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2.
Curr Neurol Neurosci Rep ; 21(3): 6, 2021 02 02.
Artículo en Inglés | MEDLINE | ID: mdl-33527217

RESUMEN

PURPOSE OF REVIEW: Increasingly sophisticated systems for monitoring the brain have led to an increase in the use of multimodality monitoring (MMM) to detect secondary brain injuries before irreversible damage occurs after brain trauma. This review examines the challenges and opportunities associated with MMM in this population. RECENT FINDINGS: Locally and internationally, the use of MMM varies. Practical challenges include difficulties with data acquisition, curation, and harmonization with other data sources limiting collaboration. However, efforts toward integration of MMM data, advancements in data science, and the availability of cloud-based infrastructures are now affording the opportunity for MMM to advance the care of patients with brain trauma. MMM provides data to guide the precision management of patients with traumatic brain injury in real time. While challenges exist, there are exciting opportunities for MMM to live up to this promise and to drive new insights into the physiology of the brain and beyond.


Asunto(s)
Lesiones Traumáticas del Encéfalo , Lesiones Encefálicas , Encéfalo , Lesiones Encefálicas/diagnóstico , Lesiones Traumáticas del Encéfalo/diagnóstico por imagen , Lesiones Traumáticas del Encéfalo/terapia , Ciencia de los Datos , Humanos , Presión Intracraneal , Monitoreo Fisiológico
3.
J Physiol ; 599(7): 1977-1996, 2021 04.
Artículo en Inglés | MEDLINE | ID: mdl-33586133

RESUMEN

KEY POINTS: The human brain is particularly vulnerable to heat stress; this manifests as impaired cognition, orthostatic tolerance, work capacity and eventually, brain death. The brain's limitation in the heat is often ascribed to inadequate cerebral blood flow (CBF), but elevated intracranial pressure is commonly observed in mammalian models of heat stroke and can on its own cause functional impairment. The CBF response to incremental heat strain was dependent on the mode of heating, decreasing by 30% when exposed passively to hot, humid air (sauna), while remaining unchanged or increasing with passive hot-water immersion (spa) and exercising in a hot environment. Non-invasive intracranial pressure estimates (nICP) were increased universally by 18% at volitional thermal tolerance across all modes of heat stress, and therefore may play a contributing role in eliciting thermal tolerance. The sauna, more so than the spa or exercise, poses a greater challenge to the brain under mild to severe heating due to lower blood flow but similarly increased nICP. ABSTRACT: The human brain is particularly vulnerable to heat stress; this manifests as impaired cognitive function, orthostatic tolerance, work capacity, and eventually, brain death. This vulnerability is often ascribed to inadequate cerebral blood flow (CBF); however, elevated intracranial pressure (ICP) is also observed in mammalian models of heat stroke. We investigated the changes in CBF with incremental heat strain under three fundamentally different modes of heating, and assessed whether heating per se increased ICP. Fourteen fit participants (seven female) were heated to thermal tolerance or 40°C core temperature (Tc ; oesophageal) via passive hot-water immersion (spa), passive hot, humid air exposure (sauna), cycling exercise, and cycling exercise with CO2 inhalation to prevent heat-induced hypocapnia. CBF was measured with duplex ultrasound at each 0.5°C increment in Tc and ICP was estimated non-invasively (nICP) from optic nerve sheath diameter at thermal tolerance. At thermal tolerance, CBF was decreased by 30% in the sauna (P < 0.001), but was unchanged in the spa or with exercise (P ≥ 0.140). CBF increased by 17% when end-tidal P C O 2 was clamped at eupnoeic pressure (P < 0.001). On the contrary, nICP increased universally by 18% with all modes of heating (P < 0.001). The maximum Tc was achieved with passive heating, and preventing hypocapnia during exercise did not improve exercise or thermal tolerance (P ≥ 0.146). Therefore, the regulation of CBF is dramatically different depending on the mode and dose of heating, whereas nICP responses are not. The sauna, more so than the spa or exercise, poses a greater challenge to the brain under equivalent heat strain.


Asunto(s)
Trastornos de Estrés por Calor , Calefacción , Presión Sanguínea , Circulación Cerebrovascular , Ejercicio Físico , Femenino , Humanos , Presión Intracraneal
4.
High Blood Press Cardiovasc Prev ; 28(2): 115-128, 2021 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-33599966

RESUMEN

INTRODUCTION: Intracerebral haemorrhage (ICH) is associated with high morbidity and mortality. Blood pressure (BP) control is one of the main management strategies in acute ICH. Limited data currently exist regarding intracranial pressure (ICP) in acute ICH. The relationship between BP lowering and ICP is yet to be fully elucidated. METHODS: We conducted a systematic review to investigate the effects of BP lowering on ICP in acute ICH. The study protocol was registered on PROSPERO (CRD42019134470). RESULTS: Following PRISMA guidelines, MEDLINE, EMBASE and CENTRAL were searched for studies on ICH with BP and ICP or surrogate measures. 1096 articles were identified after duplicates were removed; 18 studies meeting the inclusion criteria. Dihydropyridine calcium channel blockers (CCBs) were the most common agent used to lower BP, but had a varying effect on ICP. Other BP-lowering agents used also had a varying effect on ICP. DISCUSSION AND CONCLUSION: Further work, including large observational or randomized interventional studies, is needed to develop a better understanding of the effect of BP lowering on ICP in acute ICH, which will assist the development of more effective management strategies. TRIAL REGISTRATION: The study protocol was registered on PROSPERO (CRD42019134470) on 29/05/2019.


Asunto(s)
Antihipertensivos/uso terapéutico , Presión Sanguínea/efectos de los fármacos , Hemorragia Cerebral/tratamiento farmacológico , Presión Intracraneal/efectos de los fármacos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Resultado del Tratamiento , Adulto Joven
5.
Artículo en Ruso | MEDLINE | ID: mdl-33560622

RESUMEN

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.


Asunto(s)
Lesiones Encefálicas , Hipertensión Intracraneal , Presión Sanguínea , Circulación Cerebrovascular , Homeostasis , Humanos , Hipertensión Intracraneal/etiología , Hipertensión Intracraneal/terapia , Presión Intracraneal
6.
Curr Opin Crit Care ; 27(2): 87-94, 2021 04 01.
Artículo en Inglés | MEDLINE | ID: mdl-33395087

RESUMEN

PURPOSE OF REVIEW: To provide an overview on recent advances in the field of assessment and monitoring of patients with severe traumatic brain injury (sTBI) in neurocritical care from a neurosurgical point of view. RECENT FINDINGS: In high-income countries, monitoring of patients with sTBI heavily relies on multimodal neurocritical parameters, nonetheless clinical assessment still has a solid role in decision-making. There are guidelines and consensus-based treatment algorithms that can be employed in both absence and presence of multimodal monitoring in the management of patients with sTBI. Additionally, novel dynamic monitoring options and machine learning-based prognostic models are introduced. Currently, the acute management and treatment of secondary injury/insults is focused on dealing with the objective evident pathology. An ongoing paradigm shift is emerging towards more proactive treatment of neuroworsening as soon as premonitory signs of deterioration are detected. SUMMARY: Based on the current evidence, serial clinical assessment, neuroimaging, intracranial and cerebral perfusion pressure and brain tissue oxygen monitoring are key components of sTBI care. Clinical assessment has a crucial role in identifying the crashing patient with sTBI, especially from a neurosurgical standpoint. Multimodal monitoring and clinical assessment should be seen as complementary evaluation methods that support one another.


Asunto(s)
Lesiones Traumáticas del Encéfalo , Lesiones Encefálicas , Encéfalo , Lesiones Traumáticas del Encéfalo/cirugía , Circulación Cerebrovascular , Humanos , Presión Intracraneal , Monitoreo Fisiológico , Neurocirujanos
7.
Nat Commun ; 12(1): 447, 2021 01 19.
Artículo en Inglés | MEDLINE | ID: mdl-33469018

RESUMEN

Cerebrospinal fluid (CSF) provides vital support for the brain. Abnormal CSF accumulation, such as hydrocephalus, can negatively affect perinatal neurodevelopment. The mechanisms regulating CSF clearance during the postnatal critical period are unclear. Here, we show that CSF K+, accompanied by water, is cleared through the choroid plexus (ChP) during mouse early postnatal development. We report that, at this developmental stage, the ChP showed increased ATP production and increased expression of ATP-dependent K+ transporters, particularly the Na+, K+, Cl-, and water cotransporter NKCC1. Overexpression of NKCC1 in the ChP resulted in increased CSF K+ clearance, increased cerebral compliance, and reduced circulating CSF in the brain without changes in intracranial pressure in mice. Moreover, ChP-specific NKCC1 overexpression in an obstructive hydrocephalus mouse model resulted in reduced ventriculomegaly. Collectively, our results implicate NKCC1 in regulating CSF K+ clearance through the ChP in the critical period during postnatal neurodevelopment in mice.


Asunto(s)
Líquido Cefalorraquídeo/metabolismo , Plexo Coroideo/patología , Hidrocefalia/patología , Miembro 2 de la Familia de Transportadores de Soluto 12/metabolismo , Animales , Animales Recién Nacidos , Plexo Coroideo/diagnóstico por imagen , Plexo Coroideo/crecimiento & desarrollo , Plexo Coroideo/metabolismo , Dependovirus/genética , Modelos Animales de Enfermedad , Embrión de Mamíferos , Femenino , Vectores Genéticos/administración & dosificación , Vectores Genéticos/genética , Humanos , Hidrocefalia/congénito , Hidrocefalia/diagnóstico , Hidrocefalia/fisiopatología , Inyecciones Intraventriculares , Presión Intracraneal/fisiología , Imagen por Resonancia Magnética , Masculino , Ratones , Ratones Transgénicos , Miembro 2 de la Familia de Transportadores de Soluto 12/genética
8.
J Stroke Cerebrovasc Dis ; 30(3): 105540, 2021 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-33360250

RESUMEN

OBJECTIVES: Intracranial pressure (ICP) monitors have been used in some patients with spontaneous intracranial hemorrhage (ICH) to provide information to guide treatment without clear evidence for its use in this population. We assessed the impact of ICP monitor placement, including external ventricular drains and intraparenchymal monitors, on neurologic outcome in this population. MATERIALS AND METHODS: In this secondary analysis of the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation III trial, the primary outcome was poor outcome (modified Rankin Scale score 4-6) and the secondary outcome was death, at 1 year from onset. We compared outcomes in patients with or without an ICP monitor using unadjusted and adjusted logistic regression models. The analyses were repeated in a balanced cohort created with propensity score matching. RESULTS: Seventy patients underwent ICP monitor placement and 424 did not. Poor outcome was seen in 77.1% of patients in the ICP-monitor subgroup compared with 53.8% in the no-monitor subgroup (p<0.001). Of patients in the ICP-monitor subgroup, 31.4% died, compared with 21.0% in the no-monitor subgroup (p=0.053). In multivariate models, ICP monitor placement was associated with a >2-fold greater risk of poor outcome (odds ratio 2.76, 95% CI 1.30-5.85, p=0.008), but not with death (p=0.652). Our findings remained consistent in the propensity score-matched cohort. CONCLUSION: These results question whether ICP monitor-guided therapy in patients with spontaneous nontraumatic ICH improves outcome. Further work is required to define the causal pathway and improve identification of patients that might benefit from invasive ICP monitoring.


Asunto(s)
Hemorragias Intracraneales/terapia , Presión Intracraneal , Monitoreo Fisiológico/instrumentación , Anciano , Ensayos Clínicos Fase III como Asunto , Bases de Datos Factuales , Femenino , Humanos , Hemorragias Intracraneales/diagnóstico , Hemorragias Intracraneales/mortalidad , Hemorragias Intracraneales/fisiopatología , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Ensayos Clínicos Controlados Aleatorios como Asunto , Recuperación de la Función , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento
9.
Emerg Med Clin North Am ; 39(1): 133-154, 2021 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-33218654

RESUMEN

Management of acute neurologic disorders in the emergency department is multimodal and may require the use of medications to decrease morbidity and mortality secondary to neurologic injury. Clinicians should form an individualized treatment approach with regard to various patient specific factors. This review article focuses on the pharmacotherapy for common neurologic emergencies that present to the emergency department, including traumatic brain injury, central nervous system infections, status epilepticus, hypertensive emergencies, spinal cord injury, and neurogenic shock.


Asunto(s)
Servicio de Urgencia en Hospital , Enfermedades del Sistema Nervioso/tratamiento farmacológico , Anticonvulsivantes/uso terapéutico , Lesiones Traumáticas del Encéfalo/tratamiento farmacológico , Infecciones del Sistema Nervioso Central/tratamiento farmacológico , Urgencias Médicas , Humanos , Presión Intracraneal/efectos de los fármacos , Neurofarmacología , Estado Epiléptico/tratamiento farmacológico
10.
Curr Opin Ophthalmol ; 32(1): 69-73, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-33196542

RESUMEN

PURPOSE OF REVIEW: During prolonged spaceflight, astronauts often experience ocular changes, due to constant head-ward fluid shifts in space as compared with Earth. This article reviews symptoms, likely causes, and potential solutions, such as lower body negative pressure, to counteract space-associated neuroocular syndrome (SANS). RECENT FINDINGS: Low gravity conditions and other aspects of spaceflight affect the eye detrimentally, causing SANS which is characterized by optic disc edema, choroidal thickening, cotton wool spots, and a hyperopic shift. SANS is probably caused by altered hemodynamic flows in the head and neck as well as mildly elevated intracranial and intraocular pressures. Carbon dioxide and other chemicals in space-craft may influence SANS as well. SANS may be counteracted by using lower body negative pressure, thigh cuffs, spacecraft engineering, and/or artificial gravity by a centrifuge. SUMMARY: Prolonged space missions are associated with optic disc edema, choroidal thickening, cotton wool spots, and a hyperopic shift. Possible causes and countermeasures are currently being researched to reduce the risk of SANS. Although many countermeasures to SANS are under investigation lower body negative pressure exhibits great promise in counteracting the headward fluid shifts in space. Understanding and prevention of SANS is critical to future space exploration, especially to long-duration missions to the moon and Mars.


Asunto(s)
Enfermedades de la Coroides/etiología , Hiperopía/etiología , Papiledema/etiología , Vuelo Espacial , Trastornos de la Visión/etiología , Ingravidez/efectos adversos , Astronautas , Enfermedades de la Coroides/prevención & control , Transferencias de Fluidos Corporales , Humanos , Hiperopía/prevención & control , Presión Intracraneal , Presión Negativa de la Región Corporal Inferior , Papiledema/prevención & control , Trastornos de la Visión/prevención & control
11.
Sci Rep ; 10(1): 21787, 2020 12 11.
Artículo en Inglés | MEDLINE | ID: mdl-33311523

RESUMEN

Although criteria for surgical treatment of acute subdural hematoma (SDH) have been proposed, interaction exists between SDH, midline shift (MLS), and intracranial pressure (ICP). Based on our half sphere finite-element model (FEM) of the supratentorial brain parenchyma, tools for ICP estimation using SDH thickness (SDHx) and MLS were developed. We performed 60 single load step, structural static analyses, simulating a left-sided SDH compressing the cerebral hemispheres. The Young's modulus was taken as 10,000 Pa. The ICP loads ranged from 10 to 80 mmHg with Poisson's ratios between 0.25 and 0.49. The SDHx and the MLS results were stored in a lookup table. An ICP estimation equation was derived from these data and then was converted into a nomogram. Numerical convergence was achieved in 49 model analyses. Their SDHx ranged from 0.79 to 28.3 mm, and the MLS ranged from 1.5 to 16.9 mm. The estimation formula was log(ICP) = 0.614-0.520 log(SDHx) + 1.584 log(MLS). Good correlations were observed between invasive ICP measurements and those estimated from preoperative SDHx and MLS data on images using our model. These tools can be used to estimate ICP noninvasively, providing additional information for selecting the treatment strategy in patients with SDH.


Asunto(s)
Hematoma Subdural Agudo/fisiopatología , Presión Intracraneal , Modelos Neurológicos , Nomogramas , Humanos
12.
An. Fac. Cienc. Méd. (Asunción) ; 53(3): 173-176, 20201201.
Artículo en Español | LILACS | ID: biblio-1178015

RESUMEN

Introducción: Los Quistes Aracnoideos son colecciones benignas de líquido cefalorraquídeo que representan el 1% de lesiones ocupantes de espacios intracraneales. Se detecta frecuentemente antes de los 20 años, entre 60 a 90% de los casos. La prevalencia estimada es de 1,4% en adultos, siendo la menos frecuente la ubicación intraventricular. Caso Clínico: Mujer de 60 años de edad, consultó por cefalea holocraneana de larga data y ocasionales mareos. Sin alteraciones al examen físico neurológico. Se le realizó tomografía axial computarizada donde llamó la atención una leve alteración de la densidad intraventricular por lo que se procedió a realizar resonancia magnética nuclear que demostró imágenes quísticas en atrio de ventrículos laterales, bilateral. No se requirió de una intervención quirúrgica debido a que la paciente no presentaba sintomatología significativa. Discusión: El tratamiento quirúrgico es recomendado en pacientes sintomáticos, en quistes de gran extensión y en los que cursan con complicaciones. Para los pacientes que cursen sólo con dolor de cabeza, sin hidrocefalia secundaria o un aumento evidente de la presión intracraneal se recomienda la observación con o sin repetición de las imágenes.


Introduction: Arachnoid cysts are benign collections of cerebrospinal fluid that represents 1% of lesions occupying intracranial spaces. It is frequently detected before the age of 20, between 60 to 90% of cases. The estimated prevalence is 1.4% in adults, the least frequent being intraventricular location. Clinical Case: A 60-year-old woman attended for a long-standing holocranial headache and occasional dizziness. No alteration in the neurological physical examination. A computerized axial tomography was performed, where a slight alteration in the intraventricular density drew attention, for which a nuclear magnetic resonance was carried out, which showed cystic images in the atrium of bilateral lateral ventricles. No surgical intervention was required because the patient did not present a significant symptomatology. Discussion: Surgical treatment is recommended in symptomatic patients, in cysts of great extension and in those with complications. For patients with only headache, without secondary hydrocephalus or an obvious increase in intracranial pressure, observation with or without repetition of the images is recommended.


Asunto(s)
Espectroscopía de Resonancia Magnética , Tomografía , Cefalea , Hidrocefalia , Mujeres , Presión Intracraneal , Líquido Cefalorraquídeo , Observación
13.
PLoS One ; 15(12): e0243427, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-33315872

RESUMEN

Magnitude of intracranial pressure (ICP) elevations and their duration have been associated with worse outcomes in patients with traumatic brain injuries (TBI), however published thresholds for injury vary and uncertainty about these levels has received relatively little attention. In this study, we have analyzed high-resolution ICP monitoring data in 227 adult patients in the CENTER-TBI dataset. Our aim was to identify thresholds of ICP intensity and duration associated with worse outcome, and to evaluate the uncertainty in any such thresholds. We present ICP intensity and duration plots to visualize the relationship between ICP events and outcome. We also introduced a novel bootstrap technique to evaluate uncertainty of the equipoise line. We found that an intensity threshold of 18 ± 4 mmHg (2 standard deviations) was associated with worse outcomes in this cohort. In contrast, the uncertainty in what duration is associated with harm was larger, and safe durations were found to be population dependent. The pressure and time dose (PTD) was also calculated as area under the curve above thresholds of ICP. A relationship between PTD and mortality could be established, as well as for unfavourable outcome. This relationship remained valid for mortality but not unfavourable outcome after adjusting for IMPACT core variables and maximum therapy intensity level. Importantly, during periods of impaired autoregulation (defined as pressure reactivity index (PRx)>0.3) ICP events were associated with worse outcomes for nearly all durations and ICP levels in this cohort and there was a stronger relationship between outcome and PTD. Whilst caution should be exercised in ascribing causation in observational analyses, these results suggest intracranial hypertension is poorly tolerated in the presence of impaired autoregulation. ICP level guidelines may need to be revised in the future taking into account cerebrovascular autoregulation status considered jointly with ICP levels.


Asunto(s)
Lesiones Traumáticas del Encéfalo/terapia , Hemorragia/terapia , Presión Intracraneal/fisiología , Monitoreo Fisiológico , Adulto , Presión Sanguínea , Lesiones Traumáticas del Encéfalo/fisiopatología , Circulación Cerebrovascular , Femenino , Hemorragia/fisiopatología , Humanos , Unidades de Cuidados Intensivos , Hipertensión Intracraneal/fisiopatología , Persona de Mediana Edad , Actividad Motora/fisiología
14.
BMJ Case Rep ; 13(12)2020 Dec 12.
Artículo en Inglés | MEDLINE | ID: mdl-33310837

RESUMEN

A 24-year-old woman presented with bilateral blurring of her distance vision and 'dizzy spells'. She had no other neurological symptoms or medical history. She consulted an optometrist, and optical coherence tomography (OCT) was performed, which demonstrated papilloedema. She was referred to the local eye clinic for assessment and from there was referred for neurological assessment.Her initial investigations revealed no abnormalities, and brain imaging was reported to be normal. In the absence of an alternative diagnosis, idiopathic intracranial hypertension (IIH) was considered and a lumbar puncture was performed. This showed elevated protein but normal cerebrospinal fluid (CSF) pressure. MRI of the brain the next day revealed a large cerebellopontine lesion in keeping with vestibular schwannoma. She was referred to neurosurgery for operative management.This case highlights three interesting points: the aetiology of her papilloedema without raised intracranial pressure, the decision to perform a lumbar puncture in suspected IIH and community OCT as a clinical adjunct.


Asunto(s)
Neuroma Acústico/complicaciones , Neuroma Acústico/diagnóstico , Papiledema/etiología , Femenino , Humanos , Presión Intracraneal/fisiología , Imagen por Resonancia Magnética , Neuroma Acústico/cirugía , Papiledema/diagnóstico por imagen , Punción Espinal , Tomografía de Coherencia Óptica , Tomografía Computarizada por Rayos X , Adulto Joven
15.
Neurocirugía (Soc. Luso-Esp. Neurocir.) ; 31(5): 209-215, sept.-oct. 2020. ilus, tab
Artículo en Inglés | IBECS | ID: ibc-195153

RESUMEN

BACKGROUND: Normal perfusion pressure breakthrough (NPPB) phenomenon is a major life-threatening complication that restricts the treatment of complex intracranial arteriovenous malformations. The aim of the study it to develop a rat model mimicking NPPB phenomenon that enables the evaluation of any therapy to prevent such complication. METHODS: Twenty Wistar male rats were randomly assigned to either a study or a control group. Study animals underwent an end-to-side left external jugular vein-common carotid artery anastomosis and ligation of bilateral external carotid arteries. Control animals only underwent ligation of bilateral external carotid arteries. All animals were sacrificed sixty days after the procedure. Hemodynamic parameters [mean arterial pressure (MAP), intracranial pressure (ICP) and cerebral perfusion pressure (CPP)], blood-brain barrier (BBB) permeability (measured by fluorescein staining) and histological features were then compared between both groups. RESULTS: A significant decrease in MAP and CPP was confirmed in the study group. An increase in ICP was also observed. A significant decrease in MAP and CPP was also present in the study group when comparing preoperative values with those recorded on days 0 (postoperative), 7 and 60. Fluorescein staining findings were consistent with signs of BBB disruption in study animals. Histological analysis demonstrated an increased number of pyknotic neurons in the ipsilateral hemisphere of rat brains included in the study group. CONCLUSION: These results confirm that this model mimics a vascular steal state with chronic cerebral hypoperfusion comparable to patients with AVMs behavior and disruption of the BBB after fistula closure comparable to NPPB phenomenon disorders


INTRODUCCIÓN: El síndrome de restablecimiento de la presión de perfusión cerebral (PPC) normal es una complicación grave, que supone un riesgo vital y limita el tratamiento de malformaciones arteriovenosas complejas. El objetivo de este estudio es desarrollar un modelo animal remedando dicho síndrome que permita evaluar terapias para su prevención. MÉTODOS: Veinte ratas macho Wistar fueron asignadas aleatoriamente a un grupo estudio o control. Los animales de estudio se sometieron a una anastomosis término-lateral entre la vena yugular externa y la arteria carótida común izquierdas y ligadura bilateral de las arterias carótidas externas. Los animales control se sometieron a la ligadura bilateral de las arterias carótidas externas. Todos los animales se sacrificaron 60 días después. Se compararon parámetros hemodinámicos (presión arterial media [PAM], presión intracraneal [PIC] y PPC), permeabilidad de la barrera hemato-encefálica (BHE) y características histológicas entre ambos grupos. RESULTADOS: El grupo estudio mostró un descenso significativo de la PAM y la PPC, así como un aumento de la PIC respecto al grupo control. Al comparar los valores preoperatorios con aquéllos registrados los días 0 (postoperatorio), 7 y 60 en el grupo estudio, también se confirmó un descenso significativo de la PAM y la PPC. La disrupción de la BHE fue constatada únicamente en el grupo estudio mediante la extravasación de fluoresceína sódica. El análisis histológico demostró mayor número de neuronas picnóticas en el hemisferio ipsilateral a la anastomosis de los animales estudio. CONCLUSIÓN: Los resultados descritos apuntan a un modelo que remeda el estado de robo vascular con hipoperfusión cerebral crónica comparable al que sufren los pacientes con malformaciones arteriovenosas, así como la disrupción de la BHE tras el cierre de la anastomosis, comparable al acontecido en el síndrome de restablecimiento de la PPC normal tras la exclusión de la malformación


Asunto(s)
Animales , Masculino , Ratas , Malformaciones Arteriovenosas Intracraneales/terapia , Presión Intracraneal , Modelos Animales , Malformaciones Arteriovenosas Intracraneales/veterinaria , Ratas Wistar , Anastomosis Arteriovenosa , Ligadura/veterinaria , Monitorización Hemodinámica/veterinaria
16.
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue ; 32(8): 960-964, 2020 Aug.
Artículo en Chino | MEDLINE | ID: mdl-32912410

RESUMEN

OBJECTIVE: To explore the significance of multimodal monitoring in the monitoring and treatment of neurocritical care patients. METHODS: 104 neurocritical care patients admitted to the department of Critical Care Medicine of Fujian Provincial Hospital from March 2019 to January 2020 were enrolled. Patients were randomly assigned into two groups, with 52 in each group. In the routine monitoring treatment group, heart rate, blood pressure, respiratory rate and the changes in consciousness and pupils were monitored after operation. The patients were treated with routine medicine to reduce intracranial pressure (ICP), maintain proper cerebral perfusion pressure (CPP), balance fluid intake and output, and maintain the airway clear. Patients in the multimodal monitoring treatment group were treated with invasive ICP monitoring, ultrasound to assess brain structure, ultrasound to measure optic nerve sheath diameter (ONSD), transcranial color doppler (TCCD), internal jugular venous blood oxygen saturation monitoring, near-infrared spectroscopy (NIRS), non-invasive cerebral blood oxygen saturation monitoring and quantitative electroencephalogram monitoring. According to the monitoring results, the patients were given targeted treatment with the goal of controlling ICP and improving brain metabolism. The length of intensive care unit (ICU) stay, the incidences of neurological complications (secondary cerebral infarction, cerebral hemorrhage, high intracranial pressure, etc.), and the incidences of poor prognosis [6 months after the onset of Glasgow outcome score (GOS) 1 to 3] were compared between the two groups. Spearman rank correlation analysis of the correlation between invasive ICP and the ICP value which was calculated by TCCD. The receiver operating characteristic (ROC) curve of invasive ICP and pulsatility index of middle cerebral artery (PIMCA) were used to predict poor prognosis. RESULTS: The length of ICU stay in the multimodal monitoring treatment group was significantly shorter than that of the routine monitoring treatment group (days: 6.27±3.81 vs. 9.61±5.09, P < 0.01), and the incidence of neurological complications was significantly lower than that in the routine monitoring treatment group (9.62% vs. 25.00%, P < 0.05). In the multimodal monitoring treatment group, 37 cases had a good prognosis and 15 cases had a poor prognosis, while the routine monitoring treatment group had a good prognosis in 27 cases and a poor prognosis in 25 cases. The incidence of poor prognosis in the multimodal monitoring treatment group was lower than that of the routine monitoring treatment group (28.85% vs. 48.08%, P < 0.05). In the multimodal monitoring treatment group, the invasive ICP and PIMCA of patients with good prognosis were significantly lower than those of patients with poor prognosis [invasive ICP (mmHg, 1 mmHg = 0.133 kPa): 16 (12, 17) vs. 22 (20, 24), PIMCA: 0.90±0.33 vs. 1.39±0.58, both P < 0.01]. There was no significant difference in resistance index of the middle cerebral artery (RIMCA) between the good prognosis group and the poor prognosis group (0.63±0.12 vs. 0.66±0.15, P > 0.05). There was a positive correlation between the invasive ICP and the ICP value which was calculated by TCCD (r = 0.767, P < 0.001). ROC curve analysis showed that the area under ROC curve (AUC) of invasive ICP for poor prognosis prediction was 0.906, the best cut-off value was ≥ 18 mmHg, the sensitivity was 86.49%, and the specificity was 86.67%. The AUC of PIMCA for poor prognosis prediction was 0.759, the best cut-off value was ≥ 1.12, the sensitivity was 81.08%, and the specificity was 60.00%. The AUC of invasive ICP was greater than PIMCA (Z = 2.279, P = 0.023). CONCLUSIONS: Comprehensive analysis of multimodal monitoring indicators for neurocritical care patients to guide clinical treatment can reduce the length of hospital stay, and reduce the risk of neurosurgery complications and disability; invasive ICP can predict poor prognosis of neurocritical care patients.


Asunto(s)
Cuidados Críticos , Hipertensión Intracraneal , Circulación Cerebrovascular , Humanos , Presión Intracraneal , Sensibilidad y Especificidad , Ultrasonografía Doppler Transcraneal
17.
Medicine (Baltimore) ; 99(38): e22004, 2020 Sep 18.
Artículo en Inglés | MEDLINE | ID: mdl-32957318

RESUMEN

BACKGROUND: Mannitol and hypertonic saline (HTS) are effective in reducing intracranial pressure (ICP) after severe traumatic brain injury (TBI). However, their efficacy on the ICP has not been evaluated rigorously. OBJECTIVE: To evaluate the efficacy of repeated bolus dosing of HTS and mannitol in similar osmotic burdens to treat intracranial hypertension (ICH) in patients with severe TBI. METHODS: The authors used an alternating treatment protocol to evaluate the efficacy of HTS with that of mannitol given for ICH episodes in patients treated for severe TBI at their hospital during 2017 to 2019. Doses of similar osmotic burdens (20% mannitol, 2 ml/kg, or 10% HTS, 0.63 ml/kg, administered as a bolus via a central venous catheter, infused over 15 minutes) were given alternately to the individual patient with severe TBI during ICH episodes. The choice of osmotic agents for the treatment of the initial ICH episode was determined on a randomized basis; osmotic agents were alternated for every subsequent ICH episode in each individual patient. intracranial pressure (ICP), mean arterial pressure (MAP), and cerebral perfusion pressure (CPP) were continuously monitored between the beginning of each osmotherapy and the return of ICP to 20 mm Hg. The duration of the effect of ICP reduction (between the beginning of osmotherapy and the return of ICP to 20 mm Hg), the maximum reduction of ICP and its time was recorded after each dose. Serum sodium and plasma osmolality were measured before, 0.5 hours and 3 hours after each dose. Adverse effects such as central pontine myelinolysis (CPM), severe fluctuations of serum sodium and plasma osmolality were assessed to evaluate the safety of repeated dosing of HTS and mannitol. RESULTS: Eighty three patients with severe TBI were assessed, including 437 ICH episodes, receiving 236 doses of HTS and 221 doses of mannitol totally. There was no significant difference between equimolar HTS and mannitol boluses on the magnitude of ICP reduction, the duration of effect, and the time to lowest ICP achieved (P > .05). The proportion of efficacious boluses was higher for HTS than for mannitol (P = .016), as was the increase in serum sodium (P = .038). The serum osmolality increased immediately after osmotherapy with a significant difference (P = .017). No cases of CPM were detected. CONCLUSION: Repeat bolus dosing of 10% HTS and 20% mannitol appears to be significantly and similarly effective for treating ICH in patients with severe TBI. The proportion of efficacious doses of HTS on ICP reduction may be higher than mannitol.


Asunto(s)
Lesiones Traumáticas del Encéfalo/complicaciones , Diuréticos Osmóticos/uso terapéutico , Hipertensión Intracraneal/tratamiento farmacológico , Hipertensión Intracraneal/etiología , Manitol/uso terapéutico , Solución Salina Hipertónica/uso terapéutico , Adulto , Circulación Cerebrovascular/efectos de los fármacos , Diuréticos Osmóticos/administración & dosificación , Diuréticos Osmóticos/efectos adversos , Femenino , Humanos , Presión Intracraneal/efectos de los fármacos , Masculino , Manitol/administración & dosificación , Manitol/efectos adversos , Persona de Mediana Edad , Solución Salina Hipertónica/administración & dosificación , Solución Salina Hipertónica/efectos adversos , Índices de Gravedad del Trauma
18.
Medicine (Baltimore) ; 99(35): e21655, 2020 Aug 28.
Artículo en Inglés | MEDLINE | ID: mdl-32871879

RESUMEN

BACKGROUND: To compare the effects of 3% hypertonic saline solution and 20% mannitol solution on intracranial hypertension. METHODS: WAN-FANGDATA, CNKI, and CQVIP databases were searched, and relevant literatures of randomized controlled trials comparing 3% hypertonic saline solution with mannitol in reducing intracranial hypertension from 2010 to October 2019 were collected. Meta-analysis was performed using RevMan software. RESULTS: As a result, 10 articles that met the inclusion criteria were finally included. A total of 544 patients were enrolled in the study, 270 in the hypertonic saline group and 274 in the mannitol group. There was no significant difference in the decrease of intracranial pressure and the onset time of drug between the 2 groups after intervention (all P > .05). There was a statistically significant difference between the hypertonic saline group and the mannitol group in terms of duration of effect in reducing intracranial pressure (95% confidence interval: 0.64-1.05, Z = 8.09, P < .00001) and cerebral perfusion pressure after intervention (95% confidence interval: 0.15-0.92, Z = 2.72, P = .007). CONCLUSION: Both 3% hypertonic saline and mannitol can effectively reduce intracranial pressure, but 3% hypertonic saline has a more sustained effect on intracranial pressure and can effectively increase cerebral perfusion pressure.


Asunto(s)
Lesiones Traumáticas del Encéfalo/tratamiento farmacológico , Diuréticos Osmóticos/uso terapéutico , Hipertensión Intracraneal/tratamiento farmacológico , Manitol/uso terapéutico , Solución Salina Hipertónica/uso terapéutico , Lesiones Traumáticas del Encéfalo/complicaciones , Diuréticos Osmóticos/farmacología , Humanos , Hipertensión Intracraneal/etiología , Presión Intracraneal/efectos de los fármacos , Manitol/farmacología , Solución Salina Hipertónica/farmacología
19.
Rev. chil. neuro-psiquiatr ; 58(3): 286-293, set. 2020. tab, ilus
Artículo en Español | LILACS | ID: biblio-1138583

RESUMEN

Resumen Introducción: La Hipertensión Intracraneal Idiopática (HICI) es un síndrome neurológico caracterizado por un aumento de la presión intracraneal en ausencia de lesión estructural o hidrocefalia. Los síntomas incluyen cefalea, tinnitus pulsátil, oscurecimientos visuales transitorios y pérdida visual. Dentro de los signos destacan diplopía por parálisis del VI par, edema de papila y disminución de la agudeza visual. Los pacientes no tienen compromiso de conciencia ni signos neurológicos focales. La principal complicación es la pérdida visual que puede ser irreversible. La asociación entre HICI y nitrofurantoína (NTF) se reportó en 1974. Caso clínico: Mujer de 42 años, con sobrepeso, que desarrolló una HICI aproximadamente 18 meses posterior al inicio de nitrofurantoína profiláctica. Consultó por cefalea frontal, opresiva que aumentaba con la maniobra de Valsalva, asociada a disminución fluctuante de la agudeza visual y episodios de oscurecimiento. Al examen destacó edema de papila bilateral, sin déficit neurológico focal. La presión del líquido cefalorraquídeo (LCR) fue de 25,5 cm de agua. La resonancia magnética mostró signos de aumento de la presión del LCR, sin lesiones estructurales ni hidrocefalia. El cuadro se recuperó concomitantemente a la suspensión de la NTF y el uso de topiramato. No se constató daño visual permanente. Conclusiones: Se debe sospechar la HICI en mujeres en edad fértil con sobrepeso. Dentro de los gatillantes del síndrome destacan varios fármacos, entre ellos la NTF. El principal objetivo del tratamiento de la HICI es preservar la función visual.


Abstract Introduction: Idiopathic intracranial hypertension (IIH) is a syndrome characterized by increased intracranial pressure without a space occupying lesion or hydrocephalus. The symptoms are headache, pulsatile tinnitus, transient visual obscurations, and visual loss. Signs are diplopia caused by sixth cranial nerve paresis and papilledema with its associated loss of sensory visual function. The patient maintains an alert and oriented mental state, but has no localizing neurologic findings. The only major morbidity with IIH is visual loss. The association between IIH and nitrofurantoin was reported in 1974. Case: A 42 years old female, overweighed, who developed IIH 18 months after the start of prophylactic nitrofurantoin. She had frontal oppressive headache that increased with the Valsalva maneuver, fluctuant visual loss and transient visual obscurations. She had bilateral papilledema without localizing neurologic findings. The cerebrospinal fluid (CSF) pressure was 25.5 cm H2O. Magnetic resonance imaging showed signs of increased CSF pressure without structural lesions or hydrocephalus. IIH recovered with the withdrawal of nitrofurantoin and the use of topiramate. There was not permanent visual loss. Conclusions: It is recommendable to suspect IIH in obese women in the childbearing years. There are several drugs associated with IIH including nitrofurantoin. The main objective of treatment is to prevent visual loss.


Asunto(s)
Humanos , Femenino , Adulto , Parálisis , Seudotumor Cerebral , Presión Intracraneal , Cefalea , Nitrofurantoína
20.
Rinsho Shinkeigaku ; 60(9): 620-626, 2020 Sep 29.
Artículo en Japonés | MEDLINE | ID: mdl-32779600

RESUMEN

A 72-year-old man on hemodialysis for 7 years with end-stage renal disease was admitted to our institution due to an acute headache. Physical examination revealed normal signs except for noise on the back of his neck. His head CT and brain MRI showed no abnormal findings, while his MRA demonstrated abnormal signals in the left transverse to sigmoid sinus (T-S) suggesting a left dural arteriovenous fistula. After admission, his headache persisted and left orbital numbness also occurred. His digital subtraction angiography performed on the 5th day after admission showed no vascular malformation of either the T-S or cavernous sinus (CS). However, it showed occlusion of the left brachiocephalic vein (BCV) and the origin of the left internal jugular vein (IJV) resulting in intracranial venous reflux. These findings indicated the possibility that his acute headache was caused by intracranial venous reflux and increase of intracranial pressure resulting from the occlusion of the BCV ipsilateral to a dialysis shunt. Percutaneous transluminal angioplasty (PTA) for occlusion of the left BCV was performed on the 9th day and successful dilation of the lesion with a residual stenotic ratio less than 30 percent was obtained. After the angioplasty, venous reflux to the intracranial vein was markedly reduced and his headache and orbital numbness disappeared. One day after the procedure, MRA demonstrated the disappearance of the abnormal signals of the left T-S. Twelve months after discharge, he felt discomfort in the left of his face and the re-occlusion of the left VCV was demonstrated by angiography, therefore he received re-PTA. We recommend that physicians consider occlusion of the BCV ipsilateral to a dialysis shunt and intracranial venous reflux as a cause of acute headache in patients on hemodialysis.


Asunto(s)
Venas Braquiocefálicas , Venas Cerebrales , Trastornos Cerebrovasculares/etiología , Cefalea/etiología , Diálisis Renal/efectos adversos , Enfermedad Aguda , Anciano , Angiografía de Substracción Digital , Angioplastia , Venas Braquiocefálicas/diagnóstico por imagen , Venas Braquiocefálicas/cirugía , Malformaciones Vasculares del Sistema Nervioso Central/diagnóstico por imagen , Malformaciones Vasculares del Sistema Nervioso Central/etiología , Venas Cerebrales/diagnóstico por imagen , Trastornos Cerebrovasculares/diagnóstico por imagen , Humanos , Presión Intracraneal , Angiografía por Resonancia Magnética , Masculino , Recurrencia , Reoperación
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