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1.
Acta Neurol Scand ; 135(3): 291-301, 2017 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-27028091

RESUMEN

OBJECTIVES: Suspected cerebrospinal fluid shunt (CSF) dysfunction in hydrocephalic patients poses a diagnostic uncertainty. The clinical picture can be non-specific and CT imaging alone is not always pathognomonic. Infusion tests are an increasingly used investigation for real-time hydrodynamic assessment of shunt patency. We report the correlation between infusion test results with the quality of ventricular drain placement on CT scans in a large retrospective group of hydrocephalic patients. MATERIALS & METHODS: Three hundred and six infusion test results performed in 200 patients were correlated with 306 corresponding CT head scans. Nominal logistic regression was used to correlate shunt catheter position on CT imaging to patency of ventricular drain as determined by infusion tests. RESULTS: Infusion test results of shunt patency are statistically congruent with the analysis of shunt catheter position on CT head scans. Catheter tips completely surrounded by either parenchyma or CSF on CT imaging are strongly associated with evidence of occlusion or patency from infusion tests, respectively (χ² = 51.68, P < 0.0001, n = 306 and χ² = 31.04, P < 0.0001, n = 306). CONCLUSIONS: The most important anatomical factor for shunt patency is the catheter tip being completely surrounded by CSF. Infusion tests provide functional and reliable assessment of shunt patency in vivo and are strongly correlated with the position of the ventricular catheter on CT imaging.


Asunto(s)
Derivaciones del Líquido Cefalorraquídeo/normas , Hidrocefalia , Punción Espinal/normas , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Derivaciones del Líquido Cefalorraquídeo/efectos adversos , Niño , Preescolar , Femenino , Humanos , Hidrocefalia/líquido cefalorraquídeo , Hidrocefalia/diagnóstico por imagen , Hidrocefalia/cirugía , Lactante , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Adulto Joven
2.
Br J Neurosurg ; 30(4): 388-96, 2016 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-27188663

RESUMEN

BACKGROUND: For critically ill adult patients with acute traumatic brain injury (TBI), we assessed the clinical and cost-effectiveness of: (a) Management in dedicated neurocritical care units versus combined neuro/general critical care units within neuroscience centres. (b) 'Early' transfer to a neuroscience centre versus 'no or late' transfer for those who present at a non-neuroscience centre. METHODS: The Risk Adjustment In Neurocritical care (RAIN) Study included prospective admissions following acute TBI to 67 UK adult critical care units during 2009-11. Data were collected on baseline case-mix, mortality, resource use, and at six months, Glasgow Outcome Scale Extended (GOSE), and quality of life (QOL) (EuroQol 5D-3L). We report incremental effectiveness, costs and cost per Quality-Adjusted Life Year (QALY) of the alternative care locations, adjusting for baseline differences with validated risk prediction models. We tested the robustness of results in sensitivity analyses. FINDINGS: Dedicated neurocritical care unit patients (N = 1324) had similar six-month mortality, higher QOL (mean gain 0.048, 95% CI -0.002 to 0.099) and increased average costs compared with those managed in combined neuro/general units (N = 1341), with a lifetime cost per QALY gained of £14,000. 'Early' transfer to a neuroscience centre (N = 584) was associated with lower mortality (odds ratio 0.52, 0.34-0.80), higher QOL for survivors (mean gain 0.13, 0.032-0.225), but positive incremental costs (£15,001, £11,123 to £18,880) compared with 'late or no transfer' (N = 263). The lifetime cost per QALY gained for 'early' transfer was £11,000. CONCLUSIONS: For critically ill adult patients with acute TBI, within neuroscience centres management in dedicated neurocritical care units versus combined neuro/general units led to improved QoL and higher costs, on average, but these differences were not statistically significant. This study finds that 'early' transfer to a neuroscience centre is associated with reduced mortality, improvement in QOL and is cost-effective.


Asunto(s)
Lesiones Traumáticas del Encéfalo/economía , Lesiones Traumáticas del Encéfalo/terapia , Enfermedad Crítica/economía , Enfermedad Crítica/terapia , Adulto , Anciano , Lesiones Encefálicas/economía , Lesiones Encefálicas/terapia , Análisis Costo-Beneficio/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Calidad de Vida , Años de Vida Ajustados por Calidad de Vida
3.
Adv Tech Stand Neurosurg ; 38: 115-36, 2012.
Artículo en Inglés | MEDLINE | ID: mdl-22592414

RESUMEN

With improvements in neurocritical care advanced measures of treating raised intracranial pressure (ICP) are more frequently utilised. Decompressive craniectomy is an effective ICP-lowering procedure; however its benefits are maximised with optimal surgical technique and perioperative care, as well as by paying attention to possible complications. This article focuses on the current indications and rationale for decompressive craniectomy, and the surgical technique of bifrontal and unilateral decompression. The key surgical points include a large craniectomy window and opening of the dura, leaving it unsutured or performing a wide non-constricting duroplasty. Perioperative care and possible complications are also discussed.


Asunto(s)
Craniectomía Descompresiva , Presión Intracraneal , Lesiones Encefálicas , Descompresión Quirúrgica , Duramadre/cirugía , Humanos , Hipertensión Intracraneal , Atención Perioperativa , Resultado del Tratamiento
4.
Acta Neurochir Suppl ; 95: 83-8, 2005.
Artículo en Inglés | MEDLINE | ID: mdl-16463826

RESUMEN

This study investigated the changes in extracellular chemistry during reversible human cerebral ischaemia. Delayed analysis was performed on samples taken from a subgroup of patients during aneurysm surgery previously reported. Frozen microdialysis samples from 14 patients who had all undergone temporary clipping of the ipsilateral internal carotid artery (ICA) were analysed for another 15 amino acids with HPLC and for glycerol with CMA-600. Changes were characterised according to whether cerebral tissue oxygen pressure (PBO2) decreases were brief or prolonged. Brief ICA clipping (maximum duration of 16 minutes) in 11 patients was not associated with changes in amino acids or glycerol. Cerebral ischaemia, defined by a PBO2 decrease below 1.1 kPa for at least 30 minutes during ICA occlusion, occurred in 3 patients. None of whom developed an infarct in the monitored region. This prolonged reversible ischaemia was associated with transient delayed increases in gamma-amino butyric acid (GABA) as well as glutamate and glycerol, each by two-to-three folds. This study demonstrates detectable transient increases in human extracellular glutamate, GABA and glycerol during identified periods of reversible cerebral ischaemia, maximal 30-60 minutes after onset of ischaemia, but not in other amino acids detected by HPLC.


Asunto(s)
Aminoácidos/metabolismo , Encéfalo/metabolismo , Líquido Extracelular/metabolismo , Ataque Isquémico Transitorio/metabolismo , Oxígeno/metabolismo , Adulto , Anciano , Aminoácidos/análisis , Biomarcadores/metabolismo , Femenino , Glicerol/metabolismo , Humanos , Aneurisma Intracraneal/complicaciones , Aneurisma Intracraneal/metabolismo , Aneurisma Intracraneal/cirugía , Ataque Isquémico Transitorio/diagnóstico , Ataque Isquémico Transitorio/etiología , Masculino , Microdiálisis/métodos , Persona de Mediana Edad , Monitoreo Fisiológico/métodos , Neurotransmisores/análisis , Neurotransmisores/metabolismo , Oximetría/métodos , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Resultado del Tratamiento , Ácido gamma-Aminobutírico/metabolismo
5.
Acta Neurochir Suppl ; 95: 123-7, 2005.
Artículo en Inglés | MEDLINE | ID: mdl-16463835

RESUMEN

Following aneurysmal subarachnoid haemorrhage (SAH), cerebral blood flow (CBF) may be reduced, resulting in poor outcome due to cerebral ischaemia and subsequent stroke. Hypertonic saline (HS) is known to be effective in reducing intracranial pressure (ICP). We have previously shown a 20-50% increase in CBF in ischaemic regions after intravenous infusion of HS. This study aims to determine the effect of HS on CBF augmentation, substrate delivery and metabolism. Continuous monitoring of arterial blood pressure (ABP), ICP, cerebral perfusion pressure (CPP), brain tissue oxygen (PbO2), middle cerebral artery flow velocity (FV), and microdialysis was performed in 14 poor grade SAH patients. Patients were given an infusion of 23.5% HS, and quantified xenon computerised tomography scanning (XeCT) was carried out before and after the infusion in 9 patients. The results showed a significant increase in ABP, CPP, FV and PbO2, and a significant decrease in ICP (p < 0.05). Nine patients showed a decrease in lactate-pyruvate ratio at 60 minutes following HS infusion. These results show that HS safely and effectively augments CBF in patients with poor grade SAH and significantly improves cerebral oxygenation. An improvement in cerebral metabolic status in terms of lactate-pyruvate ratio is also associated with HS infusion.


Asunto(s)
Isquemia Encefálica/prevención & control , Isquemia Encefálica/fisiopatología , Circulación Cerebrovascular/efectos de los fármacos , Presión Intracraneal/efectos de los fármacos , Solución Salina Hipertónica/administración & dosificación , Hemorragia Subaracnoidea/tratamiento farmacológico , Hemorragia Subaracnoidea/fisiopatología , Adulto , Anciano , Velocidad del Flujo Sanguíneo/efectos de los fármacos , Encéfalo/efectos de los fármacos , Encéfalo/fisiopatología , Isquemia Encefálica/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Índice de Severidad de la Enfermedad , Hemorragia Subaracnoidea/complicaciones , Resultado del Tratamiento
6.
Acta Neurochir Suppl ; 81: 359-62, 2002.
Artículo en Inglés | MEDLINE | ID: mdl-12168347

RESUMEN

Current monitoring of the cerebral extracellular chemistry of neurosurgical patients using microdialysis does not provide the true extracellular concentration because full equilibration across the membrane is not achieved. By varying the flow rate and extrapolating to zero flow, the relative recovery i.e. the concentration of the substance in the microdialysate as a proportion of the true concentration in the extracellular space may be calculated. The disadvantage of this method is that it depends on the underlying baseline chemistry being constant during measurements for the calculations, which is not the case in the changing environment of a neuro-intensive unit. We have therefore designed a modification of the extrapolation to zero flow method using an adjacent constant flow rate catheter to monitor the baseline. The results demonstrate that the relative recovery varies considerably with flow rate, and for the CMA70 10 mm membrane catheter, is approximately 70% at a rate of 0.3 microliter/min and 30% at a rate of 1.0 microliter/min for glucose, lactate, pyruvate and glutamate.


Asunto(s)
Encéfalo/metabolismo , Ácido Glutámico/metabolismo , Ácido Láctico/metabolismo , Procedimientos Neuroquirúrgicos , Ácido Pirúvico/metabolismo , Biomarcadores , Velocidad del Flujo Sanguíneo , Catéteres de Permanencia , Circulación Cerebrovascular , Espacio Extracelular/metabolismo , Lóbulo Frontal/metabolismo , Glucosa/metabolismo , Humanos , Microdiálisis/métodos , Monitoreo Fisiológico/métodos , Perfusión , Cuidados Posoperatorios , Pronóstico
7.
Acta Neurochir Suppl ; 81: 363-5, 2002.
Artículo en Inglés | MEDLINE | ID: mdl-12168348

RESUMEN

OBJECTIVE: Temporary Internal Carotid Artery (ICA) clipping necessary during aneurysm surgery was used as a model to investigate metabolic changes in the human brain during defined episodes of ischaemia. DESIGN: An observational study using intracerebral monitors: PBO2 (Neurotrend) and microdialysis (CMA, Sweden). SUBJECTS: 16 patients monitored during complex aneurysm surgery. OUTCOME MEASURES: Changes in extracellular concentrations of glucose, lactate, and glutamate and lactate/pyruvate ratio (L/P). RESULTS: Mean age was 55. 10 patients presented with subarachnoid haemorrhage and 6 with mass effect (4 giant). Temporary ICA occlusion was required for dissection (n = 9), intraoperative rupture (n = 5) or aneurysmal thrombectomy (n = 2). The mean total duration was 15 minutes (range 4-52 minutes). No infarcts developed in the monitored regions. Microdialysis was unsuccessful in 3 patients and Neurotrend in 1. Patients were grouped according to the degree and duration of fall in PBO2: minimal brief falls were not associated with microdialysis changes (n = 5). More pronounced falls were associated with increases in L/P (n = 4). Only prolonged occlusions averaging 42 minutes (n = 3) with PBO2 sustained below 1 kPa were associated with rises in glutamate. CONCLUSIONS: Brief temporary ICA occlusion caused an initial increased L/P. Glutamate increases were only seen after occlusion that was prolonged with PBO2 below 1.0 kPa.


Asunto(s)
Isquemia Encefálica/metabolismo , Encéfalo/metabolismo , Arteria Carótida Interna/cirugía , Ácido Glutámico/metabolismo , Aneurisma Intracraneal/cirugía , Ácido Láctico/metabolismo , Ácido Pirúvico/metabolismo , Adulto , Anciano , Biomarcadores , Isquemia Encefálica/etiología , Craneotomía , Humanos , Persona de Mediana Edad , Monitoreo Intraoperatorio/métodos , Procedimientos Neuroquirúrgicos/métodos , Factores de Tiempo
8.
Health Technol Assess ; 17(23): vii-viii, 1-350, 2013 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-23763763

RESUMEN

OBJECTIVES: To validate risk prediction models for acute traumatic brain injury (TBI) and to use the best model to evaluate the optimum location and comparative costs of neurocritical care in the NHS. DESIGN: Cohort study. SETTING: Sixty-seven adult critical care units. PARTICIPANTS: Adult patients admitted to critical care following actual/suspected TBI with a Glasgow Coma Scale (GCS) score of < 15. INTERVENTIONS: Critical care delivered in a dedicated neurocritical care unit, a combined neuro/general critical care unit within a neuroscience centre or a general critical care unit outside a neuroscience centre. MAIN OUTCOME MEASURES: Mortality, Glasgow Outcome Scale - Extended (GOSE) questionnaire and European Quality of Life-5 Dimensions, 3-level version (EQ-5D-3L) questionnaire at 6 months following TBI. RESULTS: The final Risk Adjustment In Neurocritical care (RAIN) study data set contained 3626 admissions. After exclusions, 3210 patients with acute TBI were included. Overall follow-up rate at 6 months was 81%. Of 3210 patients, 101 (3.1%) had no GCS score recorded and 134 (4.2%) had a last pre-sedation GCS score of 15, resulting in 2975 patients for analysis. The most common causes of TBI were road traffic accidents (RTAs) (33%), falls (47%) and assault (12%). Patients were predominantly young (mean age 45 years overall) and male (76% overall). Six-month mortality was 22% for RTAs, 32% for falls and 17% for assault. Of survivors at 6 months with a known GOSE category, 44% had severe disability, 30% moderate disability and 26% made a good recovery. Overall, 61% of patients with known outcome had an unfavourable outcome (death or severe disability) at 6 months. Between 35% and 70% of survivors reported problems across the five domains of the EQ-5D-3L. Of the 10 risk models selected for validation, the best discrimination overall was from the International Mission for Prognosis and Analysis of Clinical Trials in TBI Lab model (IMPACT) (c-index 0.779 for mortality, 0.713 for unfavourable outcome). The model was well calibrated for 6-month mortality but substantially underpredicted the risk of unfavourable outcome at 6 months. Baseline patient characteristics were similar between dedicated neurocritical care units and combined neuro/general critical care units. In lifetime cost-effectiveness analysis, dedicated neurocritical care units had higher mean lifetime quality-adjusted life-years (QALYs) at small additional mean costs with an incremental cost-effectiveness ratio (ICER) of £14,000 per QALY and incremental net monetary benefit (INB) of £17,000. The cost-effectiveness acceptability curve suggested that the probability that dedicated compared with combined neurocritical care units are cost-effective is around 60%. There were substantial differences in case mix between the 'early' (within 18 hours of presentation) and 'no or late' (after 24 hours) transfer groups. After adjustment, the 'early' transfer group reported higher lifetime QALYs at an additional cost with an ICER of £11,000 and INB of £17,000. CONCLUSIONS: The risk models demonstrated sufficient statistical performance to support their use in research but fell below the level required to guide individual patient decision-making. The results suggest that management in a dedicated neurocritical care unit may be cost-effective compared with a combined neuro/general critical care unit (although there is considerable statistical uncertainty) and support current recommendations that all patients with severe TBI would benefit from transfer to a neurosciences centre, regardless of the need for surgery. We recommend further research to improve risk prediction models; consider alternative approaches for handling unobserved confounding; better understand long-term outcomes and alternative pathways of care; and explore equity of access to postcritical care support for patients following acute TBI. FUNDING: The National Institute for Health Research Health Technology Assessment programme.


Asunto(s)
Lesiones Encefálicas/rehabilitación , Calidad de Vida , Ajuste de Riesgo/métodos , Enfermedad Aguda , Adulto , Factores de Edad , Lesiones Encefálicas/economía , Estudios de Cohortes , Costos y Análisis de Costo , Cuidados Críticos , Femenino , Escala de Coma de Glasgow , Escala de Consecuencias de Glasgow , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Evaluación de Procesos y Resultados en Atención de Salud , Transferencia de Pacientes/economía , Transferencia de Pacientes/estadística & datos numéricos , Años de Vida Ajustados por Calidad de Vida , Reproducibilidad de los Resultados , Factores de Tiempo , Reino Unido
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