Long-Term Effect of Decompressive Craniectomy on Intracranial Pressure and Possible Implications for Intracranial Fluid Movements

Lilja-Cyron, Alexander; Andresen, Morten; Kelsen, Jens; Andreasen, Trine Hjorslev; Fugleholm, Kåre; Juhler, Marianne

doi:10.1093/neuros/nyz049

Cited by 27 publications

(33 citation statements)

References 52 publications

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“…Our patients did not have the required parameters monitored in order to test this. Furthermore, previous decompressive craniectomy, especially if a reconstruction is delayed significantly, can have negative effects on brain perfusion and contribute to the development of ventriculomegaly [28]. We have not been able to explore here the effect of TBI severity on the development of PTH due to insufficient numbers of patients.…”

Section: Comparison Between Tbi and Inph Groupsmentioning

confidence: 98%

“…In selecting patients for Group A, we had to exclude those with decompressive craniectomy, and recent cranioplasty, as these radically influence CSF dynamics [3,[26][27][28], and are inconsistent with CSF dynamics in patients with an intact skull. We had also pre-specified the exclusion of patients with brain atrophy, as determined by Rout < 6 mmHg/min/ml [1,43].…”

Section: Comparison Between Tbi and Inph Groupsmentioning

confidence: 99%

“…Long recordings (ideally several hours) of baseline ICP and CSF dynamics required in order to properly estimate CSF parameters and ICP monitoring are quite invasive [1,16,19,[26][27][28]. Instead, our department has been using constant-rate infusion studies for patients with hydrocephalus and other CSF disorders.…”

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confidence: 99%

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Cerebrospinal fluid dynamics in non-acute post-traumatic ventriculomegaly

Lalou

Levrini

Czosnyka

et al. 2020

Fluids Barriers CNS

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Background: Post-traumatic hydrocephalus (PTH) is potentially under-diagnosed and under-treated, generating the need for a more efficient diagnostic tool. We aim to report CSF dynamics of patients with post-traumatic ventriculomegaly. Materials and methods: We retrospectively analysed post-traumatic brain injury (TBI) patients with ventriculomegaly who had undergone a CSF infusion test. We calculated the resistance to CSF outflow (Rout), AMP (pulse amplitude of intracranial pressure, ICP), dAMP (AMPplateau-AMPbaseline) and compensatory reserve index correlation coefficient between ICP and AMP (RAP). To avoid confounding factors, included patients had to be non-decompressed or with cranioplasty > 1 month previously and Rout > 6 mmHg/min/ml. Compliance was assessed using the elasticity coefficient. We also compared infusion-tested TBI patients selected for shunting versus those not selected for shunting (consultant decision based on clinical and radiological assessment and the infusion results). Finally, we used data from a group of shunted idiopathic Normal Pressure Hydrocephalus (iNPH) patients for comparison. Results: Group A consisted of 36 patients with post-traumatic ventriculomegaly and Group B of 45 iNPH shunt responders. AMP and dAMP were significantly lower in Group A than B (0.55 ± 0.39 vs 1.02 ± 0.72; p < 0.01 and 1.58 ± 1.21 vs 2.76 ± 1.5; p < 0.01. RAP baseline was not significantly different between the two. Elasticity was higher than the normal limit in all groups (average 0.18 1/ml). Significantly higher Rout was present in those with probable PTH selected for shunting compared with unshunted. Mild/moderate hydrocephalus, ex-vacuo ventriculomegaly/ encephalomalacia were inconsistently reported in PTH patients. Conclusions: Rout and AMP were significantly lower in PTH compared to iNPH and did not always reflect the degree of hydrocephalus or atrophy reported on CT/MRI. Compliance appears reduced in PTH.

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Section: Comparison Between Tbi and Inph Groupsmentioning

confidence: 98%

Section: Comparison Between Tbi and Inph Groupsmentioning

confidence: 99%

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Cerebrospinal fluid dynamics in non-acute post-traumatic ventriculomegaly

Lalou

Levrini

Czosnyka

et al. 2020

Fluids Barriers CNS

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“…It has previously been shown that there is a difference of about 7 mmHg in ICP measured in the supine and sitting positions, consistent with our measurements. 33 However, in a recent study, Lilja-Cyron et al 34 demonstrated that postural ICP change is abolished in patients with large craniectomy defects. This is somewhat intuitive given that DC creates a large low-resistance defect in the rigid supratentorial cranial vault, invalidating the Monro-Kellie 35 , 36 doctrine that the sum of the contents of the skull is a fixed volume.…”

Section: Discussionmentioning

confidence: 97%

First-In-Human Experience With Integration of Wireless Intracranial Pressure Monitoring Device Within a Customized Cranial Implant

et al. 2020

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BACKGROUND Decompressive craniectomy is a lifesaving treatment for intractable intracranial hypertension. For patients who survive, a second surgery for cranial reconstruction (cranioplasty) is required. The effect of cranioplasty on intracranial pressure (ICP) is unknown. OBJECTIVE To integrate the recently Food and Drug Administration-approved, fully implantable, noninvasive ICP sensor within a customized cranial implant (CCI) for postoperative monitoring in patients at high risk for intracranial hypertension. METHODS A 16-yr-old female presented for cranioplasty 4-mo after decompressive hemicraniectomy for craniocerebral gunshot wound. Given the persistent transcranial herniation with concomitant subdural hygroma, there was concern for intracranial hypertension following cranioplasty. Thus, cranial reconstruction was performed utilizing a CCI with an integrated wireless ICP sensor, and noninvasive postoperative monitoring was performed. RESULTS Intermittent ICP measurements were obtained twice daily using a wireless, handheld monitor. The ICP ranged from 2 to 10 mmHg in the supine position and from −5 to 4 mmHg in the sitting position. Interestingly, an average of 7 mmHg difference was consistently noted between the sitting and supine measurements. CONCLUSION This first-in-human experience demonstrates several notable findings, including (1) newfound safety and efficacy of integrating a wireless ICP sensor within a CCI for perioperative neuromonitoring; (2) proven restoration of normal ICP postcranioplasty despite severe preoperative transcranial herniation; and (3) proven restoration of postural ICP adaptations following cranioplasty. To the best of our knowledge, this is the first case demonstrating these intriguing findings with the potential to fundamentally alter the paradigm of cranial reconstruction.

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“…But beyond any putative relationship between ICP and CBF, provocative, pre-clinical work by Lafrenaye et al [15] has suggested that ICP values below the threshold for effects on CBF may have cellular effects independent of effects on perfusion-resulting in neuronal membrane damage and neuronal injury. Similarly, effects of ICP and ICP-directed therapy on the recently recognized glymphatic pathway add further nuance to the picture [16].…”

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confidence: 99%