Corrado Iaccarino

Clinical applications of intracranial pressure monitoring in traumatic brain injury

BackgroundIntracranial pressure (ICP) monitoring has been for decades a cornerstone of traumatic brain injury (TBI) management. Nevertheless, in recent years, its usefulness has been questioned in several reports. A group of neurosurgeons and neurointensivists met to openly discuss, and provide consensus on, practical applications of ICP in severe adult TBI.MethodsA consensus conference was held in Milan on October 5, 2013, putting together neurosurgeons and intensivists with recognized expertise in treatment of TBI. Four topics have been selected and addressed in pro-con presentations: 1) ICP indications in diffuse brain injury, 2) cerebral contusions, 3) secondary decompressive craniectomy (DC), and 4) after evacuation of intracranial traumatic hematomas. The participants were asked to elaborate on the existing published evidence (without a systematic review) and their personal clinical experience. Based on the presentations and discussions of the conference, some drafts were circulated among the attendants. After remarks and further contributions were collected, a final document was approved by the participants.Summary and conclusionsThe group made the following recommendations: 1) in comatose TBI patients, in case of normal computed tomography (CT) scan, there is no indication for ICP monitoring; 2) ICP monitoring is indicated in comatose TBI patients with cerebral contusions in whom the interruption of sedation to check neurological status is dangerous and when the clinical examination is not completely reliable. The probe should be positioned on the side of the larger contusion; 3) ICP monitoring is generally recommended following a secondary DC in order to assess the effectiveness of DC in terms of ICP control and guide further therapy; 4) ICP monitoring after evacuation of an acute supratentorial intracranial hematoma should be considered for salvageable patients at increased risk of intracranial hypertension with particular perioperative features.

Use of "custom made" porous hydroxyapatite implants for cranioplasty: postoperative analysis of complications in 1549 patients.

Background: Cranioplasty is a surgical intervention aimed at reestablishing the integrity of skull defects, and should be considered the conclusion of a surgical act that began with bone flap removal. Autologous bone is still considered the treatment of choice for cranioplasty. An alternative choice is bioceramic porous hydroxyapatite (HA) as it is one of the materials that meets and comes closest to the biomimetic characteristics of bone. Methods: The authors analyzed the clinical charts, compiled by the neurosurgeon, of all patients treated with custom-made porous HA devices (Custom Bone Service Fin-Ceramica, Faenza) from which epidemiological and pathological data as well as material-related complications were extrapolated. Results: From November 1997 to December 2010, 1549 patients underwent cranioplasty with the implantation of 1608 custom-made porous HA devices. HA was used in 53.8% of patients for decompressive craniectomy after trauma or intracranial hemorrhage, while the remaining cases were for treated for comminuted fracture, cutaneous or osseous resection, cranial malformation, autologous bone reabsorption or infection or rejection of previously implanted material. The incidence of adverse events in patients treated for cranioplasty, as first line treatment was 4.78% (56 events/1171 patients), and 5.02%, (19 events/378 patients) at second line. Conclusion: This study demonstrates that HA is a safe and effective material, is well tolerated in both adult and pediatric patients, and meets the requirements necessary to repair craniolacunia.

Intracranial pressure monitoring after endoscopic third ventriculostomy: an effective method to manage the ‘adaptation period’

Endoscopic third ventriculostomy (ETV) has become the treatment of choice for non-communicating hydrocephalus. Nevertheless, which technique should be considered of choice to identify features correlating with the failure of an endoscopic procedure and which is the optimal postoperative period care standard are still a matter of debate. Traditional neuroimaging techniques have several limitations in assessing the success of the procedure mostly in the early postoperative period. Indeed, a decrease in the ventricular size is often minimal and not visible before 3-4 weeks. MRI, able to detect the presence of a flow void signal through the third ventricle floor, has been reported to have a significantly high incidence of false positives. In our experience, the continuous measuring of intracranial pressure (ICP) by means of a ventricular catheter has been of great help in verifying the correct functioning of the communication between the ventricle and the subarachnoidal spaces during the first postoperative days. Furthermore, ICP monitoring allowed us to safely deal with the intracranial hypertension that may occur shortly after ETV.

Intracranial pressure patterns after endoscopic third ventriculostomy. Preliminary experience

Summary.Background. Endoscopic Third Ventriculostomy (ETV) has become the treatment of choice for non-communicating hydrocephalus as it is able to couple high success rate (60–80%) with rare complications (about 5%). Nevertheless, which is the best postoperative care standard and whether or not it is possible to predict the success of the procedure is still discussed. Traditional neuro-imaging techniques show several limitations in the early postoperative period. Indeed, a decrease of the ventricular size is often minimal and not visible before three weeks, while, MRI visualization of a flow void signal through the third ventricle floor, seems to have a significant incidence of false positives. The use of postoperative ICP measurement after ETV has been suggested as a valid monitoring method, mostly in the early postoperative period. In previously unpublished data the authors observed the existence of different ICP patterns following ETV. This finding prompted the authors to search for a relationship among ICP patterns, stoma functioning and prediction of success.Method. At our institution 26 consecutive patients affected by obstructive triventricular hydrocephalus underwent ETV. Among them there were 11 primitive aqueductal stenosis (AS), 5 shunt malfunctions, 2 third ventricle mass, 3 intraventricular cysts, and 5 patients with different lesions (1 quadrigeminal cistern arachnoidal cyst, 1 pineal region mass, 2 tectal tumours, and 1 supracerebellar abscess) compressing the aqueduct of Sylvius from outside named “ab estrinseco” aqueductal stenosis. All patients underwent postoperative Intra Cranial Pressure (ICP) monitoring by means of a ventricular catheter.Findings. Transient ICP rises of any grade, mostly responsive to periodical liquoral subtractions, occurred shortly after ETV in as many as 50% of our patients. No major complications occurred. The effect of ETV on ICP trend was found to be variable among groups of patients thus identifying different ICP patterns. Patients with ab estrinseco Sylvian aqueduct compression showed the best effect on ICP, whilst, patients with intraventricular mass lesions causing triventricular hydrocephalus and shunt-dependent patients, revealed a clear trend to develop a more severe intracranial hypertension after ETV.Conclusions. Patients with shunt malfunction and patients with intraventricular mass lesions, showing a more pronounced trend to develop severe intracranial hypertension after ETV, should always be considered for postoperative ICP monitoring in order to detect and, eventually, treat any ICP rises which may occur. Unfortunately, it is still difficult to assign a predictive value to the different postoperative ICP patterns. The authors encourage postoperative ICP monitoring in all patients in order to define all the possible ICP patterns following ETV.

Combined Endoscopic Transsphenoidal–Transventricular Approach for Resection of a Giant Pituitary Macroadenoma

OBJECTIVES Sellar lesions, such as pituitary adenomas, even when extended to the suprasellar space may be usually removed through a trans-sphenoidal approach. Larger lesions extending well beyond the edges of the sellar diaphragm such as giant adenomas are best controlled with craniotomy and/or a combined approach that implies both, transphenoidal and transcranial route. Currently, the availability of more sophisticated endoscopes in this type of surgery has provided optimal angles of view and rendered the trans-sphenoidal route less invasive yet, more effective. CASE DESCRIPTION The authors report a case of a giant pituitary adenoma successfully managed by a simultaneous, combined endoscopic trans-sphenoidal-transventricular approach. CONCLUSION In selected case of giant pituitary adenoma with ventricular extension, this technique may help to achieve a gross total removal avoiding the need of staged procedures allowing also a direct visualization of the extent of removal. Finally this approach can potentially improve gross total resection rate of different types of tumor involving this region such as cranipharyngiomas while reducing morbidity and mortality.

Patients with brain contusions: predictors of outcome and relationship between radiological and clinical evolution

OBJECT Traumatic parenchymal mass lesions are common sequelae of traumatic brain injuries (TBIs). They occur in up to 8.2% of all TBI cases and 13%-35% of severe TBI cases, and they account for up to 20% of surgical intracranial lesions. Controversy exists concerning the association between radiological and clinical evolution of brain contusions. The aim of this study was to identify predictors of unfavorable outcome, analyze the evolution of brain contusions, and evaluate specific indications for surgery. METHODS In a retrospective, multicenter study, patients with brain contusions were identified in separate patient cohorts from 11 hospitals over a 4-year period (2008-2011). Data on clinical parameters and course of the contusion were collected. Radiological parameters were registered by using CT images taken at the time of hospital admission and at subsequent follow-up times. Patients who underwent surgical procedures were identified. Outcomes were evaluated 6 months after trauma by using the Glasgow Outcome Scale-Extended. RESULTS Multivariate analysis revealed the following reliable predictors of unfavorable outcome: 1) increased patient age, 2) lower Glasgow Coma Scale score at first evaluation, 3) clinical deterioration in the first hours after trauma, and 4) onset or increase of midline shift on follow-up CT images. Further multivariate analysis identified the following as statistically significant predictors of clinical deterioration during the first hours after trauma: 1) onset of or increase in midline shift on follow-up CT images (p < 0.001) and 2) increased effacement of basal cisterns on follow-up CT images (p < 0.001). CONCLUSIONS In TBI patients with cerebral contusion, the onset of clinical deterioration is predictably associated with the onset or increase of midline shift and worsened status of basal cisterns but not with hematoma or edema volume increase. A combination of clinical deterioration and increased midline shift/basal cistern compression is the most reasonable indicator for surgery.

The therapeutic cranioplasty still needs an ideal material and surgical timing.

In their article “Comparison of Polyetheretherketone (PEEK) and Titanium Cranioplasty after Decompressive Craniectomy,” Thien et al. (21) compare 24 patients with a polyetheretherketone (PEEK) cranioplasty with 108 patients with a titanium cranioplasty. The authors observed no differences in the complication rates between those patients undergoing PEEK and those undergoing titanium cranioplasty, and they provide additional information about the risks of complications associated with both materials. According to the authors, this is the largest published series of PEEK cranioplasties and one of the few reports in which titanium and PEEK cranioplasty are compared. The authors performed cranioplasty at least 8 weeks after decompressive craniectomy, provided that the patient was medically well with no brain swelling and no ongoing issues such as sepsis. Nevertheless, they do not report any specific protocol for the assessment of recovery from any kind of infection. The authors found that the only factor associated with cranioplasty complications was a previous “deep” infection, defined as “cranial infection involving deep soft tissue, spaces and/or brain.” There is clear, renewed interest in the methods and complications of cranioplasties, which is obviously directly related to the increasing number of reports about decompressive craniectomy. Unfortunately, like for decompressive craniectomies, very few perspective studies are available about cranial reconstruction. The aims of the cranioplasty are protection of the brain, restoration of the brain’s hydrodynamic conditions, and cosmetics. This procedure is always a second step performed after a previous surgical procedure where autologous bone has been removed. The bone decompression is a form of “cure” of an otherwise-nontreatable intracranial pressure increase in different pathologies like traumatic, vascular, or infectious diseases. Complications related to the vault reconstruction obviously also are related to the complications caused by the “first” pathology and to the previous surgical procedures.

Exclusively intracranial and cranial fasciitis of the adult age.

The unusual case of an exclusively intracranial localization of fasciitis (CF) in a man aged 47 is reported. The cystic lesion had been accidentally discovered 10 years before when the patient sustained a contralateral ischemic stroke; the cyst, being absolutely silent, was not operated on at that time. After 10 years, the patient complained of seizures and mild right-sided paresis. CT scan revealed a dramatic increase of the lesion whose mass effect caused an initial subfalcial herniation of the brain. The mass was grossly removed, the patient recovered and become seizure-free. CF, rare in childhood, is exceptional in the adult age. The importance of a correct histological diagnosis is hereby stressed, because CF is absolutely benign, self-limiting, and does not require further treatment, but may be misdiagnosed as sarcoma.

Intraoperative neurophysiological monitoring for intradural extramedullary tumors: why not?

BACKGROUND While intraoperative neurophysiological monitoring (IOM) for intramedullary tumors has become a standard in neurosurgical practice, IOM for intradural extramedullary tumors (IDEMs) is still under debate. The aim of this study is to evaluate the role of IOM during surgery for IDEMs. METHODS From March 2008 to March 2013, 68 patients had microsurgery with IOM for IDEMs (31 schwannomas, 25 meningiomas, 6 ependymomas of the cauda/filum terminalis, 4 dermoid cysts and 2 other lesions). The IOM included somatosensory evoked potentials (SEPs), motor evoked potentials (MEPs), and--in selected cases--D-waves. Also preoperative and postoperative neurophysiological assessment was performed with SEPs and MEPs. All patients were evaluated at admission and at follow up (minimum 6 months) with the Modified McCormick Scale (mMCs). RESULTS Three different IOM patterns were observed during surgery: no change in evoked potentials (63 cases), transitory evoked potentials change (3 cases) and loss of evoked potentials (2 cases). In the first setting surgery was never stopped and a radical tumor removal was achieved (no stop surgery group). In 3 cases of transitory evoked potentials change, surgery was temporarily halted but the tumors were at the end completely removed (stop and go surgery group). In 2 more patients the loss of evoked potentials led to an incomplete resection (stop surgery group). No patients presented a worsening of the pre-operative clinical conditions (at admission 47 patients presented mMCs 1-2 and 21 patients mMCs 3-5, while at follow up 62 patients are mMCS 1-2 and 6 patients mMCs 3-5). CONCLUSIONS In our series significant IOM changes occurred in 5 out of 68 patients with IDEMs (7.35%), and it is conceivable that the modification of the surgical strategy - induced by IOM - prevented or mitigated neurological injury in these cases. Vice versa, in 63 patients (92.65%) IOM invariably predicted a good neurological outcome. Furthermore this technique allowed a safer tumor removal in IDEMs placed in difficult locations as cranio-vertebral junction or in antero/antero-lateral position (where rotation of spinal cord can be monitored) and even in case of tumor adherent to the spinal cord without a clear cleavage plane.

Decompressive Craniectomies: Time to Discuss Not the DECRA Study but the Comments to the DECRA Study

t any rate, some points, in my opinion, need to be highlighted. The ECRA study is the first large randomized study ever published on ecompressive craniectomies in patients with traumatic brain injuries TBIs). This is a fact that cannot be disputed. Unfortunately, the results in favor of nonsurgical management) were not what the authors and he neurosurgical community expected. Obviously, as it is stressed in he paper by Honeybul et al. published in this issue of WORLD NEUROURGERY, the results are related to the patients included in the study the presence of diffuse injury and transient increase of intracranial ressure [ICP] greater than 20 mmHg), who are probably not the best andidates for surgical decompression (11). We are all aware that this tudy is not the end of the decompressive craniectomies; patients with ustained, increased ICP, or intracranial posttraumatic hematomas will robably benefit from hematoma evacuation and bone decompresion. Furthermore, another randomized study with different and more easonable entry criteria is still on its way. The results of this ongoing rial, Rescue ICP (10), also will add important information to the use of procedure that is still under debate.