Initial blood pressure is important for long-term outcome after traumatic spinal cord injury.

OBJECTIVE: Patients with traumatic spinal cord injury (TSCI) are at risk of developing neurogenic shock that causes hypotension and thereby secondary injury to the spinal cord due to ischemia. Hemodynamic treatment of patients with acute TSCI remains inadequately elucidated. Guidelines for management are divergent and based on limited evidence. To this end, the authors evaluated whether mean arterial blood pressure (MABP) during the prehospital and initial hospital phases of TSCI treatment is correlated with long-term neurological outcome. METHODS: The authors performed a retrospective cohort study based on a chart review of MABP data collected during the prehospital transport, in the operating room (OR), and in the neurointensive care unit (NICU) during the first 7 days after trauma. Data from the NICU were divided into two periods: days 1-2 and days 3-7. Data were analyzed using Spearman's rank correlation to evaluate for any correlation between MABP and changes in the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) score 1 year postinjury. In the analysis, the MABP target value was 80 mm Hg. Hypotension was treated with metaoxedrin or norepinephrine. Statistically significant differences were evaluated using Spearman's rank correlation coefficient. RESULTS: The chart review yielded 129 patients treated for TSCI. The inclusion period was 2010-2017. For the prehospital transport measurements of MABP, the Spearman's rank correlation coefficient was a rho of 0.5662 (p < 0.001), for OR measurements it was a rho of 0.6818 (p < 0.001), and for the NICU measurements it was a rho of 0.4611 (p < 0.001); for NICU unit days 1-2 and days 3-7, the Spearman's rank correlation coefficient was a rho of 0.2209 (p = 0.0681). CONCLUSIONS: Continuous MABP levels exceeding 80 mm Hg have a significant impact on neurological outcome-from earliest possible stabilization in the prehospital care, through hospital admission, the surgical phase, and into the first 2 days in the NICU.

Rapid ventricular pacing for a basilar artery pseudoaneurysm in a pediatric patient: case report.

Large cerebral aneurysms of the basilar apex are difficult to treat. Recently, endovascular treatment has mitigated much of the morbidity associated with treating these lesions. However, the morphology of aneurysms of the vertebrobasilar system can preclude endovascular treatment. Rapid ventricular pacing (RVP) facilitates open surgical treatment of cerebral aneurysms. It can assist in reducing the pressure of the neck of the aneurysm, allowing safe application of a clip. The authors present a case of a pediatric patient who developed a basilar artery pseudoaneurysm that required surgery. Given the large size of the aneurysm, RVP was performed, allowing the surgeons to dissect the dome of the aneurysm from the surrounding tissue and pontine perforating branches away from the lesion to safely clip the lesion. The patient had an uneventful recovery. To the authors' knowledge, this represents the first known case of RVP to aid in basilar artery clip occlusion in a pediatric patient.

Intrathecal morphine analgesia after cervical and thoracic spinal cord tumor surgery.

OBJECT: The aim of this study was to provide evidence for the effect of intrathecal morphine application after spinal cord tumor resection. METHODS: Twenty patients participated in a prospective open proof-of-concept study. During dural closure, morphine (7 µg/kg) was injected into the subarachnoid space. All patients were monitored in an intensive care setting postoperatively. Pain, additional opioids given, and vital parameters were recorded. RESULTS: Six patients received a mean morphine dose of 365 µg between C-3 and C-7 and 14 patients received a mean dose of 436 µg between T-2 and T-12. In the cervical and thoracic groups, the mean Numeric Rating Scale score was highest upon intensive care unit admission (1.2 and 2.5, respectively) and declined at 12 hours (0.5 and 0.8, respectively). Minimal extra morphine was required. Minor side effects occurred without consequence. CONCLUSIONS: Intrathecal morphine for postoperative analgesia after resection of cervical and thoracic spinal cord tumors is effective and safe. These preliminary results require confirmation by larger comparative studies and further clinical experience.

Pressure autoregulation monitoring and cerebral perfusion pressure target recommendation in patients with severe traumatic brain injury based on minute-by-minute monitoring data.

OBJECT: In severe traumatic brain injury, a universal target for cerebral perfusion pressure (CPP) has been abandoned. Attempts to identify a dynamic CPP target based on the patient's cerebrovascular autoregulatory capacity have been promising so far. Bedside monitoring of pressure autoregulatory capacity has become possible by a number of methods, Czosnyka's pressure reactivity index (PRx) being the most frequently used. The PRx is calculated as the moving correlation coefficient between 40 consecutive 5-second averages of intracranial pressure (ICP) and mean arterial blood pressure (MABP) values. Plotting PRx against CPP produces a U-shaped curve in roughly two-thirds of monitoring time, with the bottom of this curve representing a CPP range corresponding with optimal autoregulatory capacity (CPPopt). In retrospective series, keeping CPP close to CPPopt corresponded with better outcomes. Monitoring of PRx requires high-frequency signal processing. The aim of the present study is to investigate how the processing of the information on cerebrovascular pressure reactivity that can be obtained from routine minute-by-minute ICP and MABP data can be enhanced to enable CPPopt recommendations that do not differ from those obtained by the PRx method, show the same associations with outcome, and can be generated in more than two-thirds of monitoring time. METHODS: The low-frequency autoregulation index (LAx) was defined as the moving minute-by-minute ICP/MABP correlation coefficient calculated over time intervals varying from 3 to 120 minutes. The CPPopt calculation was based on LAx-CPP plots and done for time windows between 1 and 24 hours and for each LAx type. The resulting matrix of CPPopts were then averaged in a weighted manner, with the weight based on the goodness of fit of a U-shape and the lower value of the LAx corresponding to the U-bottom, to result in a final CPPopt recommendation. The association between actual CPP/CPPopt and outcome was assessed in the multicenter Brain Monitoring with Information Technology Research Group (BrainIT) database (n = 180). In the Leuven-Tübingen database (60-Hz waveform data, n = 21), LAx- and PRx-based CPPopts were compared. RESULTS: In the BrainIT database, CPPopt recommendations were generated in 95% of monitoring time. Actual CPP being close to LAx-based CPPopt was associated with increased survival. In a multivariate model using the Corticosteroid Randomization After Significant Head Injury (CRASH) model as covariates, the average absolute difference between actual CPP and CPPopt was independently associated with increased mortality. In the high-frequency data set no significant difference was observed between PRx-based and LAx-based CPPopts. The new method issued a CPPopt recommendation in 97% of monitoring time, as opposed to 44% for PRx-based CPPopt. CONCLUSIONS: Minute-by-minute ICP/MABP data contain relevant information for autoregulation monitoring. In this study, the authors' new method based on minute-by-minute data resolution allowed for CPPopt calculation in nearly the entire monitoring time. This will facilitate the use of pressure reactivity monitoring in all ICUs.