Principles and Management of Increased Intracranial Pressure

Intracranial pressure (ICP) is a reflection of the total volume inside the skull. Normal ICP is 5 to 15 mm Hg. Intracranial hypertension is defined as sustained ICP of more than 20 mm Hg. Increased ICP may lead to a reduction of cerebral perfusion pressure, a shift of brain tissue, and, as a result, secondary brainstem injury. Early recognition and treatment of elevated ICP are needed to prevent irreversible damage.

Electroencephalogram Background Predicts Time to Full Oral Feedings in Hypoxic-Ischemic Encephalopathy

Objective Infants with a history of neonatal hypoxic-ischemic encephalopathy (HIE) are at risk for oral motor dysfunction. Previous studies have associated the need for gastrostomy tube at neonatal intensive care unit discharge with brainstem injury on magnetic resonance imaging (MRI). However, the factors associated with time to full oral feeds in this population have not been previously described. This study aimed to study factors associated with time to full oral feeds in this population. Study Design This is a single-center, retrospective study that examined these factors using Cox regression. Results A total of 150 infants who received therapeutic hypothermia from 2011 to 2017 were included in this study. The single clinical factor significantly associated with time to full oral feeds was the severity of background abnormality on electroencephalogram in the first 24 hours of age (severe vs. mild 95% confidence interval [CI]: 0.34–0.74; moderate vs. mild 95% CI: 0.19–0.45). Brainstem injury on MRI was the factor most highly associated with need for gastrostomy tube placement (p = 0.028), though the overall incidence of need for gastrostomy tube feeds in this population was low (5%). Conclusion These findings may help clinicians counsel families on what to expect in neonates with HIE and make decisions on the need for and timing to pursue gastrostomy tube in this population. Key Points

Duret Hemorrhage after Extradural Hematoma Evacuation–A Rare Entity

Traumatic brainstem injury can be classified as primary or secondary. Secondary brainstem hemorrhage that evolves from raised intracranial pressure (ICP) and transtentorial herniation is referred to as Duret hemorrhage. We report a 25-year-old male who underwent emergency craniotomy, with evacuation of acute epidural hematoma, and postoperatively developed fatal Duret hemorrhage. Duret hemorrhage after acute epidural hematoma (EDH) evacuation is a very rare complication and the outcome is grave in most of the cases.

Pathophysiology of Signs and Symptoms of Coma

Chapter 1 provides some important background information on the pathophysiology of impaired consciousness, as well as on the signs and symptoms that accompany it. It starts with definitions of key terms: consciousness, acutely altered states of consciousness, and subacute or chronic alterations of consciousness, as well as the definitions for stupor, coma, and other states of altered consciousness. It looks at how to approach the diagnosis of the comatose patient, and it then explains the physiology and pathophysiology of consciousness and coma. Finally, it describes three types of brain damage that may lead to altered consciousness or coma: bilateral hemispheric damage, diencephalic injury, and upper brainstem injury.