Predictive value of initial computerized tomography scan, intracranial pressure, and state of autoregulation in patients with traumatic brain injury

2006 ◽  
Vol 104 (5) ◽  
pp. 731-737 ◽  
Author(s):  
Magdalena Hiler ◽  
Marek Czosnyka ◽  
Peter Hutchinson ◽  
Marcella Balestreri ◽  
Peter Smielewski ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Ct Scan ◽  
Computerized Tomography ◽  
Reactivity Index ◽  
Monitoring Period ◽  
Pressure Reactivity ◽  
Severe Tbi ◽  
Ct Scan Classification

Object The authors explored the relationship between computerized tomography (CT) scan findings and intracranial pressure (ICP) measurements obtained in the first 24 hours of monitoring to identify parameters predicting outcome in patients with severe traumatic brain injury (TBI). Methods Intracranial pressure, mean arterial blood pressure, cerebral perfusion pressure (CPP), and pressure reactivity index were measured continuously in 126 patients with severe TBI who were admitted to a neuroscience critical care unit. Mean values in the initial 24 hours of monitoring and in the total period of monitoring were compared with types of injury categorized on the basis of the initial CT scan according to the classification of Marshall, et al., and with Glasgow Outcome Scale scores. The initial CT scan classification correlated significantly but weakly with ICP measured during the first 24 hours of monitoring (p = 0.036) but not with mean ICP over the total time of intensive care. Both midline shift and the ratio of frontal horn diameter to internal diameter correlated with ICP in the first 24 hours (p < 0.007) and with ICP over the total monitoring period (p < 0.03). Outcome score correlated with initial CT scan findings (p = 0.018), ICP over the total monitoring period (p < 0.0023), pressure reactivity over the total monitoring period (p < 0.0002), and pressure reactivity in the first 24 hours (p < 0.0001) but not with ICP in the first 24 hours. Patients with disturbed pressure reactivity in the first 24 hours after injury had a significantly higher mortality rate than patients with intact pressure reactivity (28.6% compared with 9.5%; p < 0.001). Conclusions Patients with severe TBI who have early loss of autoregulation have a worse prognosis. Mean ICP values in patients with diffuse TBI cannot be predicted by using the Marshall CT scan classification.

Patient-specific thresholds of intracranial pressure in severe traumatic brain injury

2014 ◽  
Vol 120 (4) ◽  
pp. 893-900 ◽  
Author(s):  
Christos Lazaridis ◽  
Stacia M. DeSantis ◽  
Peter Smielewski ◽  
David K. Menon ◽  
Peter Hutchinson ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Severe Traumatic Brain Injury ◽  
Continuous Monitoring ◽  
Cross Validation ◽  
Area Under The Curve ◽  
Reactivity Index ◽  
Patient Specific ◽  
Pressure Reactivity

Object Based on continuous monitoring of the pressure reactivity index (PRx), the authors defined individualized intracranial pressure (ICP) thresholds by graphing the relationship between ICP and PRx. These investigators hypothesized that an “ICP dose” based on individually assessed ICP thresholds would correlate more closely with the 6-month outcome when compared with ICP doses derived by the recommended universal thresholds of 20 and 25 mm Hg. Methods This study was a retrospective analysis of prospectively collected data from 327 patients with severe traumatic brain injury. Results Individualized thresholds were visually identified from graphs of PRx versus ICP; PRx > 0.2 was the cutoff. Intracranial pressure doses were then computed as the cumulative area under the curve above the defined thresholds in graphing ICP versus time. The term “Dose 20” (D20) was used to refer to an ICP threshold of 20 mm Hg; the markers D25 and DPRx were calculated similarly. Separate logistic regression models were fit with death as the outcome and each dose as the predictor, both alone and adjusted for covariates. The discriminative ability of each dose for mortality was assessed by receiver operating characteristic AUC analysis in which 5-fold cross-validation was used. A clearly identifiable PRx-based threshold was possible in 224 patients (68%). The DPRx (AUC 0.81, 95% CI 0.74–0.87) was found to have the highest area under the curve (AUC) over both D20 (0.75, 95% CI 0.68–0.81) and D25 (0.77, 95% CI 0.70–0.83); in the cross-validation model, DPRx remained the best discriminator of mortality (DPRx: AUC 0.77 [95% CI 0.68–0.89]; D20: 0.72 [95% CI 0.66–0.81]; and D25: 0.65 [95% CI 0.56–0.73]). Conclusions The authors explored the importance of different ICP thresholds for outcome by calculating patient-specific ICP doses based on the continuous monitoring of cerebrovascular pressure reactivity. They found that these individualized doses of intracranial hypertension were stronger predictors of death than doses derived from the universal thresholds of 20 and 25 mm Hg. The PRx could offer a method that can be directed toward individualizing the ICP threshold.

Effect of decompressive craniectomy on intracranial pressure and cerebrospinal compensation following traumatic brain injury

2008 ◽  
Vol 108 (1) ◽  
pp. 66-73 ◽  
Author(s):  
Ivan Timofeev ◽  
Marek Czosnyka ◽  
Jurgens Nortje ◽  
Peter Smielewski ◽  
Peter Kirkpatrick ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Decompressive Craniectomy ◽  
Reactivity Index ◽  
Pressure Reactivity ◽  
Sustained Reduction ◽  
Compensatory Reserve ◽  
Injured Patients ◽  
Cerebrovascular Pressure Reactivity

Object Decompressive craniectomy is an advanced treatment option for intracranial pressure (ICP) control in patients with traumatic brain injury. The purpose of this study was to evaluate the effect of decompressive craniectomy on ICP and cerebrospinal compensation both within and beyond the first 24 hours of craniectomy. Methods This study was a retrospective analysis of the physiological parameters from 27 moderately to severely head-injured patients who underwent decompressive craniectomy for progressive brain edema. Of these, 17 patients had undergone prospective digital recording of ICP with estimation of ICP waveform–derived indices. The pressure-volume compensatory reserve (RAP) index and the cerebrovascular pressure reactivity index (PRx) were used to assess those parameters. The values of parameters prior to and during the 72 hours after decompressive craniectomy were included in the analysis. Results Decompressive craniectomy led to a sustained reduction in median (interquartile range) ICP values (21.2 mm Hg [18.7; 24.2 mm Hg] preoperatively compared with 15.7 mm Hg [12.3; 19.2 mm Hg] postoperatively; p = 0.01). A similar improvement was observed in RAP. A significantly lower mean arterial pressure (MAP) was needed after decompressive craniectomy to maintain optimum cerebral perfusion pressure (CPP) levels, compared with the preoperative period (99.5 mm Hg [96.2; 102.9 mm Hg] compared with 94.2 mm Hg [87.9; 98.9 mm Hg], respectively; p = 0.017). Following decompressive craniectomy, the PRx had positive values in all patients, suggesting acquired derangement in pressure reactivity. Conclusions In this study, decompressive craniectomy led to a sustained reduction in ICP and improvement in cerebral compliance. Lower MAP levels after decompressive craniectomy are likely to indicate a reduced intensity of treatment. Derangement in cerebrovascular pressure reactivity requires further studies to evaluate its significance and influence on outcome.

scholarly journals Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring

2012 ◽  
Vol 117 (4) ◽  
pp. 729-734 ◽  
Author(s):  
Arash Farahvar ◽  
Linda M. Gerber ◽  
Ya-Lin Chiu ◽  
Nancy Carney ◽  
Roger Härtl ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Intracranial Hypertension ◽  
Severe Traumatic Brain Injury ◽  
Lower Mortality ◽  
Icp Monitoring ◽  
Improvement Program ◽  
Severe Tbi ◽  
Gcs Score

Object Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe traumatic brain injury (TBI), but there is limited evidence that monitoring and treating intracranial hypertension reduces mortality. This study uses a large, prospectively collected database to examine the effect on 2-week mortality of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP monitor. Methods From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score <9), 1446 patients were treated with ICP-lowering therapies. Of those, 1202 had an ICP monitor inserted and 244 were treated without monitoring. Patients were admitted to one of 20 Level I and two Level II trauma centers, part of a New York State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009. This database also contains information on known independent early prognostic indicators of mortality, including age, admission GCS score, pupillary status, CT scanning findings, and hypotension. Results Age, initial GCS score, hypotension, and CT scan findings were associated with 2-week mortality. In addition, patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 0.02) than those treated without an ICP monitor, after adjusting for parameters that independently affect mortality. Conclusions In patients with severe TBI treated for intracranial hypertension, the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor. Based on these findings, the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring.

Predictive and Discriminative Power of Pressure Reactivity Indices in Traumatic Brain Injury

Neurosurgery ◽  
2020 ◽  
Vol 87 (4) ◽  
pp. 655-663 ◽  
Author(s):  
Lennart Riemann ◽  
Erta Beqiri ◽  
Alexander Younsi ◽  
Marek Czosnyka ◽  
Peter Smielewski
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Predictive Power ◽  
Time Windows ◽  
Predictive Ability ◽  
Reactivity Index ◽  
Discriminative Ability ◽  
Reactivity Indices ◽  
Pressure Reactivity ◽  
Cerebral Blood Flow Autoregulation

Abstract BACKGROUND Dysfunctional cerebral blood flow autoregulation plays a crucial role in the secondary damage after traumatic brain injury. The pressure reactivity index (PRx) can be used to monitor dynamic cerebral blood flow autoregulation indirectly. OBJECTIVE To test different versions of the long pressure reactivity index (LPRx), which is based on minute-by-minute data and calculated over extended time windows, and to study their predictive ability and examine whether “long” and “short” pressure reactivity indices could improve predictive power. METHODS PRx and 3 versions of the LPRx calculated over 20-, 60-, and 240-min time windows were assessed in relation to outcome at 6 mo in 855 patients with traumatic brain injury. Predictive power and discriminative ability of indices were evaluated using area under the operator curves and determination of critical thresholds. PRx and LPR indices were combined to evaluate whether LPR indices could improve outcome prediction by adding information about static components of autoregulation. RESULTS Correlation of each LPRx with the PRx decreased with increased time windows. LPR indices performed successively worse in their predictive and discriminative ability from 20-min to 240-min time frames. PRx had a significantly higher predictive ability compared to each LPRx. Combining LPRx and PRx did not lead to an improvement of predictive power compared to the PRx alone. CONCLUSION The critical threshold and predictive value of the PRx for unfavorable outcome and mortality have been confirmed in one of the largest so far published patient cohorts. LPRx performed significantly worse, and its discriminative and predictive abilities decreased with an increasing calculation window.

scholarly journals Increased S-Nitrosothiols and S-Nitrosoalbumin in Cerebrospinal Fluid after Severe Traumatic Brain Injury in Infants and Children: Indirect Association with Intracranial Pressure

2003 ◽  
Vol 23 (1) ◽  
pp. 51-61 ◽  
Author(s):  
Hülya Bayir ◽  
Patrick M. Kochanek ◽  
Shang-Xi Liu ◽  
Antonio Arroyo ◽  
Anatoly Osipov ◽  
...  
Keyword(s):  
Traumatic Brain Injury ◽  
Cerebrospinal Fluid ◽  
Brain Injury ◽  
Intracranial Pressure ◽  
Fold Increase ◽  
Infants And Children ◽  
No Production ◽  
Secondary Damage ◽  
Severe Tbi ◽  
Pediatric Tbi

Nitric oxide (NO) is implicated in both secondary damage and recovery after traumatic brain injury (TBI). Transfer of NO groups to cysteine sulfhydryls on proteins produces S-nitrosothiols (RSNO). S-nitrosothiols may be neuroprotective after TBI by nitrosylation of N-methyl-D-aspartate receptor and caspases. S-nitrosothiols release NO on decomposition for which endogenous reductants (i.e., ascorbate) are essential, and ascorbate is depleted in cerebrospinal fluid (CSF) after pediatric TBI. This study examined the presence and decomposition of RSNO in CSF and the association between CSF RSNO level and physiologic parameters after severe TBI. Cerebrospinal fluid samples (n = 72) were obtained from 18 infants and children on days 1 to 3 after severe TBI (Glasgow Coma Scale score < 8) and 18 controls. Cerebrospinal fluid RSNO levels assessed by fluorometric assay peaked on day 3 versus control (1.42 ± 0.11 μmol/L vs. 0.86 ± 0.04, P < 0.05). S-nitrosoalbumin levels were also higher after TBI (n = 8, 0.99 ± 0.09 μmol/L on day 3 vs. n = 6, 0.42 ± 0.02 in controls, P < 0.05). S-nitrosoalbumin decomposition was decreased after TBI. Multivariate analysis showed an inverse relation between CSF RSNO and intracranial pressure and a direct relation with barbiturate treatment. Using a novel assay, the presence of RSNO and S-nitrosoalbumin in human CSF, an ∼1.7-fold increase after TBI, and an association with low intracranial pressure are reported, supporting a possible neuroprotective role for RSNO. The increase in RSNO may result from increased NO production and/or decreased RSNO decomposition.

scholarly journals KORELASI DIAMETER SELUBUNG NERVUS OPTIK DAN MARSHALL CT SCORE DENGAN SKALA KOMA GLASGOW PADA CEDERA KEPALA

2020 ◽  
Vol 35 (3) ◽  
Author(s):  
Rani Maria Yogipranata ◽  
Hermina Sukmani
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Optic Nerve ◽  
Intracranial Pressure ◽  
Glasgow Coma Scale ◽  
Ct Scan ◽  
Optic Nerve Sheath Diameter ◽  
Optic Nerve Sheath ◽  
Coma Scale ◽  
Nerve Sheath

CORRELATION BETWEEN OPTIC NERVE SHEATH DIAMETER AND MARSHALL CT SCORE WITH GLASGOW COMA SCALE IN TRAUMATIC BRAIN INJURYABSTRACTIntroduction: In traumatic brain injury (TBI), non-contrast brain CT scan is able to detect an increase in intracranial pressure, which is crucial in patient’s management. Optic nerve sheath diameter’s (ONSD) measurement is a new method that is expected to assess an increase in intracranial pressure noninvasively. Marshall CT score is a valid instrument, a de facto standard to classify head injury patient which correlates with an increased intracranial pressure.Aims: To see the correlation between ONSD and Marshall CT score with Glasgow Coma Scale (GCS).Methods: This was a retrospective, analytic observational with cross-sectional research’s design taken from the patients’ medical record admitted in Dr. Kariadi Hospital, Semarang, between March-August 2017. Measurement of ONSD and Marshall CT score were done by a radiologist. Rank Spearman’s were used to assess the correlation between variables.Results: There were 34 subjects, the majority were man (67,6%), with highest incidents in less than 30 years age (41,2%) and mostly caused by accident  (76,4%). Statistical analysis showed a moderate negative degree correlation between ONSD and Marshall CT score with GCS.Discussion: Enlargement of ONSD and higher Marshall CT score were correlated negatively related with the GCSin TBI patients with increased intracranial pressure.Keywords: Glasgow Coma Scale, Marshall CT score, optic nerve sheath diameter’s, traumatic brain injuryABSTRAK Pendahuluan: Pada cedera kepala atau traumatic brain injury (TBI), penggunaan CT scan kepala tanpa kontras dapat mendeteksi tanda-tanda peningkatan tekanan intrakranial (TIK), yang penting bagi tata laksana pasien. Sementara pengukuran diameter optic nerve sheath yang disebut optic nerve sheath diameter (ONSD) merupakan metode baru yang diharapkan dapat menilai peningkatan tekanan intrakranial secara non-invasif. Marshall CT score merupakan instrumen valid dan menjadi standar de facto dalam mengklasifikasikan pasien cedera kepala yang berkorelasi dengan peningkatan TIK.Tujuan: Untuk melihat adanya korelasi antara diameter N. Optikus dan Marshall CT score dengan Skala KomaGlasgow (Glasgow Coma Scale/GCS).Metode: Penelitian analitik observasional retrospektif secara potong lintang dari data rekam medis pasien cedera kepala dewasa yang dirawat di RSUP Prof. Dr. Kariadi, Semarang, pada bulan Maret-Agustus 2017. Selanjutnya kesemua subjek dilakukan pengukuran ONSD pada kedua mata serta penilaian Marshall CT score oleh seorang spesialis radiologi. Dilakukan uji korelasi Rank Spearman’s untuk menilai ketiga parameter tersebut.Hasil: Terdapat 34 subjek yang terutama laki-laki (67,6%) dengan usia terbanyak <30 tahun (41,2%) dan penyebab terbanyak adalah kecelakaan (76,4%). Didapatkan korelasi negatif derajat sedang antara ONSD dan Marshall CT score dengan GCS.Diskusi: Peningkatan diameter optic nerve sheath dan Marshall CT score berkorelasi dengan penurunan skor GCSpada pasien cedera kepala yang mengalami peningkatan TIK.Kata kunci: Cedera kepala, diameter optic nerve sheath, Marshall CT score, Skala Koma Glasgow

CT Evaluation of Optic Nerve Sheath Diameter in Traumatic Brain Injury and its Correlation with Rotterdam CT Scoring

2020 ◽  
Vol 10 (2) ◽  
pp. 26-32
Author(s):  
Mahesh Gautam ◽  
Prakash Kafle ◽  
Manish Raj Pathak ◽  
Ganesh Devkota ◽  
Nawaraj Ranabhat
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Optic Nerve ◽  
Intracranial Pressure ◽  
Ct Scan ◽  
Brain Injuries ◽  
Optic Nerve Sheath Diameter ◽  
Optic Nerve Sheath ◽  
Operating Characteristics ◽  
Nerve Sheath

Introduction: Elevated intracranial pressure is one of the fatal events associated with traumatic brain injury. Optic nerve sheath diameter measurement is an indirect way of assessing intracranial pressure. Optic nerve sheath diameter and Rotterdam score are prognosticators of traumatic brain injury. This study aimed to measure the optic nerve sheath diameter in the initial CT scan and correlate with the Rotterdam score.Methods: Retrospective analytical study comprising consecutive patients from July 2019 to December 2019 who underwent decompressive craniotomy for traumatic brain injuries were included. Optic nerve sheath diameter was measured 3mm behind the eyeball in axial images and Rotterdam CT Score was done on the same CT image in another setting. The receiver operating characteristics curve was plotted to measure the accuracy of optic nerve sheath diameter in predicting the severity of traumatic brain injury.Results: Sixty patients with a mean age of 42.5±14.6years were included. The mean optic nerve sheath diameter with Rotterdam Score of 1, 2 and 3 was 3.8±0.64mm and with Rotterdam Score of 4, 5 and 6 was 5.1±0.66mm. The area under the curve of severe Rotterdam CT Score vs optic nerve sheath diameter was 0.915 (p<0.0001, 95% CI 0.84-0.98) and spearman Rho correlation coefficient value was 0.83 suggesting positive relation.Conclusion: Higher mean optic nerve sheath diameter was observed with a severe Rotterdam CT score. Thus, optic nerve sheath diameter of initial CT scan in traumatic brain injury cases could be an important radiological tool to rule out the presence of raised intracranial pressure.

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

Neurosurgery ◽  
2010 ◽  
Vol 66 (6) ◽  
pp. 1111-1119 ◽  
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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