This study supports the concept of cerebrovascular pressure reactivity-based individual optimal cerebral perfusion pressure. Driving cerebral perfusion pressure in excess of optimal cerebral perfusion pressure does not yield improvements in brain tissue oxygen after head injury and should be avoided, whereas cerebral perfusion pressure below optimal cerebral perfusion pressure may result in secondary cerebral ischemia.
Based on current studies, reviews, and knowledge of cerebrospinal fluid dynamics, brain water dynamics, intracranial pressure, and cerebral perfusion physiology, a new concept is deducted that can describe normal and pathological changes of cerebrospinal fluid circulation and pathophysiology of idiopathic intracranial hypertension.
Decannulation was achieved in 59.4% of stroke patients surviving the first 12 months after tracheostomy and was associated with better functional outcome compared to patients without decannulation. Further prospective studies with larger sample sizes are needed to confirm our results.
591CliNiCal artiCle J Neurosurg 125:591-597, 2016 I dIopathIc normal pressure hydrocephalus (iNPH) has been a challenging entity for the past 50 years, since its first description by Hakim.21 Despite extensive research, its pathophysiological basis and pathogenesis remain matters of ongoing debate. Due to the uncertainty in diagnostic measures, several algorithms, diagnostic tools, and scoring systems have been proposed. A recent multicenter trial based the decision for surgical therapy on clinical signs and symptoms only, dividing cases into questionable and typical iNPH.23 Given the multitude of noninvasive and invasive measures to select symptomatic patients for hydrocephalus therapy, a prospective analysis of diagnostic and predictive parameters and their individual contributions within the diagnostic algorithm was warranted.
Patients and MethodsPatients with suspicious clinical and MRI signs for iNPH were examined in a prospective study. Local ethics committee approval was obtained.abbreviatioNs AMP Q = ICP amplitude quotient; ELD = external lumbar drainage; ETV = endoscopic third ventriculostomy; ICP = intracranial pressure; iNPH = idiopathic normal pressure hydrocephalus; LIFT = lumbar infusion test; MMSE = Mini-Mental State Examination; mRS = modified Rankin Scale; OVM = overnight ICP monitoring; RAP = correlation coefficient between pulse amplitude and ICP; ROC = receiver operating characteristic; ROut = resistance to outflow of CSF; SLHS = Stein and Langfitt Hydrocephalus Score; VP = ventriculoperitoneal; ∆Kiefer = change in Kiefer score. obJeCtive The aim of the study was to analyze the diagnostic and predictive values of clinical tests, CSF dynamics, and intracranial pulsatility tests, compared with external lumbar drainage (ELD), for shunt response in patients with idiopathic normal pressure hydrocephalus (iNPH). Methods Sixty-eight consecutive patients with suspected iNPH were prospectively evaluated. Preoperative assessment included clinical tests, overnight intracranial pressure (ICP) monitoring, lumbar infusion test (LIFT), and ELD for 24-72 hours. Simple and multiple linear regression analyses were conducted to identify predictive parameters concerning the outcome after shunt therapy. results Positive response to ELD correctly predicted improvement after CSF diversion in 87.9% of the patients. A Mini-Mental State Examination (MMSE) value below 21 was associated with nonresponse after shunt insertion (specificity 93%, sensitivity 67%). Resistance to outflow of CSF (ROut) > 12 mm Hg/ml/min was false negative in 21% of patients. Intracranial pulsatility parameters yielded different results in various parameters (correlation coefficient between pulse amplitude and ICP, slow wave amplitude, and mean ICP) but did not correlate to outcome. In multiple linear regression analysis, a calculation of presurgical MMSE versus the value after ELD, ROut, and ICP amplitude quotient during LIFT was significantly associated with outcome (p = 0.04). CoNClusioNs Despite a multitude of invasive tests, presurgical cl...
Our results show that DWI parameters are regionally dependent and reflect multifactorial (patho-) physiological mechanisms, which need to be interpreted carefully. It seems that improvement of gait is caused by a decrease of interstitial water deposition in the SCWM.
Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) profoundly impacts hemostasis and microvasculature. In the light of the dilemma between thromboembolic and hemorrhagic complications, in the present paper, we systematically investigate the prevalence, mortality, radiological subtypes, and clinical characteristics of intracranial hemorrhage (ICH) in coronavirus disease (COVID-19) patients. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we performed a systematic review of the literature by screening the PubMed database and included patients diagnosed with COVID-19 and concomitant ICH. We performed a pooled analysis, including a prospectively collected cohort of critically ill COVID-19 patients with ICH, as part of the PANDEMIC registry (Pooled Analysis of Neurologic Disorders Manifesting in Intensive Care of COVID-19). Results: Our literature review revealed a total of 217 citations. After the selection process, 79 studies and a total of 477 patients were included. The median age was 58.8 years. A total of 23.3% of patients experienced the critical stage of COVID-19, 62.7% of patients were on anticoagulation and 27.5% of the patients received ECMO. The prevalence of ICH was at 0.85% and the mortality at 52.18%, respectively. Conclusion: ICH in COVID-19 patients is rare, but it has a very poor prognosis. Different subtypes of ICH seen in COVID-19, support the assumption of heterogeneous and multifaceted pathomechanisms contributing to ICH in COVID-19. Further clinical and pathophysiological investigations are warranted to resolve the conflict between thromboembolic and hemorrhagic complications in the future.
We investigated two commercially available probes for measurement of the partial pressure of brain tissue oxygen (PbrO2) and calculation of the index of brain tissue oxygen pressure reactivity (ORx) in 7 patients after aneurysmal subarachnoid hemorrhage (SAH). Simultaneous monitoring of PbrO2 using the Licox(®) probe and the multiparameter Raumedic probe (Neurovent PTO(®)), measuring PbrO2, intracranial pressure (ICP) and brain temperature (Neurovent PTO) was performed for a median of 9 days (range 7-17 days). Both probes provided stable monitoring throughout the desired period. Mean PbrO2 from Licox and Neurovent PTO was 16.1 ± 9.0 mmHg and 17.5 ± 11.9 mmHg respectively. Mean ORx was 0.35 ± 0.44 and 0.31 ± 0.43 respectively. There was a difference in the measurement of PbrO2 of -2.73 ± 10.1 mmHg (Licox - Raumedic). The difference in the two values for the calculated ORx was far smaller (0.03 ± 0.31; Licox - Raumedic) and the correlation coefficient higher than for both values of PbrO2 (0.76 for ORx vs. 0.56 for PbrO2). The calculation of the autoregulation parameter ORx seemed more independent of the measurement process than the measurement of PbrO2 itself and signifies the potential clinical importance of this parameter.
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