of the questionnaire explored the level of knowledge at the Low level. In the diagnosis stage, the need to strengthen nursing knowledge on the actions of patient with severe traumatic brain injury and intracranial pressure monitoring was confirmed. Conclusions: It was diagnosed the need to strengthen knowledge to cope with care for patients with traumatic brain injury.

Decompressive Craniectomy in Extensive Ischemic Stroke. An Experience in a Single Institution / Craniectomia descompressiva no acidente vascular cerebral isquêmico extenso. Uma experiência em uma única instituição

Introduction Decompressive craniectomy (DC) is a valuable treatment for reducing early lethality in malignant intracranial hypertension (IH); however, it has been shown that the decision to implement DC in patients with extensive ischemic stroke should not be based solely on the detection of IH with the use of intracranial pressure (ICP) devices. Objective To establish the usefulness of DC in patients with extensive ischemic stroke who came to the emergency room during the period between May 2018 and March 2019. Methods This was an analytical, prospective, and longitudinal study whose population corresponded to all patients with a diagnosis of extensive ischemic stroke. Results The sample consisted of 5 patients, of which 3 were female and 2 males, the average age was 62.2 years old (minimum 49 years old, maximum 77 years old). Of all the patients who underwent DC, it was found that 80% of the patients did not present an increase in intracranial pressure. Decompressive craniectomy was not performed in a case that responded adequately to medical treatment. The mean values of ICP were 25 mmHg with a minimum value of 20 mmHg and a maximum value of 25 mmHg; in patients with a moderate value, the ICP averages were < 20 mmHg. The mortality was of 40% (RANKIN of 6 points). Conclusions Decompressive craniectomy is useful in extensive ischemic stroke. The decision to implement DC in patients with extensive stroke rests on clinicoradiological parameters. The monitoring of the IPC was not particularly useful in the early detection of the neurological deterioration of the patients studied.

Fundamento A craniectomia descompressiva (CD) é um tratamento valioso para reduzir a letalidade precoce na hipertensão intracraniana (HI) maligna; no entanto, foi demonstrado que a decisão de implementar a CD em pacientes com acidente vascular cerebral (AVC) isquêmico extenso não deve ser baseada apenas na detecção de HI com o uso de dispositivos de pressão intracraniana (PIC). Objetivo Estabelecer a utilidade da CD em pacientes com AVC isquêmico extenso que chegaram ao pronto-socorro no período entre maio de 2018 e março de 2019. Métodos Foi realizado um estudo analítico, prospectivo e longitudinal cuja população correspondeu a todos os pacientes com diagnóstico de AVC isquêmico extenso. Resultados A amostra foi composta por 5 pacientes, sendo 3 do sexo feminino e 2 do sexo masculino, com média de idade de 62,2 anos (mínimo 49 anos, máximo 77 anos). De todos os pacientes que realizaram CD, verificou-se que 80% dos pacientes não apresentaram aumento da pressão intracraniana. Não foi realizada uma CD que tenha respondido adequadamente ao tratamento médico. Os valores médios de pressão intracraniana foram de 25 mmHg, com o valor mínimo de 20 mmHg e o valor máximo de 25 mmHg; em pacientes com escala moderada, as médias de PIC foram < 20 mm Hg. A mortalidade foi de 40% (RANKIN de 6 pontos). Conclusões A DC é útil no AVC isquêmico extenso. A decisão de implementar uma CD em pacientes com AVC extenso depende de parâmetros clínico-radiológicos. O monitoramento do PCI não foi muito útil na detecção precoce da deterioração neurológica dos pacientes estudados.

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.

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.

Ecografía de nervio óptico para estimar hipertensión intracraneal en pacientes adultos con neurotrauma / Optic Nerve Ultrasound to Estimate Intracranial Hypertension in Adult Patients with 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(AU)

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(AU)

Manuel Balado y las diferenciasde presión craneal y espinal / Manuel Balado and the cranial and spinal pressure differences

Manuel Balado (1897-1942), pionero de la neurocirugía argentina, es más conocido por sus estudios sobre la vía óptica y la sistematización de la iodoventriculografía. Sus inquietudes, sin embargo, abarcaron numerosos otros campos, siendo uno de ellos la existencia de diferencias de presión entre compartimientos craneales y espinales. En sus Lecciones de Cirugía Neurológica, el primer texto exclusivo de la especialidad en la Argentina, hizo una descripción original de los mismos. Reproducimos aquí varios de los mismos, la mayoría aún válidos, y los analizamos en su contexto y a la luz de los conocimientos actuales. No hemos hallado descripciones similares en la bibliografía de su tiempo(AU)

Manuel Balado (1897-1942), a pioneer of Argentinian neurosurgery, is best known for his studies on the optic pathway and iodoventriculography. Their concerns, however, encompassed numerous other fields, one of them being the pressure differences between the cranial and spinal compartments. In his Lessons on Neurological Surgery, the first exclusive text of the specialty in Argentina, he made an original description of them. We reproduce here several of his schemes, most of them still valid, and we analyze them in their context and in the light of current knowledge. We did not find similar descriptions in the bibliography of his time(AU)

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.

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.

Non-invasive study of intracranial pressure in pre- and post-chemotherapy patients for the treatment of breast neoplasia / Estudo não-invasivo da pressão intracraniana pré e pós-quimioterapia em pacientes em tratamento para câncer de mama

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.

INTRODUÇÃO: O câncer de mama é o tipo mais comum entre as mulheres e traz para elas significativas alterações orgânicas. Um novo método de monitoramento da pressão intracraniana consiste em um sistema externo de sensores que detecta deformações micrométricas nos ossos cranianos e transmite, em tempo real, sinais elétricos que são visualizados em um monitor. OBJETIVO: Identificar alterações na pressão intracraniana devido às conexões de quimioterapia por meio de metodologia não invasiva. MÉTODOS: O presente estudo foi realizado no Hospital Santa Casa de Misericórdia da cidade de Ponta Grossa, PR, Brasil, em 2017. Foram avaliadas as variáveis relação P2/P1 (avaliação morfológica da PIC), parâmetros laboratoriais, comorbidades e aspectos clínicos dos voluntários. A toxicidade vascular da quimioterapia frequentemente causa disfunção endotelial, resultando na perda dos efeitos vasodilatadores e suprime as funções anti-inflamatórias e de reparo vascular. RESULTADOS: Os valores da relação P2/P1 antes e após a quimioterapia também foram comparados entre os grupos. Uma diferença estatisticamente significativa foi observada nos valores de P2/P1 pré-quimioterapia em comparação com os valores pós-quimioterapia. CONCLUSÃO: Variações na PIC podem ocorrer em pacientes com câncer. Mais estudos são necessários para avaliar se essa alteração pode contribuir para a ocorrência dos efeitos colaterais da quimioterapia.