Hemodynamic effects of mannitol infusion in patients with acute intracerebral hemorrhage

PURPOSE: To evaluate hemodynamic effects of mannitol infusion in patients with acute intracerebral hemorrhage. METHODS: Thirty patients with acute intracerebral hemorrhage were enrolled. Transcranial doppler was used to detect variables of bilateral middle cerebral arteria (MCA) including mean velocity (Vm) and pulsitility index (PI) before and after125ml and 250ml mannitol infusion (0, 30, 60, 90, 120, 180, 240 min). RESULTS: When 125ml or 250ml mannitol was infused in patients with acute intracerebral hemorrhage, Vm of bilateral MCA elevated, and reached the top at 30min, and then decreased. PI decreased in the affected MCA (250ml) and in the unaffected MCA (125ml and 250ml). CONCLUSION: Mannitol infusion in patients with acute intracerebral hemorrhage can improve cerebral blood flow in bilateral hemispheres and decrease intracranial pressure in the hemorrhagic hemisphere (250ml) and in the nonhemorrhagic hemisphere (125ml and 250ml).

Aspectos de segurança do tratamento com hrGH: [revisão] / Safety aspects of treatments with hrGH: [review]

O tratamento com hormônio de crescimento recombinante humano (hrGH) tem sido realizado há mais de 20 anos, visto que seu perfil de segurança é considerado excelente. Nos principais bancos de dados internacionais, os eventos adversos relatados são raros, principalmente em pacientes com deficiência isolada do hormônio de crescimento e na baixa estatura idiopática. Em relação à associação com risco de malignidade ou de recorrência tumoral, os dados sugerem que não há maior incidência em pacientes em uso de hrGH do que na população geral. A hipertensão intracraniana benigna é rara, porém sua incidência é maior em pacientes com insuficiência renal crônica. Apesar de os eventos adversos serem raros, é importante manter a monitorização cuidadosa dos pacientes em uso do hrGH, principalmente aqueles em uso de doses farmacológicas ou com patologias associadas que confiram maior risco de complicação.

Recombinant human growth hormone (hrGH) has been used for treatment of growth hormone deficient children over 20 years and it can be considered to have an excellent safety profile. The main international surveys show few adverse drug reactions reported, specially in idiopathic growth hormone deficiency and in idiopathic short stature. With regard to cancer risk or tumor recurrence, it seems that there is no greater risk with hrGH treatment in comparison to general population. The idiopathic intracranial hypertension is a rare condition, but its incidence is higher in patients with chronic renal failure. The adverse events are rare in patients treated with hrGH, but these patients should be carefully monitored, specially those with pharmacologycal doses or with another clinical condition of greater risk.

[ effect of sex steroid hormones on brain edema and intracranial pressure after experimental traumatic brain injury in rats]

We investigated the role of sex hormones on changes in brain edema intracranial pressure [ICP], cerebral perfusion pressure [CCP] after trauma brain injury [TBI] in ovarectomized female [OVX] rats. In this study female rats are divided into five groups. Control group [Intact] sham group and other groups include: vehicle, estrogen group [1mg/kg] and progesterone group [8 mg/kg] which on all groups TBI was induced by Marmarou method. 30 minutes after TBI, drugs were injected i.p. ICP was measured in spinal cord using a standard procedure. CPP was calculated by the mean arterial pressure [MAP] - ICP. Neurologic scores were measured by motor, eye and respiratory reflex. The results showed after TBI, water content was significantly lower in estrogen and progesterone groups [P<0.001] compared with vehicle group. Analysis showed a stable ICP up to 24 hours. The ICP in estrogen and progesterone groups was significantly decreased at 4 and 24 hours as compared to vehicle group [P<0.001in both cases]. The CPP at 24 hours after TBI, significantly increased in estrogen and progesterone groups compared with vehicle [P<0.001]. Also after TBI, neurologic scores was significantly higher in estrogen and progesterone groups as compared with vehicle [at 1 hours P<0.05, and at 24hours P<0.001 for estrogen], [at 1 hours P<0.01 for progesterone]. Our findings indicated an improvement of ICP, CPP and neurologic scores produced by pharmacologic doses of estrogen and progesterone after TBI in OVX rat. These effects may be contribute to neuroprotective effects of these hormones

Hypertonic saline solution increases cerebral perfusion pressure during clinical orthotopic liver transplantation for fulminant hepatic failure: preliminary results

Neste estudo testamos a hipótese de que os efeitos benéficos decorrentes da administração da solução salina hipertônica (NaCl 7,5%, 4 mL/kg) sobre a hemodinâmica sistêmica e cerebral na hipertensão intracraniana e no choque hemorrágico, possam atenuar a diminuição da pressão de perfusão cerebral que freqüentemente acompanha o transplante do fígado para hepatite fulminante.MÉTODO: Foram estudados 10 pacientes com hepatite fulminante em encefalopatia grau IV e monitorização de pressão intracraniana submetidos ao transplante do fígado. A hemodinâmica sistêmica e cerebral de 3 pacientes que receberam solução salina hipertônica durante a fase anepática (Grupo SSH) foi analisada comparando com os dados obtidos de 7 pacientes transplantados anteriormente nas mesmas condições (Grupo Controle). Os valores de pressão intracraniana máxima e a correspondente pressão arterial média foram coletados em quatro tempos: (T1) nos últimos 10 min da fase de disseccão, (T2) nos primeiros 10 minutos da fase anepática, (T3) no final da fase anepática e (T4) nos primeiros 5 min da reperfusão.RESULTADO: Imediatamente após a infusão da solução salina hipertônica a pressão intracraniana diminuiu 50,4%. Nos primeiros 5 min da reperfusão a pressão intracraniana no Grupo SSH se manteve estável e todos os pacientes apresentavam pressão intracraniana menor que 20 mmHg enquanto no Grupo Controle a pressão intracraniana aumentou 46,5% (p<0,001). O Grupo SSH apresentou maior estabilidade hemodinâmica, nos primeiros 5 min da reperfusão hepática, a pressão arterial média no Grupo SSH aumentou 21,1% e no Grupo Controle diminuiu 11,1% (p<0,001). Nos primeiros 5 min da reperfusão a pressão de perfusão cerebral no Grupo SSH aumentou 28,3% e no Grupo Controle diminuiu 28,5% (p< 0,001). A natremia no final da fase anepáica e após 3 horas da reperfusão foi significativamente maior no Grupo SSH (153.00 ± 2.66 and 149.00 ± 1.73 mEq/L) que no Grupo Controle (143.71 ± 3.30 and 142.43 ± 1.72 mEq/L), p=0.003 e p< 0.001 respectivamente.CONCLUSÃO: Estes resultados sugerem que a solução salina hipertônica pode ser utilizada com sucesso como medida neuroprotetora no transplante de fígado para hepatite fulminante, promovendo diminuição efetiva da pressão intracraniana e estabilidade cardiocirculatória, proporcionando aumento sustentado da PPC durante a cirurgia.

Effects of Hypertonic (7%) Saline on Brain Injury in Experimental Escherichia coli Meningitis

We sought to know whether hypertonic (7%) saline (HTS) attenuates brain injury by improving cerebral perfusion pressure (CPP) and down-modulating acute inflammatory responses in experimental bacterial meningitis in the newborn piglet. Twenty-five newborn piglets were assorted into three groups: 6 in the control group (C), 10 in the meningitis group (M), and 9 in the meningitis with HTS infusion group (H). Meningitis was induced by intracisternal injection of 10(8) colony forming units of Escherichia coli in 100 microliter of saline. 10 mL/kg of HTS was given intravenously as a bolus 6 hr after induction of meningitis, thereafter the infusion rate was adjusted to maintain the serum sodium level between 150 and 160 mEq/L. HTS significantly attenuated meningitis-induced brain cell membrane disintegration and dysfunction, as indicated by increased lipid peroxidation products and decreased Na+, K+-ATPase activity in the cerebral cortex in M. HTS significantly attenuated acute inflammatory markers such as increased intracranial pressure, elevated lactate level and pleocytosis in the cerebrospinal fluid observed in M. Reduced CPP observed in M was also significantly improved with HTS infusion. These findings implicate some attenuation of the meningitis-induced alterations in cerebral cortical cell membrane structure and function with HTS, possibly by improving CPP and attenuating acute inflammatory responses.

Current concepts in the management of acute ischemic stroke.

The treatment of stroke is multifaceted, and is governed by three, well established goals: 1) To minimize the extent of brain; 2) To medically support the stroke patient; and 3) To prevent further brain injury secondary to initial event or repeated vascular insults. Certain guidelines for emergency care, based on clinical experience and knowledge of pathophysiology, have been accepted in many institutions as the standard. This article provides guidelines about the current management of acute ischemic stroke based on currently available data from clinical trials. The target audiences for this article are emergency room physicians and neurologists, who manage the patients during the first few hours after stroke.

Effect of pipecuronium and pancuronium on intracranial pressure and cardiovascular parameters in patients with supratentorial tumours.

A prospective, randomised, single blind study was conducted to evaluate and compare the intracranial pressure (ICP) and cardiovascular effects of pipecuronium (PPC) and pancuronium (PNC) in 20 patients undergoing supratentorial surgery. Patients were randomly divided into two groups. Patients in Group I (n = 10) received pancuronium (0.1 mg kg(-1)) and in Group II (n = 10) pipecuronium (0.07 mg kg(-1)) for intubation. Intracranial pressure (ICP), heart rate (HR), systolic, diastolic and mean arterial pressures (SAP, DAP, MAP), central venous pressure (CVP), nasopharyngeal temperature and arterial blood gases (ABG) were monitored at the following time periods: before induction (0 minutes); 3 minutes after thiopentone and muscle relaxant; immediately after intubation; and 4, 6, 8, 10, 20 and 30 minutes following intubation. The rise in intracranial pressure at intubation was significantly greater in group I (21.10+/-3.97 torr, 122.59%) when compared to group II patients (1.80+/-0.70 torr, 10.04%) (p<0.0 1). Cardiovascular parameters also showed a significantly greater degree of rise in group I when compared to group II patients. Heart rate increased by 29+/-6.32 beats min(-1) (33.52%) and systolic arterial pressure by 11.60+/-7.37 torr (9.47%) in group I. These parameters did not change significantly in group II. No significant alterations were observed in the other measured parameters in either of the two groups.

Dexametasona en meningitis bacteriana aguda del niño: un análisis métrico / Dexamethasone in acute bacterial meningitis in children: a metric analysis

Recientemente se ha puesto en duda la utilidad en el manejo de la meningitis bacteriana aguda en niños, planteando un serio problema de desición clínica. Ya que el uso de dexametasona no sólo tiene bases empíricas, se revisaron los respaldos biológicos de su empleo, así como ensayos clínicos controlados en niños. 5 estudios cumplieron los criterios de inclusión. Los resultados respaldan el empleo de dexamentasona en la prevención de secuelas neurológicas (RR= 2,37; IC: 95 por ciento= 1,34 a 4,22; p <0,004) y audiológicas (RR= 2,25; IC: 95 por ciento= 1,59 a 3,2; p <0,00003). Las diferencias entre los resultados de los estudios pueden explicarse por la falta de compatibilidad (desigualdades en la duración de la enfermedad antes del diagnóstico, tratamientos y etiología). Aunque los efectos de la dexametasona no son de la magnitud esperada de los fundamentos biológicos, el esteroide disminuye los impactos globales neurólogicos y audiológicos en los sobrevivientes y debería considerarse como terapia adjunta en meningitis bacteriana aguda, para emplearla con la debida cautela a las interrogantes sobre covariables tales como la etiología

Neuromonitorización transoperatoria / Transoperative neuromonitoring

El proposito de este capítulo es revisar la neuromonitorización en quirófano coincidiendo con los metodos actuales y trasmitir nuestra experiencia en la práctica de ellos en nuestro hospital. En quirófano la monitorización de las variables más frecuentes (frecuencia cardiaca, presión arterial, SaO2, temperatura, hemoglobina), son visualizados en forma continua como un monitoreo básico. Estos son de valor para mostrar en todo momento lo referente al flujo sanguíneo cerebral en su componente arterial, de la presión de perfusión cerebral (PPC). El componente venoso es la presión en las venas en el espacio subaracnoideo, esto es bien medido por la presión intracraneana (PIC). La actividad eléctricacerebral (EEG), potenciales evocados (PE), saturación venosa yugularde oxigeno (SVjO2); son monitoreos avanzados empleados en forma opcional, dependiendo de las necesidades quirúrgicas y de la capacidad económica del hospital

Comparative effect of hypertonic saline and mannitol on intracranial pressure, electrolyte changes and some haemodynamic functions in brain tumour surgery

This work was done on 20 adults patients scheduled for elective brain surgery to compare the effects of hypertonic saline 7.5% [in a dose of 4 ml/kg infused over 10 minutes] and mannitol 20% [in a dose of 1 g/kg]. It was found that hypertonic saline improved circulation by plasma volume expansion with significant increase in MABP and CVP and significant increase in AMBP and CVP and reduction of brain bulk more than mannitol. Serum sodium and osmolality was elevated more with hypertonic saline than in mannitol, while serum potassium was more maintained with hypertonic saline than with mannitol. Urine output increased gradually in hypertonic saline, while in mannitol, there was rapid diuresis. Hypertonic saline is recommended to be a safe method for reduction of ICP

effect of lidocaine versus nalbuphine hydrochlorides and phenobarbital as permedicants for control of acute intracranial hypertension, experimental study

Forty adult male cats were randomly collected and divided into four equal groups. The first group was considered as control, B, C, D groups were pretreated with lidocaine 1.5 mg/kg, nalbuphine 0.5 mg/kg and phenobarbital 0.5 mg/kg. A rubber balloon catheter was inserted extradurally after right craniectomy and inflated by saline as 1 cm bolus every one minute. Intracranial pressure, cerebral perfusion pressure, brain compliance and cerebro-spinal pH were estimated after each bolus saline injection to study and compare the effectiveness of lidocaine, nalbuphine and phenobarbital as premedicants for the brain protection against the rapid increase in the intracranial tension. Results showed that lidocaine was the most protective one, followed by phenobarbital and then nalbuphine. Lidocaine significantly increases the tolerance of the cranial cavity to accept added volumes before the onset of brain ischemia

Effect of diprivan on intracranial pressure in patients with head injuries

The effects of diprivan bolus dose on intracranial pressure [ICP] were studied in 10 male patients with head injuries and brain oedema. Diprivan 2.0mg/kg injected intravenously over 60s caused statistically significant reduction [p < 0.05] in ICP and cerebral perfusion pressure [CPP] with maximum reduction at 3.0 min. CPP was maintained above 50 mm Hg in all measurements. Arterial blood pressure was decreased significantly [p < 0.05] with the lowest values occurring at 3.0 min for both systolic and mean blood pressure and at 7.0 min for diastolic blood pressure. Heart rate showed no significant change, except at 1-min intervals, where a significant increase was found [p < 0.05]. We conclude that diprivan is effective in lowering ICP, while its lowering effect on CCP needs further investigation

Effects of propofol and thiopental sodium on the intracranial pressure under halothane or isoflurane anesthesia in the rabbit

The effects of halothane or isoflurane, alone and in combination with propofol or thiopental were investigated for their effects on intracranial pressure (ICP) in the rabbit, with inducing artificially-increased ICP with an intracranial balloon. The higher the end-tidal concentrations of either halothane or isoflurane, the lower the mean arterial pressures (MAP) and cerebral perfusion pressures (CPP). However, the ICP was not influenced by the depth of anesthesia for either inhalation anesthetics. The mean ICPs at 1.5 MAC of halothane and isoflurane were 14 +/- 2 and 20 +/- 2 mmHg, respectively. With the increase of intracranial volume using a 0.7 ml-saline balloon, the ICPs were increased to 193 and 205% in halothane and isoflurane anesthesia, respectively. The ICPs were returned to the levels prior to balloon inflation by the injection of thiopental or propofol. The authors conclude that propofol could be used to reduce ICP under halothane or isoflurane anesthesia if it is ascertained to have the characteristics of a balanced coupling between cerebral metabolism and blood flow like barbiturates do and that either halothane or isoflurane with increased concentrations may decrease MAP without significant change of ICP.

The treatment of neurocysticercosis with praziquantel.

Twenty-five patients with cerebral cysticercosis admitted to the Bangkok Hospital for Tropical Diseases from March 1987 to November 1989 were studied. The patients had a mean age of 41 +/- 5 years with a mean body weight of 57 +/- 4 kgs. Male to female ratio was 1.5:1. Eight patients (32%) gave a history of having taeniasis with a mean duration of 3.6 years before having symptoms of cerebral cysticercosis. Six patients (24%) also had subcutaneous cysticercosis with a duration of 20 +/- 8 months. The important clinical symptoms were headache, focal seizure, epilepsy and dementia. Fourteen patients (56%) had headache, 12 patients (48%) had focal seizure and four patients (16%) had a mild degree of dementia. Baseline study included routine blood examination, biochemical tests, cerebrospinal fluid for routine examinations and immunological study. Biopsy of subcutaneous cysts, plain films of soft tissue and computerized tomography of brain. Praziquantel was given orally at a dosage of 45 mg/kg/day in 3 divided doses at 4-5 hour interval for 15 days. Patients who were taking anti-epileptic drugs before were permitted to continue their medications. The evaluation of results of treatment was done a year post treatment, ten patients (40%) were asymptomatic, 12 patients (48%) had much clinical improvement, their epileptic attack was controlled by 1-2 tablets of phenobarbital (1/2 g) at bedtime. Two patients (8%) had mild headache. One patient (4%) was not improved. Those patients with dementia were not improved.(ABSTRACT TRUNCATED AT 250 WORDS)

Efectos de bajas dosis de droperidol-fentanil sobre la presión de perfusión cerebral en pacientes con lesión expansiva intracraneal / Effects of low doses of droperidol-fetanyl on cerebral perfusion pressure in patients with expansive intracranial lesion

Se analizó el efecto del droperidol-fentanil (DF) proporción 50: 1) administrado como premedicación inmediata en cinco pacientes con lesiones expansivas intracraneales, sobre la Presión Intracraneal (PIC), Presión Arterial Media (PAM) y Presion de Perfusión Cerebral (PPC). Las determinaciones fueron efectuadas en el período basal, sobreelevando la cabeza 35- y siete minutos después de haber administrado el fármaco. Se concluyó que el DF en pacientes respirando espontáneamente al disminuir la PAM y aumentar la PIC, produce un pinzamiento riesgoso de la PPC. El aumento de la PIC podría explicarse por el incremento de la pCO2 arterial, excepto en un caso

Efeitos do diazóxido sobre a pressäo intracraniana e o diâmetro dos vasos piais: estudo experimental em cäes / Effects of the diazoxide in intracranial pressure and the diameter of pial vessels: experimental study in dogs

Várias drogas têm sido utilizadas em neurocirurgia para evitar o aumento da pressäo intracraniana e o espasmo de vasos cerebrais. O diazóxido, um agente hipotensor de açäo direta sobre a musculatura lisa dos vasos ainda näo foi estudado. Dessa maneira resolvemos pesquisar os efeitos dessa droga, administrada por via venosa (3 mg.kg-1) sobre a pressäo intracraniana e o diâmetro dos vasos piais em 16 cäes. Os animais foram divididos em dois grupos de 8. No grupo 1 foi estudado o efeito do diazóxido sobre a pressäo intracraniana, medida através de uma agulha colocada na cisterna magna, ligada a um transdutor e a um fisiógrafo. Ao mesmo tempo se registrava a pressäo arterial e se media o pH, PaO2 e PaCO2, nos tempos 1 (antes) 2,3 e 4 (1,15 e 30 min) após a injeçäo da droga. No grupo 2, media-se o diâmetro de arteríolas e vênulas piais através de uma perfuraçäo na regiäo craniana parieto-temporal e fotografia dos vasos piais nos mesmos tempos empregados no grupo anterior. Eram realizadas também medidas da pressäo arterial e dos gases sangüíneos. Observou-se que o diazóxido determina hipotensäo arterial logo após a sua injeçäo venosa, que persiste por 30 minutos. Ao mesmo tempo induz aumento significante do diâmetro das arteríolas piais. Näo há variaçäo significante da pressäo intracraniana e das vênulas piais. Esses resultados sugerem a possibilidade do uso dessa droga na profilaxia e no tratamento de espasmos vasculares cerebrais