raised intracranial pressure

Noninvasive estimation of raised intracranial pressure using ocular ultrasonography in liver transplant recipients with acute liver failure -A report of two cases-

Authors: Kim YK, Seo H, Yu J, Hwang GS.

Intracranial pressure (ICP) monitoring is an important issue for liver transplant recipients, since increased ICP is associated with advanced hepatic encephalopathy or graft reperfusion during liver transplantation. Invasive monitoring of ICP is known as a gold standard method, but it can provoke bleeding and infection; thus, its use is a controversial issue. Studies have shown that optic nerve sheath diameter > 5 mm by ocular ultrasonography is useful for evaluating ICP > 20 mmHg noninvasively in many clinical settings. In this case report, we present experiences of using ocular ultrasound as a diagnostic tool that could detect changes in ICP noninvasively during liver transplantation.

Pretreatment With Midazolam Blunts the Rise in Intracranial Pressure Associated With Ketamine Sedation for Lumbar Puncture in Children.

Authors: Michalczyk K, Sullivan JE, Berkenbosch JW.

OBJECTIVE:: Ketamine has a long history of use during pediatric procedural sedation. Concerns about raising intracranial pressure may limit use in certain situations. Whereas some data suggest that benzodiazepine coadministration may blunt this response, pediatric data during procedural sedation do not exist. We evaluated the effects of midazolam pretreatment on intracranial pressure during ketamine sedation in children. DESIGN:: Prospective, randomized clinical study. SETTING:: Outpatient Medical Observation unit at Kosair Children's Hospital. PATIENTS:: A total of 25 oncology patients in whom sedated lumbar puncture was scheduled. INTERVENTIONS:: Patients alternated between sedation in Group A (midazolam/ketamine prior to lumbar puncture) or Group B (ketamine only prior to lumbar puncture). Opening pressure, medication doses, sedation depth, and complications were recorded. A control group of non-ketamine-sedated patients (Group C) was added to differentiate drug vs. disease-specific opening pressure changes. Between-group differences were compared by linear mixed effects model or contingency table with p < 0.05 considered significant. MEASUREMENTS AND MAIN RESULTS:: Twenty-five patients aged 82 ± 49 months were sedated 84 times. Thirty-five sedations were in Group A, 39 in Group B, and 10 in Group C. Mean (95% confidence interval) adjusted opening pressure in Group A (22.0 cm H2O) was lower than Group B (26.5 cm H2O, p = 0.013). Opening pressure in Group C (17.3 cm H2O) was lower than in Group B (p = 0.002) but not in Group A (p = 0.096). Ketamine doses were similar between Groups A and B (1.4 ± 0.6 mg/kg vs. 1.4 ± 0.4 mg/kg, p = NS). Mean midazolam pretreatment dose was 0.09 ± 0.02 mg/kg and did not correlate with measured opening pressure. Four patients, all in Group B, experienced significant emergence reactions. CONCLUSION:: While pretreatment with midazolam is associated with a reduction in intracranial pressure compared with sedation with ketamine alone, ketamine-containing regimens are associated with higher opening pressures than non-ketamine-containing regimens.

Results of early surgery for sagittal suture synostosis: long-term follow-up and the occurrence of raised intracranial pressure

Authors: van Veelen ML, Eelkman Rooda OH, de Jong T, Dammers R, van Adrichem LN, Mathijssen IM.

PURPOSE: Numerous techniques are used to correct sagittal synostosis. Although cosmetic results and operative complications are well documented, little is known about functional outcome. In our institution, the technique for extended strip craniectomy evolved over time. This study compares cosmetic results, complications, and signs of raised intracranial pressure (ICP) between the variants of the extended strip craniectomy.
METHODS: Seventy-nine consecutive patients undergoing early extended strip craniectomy for scaphocephaly (2002-2008) were included. Four techniques were used: A, a simple bilateral parietal flap with out-fracturing of the bone flap; B, C, and D included remodeling of the parietal flap by adding triangular cuts and bending or suturing the resulting fingers. In technique D, the sagittal strip was rotated and fixed between the parietal flaps. Data on head circumference (HC), skull X-ray, and fundoscopy were collected prospectively.
RESULTS: For all patients, the average cranial index (CI) was 74 after 3 months and 72 after 2 years. Although technique D resulted in the best initial improvement, there was no significant percentage increase in CI after 24 months between the four techniques. Postoperatively, 9 % of the patients developed papilledema, 42 % developed a fontanel bulge, and 57 % had diminished HC. Four patients were reoperated on because of raised ICP.
CONCLUSIONS: Postoperative CI is mainly determined by preoperative CI and hardly affected by type of extended strip craniectomy. Signs of raised ICP occurred more frequently than expected, therefore structural follow-up is required to detect such signs. Technique and timing of surgery should aim at creating sufficient intracranial volume.

Frank-ter Haar syndrome associated with sagittal craniosynostosis and raised intracranial pressure

Authors: Bendon CL, Fenwick AL, Hurst JA, Nürnberg G, Nürnberg P, Wall SA, Wilkie AO, Johnson D.

BACKGROUND: Frank-ter Haar syndrome is a rare disorder associated with skeletal, cardiac, ocular and craniofacial features including hypertelorism and brachycephaly. The most common underlying genetic defect in Frank-ter Haar syndrome appears to be a mutation in the SH3PXD2B gene on chromosome 5q35.1. Craniosynostosis, or premature fusion of the calvarial sutures, has not previously been described in Frank-ter Haar syndrome.
CASE PRESENTATION: We present a family of three affected siblings born to consanguineous parents with clinical features in keeping with a diagnosis of Frank-ter Haar syndrome. All three siblings have a novel mutation caused by the deletion of exon 13 of the SH3PXD2B gene. Two of the three siblings also have non-scaphocephalic sagittal synostosis associated with raised intracranial pressure.
CONCLUSION: The clinical features of craniosynostosis and raised intracranial pressure in this family with a confirmed diagnosis of Frank-ter Haar syndrome expand the clinical spectrum of the disease. The abnormal cranial proportions in a mouse model of the disease suggests that the association is not coincidental. The possibility of craniosynostosis should be considered in individuals with a suspected diagnosis of Frank-ter Haar syndrome.

Prevalence of Raised Intracranial Pressure in Cerebral Malaria Detected by Optic Nerve Sheath Ultrasound

Authors: Beare NA, Glover SJ, Lewallen S, Taylor TE, Harding SP, Molyneux ME.

We aimed to use optic nerve sheath (ONS) ultrasound to determine the prevalence of raised intracranial pressure (ICP) in African children with cerebral malaria (CM); if increased, ONS diameter is associated with poor outcome. We measured ONS diameter in 101 children with CM and 11 children with malaria and impaired consciousness in Malawi. The prevalence of raised ICP detected by increased ONS diameter was 49%. Case fatality was similar in children with increased ONS diameter on admission (9/55) and those children without increased ONS diameter (11/57). Neurological sequelae were more common in those children with increased ONS diameter (7/46 versus 2/46, P < 0.05). Lumbar puncture (LP) opening pressure was elevated in 95% of 46 children who underwent LP. In Malawian children with CM, raised ICP is less commonly detected by ONS ultrasound than LP. This study suggests that raised ICP is not universal in CM and that other mechanisms may account for coma.

Sheehan Syndrome Associated With Raised Intracranial Pressure

Authors: Moodley KK, Broad R, Chung K, Riordan-Eva P, Sibtain NA, Moran NF.

BACKGROUND: Intracranial hypertension (IH) has been associated with hypocortisolism caused by either primary adrenocortical insufficiency or corticosteroid withdrawal.
METHOD: The authors describe a case of IH in association with Sheehan syndrome (SS) in a postpartum 29-year-old woman.
RESULTS: The clinical manifestations of IH resolved with corticosteroid replacement.
CONCLUSIONS: This case supports a causal role of hypocortisolism in IH. The authors are unaware of previous reports of hypocortisolism caused by SS leading to IH.

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