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13 results

  • 3.13.1 - Traumatic Brain Injury

  • from Section 3.13 - Severe Trauma and Multiple Injuries
  • Edited by Ned Gilbert-Kawai, The Royal Liverpool Hospital, Debashish Dutta, Princess Alexandra Hospital NHS Trust, Harlow, Carl Waldmann, Royal Berkshire Hospital, Reading
  • Book:
    Intensive Care Medicine
    Published online:
    27 July 2023
    Print publication:
    01 December 2021, pp 393-397

  • Summary

    Key Learning Points

    1. 1. Critical care management of traumatic brain injuries aims to avoid the development of secondary insults, which may impact on survival outcomes.

    2. 2. Intracranial hypertension is associated with increased mortality in patients with traumatic brain injury.

    3. 3. Interventions proposed to control intracranial hypertension should be made after balancing the associated risks and benefits.

    4. 4. Avoidance of corticosteroids in traumatic brain injuries is the only Grade I recommendation included in the Brain Trauma Foundation Guidelines.

    5. 5. Further research is needed to make clear recommendations regarding the role of decompressive craniectomy on functional outcomes.

  • 4.10 - Neuromonitoring and Cerebral Protection

  • from Section 4 - Therapeutic Interventions and Organ Support
  • Edited by Ned Gilbert-Kawai, The Royal Liverpool Hospital, Debashish Dutta, Princess Alexandra Hospital NHS Trust, Harlow, Carl Waldmann, Royal Berkshire Hospital, Reading
  • Book:
    Intensive Care Medicine
    Published online:
    27 July 2023
    Print publication:
    01 December 2021, pp 515-518

  • Summary

    Key Learning Points

    1. 1. The physiological changes governing the Monro–Kellie doctrine become quickly exhausted when the intracranial volume reaches a critical value, thus expediting intracranial hypertension.

    2. 2. The main factors influencing the balance between cerebral oxygen delivery and consumption are cerebral blood flow (CBF), arterial oxygen saturation (SaO2), haemoglobin concentration and cerebral metabolic rate of oxygen (CMRO2).

    3. 3. In the critical care unit, the most common advanced neuromonitoring technique involves measurement of intracranial pressure (ICP) and estimation of cerebral perfusion pressure (CPP). However, brain tissue oxygen tension (PtiO2), jugular venous oxygen saturation (SjvO2), cerebral microdialysis, transcranial Doppler ultrasound and continuous electroencephalography are also helpful to detect early complications.

    4. 4. Jugular venous oxygen saturation (SjvO2) values <55 per cent may indicate elevated CMRO2, low CBF, systemic oxygen desaturation or cerebral ischaemia. Conversely, readings >75 per cent may represent high CBF, metabolic suppression or massive cerebral infarction.

    5. 5. Cerebral microdialysis is an evolving technique that can help to diagnose cerebral ischaemia, traumatic axonal injury and inflammatory insults at early stages. However, more research is needed to validate its clinical use.

  • Fulminant intracranial hypertension as a result of otological surgery: case report and discussion of management

  • A Morris, J N Higgins, P R Axon
  • Journal:
    The Journal of Laryngology & Otology / Volume 135 / Issue 6 / June 2021
    Published online by Cambridge University Press:
    18 May 2021, pp. 551-554
    Print publication:
    June 2021
  • Background

    Dural venous sinus injury is a rare complication of otological surgery that can lead to life-threatening sequelae, the management of which is complex and poorly described.

    Case report

    This paper describes the case of a 40-year-old female who underwent routine right myringoplasty complicated by sigmoid sinus laceration. The patient subsequently developed right-sided lateral sinus thrombosis leading to fulminant intracranial hypertension. The patient underwent successful emergency management by surgical reconstruction of the sigmoid sinus, followed by endovascular thrombolysis, catheter balloon angioplasty and endovascular stenting.

    Conclusion

    Torrential haemorrhage following otological procedures is uncommon and rarely requires packing of a bleeding venous sinus. This case highlights that injury to a highly dominant venous sinus can lead to venous outflow obstruction and life-threatening intracranial hypertension. To our knowledge, the development of this complication following otological surgery and its management has not been reported previously.

  • Management of spontaneous cerebrospinal fluid leaks of the sphenoid sinus: our experience

  • G Fyrmpas, I Konstantinidis, P Selviaridis, J Constantinidis
  • Journal:
    The Journal of Laryngology & Otology / Volume 128 / Issue 9 / September 2014
    Published online by Cambridge University Press:
    02 September 2014, pp. 797-802
    Print publication:
    September 2014
  • Background:

    Closure of spontaneous sphenoid sinus cerebrospinal fluid leaks can be challenging because of the relative inaccessibility of the lateral recess and the presence of intracranial hypertension. We present our experience of such cases and highlight factors associated with a successful outcome.

    Methods:

    Eleven patients with spontaneous, laboratory confirmed, sphenoid sinus cerebrospinal fluid leaks were included. All patients underwent endoscopic closure by either a three-layer technique or fat obliteration.

    Results:

    In all but one patient, the leak was successfully sealed (success rate, 90.9 per cent; mean follow up, 37.1 months). Elevated intracranial pressure was measured in eight patients, two of whom did not exhibit relevant clinical or radiological characteristics. Five patients received diuretics and dietary advice for weight reduction. In one patient with recurrence two weeks after repair, successful revision was performed by additional placement of a ventriculoperitoneal shunt (follow up, 67 months).

    Conclusion:

    Long-lasting cerebrospinal fluid fistula sealing in the sphenoid sinus requires stable reconstruction of the defect in three layers or fat obliteration if the anatomy is unfavourable. All patients should be intra- and post-operatively screened for elevated intracranial pressure to identify those who need additional intracranial pressure reduction measures.

  • Case 10 - Trigeminocardiacreflex

  • from Section I - Neuroanesthesia
  • Edited by George A. Mashour, Ehab Farag
  • Book:
    Case Studies in Neuroanesthesia and Neurocritical Care
    Published online:
    03 May 2011
    Print publication:
    03 February 2011, pp 33-35

  • Summary

    Intracranial pressure (ICP) is of paramount importance because the cranial vault is nondistensible and within it is contained three noncompressible substances: brain, blood, and cerebrospinal fluid (CSF). This chapter presents a case study of a 75-year-old male who presented for emergent subdural hematoma evacuation. The immediate anesthetic goal was to minimize the rise in ICP while at the same time maintaining adequate cerebral perfusion pressure until the neurosurgeons could provide definitive treatment. Definitive correction of intracranial hypertension was achieved with hematoma evacuation. Intracranial hematomas, blood-filled space-occupying lesions, are classified by their location relative to the meningeal layers. Numerous therapeutic maneuvers exist for lowering ICP, each with the common mechanism of decreasing the volume of one or more intracranial components. increased ICP can be a life-threatening condition, the definitive treatment of which is often in the hands of the neurosurgeon.

  • Case 11 - Sittingcraniotomy

  • from Section I - Neuroanesthesia
  • Edited by George A. Mashour, Ehab Farag
  • Book:
    Case Studies in Neuroanesthesia and Neurocritical Care
    Published online:
    03 May 2011
    Print publication:
    03 February 2011, pp 36-37

  • Summary

    The injury spectrum in traumatic brain injury (TBI) encompasses not only the initial insult, but includes the cascade of systemic responses and pathophysiology that occur after the focal or diffuse brain injury. This chapter presents a case study of a 49-year-old male motorcyclist who was evaluated in the emergency room after a motor vehicle collision with an articulated truck. Around the time of computed tomography (CT) scanning, the patient's right pupil became dilated and unreactive. Hypoxic cerebral damage, a common postmortem finding in TBI, is associated with arterial hypoxemia, decreased mean arterial pressure, or cerebral hypoperfusion, occurring as a consequence of shock, intracranial hypertension, or cerebral vasospasm. Although a definitively effective neuroprotective therapy in central nervous system (CNS) trauma remains elusive, through the skilled interactions of prehospital, emergency department, anesthesiology, and surgical personnel, the lives of many critically injured individuals can be saved and their neurologic function preserved.

  • Chapter 47 - Core areas required for UK/European Diploma examinations

  • from Section IV: - Examinations
  • Edited by Fang Gao Smith, University of Warwick
  • Edited in association with Joyce Yeung
  • Book:
    Core Topics in Critical Care Medicine
    Published online:
    06 July 2010
    Print publication:
    22 April 2010, pp 369-373

  • Summary

    Paracetamol poisoning is the most common cause of acute liver failure (ALF) in Western Europe, Australia and USA. The N-acetyl derivative of the amino acid cysteine (NAC) serves as a precursor to the production of glutathione and is the treatment of choice in early paracetamol toxicity. Patients with hyperacute or acute liver failure often require significant volumes of fluid resuscitation. Patients with liver failure are prone to hypoglycaemia. Liver failure leads to a loss of synthetic function of hepatocytes and reduction of coagulation factors, and international normalized ratio (INR) is a very important prognostic factor. The complications of liver failure include hepatic encephalopathy, intracranial hypertension, renal failure and adrenal dysfunction. In a selected group of patients liver transplantation is the treatment of choice. Overall survival, without transplantation, is about 40% following the onset of ALF. Acute on chronic liver failure represents the decompensation of otherwise stable chronic liver disease.

  • Chronic, otogenic, epidural pneumatocoele with delayed mass effect: case report

  • F Barbieri, F Fiorino
  • Journal:
    The Journal of Laryngology & Otology / Volume 124 / Issue 5 / May 2010
    Published online by Cambridge University Press:
    30 November 2009, pp. 552-556
    Print publication:
    May 2010

  • Introduction: Mastoid hyperpneumatisation predisposes to intracranial pneumatocoele development, due to the risk of rupture of the thin, bony walls. Intracranial pneumatocoele may be precipitated by even minor head trauma or an abrupt change in middle-ear pressure, with the potential risk of infectious or compressive intracranial complications.

    Case report: A 19-year-old man with mastoid hyperpneumatisation developed a chronic intracranial–epidural pneumatocoele of traumatic origin in the right parieto-occipital area, in contiguity with the posterior mastoid cells. Eighteen months later, after a common cold, the patient developed signs of intracranial hypertension, due to the pneumatocoele spreading to the right epidural anterior fossa. A large right mastoidectomy extended to the retrosigmoid cells was performed, and a watertight seal applied over a large retrosigmoid cell using bovine pericardium and a mixture of bone powder and fibrin glue.

    Results: The patient was discharged on post-operative day three with no symptoms. Ten days after surgery, computed tomography monitoring showed complete reabsorption of the pneumatocoele.

    Conclusion: In cases of chronic, otogenic, epidural pneumatocoele, the possibility of the sudden onset of serious complications suggests the need for early repair of the communication between the temporal bone and the intracranial compartments. Closure of the fistula using autogenic and/or allogenic materials is usually adequate to resolve the pneumatocoele.

  • The role of hypertonic saline in neurotrauma

  • H. White, D. Cook, B. Venkatesh
  • Journal:
    European Journal of Anaesthesiology / Volume 25 / Issue S42 / February 2008
    Published online by Cambridge University Press:
    01 February 2008, pp. 104-109
    Print publication:
    February 2008

  • Animal and human studies suggest that hypertonic saline is a potential therapeutic agent to assist with the medical treatment of patients with traumatic brain injury. It may have a place as osmotherapy to decrease brain size, predominately of uninjured brain and has several potential advantages over mannitol. Hypertonic saline has clinically desirable physiological effects on cerebral blood flow, intracranial pressure and inflammatory responses in models of neurotrauma. Animal studies support its use, but definitive human trials using mortality end-points in brain trauma are lacking. Hypertonic saline may be considered a therapeutic adjunct to the medical management of traumatic brain injury, awaiting definitive evidence to support routine use.