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Short pressure reactivity index versus long pressure reactivity index in the management of traumatic brain injury

Erhard W. Lang, Magdalena Kasprowicz, Peter Smielewski, Edgar Santos, John Pickard, and Marek Czosnyka

, 17 and it is used for online calculation of the optimal cerebral perfusion pressure (CPPopt). 2 , 29 The PRx is calculated from mean ABP and ICP within a frequency range of 0.003–0.05 Hz. Recently a new PRx, called long (L)-PRx, that considers slower changes in ABP and ICP (within a frequency range of 0.0008–0.008 Hz) has been introduced. 27 , 28 Its utility and prognostic relevance have been confirmed in a small series of 18 patients with spontaneous intracranial hemorrhage, 28 and in a second series of 29 patients with TBI. 27 The aim of our study was to

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Head of bed elevation in pediatric patients with severe traumatic brain injury

Shih-Shan Lang, Amber Valeri, Bingqing Zhang, Phillip B. Storm, Gregory G. Heuer, Lauren Leavesley, Richard Bellah, Chong Tae Kim, Heather Griffis, Todd J. Kilbaugh, and Jimmy W. Huh

P ediatric traumatic brain injury (TBI) remains one of the leading causes of long-term disability and mortality worldwide. 1–4 The cornerstone of acute neurocritical care management in severe pediatric TBI is to prevent or treat elevated intracranial pressure (ICP) and low cerebral perfusion pressure (CPP). 5 Elevation of the head of the bed (HOB) to 30° in a neutral position has become the standard management for the treatment of ICP in the hopes of decreasing cerebral blood and fluid volume and increasing cerebral venous outflow with improvement in jugular

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Brain tissue oxygen monitoring after severe traumatic brain injury in children: relationship to outcome and association with other clinical parameters

Clinical article

Martina Stippler, Veronica Ortiz, P. David Adelson, Yue-Fang Chang, Elizabeth C. Tyler-Kabara, Stephen R. Wisniewski, Ericka L. Fink, Patrick M. Kochanek, S. Danielle Brown, and Michael J. Bell

importance of brain temperature in patients after severe head injury: relationship to intracranial pressure, cerebral perfusion pressure, cerebral blood flow, and outcome . J Neurotrauma 19 : 559 – 571 , 2002 10.1089/089771502753754046 33 Spiotta AM , Stiefel MF , Heuer GG , Bloom S , Maloney-Wilensky E , Yang W , : Brain hyperthermia after traumatic brain injury does not reduce brain oxygen . Neurosurgery 62 : 864 – 872 , 2008 10.1227/01.neu.0000316900.63124.ce 34 Stiefel MF , Spiotta A , Gracias VH , Garuffe AM , Guillamondegui

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Occlusion of the pig superior sagittal sinus, bridging and cortical veins: multistep evolution of sinus-vein thrombosis

Georg Fries, Thomas Wallenfang, Johannes Hennen, Markus Velthaus, Axel Heimann, Hans Schild, Axel Perneczky, and Oliver Kempski

beginning of each experiment, 2 ml of Evans blue dye (2%) was administered intravenously. Intraventricular pressure, cerebral tissue pressure, superior sagittal sinus pressure anterior and posterior to the occlusion site, mean arterial blood pressure (MABP), and central venous pressure were monitored throughout the experiment. Cerebral perfusion pressure (CPP) was calculated according to the formula: CPP = MABP — mean cerebral tissue pressure. Four hours after occlusion and continuous pressure monitoring, the animals were sacrificed by bolus injection of 40 ml KCl. The

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Prognostic value of early computerized tomography scanning following craniotomy for traumatic hematomas

Santiago Lubillo, José Bolaños, Luis Carreira, José Cardeñosa, Javier Arroyo, and José Manzano

head injury who were admitted to our intensive care unit (ICU) at the Hospital Universitario del Pino during a period of 4 years (1993–1997). All patients had isolated, severe closed head injury with intracranial hematoma (postresuscitation Glasgow Coma Scale [GCS] 29 score of 8 or less) and were admitted to the ICU after undergoing removal of the hematoma. Both ICP and cerebral perfusion pressure (CPP) were continuously measured, and in all patients a CT scan was obtained within 2 to 12 hours after craniotomy. The patients' ages ranged from 16 to 76 years (mean 36

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Outcome of severe traumatic brain injury: comparison of three monitoring approaches

Ruwaida Isa, Wan Aasim Wan Adnan, Ghazaime Ghazali, Zamzuri Idris, Abdul Rahman Izaini Ghani, Sani Sayuthi, Mohamed Saufi Awang, Mazira Mohamad Ghazali, Nyi Nyi Naing, and Jafri Malin Abdullah

The determination of cerebral perfusion pressure (CPP) is regarded as vital in monitoring patients with severe traumatic brain injury. Besides indicating the status of cerebral blood flow (CBF), it also reveals the status of intracranial pressure (ICP). The abnormal or suboptimal level of CPP is commonly correlated with high values of ICP and therefore with poor patient outcomes. Eighty-two patients were divided into three groups of patients receiving treatment based on CPP and CBF, ICP alone, and conservative methods during two different observation periods. The characteristics of these three groups were compared based on age, sex, time between injury and hospital arrival, Glasgow Coma Scale score, pupillary reaction to light, surgical intervention, and computerized tomography scanning findings according to the Marshall classification system. Only time between injury and arrival (p = 0.001) was statistically significant. There was a statistically significant difference in the proportions of good outcomes between the multimodality group compared with the group of patients that underwent a single intracranial-based monitoring method and the group that received no monitoring (p = 0.003) based on a disability rating scale after a follow up of 12 months. Death was the focus of outcome in this study in which the multimodality approach to monitoring had superior results.

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Intracranial hypertension and cerebral ischemia after severe traumatic brain injury

Roman Hlatky, Alex B. Valadka, and Claudia S. Robertson

Arterial hypotension and intracranial hypertension are detrimental to the injured brain. Although artificial elevation of cerebral perfusion pressure (CPP) has been advocated as a means to maintain an adequate cerebral blood flow (CBF), the optimal CPP for the treatment of severe traumatic brain injury (TBI) remains unclear. In addition, CBF evolves significantly over time after TBI, and CBF may vary considerably in patient to patient. For these reasons, a more useful approach may be to consider the optimal CPP in an individual patient at any given time, rather than having an arbitrary goal applied uniformly to all patients. Important information for optimizing CBF is provided by monitoring intracranial pressure in combination with assessment of the adequacy of CBF by using global indicators (for example, jugular oximetry), supplemented when appropriate by local data, such as brain tissue oxygen tension.

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Evaluating the outcome of severe head injury with transcranial Doppler ultrasonography

José A. Moreno, Eduard Mesalles, Juan Gener, Antonio Tomasa, Adolfo Ley, Josep Roca, and Jaime Fernández-Llamazares

The authors conducted a study to determine the value of transcranial Doppler (TCD) ultrasonography in evaluating the outcome of severely head injured patients and to correlate the TCD values with those obtained from intracranial pressure (ICP) and cerebral perfusion pressure (CPP) monitoring.

The authors conducted a prospective study of 125 patients with severe head injury (Glascow Coma Scale scores of less than 9) who underwent TCD ultrasonography according to the standard technique of insonating the middle cerebral artery (MCA) and measuring the mean blood flow velocity and pulsatility index within the first 24 hours of admission. The ICP and CPP values, as well as other clinical, analytical, and neuroimaging data, were also recorded. After 6 months, outcome was evaluated using the Glasgow Outcome Scale. Moderate disability and complete recovery were considered “good” outcome; death, vegetative state, and severe disability were considered “poor.”

In 67 patients (54%) good outcome was demonstrated whereas in 58 (46%) it was poor. The mean blood flow velocity of the MCA in patients with good outcome was 44 cm/second; in those with poor outcomes it was 36 cm/second (p < 0.003). The mean PI in cases of good outcome was 1 whereas in poor outcome was 1.56 (p < 0.0001). The correlations of ICP and CPP to PI were statistically significant (r2 = 0.6; p < 0.0001).

When performed in the first 24 hours of severe head injury, TCD ultrasonography is valid in predicting the patient’s outcome at 6 months and correlates significantly with ICP and CPP values.

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Elevated jugular venous oxygen saturation after severe head injury

Manuela Cormio, Alex B. Valadka, and Claudia S. Robertson


The aim of this study was to investigate the incidence of elevated (≥ 75%) jugular venous oxygen saturation (SjvO2) and its relationship to cerebral hemodynamic and metabolic parameters and to outcome after severe head injury.


Data from 450 severely head injured patients admitted to the Neurosurgical Intensive Care Unit of Ben Taub General Hospital were analyzed retrospectively. The SjvO2 was measured in blood obtained from indwelling jugular bulb catheters. Patients were classified into the following categories: high (Group I), normal (Group II), or low SjvO2 (Group III) if their mean SjvO2 over the duration of monitoring was 75% or higher, 74 to 56%, or 55% or lower, respectively.

A high SjvO2 occurred in 19.1% of patients. There was no consistent relationship between SjvO2 and simultaneous cerebral blood flow (CBF) or cerebral perfusion pressure measurements. Compared with Groups II and III, the patients in Group I had a significantly higher CBF and lower cerebral metabolic rate of oxygen (CMRO2). In Group I, the out- comes were death or persistent vegetative state in 48.8% of patients and severe disability in 25.6%. These outcomes were significantly worse than for patients in Group II. Within Group I, the patients with a poor neurological outcome were older and more likely to have suffered a focal head injury; they demonstrated a lower CMRO2 and a greater rate of cerebral lactate production than the patients who attained a favorable outcome.


Posttraumatic elevation of SjvO2 is common but cannot be automatically equated with hyperemia. Instead, elevated SjvO2 is a heterogeneous condition that is associated with poor outcome after head injury and may carry important implications for the management of comatose patients.

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Dimethyl sulfoxide in experimental brain injury, with comparison to mannitol

Frederick D. Brown, Lydia M. Johns, and Sean Mullan

vessel damage. For determination of CBF, a direct injection of xenon-133 was made into the common carotid artery after ligation of the external carotid branches and placement of a single detector over each hemisphere. The flow was calculated by the initial-slope clearance technique. 22 Cerebral perfusion pressure (CPP), cerebral vascular resistance (CVR), arterial venous oxygen content (A–VO 2 ) difference, cerebral metabolic rate of oxygen consumption (CMRO 2 ), and cerebral metabolic rate of lactate production (CMRL) were calculated as previously described. 5, 6