Cortical Pressure Injury: A Hypothesis to Explain the Incongruity of Clinical and Radiologic Improvement in Decompressive Craniectomy

AbstractIt has astonished neuroscientists since the advent of decompressive craniectomy as to why a seemingly successfully achieved goal of reduction in intracranial pressure (ICP), by removing a portion of the cranial vault and the resultant intracranial volume augmentation, fails to give the desired beneficial clinical outcome in every case and in fact, at times, proves to be deleterious in some conditions with a shared problem of refractory raised ICP. The authors propose a hypothesis based on the understanding of the anatomy and physiology of the brain that can explain the fallacy.

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Intracranial volume versus static and pulsatile intracranial pressure values in children with craniosynostosis

Journal of Neurosurgery Pediatrics ◽

10.3171/2019.2.peds18767 ◽

2019 ◽

Vol 24 (1) ◽

pp. 66-74 ◽

Cited By ~ 1

Author(s):

Erlend Aambø Langvatn ◽

Radek Frič ◽

Bernt J. Due-Tønnessen ◽

Per Kristian Eide

Keyword(s):

Intracranial Pressure ◽

Intracranial Hypertension ◽

Brain Tissue ◽

Wave Amplitude ◽

Cranial Vault ◽

Intracranial Volume ◽

Raised Intracranial Pressure ◽

Pathophysiological Mechanisms ◽

Patient Cohort ◽

Before And After

OBJECTIVEReduced intracranial volume (ICV) and raised intracranial pressure (ICP) are assumed to be principal pathophysiological mechanisms in childhood craniosynostosis. This study examined the association between ICV and ICP and whether ICV can be used to estimate the ICP.METHODSThe authors analyzed ICV and ICP measurements from children with craniosynostosis without concurrent hydrocephalus and from age-matched individuals without craniosynostosis who underwent diagnostic ICP measurement.RESULTSThe study included 19 children with craniosynostosis (mean age 2.2 ± 1.9 years) and 12 reference individuals without craniosynostosis (mean age 2.5 ± 1.6 years). There was no difference in ICV between the patient and reference cohorts. Both mean ICP (17.1 ± 5.6 mm Hg) and mean wave amplitude (5.9 ± 2.6 mm Hg) were higher in the patient cohort. The results disclosed no significant association between ICV and ICP values in the patient or reference cohorts, and no association was seen between change in ICV and ICP values after cranial vault expansion surgery (CVES) in 5 children in whom ICV and ICP were measured before and after CVES.CONCLUSIONSIn this cohort of children with craniosynostosis, there was no significant association between ICV and ICP values prior to CVES and no significant association between change in ICV and ICP values after CVES in a subset of patients. Therefore, ICV could not reliably estimate the ICP values. The authors suggest that intracranial hypertension in childhood craniosynostosis may not be caused by reduced ICV alone but rather by a distorted relationship between ICV and the volume of intracranial content (brain tissue, CSF, and blood).

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Decompressive Craniectomy for Elevated Intracranial Pressure and Its Effect on the Cumulative Ischemic Burden and Therapeutic Intensity Levels After Severe Traumatic Brain Injury

Neurosurgery ◽

10.1227/01.neu.0000369607.71913.3e ◽

2010 ◽

Vol 66 (6) ◽

pp. 1111-1119 ◽

Cited By ~ 48

Author(s):

Gregory M. Weiner ◽

Michelle R. Lacey ◽

Larami Mackenzie ◽

Darshak P. Shah ◽

Suzanne G. Frangos ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Decompressive Craniectomy ◽

Severe Traumatic Brain Injury ◽

Intensity Level ◽

Before And After ◽

Severe Tbi ◽

Therapeutic Intensity ◽

The Brain

Abstract BACKGROUND Increased intracranial pressure (ICP) can cause brain ischemia and compromised brain oxygen (PbtO2 ≤ 20 mm Hg) after severe traumatic brain injury (TBI). OBJECTIVE We examined whether decompressive craniectomy (DC) to treat elevated ICP reduces the cumulative ischemic burden (CIB) of the brain and therapeutic intensity level (TIL). METHODS Ten severe TBI patients (mean age, 31.4 ± 14.2 years) who had continuous PbtO2 monitoring before and after delayed DC were retrospectively identified. Patients were managed according to the guidelines for the management of severe TBI. The CIB was measured as the total time spent between a PbtO2 of 15 to 20, 10 to 15, and 0 to 10 mm Hg. The TIL was calculated every 12 hours. Mixed-effects models were used to estimate changes associated with DC. RESULTS DC was performed on average 2.8 days after admission. DC was found to immediately reduce ICP (mean [SEM] decrease was 7.86 mm Hg [2.4 mm Hg]; P = .005). TIL, which was positively correlated with ICP (r = 0.46, P ≤ .001), was reduced within 12 hours after surgery and continued to improve within the postsurgical monitoring period (P ≤ .001). The duration and severity of CIB were significantly reduced as an effect of DC in this group. The overall mortality rate in the group of 10 patients was lower than predicted at the time of admission (P = .015). CONCLUSION These results suggest that a DC for increased ICP can reduce the CIB of the brain after severe TBI. We suggest that DC be considered early in a patient's clinical course, particularly when the TIL and ICP are increased.

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Methylprednisolone Modulates Intracranial Pressure in the Brain Cellular Edema Induced by Water Intoxication

Physiological Research ◽

10.33549/physiolres.933797 ◽

2017 ◽

pp. S511-S516 ◽

Cited By ~ 3

Author(s):

P. KOZLER ◽

D. MAREŠOVÁ ◽

J. POKORNÝ

Keyword(s):

Intracranial Pressure ◽

Intracranial Hypertension ◽

Brain Edema ◽

Continuous Monitoring ◽

Water Intoxication ◽

Pressure Increase ◽

Intracranial Volume ◽

Pressure Transmitter ◽

The Brain

Continuous monitoring of the intracranial pressure (ICP) detects impending intracranial hypertension resulting from the impaired intracranial volume homeostasis, when expanding volume generates pressure increase. In this study, cellular brain edema (CE) was induced in rats by water intoxication (WI). Methylprednisolone (MP) was administered intraperitoneally (i.p.) before the start of CE induction, during the induction and after the induction. ICP was monitored for 60 min within 20 h after the completion of the CE induction by fibreoptic pressure transmitter. In rats with induced CE, ICP was increased (MeanSEM: 14.25±2.12) as well as in rats with MP administration before the start of CE induction (10.55±1.27). In control rats without CE induction (4.62±0.24) as well as in rats with MP applied during CE induction (5.52±1.32) and in rats with MP applied after the end of CE induction (6.23±0.73) ICP was normal. In the last two groups of rats, though the CE was induced, intracranial volume homeostasis was not impaired, intracranial volume as well as ICP were not increased. It is possible to conclude that methylprednisolone significantly influenced intracranial homeostasis and thus also the ICP values in the model of cellular brain edema.

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Decompressive craniectomy of post-traumatic brain injury: an in silico modelling approach for intracranial hypertension management

Scientific Reports ◽

10.1038/s41598-020-75479-7 ◽

2020 ◽

Vol 10 (1) ◽

Author(s):

Chryso Lambride ◽

Nicolas Christodoulou ◽

Anna Michail ◽

Vasileios Vavourakis ◽

Triantafyllos Stylianopoulos

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Intracranial Hypertension ◽

Brain Tissue ◽

Decompressive Craniectomy ◽

In Silico ◽

Pressure Loading ◽

Post Traumatic ◽

The Brain

Abstract Traumatic brain injury (TBI) causes brain edema that induces increased intracranial pressure and decreased cerebral perfusion. Decompressive craniectomy has been recommended as a surgical procedure for the management of swollen brain and intracranial hypertension. Proper location and size of a decompressive craniectomy, however, remain controversial and no clinical guidelines are available. Mathematical and computational (in silico) models can predict the optimum geometric conditions and provide insights for the brain mechanical response following a decompressive craniectomy. In this work, we present a finite element model of post-traumatic brain injury and decompressive craniectomy that incorporates a biphasic, nonlinear biomechanical model of the brain. A homogenous pressure is applied in the brain to represent the intracranial pressure loading caused by the tissue swelling and the models calculate the deformations and stresses in the brain as well as the herniated volume of the brain tissue that exits the skull following craniectomy. Simulations for different craniectomy geometries (unilateral, bifrontal and bifrontal with midline bar) and sizes are employed to identify optimal clinical conditions of decompressive craniectomy. The reported results for the herniated volume of the brain tissue as a function of the intracranial pressure loading under a specific geometry and size of craniectomy are exceptionally relevant for decompressive craniectomy planning.

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Successful treatment of post-shunt craniocerebral disproportion by coupling gradual external cranial vault distraction with continuous intracranial pressure monitoring

Journal of Neurosurgery Pediatrics ◽

10.3171/2013.2.peds12404 ◽

2013 ◽

Vol 11 (6) ◽

pp. 653-657 ◽

Cited By ~ 10

Author(s):

Adam L. Sandler ◽

Lawrence B. Daniels ◽

David A. Staffenberg ◽

Eliezer Kolatch ◽

James T. Goodrich ◽

...

Keyword(s):

Intracranial Pressure ◽

Temporal Correlation ◽

Cranial Vault ◽

Intracranial Volume ◽

Icp Monitoring ◽

Plateau Waves ◽

Craniocerebral Disproportion ◽

Reproducible Method ◽

Definition Of ◽

Cranial Expansion

A subset of hydrocephalic patients in whom shunts are placed at an early age will develop craniocerebral disproportion (CCD), an iatrogenic mismatch between the fixed intracranial volume and the growing brain. The lack of a reliable, reproducible method to diagnose this condition, however, has hampered attempts to treat it appropriately. For those practitioners who acknowledge the need to create more intracranial space in these patients, the lack of agreed-upon therapeutic end points for cranial vault expansion has limited the use of such techniques and has sometimes led to problems of underexpansion. Here, the authors present a definition of CCD based primarily on the temporal correlation of plateau waves on intracranial pressure (ICP) monitoring and headache exacerbation. The authors describe a technique of exploiting continued ICP monitoring during progressive cranial expansion in which the goal of distraction is the cessation of plateau waves. Previously encountered problems of underexpansion may be mitigated through the simultaneous use of ICP monitors and gradual cranial expansion over time.

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Open-wound treatment for gunshot to the brain

Journal of Neurosurgery Pediatrics ◽

10.3171/2012.3.peds1225 ◽

2012 ◽

Vol 10 (1) ◽

pp. 64-66 ◽

Cited By ~ 2

Author(s):

Pepijn van den Munckhof ◽

Vincent G. Geukers ◽

Fonnet E. Bleeker ◽

Celia E. Allison ◽

W. Peter Vandertop

Keyword(s):

Intracranial Pressure ◽

Decompressive Craniectomy ◽

Gunshot Wound ◽

Wound Treatment ◽

Elevated Intracranial Pressure ◽

Open Wound ◽

Functional Level ◽

Open Wound Treatment ◽

The Brain

The authors report a case of a gunshot wound to the brain in a 2.5-year-old girl. To treat the uncontrollably elevated intracranial pressure, the patient underwent bilateral decompressive craniectomy and experimental open-wound treatment. She recovered to a good functional level.

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Paradoxical Brain Herniation after Cranioplasty: Secondary Sunken Flap Syndrome

Journal of Neurosciences in Rural Practice ◽

10.1055/s-0041-1741565 ◽

2022 ◽

Author(s):

Navneet Singla ◽

Archit Latawa

Keyword(s):

Case Report ◽

Intracranial Pressure ◽

Decompressive Craniectomy ◽

Atmospheric Pressure ◽

Brain Herniation ◽

Delay In Diagnosis ◽

Life Saving ◽

Acute Neurological Deterioration ◽

The Brain ◽

Syndrome Of The Trephined

AbstractDecompressive craniectomy is a life-saving procedure done for innumerable etiologies. Though, not a technically demanding procedure, it has its own complications. Among many, sinking flap syndrome or syndrome of the trephined or paradoxical herniation of brain is frequently underestimated. It results from the pressure difference between the atmospheric pressure and the intracranial pressure causing the brain to shift inward at the craniectomy site. This can present with either nonspecific symptoms leading to delay in diagnosis or acute neurological deterioration, memory disturbances, weakness, confusion, lethargy, and sometimes death if not treated. Cranioplasty is a time validated procedure used to treat paradoxical brain herniation with good and early neurological recovery. We, here in, are going to describe a case report in which the paradoxical herniation occurred after cranioplasty which has not been described in literature.

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