Intracranial pressure

Gorham-Stout syndrome affecting the temporal bone with cerebrospinal fluid leakage

Authors: Morimoto N, Ogiwara H, Miyazaki O, Kitamuara M, Nishina S, Nakazawa A, Maekawa T, Morota N.

Gorham-Stout syndrome is a rare disorder characterized by progressive osteolysis that leads to the disappearance of bone. Lymphvascular proliferation causes the local destruction of bony tissue. Owing to the low incidence of this syndrome, little is known about its etiology or treatment. We present an 11-year-old girl with Gorham-Stout syndrome that involved right petrous apex in temporal bone and upper clivus, which cause intracranial pressure increase and cerebrospinal fluid (CSF) leakage. The patient required surgical repair of CSF leakage by extradural middle fossa approach with temporal fascia flap. Combined treatment with interferon and propranolol prevented the progression of osteolysis.
Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Significant Practice Pattern Variations Associated With Intracranial Pressure Monitoring

Authors: Olson DM, Lewis LS, Bader MK, Bautista C, Malloy R, Riemen KE, McNett MM.

PURPOSE: The purpose of this study was to describe nursing practice in the care of patients with intracranial pressure monitoring. Although standards for care of such patients have been established, there continue to be variations in the nursing practice.
METHODS: This was an observational study in which data were collected from 28 nurse-patient dyads at 16 different hospitals across the United States. Each dyad was observed for 2 hours; nursing actions and patient responses including intracranial pressure readings were documented.
RESULTS: Differences in the care of patients with intracranial pressure monitoring were prevalent. Variations in practice were prompted by healthcare provider prescriptions as well as nursing decisions. Prescriptions and interventions were often not supported by the available scientific evidence.
VIDEO ABSTRACT: For more insights from the authors, see Supplemental Digital Content 1, at

Salt or sugar for your injured brain? A meta-analysis of randomised controlled trials of mannitol versus hypertonic sodium solutions to manage raised intracranial pressure in traumatic brain injury

Authors: Rickard AC, Smith JE, Newell P, Bailey A, Kehoe A, Mann C.

BACKGROUND: Rising intracranial pressure (ICP) is a poor prognostic indicator in traumatic brain injury (TBI). Both mannitol and hypertonic sodium solutions are used to treat raised ICP in patients with TBI.
OBJECTIVE: This meta-analysis compares the use of mannitol versus hypertonic sodium solutions for ICP control in patients with TBI.
DATA SOURCES AND STUDY ELIGIBILITY: Randomised clinical trials in adults with TBI and evidence of raised ICP, which compare the effect on ICP of hypertonic sodium solutions and mannitol.
METHODS: The primary outcome measure is the pooled mean reduction in ICP. Studies were combined using a Forest plot.
RESULTS: Six studies were included, comprising 171 patients (599 episodes of raised ICP). The weighted mean difference in ICP reduction, using hypertonic sodium solutions compared with mannitol, was 1.39 mm Hg (95% CI -0.74 to 3.53).
LIMITATIONS: Methodological differences between studies limit the conclusions of this meta-analysis.
CONCLUSIONS: The evidence shows that both agents effectively lower ICP. There is a trend favouring the use of hypertonic sodium solutions in patients with TBI.

Surgical treatment of elevated intracranial pressure: decompressive craniectomy and intracranial pressure monitoring

Authors: El Ahmadieh TY, Adel JG, El Tecle NE, Daou MR, Aoun SG, Nanney AD 3rd, Bendok BR.

Surgical techniques that address elevated intracranial pressure include (1) intraventricular catheter insertion and cerebrospinal fluid drainage, (2) removal of an intracranial space-occupying lesion, and (3) decompressive craniectomy. This review discusses the role of surgery in the management of elevated intracranial pressure, with special focus on intraventricular catheter placement and decompressive craniectomy. The techniques and potential complications of each procedure are described, and the existing evidence regarding the impact of these procedures on patient outcome is reviewed. Surgical management of mass lesions and ischemic or hemorrhagic stroke occurring in the posterior fossa is not discussed herein.

Management of intracerebral pressure in the neurosciences critical care unit

Authors: Marshall SA, Kalanuria A, Markandaya M, Nyquist PA.

Management of intracranial pressure in neurocritical care remains a potentially valuable target for improvements in therapy and patient outcomes. Surrogate markers of increased intracranial pressure, invasive monitors, and standard therapy, as well as promising new approaches to improve cerebral compliance are discussed, and a current review of the literature addressing this metric in neuroscience critical care is provided.

Spontaneous cerebrospinal fluid leak repair: A five-year prospective evaluation

Authors: Chaaban MR, Illing E, Riley KO, Woodworth BA.

OBJECTIVES / HYPOTHESIS Mounting evidence indicates the majority of spontaneous cerebrospinal fluid (CSF) leaks are associated with intracranial hypertension. The objectives of the current study were to assess outcomes regarding spontaneous CSF leaks focusing on premorbid factors, surgical technique, and management of intracranial pressure.
STUDY DESIGN: Prospective cohort.
METHODS: Prospective evaluation of patients with spontaneous CSF leaks was performed. Data regarding demographics, nature of presentation, body mass index (BMI), location and size of defect, intracranial pressure, clinical follow-up, and complications were collected.
RESULTS: Over 5 years, 46 patients (average age, 51 years) with 56 spontaneous CSF leaks were treated by a single otolaryngologist. Twenty-one subjects presented with recurrence of their CSF leak following previous endoscopic and/or open approaches by other physicians. Obesity was present in 78% of individuals (average BMI, 35.6). Fifty-two CSF leaks (93%) were successfully repaired at first attempt. With secondary repair, all CSF leaks were closed at last clinical follow-up (average, 93 weeks). Three patients developed late failures (>2 months), with one recurrence at a distinct location from the primary site at 8 months postprocedure (associated with ventriculoperitoneal shunt failure). Opening pressures via lumbar puncture averaged 24.3 ± 8.3 cm H2 0, which increased significantly to 32.3 ± 9.0 cm H2 0 (P < .0001) following closure of the skull base defect(s). Management of intracranial hypertension included acetazolamide (n = 23) or permanent CSF diversion (n = 19, including five revisions of failed preexisting shunts).
CONCLUSIONS: Although spontaneous CSF leaks have the highest recurrence rate of any etiology, prospective evaluation demonstrates high success rates with control of intracranial hypertension.
LEVEL OF EVIDENCE: 4. Laryngoscope, 2013.


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