Search Results (36)

Paediatric brain tumours and their treatments are associated with long-term cognitive impairment. While the aetiology of cognitive impairment is complex and multifactorial, multiparametric Magnetic Resonance Imaging (MRI) can identify many risk factors including tumour location, damage to eloquent structures and tumour phenotype. Hydrocephalus and raised intracranial pressure can be observed, along with risk factors for post-operative paediatric cerebellar mutism syndrome or epilepsy. MRI can also identify complications of surgery or radiotherapy and monitor treatment response. Advanced imaging sequences provide valuable information about tumour and brain physiology, but clinical use is limited by extended scanning times and difficulties in processing and analysis. Brain eloquence classifications exist, but focus on adults with neurological deficits and are outdated. For the analysis of childhood tumours, limited numbers within tumour subgroups and the investigation of long-term outcomes necessitate using historical scans and/or multi-site collaboration. Variable imaging quality and differing acquisition parameters limit the use of segmentation algorithms and radiomic analysis. Harmonisation can standardise imaging in collaborative research, but can be challenging, while data-sharing produces further logistical challenges. Consequently, most research consists of small single-centre studies limited to regional analyses of tumour location. Technological advances reducing scanning times increase the feasibility of clinical acquisition of high-resolution standardised imaging including advanced physiological sequences. The RAPNO and SIOPE paediatric brain tumour imaging guidelines have improved image standardisation, which will benefit future collaborative imaging research. Modern machine learning techniques provide more nuanced approaches for integration and analysis of the complex and multifactorial data involved in cognitive outcome prediction. Full article

Background: In normal pressure hydrocephalus (NPH) there is blood–brain barrier (BBB) disruption, which should increase the CSF formation rate (CSF_fr) and, therefore, also increase the intracranial pressure (ICP). However, the ICP is normal in NPH. A lumped parameter study was performed to look at the interrelation between the ICP, cerebral blood flow (CBF), and the degree of BBB disruption in NPH. The model suggested that the CSF_fr could be reduced in this condition if the BBB disruption was moderated by a reduction in the capillary transmural pressure (TMP) secondary to arteriolar constriction and a reduced CBF. In early Alzheimer’s disease (AD), there is BBB disruption, reduced ICP, and global ischemia. This raises the possibility that the same physiology may occur in AD as occurs in NPH. Methods: A lumped parameter model previously used to describe the hydrodynamics of NPH was modified to investigate the effects of changes in CSF pressure and blood flow in patients with mild cognitive impairment (MCI) and AD. Results: The model indicates that the average capillary TMP is normal in MCI, but decreases as AD progresses. Removing CSF in AD patients during a tap test initially increases the capillary TMP. The brain in AD responds to a tap test by increasing its level of ischemia, and this reduces the capillary TMP. Conclusions: A hypothesis is put forward that the BBB disruption in AD is partially mitigated by the brain making itself ischemic. Modelling gives support to this hypothesis. The model can suggest a cause for the development of ischemic neuronal loss and amyloid accumulation secondary to glymphatic flow disruption as AD progresses. Full article

Neonatal intraventricular hemorrhage is a serious condition associated with significant acute and long-term morbidity and mortality. Neurosurgical intervention aims to relieve life-threatening raised intracranial pressure and prevent neurological deterioration. In recent years, advancements in disease understanding have paved the way for clinicians to re-evaluate conventional approaches in the management of affected patients. Examples include various neurosurgical techniques to actively reduce blood products with a view to avoid the consequences of complex hydrocephalus and intraparenchymal injury in the developing brain. In this entry paper, we aim to provide an overview of the current perspectives, pathophysiology and management strategies for this difficult condition. Full article

Background/Objectives: Intracranial arachnoid cysts (ACs) may be congenital, primary, or secondary due to trauma. These cysts are benign, contain cerebrospinal fluid (CSF), and are classified based on location, size, and their clinical symptomatology. They are uncommon lesions in children, rarely leading to severe mass-effect neurological symptomatology. Methods: The present report describes a 30-month-old female presenting with quadriparesis. An emergency magnetic resonance imaging (MRI) study revealed the presence of a primary intracranial arachnoid cyst of the posterior cranial fossa, exerting significant pressure on the medulla oblongata and the cervical portion of the spinal cord, displacing them dorsally, with a remnant diameter of 2.5 mm. Results: This benign malformation located in a crucial area might have been complicated by severe neurological deterioration and required prompt intervention, so the patient underwent a suboccipital craniectomy in a sitting position, along with a neurosurgical procedure, which established a lasting communication channel between the cyst and the basal cisterns. This led to a favorable outcome. Conclusions: Up to the present report, postoperative complete resolution of quadriparesis secondary to a posterior cranial fossa arachnoid cyst has not been reported. At present, no therapeutic modality has been established as the definitive standard of care for pediatric ACs, and their management raises a great deal of controversy among neurosurgeons. The narrative literature review of the present study integrates the various perspectives regarding ACs and their possible treatment approaches that are currently available. Full article

Post-traumatic cerebral venous sinus thrombosis (ptCVST) often remains underdiagnosed due to the non-specific nature of clinical signs, commonly mimicking severe traumatic brain injury (TBI) manifestations. Early recognition of this rare and potentially life-threatening complication is crucial for the effective management of severe TBI patients in Intensive Care. The present study reports the case of a 66-year-old male who was transferred to the emergency department due to moderate TBI. Initial emergency brain computed tomography (CT) scans revealed certain traumatic lesions, not necessitating any urgent neurosurgical intervention. During his stay in an Intensive Care Unit (ICU), multiple transient episodes of intracranial pressure (ICP) values were managed conservatively, and through placement of an external ventricular drain. Following a series of CT scans, there was a continuous improvement of the initial traumatic hemorrhagic findings despite his worsening clinical condition. This paradox raised suspicion for ptCVST, and a brain CT venography (CTV) was carried out, which showed venous sinus thrombosis close to a concomitant skull fracture. Therapeutic anticoagulant treatment was administered. The patient was discharged with an excellent neurological status. To date, there are no clearly defined guidelines for medical and/or surgical management of patients presenting with ptCVST. Therapy is mainly based on intracranial hypertension control and the maintenance of normal cerebral perfusion pressure (CCP) in the ICU. The mismatch between clinical and imaging findings in patients with TBI and certain risk factors raises the suspicion of ptCVST. Full article

Background: Effective fluid management is important for patients at risk of increased intracranial pressure (ICP). Maintaining constant cerebral perfusion represents a challenge, as both hypovolemia and fluid overload can severely impact patient outcomes. Fluid responsiveness tests, commonly used in critical care settings, are often deemed potentially hazardous for these patients due to the risk of disrupting cerebral perfusion. Methods: This single-center, prospective, clinical observational study enrolled 40 patients at risk for increased ICP, including those with acute brain injury. Informed consent was obtained from each participant or their legal guardians before inclusion. The study focused on the dynamics of ICP and cerebral perfusion pressure (CPP) changes during the Passive Leg Raise Test (PLRT) and the End-Expiratory Occlusion Test (EEOT). Results: The results demonstrated that PLRT and EEOT caused minor and transient increases in ICP, while consistently maintaining stable CPP. EEOT induced significantly lower ICP elevations, making it particularly suitable for use in high-risk situations. Conclusions: PLRT and EEOT can be considered feasible and safe for assessing fluid responsiveness in patients at risk for increased ICP. Notably, EEOT stands out as a preferred method for high-risk patients, offering a dependable strategy for fluid management without compromising cerebral hemodynamics. Full article

Binding of substance P to the tachykinin NK1 receptor is involved in numerous physiological and pathophysiological processes ranging from modulation of sensory and motor function to inflammation, cancer, and brain injury, amongst others. NK1 antagonists therefore have enormous potential as a therapeutic intervention in a wide variety of human disease states, albeit that the clinical potential is yet to be fully realised. In the current review, the role of substance P in the pathophysiology of traumatic brain injury (TBI) will be discussed, summarising both experimental and clinical observations in mild, moderate, and severe TBI. In addition, the potential for NK1 antagonists to be a valuable therapeutic intervention against chronic traumatic encephalopathy (CTE) after repeated concussive brain injury as well as raised intracranial pressure (ICP) following severe TBI will be addressed, highlighting the various pathophysiological processes that are attenuated by the intervention. Full article

Ultrasonographic optic nerve sheath diameter (ONSD) measurement is an accurate, portable, and non-invasive method of detecting raised intracranial pressure that can also reflect dynamic, real-time changes in intracranial pressure fluctuations. Various studies have shown the mean range of ONSD to vary greatly across different population groups. This study aimed to determine the mean ONSD in healthy Black South African adults. In this cross-sectional study, healthy black South African adult participants underwent optic nerve sheath ultrasound of the right eye, with the diameter being measured at 3 mm behind the retina in two different planes. The average of the two measurements was used to find the mean optic nerve sheath diameter. This measurement was compared to that found in a Canadian adult population, and the effect of age, gender, and co-morbidities on ONSD was assessed. A total of 99 participants were included in this study, of which 39 were male and 60 were female. The mean ONSD was found to be 5.1 mm (SD ± 0.33). This value was significantly higher than the mean ONSD observed in the Canadian population (p < 0.001). There was no significant difference found between the mean ONSD in males and females (p = 0.652), and both age and presence of co-morbidities were not found to significantly correlate with ONSD. (p = 0.693 and p = 0.974, respectively). Full article

Background: Futile recanalization (FR) continues to raise concern despite the success of endovascular thrombectomy (EVT) in acute ischemic stroke (AIS). Understanding the prevalence of FR and identifying associated factors are crucial for refining patient prognoses and optimizing management strategies. Objectives: This study aims to comprehensively assess the pooled prevalence of FR, explore the diverse factors connected with FR, and establish the association of FR with long-term clinical outcomes among AIS patients undergoing EVT. Materials and Methods: Incorporating studies focusing on FR following EVT in AIS patients, we conducted a random-effect meta-analysis to assess the pooled prevalence and its association with various clinical and imaging risk factors linked to FR. Summary estimates were compiled and study heterogeneity was explored. Results: Our comprehensive meta-analysis, involving 11,700 AIS patients undergoing EVT, revealed a significant pooled prevalence of FR at 51%, with a range of 48% to 54% (Effect Size [ES]: 51%; 95% Confidence Interval [CI]: 48–54%; z = 47.66; p < 0.001). Numerous clinical factors demonstrated robust correlations with FR, including atrial fibrillation (Odds Ratio [OR]: 1.39, 95% CI 1.22 1.59; p < 0.001), hypertension (OR 1.65, 95% CI 1.41 1.92; p < 0.001), diabetes mellitus (OR 1.71, 95% CI 1.47 1.99; p < 0.001), previous stroke or transient ischemic attack (OR 1.298, 95% CI 1.06 1.59; p = 0.012), prior anticoagulant usage (OR 1.33, 95% CI 1.08 1.63; p = 0.007), cardioembolic strokes (OR 1.34, 95% CI 1.10 1.63; p = 0.003), and general anesthesia (OR 1.53, 95% CI 1.35 1.74; p < 0.001). Conversely, FR exhibited reduced likelihoods of smoking (OR 0.66, 95% CI 0.57 0.77; p < 0.001), good collaterals (OR 0.33, 95% CI 0.23 0.49; p < 0.001), male sex (OR 0.87, 95% CI 0.77 0.97; p = 0.016), and intravenous thrombolysis (IVT) (OR 0.75, 95% CI 0.66 0.86; p < 0.001). FR was strongly associated with increasing age (standardized mean difference [SMD] 0.49, 95% CI 0.42 0.56; p < 0.0001), baseline systolic blood pressure (SMD 0.20, 95% CI 0.13 0.27; p < 0.001), baseline National Institute of Health Stroke Severity Score (SMD 0.75, 95% CI: 0.65 0.86; p < 0.001), onset-to-treatment time (SMD 0.217, 95% CI 0.13 0.30; p < 0.001), onset-to-recanalization time (SMD 0.38, 95% CI 0.19; 0.57; p < 0.001), and baseline blood glucose (SMD 0.31, 95% CI 0.22 0.41; p < 0.001), while displaying a negative association with reduced baseline Alberta Stroke Program Early CT Score (ASPECTS) (SMD −0.37, 95% CI −0.46 −0.27; p < 0.001). Regarding clinical outcomes, FR was significantly associated with increased odds of symptomatic intracranial hemorrhages (OR 7.37, 95% CI 4.89 11.12; p < 0.001), hemorrhagic transformations (OR 2.98, 95% CI 2.37 3.75; p < 0.001), and 90-day mortality (OR 19.24, 95% CI 1.57 235.18; p = 0.021). Conclusions: The substantial prevalence of FR, standing at approximately 51%, warrants clinical consideration. These findings underscore the complexity of FR in AIS patients and highlight the importance of tailoring management strategies based on individual risk factors and clinical profiles. Full article

The effects of climate change are now evident on a global level and indisputable even to the most skeptical. Melting ice, rising sea levels, and changing climate zones are a daily occurrence and subject of debate in the media. Beyond the obvious effects of these phenomena on human lives, countless others arise and await being studied. Meanwhile, it has been proven that many health problems are related to changes in weather and large fluctuations of temperature. Specifically, studies have been conducted to correlate the rupture of intracranial aneurysms with seasonal and climatic conditions. The conclusions of these studies linked the rupture of intracranial aneurysms with higher temperatures, as well as with higher atmospheric pressure. Inevitably, one of the questions raised is whether the change in weather brings about conditions that favor the rupture of intracranial aneurysms throughout the year. The purpose of this paper is to present the results of studies that correlate these two factors and, then, to demonstrate that these meteorological conditions now prevail throughout the year, influencing, perhaps, and distributing the rupture of intracranial aneurysms during all seasons. Full article

Background: Haemorrhagic stroke, accounting for 10–20% of all strokes, often requires decompressive surgery as a life-saving measure for cases with massive oedema and raised intracranial pressure. This study was conducted to compare the demographics, characteristics and rehabilitation profiles of patients with severe haemorrhagic stroke who were managed surgically versus those who were managed non-surgically. Methods: A single-centre retrospective study of electronic medical records was conducted over a 3-year period from 1 January 2018 to 31 December 2020. The inclusion criteria were first haemorrhagic stroke, age of >18 years and an admission Functional Independence Measure (FIM™) score of 18–40 upon admission to the rehabilitation centre. The primary outcome measure was discharge FIM™. Secondary outcome measures included modified Rankin Scale (mRS), rehabilitation length of stay (RLOS) and complication rates. Results: A total of 107 patients’ records were analysed; 45 (42.1%) received surgical intervention and 62 (57.9%) patients underwent non-surgical management. Surgically managed patients were significantly younger than non-surgical patients, with a mean age of [surgical 53.1 (SD 12) vs. non-surgical 61.6 (SD 12.3), p = 0.001]. Admission FIM was significantly lower in the surgical vs. non-surgical group [23.7 (SD6.7) vs. 26.71 (SD 7.4), p = 0.031). However, discharge FIM was similar between both groups [surgical 53.91 (SD23.0) vs. non-surgical 57.0 (SD23.6), p = 0.625). Similarly, FIM gain (surgical 30.1 (SD 21.1) vs. non-surgical 30.3 (SD 21.1), p = 0.094) and RLOS [surgical 56.2 days (SD 21.5) vs. non-surgical 52.0 days (SD 23.4), p = 0.134) were not significantly different between groups. The majority of patients were discharged home (surgical 73.3% vs. non-surgical 74.2%, p = 0.920) despite a high level of dependency. Conclusions: Our findings suggest that patients with surgically managed haemorrhagic stroke, while older and more dependent on admission to rehabilitation, achieved comparable FIM gains, discharge FIM and discharge home rates after ~8 weeks of rehabilitation. This highlights the importance of rehabilitation, especially for surgically managed haemorrhagic stroke patients. Full article

Purpose: Intracranial pressure (ICP) monitoring is a “gold standard” monitoring modality for severe traumatic brain injury (TBI) patients. The capacity to predict ICP crises could further minimise the rate of secondary brain injury and improve the outcomes of TBI patients by facilitating timely intervention prior to a potential crisis. This systematic review sought (i) to identify the most efficacious approaches to the prediction of ICP crises within TBI patients, (ii) to access the clinical suitability of existing predictive models and (iii) to suggest potential areas for future research. Methods: Peer-reviewed primary diagnostic accuracy studies, assessing the performance of ICP crisis prediction methods within TBI patients, were included. The QUADAS-2 tool was used to evaluate the quality of the studies. Results: Three optimal solutions to predicting the ICP crisis were identified: a long short-term memory (LSTM) model, a Gaussian processes (GP) approach and a logistic regression model. These approaches performed with an area under the receiver operating characteristics curve (AUC-ROC) ranging from 0.86 to 0.95. Conclusions: The review highlights the existing disparity of the definition of an ICP crisis and what prediction horizon is the most clinically relevant. Moreover, this review draws attention to the existing lack of focus on the clinical intelligibility of algorithms, the measure of how algorithms improve patient care and how algorithms may raise ethical, legal or social concerns. The review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD42022314278). Full article

Intracranial hypertension and adequacy of brain blood flow are primary concerns following traumatic brain injury. Intracranial pressure (ICP) monitoring is a critical diagnostic tool in neurocritical care. However, all ICP sensors, irrespective of design, are subject to systematic and random measurement inaccuracies that can affect patient care if overlooked or disregarded. The wide choice of sensors available to surgeons raises questions about performance and suitability for treatment. This observational study offers a critical review of the clinical and experimental assessment of ICP sensor accuracy and comments on the relationship between actual clinical performance, bench testing, and manufacturer specifications. Critically, on this basis, the study offers guidelines for the selection of ICP monitoring technologies, an important clinical decision. To complement this, a literature review on important ICP monitoring considerations was included. This study utilises illustrative clinical and laboratory material from 1200 TBI patients (collected from 1992 to 2019) to present several important points regarding the accuracy of in vivo implementation of contemporary ICP transducers. In addition, a thorough literature search was performed, with sources dating from 1960 to 2021. Sources considered to be relevant matched the keywords: “intraparenchymal ICP sensors”, “fiberoptic ICP sensors”, “piezoelectric strain gauge sensors”, “external ventricular drains”, “CSF reference pressure”, “ICP zero drift”, and “ICP measurement accuracy”. Based on single centre observations and the 76 sources reviewed in this paper, this material reports an overall anticipated measurement accuracy for intraparenchymal transducers of around ± 6.0 mm Hg with an average zero drift of <2.0 mm Hg. Precise ICP monitoring is a key tenet of neurocritical care, and accounting for zero drift is vital. Intraparenchymal piezoelectric strain gauge sensors are commonly implanted to monitor ICP. Laboratory bench testing results can differ from in vivo observations, revealing the shortcomings of current ICP sensors. Full article

Idiopathic intracranial hypertension (IIH) is a neurological disorder characterised by optic disc swelling secondary to raised intracranial pressure (ICP) of unknown cause. Obesity is the most established and prevalent risk factor in developed countries. As obesogenic diets are high in calories and nutrient-poor, there may be associated nutritional deficiencies that contribute to the clinical presentation of IIH. Yet none, aside from iron deficiency, are currently included in the inclusion or exclusion criteria for the diagnosis of IIH. Our primary aim was to determine which micronutrient deficiencies, aside from iron deficiency, could present with optic disc swelling associated with or without intracranial hypertension that could potentially meet current IIH diagnostic criteria. To this end, we conducted a systematic search of articles published between 1 January 1980 and 18 December 2020 reporting cases of optic disc swelling associated with micronutrient deficiencies. In total, 65 cases met the eligibility criteria from initial searches: all were case reports and case series with a high risk of bias. Our findings suggest that patients with IIH or unexplained optic disc swelling ought to be screened, investigated, and treated for associated micronutrient deficiencies in vitamin A, B1 and B12; and weight loss interventions in IIH patients ought to promote better nutrition in addition to overall calorie restriction. Full article

Background: Pregnant women are more likely to suffer post-puncture symptoms such as headaches and nausea due to the outflow of cerebrospinal fluid after spinal anesthesia. Because ketamine has the effect of raising intracranial pressure, it may be able to improve the symptoms of perioperative hypocranial pressure and effectively prevent the occurrence of hypocranial pressure-related side effects. Method: Keywords such as ketamine, cesarean section, and spinal anesthesia were searched in databases including Medline, Embase, Web of Science, and Cochrane from 1976 to 2021. Thirteen randomized controlled trials were selected for the meta-analysis. Results: A total of 12 randomized trials involving 2099 participants fulfilled the inclusion criteria. There was no significant association between ketamine and the risk of headaches compared to the placebo (RR = 1.12; 95% CI: 0.53, 2.35; p = 0.77; I² = 62%). There was no significant association between ketamine and nausea compared to the placebo (RR = 0.66; 95% CI: 0.40, 1.09; p = 0.10; I² = 57%). No significant associations between ketamine or the placebo and vomiting were found (RR = 0.94; 95% CI: 0.53, 1.67; p = 0.83; I² = 72%). Conclusion: Intravenous ketamine does not improve the symptoms caused by low intracranial pressure after spinal anesthesia in patients undergoing cesarean section. Full article