Management of Intracranial Pressure: Part I: Pharmacologic Interventions.

Dangerous, sustained elevation in intracranial pressure (ICP) is a risk for any patient following severe brain injury. Intracranial pressure elevations that do not respond to initial management are considered refractory to treatment, or rICP. Patients are at significant risk of secondary brain injury and permanent loss of function resulting from rICP. Both nonpharmacologic and pharmacologic interventions are utilized to intervene when a patient experiences either elevation in ICP or rICP. In part 1 of this 2-part series, pharmacologic interventions are discussed. Opioids, sedatives, osmotic diuretics, hypertonic saline solutions, and barbiturates are drug classes that may be used in an attempt to normalize ICP and prevent secondary injury. Nursing care of these patients includes collaboration with an interprofessional team and is directed toward patient and family comfort. The utilization of an evidence-based guideline for the management of rICP is strongly encouraged to improve patient outcomes.

Evaluation of aqueductal CSF flow dynamics with phase contrast cine MR imaging in idiopathic intracranial hypertension patients: preliminary results.

OBJECTIVE: We aimed to evaluate dynamic cerebrospinal fluid (CSF) flow in idiopathic intracranial hypertension (IIH) patients with new MRI technology phase contrast cine (PCC) MRI. PATIENTS AND METHODS: Nineteen patients diagnosed with idiopathic intracranial hypertension and 11 healthy volunteers were included in this study. Nine of the IIH cases had been previously diagnosed and had been on drug treatment and 10 cases were diagnosed with IIH recently and had not been put on drug treatment yet. All CSF flow datas were evaluated by phase contrast-MRI using a 1,5 T MRI. The CSF flow was calculated in the equidistant MRI sequence which was taken through a cardiac cycle. RESULTS: Mean aqueduct area in the IIH group was 3.04 ± 1.14 mm², mean peak rate was 3.29 ± 1.77 cm/sec, mean average rate was 0.35 ± 0.33 cm/sec and mean flow was 0.67 ± 0.95 ml/min. In the control group mean aqueduct area was 2.87 ± 1.01 mm², mean peak rate was 4.20 ± 1.40 cm/sec, mean average rate was 0.37 ± 0.18 cm/sec and mean flow was 0.64 ± 0.40 ml/min. A statistically significant difference was found for the PCC MRI parameter of mean rate value (p: 0.007) between the control group and IIH patients. A statistically insignificant (p: 0.058) but marked difference was found for mean flow value. CONCLUSIONS: To our knowledge this study is the first CSF flow study in the idiopathic intracranial hypertension patients. We found a difference between the IIH groups and controls in mean rate and flow parameters. It was interesting that the mean rate and flow values of the untreated group that were higher than the controls. CSF flow analysis may be a marker to follow up IIH patients.

Radiation therapy for oncological emergencies.

AIMS AND BACKGROUND: Radiation therapy holds a fundamental role in oncological emergencies such as superior vena cava syndrome, spinal cord compression and endocranial hypertension. The purpose of our study was, by comparing schedules of treatment, to confirm the efficacy of hypofractionated radiation therapy. METHODS: From January 1994 to December 1998, 43 patients with superior vena cava syndrome, 37 patients with metastatic spinal cord compression and 108 patients with endocranial hypertension secondary to metastasis were treated at our institution. In the group of patients with superior vena cava syndrome, radiotherapy schedules were: 4 Gy x 5 to a total dose of 20 Gy (23 patients) and 3 Gy x 10 to a total dose of 30 Gy (20 patients). In the group of patients with spinal cord compression, radiation schedules were: 3 Gy x 10 to a total dose of 30 Gy (15 patients); 4 Gy x 5 to a total dose of 20 Gy (12 patients); a single fraction of 8 Gy in 10 cases, repeated after 1 week in 7 responder cases to a total dose of 16 Gy. 5 out of 37 patients were underwent to laminectomy plus stabilization of the spine and post-operative radiotherapy. In the group of patients with endocranial hypertension, radiotherapy schedules were: 6 Gy x 2 to a total dose of 12 Gy (53 patients), repeated after 4 weeks in 34 responder patients and 3 Gy x 10 to a total dose of 30 Gy (55 patients). RESULTS: The patients with superior vena cava syndrome, revaluated after 4 weeks at the end of treatment, obtained a partial remission of symptomatology in 73.9% with 20 Gy and in 75% with 30 Gy. The patients with spinal cord compression obtained symptomatic relief in 73.3% with 30 Gy, in 66.6% with 20 Gy and in 70% of cases treated with 8 Gy. The patients with endocranial hypertension obtained symptomatic relief in 64.1% with 12 Gy and in 63.3% with 30 Gy. CONCLUSION: Histology, pretreatment and performance status were important prognostic factors for the response to therapy. Our results demonstrated no significant difference among different schedules of radiotherapy and confirmed the importance of radiotherapy for oncological emergencies: it improves the quality of life and, in responding patients, is associated with a longer survival time.