Reducing Intracranial Pressure May Increase Survival among Patients with Bacterial Meningitis

Authors: Peter Lindvall1, Clas Ahlm2, Mats Ericsson2, Leif Gothefors3, Silvana Naredi4, and Lars-Owe D. Koskinen1 

(1Department of Neurosurgery, Umeå University Hospital, Umeå, Sweden. 2Division of Infectious Diseases, Department of Clinical Microbiology, Umeå University Hospital, Umeå, Sweden. 3Department of Paediatrics, Umeå University Hospital, Umeå, Sweden. 4Department of Anaesthesia and Intensive Care, Umeå University Hospital, Umeå, Sweden)

Clin Infect Dis. (2004) 38 (3).

We reported findings concerning continuous intracranial pressure (ICP) and cerebral perfusion pressure (CPP) measurements and mortality in patients with severe bacterial meningitis treated on the basis of an ICP-targeted approach. Eighteen patients with severe bacterial meningitis were admitted for neurointensive care at Umeå University Hospital (Umeå, Sweden). In 15 patients, ICP was measured continuously through an ICP measuring device. During care, all patients but one developed intracranial hypertension with an ICP of ⩾15 mm Hg (14 of 15 patients). Ten (67%) of 15 patients survived and were discharged, and 5 patients (33%) died. Mean ICP was significantly higher and CPP was markedly decreased in nonsurvivors, compared with survivors. Among the survivors, ICP was gradually reduced. Treatment of patients with severe bacterial meningitis should include neurointensive care and continuous ICP measurement. Increased ICP may be reduced by using the ICP-targeted therapy that closely resembles the “Lund concept.”

Slope of the intracranial pressure waveform after traumatic brain injury

Authors: Franklin D. Westhout, MD, Laura S. Paré, MD, FRCSC, Ralph J. Delfino, MD, PhD, Steven C. Cramer, MD

Published online "Surgical Neurology" 13 February 2008.

Greater systolic ICP waveform slope during inspiration has not been described previously after TBI and is consistent with prior observations in subjects with hydrocephalus. The strong correlation between ICP slope and simultaneous mean ICP suggests that increasing ICP slope might indicate loss of intracranial compliance after TBI. 

Relationship between Intracranial Pressure and Cortical Spreading Depression following Fluid Percussion Brain Injury in Rats

Authors: G.G. Rogatsky, J. Sonn, Y. Kamenir, N. Zarchin, A. Mayevsky. Journal of Neurotrauma. December 2003.

The rising number of cortical spreading depression (CSD) cycles under condition of an ICP level ≥20 mm Hg may demonstrate, with high probability, the unfavorable development of TBI, caused by growing secondary hypoxic insult.

Long term outcomes after uncomplicated mild traumatic brain injury: A comparison with trauma controls

Authors: Jennie Ponsford, Peter Cameron, Mark Fitzgerald, Michele Grant, Antonina Mikocka-Walus.

The question as to whether mild traumatic brain injury (mTBI) results in persisting sequelae over and above those experienced by individuals sustaining general trauma remains controversial. This prospective study aimed to document outcomes one week and three months post-injury following mTBI assessed in the Emergency Department (ED) of a Major Adult Trauma Centre. One hundred and twenty three (123) patients presenting with uncomplicated mTBI and 100 matched trauma controls completed measures of post-concussive symptoms and cognitive performance (Immediate Post-Concussion Assessment and Cognitive Testing battery; ImPACT) and pre-injury health-related quality of life (SF-36) in the ED. These measures together with measures of psychiatric status (MINI) pre- and post-injury, Hospital Anxiety and Depression Scale, Visual Analogue Scale for pain, Functional Assessment Questionnaire and PTSD Checklist-Specific, were re-administered at follow-up. Participants with mTBI showed significantly more severe post-concussive symptoms in the ED and at one week post-injury. They performed more poorly than controls on the Visual Memory subtest of ImPACT at one week and three months post-injury. Both mTBI and control groups recovered well physically and most were employed three months post-injury. There were no significant group differences in psychiatric function. However, the group with mild TBI was more likely to report ongoing memory and concentration problems in daily activities. Further investigation of factors associated with these ongoing problems is warranted.

Functionally-Detected Cognitive Impairment in High School Football Players Without Clinically-Diagnosed Concussion

Authors: Thomas M. Talavage, Eric Nauman, Evan L. Breedlove, Umit Yoruk, Anne E Dye, Katie Morigaki, Henry Feuer, Larry J. Leverenz.

Head trauma and concussion in football players has recently received considerable attention. Post-mortem evidence suggests that accrual of damage to the brain may occur with repeated blows to the head, even when individual blows fail to produce clinical symptoms. There is an urgent need for improved detection and characterization of head trauma to reduce future injury risk and promote development of new therapies. This study examined neurologic performance and health in the presence of head collision events in high school football players, using longitudinal measures of collision events (HIT system), neurocognitive testing (ImPACT), and functional MRI (fMRI). Longitudinal assessment (including baseline) was conducted in 11 males (ages 15-19) participating on the varsity and junior varsity football teams at a single high school. We expected and observed subjects in two previously described categories: (1) no clinically-diagnosed concussion and no changes in neurological behavior and (2) clinically-diagnosed concussion with changes in neurological behavior. Additionally, we observed players in a previously undiscovered third category who exhibited no clinically-observed symptoms associated with concussion, but who demonstrated measurable neurocognitive (primarily visual working memory) and neurophysiologic (altered activation in dorsolateral prefrontal cortex, DLPFC) impairments. This new category was associated with significantly higher numbers of head collision events to the top-front of the head, directly above DLPFC. Observation of this category suggests that more players are suffering neurologic injury than are presently detected via traditional concussion-assessment mechanisms. These individuals are unlikely to undergo clinical evaluation and thus continue to participate in football-related activities even when changes in brain physiology (and potential brain health) are present, likely increasing risk of future neurologic injury.

Intracranial Pressure in Primary Open Angle Glaucoma, Normal Tension Glaucoma, and Ocular Hypertension: A Case–Control Study

Authors: John P. Berdahl 1 , Michael P. Fautsch 2 , Sandra S. Stinnett 1 and R. Rand Allingham 1

1From the Duke University Eye Center, Durham, North Carolina; and the
2Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota.

PURPOSE. To compare intracranial pressure (ICP) in subjects with primary open-angle glaucoma (POAG), normal-tension glaucoma (NTG; subset of POAG), and ocular hypertension (OHT) with that in subjects with no glaucoma.

METHODS. The study was a retrospective review of medical records of 62,468 subjects who had lumbar puncture between 1985 and 2007 at the Mayo Clinic. Of these, 57 POAG subjects, 11 NTG subjects (subset of POAG), 27 OHT subjects, and 105 control subjects met the criteria and were analyzed. A masked comparison of the relationship between ICP and other ocular and nonocular variables was performed by using univariate and multivariate analyses.

RESULTS. ICP was significantly lower in POAG compared with age-matched control subjects with no glaucoma (9.1 ± 0.77 mm Hg vs. 11.8 ± 0.71 mm Hg; P < 0.0001). Subjects with NTG also had reduced ICP compared with the control subjects (8.7 ± 1.16 mm Hg vs. 11.8 ± 0.71 mm Hg; P < 0.01). ICP was higher in OHT than in age-matched control subjects (12.6 ± 0.85 mm Hg vs. 10.6 ± 0.81 mm Hg; P < 0.05).

CONCLUSIONS. ICP is lower in POAG and NTG and elevated in OHT. ICP may play an important role in the development of POAG and NTG and in preventing the progression of OHT to POAG. Further prospective and experimental studies are warranted to determine whether ICP has a fundamental role in the pathogenesis of glaucoma.

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