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IMPORTANCE: Treatment for intracranial pressure (ICP) has been increasingly informed by machine learning (ML)-derived ICP waveform characteristics. There are gaps, however, in understanding how ICP monitor type may bias waveform characteristics used for these predictive tools since differences between external ventricular drain (EVD) and intraparenchymal monitor (IPM)-derived waveforms have not been well accounted for. OBJECTIVES: We sought to develop a proof-of-concept ML model differentiating ICP waveforms originating from an EVD or IPM. DESIGN, SETTING, AND PARTICIPANTS: We examined raw ICP waveform data from the ICU physiology cohort within the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury multicenter study. MAIN OUTCOMES AND MEASURES: Nested patient-wise five-fold cross-validation and group analysis with bagged decision trees (BDT) and linear discriminant analysis were used for feature selection and fair evaluation. Nine patients were kept as unseen hold-outs for further evaluation. RESULTS: ICP waveform data totaling 14,110 hours were included from 82 patients (EVD, 47; IPM, 26; both, 9). Mean age, Glasgow Coma Scale (GCS) total, and GCS motor score upon admission, as well as the presence and amount of midline shift, were similar between groups. The model mean area under the receiver operating characteristic curve (AU-ROC) exceeded 0.874 across all folds. In additional rigorous cluster-based subgroup analysis, targeted at testing the resilience of models to cross-validation with smaller subsets constructed to develop models in one confounder set and test them in another subset, AU-ROC exceeded 0.811. In a similar analysis using propensity score-based rather than cluster-based subgroup analysis, the mean AU-ROC exceeded 0.827. Of 842 extracted ICP features, 62 were invariant within every analysis, representing the most accurate and robust differences between ICP monitor types. For the nine patient hold-outs, an AU-ROC of 0.826 was obtained using BDT. CONCLUSIONS AND RELEVANCE: The developed proof-of-concept ML model identified differences in EVD- and IPM-derived ICP signals, which can provide missing contextual data for large-scale retrospective datasets, prevent bias in computational models that ingest ICP data indiscriminately, and control for confounding using our models output as a propensity score by to adjust for the monitoring method that was clinically indicated. Furthermore, the invariant features may be leveraged as ICP features for anomaly detection.

BACKGROUND: The monitoring and analysis of quasi-periodic biological signals such as electrocardiography (ECG), intracranial pressure (ICP), and cerebral blood flow velocity (CBFV) waveforms plays an important role in the early detection of adverse patient events and contributes to improved care management in the intensive care unit (ICU). This work quantitatively evaluates existing computational frameworks for automatically extracting peaks within ICP waveforms. METHODS: Peak detection techniques based on state-of-the-art machine learning models were evaluated in terms of robustness to varying noise levels. The evaluation was performed on a dataset of ICP signals assembled from 700 h of monitoring from 64 neurosurgical patients. The groundtruth of the peak locations was established manually on a subset of 13, 611 pulses. Additional evaluation was performed using a simulated dataset of ICP with controlled temporal dynamics and noise. RESULTS: The quantitative analysis of peak detection algorithms applied to individual waveforms indicates that most techniques provide acceptable accuracy with a mean absolute error (MAE) ≤ 10 ms without noise. In the presence of a higher noise level, however, only kernel spectral regression and random forest remain below that error threshold while the performance of other techniques deteriorates. Our experiments also demonstrated that tracking methods such as Bayesian inference and long short-term memory (LSTM) can be applied continuously and provide additional robustness in situations where single pulse analysis methods fail, such as missing data. CONCLUSION: While machine learning-based peak detection methods require manually labeled data for training, these models outperform conventional signal processing ones based on handcrafted rules and should be considered for peak detection in modern frameworks. In particular, peak tracking methods that incorporate temporal information between successive periods of the signals have demonstrated in our experiments to provide more robustness to noise and temporary artifacts that commonly arise as part of the monitoring setup in the clinical setting.

BACKGROUND: Orbital roof fractures are often the result of high-velocity collisions and are seen in 1-9% of patients with craniofacial trauma. Although the majority of orbital roof fractures are displaced superiorly, a subset results in inferior displacement of fracture fragments, posing a risk for muscle/nerve entrapment and possible blindness. Many of these patients have severe traumatic brain injury (TBI) and, in addition to orbital fractures, also have elevated intracranial pressure (ICP). Management of depressed orbital roof fractures in the setting of severe TBI with elevated ICP represents a management dilemma. CASE DESCRIPTION: Two cases of severe TBI with associated downward displacement of orbital roof fractures were reviewed. Both cases exhibited elevated ICP correlated with the degree of orbital roof fracture depression. Surgical intervention involving elevation and repair of the fractures was undertaken when there was a significant risk of injury to the extraocular muscles and/or the optic nerve due to the extent of the fracture depression. CONCLUSION: Depressed orbital roof fractures may migrate in response to changes in ICP. Serial computed tomography scans and eye examinations may aid with determining the need for and timing of surgical intervention.

OBJECTIVES: Elevated intracranial pressure (ICP) is a potentially devastating complication of neurologic injury. Developing an ICP prediction algorithm to help the clinician adjust treatments and potentially prevent elevated ICP episodes. DESIGN: Retrospective study. SETTING: Three hundred thirty-five ICUs at 208 hospitals in the United States. SUBJECTS: Adults patients from the electronic ICU (eICU) Collaborative Research Database was used to train an ensemble machine learning model to predict the ICP 30 minutes in the future. Predictive performance was evaluated using a left-out test dataset and externally evaluated on the Medical Information Mart for Intensive Care-III (MIMIC-III) Matched Waveform Database. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Predictors included age, assigned sex, laboratories, medications and infusions, input/output, Glasgow Coma Scale (GCS) components, and time-series vitals (heart rate, ICP, mean arterial pressure, respiratory rate, and temperature). Each patient ICU stay was divided into successive 95-minute timeblocks. For each timeblock, the model was trained on nontime-varying covariates as well as on 12 observations of time-varying covariates at 5-minute intervals and asked to predict the 5-minute median ICP 30 minutes after the last observed ICP value. Data from 931 patients with ICP monitoring in the eICU dataset were extracted (46,207 timeblocks). The root mean squared error was 4.51 mm Hg in the eICU test set and 3.56 mm Hg in the MIMIC-III dataset. The most important variables driving ICP prediction were previous ICP history, patients temperature, weight, serum creatinine, age, GCS, and hemodynamic parameters. CONCLUSIONS: IntraCranial pressure prediction AlgoRithm using machinE learning, an ensemble machine learning model, trained to predict the ICP of a patient 30 minutes in the future based on baseline characteristics and vitals data from the past hour showed promising predictive performance including in an external validation dataset.

BACKGROUND AND OBJECTIVES: Elevated intracranial pressure (ICP) in myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD) has been largely unexplored. The objectives of this study were to determine the frequency of increased ICP in MOGAD and its association with disease course and outcomes and to highlight cases requiring medical and/or surgical management of increased ICP. METHODS: In this retrospective, single-center cohort study, we examined the clinical and paraclinical data from the initial presentation and follow-up data of children diagnosed with MOGAD. In those with opening pressure (OP) measurements, univariate analyses were used to evaluate factors associated with increased ICP, which was defined as OP > 28 cm H2O. We also present a case series of patients with or without OP measurement who required medical and/or surgical management of increased ICP. RESULTS: Of 86 children with MOGAD, 43 (50.0%) had an OP recorded and 7 (8.1%) required ICP management. In those with OP recorded, the median (interquartile range) OP for the different MOGAD phenotypes were: 30.0 (22.8-41.6) (acute disseminated encephalomyelitis, ADEM), 20.5 (16.1-23.6) (optic neuritis), 17.0 (17.0-22.5) (myelitis), and 19.5 (16.5-29.3) (other) cm H20. Overall, 20.9% had increased ICP based on an OP > 28 cm H2O, of whom 77.8% presented with ADEM. In a subgroup analysis of those presenting with ADEM, those with an elevated ICP had longer hospital stay (p = 0.007) and neurologic disability (defined as modified Rankin Scale >1) (p = 0.049). In those with or without OP recorded, 7 (6 with ADEM, one with cerebral cortical encephalitis) required ICP-directed therapies. Findings on brain MRI in these 7 children revealed extensive disease burden with bilateral cerebral involvement and evidence of restricted diffusion. While neuropsychological data in this small subset revealed significant variability, all sustained identifiable deficits after discharge, including attention-deficit hyperactivity disorders and language and learning disorders. DISCUSSION: In pediatric MOGAD, increased OP and ADEM at initial presentation were associated with longer hospital stays and greater long-term morbidity. Although invasive ICP monitoring has not been specifically advocated in the management of MOGAD, it is important to recognize signs and symptoms of increased ICP in these patients and consider ICP monitoring and management strategies based on clinical and radiologic findings, especially in those presenting with ADEM and with OP > 28 cm H2O.

Background: We assessed the correlation between optic nerve sheath diameter (ONSD) values measured by bedside ultrasound and intracranial pressure (ICP) changes among patients under neurocritical care and evaluated the diagnostic performance of ONSD for increased ICP. Methods: Sixty-seven neurologically critical patients who were hospitalised in the intensive care unit (ICU) of Jining No.1 People's Hospital between September 2023 and March 2024 and underwent lumbar puncture were included. The ONSD was measured and recorded using bedside ultrasound before the lumbar puncture. Patients were divided into normal and increased ICP groups on the basis of the initial lumbar puncture pressure on admission, and both groups were compared. Spearman's correlation analysis was used for evaluating the correlation between ONSD values and ICP. Receiver operating characteristic (ROC) curves were employed for evaluating the diagnostic performance of ONSD for increased ICP. Result: At admission, the Glasgow Coma Scale scores of patients in the increased ICP group were significantly lower than those of patients in the normal ICP group (P < 0.05). The ONSD level of patients in the increased ICP group was significantly higher than that of patients in the normal ICP group (P < 0.05). Spearman's correlation analysis revealed that ONSD positively correlated with ICP among patients with severe neurological diseases (r = 0.777, P < 0.001). The area under the ROC curve when using ONSD for diagnosing lumbar puncture opening pressure ≥ 200 mmH2O was 0.896 (95% confidence interval, 0.817–0.974). When using ONSD ≥ 4.74 mm as the threshold for diagnosing lumbar puncture opening pressure ≥ 200 mmH2O, the sensitivity and specificity were 0.909 and 0.765, respectively. Conclusion: In patients with critical neurological illness, ONSD measured using bedside ultrasound positively correlated with ICP. Increased ICP can be diagnosed for ONSD ≥ 4.74 mm. The ONSD value measured by bedside ultrasound can be used for evaluating ICP among patients with critical neurological illness. [ABSTRACT FROM AUTHOR]

External ventricular drain (EVD) placement is often associated with complications; however, predictors of adverse outcomes after EVD placement are not well understood. This study aimed to identify predictors of EVD tract hemorrhage and to compare post-EVD hemorrhage rates between computer-assisted navigation and freehand technique EVD placement. This retrospective study included 147 consecutive patients who presented with increased intracranial pressure (ICP) requiring an EVD. Multivariable logistic regression was used to assess the relationship between predictors and adverse outcomes after EVD placement. The most common presenting pathologies in patients who had EVD placement were intraparenchymal hemorrhage (IPH) (43%) and subarachnoid hemorrhage (SAH) (28%). 14% of patients experienced EVD tract hemorrhage. Patients with platelet counts < 120 × 10³/µL (OR = 4.47, 95% CI = 1.01-20, p = 0.038), white blood cell counts < 11 × 10³/µL (OR = 3.3, 95% CI = 1.01–10.7, p = 0.048), and IPH (OR = 2.97, 95% CI = 1.06–10.7, p = 0.048) had increased risks of tract hemorrhage. The use of computer-assisted navigation did not reduce the risk of tract hemorrhage after EVD placement compared to the freehand technique. This study identified factors associated with increased risks of hemorrhage after EVD placement, which can help triage at-risk patients and reduce adverse outcomes of this procedure. [ABSTRACT FROM AUTHOR]

ABSTRACT The blast shock waves generated by the explosion are severe threat to soldiers on the battlefield, while the helmets currently equipped for the soldiers cannot offer sufficient blast protection. Some helmet pads have been developed to improve the protection performance of the combat helmets against shock waves. However, it remains unclear how to design the helmet pads to protect the head more effectively against blast shock waves. This study aims to design a new mechanics‐guided helmet pad and evaluate its protection performance by numerical simulations. The design of the new helmet pad is guided by the oblique reflection theory (ORT), and the advanced combat helmet (ACH) pad is applied for comparison. The protection performance of the pads against blast waves from two directions (frontal and lateral) was investigated. The differences in the distributions of overpressure inside the helmet using two types of pads were analyzed, and the intracranial pressure (ICP) of head was compared. The ORT‐guided pads can reduce the overpressure inside the helmet, minimizing the possibility of blast‐induced traumatic brain injury. Furthermore, the underwash phenomenon can also be controlled when the new pads are applied. The results in this study provide an important theoretical basis and some guidelines on the design of helmet pads for the protection of human brain from blast shock waves. [ABSTRACT FROM AUTHOR]

Purpose: Intracranial pressure (ICP) control is important to avoid secondary brain injury in patients with intracranial pathologies. Current methods for measuring ICP are invasive and carry risks of infection and hemorrhage. Previously we found correlation between ICP and the arteriole-venous ratio (A/V ratio) of retinal vessels in an outpatient setting. This study investigated the usability of fundoscopy for non-invasive ICP estimation with the addition of intraocular pressure (IOP) in patients in a neuro-intensive care unit (NICU). Methods: This single-center prospective cohort study was conducted at the NICU of Odense University Hospital from September 2020 to May 2021. Adult patients with a Glasgow Coma Score of 8 or less, who underwent invasive pressure neuromonitoring were included. Fundoscopy videos were captured daily and analyzed using deep learning algorithms. The A/V ratio was calculated and correlated with ICP. The data was analyzed using mixed-effect linear regression models. Results: Forty patients were enrolled. Fifteen were included in the final analysis. ICP ranged from -1 to 31 mmHg (mean: 10.9, SD: 5.7), and IOP ranged from 4 to 13 mmHg (mean: 7.4, SD: 2.1). The A/V ratio showed a significant negative correlation with ICP > 15 mmHg (regression slope: -0.0659, 95%-CI: [-0.0665;-0.0653], p < 0.001). No significant change in A/V ratio was observed for ICP ≤ 15 mmHg. A similar significant correlation was found for ICP > IOP (regression slope: -0.0055, 95%-CI: [-0.0062;-0.0048], p < 0.001). Taking the IOP into account did not improve the model. The sensitivity analysis showed a sensitivity of 80.08% and a specificity of 22.51%, with an AUC of 0.6389. Conclusion: In line with our previous work, non-invasive fundoscopy is a potential tool for detecting elevated ICP. However, challenges such as image quality and diagnostic specificity remains. Further research with larger, multi-center studies are needed to validate the utility. Standardization may enhance the technique's clinical applicability. [ABSTRACT FROM AUTHOR]

Detecting and monitoring elevated intracranial pressure (ICP) is crucial in managing various neurologic and neuro-ophthalmic conditions, where early detection is essential to prevent complications such as seizures and stroke. Although traditional methods such as lumbar puncture, intraparenchymal and intraventricular cannulation, and external ventricular drainage are effective, they are invasive and carry risks of infection and brain hemorrhage. This has prompted the development of non-invasive techniques. Given that direct, non-invasive access to the brain is limited, a significant portion of research has focused on utilizing the eyes, which uniquely provide direct access to their internal structure and offer a cost-effective tool for non-invasive ICP assessment. This review explores the existing non-invasive ocular techniques for assessing chronically elevated ICP. Additionally, to provide a comprehensive perspective on the current landscape, invasive techniques are also examined. The discussion extends to the limitations inherent to each technique and the prospective pathways for future advancements in the field. [ABSTRACT FROM AUTHOR]

Background and Purpose: Elevated intracranial pressure (ICP) resulting from severe head injury or stroke poses a risk of secondary brain injury that requires neurosurgical intervention. However, currently available noninvasive monitoring techniques for predicting ICP are not sufficiently advanced. We aimed to develop a minimally invasive ICP prediction model using simple CT images to prevent secondary brain injury caused by elevated ICP. Methods: We used the following three methods to determine the presence or absence of elevated ICP using midbrain‐level CT images: (1) a deep learning model created using the Python (PY) programming language; (2) a model based on cistern narrowing and scaling of brainstem deformities and presence of hydrocephalus, analyzed using the statistical tool Prediction One (PO); and (3) identification of ICP by senior residents (SRs). We compared the accuracy of the validation and test data using fivefold cross‐validation and visualized or quantified the areas of interest in the models. Results: The accuracy of the validation data for the PY, PO, and SR methods was 83.68% (83.42%‐85.13%), 85.71% (73.81%‐88.10%), and 66.67% (55.96%‐72.62%), respectively. Significant differences in accuracy were observed between the PY and SR methods. Test data accuracy was 77.27% (70.45%‐77.2%), 84.09% (75.00%‐85.23%), and 61.36% (56.82%‐68.18%), respectively. Conclusions: Overall, the outcomes suggest that these newly developed models may be valuable tools for the rapid and accurate detection of elevated ICP in clinical practice. These models can easily be applied to other sites, as a single CT image at the midbrain level can provide a highly accurate diagnosis. [ABSTRACT FROM AUTHOR]

Patients with acute brain injury (ACI) often require mechanical ventilation (MV) and are subject to pulmonary complications, thus justifying the use of Airway Clearance Techniques (ACTs), but their effects on intracranial pressure (ICP) are unknown. This study investigates the neurological and hemodynamics safety of an ACT called ventilator hyperinflation (VHI) in patients with ACI. This was a randomized clinical equivalence trial, which included patients aged ≥ 18 years with a clinical diagnosis of hemorrhagic stroke, with symptom onset within 48 h. The participants were randomly allocated to the Experimental Group (EG, n = 15), which underwent VHI followed by tracheal aspiration (TA), and the Control Group (CG, n = 15), which underwent TA only. Neurological safety was verified by analyzing the morphology of the ICP wave through the non-invasive B4C sensor, which detects bone deformation of the skull, resulting in a P2/P1 ratio and TTP, and hemodynamics through a multi-parameter monitor. Evaluations were recorded during five instances: T1 (baseline/pre-VHI), T2 (post-VHI and before TA), T3 (post-TA), T4 and T5 (monitoring 10 and 20 min after T3). The comparison between groups showed that there was no effect of the technique on the neurological variables with a mean P2/P1 ratio [F (4,112) = 1.871; p = 0.120; np2 = 0.063] and TTP [F (4,112) = 2.252; p = 0.068; np2 = 0.074], and for hemodynamics, heart rate [F (4,112) = 1.920; p = 0.112; np2 = 0.064] and mean arterial pressure [F(2.73, 76.57) = 0.799; p = 0.488; np2 = 0.028]. Our results showed that VHI did not pose a neurological or hemodynamics risk in neurocritical patients after ACI. [ABSTRACT FROM AUTHOR]

Objective: To determine sex differences in clinical profiles and treatment outcomes in patients with spontaneous intracranial hypotension. Background: Spontaneous intracranial hypotension is associated with considerable functional disability and potentially fatal complications, and it is uncertain whether males and females should be managed differently. Methods: This was a cohort study of consecutive patients with spontaneous intracranial hypotension enrolled from a medical center. Medical records and imaging findings were reviewed. The outcome of treatment responses to epidural blood patches and risks of subdural hematoma were measured. Results: In total, 442 patients with spontaneous intracranial hypotension (165 males, 277 females) were included in the analysis. Males were more likely to have a delayed (>30 days) initial presentation than females (32.1% [53/165] vs. 19.9% [55/277], p = 0.004), and males were less likely to have nausea (55.8% [92/165] vs. 67.1% [186/277], p = 0.016), vomiting (43.0% [71/165] vs. 54.2% [150/277], p = 0.024), photophobia (9.7% [16/165] vs. 17.0% [47/277], p = 0.034), and tinnitus (26.7% [44/165] vs. 39.7% [110/277], p = 0.005) compared with females despite comparable radiologic findings. Among the 374 patients treated with epidural blood patches, males were more likely to be nonresponders to the first epidural blood patch (58.0% [80/138] vs. 39.0% [92/236], OR = 2.2, 95% CI = 1.4–3.3, p < 0.001). Males were at a higher risk of having subdural hematoma (29.7% [49/165] vs. 10.8% [30/277], OR = 3.5, 95% CI = 2.1–5.8, p < 0.001). Among patients with subdural hematoma, males had greater thickness (12.8 ± 4.3 vs. 8.1 ± 5.9 mm, p < 0.001) and were more likely to receive surgical drainage (55.1% [27/49] vs. 10.0% [3/30], OR = 11.0, 95% CI = 3.0–41.3, p < 0.001) than females. Conclusion: In the present study, spontaneous intracranial hypotension in males was characterized by a delayed presentation, poorer response to the first epidural blood patch, and a higher risk of subdural hematoma. Caution should be exercised in the management of males with spontaneous intracranial hypotension. The generalizability of the findings needs to be further confirmed. Plain Language Summary: Spontaneous intracranial hypotension is associated with considerable functional disability and potentially fatal complications, and it is uncertain whether management of this condition should differ between males and females. In this large cohort of 442 patients with spontaneous intracranial hypotension, we found that males had a longer delay in presentation, poorer response to the first epidural blood patch, and higher risks for developing subdural hematoma and having surgical drainage compared to females. The findings suggest that spontaneous intracranial hypotension in males should be managed with great caution; more aggressive measures, such as early or multiple epidural blood patches, might be necessary. [ABSTRACT FROM AUTHOR]

Background: Traumatic brain injuries (TBIs) are one of the leading causes of death or long‐term disability around the world. As a result of improvements in supportive care, patients are surviving more severe insults with more pronounced dependency on their families, hospitals, and long‐term care facilities. The introduction of brain tissue oxygenation (PbtO2) monitoring aims to recognize episodes of reduced cerebral perfusion with and without associated increased intracranial pressure (ICP). Aim: The aim of this review is to determine the impact of PbtO2 on the Glasgow Outcome Scale/Glasgow Outcome Scale Extended (GOS/GOSE) in patients with moderate to severe TBI. Study Design: Systematic review with narrative and meta‐analysis. All original research in which adult patients undergoing PbtO2 were compared with a control group of traditional ICP/cerebral perfusion pressure (CPP) monitoring. Both randomized controlled trials and observational studies were included in this review. Methods: Databases were searched in September 2022. The primary outcome of the review was the impact of PbtO2 monitoring on GOS/GOSE, while secondary outcomes were mortality and length of stay (LOS) in the intensive care unit (ICU). Results: Seven studies with a combined number of 770 patients were included in the review. These patients were adults ≥16 years of age. Only two of the studies included found a statistically significant association between PbtO2 monitoring and improved long‐term neurological outcomes in patients with TBI (p =.01, p <.01). A meta‐analysis of the secondary outcomes identified an associated reduction of mortality in favour of the group treated with PbtO2 monitoring (p <.0001). Results from studies examining LOS in ICU have demonstrated an associated increase of LOS in ICU in patients treated with PbtO2‐guided therapy. Conclusion: From the studies included in this review, only two found a statistically significant association between PbtO2 monitoring and long‐term outcomes. It is unclear whether PbtO2 goal‐directed therapy has a positive impact on the long‐term neurological functions and mortality of patients suffering from TBI. A multicentre randomized controlled trial may provide further evidence, but not necessarily conclusive. Relevance to Clinical Practice: Further research is warranted to determine the efficacy of the introduction of this new monitoring system to guide local policy change. [ABSTRACT FROM AUTHOR]

Dural venous sinus stenting is an emerging and exciting area in otolaryngology in collaboration with neurosurgeons and neuroradiologists. The first cases were reported 20 years ago. It is now considered part of the routine treatment of increased intracranial pressure due to transverse sinus stenosis. ENT doctors are the first to see these patients in their clinics, as sinus headaches, pulsating tinnitus, and dizziness are the most common symptoms. Previously, with limited success, high-dose diuretics and intracranial shunts had been the only options for treating these patients. Other methods, such as covering the sigmoid sinuses with graft material, appear to cause a sudden increase in intracranial pressure that can lead to blindness and even death. This overview summarizes the clinical and imaging characteristics of patients who will benefit from endovascular sinus stenting for elevated intracranial pressure. [ABSTRACT FROM AUTHOR]

Subarachnoid hemorrhage (SAH) is a devastating type of stroke, leading to high mortality and morbidity rates. Cerebral vasospasm and delayed cerebral ischemia (DCI) are common complications following SAH that contribute significantly to the poor outcomes observed in these patients. Intrathecal (IT) nicardipine delivered via an existing external ventricular drain is an off‐label intervention that has been shown to be correlated with reduced DCI and improved patient outcomes. The current study aims to characterize the population pharmacokinetic (popPK) properties of intermittent IT nicardipine. Following informed consent, serial cerebrospinal fluid (CSF) samples were obtained from 16 SAH patients (50.4 ± 9.3 years old; 13 females) treated with IT nicardipine every 6 h (q6h, n = 8) or every 8 h (q8h, n = 8) for an average of 72 ± 21 doses. High‐performance liquid chromatography was used to quantify CSF concentration from each sample. Our popPK analysis showed that the CSF pharmacokinetics of IT nicardipine in the cohort was adequately described by a two‐compartment model with a lag time. Model parameter estimates were reliable (relative standard error <50%). Intracranial pressure influenced both the total clearance and the central volume of nicardipine (i.e., negative correlation, P <−.001). Calculated PK parameters were similar between q6h and q8h dosing regimens. Despite a small cohort of SAH patients, we successfully developed a popPK model to describe the nicardipine disposition kinetics in the CSF following IT administration. These findings may help inform future clinical trials designed to examine the optimal dosing of IT nicardipine. [ABSTRACT FROM AUTHOR]

Targeting single monitoring modalities such as intracranial pressure (ICP) or cerebral perfusion pressure alone has shown to be insufficient in improving outcome after traumatic brain injury (TBI). Multimodality monitoring (MMM) allows for a more complete description of brain function and for individualized management. Transcranial Doppler (TCD) represents the gold standard for continuous cerebral blood flow velocity assessment, but requires high levels skill and time. In TBI, the practical aspects of conducting extended TCD monitoring sessions have yet to be evaluated. Patients with acute moderate-to-severe TBI admitted to the neurocritical care unit between March 2022 and December 2023 receiving invasive ICP measurements were evaluated for inclusion. Exclusion criteria included trauma incompatible with TCD monitoring and if MMM was unwarranted. Daily MMM sessions (in addition to regular monitoring) were performed using TCD (Delica EMS 9D System or the DWL Doppler Box) for ≤5 d. Quantitative and qualitative feasibility, safety, and quality metrics were assessed. Of 74 patients, 36 (75% male; mean age, 44 ± 17 y) were included. Common reasons for exclusion were skull fractures (n = 12) and decompressive craniectomy (n = 9). We acquired 88 recordings (mean, 275 ± 88 min). Overall monitoring times increased, and set-up times decreased. Physiologic variables (including ICP/brain temperature) did not change with TCD application. A single adverse event (dislodging of a microdialysis catheter) occurred. Implementing extended TCD monitoring in MMM protocols is feasible and safe. Considering these results, inclusion of long-term TCD as part of the MMM is strongly encouraged to allow for in-depth description and direct evaluation of hemodynamic changes after TBI. [ABSTRACT FROM AUTHOR]

Background Patients with cancer often experience nausea. In some cases, a specific cause such as chemotherapeutic adverse effects, raised intracranial pressure or malignant bowel obstruction is identified. In other cases, no specific cause is apparent. Objective This article summarises the evidencebased management of nausea in advanced cancer. It includes the nausea of select, specific contexts such as raised intracranial pressure and bowel obstruction. Discussion It is not commonly appreciated that lowdose oral haloperidol is the standard of care arm for many trials looking to reduce nausea in advanced cancer. It is available cheaply through the Pharmaceutical Benefits Scheme. The relative merits of other medications are discussed, as are the merits of an empiric versus a mechanistic approach to treatment. [ABSTRACT FROM AUTHOR]

Introduction: Colloid cysts are rare intracranial tumors that can cause obstructive hydrocephalus, a potentially life-threatening condition. Despite being typically benign, they often present with insidious symptoms, leading to delayed diagnosis and catastrophic outcomes. Case Report: A 29-year-old woman presented with a two-month history of worsening headaches, nausea, and vomiting. Neuroimaging revealed a colloid cyst obstructing the third ventricle, resulting in hydrocephalus. Despite emergency placement of an external ventricular drain, the patient's neurological condition deteriorated rapidly, culminating in brain death. Conclusions: This case highlights the critical importance of the early diagnosis and aggressive management of colloid cyst-induced hydrocephalus. The rapid progression of symptoms and devastating outcomes underscore the need for increased awareness among healthcare providers. Given the high mortality associated with this condition, further research is warranted to identify predictive factors and develop effective treatment strategies. [ABSTRACT FROM AUTHOR]

The article discusses a case of thyroid storm in a 7-year-old girl with transient central diabetes insipidus. The girl presented with seizures, fever, and other symptoms, leading to a diagnosis of Graves' disease. Treatment with anti-thyroid drugs, iodine solution, and other medications led to improvement. The case highlights the importance of considering rare diagnoses like thyroid storm in critically ill children and the need for prompt diagnosis and aggressive treatment. Additionally, it is the first pediatric case report of the association between Graves' disease and transient central diabetes insipidus. [Extracted from the article]

Background Aim Study design Results Conclusion Relevance to Clinical Practice Early mobilization are key components of the ABCDEF Care Bundle and critical treatments to reduce acquired muscle weakness, delirium and prolonged intensive care unit (ICU) stay.This study aimed to determine whether routine early mobilization related to intracranial pressure in intensive care patients on mechanical ventilation, using optic nerve sheath diameter measurement (ONSD).This study was planned as a prospective, cohort study in the third‐step adult ICU of a faculty hospital. The study included only patients who were intubated and followed up on a mechanical ventilator and were clinically stable. Passive range of motion (PROM) exercises were performed daily by the physiotherapists as part of routine care from the day of hospitalization. ONSD was assessed before, during and 10 min after PROM exercises.The study included 20 eligible patients out of the 142 who were evaluated upon admission to the ICU. The median age of the patients was 65 years, and nine (45%) of them were female. The analyses showed that there was no statistically significant change in ONSD during and at the end of the PROM (ONSD right eye p:.621, Partial η2: 0.025, ONSD left eye p:.935, Partial η2: 0.004). Similarly, there was no statistically significant change in haemodynamic parameters in during and at the end of the PROM (Heart beat p:.849, Partial η2: 0.009, Systolic Pressure p:.435, Partial η2: 0.043, Diastolic Pressure p:.128, Partial η2:0.103, Saturation p:.103, Partial η2: 0.113 and Respiratory rate p:.071, Partial η2:0.130).This study suggests that daily extremity physiotherapy exercises can be safely applied without causing increased intracranial pressure or haemodynamic instability in intensive care patients followed up on mechanical ventilation, including patients with vasopressor therapy.Early mobilization, including PROM, is considered safe in terms of intracranial pressure for intubated patients in the ICU. [ABSTRACT FROM AUTHOR]

Background: Tuberculous meningitis (TBM) with adults Epstein-Barr (EB) virus encephalitis is a very rare infectious disease, with a high mortality and disability. Metagenomic next-generation sequencing (mNGS) of cerebrospinal fluid (CSF) is highly diagnostic. We report on a case of severe meningoencephalitis caused by coinfection with mycobacterium tuberculosis and EB virus. Brain MRI indicated a parenchyma lesion in the brain. mNGS of CSF indicated Mycobacterium tuberculosis and EB virus amplification, positive serum EB virus IgG antibodies, and improved symptoms after anti-tuberculosis and antiviral treatment. A reexamination of the brainMRI revealed that the significantly absorption of the lesions. Case report: A 49-year-old male patient presented with a chief complaint of headache and fever with consciousness disturbance. The brain magnetic resonance imaging showed a lesions in the right parenchymal brain with uneven enhancement, accompanied by significantly increased intracranial pressure, elevated CSF cell count and protein levels, as well as notably decreased glucose and chloride levels. mNGS of CSF showed the coexistence of Mycobacterium tuberculosis and EBV. The patient was diagnosed as TBM with EBV encephalitis. The patient's symptoms gradually improved with the active administration of anti-tuberculosis combined with antiviral agents, the use of hormones to reduce inflammatory reaction, dehydration to lower intracranial pressure, and intrathecal injection. Subsequent follow-up brain magnetic resonance imaging indicated significant absorption of the lesions, along with a marked decrease in CSF count and protein levels, as well as obvious increase in glucose and chloride levels. Conclusion: TBM associated with adult EBV encephalitis is extremely rare. The disease's early stages are severe and have a high fatality rate. A prompt and accurate diagnosis is particularly important. NGS of CSF is of great value for early diagnosis. [ABSTRACT FROM AUTHOR]

Key points Spontaneous cerebrospinal fluid rhinorrhea (sCSFR) is often accompanied by an increase in intracranial pressure (ICP). The widening of optic nerve sheath diameter (ONSD) is an indicator of increased ICP. Using CT to measure ONSD is a simple and noninvasive auxiliary method for determining high ICP in sCSFR patients. Spontaneous cerebrospinal fluid rhinorrhea (sCSFR) is often accompanied by an increase in intracranial pressure (ICP).The widening of optic nerve sheath diameter (ONSD) is an indicator of increased ICP.Using CT to measure ONSD is a simple and noninvasive auxiliary method for determining high ICP in sCSFR patients. [ABSTRACT FROM AUTHOR]

Background: Increased intracranial pressure (ICP) in patients with idiopathic intracranial hypertension (IIH) affects the retinal microvasculature, which can be imaged and quantified by optical coherence tomography angiography (OCTA). We aimed to identify the mediating factor between ICP and OCTA parameters association in IIH patients. Methods: IIH patients with active intracranial hypertension were enrolled. OCTA imaging was performed after ICP measurement. We quantified the branching complexity of the retinal arterioles and venules from the superficial vascular complex of the OCTA image. Eyes of IIH patients were stratified into eyes with papilledema (IIH-P) and eyes without papilledema (IIH-WP). All participants underwent visual acuity (VA) examination. Results: One hundred and thirty-eight eyes from 70 IIH patients and 146 eyes from 73 controls were included. Compared to the control group, IIH patients and IIH-P had reduced arteriole complexity and increased venule complexity (p < 0.05). For IIH patients and IIH-P, increased retinal venule complexity correlated with increased ICP and reduced VA (p < 0.05); while decreased arteriole complexity only correlated with Frisen scores (p = 0.026). Papilledema mediated the effect (p < 0.001) between ICP and arteriole complexity while ICP had a direct effect (p < 0.001) on venule complexity. Conclusion: Retinal venules imaged via OCTA may reflect ICP levels and may underpin the direct effect of increased ICP in IIH patients. [ABSTRACT FROM AUTHOR]

Background: Hyperthermia is strongly associated with a worse neurological outcome in traumatic brain injury (TBI) and can be exacerbated by shivering. However, effective treatments for uncontrolled shivering have yet to be established. We successfully treated a patient with severe TBI and repeated episodes of shivering using dantrolene sodium hydrate (dantrolene). Case Report: A 28-year-old healthy male sustained an acute subdural hematoma with a midline shift following a traffic accident. He underwent emergency evacuation of the hematoma and craniectomy and was admitted to the Intensive Care Unit. The patient experienced severe shivering on the first day of hospitalization. Neuroprotective drugs were administered, and targeted temperature management at normothermia was initiated, initially controlling the shivering. On day 9 of hospitalization, shivering recurred, with a high fever. Despite the reintroduction of general anesthesia and targeted temperature management, the shivering was intractable. We administered dantrolene, which successfully eliminated the shivering. After the intervention, the patient's body temperature and intracranial pressure were well managed. The patient was subsequently transferred to a rehabilitation hospital, with a favorable neurological outcome 70 days after the injury. Conclusions: This case report demonstrates that dantrolene is an effective option for managing uncontrollable shivering in the context of intracranial pressure control after severe brain injury. This finding suggests the potential for the broader use of dantrolene in similar clinical scenarios and supports further investigation of its efficacy and mechanisms of action in TBI care. [ABSTRACT FROM AUTHOR]

Background: Infusion testing is an established method for assessing CSF resistance in patients with idiopathic normal pressure hydrocephalus (iNPH). To what extent the increased resistance is related to the glymphatic system is an open question. Here we introduce a computational model that includes the glymphatic system and enables us to determine the importance of (1) brain geometry, (2) intracranial pressure, and (3) physiological parameters on the outcome of and response to an infusion test. Methods: We implemented a seven-compartment multiple network porous medium model with subject specific geometries from MR images using the finite element library FEniCS. The model consists of the arterial, capillary and venous blood vessels, their corresponding perivascular spaces, and the extracellular space (ECS). Both subject specific brain geometries and subject specific infusion tests were used in the modeling of both healthy adults and iNPH patients. Furthermore, we performed a systematic study of the effect of variations in model parameters. Results: Both the iNPH group and the control group reached a similar steady state solution when subject specific geometries under identical boundary conditions was used in simulation. The difference in terms of average fluid pressure and velocity between the iNPH and control groups, was found to be less than 6% during all stages of infusion in all compartments. With subject specific boundary conditions, the largest computed difference was a 75% greater fluid speed in the arterial perivascular space (PVS) in the iNPH group compared to the control group. Changes to material parameters changed fluid speeds by several orders of magnitude in some scenarios. A considerable amount of the CSF pass through the glymphatic pathway in our models during infusion, i.e., 28% and 38% in the healthy and iNPH patients, respectively. Conclusions: Using computational models, we have found the relative importance of subject specific geometries to be less important than individual differences in resistance as measured with infusion tests and model parameters such as permeability, in determining the computed pressure and flow during infusion. Model parameters are uncertain, but certain variations have large impact on the simulation results. The computations resulted in a considerable amount of the infused volume passing through the brain either through the perivascular spaces or the extracellular space. [ABSTRACT FROM AUTHOR]

Introduction: Septic shock, a life-threatening condition, can result in cerebral dysfunction and heightened mortality rates. In these patients, disturbances in cerebral hemodynamics, as reflected by impairment of myogenic cerebral autoregulation (CA), metabolic regulation, expressed by critical closing pressure (CrCP) and reductions in intracranial compliance (ICC), can adversely impact septic shock outcomes. The general recommendation is to maintain a target mean arterial pressure (MAP) of 65 mmHg but the effect of different MAP targets on cerebral hemodynamics in these patients is not clear and optimal targets might be dependent on the status of CA. This protocol aims to assess the cerebral hemodynamics profile at different pressure targets in septic shock patients. Methods: Prospective, non-randomized, single-center trial, which will study cerebral hemodynamics in patients with septic shock within 48 hours of its onset. Patients will be studied at their baseline MAP and at three MAP targets (T1: 65, T2: 75, T3: 85 mmHg). Cerebral hemodynamics will be assessed by transcranial Doppler (TCD) and a skull micro-deformation sensor (B4C). Dynamic CA will be expressed by the autoregulation index (ARI), calculated by transfer function analysis, using fluctuations of MAP as input and corresponding oscillations in cerebral blood velocity (CBv). The instantaneous relationship between arterial blood pressure and CBv will be used to estimate CrCP and resistance-area product (RAP) for each cardiac cycle using the first harmonic method. The B4C will access ICC by intracranial pressure waveforms (P2/P1). The primary aim is to assess cerebral hemodynamics (ARI, CrCP, RAP, and P2/P1) at different targets of MAP in septic shock patients. Our secondary objective is to assess cerebral hemodynamics at 65mmHg (target recommended by guidelines). In addition, we will assess the correlation between markers of organ dysfunction (such as lactate levels, vasoactive drugs usage, SOFA score, and delirium) and CA. Ethics and dissemination: The results of this study may help to understand the effect of the recommended MAP and variations in blood pressure in patients with septic shock and impaired CA and ICC. Furthermore, the results can assist large trials in establishing new hypotheses about neurological management in this group of patients. Approval was obtained from the local Ethics Committee (28134720.1.0000.0048). It is anticipated that the results of this study will be presented at national and international conferences and will be published in peer-reviewed journals in 2024 and 2025. Trial registration: Trial registration number:NCT05833607. https://clinicaltrials.gov/study/NCT05833607. [ABSTRACT FROM AUTHOR]

Background: Cerebral venous sinus thrombosis (CVST) is a rare but potentially life-threatening subtype of stroke. Prompt and appropriate anticoagulation is crucial for improving the prognosis of CVST and preventing its recurrence. Identifying the underlying cause of CVST is decisive for guiding anticoagulant selection and determining treatment duration. Case Presentation: A 50-year-old man presented with a 35-day history of headache, nausea, vomiting, and blurred vision. Digital subtraction angiography performed at another facility revealed CVST. A contrast-enhanced black-blood MRI at our center confirmed the diagnosis, which was supported by a high intracranial pressure of 330mmH2O. Laboratory tests showed elevated leukocytes and platelet counts, raising suspicion of an underlying myeloproliferative neoplasms (MPNs). A bone marrow biopsy demonstrated increased megakaryocytes and granulocytes, and genetic testing identified the presence of the Janus kinase 2 V617F (JAK2 V617F) mutation, leading to a diagnosis of pre-primary myelofibrosis (pre-PMF). During hospitalization, anticoagulation with nadroparin calcium and fibrinolytic therapy were initiated. Upon discharge, rivaroxaban and aspirin were prescribed to prevent CVST recurrence and arterial thrombosis. Conclusion: This case highlights the importance of recognizing dynamic changes in routine blood tests that may link CVST to underlying hematological disorders. The JAK2 mutation is not only associated with MPNs but also increases the risk of thrombosis, including CVST. Further investigation is warranted to better understand the mechanisms by which JAK2 mutations contribute to thrombosis and to explore the potential benefits of JAK2 inhibitors in reducing this risk. [ABSTRACT FROM AUTHOR]

Patients with acute brain injury are vulnerable to secondary deterioration, which may go undetected by traditional monitoring. However, multimodal neuromonitoring of brain tissue oxygen tension (PbtO2) and energy metabolism may be able to detect such episodes. We report a retrospective, observational study of 94 patients with aneurysmal subarachnoid haemorrhage (SAH) or traumatic brain injury (TBI) who underwent multimodal neuromonitoring during admission. We examined the co-occurrence of pathological neuromonitoring values: elevated intracranial pressure (ICP, > 20 mmHg), inadequate cerebral perfusion pressure (CPP, < 60 mmHg), brain hypoxia (PbtO2 < 20 mmHg), and metabolic crisis (lactate/pyruvate ratio > 40 and a glucose level < 0.2 mmol/L in cerebral microdialysate). Mixed effects linear regression demonstrated significant associations between abnormal ICP/CPP, cerebral hypoxia and metabolic crisis. However, brain hypoxia occurred in 40% and 31% of observations in patients with SAH and TBI, respectively, despite normal concurrent values of ICP. Similarly, metabolic crisis was observed in 8% and 16% of measurements for SAH and TBI, respectively, despite a normal ICP. The pattern was identical for CPP. In conclusion, although all neuromonitoring variables are interrelated, brain hypoxia and metabolic crisis are common despite an absence of abnormalities in conventional monitoring. Multimodal neuromonitoring may help identify such episodes and guide individualised treatment. [ABSTRACT FROM AUTHOR]

Patients with traumatic brain injury (TBI) frequently exhibit concomitant immunosuppression. In this study, we evaluated the predictive values of soluble programmed death-1 (sPD-1) and soluble programmed death ligand-1 (sPD-L1) in patients with severe TBI. Peripheral blood sPD-1 and sPD-L1 levels were measured within 48 h of patient admission. A total of 20 healthy volunteers and 82 patients were enrolled in this study. The levels of sPD-1 and sPD-L1 were upregulated in patients with severe TBI (P < 0.001). They were significantly increased in the post-TBI severe pneumonia group and among non-survivors (P < 0.001). The area under the curves (AUCs) for sPD-1 and sPD-L1 levels to predict severe pneumonia were 0.714 and 0.696, respectively, and the AUCs to predict mortality were 0.758 and 0.735. The levels of sPD-1 and sPD-L1 are correlated with the GCS scores at admission, APACHE II scores, length of MV, and time elapsed to mortality. The levels of sPD-1 and sPD-L1 emerged as independent predictive factors for severe pneumonia and mortality. This study demonstrates that upregulation of sPD-1 and sPD-L1 in severe TBI patients is significantly associated with severe pneumonia and mortality, suggesting their potential as predictive biomarkers for these outcomes. [ABSTRACT FROM AUTHOR]

The cerebral blood flow, CBF, is an important clinical parameter in neuro-intensive care. The possibility to continuously monitor CBF, computed from referential ICP, rICP (calculated from measured intracranial pressure, ICP, and central venous pressure, CVP) and venous outflow resistance, Rv, could importantly improve patient care. For the CBF(1) method the pulsative part of CBF (with rICP increase due to vascular volume increase) gives the venous outflow resistance, Rv. The CBF max method finds Rv from the close correlation between rICP and Rv. For both CBF(1) and CBF max, rICP divided with Rv gives CBF. The parameters rICP, Rv and CBF were calculated from measurements of ICP increase, and of intracerebral venous volume increase in nine subjects, by the CBF(1) method. The result, together with the finding of a close correlation between rICP and Rv, which made CBF dependent on rICP only, gave confirmation of the theory for computation of CBF, with two methods for continuous monitoring of CBF from rICP, one (CBF(1)) using the systolic ICP increase to find Rv, and one (CBF max) using the relationship between Rv and rICP at rICP exceeding about 10 mmHg in this study. [ABSTRACT FROM AUTHOR]

Endovascular treatment has been acknowledged as an effective treatment for intracranial aneurysms, showcasing favorable clinical outcomes and providing robust protection against rebleeding and rupture. Notably, during the endovascular procedure, significant complications include intraprocedural aneurysmal rupture (IAR) induced by microcatheters, microguidewires, or spring coils, along with thromboembolic events, significantly escalating patient mortality and disability. Current approaches against for IARs involve various strategies such as heparin reversal, compression of the common carotid artery or upstream soft guidewire to mitigate blood flow, management of intracranial pressure and blood pressure, and balloon-assisted or unassisted rapid dense embolization of the aneurysm. Nevertheless, these measures may prove insufficient in halting hemorrhage, especially in scenarios where additional coils cannot be added for dense embolization due to inherent limitations. In this context, we introduce a novel strategy for the prompt, safe, and effective cessation of aneurysm bleeding, which involves injecting an appropriate quantity of Onyx into the aneurysm through a microcatheter while safeguarded by an aneurysm-carrying arterial braided stent. Initially, we attempted dense embolization by filling multiple coils. However, in cases where continued coil filling proved unfeasible or failed to sufficiently prevent contrast agent extravasation, we opted for Onyx injection into the aneurysm. Utilizing Onyx effectively prevented further blood extravasation without adversely impacting the aneurysm-carrying artery or distal vessels, leading to favorable prognoses for all patients. This article delineates our embolization strategy, highlighting the efficacy and safety of Onyx injection as an alternative or complementary measure in managing complications arising from endovascular coil embolization. [ABSTRACT FROM AUTHOR]

Background: Preeclampsia is implicated in 14% of maternal deaths worldwide, mostly due to complications such as intracranial hemorrhage and cerebral edema. Cerebral edema increases intracranial pressure, which can be predicted by ultrasonographic measurement of the optic nerve sheath diameter (ONSD). Greater diameters have been reported in women with preeclampsia and eclampsia; however, data are lacking on the possible association with maternal and neonatal adverse outcomes. This study aimed to determine whether there is an association between hypertensive disorders of pregnancy and the ONSD, and between this measurement and maternal and neonatal adverse outcomes. Methods: This was a cohort study involving 183 women in the third trimester of pregnancy or within 24 h following childbirth, distributed as follows: control group (n = 30), gestational hypertension (n = 14), chronic hypertension (n = 12), preeclampsia without severe features (n = 12), preeclampsia with severe features (n = 62), superimposed preeclampsia (n = 23) and eclampsia (n = 30). The participants underwent ocular ultrasonography, and data on maternal and neonatal outcomes were collected from the medical records. To compare the groups, analysis of variance was used for the normally distributed numerical variables and the Kruskal–Wallis test was used for variables with non-normal distribution. Two-tailed p-values ≤ 0.05 were considered statistically significant. Results: Overall comparison between the seven groups showed no statistically significant difference in the mean ONSD (p = 0.056). Nevertheless, diameters were significantly greater in the eclampsia group compared to the control group (p = 0.003). Greater diameters were associated with maternal admission to the intensive care unit (ICU) (p < 0.01) and maternal near miss (p = 0.01). There was no association between ONSD and admission to the neonatal ICU (p = 0.1), neonatal near miss (p = 0.34) or neonatal death (p = 0.26). Conclusions: No association was found between ONSD and the hypertensive disorders of pregnancy in the overall analysis; however, ONSD was greater in women with eclampsia compared to controls. Greater diameters were associated with maternal admission to the ICU and maternal near miss. These findings suggest a potential use for bedside ultrasound as an additional tool for stratifying risk in patients with hypertensive disorders of pregnancy. [ABSTRACT FROM AUTHOR]

Intracranial pressure (ICP) is a physiological parameter that conventionally requires invasive monitoring for accurate measurement. Utilising multivariate predictive models, we sought to evaluate the utility of non-invasive, widely accessible MRI biomarkers in predicting ICP and their reversibility following cerebrospinal fluid (CSF) diversion. The retrospective study included 325 adult patients with suspected CSF dynamic disorders who underwent brain MRI scans within three months of elective 24-h ICP monitoring. Five MRI biomarkers were assessed: Yuh sella grade, optic nerve vertical tortuosity (VT), optic nerve sheath distension, posterior globe flattening and optic disc protrusion (ODP). The association between individual biomarkers and 24-h ICP was examined and reversibility of each following CSF diversion was assessed. Multivariate models incorporating these radiological biomarkers were utilised to predict 24-h median intracranial pressure. All five biomarkers were significantly associated with median 24-h ICP (p < 0.0001). Using a pair-wise approach, the presence of each abnormal biomarker was significantly associated with higher median 24-h ICP (p < 0.0001). On multivariate analysis, ICP was significantly and positively associated with Yuh sella grade (p < 0.0001), VT (p < 0.0001) and ODP (p = 0.003), after accounting for age and suspected diagnosis. The Bayesian multiple linear regression model predicted 24-h median ICP with a mean absolute error of 2.71 mmHg. Following CSF diversion, we found pituitary sella grade to show significant pairwise reversibility (p < 0.001). ICP was predicted with clinically useful precision utilising a compact Bayesian model, offering an easily interpretable tool using non-invasive MRI data. Brain MRI biomarkers are anticipated to play a more significant role in the screening, triaging, and referral of patients with suspected CSF dynamic disorders. [ABSTRACT FROM AUTHOR]

• The FROUNT inhibitor, Disulfiram, suppressed inflammatory cell infiltration. • Disulfiram suppressed microglia activation after subarachnoid hemorrhage in animals. • Disulfiram suppressed the death after experimental subarachnoid hemorrhage. • Disulfiram prevented the neuronal death after experimental subarachnoid hemorrhage. • Disulfiram prevented the vasospasm after experimental subarachnoid haemorrhage. Subarachnoid hemorrhage due to rupture of intracranial aneurysms has a poor outcome, making this disease being the social problem. Inflammation evoked by the increase in intracranial pressure and the clot in the subarachnoid space after the onset of SAH exacerbates neuronal death and vasospasm, resulting in the poor outcome and severe aftereffects. Here, FROUNT mediates CCR2 and CCR5 signaling as an intracellular molecule binding to these chemoattractant receptors which facilitate the migration of inflammatory cells, such as macrophages, in situ to trigger inflammation there. Animal model of subarachnoid hemorrhage was established in rats through intrathecal injection of autologous blood. The effect of the FROUNT inhibitor, disulfiram, on survival rate, neuronal death in hippocampus or vasospasm was then examined. The intrathecal administration of disulfiram significantly suppressed the infiltration of CD68-positive macrophages and myeloperoxidase-positive neutrophils toward the clot in the cistern in situ. In this condition, disulfiram ameliorated the death of animals after the onset of subarachnoid hemorrhage in rats. In addition, disulfiram suppressed both the two major events after subarachnoid hemorrhage, the neuronal death in hippocampus and vasospasm. The pharmacological inhibition of CCR2 and CCR5 signaling by disulfiram could thus be the therapeutic strategy to improve the outcome of subarachnoid hemorrhage. [ABSTRACT FROM AUTHOR]

For many years, noninvasive methods to measure intracranial pressure (ICP) have been unsuccessful. However, such methods are crucial for the assessment of patients with nonpenetrating traumatic brain injuries (TBIs) who are unconscious. In this study, we explored the use of transcranial transmission ultrasound (TTUS) to gather experimental data through brain pulsatility, assessing its effectiveness in detecting high ICP using machine learning analysis. We included patients with severe TBI under invasive ICP monitoring in our intensive care unit. During periods of both normal and elevated ICP, we simultaneously recorded ICP, arterial blood pressure, heart rate, and TTUS measurements. Our classification model was based on data from 9 patients, encompassing 387 instances of elevated ICP (>15 mmHg) and 345 instances of normal ICP (<10 mmHg), and validated through a leave-one-subject-out method. The study, conducted from October 2021 to October 2022, involved 25 patients with an average age of 61.6 ± 17.6 years, producing 279 datasets with an average ICP of 11.3 mmHg (1st quartile 6.1 mmHg; 3rd quartile 14.8 mmHg). The automated TTUS analysis effectively identified ICP values over 15 mmHg with 100% sensitivity and 47% specificity. It achieved a 100% negative predictive value and a 14% positive predictive value. This suggests that TTUS can accurately rule out high ICP above 15 mmHg in TBI patients, indicating patients who may need immediate imaging or intervention. These promising results, if confirmed and expanded in larger studies, could lead to the first reliable, noninvasive screening tool for detecting elevated ICP. [ABSTRACT FROM AUTHOR]

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Randomized controlled trials (RCTs) are the cornerstone to evaluate the efficacy of an intervention. To assess the methodology of clinical research, we performed a systematic review that evaluated the different outcomes used in RCTs targeting the early phase of moderate-to-severe adult TBI from 1983 to October 31, 2023. We extracted each outcome and organized them according to the COMET and OMERACT framework (core area, broad domains, target domains, and finally outcomes). A total of 190 RCTs were included, including 52,010 participants. A total of 557 outcomes were reported and classified between the following core areas: pathophysiological manifestations [169 RCTs (88.9%)], life impact [117 RCTs (61.6%)], death [94 RCTs (49.5%)], resource use [72 RCTs (37.9%)], and adverse events [41 RCTs (21.6%)]. We identified 29 broad domains and 89 target domains. Among target domains, physical functioning [111 (58.4%)], mortality [94 (49.5%)], intracranial pressure target domain [68 (35.8%)], and hemodynamics [53 (27.9%)] were the most frequent. Outcomes were mostly clinician-reported [177 (93.2%)], while patient-reported outcomes were rarely reported [11 (5.8%)]. In our review, there was significant heterogeneity in the choice of end-points in TBI clinical research. There is an urgent need for consensus and homogeneity to improve the quality of clinical research in this area. [ABSTRACT FROM AUTHOR]

Following ischemic stroke, substance P (SP)-mediated neurogenic inflammation is associated with profound blood-brain barrier (BBB) dysfunction, cerebral edema, and elevated intracranial pressure (ICP). SP elicits its effects by binding the neurokinin 1 tachykinin receptor (NK1-R), with administration of an NK1-R antagonist shown to ameliorate BBB dysfunction and cerebral edema in rodent and permanent ovine stroke models. Given the importance of reperfusion in clinical stroke, this study examined the efficacy of NK1-R antagonist treatment in reducing cerebral edema and ICP in an ovine model of transient middle cerebral artery occlusion (tMCAo). Anesthetized sheep (n = 24) were subject to 2-hours tMCAo and randomized (n = 6/group) to receive early NK1-R treatment (days 1–3 post-stroke), delayed NK1-R treatment (day 5 post-stroke), or saline vehicle. At 6-days post-stroke animals were re-anaesthetized and ICP measured, followed by MRI to evaluate infarction, edema and BBB dysfunction. Following both early and delayed NK1-R antagonist administration, ICP was significantly reduced on day 6 compared to vehicle animals (p < 0.05), accompanied by a reduction in cerebral edema, midline shift and BBB dysfunction (p < 0.05). This study demonstrates that NK1-R antagonist treatment is an effective novel therapy for cerebral edema and elevated ICP following stroke in an ovine model, warranting future clinical evaluation. [ABSTRACT FROM AUTHOR]

Detecting increased intracranial pressure early in pediatric patients is essential, as early initiation of therapy prevents morbidity and mortality. The objective of this study was to determine the diagnostic accuracy of the optic nerve sheath diameter (ONSD) measured via ultrasound for the prediction of increased intracranial pressure. Four databases, namely, PubMed, EMBASE, Scopus, and CINAHL, were searched for this systematic review and meta-analysis. The study's predefined inclusion criteria considered diagnostic accuracy, cross-sectional, prospective observational, and retrospective studies with a focus on children with elevated intracranial pressure from causes such as traumatic brain injury and cerebral edema, the diagnostic accuracy of the optic nerve sheath diameter measured using ultrasound was assessed. The primary outcome measures included sensitivity and specificity. The study included invasive monitoring (external ventricular drain) and noninvasive measures as the gold standards for increased intracranial pressure. Two authors extracted and reviewed the data. Baseline data, outcome measures, and diagnostic accuracy data were extracted. Twenty-five studies with 1591 patients and 3143 ONSD measurements via ultrasound were analyzed. The pooled sensitivity and specificity of the ONSD measured via ultrasound for the prediction of increased intracranial pressure were 92% (86%–96%) and 89% (77%–96%), respectively. The pooled positive and negative likelihood ratios were 8.6 and 0.08, respectively. Optic nerve ultrasonography stands out as a precise and valuable diagnostic tool applicable across diverse patient populations and clinical scenarios. We recommend routine ocular ultrasound for optic nerve sheath diameter measurement in pediatric patients to increase the accuracy of diagnosing increased intracranial pressure. [ABSTRACT FROM AUTHOR]

Extracranial complications occur commonly in patients with traumatic brain injury (TBI) and can have implications for patient outcome. Patient-specific risk factors for developing these complications are not well studied, particularly in low and middle-income countries (LMIC). The study objective was to determine patient-specific risk factors for development of extracranial complications in TBI. We assessed the relationship between patient demographic and injury factors and incidence of extracranial complications using data collected September 2008-October 2011 from the BEST TRIP trial, a randomized controlled trial assessing TBI management protocolized on intracranial pressure (ICP) monitoring versus imaging and clinical exam, and a companion observational patient cohort. Extracranial infections (55%), respiratory complications (19%), hyponatremia (27%), hypernatremia (27%), hospital acquired pressure ulcers (6%), coagulopathy (9%), cardiac arrest (10%), and shock (5%) occurred at a rate of ≥5% in our study population; overall combined rate of these complications was 82.3%. Tracheostomy in the intensive care unit (P < 0.001), tracheostomy timing (P = 0.025), mannitol and hypertonic saline doses (P < 0.001), brain-specific therapy days and brain-specific therapy intensity (P < 0.001), extracranial surgery (P < 0.001), and neuroworsening with pupil asymmetry (P = 0.038) were all significantly related to the development of one of these complications by univariable analysis. Multivariable analysis revealed ICP monitor use and brain-specific therapy intensity to be the most common factors associated with individual complications. Extracranial complications are common following TBI. ICP monitoring and treatment are related to extra-cranial complications. This supports the need for reassessing the risk-benefit balance of our current management approaches in the interest of improving outcome. [ABSTRACT FROM AUTHOR]

The use of invasive or noninvasive intracranial pressure (ICP) monitoring post-decompressive craniectomy (DC) has been a continuous matter of debate. Accordingly, this meta-analysis aims to examine the existing evidence of both approaches and compare their impact among patients undergoing DC, guiding clinical decision-making in the management of elevated ICP. The databases used were Pubmed, Cochrane, Web of Science, and Embase. Inclusion criteria included: (1) English studies; (2) randomized and nonrandomized studies; (3) reporting on invasive OR noninvasive ICP monitoring after DC; (4) with at least one of the outcomes of interest: incidence of mortality, new cerebral hemorrhages, and the Glasgow Outcome Scale. The study followed the Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Thirty-six studies were included in this meta-analysis, resulting in a sample of 1624 patients. One thousand two hundred eighty-six underwent invasive monitoring, and 338 underwent noninvasive methods. In the invasive group, a mortality rate of 17% (95% confidence interval [CI]: 12%–22%), a good outcome rate of 58% (95% CI: 38%–49%), a poor outcome rate of 42% (95% CI: 21%–62%), and an overall incidence of new hemorrhages of 4% (95% CI: 0%–8%) were found. Whereas in the noninvasive sample, a mortality rate of 20% (95% CI: 15%–26%) and a good outcome rate of 38% (95% CI: 25%–52%) were obtained. It seems that the effectiveness of invasive and noninvasive ICP monitoring methods are comparable in post-DC patients. While invasive monitoring remains gold standard, noninvasive methods offer a safer and cost-effective alternative, potentially improving post-DC patient care, and can mostly be used simultaneously with invasive methods. [ABSTRACT FROM AUTHOR]

Objective: This study is aimed at identifying the most common drugs associated with the risk of intracranial pressure increase (IPI) based on the US Food and Drug Administration Adverse Event Reporting System (FAERS) database. Methods: OpenVigil 2.1 was used to query the FAERS database and data from the first quarter of 2004 to the third quarter of 2022 were retrieved. Pharmacovigilance tools were employed for the quantitative detection of signals, where a signal represents a drug‐induced adverse event, including the reporting odds ratio (ROR > 1 with 95% confidence interval, the reports number ≥ 2) and proportional reporting ratio (PRR > 2, χ2 ≥ 4). Results: Among the 12,060,031 adverse event reports, there were 3113 cases in which drugs were the primary suspect cause of IPI. Drug‐induced intracranial pressure increase (DIPI) was more often observed in young females. The Top 5 drugs with the highest ROR and PRR were minocycline, doxycycline, acetazolamide, somatropin recombinant, and cytarabine. Conclusion: Potential risks of DIPI should be closely monitored in clinical practice. Our study is consistent with clinical observations, which call for further research to establish the basis of these drugs and IPI. [ABSTRACT FROM AUTHOR]

Hydrocephalus, characterized by progressive expansion of the CSF-filled ventricles (ventriculomegaly), is the most common reason for brain surgery. 'Communicating' (i.e. non-obstructive) hydrocephalus is classically attributed to a primary derangement in CSF homeostasis, such as choroid plexus-dependent CSF hypersecretion, impaired cilia-mediated CSF flow currents, or decreased CSF reabsorption via the arachnoid granulations or other pathways. Emerging data suggest that abnormal biomechanical properties of the brain parenchyma are an under-appreciated driver of ventriculomegaly in multiple forms of communicating hydrocephalus across the lifespan. We discuss recent evidence from human and animal studies that suggests impaired neurodevelopment in congenital hydrocephalus, neurodegeneration in elderly normal pressure hydrocephalus and, in all age groups, inflammation-related neural injury in post-infectious and post-haemorrhagic hydrocephalus, can result in loss of stiffness and viscoelasticity of the brain parenchyma. Abnormal brain biomechanics create barrier alterations at the brain–CSF interface that pathologically facilitates secondary enlargement of the ventricles, even at normal or low intracranial pressures. This 'brain-centric' paradigm has implications for the diagnosis, treatment and study of hydrocephalus from womb to tomb. [ABSTRACT FROM AUTHOR]

Background: Basal cisternostomy (BC) is a surgical technique to reduce intracranial hypertension following moderate to severe traumatic brain injury (TBI). As the efficacy and safety of BC in patients with TBI has not been well-studied, we aim to summarize the published evidence on the effect of BC as an adjunct to decompressive hemicraniectomy (DHC) on clinical outcome following moderate to severe TBI. Methods: A systematic literature review was carried out in PubMed/MEDLINE and EMBASE to identify studies evaluating BC as an adjunct to decompressive hemicraniectomy (DHC) in moderate to severe TBI. Random effects meta-analysis was performed to calculate summary effect estimates. Results: Eight studies reporting on 1345 patients were included in the qualitative analysis, of which five (1206 patients) were considered for meta-analysis. Overall, study quality was low and clinical heterogeneity was high. Adjuvant BC (BC + DHC) compared to standalone DHC was associated with a reduction in the length of stay in the ICU (Mean difference [MD]: -3.25 days, 95% CI: -5.41 to -1.09 days, p = 0.003), significantly lower mean brain outward herniation (MD: -0.68 cm, 95% CI: -0.90 to -0.46 cm, p < 0.001), reduced odds of requiring osmotherapy (OR: 0.09, 95% CI: 0.02 to 0.41, p = 0.002) as well as decreased odds of mortality at discharge (OR 0.68, 95% CI: 0.4 to 0.96, p = 0.03). Adjuvant BC compared to DHC did not result in higher odds of a favourable neurological outcome (OR = 2.50, 95% CI: 0.95–6.55, p = 0.06) and did not affect mortality at final follow-up (OR: 0.80, 95% CI: 0.17 to 3.74, p = 0.77). Conclusion: There is insufficient data to demonstrate a potential beneficial effect of adjuvant BC. Despite some evidence for reduced mortality and length of stay, there is no effect on neurological outcome. However, these results need to be interpreted with caution as they carry a high risk of bias due to overall scarcity of published clinical data, technical variations, methodological differences, limited cohort sizes, and a considerable heterogeneity in study design and reported outcomes. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether idiopathic intracranial hypertension (IIH) may affect white matter integrity and optic pathways by using diffusion tensor imaging (DTI) and to correlate the DTI metrics with intracranial pressure (ICP). Methods: This study is a retrospective case–control study. A total of 42 patients who underwent lumbar puncture and those with elevated ICP, meeting the diagnostic criteria for IIH, were included in the study. All patients had supportive magnetic resonance imaging findings for the diagnosis of IIH. The headache control group comprised 36 patients who presented to the Neurology Department with infrequent episodic tension‐type headache, had a normal neurologic examination, and had clinical and radiological findings suggestive of normal ICP. For each patient with IIH, clinical findings and ophthalmological measurements were recorded. The apparent diffusion coefficient (ADC), fractional anisotropy (FA), axial diffusivity (AD), and radial diffusivity (RD) values were calculated using a region of interest‐based method in different white matter tracts and optic pathways and compared. Results: A total of 42 patients diagnosed with IIH (three males, 39 females), with a mean (standard deviation [SD] age of 38.1 (8.9) years), and 36 headache controls (10 males, 26 females, mean [SD] age; 38.1 [9.4] years) were included in the study. The mean (SD) body mass index (BMI) of the patients with IIH was 25.2 (1.9) kg/m2, and the mean (SD) BMI of the headache controls was 23.3 (1.5) kg/m2 (p < 0.001). Decreased FA values and increased RD values in the cingulum were detected in patients with IIH compared to the headache controls (p = 0.003, Cohen's d = 0.681; p = 0.002 Cohen's d = −0.710). Decreased AD values in the left and right superior cerebellar peduncle and increased ADC values in the middle cerebellar peduncle were detected in patients with IIH compared to the headache controls (p < 0.001, Cohen's d = 0.961; p = 0.009, Cohen's d = 0.607; p = 0.015, Cohen's d = −0.564). Increased ADC and RD values and decreased FA values in optic nerve were detected in patients with IIH (p = 0.010, Cohen's d = −0.603; p = 0.004, Cohen's d = −0.676; p = 0.015 Cohen's d = 0.568). A positive correlation was found between the cerebrospinal fluid pressure and ADC values of the left and right superior and left inferior longitudinal fasciculus, genu of the corpus callosum, and right optic radiation (r = 0.43, p = 0.005; r = 0.31, p = 0.044; r = 0.39, p = 0.010; r = 0.35, p = 0.024; r = 0,41, p = 0.007). There was a positive correlation between the retinal nerve fiber layer thickness and the ADC values of the optic nerve (r = 0.32, p = 0.039). Conclusions: Intracranial hypertension can be associated with deteriorated DTI values, which might be interpreted as a sign of impaired white matter microstructural integrity in many brain regions beyond the periventricular white matter. Pressure‐induced edema and axonal degeneration may be the potential underlying mechanisms of this microstructural damage. Plain Language Summary: Females of reproductive age with obesity are disproportionately affected by idiopathic intracranial hypertension (IIH), and the incidence of this diagnosis is increasing along with the prevalence of obesity. We do not yet understand how IIH develops, but dysregulation of intracranial pressure is an important area of research interest, so we hypothesized that increased intracranial pressure may affect white matter microstructure and optic pathways in patients with IIH. Using data from a specialized imaging technique, we found that patients with IIH may have impaired white matter microstructural integrity in several areas of the brain and microstructural alterations in the optic nerve. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To standardize optic nerve sheath diameter (ONSD) point-of-care ultrasonography (POCUS) and improve its research and clinical utility by developing the ONSD POCUS Quality Criteria Checklist (ONSD POCUS QCC). DESIGN: Three rounds of modified Delphi consensus process and three rounds of asynchronous discussions. SETTING: Online surveys and anonymous asynchronous discussion. SUBJECTS: Expert panelists were identified according to their expertise in ONSD research, publication records, education, and clinical use. A total of 52 panelists participated in the Delphi process. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Three Delphi rounds and three asynchronous discussion rounds generated consensus on quality criteria (QC). This started with 29 QC in addition to other QC proposed by expert panelists. The QC items were categorized into probe selection, safety, body position, imaging, measurement, and research considerations. At the conclusion of the study, 28 QC reached consensus to include in the final ONSD POCUS QCC. These QC were then reorganized, edited, and consolidated into 23 QC that were reviewed and approved by the panelists. CONCLUSIONS: ONSD POCUS QCC standardizes ONSD ultrasound imaging and measurement based on international consensus. This can establish ONSD ultrasound in clinical research and improve its utility in clinical practice. [ABSTRACT FROM AUTHOR]

Purpose: The diagnosis of chronic increased intracranial pressure (IIP)is often based on subjective evaluation or clinical metrics with low predictive value. We aimed to quantify cranial bone changes associated with pediatric IIP using CT images and to identify patients at risk. Methods: We retrospectively quantified local cranial bone thickness and mineral density from the CT images of children with chronic IIP and compared their statistical differences to normative children without IIP adjusting for age, sex and image resolution. Subsequently, we developed a classifier to identify IIP based on these measurements. Finally, we demonstrated our methods to explore signs of IIP in patients with non-syndromic sagittal craniosynostosis (NSSC). Results: We quantified a significant decrease of bone density in 48 patients with IIP compared to 1,018 normative subjects (P <.001), but no differences in bone thickness (P =.56 and P =.89 for age groups 0–2 and 2–10 years, respectively). Our classifier demonstrated 83.33% (95% CI: 69.24%, 92.03%) sensitivity and 87.13% (95% CI: 84.88%, 89.10%) specificity in identifying patients with IIP. Compared to normative subjects, 242 patients with NSSC presented significantly lower cranial bone density (P <.001), but no differences were found compared to patients with IIP (P =.57). Of patients with NSSC, 36.78% (95% CI: 30.76%, 43.22%) presented signs of IIP. Conclusion: Cranial bone changes associated with pediatric IIP can be quantified from CT images to support earlier diagnoses of IIP, and to study the presence of IIP secondary to cranial pathology such as non-syndromic sagittal craniosynostosis. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to find out the efficacy of using Hypertonic saline solution (HSS) over mannitol in the management of TBI by comparing their performance in improving different outcomes. Methods: Electronic databases were searched for randomized controlled trials (RCTs) assessing the impact of HSS vs. mannitol on ICP in patients who suffered TBI. Outcomes of interest were mortality, neurologic functional outcomes, risk ratio (RR) of successful ICP treatment, reduction in ICP after 30–60 and 90–120 min, improvement in cerebral perfusion pressure (CPP) at 30–60 and 90–120 min, and also treatment failure. Evaluations were reported as RR or mean difference (MD) with 95% confidence intervals (CIs) using weighted random-effects models. Results: The analysis included 624 patients from 15 RCTs. HSS infusion had a significant impact on the improvement of CPP at 30–60 min [MD = 5.54, 95% CI (3.04, 8.03),p < 0.001] compared to mannitol. However, results yielded no significant difference between HSS and mannitol in terms of mortality, neurologic functional outcomes, successful ICP treatment, reduction in ICP after 30–60 min and 90–120 min, improvement in CPP at 90–120 min, and treatment failure. Conclusion: HSS and mannitol are both effective treatments for elevated ICP due to TBI. However, further research is required to derive a better comparison. [ABSTRACT FROM AUTHOR]

Purpose: Peri-operative management of nasal cerebrospinal fluid (CSF) leaks is not consensual due to limited evidence. The main aim of this study was to identify key factors in peri-operative management of endoscopic endonasal CSF leak repair among international experts. Methods: A 60-item survey questionnaire collected opinions of members of international learned societies of ENT surgeons and neurosurgeons on nasal packing, post-operative instructions, antibiotic prophylaxis, and CSF volume depletion. Results: The survey had 153 respondents (124 otorhinolaryngologists and 29 neurosurgeons). A resting position was recommended by 85% (130/151) of respondents for extended CSF leak of the anterior skull base, mainly in Fowler's position (72% (110/153)). Nasal packing was used by 85% (130/153) of respondents; 33.3% (51/153) used it to stabilize the reconstruction, and 22.2% (34/153) to prevent bleeding. It was usually removed after 48 h in 44.4% of cases (68/153). CSF depletion was considered by 47.1% (72/153) of respondents in case of CSF leak recurrence and by 34.6% (53/153) in cases of increased intracranial pressure. All respondents gave specific postoperative instructions to patients including driving, running, swimming, diving restrictions and flighting restrictions. In subgroup analysis, ENT surgeons more often recommended a resting position than neurosurgeons (71% vs. 37.9% ; p = 0.0008) and prescribed more antibiotics (82.3% vs. 21.4% ; p < 0.0001). Conclusion: Although postoperative management after CSF closure remains challenging and not codified, this international survey revealed some points of consensus concerning resting position and restriction of post-operative activities. Prospective clinical studies must be undertaken to evaluate their efficiency. [ABSTRACT FROM AUTHOR]

Background: Traumatic brain injury (TBI) poses a significant challenge to healthcare providers, necessitating meticulous management of hemodynamic parameters to optimize patient outcomes. This article delves into the critical task of defining and meeting continuous arterial blood pressure (ABP) and cerebral perfusion pressure (CPP) targets in the context of severe TBI in neurocritical care settings. Methods: We narratively reviewed existing literature, clinical guidelines, and emerging technologies to propose a comprehensive approach that integrates real-time monitoring, individualized cerebral perfusion target setting, and dynamic interventions. Results: Our findings emphasize the need for personalized hemodynamic management, considering the heterogeneity of patients with TBI and the evolving nature of their condition. We describe the latest advancements in monitoring technologies, such as autoregulation-guided ABP/CPP treatment, which enable a more nuanced understanding of cerebral perfusion dynamics. By incorporating these tools into a proactive monitoring strategy, clinicians can tailor interventions to optimize ABP/CPP and mitigate secondary brain injury. Discussion: Challenges in this field include the lack of standardized protocols for interpreting multimodal neuromonitoring data, potential variability in clinical decision-making, understanding the role of cardiac output, and the need for specialized expertise and customized software to have individualized ABP/CPP targets regularly available. The patient outcome benefit of monitoring-guided ABP/CPP target definitions still needs to be proven in patients with TBI. Conclusions: We recommend that the TBI community take proactive steps to translate the potential benefits of personalized ABP/CPP targets, which have been implemented in certain centers, into a standardized and clinically validated reality through randomized controlled trials. [ABSTRACT FROM AUTHOR]