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| 2. |
- Engquist, Henrik, et al.
(författare)
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Hemodynamic Disturbances in the Early Phase After Subarachnoid Hemorrhage : Regional Cerebral Blood Flow Studied by Bedside Xenon-enhanced CT.
- 2018
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Ingår i: Journal of Neurosurgical Anesthesiology. - 0898-4921 .- 1537-1921. ; 30:1, s. 49-58
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: The mechanisms leading to neurological deterioration and the devastating course of delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) are still not well understood. Bedside xenon-enhanced computerized tomography (XeCT) enables measurements of regional cerebral blood flow (rCBF) during neurosurgical intensive care. In the present study, CBF characteristics in the early phase after severe SAH were explored and related to clinical characteristics and early clinical course outcome.MATERIALS AND METHODS: Patients diagnosed with SAH and requiring mechanical ventilation were prospectively enrolled in the study. Bedside XeCT was performed within day 0 to 3.RESULTS: Data from 64 patients were obtained. Median global CBF was 34.9 mL/100 g/min (interquartile range [IQR], 26.7 to 41.6). There was a difference in CBF related to age with higher global CBF in the younger patients (30 to 49 y). CBF was also related to the severity of SAH with lower CBF in Fisher grade 4 compared with grade 3. rCBF disturbances and hypoperfusion were common; in 43 of the 64 patients rCBF<20 mL/100 g/min was detected in more than 10% of the region-of-interest (ROI) area and in 17 patients such low-flow area exceeded 30%. rCBF was not related to the localization of the aneurysm; there was no difference in rCBF of ipsilateral compared with contralateral vascular territories. In patients who initially were in Hunt & Hess grade I to III, median global CBF day 0 to 3 was significantly lower for patients who were in poor neurological state at discharge compared with patients in good neurological state, 25.5 mL/100 g/min (IQR, 21.3 to 28.3) versus 37.8 mL/100 g/min (IQR, 30.5 to 47.6).CONCLUSIONS: CBF disturbances are common in the early phase after SAH. In many patients, CBF was heterogenic and substantial areas with low rCBF were detected. Age and CT Fisher grade were factors influencing global cortical CBF. Bedside XeCT may be a tool to identify patients at risk of deteriorating so they can receive intensified management, but this needs further exploration.
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| 4. |
- Engvall, Christian, et al.
(författare)
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Human cerebral blood volume (CBV) measured by dynamic susceptibility contrast MRI and 99mTc-RBC SPECT.
- 2008
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Ingår i: Journal of Neurosurgical Anesthesiology. - 1537-1921. ; 20:1, s. 41-44
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Patients with elevated intracranial pressure risk compromising their cerebral blood flow, resulting in ischemia. Lowering of the raised intracranial pressure, is therefore, mandatory. Reduction of the cerebral blood volume (CBV) might be target. In finding ways to do so, one has to be able to measure CBV. Measurement of CBV is, however, difficult. Radio(99mTc-)labeled erythrocytes (99mTcRBC) single photon emission computer-aided tomography (SPECT) is one established method used for CBV measurement. Recently, dynamic susceptibility contrast (DSC) magnetic resonance imaging (MRI), has also been successfully used for this purpose. The aim of this study was to validate the use of DSC-MRI for the measurement of CBV by the investigation of the correlation between the regional distributions of 99mTc-RBC SPECT and DSC-MRI measurement of CBV in humans. If possible, the aim was also to find a conversion constant that will enable the DCS-MRI to be interpreted as CBV (percent of brain volume). METHODS: CBV of 8 volunteers were studied under normocapnic and hypocapnic conditions. CBV was measured with both 99mTc-RBC SPECT and DSC-MRI. RESULTS: There were significant correlations between the regional distributions of CBV measured by 99mTc-RBC SPECT and DSC-MRI (rest: F=4.53, P<0.05; hypocapnia: F=9.61, P<0.005). The derived conversion factor between DSC-MRI voxel values and 99mTc-RBC SPECT CBV (percent of brain volume) at rest was 0.0059+/-0.0013. Global CBV during normocapnia was 4.3%+/-0.6% of brain volume as measured by SPECT of brain volume and 4.5%+/-0.9% as measured by MRI. Decreasing the end-tidal pCO2 by 1.8 kPa by spontaneous hyperventilation reduced the global CBV significantly to 3.9%+/-0.5% in the SPECT group and to 3.5%+/-0.6% in the MRI group. CONCLUSIONS: The comparison of 99mTc-RBC SPECT and DSC-MRI measurements in our study indicates that DSC-MRI can be a useful method to measure CBV as a percent of brain volume.
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| 5. |
- Grände, Per-Olof, et al.
(författare)
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Osmotherapy in brain edema: a questionable therapy.
- 2012
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Ingår i: Journal of Neurosurgical Anesthesiology. - : Ovid Technologies (Wolters Kluwer Health). - 1537-1921 .- 0898-4921. ; 24:4, s. 407-412
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Tidskriftsartikel (refereegranskat)abstract
- Despite the fact that it has been used since the 1960s in diseases associated with brain edema and has been investigated in >150 publications on head injury, very little has been published on the outcome of osmotherapy. We can only speculate whether osmotherapy improves outcome, has no effect on outcome, or leads to worse outcome. Here we describe the action and potentially beneficial and adverse effects of the 2 most commonly used osmotic solutions, mannitol and hypertonic saline, and present some critical aspects of their use. There is a well-documented transient intracranial pressure (ICP)-reducing effect of osmotherapy, but an adverse rebound increase in ICP after its withdrawal has been discussed extensively in the literature and is an expected pathophysiological phenomenon. From side effects related to renal and pulmonary failure, electrolyte disturbances, and a rebound increase in ICP, osmotherapy can be negative for outcome, which may explain why we lack scientific support for its use. These drawbacks, and the fact that the most recent Cochrane meta-analyses of osmotherapy in brain edema and stroke could not find any beneficial effects on outcome, make routine use of osmotherapy in brain edema doubtful. Nevertheless, the use of osmotherapy as a temporary measure may be justified to acutely prevent brain stem compression until other measures, such as evacuation of space-occupying lesions or decompressive craniotomy, can be performed. This article is the Con part in a Pro-Con debate in the present journal on the general routine use of osmotherapy in brain edema.
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| 6. |
- Grände, Per-Olof
(författare)
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PRO: The "Lund Concept" for Treatment of Patients With Severe Traumatic Brain Injury.
- 2011
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Ingår i: Journal of Neurosurgical Anesthesiology. - 1537-1921. ; 23, s. 251-255
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Tidskriftsartikel (refereegranskat)abstract
- Two different main concepts for the treatment of severe traumatic brain injury have been established during the last 15 years, namely the more conventional concept recommended in well-established guidelines (eg, the US Guideline, European Guideline, Addelbrook's Guideline from Cambridge) on the one hand, and the Lund concept from the University Hospital of Lund, Sweden on the other. Owing to the lack of well-controlled randomized outcome studies comparing these 2 main therapeutic approaches, we cannot conclude that one is better than the other. This study is the PRO part in a PRO-CON debate on the Lund concept in the present journal. Although the Lund concept is based on a physiology-oriented approach dealing with hemodynamic principles of brain volume and brain perfusion regulation, traditional treatments are primarily based on a meta-analytic approach from clinical studies. High cerebral perfusion pressure has been an essential goal in the conventional treatments (the cerebral perfusion pressure-guided approach), even though it has been modified in a recent update of US guidelines. The Lund concept has instead concentrated on management of brain edema and intracranial pressure, simultaneously with improvement of cerebral perfusion and oxygenation (the intracranial pressure and perfusion-guided approach). Although conventional guidelines are restricted to clinical data from meta-analytic surveys, the physiological approach of the Lund therapy finds support in both experimental and clinical studies. It offers a wider base and can also give recommendations regarding fluid therapy, lung protection, optimal hemoglobin concentration, temperature control, the use of decompressive craniotomy, and ventricular drainage. This study puts forward arguments in support of the Lund therapy.
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| 7. |
- Grände, Per-Olof
(författare)
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The lund concept for the treatment of patients with severe traumatic brain injury.
- 2011
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Ingår i: Journal of Neurosurgical Anesthesiology. - : Ovid Technologies (Wolters Kluwer Health). - 1537-1921 .- 0898-4921. ; 23:4, s. 358-362
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Tidskriftsartikel (refereegranskat)abstract
- Two different main concepts for the treatment of a severe traumatic brain injury have been established during the last 15 years, namely the more conventional concept recommended in well-established guidelines (eg, U.S. Guideline, European Guideline, Addelbrook's Guideline from Cambridge), on the one hand, and the Lund concept from the University Hospital of Lund, Sweden, on the other. Owing to the lack of well-controlled randomized outcome studies comparing these 2 main therapeutic approaches, we cannot conclude that one is better than the other. This paper is the PRO part in a PRO-CON debate in this journal on the Lund concept. Although the Lund concept is based on a physiology-oriented approach dealing with the hemodynamic principles of brain volume and brain perfusion regulation, traditional treatments are primarily based on a meta-analytic approach from clinical studies. High cerebral perfusion pressure has been an essential goal in the conventional treatments (the cerebral perfusion pressure-guided approach), even though it has been modified in a recent up date of U.S. guidelines. The Lund concept has instead concentrated on management of brain edema and intracranial pressure, along with improvement of cerebral perfusion and oxygenation (the intracranial pressure and perfusion-guided approach). Although conventional guidelines are restricted to clinical data from meta-analytic surveys, the physiological approach of Lund therapy finds support in both experimental and clinical studies. It offers a wider base and can also provide recommendations regarding fluid therapy, lung protection, optimal hemoglobin concentration, temperature control, the use of decompressive craniotomy, and ventricular drainage. This paper puts forward arguments in support of Lund therapy.
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| 8. |
- Hinz, José, et al.
(författare)
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Effectiveness of an intravascular cooling method compared with a conventional cooling technique in neurologic patients
- 2007
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Ingår i: Journal of Neurosurgical Anesthesiology. - 0898-4921 .- 1537-1921. ; 19:2, s. 130-135
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Tidskriftsartikel (refereegranskat)abstract
- Fever is common among neurologic patients and is usually treated by antipyretic drugs and external cooling. An alternative method for temperature management may be an intravascular approach. The aim of the study was to compare the effectiveness and the therapeutic costs of this new method with conventional treatment in neurologic patients. Twenty-six patients who suffered from subarachnoid hemorrhage or traumatic brain injury with febrile episodes were included the study and were randomized into 2 different groups. In the "Conventional" group, fever was treated with antipyretic drugs and/or surface cooling techniques to achieve a body core temperature of 36.5 degrees C. In the "CoolGard" group, patients were treated with an intravascular cooling catheter (Coolgard, Alsius, CA). We compared the effectiveness of these 2 approaches by calculating the mean deviation from 36.5 degrees C during a 48-hour period (fever burden). We found a significant difference in the fever burden [CoolGard: -0.49 to 1.22 (median -0.06) degrees C vs. Conventional: 1.05-2.34 (median 1.41) degrees C, P<0.05]. Costs varied significantly between the CoolGard and the Conventional groups, with markedly higher daily costs in the CoolGard group [CoolGard: 15 to 140 US dollars (USD) (median 39 USD) vs. Conventional: 1 to 9 USD (median 5 USD), P<0.05]. The effectiveness of the intravascular cooling catheter is excellent compared with conventional cooling therapies.
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