Therapeutic Hypothermia With the Use of Intracranial Pressure Monitoring for Acute Disseminated Encephalomyelitis With Brainstem Lesion: A Case Report

Authors: Miyamoto K, Kozu S, Arakawa A, Tsuboi T, Hirao JI, Ono K, Arisaka O.

Acute disseminated encephalomyelitis confined to the brainstem is associated with poor prognosis. We describe a case of a 10-year-old boy with acute disseminated encephalomyelitis in the brainstem that developed after influenza A infection. A 10-year-old boy presented with fever and prolonged disturbance of consciousness and was admitted to our hospital. Magnetic resonance imaging (MRI) of the midbrain, with T2-weighted and fluid-attenuated inversion recovery images, suggested acute disseminated encephalomyelitis accompanied by a brainstem lesion. Lumbar puncture showed pleocytosis and increased protein content, including myelin basic protein, interleukin-6, and immunoglobulin G, all suggestive of acute disseminated encephalomyelitis. Treatments such as methylprednisolone pulse therapy, intravenous immunoglobulin, and therapeutic hypothermia were performed. Although the patient presented with anisocoria with increased intracranial pressure monitoring during hypothermia, prompt therapy with d-mannitol and dopamine was effective. Our case results suggest that hypothermia could be included in the choice of therapy for acute disseminated encephalomyelitis with brainstem lesions.

Deep venous structures distortion in spontaneous intracranial hypotension as an explanation for altered level of consciousness

Authors: Ajlan AM, Al-Jehani H, Torres C, Marcoux J.

Spontaneous intracranial hypotension (SIH) is a syndrome of low pressure headache associated with low CSF pressure. The condition is generally considered benign but extreme cases of SIH can lead to changes in the level of consciousness. We describe a case in which alteration in the level of consciousness was prolonged and severe, and could not be explained solely by the presence of subdural collections. MRI of the brain showed evidence of impaired venous flow secondary to brain sagging causing distortion of deep venous structures.

Increased intracranial pressure and brain edema

Authors: Dietrich W, Erbguth F.

In primary and secondary brain diseases, increasing volumes of the three compartments of brain tissue, cerebrospinal fluid, or blood lead to a critical increase in intracranial pressure (ICP). A rising ICP is associated with typical clinical symptoms; however, during analgosedation it can only be detected by invasive ICP monitoring. Other neuromonitoring procedures are not as effective as ICP monitoring; they reflect the ICP changes and their complications by other metabolic and oxygenation parameters. The most relevant parameter for brain perfusion is cerebral perfusion pressure (CPP), which is calculated as the difference between the middle arterial pressure (MAP) and the ICP. A mixed body of evidence exists for the different ICP-reducing treatment measures, such as hyperventilation, hyperosmolar substances, hypothermia, glucocorticosteroids, CSF drainage, and decompressive surgery.

Valsalva manoeuver, intra-ocular pressure, cerebrospinal fluid pressure, optic disc topography: Beijing intracranial and intra-ocular pressure study

Authors: Zhang Z, Wang X, Jonas JB, Wang H, Zhang X, Peng X, Ritch R, Tian G, Yang D, Li L, Li J, Wang N.

PURPOSE: To assess whether a Valsalva manoeuver influences intra-ocular pressure (IOP), cerebrospinal fluid pressure (CSF-P) and, by a change in the trans-laminar cribrosa pressure difference, optic nerve head morphology.
METHODS: In the first part of the study, 20 neurological patients (study group 'A') underwent measurement of IOP and lumbar CSF-P measurement in a lying position before and during a Valsalva manoeuver. In the second study part, 20 healthy subjects (study group 'B') underwent ocular tonometry and confocal scanning laser tomography of the optic nerve head before and during a Valsalva manoeuver.
RESULTS: During the Valsalva manoeuver in study group 'A', the increase in CSF-P by 10.5 ± 2.7 mmHg was significantly (p < 0.001) higher than the increase in IOP by 1.9 ± 2.4 mmHg. The change in CSF-P was not significantly (p = 0.61) correlated with the change in IOP. During the Valsalva manoeuver in study group 'B', IOP increased by 4.5 ± 4.2 mmHg and optic cup volume (p < 0.001), cup/disc area ratio (p = 0.02), cup/disc diameter ratio (p = 0.03) and maximum optic cup depth (p = 0.01) significantly decreased, while neuroretinal rim volume (p = 0.005) and mean retinal nerve fibre layer thickness (p = 0.02) significantly increased.
CONCLUSIONS: The Valsalva manoeuver-associated short-term increase in CSF-P was significantly larger than a simultaneous short-term increase in IOP. It led to a Valsalva manoeuver-associated decrease or reversal of the trans-laminar cribrosa pressure difference, which was associated with a change in the three-dimensional optic nerve head morphology: optic cup-related parameters decreased and neuroretinal rim-related parameters enlarged. These findings may be of interest for the pathogenesis of glaucomatous optic neuropathy.

Pediatric idiopathic intracranial hypertension and the underlying endocrine-metabolic dysfunction: a pilot study

Authors: Salpietro V, Mankad K, Kinali M, Adams A, Valenzise M, Tortorella G, Gitto E, Polizzi A, Chirico V, Nicita F, David E, Romeo AC, Squeri CA, Savasta S, Marseglia GL, Arrigo T, Johanson CE, Ruggieri M.

Abstract Aim: To unravel the potential idiopathic intracranial hypertension (IIH) endocrine-metabolic comorbidities by studying the natural (and targeted drug-modified) history of disease in children. IIH is a disorder of unclear pathophysiology, characterized by raised intracranial pressure without hydrocephalus or space-occupying lesion coupled with normal cerebrospinal fluid (CSF) composition. Methods: Retrospective study (years 2001-2010) of clinical records and images and prospective follow-up (years 2010-2013) in 15 children (11 girls, 4 boys; aged 5-16 years) diagnosed previously as "IIH", according to the criteria for pediatric IIH proposed by Rangwala, at four university pediatric centers in northern, central, and southern Italy. Results: We identified six potential endocrine-metabolic comorbidities including, weight gain and obesity (n=5), recombinant growth hormone therapy (n=3), obesity and metabolic syndrome (n=1), secondary hyperaldosteronism (n=1), hypervitaminosis A (n=1), and corticosteroid therapy (n=1). Response to etiologically targeted treatments (e.g., spironolactone, octreotide) was documented. Conclusions: IIH is a protean syndrome caused by various potential (risk and) associative factors. Several conditions could influence the pressure regulation of CSF. An endocrine-metabolic altered homeostasis could be suggested in some IIH patients, and in this context, etiologically targeted therapies (spironolactone) should be considered.

Short-duration hypothermia after ischemic stroke prevents delayed intracranial pressure rise

Authors: Murtha LA, McLeod DD, McCann SK, Pepperall D, Chung S, Levi CR, Calford MB, Spratt NJ.

BACKGROUND: Intracranial pressure elevation, peaking three to seven post-stroke is well recognized following large strokes. Data following small-moderate stroke are limited. Therapeutic hypothermia improves outcome after cardiac arrest, is strongly neuroprotective in experimental stroke, and is under clinical trial in stroke. Hypothermia lowers elevated intracranial pressure; however, rebound intracranial pressure elevation and neurological deterioration may occur during rewarming.
HYPOTHESES: (1) Intracranial pressure increases 24 h after moderate and small strokes. (2) Short-duration hypothermia-rewarming, instituted before intracranial pressure elevation, prevents this 24 h intracranial pressure elevation.

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