Cerebral Blood Flow and Metabolism Following Decompressive Craniectomy for Control of Increased Intracranial Pressure

Neurosurgery ◽  
2010 ◽  
Vol 67 (1) ◽  
pp. 65-72 ◽  
Author(s):  
Jean F. Soustiel ◽  
Gill E. Sviri ◽  
Eugenia Mahamid ◽  
Veniamin Shik ◽  
Sergey Abeshaus ◽  
...  
Keyword(s):  
Blood Flow ◽  
Cerebral Blood Flow ◽  
Intracranial Pressure ◽  
Decompressive Craniectomy ◽  
Injury Severity ◽  
Normal Range ◽  
Severe Injuries ◽  
Neuronal Viability ◽  
Cellular Energy ◽  
The Impact

Abstract OBJECTIVE Decompressive craniectomy (DC) is a common practice for control of intracranial pressure (ICP) following traumatic brain injury (TBI), although the impact of this procedure on the fate of operated patients is still controversial. METHODS Cerebral blood flow (CBF) and metabolic rates were monitored prospectively and daily as a surrogate of neuronal viability in 36 TBI patients treated by DC and compared with those of 86 nonoperated patients. DC was performed either on admission (n = 29) or within 48 hours of admission (n = 7). RESULTS DC successfully controlled ICP levels and maintained CBF within a normal range although the cerebral metabolic rate of oxygen (CMRO2) was significantly lower in this group. In 7 patients, pre- and postoperative recordings showed a significant ICP decrease that correlated with CBF augmentation but not with concurrent improvement of CMRO2 that remained particularly low. Logistic regression analysis of all investigated variables showed that DC was not associated with higher mortality despite more severe injuries in this group. However, operated patients were 7-fold more likely to have poor functional outcomes than nonoperated patients. Good functional outcome was strongly associated with higher CMRO2 but not with higher CBF values. CMRO2 levels were significantly lower in the DC group, even after adjustment for injury severity, and showed a progressive and sustained trend of deterioration significantly different from that of the non-DC group. CONCLUSION These results suggest that DC may enhance survival in the presence of severe brain swelling, although it is unlikely to represent an adequate answer to mitochondrial damage responsible for cellular energy crisis and edema.

scholarly journals Quantitative cerebral blood flow using xenon-enhanced CT after decompressive craniectomy in traumatic brain injury

2018 ◽  
Vol 129 (1) ◽  
pp. 241-246 ◽  
Author(s):  
Aditya Vedantam ◽  
Claudia S. Robertson ◽  
Shankar P. Gopinath
Keyword(s):  
Traumatic Brain Injury ◽  
Blood Flow ◽  
Cerebral Blood Flow ◽  
Brain Injury ◽  
Clinical Outcome ◽  
Decompressive Craniectomy ◽  
Decompressive Surgery ◽  
Hemodynamic Parameters ◽  
Enhanced Ct ◽  
The Mean

OBJECTIVEFew studies have reported on changes in quantitative cerebral blood flow (CBF) after decompressive craniectomy and the impact of these measures on clinical outcome. The aim of the present study was to evaluate global and regional CBF patterns in relation to cerebral hemodynamic parameters in patients after decompressive craniectomy for traumatic brain injury (TBI).METHODSThe authors studied clinical and imaging data of patients who underwent xenon-enhanced CT (XeCT) CBF studies after decompressive craniectomy for evacuation of a mass lesion and/or to relieve intractable intracranial hypertension. Cerebral hemodynamic parameters prior to decompressive craniectomy and at the time of the XeCT CBF study were recorded. Global and regional CBF after decompressive craniectomy was measured using XeCT. Regional cortical CBF was measured under the craniectomy defect as well as for each cerebral hemisphere. Associations between CBF, cerebral hemodynamics, and early clinical outcome were assessed.RESULTSTwenty-seven patients were included in this study. The majority of patients (88.9%) had an initial Glasgow Coma Scale score ≤ 8. The median time between injury and decompressive surgery was 9 hours. Primary decompressive surgery (within 24 hours) was performed in the majority of patients (n = 18, 66.7%). Six patients had died by the time of discharge. XeCT CBF studies were performed a median of 51 hours after decompressive surgery. The mean global CBF after decompressive craniectomy was 49.9 ± 21.3 ml/100 g/min. The mean cortical CBF under the craniectomy defect was 46.0 ± 21.7 ml/100 g/min. Patients who were dead at discharge had significantly lower postcraniectomy CBF under the craniectomy defect (30.1 ± 22.9 vs 50.6 ± 19.6 ml/100 g/min; p = 0.039). These patients also had lower global CBF (36.7 ± 23.4 vs 53.7 ± 19.7 ml/100 g/min; p = 0.09), as well as lower CBF for the ipsilateral (33.3 ± 27.2 vs 51.8 ± 19.7 ml/100 g/min; p = 0.07) and contralateral (36.7 ± 19.2 vs 55.2 ± 21.9 ml/100 g/min; p = 0.08) hemispheres, but these differences were not statistically significant. The patients who died also had significantly lower cerebral perfusion pressure (52 ± 17.4 vs 75.3 ± 10.9 mm Hg; p = 0.001).CONCLUSIONSIn the presence of global hypoperfusion, regional cerebral hypoperfusion under the craniectomy defect is associated with early mortality in patients with TBI. Further study is needed to determine the value of incorporating CBF studies into clinical decision making for severe traumatic brain injury.

Effects of Cranioplasty on Cerebral Blood Flow Following Decompressive Craniectomy: A Systematic Review of the Literature

Neurosurgery ◽  
2017 ◽  
Vol 81 (2) ◽  
pp. 204-216 ◽  
Author(s):  
Sameer H. Halani ◽  
Jason K. Chu ◽  
James G. Malcolm ◽  
Rima S. Rindler ◽  
Jason W. Allen ◽  
...  
Keyword(s):  
Systematic Review ◽  
Blood Flow ◽  
Cerebral Blood Flow ◽  
Decompressive Craniectomy ◽  
Review Of The Literature

Cerebral blood flow and evoked potentials during Cushing response in sheep

1989 ◽  
Vol 256 (3) ◽  
pp. H779-H788
Author(s):  
R. C. Koehler ◽  
J. E. Backofen ◽  
R. W. McPherson ◽  
M. D. Jones ◽  
M. C. Rogers ◽  
...  
Keyword(s):  
Blood Flow ◽  
Cardiac Output ◽  
Cerebral Blood Flow ◽  
Intracranial Pressure ◽  
Arterial Pressure ◽  
Evoked Potentials ◽  
Aortic Pressure ◽  
Base Line ◽  
Auditory Evoked Responses ◽  
Cushing Response

We determined how alterations in systemic hemodynamics, characteristic of the Cushing response, are related to changes in cerebral blood flow (CBF), cerebral metabolic rate of O2 (CMRO2), and brain electrical conductive function, as assessed by somatosensory-evoked potentials (SEP) and brain stem auditory-evoked responses (BAER). In three groups of eight pentobarbital-anesthetized sheep, intracranial pressure was gradually elevated to within 50, 25, or 0 mmHg of base-line mean arterial pressure and then held constant for 40 min by intraventricular infusion of mock cerebrospinal fluid. Microsphere-determined CBF fell when cerebral perfusion pressure was less than 50 mmHg. CMRO2 fell when CBF fell greater than 30-40%. Mean aortic pressure and cardiac output increased when CBF fell greater than 40%, i.e., at approximately the level at which CMRO2 fell. Furthermore, the magnitude of the increase in arterial pressure and cardiac output correlated with the reduction of CMRO2. SEP latency did not increase unless CBF fell greater than 55-65%, corresponding to a 20-30% reduction of CMRO2. Increased latency of BAER wave V was associated with a fall in midbrain blood flow of greater than 65-70%. Thus increase in SEP and BAER latencies required reductions of flow greater than those required to elicit a systemic response. This demonstrates that there is a range of intracranial pressure over which the increase in arterial pressure preserves sufficient CBF to sustain minimal electrical conductive function. The best predictor of the onset and magnitude of the Cushing response in adult sheep is the decrease in CMRO2.

Interaction among autoregulation, CO2 reactivity, and intracranial pressure: a mathematical model

1998 ◽  
Vol 274 (5) ◽  
pp. H1715-H1728 ◽  
Author(s):  
Mauro Ursino ◽  
Carlo Alberto Lodi
Keyword(s):  
Mathematical Model ◽  
Blood Flow ◽  
Cerebral Blood Flow ◽  
Intracranial Pressure ◽  
Nonlinear Interaction ◽  
Cerebral Blood Volume ◽  
Cerebral Hemodynamics ◽  
Pial Arteries ◽  
Arterial Circulation ◽  
Neurosurgical Patients

The relationships among cerebral blood flow, cerebral blood volume, intracranial pressure (ICP), and the action of cerebrovascular regulatory mechanisms (autoregulation and CO2 reactivity) were investigated by means of a mathematical model. The model incorporates the cerebrospinal fluid (CSF) circulation, the intracranial pressure-volume relationship, and cerebral hemodynamics. The latter is based on the following main assumptions: the middle cerebral arteries behave passively following transmural pressure changes; the pial arterial circulation includes two segments (large and small pial arteries) subject to different autoregulation mechanisms; and the venous cerebrovascular bed behaves as a Starling resistor. A new aspect of the model exists in the description of CO2 reactivity in the pial arterial circulation and in the analysis of its nonlinear interaction with autoregulation. Simulation results, obtained at constant ICP using various combinations of mean arterial pressure and CO2 pressure, substantially support data on cerebral blood flow and velocity reported in the physiological literature concerning both the separate effects of CO2 and autoregulation and their nonlinear interaction. Simulations performed in dynamic conditions with varying ICP underline the existence of a significant correlation between ICP dynamics and cerebral hemodynamics in response to CO2 changes. This correlation may significantly increase in pathological subjects with poor intracranial compliance and reduced CSF outflow. In perspective, the model can be used to study ICP and blood velocity time patterns in neurosurgical patients in order to gain a deeper insight into the pathophysiological mechanisms leading to intracranial hypertension and secondary brain damage.

scholarly journals Child safety programs for primary school children decrease the injury severity of dog bites

2021 ◽  
Author(s):  
Bernhard Kienesberger ◽  
Christoph Arneitz ◽  
Vanessa Wolfschluckner ◽  
Christina Flucher ◽  
Peter Spitzer ◽  
...  
Keyword(s):  
Primary School ◽  
School Children ◽  
Prevention Program ◽  
Injury Severity ◽  
Primary School Children ◽  
Child Safety ◽  
Dog Bite ◽  
Severe Injuries ◽  
Dog Bites ◽  
The Impact

AbstractThis study focuses on the impact of a prevention program regarding dog bites in children. As a consequence of our previous investigation in 2005, we have initiated a child safety program for primary school children starting January 2008 until present to teach children how to avoid dog attacks and how to behave in case of an attack. In our retrospective study, we analyzed all patients younger than 15 years presenting with dog-related injuries between 2014 and 2018. As the main indicator for success of the prevention measures taken, we have defined the severity of injury in comparison to our previous study. Out of 296 children with dog-related injuries, 212 (71.6%) had sustained a dog bite. In the vast majority (n = 195; 92%), these patients presented with minor injuries; the extremities were most commonly affected (n = 100; 47%). Injuries to the head (n = 95; 45%) and trunk (n = 18; 8%) were less frequent. The proportion of severe injuries (8%) was significantly lower compared to our previous study, where 26% of children presented with severe injuries necessitating surgical intervention, while the number of patients requiring in-hospital treatment declined from 27.5% in the period 1994–2003 to 9.0% in the period between 2014 and 2018 (p < 0.05).Conclusion: Teaching of primary school children may effectively reduce the injury severity of dog bites. What is Known:• Dog bites are a substantial healthcare problem especially in children. What is New:• This study shows that a broad-based prevention program for primary school children can effectively decrease the severity but not the frequency of dog bite injuries in children.

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