Intracranial pressure

Paradoxical presentation of orthostatic headache associated with increased intracranial pressure in patients with cerebral venous thrombosis

Authors: Kim JB, Kwon DY, Park MH, Kim BJ, Park KW.

Headache is the most common symptom of cerebral venous thrombosis (CVT); however, the detailed underlying mechanisms and characteristics of headache in CVT have not been well described. Here, we report two cases of CVT whose primary and lasting presentation was orthostatic headache, suggestive of decreased intracranial pressure. Contrary to our expectations, the headaches were associated with elevated cerebrospinal fluid (CSF) pressure. Magnetic resonance imaging and magnetic resonance venography showed characteristic voiding defects consistent with CVT. We suggest that orthostatic headache can be developed in a condition of decreased intracranial CSF volume in both intracranial hypotensive and intracranial hypertensive states. In these cases, orthostatic headache in CVT might be caused by decreased intracranial CSF volume that leads to the inferior displacement of the brain and traction on pain-sensitive intracranial vessels, despite increased CSF pressure on measurement. CVT should be considered in the differential diagnosis when a patient complains of orthostatic headache.

Stroke feature and management in dialysis patients

Authors: Iseki K.

Strokes remain the major complication among dialysis population as the number of diabetes and elderly is increasing. In chronic hemodialysis patients, prevalence and incidence of stroke is higher than that of the general population. According to the annual registry data of the Japanese Society for Dialysis Therapy, prevalence of stroke death has been declining, yet the incidence of nonfatal incidence of stroke is not known. Underlying mechanisms of stroke are multiple. Among them, control of hypertension is important for the primary prevention; however, the ideal target level of blood pressure is not determined. Other than hypertension, maintaining good nutritional status is utmost important. Most observational studies suggested that the target was 140/90 mm Hg at prehemodialysis session. However, blood pressure levels are variable in both at office (before and after dialysis session) and at home. It is advisable to measure blood pressure multiple occasions and also at home. In case of acute cerebral hemorrhage, glycerol is indicated to prevent cerebral edema. Blood pressure is recommended to control as systolic <180 mm Hg or mean arterial pressure <130 mm Hg, and lower blood pressure gradually to 80% of the baseline level. In case of acute cerebral infarction hypertension is not treated unless severely hypertensive, systolic >220 mm Hg or diastolic >120 mm Hg and lower blood pressure gradually to 85-90% of the baseline level. Use of warfarin is controversial in case of acute cerebral infarction. Modification of dialysis modality is needed to prevent the increase in intracranial pressure and/or recurrence of stroke.

CORRESPONDENCE: Intracranial-Pressure Monitoring in Traumatic Brain Injury

N Engl J Med 2013; 368:1748-1752May 2, 2013DOI: 10.1056/NEJMc1301076

To the Editor:

In response to the article by Chesnut et al. (Dec. 27 issue)1 reporting results of the trial on intracranial-pressure monitoring, we want to mention that environment must be taken into consideration to understand the role of intracranial-pressure monitoring on outcome. Approximately 80% of severe traumatic brain injuries occur in austere environments,2 defined as regions lacking in prehospital and advanced care in an intensive care unit (ICU). Care within organized trauma systems has been shown to reduce mortality associated with severe traumatic brain injury.3-5 Studies of traumatic brain injury in austere environments have shown rates of death that are 2 to 3 times as high as those in environments where advanced care is available.6
As the authors mention, several patients in this study arrived after 1 hour without appropriate prehospital care. In this real scenario, ICU monitoring has very little chance of making a difference by itself.  ...

A trial of intracranial-pressure monitoring in traumatic brain injury

Authors: Chesnut RM, Temkin N, Carney N, Dikmen S, Rondina C, Videtta W, Petroni G, Lujan S, Pridgeon J, Barber J, Machamer J, Chaddock K, Celix JM, Cherner M, Hendrix T.

BACKGROUND: Intracranial-pressure monitoring is considered the standard of care for severe traumatic brain injury and is used frequently, but the efficacy of treatment based on monitoring in improving the outcome has not been rigorously assessed.

Bradykinin in Blood and CSF after Acute Cerebral Lesions - Correlations with Cerebral Edema and Intracranial Pressure

Authors: Kunz M, Nussberger J, Holtmannspoetter M, Bitterling H, Plesnila N, Zausinger S.

Bradykinin (BK) was shown to stimulate the production of physiologically active metabolites, blood-brain-barrier disruption and brain edema. Purpose of this prospective study was to measure BK concentrations in blood and cerebrospinal fluid (CSF) of patients with traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) and ischemic stroke and to correlate BK levels with the extent of cerebral edema and intracranial pressure (ICP). Blood and CSF samples of 29 patients suffering from acute cerebral lesions (TBI: 7, SAH: 10, ICH: 8, ischemic stroke: 4) were collected for up to 8 days after the insult. 7 patients with lumbar drainage were used as controls. Edema (5-point scale), ICP, and the GCS (Glasgow Coma Score) at the time of sample withdrawal were correlated with BK concentrations. While all plasma-BK samples were not significantly elevated, CSF-BK levels of all patients were significantly elevated in overall (n=73) and in early (≤72h) measurements (n=55) (4.3±6.9 fmol/ml and 5.6±8.9 fmol/ml) compared to 1.2±0.7 fmol/ml of the controls (p=0.05 and p=0.006). Within 72h after ictus patients suffering from TBI (p=0.01), ICH (p=0.001) and ischemic stroke (p=0.02) showed significant increases. CSF-BK concentrations correlated with the extent of edema formation (r=0.53, p<0.001) and with ICP (r=0.49, p<0.001). Our results demonstrate that acute cerebral lesions are associated with increased CSF-BK levels. Especially after TBI, subarachnoid and intracerebral hemorrhage CSF-BK levels correlate with the extent of edema evolution and ICP. Bradykinin-blocking agents may turn out to be effective remedies in brain injuries.

Intracranial pressure variability predicts short-term outcome after intracerebral hemorrhage: A retrospective study

Authors: Tian Y, Wang Z, Jia Y, Li S, Wang B, Wang S, Sun L, Zhang J, Chen J, Jiang R.

INTRODUCTION: Elevated intracranial pressure (ICP) is generally observed in brain injury and intracerebral hemorrhage (ICH) patients and is consistently associated with poor neurological outcome. Intracranial pressure variability (IPV) is a better predictor of long-term neurological outcome than mean ICP in traumatic brain injury patients. However, whether IPV regulates functional outcome in ICH patients has not been investigated. In the present study, we investigated the relationship between IPV and functional outcome in ICH patients and determined whether IPV is a valid predictor of neurological outcome in ICH patients.

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