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Intractable Intracranial Hypertension
Published in Stephen M. Cohn, Alan Lisbon, Stephen Heard, 50 Landmark Papers, 2021
Summary: the Decompressive Craniectomy (DECRA) trial randomized 155 patients with severe traumatic brain injury (TBI) with ICPs refractory to hyperventilation, hypertonics, paralytics, and often cerebrospinal fluid diversion to either receive continued standard care management or undergo bifrontotemporal decompression after 72 hours of treatment. The randomization was stratified by treatment center as well as modality of ICP measurement (patients received either monitors or ventricular drainage catheters). There was a higher rate of complications in the surgical group (37%) than conservative (17%), skewed in part by hydrocephalus. The trial found that while decompressive craniectomy decreased ICPs effectively, it was associated with poorer functional outcomes at 6 months.
Neurology
Published in Faye Hill, Sash Noor, Neel Sharma, Tiago Villanueva, Medical and Surgical Emergencies for Students and Junior Doctors, 2021
Faye Hill, Sash Noor, Neel Sharma
Monitoring and careful control of blood pressure is important in such cases. Surgical clipping or endovascular coiling should be performed to reduce the risk of re-bleeding. Cerebral vasospasm is a common occurrence after a subarachnoid haemorrhage. This can be appropriately managed through the use of oral nimodipine. Because of the risk of hydrocephalus associated with subarachnoid haemorrhage, temporary or permanent cerebrospinal fluid diversion is required. Seizures should be best controlled with anti-epileptic therapy (see below) and in cases of hyponatraemia, which can occur in up to 30% of cases, patients may benefit from fludrocortisone and hypertonic saline.
Rosette-Forming Glioneuronal Tumor
Published in Dongyou Liu, Tumors and Cancers, 2017
In cases where there is acute obstructive hydrocephalus accompanying a tumor and causing deterioration in the consciousness level, a ventriculoperitoneal (VP) shunt operation or emergent external ventricular drainage is strongly advised for cerebrospinal fluid diversion [3]. Endoscopic third ventriculostomy can be performed during tumor removal or biopsy in cases with ventriculomegaly [4].
Symptomatic tension pneumocephalus following Palacos® cranioplasty in a shunted patient
Published in British Journal of Neurosurgery, 2019
Tim Killeen, Mathias Fortunati, Esha Myanger, Daniel Rüfenacht, Nurzhan Ryskeldiyev, Serik Akshulakov, Evaldas Cesnulis
Pneumocephalus in shunted patients is rare but has been seen to develop many years after shunt insertion as a result of further intracranial procedures, trauma or spontaneous cutaneous-dural fistulae.1 Cerebrospinal fluid diversion can produce an intermittent, negative pressure gradient with respect to the atmosphere and draw air in through a skin defect if it communicates with the intracranial space.2 Here, this defect may have been caused during the sharp dissection of the extensive scar tissue underlying the skin flap, although no such injury was noticed perioperatively. In any case, the defect appears to have functioned as a one-way valve, inhibiting egress and resulting in the large increase in volume with associated clinical deterioration and contributing to the observed mass effect. Such a tension pneumocephalus is an emergency as the shunt will potentially continue to drain CSF while air enters the cranium until the proximal catheter is blocked or kinked by shifted brain tissue. Once identified, treatment in our case was relatively straightforward – controlled decompression and application of an airtight dressing – although fistulae in less accessible regions such as the skull base1 may require adjustment of the shunt to a high pressure setting to buy time prior to definitive closure.
Continuum of care and longitudinal recovery in a 17-year-old athlete with second impact syndrome
Published in Brain Injury, 2023
Nabela Enam, Hansen Deng, Nicholas S. Race, Dewan S. Majid, David O. Okonkwo, Kevin M. Franzese
Exam on arrival revealed that the patient was intubated with spontaneous eye opening and flexion of upper extremities and triple flexion of lower extremities, with a recorded Glasgow Coma Scale (GCS) score of 8 T. He was taken emergently from the helipad to the operating room for left decompressive hemicraniectomy (DHC) and SDH evacuation. Post-operative CT imaging demonstrated improved midline shift to 5 mm (Figure 1b). Multimodal intracranial neuromonitors were placed, and an external ventricular drain (EVD) inserted for cerebrospinal fluid diversion. Based on his radiographic findings and mechanism of injury, the patient was diagnosed with second impact syndrome.
Dilated Virchow Robin spaces in brainstem
Published in British Journal of Neurosurgery, 2023
Nishanth Sadashiva, Jitender Saini
dVRS are commonly found in the mesencephalothalamic region. Majority of dVRS patients suffer from headaches and other related symptoms include vertigo, cognitive impairment, ataxia, visual changes, and seizures. Cysts in the mesencephalothalamic region can be associated with obstructive hydrocephalus and cranial nerve signs due to a mass effect.3 It does not require any surgical intervention unless it is causing obstructive hydrocephalus which may need cerebrospinal fluid diversion procedures.4