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  • 1
    In: Stroke, 2012, Vol.43(8), pp.2097-2101
    Description: BACKGROUND AND PURPOSE—: The purpose of this study was to investigate the relationship between cerebrovascular autoregulation and outcome after aneurysmal subarachnoid hemorrhage. METHODS—: In a prospective observational study, 80 patients after severe subarachnoid hemorrhage were continuously monitored for cerebral perfusion pressure and partial pressure of brain tissue oxygen for an average of 7.9 days (range, 1.9–14.9 days). Autoregulation was assessed using the index of brain tissue oxygen pressure reactivity (ORx), a moving correlation coefficient between cerebral perfusion pressure and partial pressure of brain tissue oxygen. High ORx indicates impaired autoregulation; low ORx signifies intact autoregulation. Outcome was determined at 6 months and dichotomized into favorable (Glasgow Outcome Scale 4–5) and unfavorable outcome (Glasgow Outcome Scale 1–3). RESULTS—: Twenty-four patients had a favorable and 56 an unfavorable outcome. In a univariate analysis, there were significant differences in autoregulation (ORx 0.19±0.10 versus 0.37±0.11, P〈0.001, for favorable versus unfavorable outcome, respectively), age (44.1±11.0 years versus 54.2±12.1 years, P=0.001), occurrence of delayed cerebral infarction (8% versus 46%, P〈0.001), use of coiling (25% versus 54%, P=0.02), partial pressure of brain tissue oxygen (24.9±6.6 mm Hg versus 21.8±6.3 mm Hg, P=0.048), and Fisher grade (P=0.03). In a multivariate analysis, ORx (P〈0.001) and age (P=0.003) retained an independent predictive value for outcome. ORx correlated with Glasgow Outcome Scale (r=−0.70, P〈0.001). CONCLUSIONS—: The status of cerebrovascular autoregulation might be an important pathophysiological factor in the disease process after subarachnoid hemorrhage, because impaired autoregulation was independently associated with an unfavorable outcome.
    Keywords: Medicine;
    ISSN: 0039-2499
    E-ISSN: 15244628
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  • 2
    Language: English
    In: Journal of Neurology, Neurosurgery & Psychiatry, 1 August 2013, Vol.84(8), p.850
    Description: To investigate whether gravitational valves reduce the risk of overdrainage complications compared with programmable valves in ventriculoperitoneal (VP) shunt surgery for idiopathic normal pressure hydrocephalus (iNPH).
    Keywords: Csf Dynamics ; Cerebrovascular Disease ; Dementia ; Neurosurgery ; Randomised Trials ; Open Access
    ISSN: 0022-3050
    ISSN: 00223050
    E-ISSN: 1468-330X
    E-ISSN: 1468330X
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  • 3
    In: Critical Care Medicine, 2010, Vol.38(5), pp.1343-1347
    Description: OBJECTIVE:: To evaluate the concept of a cerebrovascular pressure reactivity-guided optimal cerebral perfusion pressure after traumatic brain injury by analyzing the relationship between optimal cerebral perfusion pressure and brain tissue oxygen. DESIGN:: Prospective observational cohort study. SETTING:: Neurosurgical intensive care unit of a university hospital. PATIENTS:: Thirty-eight patients after head injury. Interventions: Continuous computerized monitoring of mean arterial pressure, intracranial pressure, and brain tissue oxygen for 5.3 ± 2.6 days. The index of cerebrovascular pressure reactivity was calculated as a moving correlation coefficient between spontaneous low-frequency fluctuations of mean arterial pressure and intracranial pressure. Optimal cerebral perfusion pressure was defined as the cerebral perfusion pressure level with the lowest average index of cerebrovascular pressure reactivity. MEASUREMENTS AND MAIN RESULTS:: Optimal cerebral perfusion pressure could be identified in 32 of 38 patients. Median optimal cerebral perfusion pressure was between 70 and 75 mm Hg (range, 60–100 mm Hg). Below the level of optimal cerebral perfusion pressure, brain tissue oxygen decreased in parallel to cerebral perfusion pressure, whereas brain tissue oxygen reached a plateau above optimal cerebral perfusion pressure. Optimal cerebral perfusion pressure correlated significantly with the cerebral perfusion pressure level, where brain tissue oxygen reached its plateau (r = .79; p 〈 .01). Average brain tissue oxygen at optimal cerebral perfusion pressure was 24.5 ± 6.0 mm Hg. CONCLUSIONS:: This study supports the concept of cerebrovascular pressure reactivity-based individual optimal cerebral perfusion pressure. Driving cerebral perfusion pressure in excess of optimal cerebral perfusion pressure does not yield improvements in brain tissue oxygen after head injury and should be avoided, whereas cerebral perfusion pressure below optimal cerebral perfusion pressure may result in secondary cerebral ischemia.
    Keywords: Blood Pressure ; Cerebrovascular Circulation ; Intracranial Pressure ; Brain -- Metabolism ; Brain Injuries -- Metabolism;
    ISSN: 0090-3493
    E-ISSN: 15300293
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  • 4
    Language: English
    In: Intensive Care Medicine, June, 2015, Vol.41(6), p.1067(10)
    Description: Byline: Fabian Guiza (1), Bart Depreitere (2), Ian Piper (3), Giuseppe Citerio (4), Iain Chambers (5), Patricia A. Jones (6), Tsz-Yan Milly Lo (7), Per Enblad (8), Pelle Nillson (8), Bart Feyen (9), Philippe Jorens (10), Andrew Maas (9), Martin U. Schuhmann (11), Rob Donald (12), Laura Moss (13), Greet Berghe (1), Geert Meyfroidt (1) Keywords: Traumatic brain injury; Adults; Children; Intracranial pressure; Cerebral perfusion pressure; Cerebrovascular autoregulation Abstract: Purpose To assess the impact of the duration and intensity of episodes of increased intracranial pressure on 6-month neurological outcome in adult and paediatric traumatic brain injury. Methods Analysis of prospectively collected minute-by-minute intracranial pressure and mean arterial blood pressure data of 261 adult and 99 paediatric traumatic brain injury patients from multiple European centres. The relationship of episodes of elevated intracranial pressure (defined as a pressure above a certain threshold during a certain time) with 6-month Glasgow Outcome Scale was visualized in a colour-coded plot. Results The colour-coded plot illustrates the intuitive concept that episodes of higher intracranial pressure can only be tolerated for shorter durations: the curve that delineates the duration and intensity of those intracranial pressure episodes associated with worse outcome is an approximately exponential decay curve. In children, the curve resembles that of adults, but the delineation between episodes associated with worse outcome occurs at lower intracranial pressure thresholds. Intracranial pressures above 20 mmHg lasting longer than 37 min in adults, and longer than 8 min in children, are associated with worse outcomes. In a multivariate model, together with known baseline risk factors for outcome in severe traumatic brain injury, the cumulative intracranial pressure--time burden is independently associated with mortality. When cerebrovascular autoregulation, assessed with the low-frequency autoregulation index, is impaired, the ability to tolerate elevated intracranial pressures is reduced. When the cerebral perfusion pressure is below 50 mmHg, all intracranial pressure insults, regardless of duration, are associated with worse outcome. Conclusions The intracranial pressure--time burden associated with worse outcome is visualised in a colour-coded plot. In children, secondary injury occurs at lower intracranial pressure thresholds as compared to adults. Impaired cerebrovascular autoregulation reduces the ability to tolerate intracranial pressure insults. Thus, 50 mmHg might be the lower acceptable threshold for cerebral perfusion pressure. Author Affiliation: (1) Department of Intensive Care Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium (2) Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium (3) Department of Clinical Physics, Southern General Hospital, Glasgow, UK (4) San Gerardo Hospital, Monza, Italy (5) James Cook University Hospital, Medical Physics, Middlesbroughnza, UK (6) Department of Paediatric Neurology, Royal Hospital for Sick Children, Edinburgh, UK (7) Department of Paediatric Intensive Care, Royal Hospital for Sick Children, Edinburgh, UK (8) Department of Neuroscience, Neurosurgery, Uppsala, Sweden (9) Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium (10) Department of Intensive Care Medicine, Antwerp University Hospital, Edegem, Belgium (11) Klinik fur Neurochirurgie, Universitatsklinikum Tubingen, Tubingen, Germany (12) School of Mathematics and Statistics, University of Glasgow, Glasgow, UK (13) Department of Clinical Physics and Bioengineering, NHS Greater Glasgow & Clyde, Glasgow, UK Article History: Registration Date: 06/04/2015 Received Date: 16/02/2015 Accepted Date: 05/04/2015 Online Date: 18/04/2015 Article note: F. Guiza and B. Depreitere contributed equally. Take-home message: In adult and paediatric patients suffering from severe traumatic brain injury, an approximately exponential curve describes the relationship between intensity and duration of episodes of increased intracranial pressure (ICP) and worse clinical outcomes. In children, compared to adults, this occurs at lower ICP thresholds of shorter duration. Electronic supplementary material The online version of this article (doi: 10.1007/s00134-015-3806-1) contains supplementary material, which is available to authorized users.
    Keywords: Intracranial Hypertension -- Research ; Brain Injuries -- Research ; Pediatric Injuries -- Research ; Medical Research
    ISSN: 0342-4642
    Source: Cengage Learning, Inc.
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  • 5
    Language: English
    In: Acta neurochirurgica. Supplement, 2018, Vol.126, pp.281-286
    Description: A drawback in the use of an external ventricular drain (EVD) originates in the fact that draining cerebrospinal fluid (CSF) (open system) and intracranial pressure (ICP) monitoring can be done at the same time but is considered to be unreliable regarding the ICP trace. Furthermore, with the more widespread use of autoregulation monitoring using blood pressure and ICP signals, the question arises of whether an ICP signal from an open EVD can be used for this purpose. Using an EVD system with an integrated parenchymal ICP probe we compared the different traces of an ICP signal and their derived parameters under opened and closed CSF drainage. Twenty patients with either subarachnoid or intraventricular hemorrhage and indication for ventriculostomy plus ICP monitoring received an EVD in combination with an air-pouch-based ICP probe. ICP was monitored via an open ventricular catheter (ICP_evd) and ICP probe (ICP_probe) simultaneously. Neuromonitoring data (ICP, arterial blood pressure, cerebral perfusion pressure, pressure reactivity index (PRx)) were recorded by ICM+ software for the time of ICU intensive care treatment. Routinely (at least every 4 h) ICP was recorded with a closed CSF drainage system for at least 15 min. ICP, ICP amplitude, and the autoregulation parameters (PRx_probe, PRx_evd) were evaluated for every episode with closed CSF drainage and during the 3 h prior with an open drainage system. One hundred and forty-four episodes with open/closed drainage were evaluated. During open drainage, overall mean ICP_evd levels were nonsignificantly different from those of ICP_probe, with 9.8 + 3.3 versus 8.2 + 3.2 mmHg, respectively. Limits of agreement ranged between 5.2 and -8.3 mmHg. However, 51 increases of ICP 〉20 mmHg with a duration of 3-30 min were missed by ICP_evd, and in 101 episodes the difference between ICPs was greater than 10 mmHg. After closure of the EVD, ICP increased moderately using both methods. Mean PRx_evd was significantly higher (falsely indicating impaired autoregulation) and more subjected to fluctuations than PRx_probe. The general practice of draining CSF and monitoring ICP via a (usually open) EVD plus frequently performed catheter closure for ICP reading is feasible for assessment of overall ICP trends. However, it does have clinically relevant drawbacks, namely, a significant amount of undetected increases in ICP above thresholds, and continuous assessment of cerebrovascular autoregulation is less reliable. In conclusion, all patients who need CSF drainage plus ICP monitoring due to the severity of their brain insult need either an EVD with integrated ICP probe or an EVD line plus a separate ICP probe.
    Keywords: Cerebral Autoregulation ; Extraventricular Drainage ; Icp Monitoring ; Intraparenchymal Icp Probe ; Probe ; Ventriculostomy ; Cerebral Intraventricular Hemorrhage -- Physiopathology ; Intracranial Pressure -- Physiology ; Monitoring, Physiologic -- Methods ; Subarachnoid Hemorrhage -- Physiopathology
    ISSN: 0065-1419
    Source: MEDLINE/PubMed (U.S. National Library of Medicine)
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  • 6
    Language: English
    In: European Journal of Pediatrics, 2018, Vol.177(4), pp.567-573
    Description: A fibrolipomatous hamartoma (FLH) is a rare lesion leading to an enlargement of the affected nerve and commonly manifests at the median nerve. Symptomatic patients are mostly adolescents or adults. In children below 10 years, this entity is rather unknown and likely to be misdiagnosed. We report three children with FLH, two severely and one mildly symptomatic, all below 4 years of age at the time of first presentation. Two of three children were initially misdiagnosed. We provide a review of the pertinent clinical and radiological findings of the entity. Two patients had a characteristic macrodactyly. The two symptomatic children underwent surgical carpal tunnel decompression. The intervention relived their symptoms with a long-lasting effect. Surgical reduction of the hamartoma mass is not indicated and medical treatment non-existent. Conclusion : A symptomatic FLH of the median nerve is rare in children below the age of 5 years but has to be kept in mind as differential diagnosis in case of wrist and/or palm swelling, macrodactyly, and pain in hand or forearm. MRI is diagnostic, with very characteristic features, which can also be identified in high-resolution nerve ultrasound. This article aims to increase the knowledge about the entity including the diagnostic features and the management options. What is Known: • Fibrolipomatous hamartomas (FLHs) of the median nerve are rare, possibly associated with macrodactyly and tissue growth at the wrist and thenar side of the palm. • An associated carpal tunnel syndrome typically occurs, if at all, in adulthood. What is New: • We describe two children below 4 years with symptomatic carpal tunnel syndrome, experiencing a long-lasting favorable outcome after carpal tunnel decompression. In this age group, only one other child undergoing surgery has been published so far. • MRI and high-resolution ultrasound demonstrate the characteristic features of FLHs and are the diagnostic modalities of choice. Biopsy is not recommended.
    Keywords: Fibrolipomatous hamartoma ; Carpal tunnel syndrome ; Median nerve ; Macrodactyly ; Nerve ultrasound
    ISSN: 0340-6199
    E-ISSN: 1432-1076
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  • 7
    Language: English
    In: Brain Research
    Description: The inflammatory response following traumatic brain injury (TBI) contributes to neuronal death with poor outcome. Although anti-inflammatory strategies were beneficial in the experimental TBI, clinical translations mostly failed, probably caused by the complexity of involved cells and mediators. We recently showed in a rat model of controlled cortical impact (CCI) that leukotriene inhibitors (LIs) attenuate contusion growth and improve neuronal survival. This study focuses on spatiotemporal characteristics of macrophages and granulocytes, typically involved in inflammatory processes, and neuronal COX-2 expression. Effects of treatment with LIs (Boscari/MK-886), started prior trauma, were evaluated by quantifying CD68 , CD43 and COX-2 cells 24 h and 72 h post-CCI in the parietal cortex (PC), CA3 region, dentate gyrus (DG) and visual/auditory cortex (v/aC). Correlations were applied to identify intercellular relationships. At 24 h, untreated animals showed granulocyte invasion in all regions, decreasing towards 72 h. Macrophages increased from 24 h to 72 h post-CCI in PC and v/aC. COX-2 neurones showed no temporal changes, except of an increase in the CA3 region at 72 h. Treatment reduced granulocytes at 24 h in the pericontusional zone and hippocampus, and macrophages at 72 h in the PC and v/aC. COX-2 expression remained unaffected by LIs, except of time-specific changes in the DG (increase/decrease at 24/72 h). Interrelations confirmed concomitant cellular reactions beyond the initial trauma site. In conclusion, LIs attenuated the cellular inflammatory response following CCI. Future studies have to clarify region-specific effects and explore the potential of a clinically more relevant therapeutic approach applying LIs after CCI. ► Invasion of granulocytes and macrophages depends on time and region after trauma. ► Neuronal COX-2 expression increases only in the CA3 region until 72 h after trauma. ► Leukotriene inhibitors reduce granulocytes and macrophages dependent on time/region. ► Leukotriene inhibitors affect neuronal COX-2 exclusively in the dentate gyrus.
    Keywords: Traumatic Brain Injury ; Neuronal Death ; Macrophage ; Granulocyte ; Cox-2 ; Anatomy & Physiology
    ISSN: 0006-8993
    E-ISSN: 1872-6240
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  • 8
    Language: English
    In: Brain research, 2013, Vol.1498, pp.69-84
    Description: The inflammatory response following traumatic brain injury (TBI) contributes to neuronal death with poor outcome. Although anti-inflammatory strategies were beneficial in the experimental TBI, clinical translations mostly failed, probably caused by the complexity of involved cells and mediators. We recently showed in a rat model of controlled cortical impact (CCI) that leukotriene inhibitors (LIs) attenuate contusion growth and improve neuronal survival. This study focuses on spatiotemporal characteristics of macrophages and granulocytes, typically involved in inflammatory processes, and neuronal COX-2 expression. Effects of treatment with LIs (Boscari/MK-886), started prior trauma, were evaluated by quantifying CD68⁺, CD43⁺ and COX-2⁺ cells 24h and 72h post-CCI in the parietal cortex (PC), CA3 region, dentate gyrus (DG) and visual/auditory cortex (v/aC). Correlations were applied to identify intercellular relationships. At 24h, untreated animals showed granulocyte invasion in all regions, decreasing towards 72h. Macrophages increased from 24h to 72h post-CCI in PC and v/aC. COX-2⁺ neurones showed no temporal changes, except of an increase in the CA3 region at 72h. Treatment reduced granulocytes at 24h in the pericontusional zone and hippocampus, and macrophages at 72h in the PC and v/aC. COX-2 expression remained unaffected by LIs, except of time-specific changes in the DG (increase/decrease at 24/72h). Interrelations confirmed concomitant cellular reactions beyond the initial trauma site. In conclusion, LIs attenuated the cellular inflammatory response following CCI. Future studies have to clarify region-specific effects and explore the potential of a clinically more relevant therapeutic approach applying LIs after CCI. ; p. 69-84.
    Keywords: Cortex ; Inflammation ; Death ; Granulocytes ; Hippocampus ; Animal Models ; Neurons ; Macrophages ; Rats ; Temporal Variation
    ISSN: 0006-8993
    Source: AGRIS (Food and Agriculture Organization of the United Nations)
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  • 9
    Language: English
    In: Child's Nervous System, 2012, Vol.28(6), pp.925-931
    Description: Byline: Onno Kuster (1,4), Jens Schittenhelm (1,5), Oliver Schwartz (2), Richard Meyermann (1), Martin U. Schuhmann (3) Author Affiliation: (1) Department of Neuropathology, Institute of Pathology and Neuropathology, University Hospital of Tubingen, Tubingen, Germany (2) Childrens Hospital, University of Munster, Munster, Germany (3) Department of Neurosurgery, Section of Pediatric Neurosurgery, University Hospital of Tubingen, Tubingen, Germany (4) Department of Neurology, University Hospital of Wurzburg, Wurzburg, Germany (5) Department of Neuropathology, Institute of Pathology and Neuropathology, University Hospital of Tubingen, Calwer-Str. 3, 72076, Tubingen, Germany Article History: Registration Date: 22/12/2011 Received Date: 17/10/2011 Accepted Date: 21/12/2011 Online Date: 05/01/2012
    Keywords: Medicine;
    ISSN: 0256-7040
    E-ISSN: 1433-0350
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  • 10
    Language: English
    In: Child's Nervous System, 2018, Vol.34(3), pp.401-408
    Description: To access, purchase, authenticate, or subscribe to the full-text of this article, please visit this link: http://dx.doi.org/10.1007/s00381-017-3650-4 Byline: Laura V. Sainz (1,2), Konstantin Hockel (1), Martin U. Schuhmann (1) Keywords: Ventriculo-peritoneal shunt; Starling resistor; Raised intracranial pressure; Cerebral venous overdrainage Abstract: Introduction Chronic overdrainage affects shunted patients producing a variety of symptoms that may be misdiagnosed. The best known symptoms are so-called shunt-related headaches. There is mounting evidence that changes in cerebrospinal venous system dynamics are a key factor to the pathophysiology of chronic overdrainage syndrome. Clinical presentation We report the case of a 29-year-old woman with a shunt since the postnatal period suffering from chronic but the most severe intermittent headache attacks, despite an open shunt and with unchanged ventricular width during attacks. Intracranial pressure (ICP) recordings were performed during headache attacks and thereafter. Diagnosis and managment Massively increased ICPs, a continuous B wave "storm," and severely compromised intracranial compliance despite an open shunt were found, a scenario that was always self-limiting with the resolution of symptoms after several hours. When mobilized to the upright position, her ICPs dropped to - 17 mm Hg, proving shunt overdrainage. Outcome and conclusions Symptomatology can only be explained by sudden venous entrapment following chronic venous distention as a result of chronic overdrainage. Subsequent therapeutic management with an overdrainage preventing shunt and satisfying clinical outcome with complete ceasing of headache attacks adds insight into the pathophysiology of chronic overdrainage syndrome. Author Affiliation: (1) 0000 0001 0196 8249, grid.411544.1, Division of Pediatric Neurosurgery, Department of Neurosurgery, Eberhard Karls University Hospital of Tubingen, Tubingen, Germany (2) grid.419651.e, Department of Neurosurgery, Hospital Universitario Fundacion Jimenez Diaz, Madrid, Spain Article History: Registration Date: 25/10/2017 Received Date: 23/09/2017 Accepted Date: 25/10/2017 Online Date: 11/11/2017
    Keywords: Ventriculo-peritoneal shunt ; Starling resistor ; Raised intracranial pressure ; Cerebral venous overdrainage
    ISSN: 0256-7040
    E-ISSN: 1433-0350
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