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Midline shift in patients with closed traumatic brain injury may be driven by cerebral perfusion pressure not intracranial pressure

Abstract

BACKGROUND:

In traumatic brain injury (TBI), swelling may disturb the potentially uniform pressure distribution in the brain, producing sustained intercompartmental pressure gradients which may associate with midline shift. The presence of pressure gradients is often neglected since bilateral invasive intracranial pressure (ICP) monitoring is not usually considered because of risks and high costs. We evaluated the presence of interhemispheric pressure gradients using bilateral transcranial Doppler (TCD) as means for non-invasive ICP (nICP) monitoring in TBI patients presenting midline shift.

METHODS:

From a retrospective cohort of 97 TBI patients with arterial blood pressure (ABP), ICP and bilateral TCD monitoring, 24 presented unilateral lesion and midline shift confirmed by computer tomography. nICP and non-invasive cerebral perfusion pressure (nCPP) on the left and right brain hemispheres were retrospectively calculated using a mathematical model associating TCD-derived cerebral blood flow velocity and ABP.

RESULTS:

The nCPP difference was correlated with midline shift (R=-0.34, p<.01) showing a tendency to record higher CPP at the side of expansion. Accordingly, nICP at the side of expansion was significantly lower in comparison to the compressed side (18.86 [±5.71] mmHg (mean ± standard deviation) versus 20.30 [±6.78] mmHg for expansion and compressed sides, respectively). Subsequently, nCPP was greater on the side of brain expansion (79.48±7.84, 78.03±8.93 mmHg [p<.01], for expansion and compressed sides, respectively).

CONCLUSIONS:

TCD-based interhemispheric nCPP difference showed significant correlation with midline shift. Cerebral perfusion pressure was greater on the side of brain expansion, acting as the driving force to shift brain structures.

IMPORTANTE ARTIGO EXPANDINDO OS CONHECIMENTOS DA MONITORAÇÃO NÃO INVASIVA DA PRESSÃO INTRACRANIANA ATRAVÉS DO DOPPLER TRANSCRANIANO E PROVENDO DADOS PARA INTERVENÇÃO ATRAVÉS DO MANUSEIO DA VOLEMIA ENCEFÁLICA NO CONTROLE  DOS DESVIOS DE TECIDO CEREBRAL (HÉRNIAS) PROMOVIDOS  POR ASSIMETRIAS NA PRESSÃO DE PERFUSÃO CEREBRAL.

LINK

A comparison of non-invasive versus invasive measures of intracranial pressure in hypoxic ischaemic brain injury after cardiac arrest.

Abstract

AIM:

Increased intracranial pressure (ICP) in hypoxic ischaemic brain injury (HIBI) can cause secondary ischaemic brain injury and culminate in brain death. Invasive ICP monitoring is limited by associated risks in HIBI patients. We sought to evaluate the agreement between invasive ICP measurements and non-invasive estimators of ICP (nICP) in HIBI patients.

METHODS:

Eligible consecutive adult (age > 18) cardiac arrest patients with HIBI were included as part of a single center prospective interventional study. Invasive ICP monitoring was undertaken and nICP measurements were undertaken using: a) transcranial Doppler ultrasonography (TCD), b) optic nerve sheet diameter ultrasound (ONSD) and c) jugular venous bulb pressure (JVP). Multiple measurements applied in linear mixed-effects models were considered to obtain the correlation coefficient between ICP and nICP as well as their prediction ability to detect intracranial hypertension (ICP ≥20 mm Hg).

RESULTS:

Eleven patients were included (median age of 47 [range 20-71], 8 male and 3 female). There was a linear relationship between ICP and nICP with ONSD (R = 0.53 [p < 0.0001]), JVP (R = 0.38 [p < 0.001]) and TCD (R = 0.30 [p < 0.01]). The ability to predict intracranial hypertension was highest for ONSD and TCD (AUC = 0.96 [95% CI: 0.90-1.00] and AUC = 0.91 [95% CI: 0.83-1.00], respectively). JVP presented the weakest prediction ability (AUC = 0.75 [95% CI: 0.56-0.94]).

CONCLUSIONS:

ONSD and TCD methods demonstrated agreement with invasively-monitored ICP, suggesting their potential roles in the detection of intracranial hypertension in HIBI after cardiac arrest.

LINK

Artigo fortalece a utilização de ferramentas não invasivas de monitorização multimodal à beira leito

em pacientes instáveis.

Advances in Neurotrauma Management

KEY POINTS 

Neurotrauma is the leading cause of trauma-related death in patients ages 1 to 45 years. It is categorized by mechanism, imaging findings, and anatomic involvement. 

Cerebral blood flow requires adequate cerebral perfusion pressure, defined by mean arterial pressure minus intracranial pressure. 

Initial management requires assessing neurologic status, maintaining adequate mean arterial pressure, treating elevated intracranial pressure (ICP), avoiding secondary injury, and obtaining emergent neuroimaging.

Airway considerations such as preoxygenation, head of bed elevation, first pass success, and postintubation analgesia and sedation are essential in avoiding further worsening of traumatic insults including hypotension and hypoxemia.

Neurosurgical consultation is required for optimal management, and the use of neurocritical care teams can improve patient outcome.

LINK

ARTIGO DE REVISÃO COM IMPORTANTE IMPACTO NA PRÁTICA CLINICA, RESPONDENDO QUESTÕES TERAPÊUTICAS, NEUROPROTEÇÃO E NEUROMONITORIZAÇÃO.

Twenty-Five Years of Intracranial Pressure Monitoring After Severe Traumatic Brain Injury

Abstract

BACKGROUND:

Intracranial pressure (ICP) is a clinically important variable after severe traumatic brain injury (TBI) and has been monitored, along with clinical outcome, for over 25 yr in Addenbrooke's hospital, Cambridge, United Kingdom. This time period has also seen changes in management strategies with the implementation of protocolled specialist neurocritical care, expansion of neuromonitoring techniques, and adjustments of clinical treatment targets.

OBJECTIVE:

To describe the changes in intracranial monitoring variables over the past 25 yr.

METHODS:

Data from 1146 TBI patients requiring ICP monitoring were analyzed. Monitored variables included ICP, cerebral perfusion pressure (CPP), and the cerebral pressure reactivity index (PRx). Data were stratified into 5-yr epochs spanning the 25 yr from 1992 to 2017.

RESULTS:

CPP increased sharply with specialist neurocritical care management (P < 0.0001) (introduction of a specific TBI management algorithm) before stabilizing from 2000 onwards. ICP decreased significantly over the 25 yr of monitoring from an average of 19 to 12 mmHg (P < 0.0001) but PRx remained unchanged. The mean number of ICP plateau waves and the number of patients developing refractory intracranial hypertension both decreased significantly. Mortality did not significantly change in the cohort (22%).

CONCLUSION:

We demonstrate the evolving trends in neurophysiological monitoring over the past 25 yr from a single, academic neurocritical care unit. ICP and CPP were responsive to the introduction of an ICP/CPP protocol while PRx has remained unchanged.

IMPORTANTE ESTUDO NA ÁREA DO NEUROTRAUMA EVIDENCIANDO QUE A UTILIZAÇÃO DE PROTOCOLO PARA CONTROLE DA PRESSÃO INTRACRANIANA E PRESSÃO DE PRESSÃO DE PERFUSÃO CEREBRAL TEM IMPACTO NA ASSISTÊNCIA.

PUBMED

Comparison of Performance of Different Optimal Cerebral Perfusion Pressure Parameters for Outcome Prediction in Adult TBI: A CENTER-TBI Study

Abstract

It has been postulated previously, that individualized cerebral perfusion pressure (CPP) targets can be derived from cerebrovascular reactivity indices. Differences between real CPP and target CPP ( named generically 'optimal CPP' ) has been linked to global outcome in adult traumatic brain injury (TBI). Different vascular reactivity indices can be utilized in the determination. The goal of this study is to evaluate optimal cerebral perfusion pressure (CPPopt) parameter, derived from three intra-cranial pressure (ICP) derived cerebrovascular reactivity indices, and determine which one is superior for 6 to 12-month outcome prediction. Using the prospectively collected data from the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study, the following indices of cerebrovascular reactivity were derived: PRx (correlation between ICP and mean arterial pressure (MAP)), PAx (correlation between pulse amplitude of ICP (AMP) and MAP), and RAC (correlation between AMP and CPP). CPPopt was derived using each index. Univariate logistic regression models were created to assess the association between CPPopt with global dichotomized outcome at 6 to 12 months, as assessed by Glasgow Outcome Score - Extended (GOSE). Models were compared via area under the receiver operating curve (AUC) and Delong's Test. A total of 204 patients had available data. CPPopt derived from PRx, PAx and RAC performed variably in their association with outcomes. PRx and RAC based CPPopt performed similarly, with RAC parameters trending towards highest AUC values. PAx based CPPopt parameters failed to reach significant associations with dichotomized outcomes at 6 to 12-months. CPPopt parameters derived from PRx and RAC appear similar in their overall ability for 6 to 12-month outcome prediction in moderate/severe adult TBI. Keywords: Autoregulation, CPP optimum, ICP indices, outcome analysis.

KEYWORDS:

ADULT BRAIN INJURY; BLOOD FLOW; CBF autoregulation; HEAD TRAUMA; TRAUMATIC BRAIN INJURY

PMID:

 

30384809

 

DOI:

 

10.1089/neu.2018.6182

Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research

PUBMED

XXXII CONGRESSO BRASILEIRO DE NEUROCIRURGIA: CURSO PRÉ CONGRESSO NEUROINTENSIVISMO E TRAUMA

05.09.2018 TARDE CURSO PRÉ-CONGRESSO: NEUROINTENSIVISMO NO  TRAUMA E LESÕES CEREBRAIS NÃO TRAUMÁTICAS Secretário: Jose Nel Carreno (Colômbia) Moderador: Jorge Luiz da Rocha Paranhos (MG) Moderador: Daniel Godoy (Argentina) Manejo da glicemia no AVEI Agudo Palestrante: Regis Goulart Rosa (RS) Manejo da PA no AVEI agudoPalestrante: Fabiane Backes (RS) Deficit cognitivo tardio em pacientes neurocríticos pós ventilaçãoPalestrante: Regis Goulart Rosa (RS) Bases fisiopatológicas das técnicas atualmente utilizadas de CDPalestrante: Robson Luis Oliveira de Amorim (AM) Evitando complicações nas CDAVCH profundo volumoso - Conduta cirurgica: endoscópica ou craniotomia? Palestrante: Rafael Contage Winter (RS) Caso Clinico - Craniotomia descompressiva Palestrante: Oscar L. Alves (Portugal) IntervaloManejo neurointensivo na "hora de ouro" da HSA aneurismáticaPalestrante: Eubrando Silvestre Oliveira (RS) Tratamento das hemorragias intracranianas por disturbio da coagulaçãoPalestrante: Erik Leonardo Jennings Simoes (PA) AVEH - Cirurgia Minimamente Invasiva x Tratamento ClínicoPalestrante: Luiz Felipe Ulrich de Alencastro (RS) Hematoma Cerebelar Espontâneo: tratamento clínico x tratamento cirúrgicoPalestrante: Audrey Beatriz Santos Araujo (MG) Deficit Isquemico Tardio pos HSA AneurismáticaPalestrante: Samia Yasin Wayhs (SP) Tratamento endovascular do Vaso Espasmo pós HSA AneurismáticaPalestrante: Mário de Barros Faria (RS) Caso Clinico: AVEH discutindo a conduta cirúrgicaPalestrante: Wellingson Silva Paiva (SP) IntervaloManejo dos edemas cerebrais traumáticos - Novos conceitosPalestrante: Juan Sahuquillo (Espanha) NAFA - Neurociencias e Neuroanestesia para todosPalestrante: Christiano dos Santos e Santos (Estados Unidos) TCE grave na sala vermelha - Conduta para evitar complicações e a lesão secundariaPalestrante: Marcelo Kern (RS) Atendimento global pre hospitalar do TCE gravePalestrante: Raul Echeverri (Colômbia) Fracassos não neurológicos no paciente com TCE gravePalestrante: Manuel Jibaja (Equador) Palestrante: Daniel Godoy (Argentina) 06.09.2018 MANHÃ

CURSO PRÉ-CONGRESSO: ATUALIZAÇÃO NO MANEJO DO TRAUMA DO SNC Coordenador: Jorge Luiz da Rocha Paranhos (MG) Presidente: Marcio Costa Nobre (MG) Secretário: Wellingson Silva Paiva (SP) Moderador: Ruy Castro Monteiro da Silva Filho (RJ) Moderador: Raul Echeverri (Colômbia) Fisiopatologia da Volemia Encefálica Palestrante: Marcelo Chioatto (MG) Desmame da VMI do paciente neurocritico Palestrante: Cassiano Teixeira (RS) Reposição volemica e uso de drogas vasoativas no atendomento incial do TCE grave Palestrante: Cassiano Teixeira (RS) Métodos não invasivos da monitoração da PIC Palestrante: Gustavo Cartaxo Patriota (PB) Monitoração da PTiO2 e SVJO2 - Análise crítica Palestrante: Gilberto Friedman (RS) Monitoração da PIC em crianças com TCE grave - Indicações e Protocolos Consenso Latino Americano no TCE grave -  Palestrante: Daniel Godoy (Argentina) Intervalo Controvérsias na extubação do paciente neurocrítico Palestrante: Manuel Jibaja (Equador) Transfusão de plasma no TCE grave Palestrante: Jose Nel Carreno (Colômbia) Autoregulação cerebral e PPC ideal na beira do leito Palestrante: Marcelo Kern (RS) Fluidoterapia no tratamento neurointensivo: proposta de um consenso Palestrante: Walter Videtta (Argentina) TCE em crianças - Discutindo condutas Palestrante: Tiago de Paiva Cavalcante (SE) Hotpoints of hot topics Palestrante: Ruy Castro Monteiro da Silva Filho (RJ) 06.09.2018 TARDE CURSO PRÉ-CONGRESSO: ATUALIZAÇÃO NO MANEJO DO TRAUMA DO SNC Coordenador: Jorge Luiz da Rocha Paranhos (MG) Presidente: Gustavo Cartaxo Patriota (PB) Secretário: Miguel Giudicissi Filho (SP) Moderador: Marcelo Chioatto (MG) Moderador: Oscar L. Alves (Portugal) Opções terapêuticas das lesões altas do plexo braquial Palestrante: Wilson Faglioni Júnior (MG) Controvérsias no TRM  Palestrante: Fernando Luiz Rolemberg Dantas (MG) Transferência Miotendinosa para tratamento de lesões do Nervo Radial Palestrante: Marcelo José da Silva de Magalhães (MG) Marcadores das lesões em neurotrauma na Era Proteônica Palestrante: Raul Echeverri (Colômbia) Guideline SNACC para o manejo perioperatório de DVE e DLE Palestrante: Christiano dos Santos e Santos (Estados Unidos) Lesões do Nervo Facial no TCE - Diagnóstico e tratamento  Palestrante: Hugo Sterman Neto (SP) Palestrante: Marcelo Chioatto (MG) Intervalo Estado da Arte na conduta clinica e cirúrgica das contusões cerebrais  Palestrante: Juan Sahuquillo (Espanha) Coagulopatia associada a lesão neurológica aguda Palestrante: Jose Nel Carreno (Colômbia) Hematoma Sub Dural Crônico: opções terapêuticas Palestrante: Carlos Vinicius Mota de Melo (CE) Condutas terapêuticas clínicas e cirúrgicas nas lesões III e IV de Marshall Palestrante: Rodrigo Moreira Faleiro (MG) Caso Clinico: TCE moderado e anticoagulação Palestrante: Oscar L. Alves (Portugal) Intervalo Indicação cirúrgica do paciente com Glasgow 3 Palestrante: Joao Gustavo Rocha Peixoto dos Santos (SP) Fístula liquorica pós trauma - Diagnóstico e tratamento  Palestrante: Marcelo Prudente Do Espirito Santo (SP) Aspectos atuais da concussão cerebral pediátrica Palestrante: Roberto Alexandre Dezena (MG) Conduta nas hidrocefalias pós traumáticas Palestrante: Leonardo Bilich Abaurre (ES) Tratamento das cefaleias pós traumáticas Palestrante: Franklin Reis (AM) Palestrante: Marcelo Chioatto (MG) Encerramento CONGRESSO BRASILEIRO NEUROCIRURGIA

Sociedade Brasileira Neurocirurgia Curso Teórico /Prático R3

The GCS-Pupils Score

OBJECTIVE Glasgow Coma Scale (GCS) scores and pupil responses are key indicators of the severity of traumatic brain damage. The aim of this study was to determine what information would be gained by combining these indicators into a single index and to explore the merits of different ways of achieving this.
METHODS Information about early GCS scores, pupil responses, late outcomes on the Glasgow Outcome Scale, and mortality were obtained at the individual patient level by reviewing data from the CRASH (Corticosteroid Randomisation After Significant Head Injury; n = 9,045) study and the IMPACT (International Mission for Prognosis and Clinical Trials in TBI; n = 6855) database. These data were combined into a pooled data set for the main analysis.
Methods of combining the Glasgow Coma Scale and pupil response data varied in complexity from using a simple arith- metic score (GCS score [range 3–15] minus the number of nonreacting pupils [0, 1, or 2]), which we call the GCS-Pupils score (GCS-P; range 1–15), to treating each factor as a separate categorical variable. The content of information about patient outcome in each of these models was evaluated using Nagelkerke’s R2.
RESULTS Separately, the GCS score and pupil response were each related to outcome. Adding information about the pupil response to the GCS score increased the information yield. The performance of the simple GCS-P was similar to the performance of more complex methods of evaluating traumatic brain damage. The relationship between decreases in the GCS-P and deteriorating outcome was seen across the complete range of possible scores. The additional 2 low- est points offered by the GCS-Pupils scale (GCS-P 1 and 2) extended the information about injury severity from a mor- tality rate of 51% and an unfavorable outcome rate of 70% at GCS score 3 to a mortality rate of 74% and an unfavorable outcome rate of 90% at GCS-P 1. The paradoxical finding that GCS score 4 was associated with a worse outcome than GCS score 3 was not seen when using the GCS-P.
CONCLUSIONS A simple arithmetic combination of the GCS score and pupillary response, the GCS-P, extends the information provided about patient outcome to an extent comparable to that obtained using more complex methods. The greater range of injury severities that are identified and the smoothness of the stepwise pattern of outcomes across the range of scores may be useful in evaluating individual patients and identifying patient subgroups. The GCS-P may be a useful platform onto which information about other key prognostic features can be added in a simple format likely to be useful in clinical practice.
https://thejns.org/doi/abs/10.3171/2017.12.JNS172780
KEYWORDS Glasgow Coma Scale; head injury; traumatic brain injury; trauma; prognosis; pupil reactivity 

Forty years on: updating the Glasgow Coma Scale

Abstract 

Teasdale G (2014) Forty years on: updating the Glasgow Coma Scale. 

Nursing Times; 110: 42, 12-16.

Since the Glasgow Coma Scale was developed 40 years ago it has been accepted throughout the world as a method for assessing impaired consciousness. This article addresses the variations in technique that have developed since the scale was published. The details of the composition of the scale and its application are reviewed, and a structured approach to assessment set out. These provide a basis for standardising practice and ensure the scales is useful, in a practical sense, in the future.

 

  

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Relationship Between Brain Pulsatility and Cerebral Perfusion Pressure

Artigo publicado na Neurocritical Care reforça o entendimento sobre o Índice de Pulsatilidade Cerebral como uma ferramenta complexa composta por vários parâmetros mutualmente independentes.

Leia o artigo na integra e entenda os conceitos.

LINK Neurocritical Care

Atualização Protocolo Morte Encefálica

Atualizações do Protocolo Morte Encefálica e sua aplicação institucional.

Local: Anfiteatro Hospital de Emergência e Trauma Senador Humberto Lucena.

Data e hora: 24.01.2018 ; `as 20h

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O NeurointensivismoBlog reinicia as atualizações desta área de atuação, agora com maior propagação da informação através do Facebook®, Instagram ® .

Nesta Quarta-Feira 17.01.2018 reinicia as aulas teóricas no Hospital de Emergência Trauma Senador Humberto Lucena. O Atualização em Neurointensivismo 2018  será dividida em módulos e serão divulgados previamente para todos os interessados.

Desejo a todos Feliz 2018.

Atenciosamente,

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II Simpósio de Neurointensivismo Alagoas

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Brazilian Intracranial Aneurysm Course: From Genesis to Rupture!

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