Ultrasound of the Optic Nerve Does Not Appear to Be a Consistently Reliable or Generalizable Method to Monitor Changes in Intracranial Pressure.

OBJECTIVE: Invasive intracranial pressure (ICP) monitoring is the gold standard, but is not always readily accessible or practical. Ultrasound of the optic nerve sheath diameter (ONSD) has been proposed for detecting both elevation and change in the ICP. Our study is a prospective observational trial that seeks to determine if ultrasound can be reliably used to identify changes in ICP with naturally occurring variations in patient care. METHODS: A convenience sample of patients with invasive ICP monitoring were enrolled. Patients were identified prior to interventions that were suspected to cause a change in ICP. Measurement of ICP and ONSD was obtained prior to the intervention, with repeated measurements of both variables obtained immediately following the intervention. RESULTS: 36 total patients were enrolled. There was a positive correlation between the ICP and the right ONSD (r = 0.255, P = 0.0003) and the ICP and the left ONSD (r = 0.274, P < 0.0001). There was no statistically significant relationship between the change in either the ICP and the right ONSD (r -0.2 P = 0.282) or left ONSD (r 0.05 P = 0.805). The location of the lesion in the brain appears to significantly affect discordance between the ONSD and the ICP. CONCLUSIONS: Ultrasound of the ONSD has shown promise as both a marker of elevated ICP and as a method to identify changes in pressure. Although the size of the ONSD and the measurement of ICP were correlated in our study, the ability to follow changes in ICP was not statistically significant. This indicates that use of ultrasound to track changes in ICP cannot be generalized and may be limited to specific circumstances. The location of the intracranial pathology appears to be a significant factor in discordance between the ICP and ONS diameter.

Management of cerebrospinal fluid leak from cervical gunshot wounds with external ventricular drainage: a small case series.

Historically, the surgical management of gunshot wounds to the spine has been controversial. Repair of a persistent cerebrospinal fluid (CSF) leak is a generally agreed upon indication. The management of such CSF leaks typically involves lumbar drainage or direct surgical repair. Here, the authors report two cases of CSF diversion with an external ventricular drain (EVD) in patients with cervical gunshot wounds. Both patients had spinal canal obliteration or physiologic myelographic block at or below the level of injury. To the best of the author's knowledge, these are the first two reports of successful EVD treatment of persistent CSF leaks related cervical gunshot wounds. The authors also propose a CSF treatment algorithm for cervical gunshot wounds that includes EVD.

MicroRNA Regulatory Network as Biomarkers of Late Seizure in Patients with Spontaneous Intracerebral Hemorrhage.

Approximately 15% of patients experience seizures after spontaneous intracerebral hemorrhage (ICH). The pathogenesis of seizures post-ICH is not well-known; however, iron deposition-related neuronal injury following hemoglobin breakdown may contribute. Profiling known miRNAs to identify biomarkers for post-ICH late seizures, we found 64 differentially expressed miRNA: 32 upregulated and 32 downregulated in seizure vs. non-seizure. Functional classification of upregulated miRNA for KEGG pathways and biological processes identified enrichment for cell cycle, protein modifications, and FoxO neurotrophin signaling pathways. No significant enrichment was found for downregulated miRNA. Molecular functions Gene Ontology (GO) terms enriched for upregulated miRNA are numerous, while downregulated miRNAs were associated with ion channel activity. RT-PCR confirmed two miRNAs, 4317 and 4325, were differentially expressed in patients who developed seizures at 1 year. MiR-4317 regulates SLC38A1, a glutamine-glutamate transporter. Integrated miRNA-mRNA network analysis identified COMMD6, APOBEC2, and RASSF6-involved in NF-kB regulation. Two miRNAs (miR-4317 and 4325) differentiated post-ICH late seizures vs. non-seizures at 1 year. The results suggest functional and miRNA-mRNA networks as potential biomarkers for post-ICH late seizures.

A case series of penetrating spinal trauma: comparisons to blunt trauma, surgical indications, and outcomes.

OBJECTIVEWhile blunt spinal trauma accounts for the majority of spine trauma, penetrating injuries affect a substantial number of patients. The goal of this study was to examine the epidemiology of penetrating spine injuries compared with blunt injuries and review the operative interventions and outcomes in the penetrating spine injury group.METHODSThe prospectively maintained trauma database was queried for spinal fractures from 2012 to 2018. Charts from patients with penetrating spine trauma were reviewed.RESULTSA total of 1130 patients were evaluated for traumatic spinal fractures; 154 injuries (13.6%) were secondary to penetrating injuries. Patients with penetrating injuries were significantly younger (29.2 years vs 44.1 years, p < 0.001), more likely male (87.7% vs 69.2%, p < 0.001), and more commonly African American (80.5% vs 33.3%, p < 0.05). When comparing primary insurers, the penetrating group had a significantly higher percentage of patients covered by Medicaid (60.4% vs 32.6%, p < 0.05) or prison (3.9% vs 0.1%, p < 0.05) or being uninsured (17.5% vs 10.3%, p < 0.05). The penetrating group had a higher Injury Severity Score on admission (20.2 vs 15.6, p < 0.001) and longer hospital length of stay (20.1 days vs 10.3 days, p < 0.001) and were less likely to be discharged home (51.3% vs 65.1%, p < 0.05). Of the penetrating injuries, 142 (92.2%) were due to firearms. Sixty-three patients (40.9%) with penetrating injuries had a concomitant spinal cord or cauda equina injury. Of those, 44 (69.8%) had an American Spinal Injury Association Impairment Scale (AIS) grade of A. Ten patients (15.9%) improved at least 1 AIS grade, while 2 patients (3.2%) declined at least 1 AIS grade. Nine patients with penetrating injuries underwent neurosurgical intervention: 5 for spinal instability, 4 for compressive lesions with declining neurological examination results, and 2 for infectious concerns, with some patients having multiple indications. Patients undergoing neurosurgical intervention did not show a significantly greater change in AIS grade than those who did not. No patient experienced a complication directly related to neurosurgical intervention.CONCLUSIONSPenetrating spinal trauma affects a younger, more publicly funded cohort than blunt spinal trauma. These patients utilize more healthcare resources and are more severely injured. Surgery is undertaken for limiting progression of neurological deficit, stabilization, or infection control.