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 10,007 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

This article gives an interim overview of the potentials of TCD as a monitoring instrument in pediatric intensive care. In the near future, typical TCD flow patterns associated with adverse neurologic outcomes must be defined so they can promptly be recognized during intensive care surveillance or intraoperatively, before permanent damage occurs. Further applications of monitoring will deliver new and exciting insights into the physiology and pathophysiology of cerebral circulation in the critically ill child. Continuous recording of the Doppler waveforms and ICP may make it possible to determine the critical CPP and to improve the control of the therapy of cerebral edema.
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PMID:Doppler assessment of the cerebral circulation in pediatric intensive care. 173 34

Since 1978, decompressive craniotomy was performed according to a standardized protocol. Exclusion criteria were age greater than or equal to 40 years, deleterious primary brain damage, operable space occupying lesions, larger infarctions in CT scan or irreversible brain stem incarceration/ischaemic damage as shown by bulbar syndrome, loss in BAEP or oscillating flow in TCD. Indication was given by progressive intracranial hypertension not controllable by conservative methods, if ICP decompensation was correlated with clinical (GCS, extension spasms, mydriasis) and electrophysiological (EEG, SEP, CCT) deteriorations. 18 patients were decompressed by unilateral. 19 by bilateral craniotomy with large fronto-parieto-temporal bone flap and a dura enlargement by use of temporal muscle/fascia. 37 patients at an age of 18 +/- 7 (4-34) years were operated 5 h-10 d after trauma. Recovery was surprisingly good: only 5 died, 2 due to an ARDS; 3 remained vegetative, all others achieved full social rehabilitation or remained moderately disabled. The best predictor of a favourable outcome was an initial posttraumatic GCS greater than or equal to 7. These in younger patients with delayed posttraumatic decompensation before irreversible ischaemic damage occurs.
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PMID:Traumatic brain swelling and operative decompression: a prospective investigation. 208 28

Neurologically critically ill patients, more often than others, are unable to communicate and, for a crucial period of time, have the vital functions of their brains hidden in the "black box" of the cranial vault behind a curtain of ambiguity and immobility. Customarily--and naively--we have relied upon beside clinical observations to pierce these barriers. Recent insights lead us to conclude that these "neurochecks" no longer suffice. This article has surveyed four major monitoring systems relied upon by neurointensivists to evaluate the pathophysiology of their patients. Of these, ICPM has the longest clinical track record. It provides a quantitative measure of the brain's capacity to withstand ICP and helps us monitor interventions to reduce it. To utilize this information intelligently requires an understanding of the principles of ICC, CPP, ICP wave morphology, and the hardware available. NICU-CEEG is a more recent introduction but, in principle, it transfers from the laboratory and operating suite to the ICU bedside, established correlations among electrophysiology, CBF, and CM. Digital EEG has allowed us to overcome significant logistical barriers and made NICU-CEEG a practical ICU tool. Early but impressive data suggest that NICU-CEEG has a significant clinical impact in patients with ACI, uncontrolled seizures, or coma. It also has revealed that NICU patients have a surprisingly high incidence of NCS, which may adversely affect their outcome. TCD has contributed greatly to diagnosis and management of SAH vasospasm. It also can be applied with benefit to patients with increased ICP, and has promising value in patients with ACI. It may prove beneficial in monitoring unstable cerebral embolization. Several bedside methods for monitoring CBF are available, but they require refinement to become true monitoring systems. These methods have revealed clinically important insights in patients with head trauma, SAH vasospasm, and ACI. Methods for directly monitoring CM and CMRo2 are improving our understanding of the brain's responses to injury, and becoming increasingly relevant to bedside management. SjvO2 can detect cerebral ischemia caused by overzealous hyperventilation and accelerated ICP. ICO holds promise as a noninvasive transcranial method for assessing Scvo2. We soon may see a scalp array of such detectors, similar to an EEG "montage," that allows us to assess multiregional Scvo2. To be useful, a clinical method should raise questions for further investigation. If the neurophysiologic monitoring systems described here provide us with some answers and lead us to ask useful new questions, they will prove their benefit to our patients.
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PMID:Neurophysiologic monitoring in the neuroscience intensive care unit. 747 20

The authors present the policy they have worked out for hydrocephalus patients with special reference to the pressure measurement and test methods and to rCBF, SPECT and transcranial Doppler sonography (TDC) studies. For diagnosis, the protocol proposed by Gjerris and Borgesen was followed in 75 cases: besides other methods (CT, radionuclide cisternography, MRI) the intracranial pressure waves routinely recorded and analyzed by means of ventricular catheters for 24 h. The patients were roughly divided into groups in terms of diagnosis, baseline pressure, compliance, results of infusion tests and of surgery. In 13 patients the investigations were supplemented by rCBF SPECT and in 42 patients by TCD studies before and after CSF shunting or withdrawal to analyze the acute effects on cerebral circulation. Clinical follow-up shows that need for shunting was indicated fairly well by the common results of baseline ICP, compliance and infusion loading. The rCBF SPECT studies revealed a significant increase of the cerebral perfusion at the basal ganglia after shunting while, on the basis of CBF velocity changes three types of vasoregulatory response could be defined with TCD. In our hands, monitoring of the pressure and craniospinal capacity has proved to be a valuable aid in decisions on surgery; however, for a more precise (and beneficial) appreciation of whether surgery is indicated the vasoregulatory responses should also be taken into account in future.
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PMID:Our policy in diagnosis and treatment of hydrocephalus. 775 7

Transcranial Doppler ultrasonography is an extremely useful adjunct in neurosurgical intensive care. Continuous improvements in TCD equipment as well as computer software have improved examination success and also vessel identification. Recent expanding applications of TCD have also allowed the study of disorders of control of the cerebral circulation. TCD can be used to detect vessel narrowing from a variety of causes, including vasospasm, and also can be used to detect cerebral emboli and to evaluate CO2 reactivity, autoregulation, and the response to certain medications, as well as to indicate progressive obstruction of the cerebral circulation as seen in conditions leading to brain death. In the future, TCD may offer the ability to estimate the ICP using noninvasive means by evaluating velocity in the middle cerebral artery and arterial blood pressure tracings. The noninvasive determination of cerebral autoregulation may be useful in evaluating strategies to improve cerebral autoregulation as well as aid in the optimal management of ICP control and preservation of optimal cerebral circulation.
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PMID:Transcranial Doppler ultrasonography. 782 74

Within 27 months 122 patients with severe head injury were treated at our clinic. Of these patients twelve (9.8%) were categorized as having a primary brain stem lesion (9 male and 3 female, mean age 28.3 years (17 to 73 years). Their injuries were caused primarily by traffic accidents. Initial and follow-up CT ruled out mass lesions or other causes for transtentorial herniation, supporting the diagnosis of primary brain stem lesion. Respiratory insufficiency and control of vegetative function demanded artificial ventilation and analog-sedation for up to 32 days (mean 18 days) on our Intensive Care Unit. In all patients we performed initial and follow-up CT scans, ICP monitoring, evoked potentials (AEP, SSEP) and TCD. MRI was carried out in four patients. One patient died during the acute hospital phase, 7 were transferred in poor and four in good condition. During rehabilitation one patient died, two, one in a vegetative state and one in poor condition were transferred to a caring facility. Eight patients with a good or moderate recovery were dismissed home, subsequently regaining their prior social function. The primary traumatic brain stem lesion presents as a dramatic clinical picture. As shown in our series the prognosis is good independent of the duration of coma. The important prognostic factors were the primary neurological state according to the Gerstenbrand and Luecking classification, the degree of the brain stem lesion in CT scan and MRI, and normal evoked potentials, indicating a favourable outcome.
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PMID:[Primary traumatic midbrain syndrome--follow-up and prognosis of acute primary brain stem damage]. 902 54

In the past several years, improvements in technology have advanced the monitoring capabilities for patients with TBI. The primary goal of monitoring the patient with TBI is to prevent secondary insults to the brain, primarily cerebral ischemia. Cerebral ischemia may occur early and without clinical correlation and portends a poor outcome. Measurement of ICP is the cornerstone of monitoring in the patient with TBI. Monitoring of ICP provides a measurement of CPP and a rough estimation of CBF. However, with alterations in pressure autoregulation, measurement of CPP does not always allow for determination of CBF. To circumvent this problem, direct measurements of CBF can be performed using clearance techniques (133Xe, N2O, Xe-CT) or invasive monitoring techniques (LDF, TDF, NIRS). Although direct and quantitative, clearance techniques do not allow for continuous monitoring. Invasive CBF monitoring techniques are new, and artifactual results can be problematic. The techniques of jugular venous saturation monitoring and TCD are well established and are powerful adjuncts to ICP monitoring. They allow the clinician to monitor cerebral oxygen extraction and blood flow velocity, respectively, for any given CPP. Use of TCD may predict posttraumatic vasospasm before clinical sequelae. Jugular venous saturation monitoring may detect clinically occult episodes of cerebral ischemia and increased oxygen extraction. Jugular venous saturation monitoring optimizes the use of hyperventilation in the treatment of intracranial hypertension. Although PET and SPECT scanning allow direct measurement of CMRO2, these techniques have limited application currently. Similarly, microdialysis is in its infancy but has demonstrated great promise for metabolic monitoring. EEG and SEP are excellent adjuncts to the monitoring arsenal and provide immediate information on current brain function. With improvements in electronic telemetry, functional monitoring by EEG or SEP may become an important part of routine monitoring in TBI.
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PMID:Monitoring in traumatic brain injury. 1008 12

Several indices have been reported which correlate with autoregulatory function [2, 3]. However, before critical thresholds for targeting therapy can be defined, a better understanding of the inherent variability of cerebrovascular reactivity as measured by these indices is required. In this study, patients had BP, ICP and bilateral MCA TCD velocity monitored before, during and after BP and CO2 challenges, applied in a random order, with measurements taken within 48 hours of injury. Four indices of reactivity were calculated: the PRx, the CORRx and the FVreact & ICPreact. At 48 hours post-injury inter-patient variation in cerebrovascular reactivity, as measured by these indices, is large and injury specific factors remain important determinants of the variance. Within patient analysis has identified instances where the combined monitoring of the PRx and the CORRx may provide information about the function of pressure autoregulation and further study of the combined use of these two indices of reactivity is warranted.
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PMID:Assessment of the variation in cerebrovascular reactivity in head injured patients. 1145 64

Neuroscientists continue the search for the "magic bullet" that will prevent the deleterious effects of primary and secondary brain injury. Indirect measurement of the effects of primary and secondary brain injury through the study of ICP- or CPP-directed management, CBF monitoring, Sjo2 monitoring, and TCD monitoring has led to improved care of persons with brain injury. Although the findings from brain injury research using microsensor and microdialysis technology are only preliminary and extensive research is still needed, these technologies have dramatically expanded knowledge about brain injury at the cellular level. Extended neuromonitoring is poised to enter a new and exciting phase because of the growth in knowledge regarding the cellular events associated with brain injury. The recent approval of NeuroTrend by the FDA will further promote this growth. Applications of the technology have already expanded to include uses beyond the management of traumatic brain injury. Microsensor and microdialysis technology is being used intraoperatively to determine "safe" temporary clipping times for aneurysm surgery and is also being used within the critical care setting to improve the monitoring and management of subarachnoid hemorrhage patients who are experiencing vasospasm. The ultimate application of this new technology is to improve long-term outcomes for patients with brain injury through the reduction of secondary brain injury. If that goal is to be accomplished, then it will be important for nurses caring for patients with brain injury to become immersed in this exciting new phase in brain injury monitoring. Nurses must obtain a comprehensive knowledge base of brain injury pathophysiology and how extended neuromonitoring can lead to improved outcomes. Technical proficiency will also be important to ensure that treatment and research conclusions are based on accurate data. Finally and perhaps most importantly, it will be critical for nurses to participate in and develop research studies that explore the impact of interventions, especially nursing care activities, on the injured brain if these exciting new advances are to be translated into tangible benefits for brain-injured patients.
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PMID:Microsensor and microdialysis technology. Advanced techniques in the management of severe head injury. 1185 47

A new absolute ICP (aICP) measurement method was designed which does not need calibration. In this study we compared a new method with invasive aICP method in ICU on the patients with closed severe traumatic brain injury. A new method is based on two-depth TCD technique for aICP and external absolute pressure aPe comparison using the eye artery (EA) as natural "balance". The intracranial segment of EA is compressed by aICP and the extracranial segment is compressed by aPe applied to the tissues surrounding the eye. The blood flow parameters in both EA segments are approximately the same when aPe = aICP. Two-depth TCD device is used as an indicator of balance aPe = aICP when the pulsatility index of blood flow velocity waveform in intracranial and extracranial segments are the same. Fifty seven simultaneous invasive and non-invasive aICP measurements were performed in aICP range from 3.0 to 37.0 mmHg. Bland Altman plot of the differences between simultaneous invasive and non-invasive aICP measurements shows the negligible mean difference (mean = 0.94 mmHg) with a standard deviation of 6.18 mmHg. This validation study shows that it is possible to measure aICP non-invasively without calibration of the system with 95% confidence interval of 12 mmHg.
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PMID:Innovative non-invasive method for absolute intracranial pressure measurement without calibration. 1646 81


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