OBJECTIVE: Increased intracranial pressure (ICP) is most likely not being transmitted uniformly within the cranium. The ICP profiles in the supra- and infratentorial compartments remain largely unclear. Increased ICP in the cerebellum, however, is insufficiently captured by supratentorial ICP (ICPsup) monitoring due to compartmentalization through the tentorium. The authors hypothesized that additional infratentorial ICP (ICPinf) monitoring can be clinically valuable in selected patients. The aims of this study were to demonstrate the safety and feasibility of ICPinf monitoring and to investigate the influence of the ICPinf on clinical outcome in a real-world setting. METHODS: Fifteen consecutive patients with posterior fossa (PF) lesions requiring surgery and anticipated prolonged neurointensive care between June 2019 and December 2021 were included. Simultaneous ICPsup and ICPinf were recorded. ICP burden was defined as a 15-minute interval with a mean ICP > 22 mm Hg. The Glasgow Outcome Scale score was assessed after 3 months. RESULTS: The mean ICPinf was substantially higher compared with ICPsup throughout the entire period of ICP recording (16.08 ± 4.44 vs 10.74 ± 3.6 mm Hg, p < 0.01). ICPinf was significantly higher in patients with unfavorable outcome when compared with those with favorable outcome (mean 17.2 ± 4.1 vs 11.4 ± 3.5 mm Hg, p < 0.05). Patients with unfavorable outcome showed significantly higher ICPinf burden compared with those with favorable outcome (mean 40.6 ± 43.8 vs 0.3 ± 0.4 hours, p < 0.05). Neither absolute ICPsup nor ICPsup burden was significantly associated with unfavorable outcome (p = 0.13). No monitoring-associated complications occurred. CONCLUSIONS: Supplementary ICPinf monitoring is safe and reliable. There is a significant transtentorial pressure gradient within the cranium showing elevated ICPs in the PF. Elevated ICP levels in the PF were strongly associated with unfavorable neurological outcome irrespective of ICPsup values.
The pressure reactivity index (PRx) is a parameter for the assessment of cerebrovascular autoregulation, but its calculation is affected by artifacts in the source biosignals-intracranial pressure (ICP) and arterial blood pressure. We sought to describe the most common short-duration artifacts and their effect on the PRx. A retrospective analysis of 935 h of multimodal monitoring data was conducted, and five types of artifacts, characterized by their shape, duration, and amplitude, were identified: rectangular, fast impulse, isoline drift, saw tooth, and constant ICP value. Subsequently, all types of artifacts were mathematically modeled and inserted into undisturbed segments of biosignals. Fast impulse, the most common artifact, did not alter the PRx index significantly when inserted into one or both signals. Artifacts present in one signal exceeded the threshold PRx in less than 5% of samples, except for isoline drift. Compared to that, the shortest rectangular artifact inserted into both signals changed PRx to a value above the set threshold in 55.4% of cases. Our analysis shows that the effect of individual artifacts on the PRx index is variable, depending on their occurrence in one or both signals, duration, and shape. This different effect suggests that potentially not all artifacts need to be removed.
- MeSH
- bolesti hlavy etiologie patofyziologie MeSH
- intrakraniální hypertenze * diagnóza etiologie patofyziologie MeSH
- intrakraniální hypotenze * diagnóza etiologie patofyziologie MeSH
- intrakraniální tlak fyziologie MeSH
- lidé MeSH
- závrať etiologie MeSH
- zvracení etiologie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- přehledy MeSH
- MeSH
- cirkumventrikulární orgány fyziologie patofyziologie MeSH
- hematoencefalická bariéra fyziologie patofyziologie MeSH
- lidé MeSH
- mozkomíšní mok * diagnostické zobrazování fyziologie MeSH
- plexus chorioideus fyziologie patofyziologie MeSH
- spinální punkce metody MeSH
- tlak mozkomíšního moku fyziologie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- přehledy MeSH
- MeSH
- edém mozku * etiologie klasifikace terapie MeSH
- intrakraniální tlak * fyziologie MeSH
- lidé MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- přehledy MeSH
BACKGROUND: Machine learning (ML) approaches can significantly improve the classical Rout-based evaluation of the lumbar infusion test (LIT) and the clinical management of the normal pressure hydrocephalus. OBJECTIVE: To develop a ML model that accurately identifies patients as candidates for permanent cerebral spinal fluid shunt implantation using only intracranial pressure and electrocardiogram signals recorded throughout LIT. METHODS: This was a single-center cohort study of prospectively collected data of 96 patients who underwent LIT and 5-day external lumbar cerebral spinal fluid drainage (external lumbar drainage) as a reference diagnostic method. A set of selected 48 intracranial pressure/electrocardiogram complex signal waveform features describing nonlinear behavior, wavelet transform spectral signatures, or recurrent map patterns were calculated for each patient. After applying a leave-one-out cross-validation training-testing split of the data set, we trained and evaluated the performance of various state-of-the-art ML algorithms. RESULTS: The highest performing ML algorithm was the eXtreme Gradient Boosting. This model showed a good calibration and discrimination on the testing data, with an area under the receiver operating characteristic curve of 0.891 (accuracy: 82.3%, sensitivity: 86.1%, and specificity: 73.9%) obtained for 8 selected features. Our ML model clearly outperforms the classical Rout-based manual classification commonly used in clinical practice with an accuracy of 62.5%. CONCLUSION: This study successfully used the ML approach to predict the outcome of a 5-day external lumbar drainage and hence which patients are likely to benefit from permanent shunt implantation. Our automated ML model thus enhances the diagnostic utility of LIT in management.
Continuous monitoring of the intracranial pressure (ICP) is essential in neurocritical care. There are a variety of ICP monitoring systems currently available, with the intraventricular fluid filled catheter transducer currently representing the "gold standard". As the placement of catheters is associated with the attendant risk of infection, hematoma formation, and seizures, there is a need for a reliable, non-invasive alternative. In the present study we suggest a unique theoretical framework based on differential geometry invariants of cranial micro-motions with the potential for continuous non-invasive ICP monitoring in conservative traumatic brain injury (TBI) treatment. As a proof of this concept, we have developed a pillow with embedded mechanical sensors and collected an extensive dataset (> 550 h on 24 TBI coma patients) of cranial micro-motions and the reference intraparenchymal ICP. From the multidimensional pulsatile curve we calculated the first Cartan curvature and constructed a "fingerprint" image (Cartan map) associated with the cerebrospinal fluid (CSF) dynamics. The Cartan map features maxima bands corresponding to a pressure wave reflection corresponding to a detectable skull tremble. We give evidence for a statistically significant and patient-independent correlation between skull micro-motions and ICP time derivative. Our unique differential geometry-based method yields a broader and global perspective on intracranial CSF dynamics compared to rather local catheter-based measurement and has the potential for wider applications.
- MeSH
- dospělí MeSH
- intrakraniální hypertenze patofyziologie MeSH
- intrakraniální tlak fyziologie MeSH
- lebka patofyziologie MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladý dospělý MeSH
- monitorování fyziologických funkcí MeSH
- senioři MeSH
- traumatické poranění mozku patofyziologie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladý dospělý MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
Kontinuální monitorace nitrolebního tlaku je v neurointenzivní péči naprosto klíčová. Přestože bylo navrženo množství alternativních metod, invazivní měření ICP pomocí katetru představuje široce uznávaný zlatý standard. Invazivní měření tlaku likvoru v mozkovém parenchymu nebo postranních komorách je však spojeno s rizikem vzniku infekce, hematomu nebo záchvatů. Uvedené komplikace měření nitrolebního tlaku jsou tak motivací pro studium neinvazivních přístupů. Námi navržená metodologie neinvazivního měření nitrolebního tlaku je založena na výpočtu diferenciálně geometrických invariantů mikro-pohybů hlavy u komatózních pacientů a její potenciál spočívá v možnosti kontinuálního měření nitrolebního tlaku v rámci konzervativní léčby mozkových traumat. Domníváme se, že navržený postup měření přesahuje hranice traumatické neurochirurgie a bylo by možné jej aplikovat i v jiných oblastech medicíny.
Continual ICP monitoring is key in the neurointensive case. Although many different approaches have been proposed, catheter based ICP measurement remains the widely used golden standard. The intraparenchymal or intraventricular ICP measurement is, however, associated with the attendant risk of infection, hematoma formation, or seizures. The listed complications are the driving force for novel non-invasive ICP measurement methods investigation. Our non-invasive method is based on the calculation of differential geometry invariants of the head micro-motions in coma patients and its potential stems from the possibility of continuous ICP monitoring in the conservative TBI treatment. Moreover, we believe that our approach goes beyond traumatic neurosurgery and neurointensive care and is applicable also in other fields of medicine.
BACKGROUND: Decompressive craniectomy (DC) has become the definitive surgical procedure to manage a medically intractable rise in intracranial pressure. DC is a life-saving procedure resulting in lower mortality but also higher rates of severe disability. Although technically straightforward, DC is accompanied by many complications. It has been reported that complications are associated with worse outcome. We reviewed a series of patients who underwent DC at our department to establish the incidence and types of complications. METHODS: We retrospectively evaluated the incidence of complications after DC performed in 135 patients during the time period from January 2013 to December 2018. Postoperative complications were evaluated using clinical status and CT during 6 months of follow-up. In addition, the impact of potential risk factors on the incidence of complications and the impact of complications on outcome were assessed. RESULTS: DC was performed in 135 patients, 93 of these for trauma, 22 for subarachnoid hemorrhage, 13 for malignant middle cerebral artery infarction, and 7 for intracerebral hemorrhage. Primary DC was performed in 120 patients and secondary DC in 15 patients. At least 1 complication occurred in each of 100 patients (74%), of which 22 patients (22%) were treated surgically. The following complications were found: edema or hematoma of the temporal muscle (34 times), extracerebral hematoma (33 times), extra-axial fluid collection (31 times), hemorrhagic progression of contusions (19 times), hydrocephalus (12 times), intraoperative malignant brain edema (10 times), temporal muscle atrophy (7 times), significant intraoperative blood loss (6 times), epileptic seizures (5 times), and skin necrosis (4 times). Trauma (p = 0.0006), coagulopathy (p = 0.0099), and primary DC (p = 0.0252) were identified as risk factors for complications. There was no significant impact of complications on outcome. CONCLUSIONS: The incidence of complications following DC is high. However, we did not confirm a significant impact of complications on outcome. We emphasize that some phenomena are so frequent that they can be considered a consequence of primary injury or natural sequelae of the DC rather than its direct complication.
