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[Test-provoked correlations between regional intracranial blood volume and intracranial pressure in infants during continuous simultaneous recording].

In a clinical study carried out in five infants with severe affections, provocation tests of different qualities were employed during the simultaneous recording of the intracranial blood volume (rICBV) and the intracranial pressure (ICP). The systematic use of a hydrostatic pressure test permits, among other things, to provide the theoretical basis for a statement of the volume/pressure response of the cerebrospinal fluid. Simultaneous measurements of rICBV and ICP enable a differenciated appraisal of the individually different critical points above which one must speak of a pathological ICP increase, with special importance being attached to the reactive hyperaemia and its prevention.

Abnormalities, Multiple↗

[Analysis of 223 cases of intracranial aneurysms--with special reference to re-rupture of the intracranial aneurysms].

Reviewing 223 cases of intracranial ruptured aneurysms including 46 cases of re-ruptured aneurysms, the following results were obtained. 1) The outcome of the re-rupture aneurysms was more miserable than that of the first rupture. Even low grade cases (Hunt and Hess 0-II) of re-rupture showed no better outcome than high grade cases (Hunt and Hess IV) of first rupture. 2) Re-rupture most often occurred on the 12th (11.6 +/- 6.7) day after the first attack of the subarachnoid hemorrhage. Re-rupture more often occurred in the vertebrobasilar system. In the internal carotid artery and its branches, aneurysms with daughter or bleb tended to rupture again. Aneurysms with daughter, regardless of these location, showed greater incidence of re-rupture than those without daughter. Also rupture often occurred in the cases of lower grade with less vasospasm and with the acute hydrocephalus. 3) It was suggested that the sequential changes of some factors of both the coagulating system and fibrinolytic system might forecast the vasospasm, infarction, re-rupture and prognosis of the patient of intracranial ruptured aneurysms. And therefore, in the cases in which re-rupture is likely, operation should be performed as early as possible, except in those showing diffuse vasospasm or clinical down hill course or in grade V.

Adult↗

[Changes in regional intracranial blood volume intracranial pressure in infants during continuous simultaneous recording--a clinical study].

In five infants with severe neurologic-neurosurgical affections, correlations between the intracranial blood volume (rICBV) and the intracranial pressure (ICP) could be proved. For the ICP range from 0 to 250 mm H2O, an increase in the pulse amplitude of the rICBV was found with increasing ICP. On the other hand, there were distinct rICBV decreases with increasing ICP in the ICP range from 300 to 450 mm H2O. Subsequent, often only slight ICP decreases in this range resulted in a reactive hyperaemisation. More pronounced hyperaemisations could be associated with moderate ICP increases of the same duration. The results are discussed on the basis of a model.

Abnormalities, Multiple↗

[Complications of the intravascular treatment of intracranial aneurysms using metal microcoils. Embolization using coils in intracranial aneurysms].

Embolization of intracranial aneurysms with coils. The authors present the results and complications of microcoils embolization of intracranial aneurysms in 28 patients. Fibers platinum microcoils were used (Target Therapeutic) 28 patients (males: 6, females: 22; mean age: 51 years) were treated, 27 suffered from sub-arachnoid hemorrhage (SAH) and one presented with a pseudotumoral syndrome (giant aneurysm). All patients were evaluated on the day of treatment, according to the World Federation of Neuro-Surgeon classification (W.F.N.S.) of SAH and after 4 months of follow-up. At a mean follow-up period of 4 months, according to Glasgow Outcome Scale (G.O.S.) there were 13 cases of good results, 5 cases of "moderate disability", 2 cases of "severe disability", 2 cases of "vegetative state" and 6 deaths. Complications were observed in 11/28 cases. Coils migration and malposition in the parent artery were linked to the procedure (mechanical detachable coil) and resulted in severe deficit (one case), transient disability (one case) or went unnoticed (4 cases). Primary or secondary complete occlusion was achieved in 8/28 patients (32%). A majority of cases (11 cases) ended with stable residual aneurysmal sac lumen while rebleeding occurred in 3 patients and was responsible for 2 deaths. In the third case a favourable outcome was obtained after balloon occlusion of the parent artery.

Adult↗

[Repercussions of nursing activities on the intracranial pressure in patients with intracranial hypertension of traumatic or non-traumatic origin].

We study, in a prospective and randomized way, the influence existing between nursing maneuvers (suctioning, bathing and turning) and Intracranial Pressure (ICP) in patients diagnosed of Intracranial Hypertension Syndrome (ICHT). The study includes 22 patients admitted in Intensive Care at Hospital Universitario San Carlos (HUSC), during one year. All the patients had ICHT of traumatic or non traumatic origin. ICP was monitorized in every one through an intraventricular catheter and was over 20 Hg mm at admission or during 24 first hours of evolution. Doubt to the repercussion that the ICP values have on clinical evolutions we conclude that the nurse has to respond in an efficient, early and autonomous way in order to avoid uncontrolled elevation of ICP values during habitual management of patient.

Aged↗

Localization of brain reinforcement mechanisms: intracranial self-administration and intracranial place-conditioning studies.

Intracranial self-administration (ICSA) and intracranial place conditioning (ICPC) methodologies have been mainly used to study drug reward mechanisms, but they have also been applied toward examining brain reward mechanisms. ICSA studies in rodents have established that the ventral tegmental area (VTA) is a site supporting morphine and ethanol reinforcement. ICPC studies confirmed that injection of morphine into the VTA produces conditioned place preference (CPP). Further confirmation that activation of opioid receptors within the VTA is reinforcing comes from the findings that the endogenous opioid peptide met-enkephalin injected into the VTA produces CPP, and that the mu- and delta-opioid agonists, DAMGO and DPDPE, are self-infused into the VTA. Activation of the VTA dopamine (DA) system may produce reinforcing effects in general because (a) neurotensin is self-administered into the VTA, and injection of neurotensin into the VTA produces CPP and enhances DA release in the nucleus accumbens (NAC), and (b) GABA(A) antagonists are self-administered into the anterior VTA and injections of GABA(A) antagonists into the anterior VTA enhance DA release in the NAC. The NAC also appears to have a major role in brain reward mechanisms, whereas most data from ICSA and ICPC studies do not support an involvement of the caudate-putamen in reinforcement processes. Rodents will self-infuse a variety of drugs of abuse (e.g. amphetamine, morphine, phencyclidine and cocaine) into the NAC, and this occurs primarily in the shell region. ICPC studies also indicate that injection of amphetamine into the shell portion of the NAC produces CPP. Activation of the DA system within the shell subregion of the NAC appears to play a key role in brain reward mechanisms. Rats will ICSA the DA uptake blocker, nomifensine, into the NAC shell; co-infusion with a D2 antagonist can block this behavior. In addition, rats will self-administer a mixture of a D1 plus a D2 agonist into the shell, but not the core, region of the NAC. The ICSA of this mixture can be blocked with the co-infusion of either a D1 or a D2 antagonist. However, the interactions of other transmitter systems within the NAC may also play key roles because NMDA antagonists and the muscarinic agonist carbachol are self-infused into the NAC. The medial prefrontal (MPF) cortex supports the ICSA of cocaine and phencyclidine. The DA system also seems to play a role in this behavior since cocaine self-infusion into the MPF cortex can be blocked by co-infusing a D2 antagonist, or with 6-OHDA lesions of the MPF cortex. Limited studies have been conducted on other CNS regions to elucidate their role in brain and drug reward mechanisms using ICSA or ICPC procedures. Among these regions, ICPC findings suggest that cocaine and amphetamine are rewarding in the rostral ventral pallidum (VP); ICSA and ICPC studies indicate that morphine is rewarding in the dorsal hippocampus, central gray and lateral hypothalamus. Finally, substance P mediated systems within the caudal VP (nucleus basalis magnocellularis) and serotonin systems of the dorsal and median raphe nuclei may also be important anatomical components involved in brain reward mechanisms. Overall, the ICSA and ICPC studies indicate that there are a number of receptors, neuronal pathways, and discrete CNS sites involved in brain reward mechanisms.

Animals↗

Giant intracranial dermoid cyst: Case report and review of the literature on intracranial dermoids and epidermoids.

A 45-year old man was referred to the Johns Hopkins Hospital with a seven-year history of repeated episodes of light-headedness, increasing irriability and forgetfulness. Examinations revealed a right superior, incongruous quadrantanopsia. EEG showed an abnormality in the left temporal lobe, and a cerebral angiogram outlined an avascular mass in the left cerebral hemisphere. At operation, the patient was found to have a giant dermoid cyst involving the left frontal, temporal and parietal lobes. Over the last 30 years we have encountered only 6 cases of intracranial epidermoids and 3 cases of intracranial dermoids. These cases are cited, and a discussion of the embryology, histology, clinical characteristics, and treatment of these lesions with a review of the literature is undertaken.

Brain↗

Photodynamic therapy for intracranial neoplasms: investigations of photosensitizer uptake and distribution using indium-111 Photofrin-II single photon emission computed tomography scans in humans with intracranial neoplasms.

Photodynamic therapy is being investigated as an adjuvant treatment for intracranial neoplasms. The efficacy of this therapy is based on the uptake of photosensitizer by neoplastic tissue, its clearance from surrounding brain tissue, and the timing and placement of photoactivating sources. Photofrin-II is the photosensitizer most actively being investigated. We labeled Photofrin-II with Indium-111 and studied the uptake and distribution of this agent in 20 patients with intracranial neoplasms, using single photon emission computed tomography (SPECT) with volume rendering in three dimensions. Of these patients, 16 had malignant glial tumors, 2 had metastatic deposits, 1 had a chordoma, and 1 had a meningioma. Anatomical-spatial data correlated well between the SPECT images and contrast-enhanced computed tomography or magnetic resonance images. Regions of focal uptake on SPECT images correlated with the surgical histopathological findings of the neoplasm. The kinetics of photosensitizer uptake varied according to the tumor's histological findings, the patient's use of steroids, and among patients with similar types of tumor histology. Peak ratios of target-to-nontarget tissue varied from 24 to 72 hours after injection. The study data show that, to be most effective, photodynamic therapy may need to be tailored for each patient by correlating SPECT images with anatomical data produced by computed tomography or magnetic resonance images. Photoactivating sources then can be placed, using computer-assisted stereotactics, to activate a prescribed volume of photosensitized tumor at the optimal time for treatment.

Adult↗

Photodynamic therapy for intracranial neoplasms: development of an image-based computer-assisted protocol for photodynamic therapy of intracranial neoplasms.

Photodynamic therapy is being studied as an adjuvant therapy for malignant gliomas. Therapeutic efficacy is based on photosensitizer uptake kinetics and the ability to deliver adequate light doses to an appropriate treatment volume at the optimal time. Our laboratory has developed an image-based, computer-assisted treatment-planning protocol to study the treatment variables leading to optimizing photodynamic therapy for intracranial neoplasms. Fifteen patients with recurrent malignant glial tumors underwent 16 treatments in the developmental phase of the project in which light treatment volume was progressively expanded. Group I (n = 4) received postresection intracavitary photoillumination only, Group II (n = 3) received limited interstitial/intracavitary photoillumination, and Group III (n = 9) received multiple interstitial/intracavitary photoillumination. Between 3 and 18 interstitial fiber probes were placed through optically lucent tumor access catheters. Computed three-dimensional image-based treatment planning provided reproducible data-based tumor volumes, treatment volumes, and stereotactic accuracy for tumor volume resection and interstitial light fiber insertion. Initial observations include: 1) treatment failures occur outside of the effective light treatment volumes; 2) effective light volumes can be expanded safely with multiple stereotactically implanted interstitial light fibers; and 3) optimal treatment involves individualized tailoring of light dose volume and geometry. This protocol allows standardized scientific study of the variables affecting the application of photodynamic therapy for intracranial neoplasms.

Adult↗

Intracranial hypertension. Advances in intracranial pressure monitoring.

Research is continuing to find improved methods for monitoring intracranial pressure as well as the effect of intracranial hypertension on the patient's recovery. Each of the methods of monitoring has its advantages and disadvantages and the use of one method over others is usually the preference of the neurosurgeon. It is the responsibility of the nurse to be aware of the strengths and weaknesses of each device in order to strengthen patient outcome. Again, the major benefits of the bolt are a low infection rate and easy insertion. Problems associated with its use of which the nurse should be aware are a tendency for a dampened waveform that gives an inaccurate pressure reading requiring irrigation that may or may not clear the catheter, and the inaccurate readings given by the bolt at high pressures. The subdural catheter can be used for long-term monitoring; however, baseline drift has been reported. Ventricular catheters have a mixed bag of results according to research. They are the most accurate of the methods used and enable cerebrospinal fluid to be drained, thereby lowering ICP. However, the catheters appear to have a higher infection rate. This is debatable, however. Some researchers advocate the prophylactic use of antibiotics. A closed drainage system should be used and if the device is used for longer than 4 days, the device should be changed and care should be taken to prevent leakage of cerebrospinal fluid. The devices currently in use have been presented and patient outcomes discussed using medical research, as none was available from the nursing literature.(ABSTRACT TRUNCATED AT 250 WORDS)

Catheters, Indwelling↗

[Cisplatin, vinblastine and bleomycin (PVB) combination chemotherapy in the treatment of intracranial malignant germ cell tumors--a preliminary report of a phase II study--The Japanese Intracranial Germ Cell Tumor Study Group].

Cisplatin, vinblastine and bleomycin (PVB) combination chemotherapy was undertaken in 30 patients with primary intracranial malignant germ cell tumors in 11 neurosurgical clinics. The response rate of 17 evaluable patients with nonrecurrent tumors was 64.7% (eight CR and three PR), and that in eight patients with recurrent tumors was 50% (two CR and two PR). The one-year and two-year survival rates were 76.2% and 67.7%, respectively, which are better than the treatment results by radiation therapy alone, i.e., 69.8% and 46.5%. These findings suggest that PVB therapy is effective for intracranial malignant germ cell tumors.

Adult↗

Benign intracranial hypertension vs. intracranial arteriovenous malformation: a possible CT dilemma.

A nine-year-old boy, presenting only with signs of increased ICP, underwent computerized tomography. This examination demonstrated no abnormalities in the precontrast scan. Following C. E., it showed scattered areas of blood-like density in both hemispheres, as well as a presumedly abnormal vessel in the left occipital region and dilated vein of Galen, sinus rectus, and tentorial veins. The presumptive diagnosis of left occipital AVM was not confirmed by angiography, which also ruled out obstructions of the intracranial sinuses. The possible mechanism responsible for this atypical CT picture is briefly discussed in the light of pertinent literature. It is suggested that careful consideration should be given to the indications for angiography in similar cases, in the presence of a "hypervascular" aspect of the postcontrast CT scan, particularly if a considerable amount of contrast medium has been used.

Cerebral Angiography↗

Can chronic increased intracranial pressure or exposure to repetitive intermittent intracranial pressure elevations raise your risk for Alzheimer's disease?

Over a decade ago, I formulated the hypothesis that cumulative effects of exposure to high intracranial pressure (ICP) may contribute to the development of Alzheimer's disease (AD), though not necessarily in an exclusive way. In addition to individual ICP characteristics (high 'physiological' ICP) and diseases causing ICP elevation, various activities with significant Valsalva effort, such as weightlifting and wind instrument playing, can generate very high ICPs. Recent studies of normal-pressure hydrocephalus (NPH), glaucoma and Alzheimer's disease provide supportive evidence for this hypothesis. A number of studies have shown a high incidence of AD related lesions in patients with NPH, which is known to be associated with prolonged elevation of ICP in a majority of cases. In both NPH and AD, an important decrease in cerebrospinal fluid (CSF) production was calculated. According to researchers in the US, the resulting CSF stagnation with impaired clearance and accumulation of neurotoxic substances may play an important role in the onset and progression of AD. They tested the hypothesis that improving CSF turnover by means of an investigational low-flow ventriculoperitoneal shunt will delay the progression of dementia in patients with Alzheimer's disease. With regard to the observed decrease in CSF production in patients suffering from NPH, it was postulated that chronic increased ICP causes downregulation of CSF production. It is hypothesized here that repetitive intermittent ICP elevations also may lead to downregulation of CSF production due to long-term cumulative effects. If the latter proves to be true, then both chronic increased ICP and repeated exposures to increased ICP (e.g., repetitive Valsalva maneuvers) may cause a similar cascade of CSF circulatory failure events leading to AD over time. Furthermore, AD may be causally related to increased ICP through other pathomechanisms. Additional supportive evidence for the role of a pressure factor in the pathogenesis of AD comes from studies concerning glaucoma. Elevated intraocular pressure (IOP) is a hallmark of glaucoma. Recently, similarities in pathophysiology between glaucoma and AD have been noted, with increased processing of amyloid precursor protein (APP) and up-regulation of beta-amyloid protein expression in retinal ganglion cells (RGCs). Given this link between AD and glaucoma, evidence for a causal relationship between repetitive intermittent ICP elevations and AD is gained from research indicating that high resistance wind instrument playing raises IOP and may result in glaucomatous damage. To test the validity of the hypothesis that exposure to repetitive but nonsustained ICP elevations may predispose to AD a non-invasive, epidemiological study is proposed in this paper.

Alzheimer Disease↗

Intracranial pressure monitoring and assessing intracranial compliance in brain injury.

Caring for the patient with a brain injury is a dynamic process with the goal of providing therapy to prevent secondary injury. Until practitioners have a better understanding of the pathophysiology of ischemia and the response of therapies for treating increased ICP, they must use the tools that exist. ICP monitoring gives a rough index of the relationships and the response of the intracranial contents to changes in volume that may produce increases in pressure and further damage. Understanding the information supplied by ICP monitoring is imperative to successful management of increased ICP.

Brain Injuries↗

[Doppler findings in intracranial vascular disorders. Differential diagnosis of extracranial and intracranial vascular occlusions (author's transl)].

Directional Doppler sonography of the carotid arteries in the neck (selective for the common carotid artery, external and internal carotid arteries) and of the supratrochlear artery permits reliable diagnoses and localizations of extracranial stenoses and occlusions of these arteries. In addition, severe intracranial vascular disorders may also be detected by these methods. Characteristic combinations of Doppler results are described in occlusions of the trunk of the middle cerebral artery, cerebral circulatory breakdown, large arteriovenous angiomas of one hemisphere and carotidcavernous fistulas, and are compared with angiographic findings. The knowledge of these Doppler findings is indispensable for the differential critical evaluation of such disorders found at the level of the neck arteries and at the fronto-orbital terminal branches of the ophthalmic artery.

Adult↗

[Reticular activity and intracranial pressure. Acute and chronic intracranial hypertension (author's transl)].

Modifications of mesencephalic and bulbar reticular formation activity were studied with microelectrodes during acute and chronic intracranial hypertension. In both cases, the mesencephalic reticular activity increased progressively until a pressure level of 70 to 90 cm of CSF was reached and then fell irreversibly to less than the base value. The bulbar reticular activity followed the same pattern but more slowly. Different hypotheses are advanced to explain these modifications and their meanings.

Animals↗

The effects of indomethacin on intracranial pressure, cerebral blood flow and cerebral metabolism in patients with severe head injury and intracranial hypertension.

In five head-injured patients with cerebral contusion and oedema in whom it was not possible to control intracranial pressure (ICP) (ICP greater than 20 mmHg) by artificial hyperventilation (PaCO2 level 3.5-4.0 kPa) and barbiturate sedation, indomethacin was used as a vasoconstrictor drug. In all patients, indomethacin (a bolus injection of 30 mg, followed by 30 mg/h for seven hours) reduced ICP below 20 mmHg for several hours. Studies of cerebral circulation and metabolism during indomethacin treatment showed a decrease in CBF at 2 h. After 7 h, ICP remained below 20 mmHg in three patients, and these still had reduced CBF. In the other patients a return of ICP and CBF to pretreatment levels was observed. In all patients indomethacin treatment was followed by a fall in rectal temperature. These results suggest that indomethacin due to its cerebral vasoconstrictor and antipyretic effect should be considered as an alternative for treatment of ICP-hypertension in head-injured patients.

Adult↗

Treatment of intracranial aneurysms by combined proximal ligation and extracranial-intracranial bypass with vein graft.

Seven patients with internal carotid artery aneurysms, and one patient with a middle cerebral artery aneurysm, were managed by combining proximal ligation with an extracranial-intracranial bypass procedure. Five bypasses were done with an interposed vein graft between the external carotid artery and the distal middle cerebral artery (vein graft), and three were superficial temporal-middle cerebral artery bypasses (superficial temporal artery grafts). As demonstrated in postoperative angiograms, all eight patients had patent bypasses with nonfilling of the aneurysm. One patient developed transient dysphasia, but there were no permanent neurological deficits associated with carotid occlusion. Four patients had resolution of their neurological problems, and another three patients improved. The distribution of flow from vein grafts is more extensive than from superficial temporal artery grafts. This offers increased protection against ischemia, and increases the likelihood of internal carotid artery aneurysm thrombosis by reducing the turbulence in the distal internal carotid artery.

Adult↗