[Perifocal edema and glymphatic system dysfunction: quantitative assessment based on diffusion tensor magnetic resonance imaging]. / Peritumoroznyi otek i disfunktsiya glimfaticheskoi sistemy golovnogo mozga: kolichestvennaya otsenka na osnove diffuzionno-tenzornoi MRT.

BACKGROUND: Pathogenesis of peritumoral cerebral edema is unclear and potentially associated with glymphatic system dysfunction. Diffusion tensor MRI (DT-MRI) with analysis of ALPS (Analysis along the Perivascular Space) index may be valuable for assessment of edema. This approach visualizes fluid flow along perivascular spaces of deep cerebral veins. OBJECTIVE: To assess glymphatic system function in supratentorial tumors and healthy volunteers using DT-MRI. MATERIAL AND METHODS: There were 52 patients (59% men) aged 43 (28-64) years with supratentorial tumors (meningioma - 20, grade 3-4 glioma - 15, metastases - 9, lymphoma - 8). Tumors and perifocal edema did not involve deep cerebral veins. The control group included 6 healthy volunteers aged 34-66 years. MRI protocol (Signa HDxt, 3 T) contained standard T1, T2, T2FLAIR, DWI and post-contrast T1 (3D BRAVO). DT-MRI had the following parameters: TR=10 000 ms, TEmin=102 ms, FOV=240 mm, isotropic voxel size 3×3×3 mm3, 60 directions of diffusion gradients. Measurements were carried out at b-factor 0 and 1000 s/mm2. Analysis was carried out in the ReadyView software. RESULTS: Right- and left-sided ALPS indices were similar in the control group (p=0.917). Perifocal edema (regardless of histological type of tumor) in the ipsilateral hemisphere was accompanied by significantly lower ALPS index (p<0.005), while these values in contralateral (intact) hemisphere were similar in both groups (p=0.7). CONCLUSION: We found significantly lower ALPS index in deep parts of the affected hemisphere in patients with perifocal edema. These data can indicate the role of glymphatic system dysfunction in pathogenesis of this pathology.

[Factors influencing peritumoral edema in meningiomas: CT- and MRI-based quantitative assessment]. / Peritumoroznyi otek pri meningiomakh i faktory, vliyayushchie na ego formirovanie: kolichestvennaya otsenka na osnove KT i MRT.

Background. Meningiomas may be accompanied by peritumoral edema. Incidence and pathogenesis of edema are nor clearly established. Prevalence and severity of edema vary significantly in patients with meningiomas similar in various parameters. OBJECTIVE: To assess peritumoral edema in intracranial meningiomas and factors influencing incidence and severity of this process. MATERIAL AND METHODS: There were 126 patients (69% women) aged 19-76 years (median 53), who were diagnosed with 142 meningiomas. Patients underwent surgery (n=111) and radiotherapy (n=15) in 2016-2018. The MRI protocol included T1, T2, T2-FLAIR, DWI and post-contrast T1-weighted images in three projections, diffusion tensor MRI in 27 cases and MR spectroscopy in 21 patients. RESULTS: Peritumoral edema was detected in 46% (n=66) of cases including 21 (31%) patients with severe edema. The ALPS index was 1.510±0.1931 in meningiomas without edema and 1.308±0.19 in those with edema (p=0.014). There was positive correlation between edema, dimensions and uneven contours of meningioma, as well as negative correlation with CSF cleft sign. Blood flow velocity was higher in atypical and anaplastic meningiomas with edema (p=0.03). Other signs (localization, histological variant, malignancy grade, characteristics of MR signal, peaks of the main metabolites, diffusion and perfusion parameters of tumor) did not significantly affect peritumoral edema in patients with meningiomas (p>0.05). CONCLUSION: Diffusion tensor tomography with ALPS index revealed significant effect of glymphatic system dysfunction on peritumoral edema. Large meningioma with uneven contours increased the risk of peritumoral edema, while CSF cleft sign reduced this risk. Other factors did not affect cerebral edema in meningiomas.

[Invasive intracranial pressure monitoring in posterior cranial fossa after neurosurgery: an exclusive option or a necessity?] / Invazivnyi monitoring vnutricherepnogo davleniya v zadnei cherepnoi yamke posle neirokhirurgicheskogo vmeshatel'stva: eksklyuzivnaya optsiya ili neobkhodimost'?

Posterior cranial fossa (PCF) surgery is associated with the risk of increased intracranial pressure (ICP) under tentorium. The last one can lead to severe brainstem syndromes and postoperative complications. The currently recommended method for ICP control with a supratentorial parenchymal sensor or CSF pressure measurement through an external ventricular drainage is ineffective. Indeed, these methods do not show the true situation in the PCF. OBJECTIVE: To determine the feasibility of ICP sensor insertion into cerebellar parenchyma for PCF edema after neurosurgery. MATERIAL AND METHODS: We retrospectively analyzed literature data (15 references) and 3 patients after ICP sensor insertion into cerebellar parenchyma for ICP control in PCF. CONCLUSION: ICP sensor insertion into cerebellar parenchyma is indicated for infratentorial postoperative edema.

[Intravascular hypothermia for cerebral ischemia after microsurgical clipping of complex MCA aneurysms]. / Vnutrisosudistaya gipotermiya pri tserebral'noi ishemii posle mikrokhirurgicheskogo klipirovaniya slozhnykh anevrizm srednei mozgovoi arterii.

Hypothermia for neuroprotection and correction of intracranial hypertension was described in both experimental and clinical studies. Effectiveness of hypothermia for improvement of functional outcomes in neurosurgical patients is still unclear despite the previous randomized trials. In available national and foreign literature, we found no trials devoted to hypothermia in patients with ischemia after surgical treatment of complex aneurysms of the middle cerebral artery (MCA). OBJECTIVE: To analyze the effectiveness of intravascular hypothermia in patients with ischemic cerebrovascular accidents in early postoperative period after microsurgical clipping of complex MCA aneurysms. MATERIAL AND METHODS: We present four patients with cerebral ischemia after microsurgical treatment of complex MCA aneurysms. In all cases, ischemic disorders developed immediately after surgery. We induced intravascular hypothermia 32-34 °C in all patients. CT-based volumetry of ischemia and edema foci was performed to objectively assess the dynamics of ischemic disorders. We carried out volumetry using segmentation of edema and ischemia foci (range 5-33 Hounsfield units). RESULTS: According to brain CT data, all four patients had enlargement of postoperative ischemic brain damage. Nevertheless, ICP was stable that made it possible to avoid decompressive craniotomy. CONCLUSION: Early hypothermia for acute ischemic injury after surgery for complex MCA aneurysms can reduce ischemic perifocal edema. This approach effectively reduces ICP and can exclude the need for decompressive craniotomy in some cases. No side effects of hypothermia justifies further research in this field.

[Periventricular changes following hydrocephalus: quantitative MR-based assessment of tissue characteristics]. / Periventrikulyarnye izmeneniya pri gidrotsefalii: kolichestvennaya otsenka tkanevykh kharakteristik metodom magnitno-rezonansnoi tomografii.

OBJECTIVE: To study tissue characteristics of periventricular white matter in patients with open hydrocephalus using DWI MRI and their correlations with CSF flow parameters. MATERIAL AND METHODS: MRI was performed in 55 patients (35 women and 20 men) with open normal pressure hydrocephalus, as well as 16 patients with malignant occlusive hydrocephalus and interstitial edema (control group). We determined the correlations between severity of hydrocephalus, periventricular lesions and CSF flow parameters considering MR data. Dimensions of ventricular system were assessed using the Evans' index, periventricular changes - using visual four-level scale with calculation of apparent diffusion coefficient (ADC) and fractional anisotropy coefficient (FA). RESULTS: Among patients with open hydrocephalus, ACD range for periventricular white matter was 1.57±0.15·10-3 mm2/s in subgroup of patients without periventricular changes (n=29) and 1.62±0.11×10-3 mm2/s in patients with periventricular changes (n=26). In the control group, mean ADC was 1.76±0.18·10-3 mm2/s (p<0.05). In patients with open hydrocephalus, FA coefficient in the areas of periventricular changes was 0.70-0.80, in case of occlusive hydrocephalus - 0.68-0.82. There was a significant relationship between the Evans' index and CSF pulsation velocity amplitude, Evans' index and stroke volume, Evans' index and cerebral aqueduct cross-sectional area in patients with open hydrocephalus. Periventricular changes were pronounced in patients with open hydrocephalus and Evans' index > 0.4 (p<0.05). CONCLUSION: According to MR data, periventricular changes in patients with open hydrocephalus differ from true periventricular interstitial edema following occlusive hydrocephalus. Severity of periventricular changes in patients with open hydrocephalus depends on patient age and width of the ventricles, but does not correlate with CSF flow parameters. In our opinion, periventricular changes are associated with dysfunction of glymphatic system. Further research is required to study the functioning of glymphatic system and related processes.

[Pupillometry as a method for monitoring of pupillary light reflex in ICU patients]. / Pupillometriya kak metod monitoringa fotoreaktsii v neiroreanimatsii.

This review is devoted to the modern method of monitoring of pupil diameter and reactivity in patients with acute brain injury. The authors present complete data on diagnostic and prognostic capabilities of automated infrared pupillometry, which should take its rightful place in comprehensive assessment of functional brain state in ICU patients. In authors' opinion, clinical introduction of pupillometry will improve prediction of outcomes following acute brain injury and quality of neurological monitoring in patients with cerebral edema and intracranial hypertension.

[Early predictive biomarkers of posttraumatic epilepsy]. / Rannie prediktivnye biomarkery posttravmaticheskoi epilepsii.

Traumatic brain injury (TBI) affects about 50 million people in the world every year. Posttraumatic epilepsy (PTE) is a significant complication of TBI of any severity. PTE occurs in 20% of patients with TBI. Treatment of patients with PTE is particularly difficult due to obvious tendency towards drug resistance. Currently, there are no validated predictive biomarkers for PTE. Development of a system of validated predictive markers would improve PTE prediction quality and therapeutic approach for these patients. This review is devoted to the current data on the most perspective predictive biomarkers of PTE for clinical practice.

[Influence of cerebral hyperthermia on intracranial pressure and autoregulation of cerebral circulation in patients with acute brain injury]. / Vliyanie tserebral'noi gipertermii na vnutricherepnoe davlenie i autoregulyatsiyu mozgovogo krovotoka u patsientov s ostroi tserebral'noi patologiei.

Background. Hyperthermia is a common symptom in ICU patients with brain injury. OBJECTIVE: To study the effect of hyperthermia on intracranial pressure (ICP) and cerebral autoregulation (Prx). MATERIAL AND METHODS: There were 8 patients with acute brain injury, signs of brain edema and intracranial hypertension. Cerebral autoregulation was assessed by using of PRx. ICP, CPP, BP, PRx were measured before and during hyperthermia. We have analyzed 33 episodes of cerebral hyperthermia over 38.30 C. Statistica 10.0 (StatSoft) was used for statistical analysis. RESULTS: Only ICP was significantly increased by 6 [3; 11] mm Hg (p<0.01). In patients with initially normal ICP, hyperthermia resulted increase of ICP in 48% of cases (median 24 [22; 28] mm Hg). In patients with baseline intracranial hypertension, progression of hypertension was noted in 100% cases (median 31 [27; 32] mm Hg) (p<0.01). Hyperthermia resulted intracranial hypertension regardless brain autoregulation status. CONCLUSION: Cerebral hyperthermia in patients with initially normal ICP results intracranial hypertension in 48% of cases. In case of elevated ICP, further progression of intracranial hypertension occurs in 100% of cases. Cerebral hyperthermia is followed by ICP elevation in both intact and impaired cerebral autoregulation.

[Clinical and MRI predictors of coma duration, intensive care and outcome of traumatic brain injury]. / Klinicheskie i magnitno-rezonansnye tomograficheskie prediktory dlitel'nosti komy, ob"ema intensivnoi terapii i iskhodov pri cherepno-mozgovoi travme.

OBJECTIVE: This research is aimed to study the clinical and MRI predictors of coma duration, the intensity of critical care, and outcome of traumatic brain injury (TBI). MATERIAL AND METHODS: The data from 309 patients with TBI of varying severity were included in the analysis, of whom 257 (86.7%) were treated in the intensive care unit (ICU), including 196 (63.4%) patients admitted in a comatose state lasting longer than 1 day. All patients underwent brain MRI within 21 days after the injury. MRI findings were classified according to MRI grading scale of brain damage level and localization proposed previously. RESULTS: The proposed MRI grading significantly correlated with the Glasgow coma (GCS, r=-0.67; p<0.0001) and Glasgow outcome (0.69; p<0.001) scores in the entire group. In a subgroup of comatose patients (GCS<9) it correlated with coma duration (r=0.52; p<0.0001). Spearman correlation analysis showed a significant relationship between the MRI classification and a number of parameters: ICU length of stay (r=0.62; p<0.0001), the duration of artificial ventilation (r=0.47; p<0.0001), the rate of artificial ventilation, sedatives, analgesics, mannitol, hypertonic saline and vasopressors usage (p<0.01). These data confirm the relationship between higher grades of MRI classification (deep brain damage) and the need for the escalation of intensive care main components. CONCLUSION: Our results support the hypothesis that the levels and localization of brain damage, estimated by the proposed MRI grading scale, might be predictors of coma duration, intensity and duration of intensive care, and TBI outcomes. A prognosis based on clinical and neuroimaging data comparison can be valuable for planning and efficient use of the hospital beds and ICU resources, for optimizing the patient flow and timing of patient transfer to neurorehabilitation facilities.

[The prognostic value of mri-classification of traumatic brain lesions level and localization depending on neuroimaging timing]. / Prognosticheskoe znachenie MRT-klassifikatsii urovnei i lokalizatsii travmaticheskogo povrezhdeniia mozga v zavisimosti ot srokov obsledovaniia patsientov.

OBJECTIVE: The aim of this study was to estimate the prognostic value of magnetic resonance imaging (MRI) classification of traumatic brain lesion localization and levels in patients with a brain injury of various severity in a few days to three weeks after the injury. MATERIAL AND METHODS: The cohort of 278 patients with traumatic brain injury (TBI) of various severity aged 8-74 y.o. (average -31.4±13.8, median - 29 (21.3; 37.0) was included in the analysis. The severity of TBI at admission varied from 3 to 15 Glasgow coma scores (GCS) (average - 8±4, median - 7 (5; 12). The main indications and conditions for MRI were: inconsistency between computed tomography (CT) data and neurological status, the necessity to clarify the location and type of brain damage, the absence of metal implants, the stabilization of the patient's vital functions, etc. MRI was performed during the first three weeks after the injury using T1, T2, T2-FLAIR, DWI, T2*GRE, SWAN sequences. The damage to the brain was classified according to 8 grades depending on the lesion levels (cortical-subcortical level, corpus callosum, basal ganglia and/or thalamus, and/or internal, and/or external capsules, uni- or bilateral brain stem injury at a different level). Outcomes were assessed by the Glasgow outcome scale (GOS) 6 months after injury. RESULTS: The significant correlations were found for the entire cohort between MRI grading and TBI severity (by GCS) and outcome (by GOS) of the injury (R=-0.66; p<0.0001; R=-0.69; p<0.0001, respectively). A high accuracy (77%), sensitivity (77%) and specificity (76%) of the proposed MRI classification in predicting injury outcomes (AUC=0.85) were confirmed using the logistic regression and ROC analysis. The assessment of MRI-classification prognostic value in subgroups of patients examined during the first, second, and third weeks after injury showed significant correlations between the GCS and the GOS as well as between MRI-grading and GCS, and GOS in all three subgroups. In the subgroup of patients examined during the first 14 days after the injury, the correlation coefficients were higher compared with those obtained in a subgroup examined 15-21 days after the injury. The highest correlations between MRI grading, TBI severity, and the outcome were found in the subgroup of patients who underwent MRI in the first three days after the injury (n=58). CONCLUSION: The proposed MRI classification of traumatic brain lesion levels and localization based on the use of different MR sequences reliably correlated with the clinical estimate of TBI severity by GCS and the outcomes by GOS in patients examined during the first three weeks after injury. The strongest correlation was observed for patients examined during the first three days after the injury.

[Autoregulation of cerebral blood flow in severe diffuse axonal brain injury: the role of neuroanatomical factors]. / Autoreguliatsiia mozgovogo krovotoka pri tiazhelom diffuznom aksonal'nom povrezhdenii golovnogo mozga: rol' neiroanatomicheskikh faktorov.

Autoregulation of cerebral blood flow (ACBF) is a system of mechanisms for maintaining stable adequate perfusion of the brain despite changes in systemic arterial pressure. In recent years, new data on the numerous metabolic and systemic mechanisms of cerebral blood flow regulation have been obtained, but the role of neurogenic regulation has not yet been fully understood and, therefore, not considered in clinical practice. AIM: The study aim was to assess the effect of anatomical injuries to deep brain structures on the extent and duration of ACBF abnormalities in a model of severe diffuse axonal injury (DAI). RESULTS: The study demonstrated that brain injury in the projection of a dopaminergic structure (substantia nigra) and a cholinergic structure (nucleus basalis of Meynert region) was more common in patients with impaired ACBF and was associated with a longer duration of the impairment. CONCLUSION: The obtained data may indicate the presence of central (neurogenic) pathways of cerebral vessel tone regulation; traumatic injury of the pathways leads to a more severe and prolonged period of impaired ACBF. Probably, injury to these regulatory structures in some patients has an indirect effect on the course of intracranial hypertension. Further experimental and clinical studies in this direction are needed to elucidate all elements of neurogenic regulation of cerebral vessel tone and ACBF mechanisms.

[Correlation of intracranial pressure and diameter of the sheath of the optic nerve by computed tomography in severe traumatic brain injury]. / Korreliatsiia vnutricherepnogo davleniia i diametra obolochki zritel'nogo nerva po dannym komp'iuternoi tomografii pri tiazheloi cherepno-mozgovoi travme.

BACKGROUND: Noninvasive techniques to evaluate intracranial pressure (ICP) are important for everyday practice in intensive care and neurosurgery departments. CT data can be used to evaluate the optic nerve sheath diameter (ONSD) and, indirectly, the ICP value. The ONSD value is an additional criterion in deciding on invasive monitoring of ICP. AIM: To analyze a correlation between CT-based ONSD and the results of invasive measurements of ICP in patients with severe traumatic brain injury. MATERIAL AND METHODS: The study evaluated 41 patients with severe traumatic brain injury within the first 48 h after injury. Invasive monitoring of ICP (Codman & Shurtlett, MA, USA) was performed during 7±1.7 days. ONSD was measured using axial CT scans (CereTom, Neurologica Danvers, MA, USA) with a slice thickness of 2.5 mm. The ONSD value was measured at a distance of 3 mm from the posterior eyeball contour. The patients were allocated in a group with normal ICP (10 patients) and a group with high ICP (31 patients). ONSD served as an ICP classifier. The data were processed using ROC analysis. RESULTS: According to the CT data, the optimal threshold ONSD value was 6.35 mm in patients in the acute TBI period. The sensitivity was 0.93 (95% СI 0.84-1.00), the specificity was 0.80 (95% СI 0.50-1.00), and AUC was 0.87 (95% СI 0.69-1.00). CONCLUSION: We found a correlation between the CT-based ONSD and the median ICP (R=0.32, p<0.05). An ONSD value of 6.35 mm and more is one of the signs of previous or existing ICP.

[Use of the IntelliVent-ASV mode for maintaining the target EtCO2 range in patients with severe TBI]. / Ispol'zovanie rezhima IntelliVent-ASV dlia podderzhaniia tselevogo diapazona EtCO2 u patsientov s tiazheloi ChMT.

PURPOSE: the study purpose was to evaluate the efficacy of the IntelliVent-ASV mode in maintaining the target range of PaCO2 in patients with severe TBI. MATERIAL AND METHODS: The study included 12 severe TBI patients with the wakefulness level scored 4-9 (GCS). This was a crossover design study. Two ventilation modes were consecutively used: IntelliVent-ASV and P-CMV, for 12 h each. When using the P-CMV mode, the ventilation parameters were set to maintain PaCO2 in a range of 35-38 mm Hg. The IntelliVent-ASV mode involved the Brain Injury ventilation algorithm. The target range of EtCO2 was set in accordance with the delta PaCO2-EtCO2 to maintain PaCO2 in a range of 35-38. At the beginning of each ventilation period and every 3 hours, the arterial blood gas composition was analyzed. When PaCO2 occurred out of the 35-38 range, appropriate adjustments were made to the ventilation parameters. In the P-CMV mode, the Pinsp and RR parameters were adjusted to achieve the target PaCO2 range. In IntelliVent mode, a shift of the target EtCO2 range was adjusted in accordance with a changed PaCO2-EtCO2 difference. In all patients, ICP, blood pressure, and EtCO2 were monitored; the arterial blood gas composition was analyzed every 3 h; the frequency of manual settings of ventilation parameters was recorded. RESULTS: The EtCO2 and PaCO2 parameters were found not to be significantly different in the P-CMV and IntelliVent modes, but the spread in these parameters was significantly lower in the IntelliVent ventilation mode. The PaCO2 parameter occurred out of the target range significantly less often in the IntelliVent mode than in the P-CMV mode. The mean frequency of manual respirator settings needed to maintain the target EtCO2 range was significantly lower in the IntelliVent-ASV mode than in the P-CMV mode. CONCLUSION: The IntelliVent-ASV mode provides more efficient maintenance of PaCO2 in the target range compared to traditional artificial ventilation using fewer manual settings of the ventilation parameters.

[Guidelines for the diagnosis and treatment of severe traumatic brain injury. Part 2. Intensive care and neuromonitoring].

Traumatic brain injury (TBI) is one of the major causes of death and disability in young and middle-aged people. The most problematic group is comprised of patients with severe TBI who are in a coma. The adequate diagnosis of primary brain injuries and timely prevention and treatment of the secondary injury mechanisms largely define the possibility of reducing mortality and severe disabling consequences. When developing these guidelines, we used our experience in the development of international and national recommendations for the diagnosis and treatment of mild traumatic brain injury, penetrating gunshot wounds to the skull and brain, severe traumatic brain injury, and severe consequences of brain injuries, including a vegetative state. In addition, we used international and national guidelines for the diagnosis, intensive care, and surgical treatment of severe traumatic brain injury, which had been published in recent years. The proposed guidelines concern intensive care of severe TBI in adults and are particularly intended for neurosurgeons, neurologists, neuroradiologists, anesthesiologists, and intensivists who are routinely involved in the treatment of these patients.

[SIMULTANEOUS MEASUREMENT OF INTRAVENTRICULAR AND PARENCHYMAL INTRACRANIAL PRESSURE IN PATIENTS WITH SEVERE TRAUMA BRAIN INJURY].

INTRODUCTION: "Standard" assessment of ICP by measuring liquor ventricular pressure recently questioned. THE OBJECTIVE OF THE STUDY: Compare the values of ventricular and parenchymal ICP against the closure of open liquor drainage and during active CSF drainage. MATERIALS AND METHODS: Examined 7 patients with TBI and intracranial hypertension syndrome, GCS 5.6 ± 1.2 points, 4.2 ± age 33 years. Compared parenchymal and ventricular ICP in three time periods: 1--during closure of ventricular drainage, 2--during of the open drains and drainage at the level of 14-15 mmHg, 3--during the period of active drainage. When comparing two methods of measurement used Bland-Altman method. RESULTS: 1. During time period of the closed drainage correlation coefficient was r = 0.83, p < 0.001. Bland-Altman method: the difference of the two measurements is equal to the minimum and 0.7 mm Hg, the standard deviation of 2.02 mm Hg 2. During time period of the open drainage was reduction of the correlation coefficient to r = 0.46, p < 0.01. Bland-Altman method: an increase in the difference of the two measurements to -0.84 mmHg, standard deviation 2.8 mm Hg 3. During time period of the active drainage of cerebrospinal fluid was marked difference between methods of measurement. Bland-Altman method: the difference was 8.64 mm Hg, and a standard deviation of 2.6 mm Hg. CONCLUSIONS: 1. During the closure of the ventricular drainage were good correlation between ventricular and parenchymal ICR 2. During open the liquor drainage correlation between the two methods of measuring the intracranial pressure is reduced. 3. During the active CSF drainage correlation between the two methods of measuring intracranial pressure can be completely lost. Under these conditions, CSF pressure is not correctly reflect the ICP 4. For an accurate and continuous measurement of intracranial pressure on the background of the active CSF drainage should be carried out simultaneous parenchymal ICP measurement.

[BRAIN NATRIURETIC PEPTIDE AS A MARKER OF SEVERITY OF PATIENT'S CONDITION AFTER SEVERE TRAUMATIC BRAIN INJURY].

The aim of the study was to assess the significance of NT-proBNP levels as a predictor of the severity of patients' condition after severe TBI and critical stress of the heart. In this prospective observational study 118 patients admitted on 1-4 day after severe TBI (GCS <8 points on admission) was supervised. The average age of patients was 32 +/- 16 years, 28 women and 90 men were in this group. 12 of the observed patients died within the first 10 days. NT-proBNP level was determined by immunochemiluminescent analyzer "Immulite 2000" (Siemens). Blood sampling was performed daily at 8:00 am during the acute period--an average for 7 days (5 to 10) from the date of admission. At the same time hemodynamic status was assessed by PiCCO. It has been shown that NT-proBNP level may be not only a marker of severity of condition and poor outcome in patients with severe TBI, but also can be used as a good predictor of exhaustion of compensatory myocardial capacity in these patients.

[PrÑ -monitoring based decision-making about decompressive craniectomy in a patient with severe traumatic brain injury. A case report].

The presented case illustrates a new approach to making a decision about decompressive craniectomy in the patient with sever traumatic brain injury and intracranial hypertension. The approach is based on continuous assessment of cerebral autoregulation using Prx-monitoring in addition to monitoring of intracranial pressure and cerebral perfusion pressure. Prx-monitoring enables timely detection of autoregulation failure and provides the opportunity to make a decision about decompressive craniectomy before starting such aggressive methods of intensive care as hypothermia or barbiturate coma.

[Guidelines for the management of severe head injury. Part 1. Neurotrauma system and neuroimaging].

Traumatic brain injury is one of the main causes of mortality and disability in young and middle-aged individuals. The patients with severe traumatic brain injury who are in coma are the most difficult to deal with. Appropriate diagnosis of the primary brain injuries and early prevention and treatment of secondary damage mechanisms largely determine the possibility of reducing mortality and severe disabling consequences. The authors compiled these guidelines based on their experience in development of international and Russian recommendations on the diagnosis and treatment of mild traumatic brain injury, penetrating gunshot injury of the skull and brain, severe traumatic brain injury, and severe consequences of brain injuries, including a vegetative state. In addition, we used the materials of international and Russian recommendations on the diagnosis, intensive care, and surgical treatment of severe traumatic brain injury published in recent years. The proposed recommendations are related to organization of medical care and diagnosis of severe traumatic brain injury in adults and are primarily addressed to neurosurgeons, neurologists, neuroradiologists, anesthesiologists, and emergency room doctors, who are routinely involved in management of these patients.

[SEPTIC SHOCK IN PATIENT WITH SEVERE HEAD TRAUMA].

The clinical observation illustrates the role of screening of inflammatory markers and advanced hemodynamic monitoring in optimization of the treatment of the patient with severe traumatic brain injury (sTBI). The level of consciousness by the Glasgow Coma Scale at admission was 5 points. From the first day of stay the patient suffered hyperthermia to 39,0° C° The diagnosis of the aspiration pneumonia was determined by radiological signs, bronchoscopy and inflammatory blood markers, C-reactive protein, leukocytosis. From the second day the constant infusion of norepinephrine was necessary to maintain mean ABP above 80 mmHg. On the 10th day the patient's condition deteriorated sharply. Developed hyperthermia to 40, 2° and cardiovascular collapse (in spite of the high level of norepinephrine support a sharp decline in ABP up to 49/20 mmHg). Invasive advanced hemodynamic PiCCO monitoring (transpulmonary thermodilution) was started Septic shock was suspected. Standard laboratory tests did not meet the criteria for septic shock. Witnessed a slight increase in CRP and procalcitonin (PCT) was within normal limits. Diagnostic search was supplemented by a study of interleukins (IL-6 and IL-2R) in the blood plasma. The significant increase in their values, was regarded as the initial manifestations of the systemic inflammatory response. Sepsis was confirmed. The extended antibiotic therapy started Continuous Veno-Venous hemofiltration was used as part of treatment of the inflammatory-toxic condition. In two days of the therapy the patient's condition has stabilized, the patient recovered consciousness in the form of opening the eyes, simple instructions. At discharge, the patient's condition according to the Glasgow outcome scale was estimated at 4 points.

[The use of intravascular hypothermia to correct intracranial hypertension in patients with severe traumatic brain injury].

OBJECTIVE: Assess to impact hypothermia on ABP, CPP, ICP and cerebral autoregulation. Material and methods. 14 patients with TBI (GOS<9) underwent hypothermia by Thermogard system within 32-35 °C (Zoll, USA). ICP was measured intraparenchymal by Codman sensor. Cerebral autoregulation was estimated by correlation coefficient Prx (Soft ICM Plus, Cambridge, UK). Temperature was measured in urinary bladder. There were selected five time periods: 1 - phase of initial state, 2 - phase of induction hypothermia, 3 - phase of hypothermia, 4 - phase of rewarming, 5 - phase after finishing hypothermia. All data preset as Mediana (min; max). Stat analysis was perfomed using Soft Statistica 10.0. Results. Phase 1 lasted nearly 7 (2; 12) h, ABP 94 (81; 102), CPP - 73 (52; 87), ICP 27 (16; 45) mm Hg, Prx 0,25 (-0,15; 0,7), temperature 38,2 °C (37; 39,8). Phase 2: 5 (2; 12) h, ABP 95 (85; 114), CPP 80 (65; 96), ICP 18 (10; 22) mm Hg, Prx -0,055 (-0,15; 0,7), temperature 35,2 °C (34,5; 35,5). Phase 3: 55 (20; 100) h, there were not significant changed ABP, CPP, Prx, ICP 15 (10; 18) mm Hg, temperature was 33,5 °C (32; 34,7). Phase 4: 17 (8; 24) h, ABP 90 (70; 100), CPP 77 (55; 85), ICP 15 (9; 27) mm Hg and Prx 0,2 (-0,2; 0,32). Temperature 36,9 °C (35,9; 38,5). Phase 5: 20 (6; 240) h, ABP 87(53; 110), CPP 72 (47; 107), ICP 17 (10; 32) mm Hg and Prx 0,2 (-0,2; 0,6). Temperature 37,7 °C (36,7; 39,0). Conclusion. Hypothermia is an effective method for correction of intracranial hypertension. Hypothermia can use as a additional option of intensive care during refractory intracranial hypertension. Rewarming phase is the most dangerous time on the re-development of intracranial hypertension and disruption of autoregulation.