Effects of positive end-expiratory pressure on intracranial pressure and compliance in brain-injured patients

1977 ◽  
Vol 47 (2) ◽  
pp. 195-200 ◽  
Author(s):  
Elizabeth A. M. Frost
Keyword(s):  
Intracranial Pressure ◽  
Brain Injuries ◽  
Head Injuries ◽  
Venous Pressure ◽  
Neurological Status ◽  
Volume Index ◽  
Positive End Expiratory Pressure ◽  
Content Type ◽  
Intracranial Compliance ◽  
Fine Print

✓ Hypoxic pulmonary disorders and head injuries associated with increased intracranial pressure (ICP) frequently co-exist. Positive end-expiratory pressure (PEEP) improves hypoxemia but has been reported to impede cerebral venous return, potentially causing a further increase in ICP. This study examined the effects of PEEP on ICP at different levels of brain compliance. Continuous ICP recordings were obtained after insertion of Scott cannulas to the lateral ventricles of seven comatose patients. Brain compliance was assessed by calculation of the pressure volume index. Patients were maintained in a 30° head-up position. Maintenance of PEEP to levels of 40 cm H2O pressure for as long as 18 hours did not increase ICP in patients with either normal or low intracranial compliance, and did not increase ICP in the absence of pulmonary disease. Central venous pressure and pulmonary artery wedge pressure increased proportionately as PEEP was increased. No consistent changes were found in blood pressure recordings, nor were there any reductions in cardiac output found during the studies. Abrupt discontinuation of PEEP did not result in increased ICP except for a transient rise on two occasions when respiratory secretions became copious and the patients were inadequately ventilated. Improved oxygenation in two patients as a result of PEEP was concomitant with improved intracranial compliance and neurological status. In patients with brain injuries, PEEP improves arterial oxygenation without increasing ICP as previously supposed. Consequently, PEEP is a valuable form of therapy for the comatose patient with pulmonary disorders such as pneumonia or pulmonary edema.

Effect of positive end expiratory pressure ventilation on intracranial pressure in man

1977 ◽  
Vol 46 (2) ◽  
pp. 227-232 ◽  
Author(s):  
Michael L. J. Apuzzo ◽  
Martin H. Weiss ◽  
Viesturs Petersons ◽  
R. Baldwin Small ◽  
Theodore Kurze ◽  
...  
Keyword(s):  
Intracranial Pressure ◽  
Perfusion Pressure ◽  
Venous Pressure ◽  
Blood Gases ◽  
Pulmonary Injury ◽  
Positive End Expiratory Pressure ◽  
Central Venous ◽  
Content Type ◽  
Arterial Blood ◽  
Peep Ventilation

✓ This study was designed to define the effect of positive end expiratory pressure (PEEP) ventilation on intracranial pressure (ICP). In 25 patients with severe head trauma with and without associated pulmonary injury the following parameters were simultaneously monitored under mechanical ventilation with and without PEEP: ICP, arterial blood pressure, central venous pressure, arterial blood gases, and cardiac rate. In addition, the volume-pressure response (VPR) was evaluated in each patient to assess cerebral elastance. The results indicate a significant increase in ICP with the application of PEEP only in the 12 patients who manifested increased cerebral elastance by VPR. Half of this latter group manifested impairment of cerebral perfusion pressure to levels less than 60 mm Hg. Return to baseline ICP levels was observed with termination of PEEP. No significantly consistent changes in other parameters were noted.

Intracranial pressure responses to alterations in arterial carbon dioxide pressure in patients with head injuries

1972 ◽  
Vol 36 (6) ◽  
pp. 714-720 ◽  
Author(s):  
Ronald L. Paul ◽  
Octavio Polanco ◽  
Stephen Z. Turney ◽  
T. Crawford McAslan ◽  
R. Adams Cowley
Keyword(s):  
Carbon Dioxide ◽  
Intracranial Pressure ◽  
Head Injuries ◽  
Intraventricular Pressure ◽  
Content Type ◽  
Arterial Carbon Dioxide ◽  
Cerebral Vasomotor Reactivity ◽  
Carbon Dioxide Pressure ◽  
Pressure Changes ◽  
Fine Print

✓ Cerebral vasomotor responses to alterations in arterial carbon dioxide (PaCO2), as manifested by intraventricular pressure changes, were studied in a group of patients with head injuries. These patients could be classified into three types based on various degrees of responsiveness thought to reflect the integrity of their cerebral vasomotor reactivity.

Little benefit from mild hypothermia therapy for severely head injured patients with low intracranial pressure

1999 ◽  
Vol 91 (2) ◽  
pp. 185-191 ◽  
Author(s):  
Tadahiko Shiozaki ◽  
Amami Kato ◽  
Mamoru Taneda ◽  
Toshiaki Hayakata ◽  
Naoyuki Hashiguchi ◽  
...  
Keyword(s):  
Intracranial Pressure ◽  
Mild Hypothermia ◽  
Neurological Status ◽  
High Dose ◽  
Fluid Restriction ◽  
Content Type ◽  
Head Injured ◽  
Factor Α ◽  
Injured Patients ◽  
Fine Print

Object. This study was performed to determine whether mild hypothermia therapy is essential for the treatment of severely head injured patients in whom intracranial pressure (ICP) can be maintained below 20 mm Hg by using conventional therapies.Methods. Sixteen consecutive severely head injured patients fulfilled the following criteria: the patient's ICP was maintained below 20 mm Hg by using fluid restriction, hyperventilation, and high-dose barbiturate therapy; and the patient had a Glasgow Coma Scale score of 8 or less on admission. After conventional therapies had been applied, the patients were divided randomly into two groups: the mild hypothermia group (HT group; eight patients) and the normothermia group (NT group; eight patients). The HT group received mild hypothermia (intracranial temperature 34°C) therapy for 48 hours followed by rewarming at 1°C per day for 3 days, whereas the NT group received normothermia (intracranial temperature 37°C) therapy for 5 days. Specimens of cerebrospinal fluid (CSF) taken from an intraventricular catheter every 24 hours were analyzed for the presence of excitatory amino acids ([EAAs] glutamate, aspartate, and glycine) and cytokines (tumor necrosis factor—α, interleukin [IL]-1β, IL-6, IL-8, and IL-10). The two groups did not differ significantly in patient age, neurological status, or level of ICP. There were no significant differences in daily changes in CSF concentrations of EAAs and cytokines between the two groups. The incidence of pneumonia was slightly higher in the HT group compared with the NT group (p = 0.059). The incidence of diabetes insipidus associated with hypernatremia was significantly higher in the HT group compared with that in the NT group (p < 0.01). The two groups did not differ with respect to their clinical outcomes.Conclusions. The authors recommend normothermia therapy for the treatment of severely head injured patients in whom ICP can be maintained at lower than 20 mm Hg by using conventional therapies, because mild hypothermia therapy does not convey any advantage over normothermia therapy in such patients.

Cerebrovascular carbon dioxide reactivity assessed by intracranial pressure dynamics in severely head injured patients

1995 ◽  
Vol 82 (3) ◽  
pp. 386-393 ◽  
Author(s):  
Masaaki Yoshihara ◽  
Kuniaki Bandoh ◽  
Anthony Marmarou
Keyword(s):  
Intracranial Pressure ◽  
Glasgow Coma Scale ◽  
Blood Volume ◽  
Volume Change ◽  
Volume Index ◽  
Content Type ◽  
Coma Scale ◽  
Head Injured ◽  
Injured Patients ◽  
Fine Print

✓ Appropriate management of intracranial pressure (ICP) in severely head injured patients depends in part on the cerebral vessel reactivity to PCO2; loss of CO2 reactivity has been associated with poor outcome. This study describes a new method for evaluating vascular reactivity in head-injured patients by determining the sensitivity of ICP change to alterations in PCO2. This method was combined with measurements of the pressure volume index (PVI), which allowed calculation of blood volume change necessary to alter ICP. The objective of this study was to investigate the ICP response and the blood volume change corresponding to alterations in PCO2 and to examine the correlation of responsivity and outcome as measured on the Glasgow Outcome Scale. The PVI and ICP at different end-tidal PCO2 levels produced by mild hypo- and hyperventilation were obtained in 49 patients with Glasgow Coma Scale scores of less than 8 and over a wide range of PCO2 (25 to 40 mm Hg) in eight patients. Given the assumption that the PVI remained constant during alteration of PaCO2, the estimated blood volume change per torr change of PCO2 was calculated by the following equation: BVR = PVI × Δlog(ICP)/ΔPCO2, where BVR = blood volume reactivity. The data in this study showed that PVI remained stable with changes in PCO2, thus validating the assumption used in the blood volume estimates. Moreover, the response of ICP to PCO2 alterations followed an exponential curve that could be described in terms of the responsivity indices to capnic stimuli. It was found that responsivity to hypocapnia was reduced by 50% compared to responsivity to hypercapnia measured within 24 hours of injury (p < 0.01). The sensitivity of ICP to estimated blood volume changes in patients with a PVI of less than 15 ml was extremely high with only 4 ml of blood required to raise ICP by 10 mm Hg. The authors conclude from these data that, following traumatic injury, the resistance vessels are in a state of persistent vasoconstriction, possibly due to vasospasm or compression. Furthermore, BVR correlates with outcome on the Glasgow Coma Scale, indicating that assessment of cerebrovascular response within the first 24 hours of injury may be of prognostic value.

Current reporting of responsiveness in acute cerebral disorders

1988 ◽  
Vol 69 (5) ◽  
pp. 692-698 ◽  
Author(s):  
Jan-Erik Starmark ◽  
Eddy Holmgren ◽  
Daniel Stålhammar
Keyword(s):  
Head Injuries ◽  
Neurological Status ◽  
Content Type ◽  
Sum Score ◽  
Grade Scale ◽  
Patient Responsiveness ◽  
Single Method ◽  
Definition Of ◽  
The Individual ◽  
Fine Print

✓ One hundred sixty-six papers published in seven neurosurgical journals from 1983 through 1985 have been surveyed to determine the methods used for assessment of overall patient responsiveness in acute cerebral disorders (coma grading). Fifty-one different coma scales or modifications were found. The Glasgow Coma Scale (GCS) sum score (that is, the sum of the scores of the individual eye, verbal, and motor scales) dominated (54%), and was used in 73 (76%) of 96 of the head-injury studies; in 56 (77%) of these 73 studies it was the single method of grading neurological status. The GCS sum score was used in 16 (23%) of 70 studies in patients with other etiologies. The Hunt and Hess scale was used in 26 (57%) of 46 reports of patients with subarachnoid hemorrhage. In 31 (55%) of the 56 studies of head injuries using the GCS alone, it was not obvious if the 12- or 13-grade scale was used. In 13 studies (23%) no reference to methodological investigations was made. In 44 papers (79%) the handling of untestable features, such as intubation or swollen eyes, was not reported. In the 56 studies using the GCS alone, coma was defined in many different ways and in 22 studies the definition of coma was not specified. In 63% of reports, the GCS sum score scale was combined in one to five groups of scores and this was done in 32 different ways. No information was available to describe the procedure of data aggregation or the reliability of the 13-grade GCS sum score. The lack of standardization makes it unnecessarily difficult to perform valid comparisons between different series of patients. Since the GCS sum score is the most widely used scale, it is suggested that the reporting of the GCS sum score should be standardized regarding pseudoscoring, coma definition, and use of combined scores. Further studies on the reliability of the GCS sum score are needed.

scholarly journals Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants

2003 ◽  
Vol 99 (1) ◽  
pp. 143-150 ◽  
Author(s):  
Michael T. Prange ◽  
Brittany Coats ◽  
Ann-Christine Duhaime ◽  
Susan S. Margulies
Keyword(s):  
Brain Injuries ◽  
Rotational Velocity ◽  
Head Injuries ◽  
Diffuse Axonal Injury ◽  
Angular Acceleration ◽  
Concrete Surface ◽  
Human Infant ◽  
Subdural Hemorrhage ◽  
Content Type ◽  
Fine Print

Object. Rotational loading conditions have been shown to produce subdural hemorrhage and diffuse axonal injury. No experimental data are available with which to compare the rotational response of the head of an infant during accidental and inflicted head injuries. The authors sought to compare rotational deceleration sustained by the head among free falls, from different heights onto different surfaces, with those sustained during shaking and inflicted impact. Methods. An anthropomorphic surrogate of a 1.5-month-old human infant was constructed and used to simulate falls from 0.3 m (1 ft), 0.9 m (3 ft), and 1.5 m (5 ft), as well as vigorous shaking and inflicted head impact. During falls, the surrogate experienced occipital contact against a concrete surface, carpet pad, or foam mattress. For shakes, investigators repeatedly shook the surrogate in an anteroposterior plane; inflicted impact was defined as the terminal portion of a vigorous shake, in which the surrogate's occiput made contact with a rigid or padded surface. Rotational velocity was recorded directly and the maximum (peak—peak) change in angular velocity and the peak angular acceleration were calculated. Analysis of variance revealed significant increases in the and associated with falls onto harder surfaces and from higher heights. During inflicted impacts against rigid surfaces, the and were significantly greater than those measured under all other conditions. Conclusions. Vigorous shakes of this infant model produced rotational responses similar to those resulting from minor falls, but inflicted impacts produced responses that were significantly higher than even a 1.5-m fall onto concrete. Because larger accelerations are associated with an increasing likelihood of injury, the findings indicate that inflicted impacts against hard surfaces are more likely to be associated with inertial brain injuries than falls from a height less than 1.5 m or from shaking.

An experimental evaluation of the Spiegelberg intracranial pressure and intracranial compliance monitor

2000 ◽  
Vol 93 (6) ◽  
pp. 1072-1077 ◽  
Author(s):  
Yun-Hom Yau ◽  
Ian R. Piper ◽  
Richard E. Clutton ◽  
Ian R. Whittle
Keyword(s):  
Intracranial Pressure ◽  
Gold Standard ◽  
Clinical Utility ◽  
Balloon Catheter ◽  
Air Pouch ◽  
Average Bias ◽  
Content Type ◽  
Intracranial Compliance ◽  
Compliance Monitor ◽  
Fine Print

✓ The goal of this study was to compare the Spiegelberg intraventricular intracranial pressure (ICP)/intracranial compliance monitoring device, which features an air-pouch balloon catheter, with existing gold-standard methods of measuring ICP and intracranial compliance.A Spiegelberg intraventricular catheter, a standard intraventricular catheter, and a Codman intraparenchymal ICP microsensor were placed in five sheep, which previously had been given anesthetic and paralytic agents, to allow comparative measurement of ICP at incremental levels (range 5–50 mm Hg). Intracranial pressure measured using the Spiegelberg intraventricular air-pouch balloon catheter displayed a linear correlation with ICP measured using the standard intraventricular fluid-filled catheter (r2 = 0.9846, p < 0.001; average bias −0.74 mm Hg), as well as with ICP measured using the Codman intraparenchymal strain-gauge sensor (r2 = 0.9778, p < 0.001; average bias 0.01 mm Hg). Automated measurements of intraventricular compliance obtained using the Spiegelberg compliance device were compared with compliance measurements that were made using the gold-standard manual cerebrospinal fluid bolus injection technique at ICPs ranging from 5 to 50 mm Hg, and a linear correlation was demonstrated between the two methods (r2 = 0.7752, p < 0.001; average bias −0.019 ml/mm Hg).The Spiegelberg air-pouch ICP/compliance monitor provides ICP and compliance data that are very similar to those obtained using both gold-standard methods and an intraparenchymal ICP monitor over a range of pathophysiological ICPs. The automated closed Spiegelberg system offers practical advantages for the measurement of intraventricular compliance. Assessment of the clinical utility and robustness of the Spiegelberg system, together with the development of an intraparenchymal device, would enhance the clinical utility of automated compliance measurement and expand the range of its applications.

Effect of the skull and dura on neural axis pressure-volume relationships and CSF hydrodynamics

1985 ◽  
Vol 63 (1) ◽  
pp. 76-81 ◽  
Author(s):  
Kenneth Shapiro ◽  
Arno Fried ◽  
Futoshi Takei ◽  
Ira Kohn
Keyword(s):  
Steady State ◽  
Bolus Injection ◽  
Venous Pressure ◽  
Volume Index ◽  
Constant Infusion ◽  
Content Type ◽  
Sagittal Sinus ◽  
Neural Axis ◽  
The Brain ◽  
Fine Print

✓ The pressure-volume index (PVI) technique of bolus manipulation of cerebrospinal fluid (CSF) was used to measure changes of neural axis volume buffering-capacity and CSF dynamics produced by different conditions of the skull and dura. Twenty-eight cats were studied in the intact state, after bilateral craniectomy, and with the dura opened. At each stage of altering the container of the brain, the following parameters were obtained: steady-state intracranial pressure (ICP), sagittal sinus venous pressure, PVI, and the resistance to the absorption of CSF. The resistance to absorption of CSF was determined using both the bolus injection and the continuous infusion of fluid. After craniectomy, PVI increased from 0.76 ± 0.04 to 1.3 ± 0.07 ml (± standard error of the mean) (p < 0.001) and increased further to 3.6 ± 0.17 ml (p < 0.001) after opening the dura. The resistance to absorption of CSF (Ro), determined by bolus injection, decreased after craniectomy from 91.3 ± 7.5 to 56.3 ± 6.2 mm Hg/ml/min (p < 0.001) and decreased further to 8.9 ± 0.66 mm Hg/ml/min (p < 0.001) after opening the dura. Although resistance determined by constant infusion was similar, results were dependent on the rate of infusion. Despite these changes of resistance and PVI, steady-state ICP and sagittal sinus venous pressure were similar in all three conditions of the skull and dura. These studies indicate that changes of the container of the brain affect pressure-volume relationships within the neural axis. However, the changes of resistance to absorption of CSF are in a direction that preserves a steady-state hydrodynamic equilibrium.

Venous ophthalmodynamometry: a noninvasive method for assessment of intracranial pressure

2000 ◽  
Vol 93 (1) ◽  
pp. 33-36 ◽  
Author(s):  
Raimund Firsching ◽  
Michael Schütze ◽  
Markus Motschmann ◽  
Wolfgang Behrens-Baumann
Keyword(s):  
Optic Nerve ◽  
Intracranial Pressure ◽  
Venous Pressure ◽  
Brain Parenchyma ◽  
Content Type ◽  
Significant Linear Correlation ◽  
Simultaneous Registration ◽  
Pressure Suction ◽  
Central Retinal Vein ◽  
Fine Print

Object. The goal of this study was to examine the potential use of ophthalmodynamometry in the noninvasive assessment of intracranial pressure (ICP). Under normal conditions, pressure within the central retinal vein is equal to or greater than ICP, because the central retinal vein passes through the optic nerve before it drains into the cavernous sinus. The optic nerve sheath is the place where ICP affects retinal venous pressure. Suction ophthalmodynamometry is an established method of investigation in ophthalmology to determine the pressure of the central retinal artery. Although observations of papilledema and lack of venous pulsations are commonly used to provide a vague assessment of ICP, ophthalmodynamometry may be used to determine the pressure of the central retinal vein. This venous pressure has never been compared with ICP.Methods. In this study the pressure of the central retinal vein was recorded in 22 patients who underwent continuous simultaneous registration of ICP for various reasons, mainly for suspected hydrocephalus. A comparison of the two pressures was made. The results indicated a highly significant linear correlation between central retinal vein pressure and ICP.These results are of great practical value because up-to-date reliable ICP monitoring has only been possible by using invasive means, by placing a probe extradurally or subdurally into the brain parenchyma or a ventricle.Conclusions. Ophthalmodynamometry can be relevant for momentary assessment and is not suitable for continuous monitoring. However, this technique can easily be repeated and may be used whenever increased ICP is suspected in a patient suffering from hydrocephalus, brain tumors, or head injury.

Self-inflicted submental and transoral gunshot wounds that produce nonfatal brain injuries: management and prognosis

2005 ◽  
Vol 102 (6) ◽  
pp. 1029-1032 ◽  
Author(s):  
J. David Kriet ◽  
Robert B. Stanley ◽  
M. Sean Grady
Keyword(s):  
Brain Injuries ◽  
Suicide Attempts ◽  
Gunshot Wounds ◽  
Neurological Status ◽  
Low Energy ◽  
Outward Appearance ◽  
Content Type ◽  
Type Of Injury ◽  
Fine Print

Object. Penetrating brain injuries caused by self-inflicted gunshot wounds are very often fatal and survivors suffer serious disabilities. Recognition of a possibly more favorable prognosis for a specific type of injury, the submental or transoral handgun or low-energy rifle wound, prompted the authors to review their experience with patients who had attempted suicide in this manner. Methods. The records of 11 consecutive patients seen over a 10-year period (1992–2001) were retrospectively reviewed. Handguns were used by eight patients and .22 caliber rifles by the others. The patients presented with predominantly unilateral frontal brain injuries that required urgent attention. One elderly patient who had made an advance directive concerning care died. All other patients underwent craniotomy and repair of associated ophthalmological and maxillofacial injuries. Follow-up review ranged from 9 months to 3 years, during which time there were no repeated suicide attempts. All but one patient expressed satisfaction with their appearance and returned to a self-sufficient lifestyle. Conclusions. Self-inflicted submental and transoral handgun and low-energy rifle wounds may produce serious but survivable brain injuries if the path of the bullet is limited to the frontal area. Early aggressive management of brain, dural, and craniomaxillofacial injuries should return the patient to a highly functional neurological status and restore an acceptable outward appearance. Outcomes, therefore, appear to be much better for these patients than for most patients with a penetrating brain injury due to a self-inflicted gunshot wound.

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