GUIA PRÁTICO E ESSENCIAL PARA TODO NEUROINTENSIVISTA

GUIA PRÁTICO E ESSENCIAL PARA TODO NEUROINTENSIVISTA

GRATUITO

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.

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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

Optimal cerebral perfusion pressure via transcranial Doppler in TBI: application of robotic technology

Abstract

Individualized cerebral perfusion pressure (CPP) targets may be derived via assessing the minimum of the parabolic relationship between an index of cerebrovascular reactivity and CPP. This minimum is termed the optimal CPP (CPPopt), and literature suggests that the further away CPP is from CPPopt, the worse is clinical outcome in adult traumatic brain injury (TBI). Typically, CPPopt estimation is based on intracranial pressure (ICP)-derived cerebrovascular reactivity indices, given ICP is commonly measured and provides continuous long duration data streams. The goal of this study is to describe for the first time the application of robotic transcranial Doppler (TCD) and the feasibility of determining CPPopt based on TCD autoregulation indices.

KEYWORDS:

CPP optimum; Robotic transcranial Doppler; TBI; TCD; Traumatic brain injury

PMID:

 

30267208

 

DOI:

 

10.1007/s00701-018-3687-5

Emergency Neurological Life Support - Salvador

Intracranial pressure in patients undergoing decompressive craniectomy: new perspective on thresholds

OBJECTIVE Decompressive craniectomy (DC) is an established part of treatment in patients suffering from malignant infarction of the middle cerebral artery (MCA) or traumatic brain injury (TBI). However, no clear evidence for intracranial pressure (ICP)-guided therapy after DC exists. The lack of this evidence might be due to the frequently used, but simpli- fied threshold for ICP of 20 mm Hg, which determines further therapy. Therefore, the objective of this study was to evalu- ate this threshold’s accuracy and to investigate the course of ICP values with respect to neurological outcome.

METHODS Data on clinical characteristics and parameters of the ICP course on the intensive care unit were collected retrospectively in 102 patients who underwent DC between December 2007 and April 2014 at the authors’ institution. The postoperative ICP course in the first 168 hours was recorded and analyzed. From these findings, ICP thresholds discriminating favorable from unfavorable outcome were calculated using conditional inference tree analysis. Addition- ally, survival analysis was performed using the Kaplan-Meier method. Prognostic factors were assessed via univariate analysis and multivariate logistic regression. Favorable outcome was defined as a score of 0–4 on the modified Rankin Scale.

RESULTS Multivariate logistic regression revealed that anisocoria, diagnosis, and ICP values differed significantly between the outcome groups. ICP values in the favorable and unfavorable outcome groups differed significantly (p < 0.001), while the mean ICP of both groups lay below the limit of 20 mm Hg (17.5 and 11.5 mm Hg, respectively). These findings were reproduced when analyzing the underlying pathologies of TBI and MCA infarction separately. Based on these findings, optimized time-dependent threshold values were calculated and found to be between 10 and 17 mm Hg. These values significantly distinguished favorable from unfavorable outcome and predicted 30-day mortality (p < 0.001).

CONCLUSIONS This study systematically evaluated ICP levels in a long-term analysis after DC and provides new, surprisingly low, time-dependent ICP thresholds for these patients. Future trials investigating the benefit of ICP-guided therapy should take these thresholds into consideration and validate them in further patient cohorts.

https://thejns.org/doi/abs/10.3171/2016.11.JNS162263

KEY WORDS intracranial pressure; decompressive craniectomy; stroke; traumatic brain injury; neurocritical care; diagnostic technique

PUBMED

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.

 

  

Smartphone-assited minimally invasive neurosurgery

OBJECTIVE Advances in video and fiber optics since the 1990s have led to the development of several commercially available high-definition neuroendoscopes. This technological improvement, however, has been surpassed by the smart- phone revolution. With the increasing integration of smartphone technology into medical care, the introduction of these high-quality computerized communication devices with built-in digital cameras offers new possibilities in neuroendosco- py. The aim of this study was to investigate the usefulness of smartphone-endoscope integration in performing different types of minimally invasive neurosurgery.
METHODS The authors present a new surgical tool that integrates a smartphone with an endoscope by use of a spe- cially designed adapter, thus eliminating the need for the video system customarily used for endoscopy. The authors used this novel combined system to perform minimally invasive surgery on patients with various neuropathological dis- orders, including cavernomas, cerebral aneurysms, hydrocephalus, subdural hematomas, contusional hematomas, and spontaneous intracerebral hematomas.
RESULTS The new endoscopic system featuring smartphone-endoscope integration was used by the authors in the minimally invasive surgical treatment of 42 patients. All procedures were successfully performed, and no complications related to the use of the new method were observed. The quality of the images obtained with the smartphone was high enough to provide adequate information to the neurosurgeons, as smartphone cameras can record images in high defi- nition or 4K resolution. Moreover, because the smartphone screen moves along with the endoscope, surgical mobility was enhanced with the use of this method, facilitating more intuitive use. In fact, this increased mobility was identified as the greatest benefit of the use of the smartphone-endoscope system compared with the use of the neuroendoscope with the standard video set.
CONCLUSIONS Minimally invasive approaches are the new frontier in neurosurgery, and technological innovation and integration are crucial to ongoing progress in the application of these techniques. The use of smartphones with endo- scopes is a safe and efficient new method of performing endoscope-assisted neurosurgery that may increase surgeon mobility and reduce equipment costs.
https://thejns.org/doi/abs/10.3171/2017.6.JNS1712
KEY WORDS brain aneurysm; epilepsy; intracerebral hematoma; subdural hematoma; third ventriculostomy; neuroendoscopy; smartphone; surgical technique 

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Relationship Between Brain Pulsatility and Cerebral Perfusion Pressure

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