| 1. |
- 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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| 2. |
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| 3. |
- 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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| 4. |
- 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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| 5. |
- 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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| 6. |
- Nilsson, Ida, et al.
(författare)
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The efficacy of P6 acupressure with sea-band in reducing postoperative nausea and vomiting in patients undergoing craniotomy : a randomized, double-blinded, placebo-controlled study
- 2015
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Ingår i: Journal of Neurosurgical Anesthesiology. - 0898-4921 .- 1537-1921. ; 27:1, s. 42-50
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Tidskriftsartikel (refereegranskat)abstract
- Background: Postoperative nausea and vomiting (PONV) is a multifactorial problem after general anesthesia. Despite antiemetic prophylaxis and improved anesthetic techniques, PONV still occurs frequently after craniotomies. P6 stimulation is described as an alternative method for preventing PONV. The primary aim of this study was to determine whether P6 acupressure with Sea-Band could reduce postoperative nausea after elective craniotomy. Secondary aims were to investigate whether the frequency of vomiting and the need for antiemetics could be reduced.Methods: In this randomized, double-blinded, placebo-controlled study, patients were randomized into either a P6 acupressure group (n = 43) or a sham group (n = 52). Bands were applied unilaterally at the end of surgery, and all patients were administered prophylactic ondansetron. Postoperative nausea was evaluated with a Numerical Rating Scale, 0 to10, and the frequency of vomiting was recorded for 48 hours.Results: We found no significant effect from P6 acupressure with Sea-Band on postoperative nausea or vomiting in patients undergoing craniotomy. Nor was there any difference in the need for rescue antiemetics. Altogether, 67% experienced PONV, and this was especially an issue at >24 hours in patients recovering from infratentorial surgery compared with supratentorial surgery (55% vs. 26%; P = 0.014).Conclusions: Unilateral P6 acupressure with Sea-Band applied at the end of surgery together with prophylactic ondansetron did not significantly reduce PONV or the need for rescue antiemetics in patients undergoing craniotomy. Our study confirmed that PONV is a common issue after craniotomy, especially after infratentorial surgery.
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| 7. |
- Svedung Wettervik, Teodor, et al.
(författare)
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Autoregulatory Cerebral Perfusion Pressure Insults in Traumatic Brain Injury and Aneurysmal Subarachnoid Hemorrhage : The Role of Insult Intensity and Duration on Clinical Outcome
- 2024
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Ingår i: Journal of Neurosurgical Anesthesiology. - : Wolters Kluwer. - 0898-4921 .- 1537-1921. ; 36:3, s. 228-236
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Tidskriftsartikel (refereegranskat)abstract
- Background: This single-center, retrospective study investigated the outcome effect of the combined intensity and duration of differences between actual cerebral perfusion pressure (CPP) and optimal cerebral perfusion pressure (CPPopt), and also for absolute CPP, in patients with traumatic brain injury (TBI) and aneurysmal subarachnoid hemorrhage (aSAH).Methods: A total of 378 TBI and 432 aSAH patients treated in a neurointensive care unit between 2008 and 2018 with at least 24 hours of CPPopt data during the first 10 days following injury, and with 6-month (TBI) or 12-month (aSAH) extended Glasgow Outcome Scale (GOS-E) scores, were included in the study. ∆CPPopt-insults (∆CPPopt=actual CPP−CPPopt) and CPP-insults were visualized as 2-dimensional plots to highlight the combined effect of insult intensity (mm Hg) and duration (min) on patient outcome.Results: In TBI patients, a zone of ∆CPPopt ± 10 mm Hg was associated with more favorable outcome, with transitions towards unfavorable outcome above and below this zone. CPP in the range of 60 to 80 mm Hg was associated with higher GOS-E, whereas CPP outside this range was associated with lower GOS-E. In aSAH patients, there was no clear transition from higher to lower GOS-E for ∆CPPopt-insults; however, there was a transition from favorable to unfavorable outcome when CPP was <80 mm Hg.Conclusions: TBI patients with CPP close to CPPopt exhibited better clinical outcomes, and absolute CPP within the 60 to 80 mm Hg range was also associated with favorable outcome. In aSAH patients, there was no clear transition for ∆CPPopt-insults in relation to outcome, whereas generally high absolute CPP values were associated overall with favorable recovery.
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| 8. |
- Svedung-Wettervik, Teodor, et al.
(författare)
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Cerebral Microdialysis Monitoring of Energy Metabolism: Relation to Cerebral Blood Flow and Oxygen Delivery in Aneurysmal Subarachnoid Hemorrhage
- 2023
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Ingår i: Journal of Neurosurgical Anesthesiology. - : Ovid Technologies (Wolters Kluwer Health). - 0898-4921 .- 1537-1921. ; 35:4, s. 384-393
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Tidskriftsartikel (refereegranskat)abstract
- Introduction: In this study, we investigated the roles of cerebral blood flow (CBF) and cerebral oxygen delivery (CDO2) in relation to cerebral energy metabolism after aneurysmal subarachnoid hemorrhage (aSAH).Methods: Fifty-seven adult aSAH patients treated on the neurointensive care unit at Uppsala, Sweden between 2012 and 2020, with at least 1 xenon-enhanced computed tomography (Xe-CT) scan in the first 14 days after ictus and concurrent microdialysis (MD) monitoring, were included in this retrospective study. CBF was measured globally and focally (around the MD catheter) with Xe-CT, and CDO2 calculated. Cerebral energy metabolites were measured using MD.Results: Focal ischemia (CBF <20 mL/100 g/min around the MD catheter was associated with lower median [interquartile range]) MD-glucose (1.2 [0.7 to 2.2] mM vs. 2.3 [1.3 to 3.5] mM; P=0.05) and higher MD-lactate-pyruvate (LPR) ratio (34 [29 to 66] vs. 25 [21 to 32]; P=0.02). A compensated/normal MD pattern (MD-LPR <25) was observed in the majority of patients (22/23, 96%) without focal ischemia, whereas 4 of 11 (36%) patients with a MD pattern of poor substrate supply (MD-LPR >25, MD-pyruvate <120 µM) had focal ischemia as did 5 of 20 (25%) patients with a pattern of mitochondrial dysfunction (MD-LPR >25, MD-pyruvate >120 µM) (P=0.04). Global CBF and CDO2, and focal CDO2, were not associated with the MD variables.Conclusions: While MD is a feasible tool to study cerebral energy metabolism, its validity is limited to a focal area around the MD catheter. Cerebral energy disturbances were more related to low CBF than to low CDO2. Considering the high rate of mitochondrial dysfunction, treatments that increase CBF but not CDO2, such as hemodilution, may still benefit glucose delivery to drive anaerobic metabolism.
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| 9. |
- Svedung Wettervik, Teodor, et al.
(författare)
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Intracranial Pressure Variability : A New Potential Metric of Cerebral Ischemia and Energy Metabolic Dysfunction in Aneurysmal Subarachnoid Hemorrhage?
- 2023
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Ingår i: Journal of Neurosurgical Anesthesiology. - : Wolters Kluwer. - 0898-4921 .- 1537-1921. ; 35:2, s. 208-214
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Tidskriftsartikel (refereegranskat)abstract
- Background: It was recently reported that lower intracranial pressure variability (ICPV) is associated with delayed ischemic neurological deficits and unfavorable outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). In this study, we aimed to determine whether lower ICPV also correlated with worse cerebral energy metabolism after aSAH.Methods: A total of 75 aSAH patients treated in the neurointensive care unit at Uppsala University Hospital, Sweden between 2008 and 2018 and with both intracranial pressure and cerebral microdialysis (MD) monitoring during the first 10 days after ictus were included in this retrospective study. ICPV was calculated with a bandpass filter limited to intracranial pressure slow waves with a wavelength of 55 to 15 seconds. Cerebral energy metabolites were measured hourly with MD. The monitoring period was divided into 3 phases; early (days 1 to 3), early vasospasm (days 4 to 6.5), and late vasospasm (days 6.5 to 10).Results: Lower ICPV was associated with lower MD-glucose in the late vasospasm phase, lower MD-pyruvate in the early vasospasm phases, and higher MD-lactate-pyruvate ratio (LPR) in the early and late vasospasm phases. Lower ICPV was associated with poor cerebral substrate supply (LPR >25 and pyruvate <120 µM) rather than mitochondrial failure (LPR >25 and pyruvate >120 µM). There was no association between ICPV and delayed ischemic neurological deficit, but lower ICPV in both vasospasm phases correlated with unfavorable outcomes.Conclusion: Lower ICPV was associated with an increased risk for disturbed cerebral energy metabolism and worse clinical outcomes in aSAH patients, possibly explained by a vasospasm-related decrease in cerebral blood volume dynamics and cerebral ischemia.
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| 10. |
- Svedung-Wettervik, Teodor, et al.
(författare)
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Systemic Hyperthermia in Traumatic Brain Injury—Relation to Intracranial Pressure Dynamics, Cerebral Energy Metabolism, and Clinical Outcome
- 2021
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Ingår i: Journal of Neurosurgical Anesthesiology. - : Wolters Kluwer. - 0898-4921 .- 1537-1921. ; , s. 329-336
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Tidskriftsartikel (refereegranskat)abstract
- Background: Systemic hyperthermia is common after traumatic brain injury (TBI) and may induce secondary brain injury, although the pathophysiology is not fully understood. In this study, our aim was to determine the incidence and temporal course of hyperthermia after TBI and its relation to intracranial pressure dynamics, cerebral metabolism, and clinical outcomes.Materials and Methods: This retrospective study included 115 TBI patients. Data from systemic physiology (body temperature, blood pressure, and arterial glucose), intracranial pressure dynamics (intracranial pressure, cerebral perfusion pressure, compliance,and pressure reactivity), and cerebral microdialysis (glucose, pyruvate, lactate, glycerol, glutamate, and urea) were analyzed during the first 10 days after injury.Results: Overall, 6% of patients did not have hyperthermia (T> 38°C) during the first 10 days after injury, whereas 20% had hyperthermia for > 50% of the time. Hyperthermia increased from 21% (±27%) of monitoring time on day 1 to 36% (± 29%) on days 6 to 10 after injury. In univariate analyses, higher body temperature was not associated with higher intracranial pressure nor lower cerebral perfusion pressure, but was associated with lower cerebral glucose concentration (P= 0.001) and higher percentage of lactate-pyruvate ratio> 25 (P=0.02) on days 6 to 10 after injury. Higher body temperature and lower arterial glucose concentration were associated with lower cerebral glucose in a multiple linear regression analysis (P=0.02 for both). There was no association between hyperthermia and worse clinical outcomes.Conclusion: Hyperthermia was most common between days 6 and 10 following TBI, and associated with disturbances in cerebral energy metabolism but not worse clinical outcome.
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