Search

Background: Spontaneous intracranial hypotension (SIH) is a debilitating disorder, with an estimated annual incidence of 3.7 per 100,000. Diagnosing SIH can be challenging for clinicians, as patients frequently present with normal investigation findings. Intracranial pressure (ICP) monitoring has been proposed as a valuable tool for patients with orthostatic headaches that are highly suggestive of SIH but have inconclusive investigation results. The primary objective of this study was to determine the proportion of patients with spontaneous orthostatic headaches and normal diagnostic work-up who exhibited abnormal ICP monitoring results. Methods: This single-centre, retrospective observational study was conducted at a tertiary referral centre specialising in SIH and CSF dynamics disorders. Consecutive patients with spontaneous orthostatic headaches and inconclusive diagnostic work-up who underwent 24-hour ICP monitoring were considered eligible. The 24-hour ICP monitoring followed a standardised protocol, measuring median ICP and pulse amplitude (a marker of brain compliance) during the daytime, nighttime, and over the entire 24-hour period. Specific cut-offs for low and high ICP states were predetermined based on the best available current evidence. Results: Thirty-eight patients (23 females, mean age 41 years ± 14SD) were identified. All patients had orthostatic headaches with a spontaneous onset. The mean duration of symptoms was 46 months ± 36SD. ICP monitoring identified 3 patients (7.9%) with low ICP (mean of the median 24-hour ICP − 2 mmHg ± 2SD) and 6 patients (15.8%) with high ICP (mean of the median 24-hour ICP 9 mmHg ± 3SD). Obvious CSF dynamics disturbances were excluded in the remaining 29 patients (76.3%, mean of the median 24-hour ICP 3 mmHg ± 3SD). The only clinical feature that was more common in patients with abnormal ICP compared to patients with normal ICP results was audiovestibular disturbance, namely aural fullness or muffled hearing (67% versus 17%, p = 0.015). There were no complications from the ICP monitoring procedure for any patient. Conclusions: When appropriately selected, patients with a clinical picture highly suggestive of SIH, who have a negative diagnostic work-up, may benefit from consideration of invasive ICP monitoring. Moreover, a significant minority of patients with orthostatic headache may paradoxically have a high CSF pressure state, which can be detected using ICP monitoring. Meeting presentations: Portions of this work were presented in abstract and oral presentation form at the Twenty-eighth Anglo-Dutch Migraine Association meeting (08/06/2018), the Tenth Meeting of the International Society for Hydrocephalus and Cerebrospinal Fluid Disorders (20/10/2018; Bologna, Italy), the Society of British Neurological Surgeons 2018 Autumn Meeting (19/09/2018; London, United Kingdom), and the European Association of Neurosurgical Societies 2023 congress (27/09/2023; Barcelona, Spain). This work is also part of the doctoral thesis of one of the authors (LD). [ABSTRACT FROM AUTHOR]

Objective: Increased intracranial pressure (ICP) can worsen the clinical condition of traumatic brain injury (TBI) patients. One non-invasive and easily bedside-performed technique to estimate ICP is ultrasonographic measurement of optic nerve sheath diameter (ONSD). This study aimed to analyze ONSD and correlate it with ICP values obtained by intraparenchymal monitoring to establish the ONSD threshold value for elevated ICP and reference range of ONSD in severe TBI patients. Methods: Forty severe TBI patients (Glasgow Coma Scale Score ≤ 8) were included. Ultrasonographic measurement of ONSD was performed and compared with intraparenchymal ICP monitoring to assess their association and determine the ONSD threshold value. Exclusion criteria included individuals under eighteen years old, penetrating TBI, or direct ocular trauma. Results: Fifty-three ONSD measurements were conducted in all patients. The mean ONSD value in the group with intracranial pressure < 20 mmHg was 5.4 mm ± 1.0, while in the group with intracranial pressure ≥ 20 mmHg, it was 6.4 mm ± 0.7 (p = 0.0026). A positive and statistically significant correlation, albeit weak (r = 0.33), was observed between ultrasonographic measurement of ONSD and intraparenchymal ICP monitoring. The statistical analysis of the ROC curve identified the best cut-off as 6.18 mm, with 77.8% sensitivity and 81.8% specificity. Conclusion: Our results reveal a positive, albeit weak, correlation between ultrasonographic measurement of ONSD and intraparenchymal ICP monitoring, with an ONSD threshold value of 6.18 mm. Achieving only 77.8% sensitivity and considering the substantial variability between ONSD measurements (standard deviation at 1.0) might limit the reliability of ICP assessment based solely on ONSD measurements. [ABSTRACT FROM AUTHOR]

While there is agreement on the indications for intracranial pressure monitoring (ICPm) in patients with sTBI, there continues to be controversy concerning the ideal timing of its implementation. It is within this context that we decided to investigate whether a protocolization approach could optimize the timeliness of ICPm implementation. Neurosurgical and SICU providers agreed to a 3-tier protocol to identify patients with sTBI who could benefit from timelier ICPm implementation. The monthly compliance was monitored for a 9-month period. The study included a pre-protocolization group of 11 patients (2022) and a post-protocolization group of 9 patients (2023-2024). There was a trend toward earlier use of ICPm but the difference did not achieve statistical significance; there was no difference in the mortality rates between groups. A protocolization approach to the treatment of patients with sTBI developed with a consensus strategy may lead to earlier implementation of ICPm and possibly improved functional outcome., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: It is unclear if intracranial pressure monitoring (ICPM) after open cranial procedures (craniotomy or craniectomy) (OC) for traumatic brain injury is associated with mortality. We hypothesized that ICPM placed early after OC was associated with lower mortality compared to no ICPM or delayed ICPM placement., Methods: Using 2020-2021 data from the American College of Surgeons Trauma Quality Improvement Program, patients ≥16 y from level 1 and 2 trauma centers who underwent OC were divided into two groups: ICPM placed within 72 h of OC (early) and no ICPM or ICPM placed after 72 h (none/delayed). Outcome was in-hospital mortality. Logistic regression was used to elucidate predictors of mortality., Results: A total of 19,830 patients (early ICPM, 29%) were included. Early patients were more likely to be from level 1 centers (63% versus 60%, P = 0.004), younger (median age 47 versus 60, P < 0.0001), to have a lower Glasgow Coma Score (median, 6 versus 14, P < 0.0001), higher injury severity score (median, 26 versus 26, P < 0.0001), an unreactive pupil (33% versus 18%, P < 0.0001), midline shift >5 mm (69% versus 60%, P < 0.0001), received ≥2 units of blood/first 4 h (14% versus 6%, P < 0.0001) and higher mortality (31% versus 19%, P < 0.0001) compared to none/delayed patients. Controlled for significant variables, early ICPM was associated with increased mortality (odds ratio 1.35, 95% confidence interval 1.24-1.47). Analysis of subjects with isolated brain injury found a similar association (odds ratio 1.32, 95% C1 1.15-1.52)., Conclusions: ICPM placed within 72 h of OC was associated with increased mortality. Indications for ICPM after OC should be investigated further in multicenter prospective studies., (Copyright © 2024 Elsevier Inc. All rights reserved.)