Archivos de la categoría Neurotraumatología

Hummingbird Neuromonitoring

Hummingbird Neuromonitoring

http://www.hummingbirdneuromonitoring.com

Hummingbird Synergy is a novel single-port access device for multimodal intracranial monitoring that can be placed safely at the bedside or in the operating room with placement accuracy and has a complication profile similar to or better than that for standard external ventricular drains 1).

Hummingbird Neuromonitoring products help clinicians manage patients suffering from conditions that cause an elevated intracranial pressure.

Provides simultaneous ICP monitoring and CSF drainage, eliminates leveling of a fluid-based system, and enables re-zeroing in situ. This powerful mixture saves nursing time and provides optimized care for the patient.

In addition to developing the first monitoring technology that eliminates capital, they have also delivered the first integrated access device for multimodal monitoring, Hummingbird Synergy. Providing precision access, Hummingbird Synergy combines access for brain probes, ventricular drainage, and parenchymal ICP through a single twist-drill hole. Together, the Hummingbird ICP and Hummingbird Synergy are a powerful combination that reduces procedural complications and optimizes patient care.

The products, which include multimodal, traditional bolt based, and tunneled catheter systems, have been used in thousands of procedures in centers across the United States. With a commitment to continuous innovation, Hummingbird addresses unmet clinical needs and is poised to become the new standard of care for treating patients suffering from traumatic brain injury and stroke.

Multimodal Monitoring Systems

Traditional Bolt Based Systems

Tunneled Ventricular System

Products

Hummingbird Synergy Ventricular

Hummingbird SynergyDuo Ventricular

Hummingbird Synergy Parenchyma

Hummingbird SynergyDuo Parenchyma

Hummingbird Synergy Parenchyma with Temperature

Hummingbird Temperature Probes

1) Chohan MO, Akbik OS, Ramos-Canseco J, Ramirez PM, Murray-Krezan C, Berlin T, Olin K, Taylor CL, Yonas H. A novel single twist-drill access device for multimodal intracranial monitoring: a 5-year single-institution experience. Neurosurgery. 2014 Sep;10 Suppl 3:400-11. doi: 10.1227/NEU.0000000000000451. PubMed PMID: 24887290.

Venous thromboembolic prophylaxis in traumatic brain injury

Venous thromboembolic prophylaxis (VTEp) is often delayed following traumatic brain injury (TBI), yet animal data suggest that it may reduce cerebral inflammation and improve cognitive recovery.

Medical charts of severe TBI patients admitted to a level 1 trauma center in 2009-2010 were queried for admission Glasgow Coma Scale (GCS), head Abbreviated Injury Scale, Injury Severity Score (ISS), osmotherapy use, emergency neurosurgery, and delay to VTEp initiation. Progression (+1 = better, 0 = no change, -1 = worse) of brain injury on head CTs and neurologic exam (by bedside MD, nurse) was collected from patient charts. Head CT Marshall classification were calculated from the initial head CT results.

A total of 22, 34, and 19 patients received VTEp at early (<3 days), intermediate (3-5 days), and late (>5 days) time intervals, respectively. Clinical and radiologic brain injury characteristics on admission were similar among the three groups (P > 0.05), but ISS was greatest in the early group (P < 0.05). Initial head CT Marshall classification were similar in early and late groups. The slowest progression of brain injury on repeated head CT scans was in the early VTEp group up to 10 days after admission.

Early initiation of prophylactic heparin in severe TBI is not associated with deterioration neurologic exam and may result in less progression of injury on brain imaging. Possible neuroprotective effects of heparin in humans need further investigation 1).

1) Kim L, Schuster J, Holena DN, Sims CA, Levine J, Pascual JL. Early initiation of prophylactic heparin in severe traumatic brain injury is associated with accelerated improvement on brain imaging. J Emerg Trauma Shock. 2014 Jul;7(3):141-148. PubMed PMID: 25114421.

Intracranial hypotension: clinical presentation, imaging findings, and imaging-guided therapy

Intracranial hypotension is a condition in which there is negative pressure within the brain cavity.

Etiology

see Spontaneous intracranial hypotension

Cerebrospinal fluid leak from the spinal canal:

A leak following a lumbar puncture (spinal tap).

A defect in the dura

Sometimes following exertion such as swinging a golf club.

A congenital weakness.

Following spinal surgery.

Following spinal trauma.

Following a shunt procedure for hydrocephalus.

Lumboperitoneal shunt.

Ventriculoperitoneal shunt with a low pressure valve.

In some cases, spinal CSF leaks can lead to a descent of the cerebellar tonsils into the spinal canal, similar to a Chiari malformation.

Large spinal dural defects can lead to herniation of the spinal cord into the defect.

Symptoms

The classic symptom is severe headache when upright, which is relieved when lying flat.

Other symptoms can include nausea, vomiting, double vision and difficulty with concentration.

The typical clinical manifestation – orthostatic headache – may be masqueraded by atypical clinical findings, including coma, frontotemporal dementia, leptomeningeal hemosiderosis-associated symptoms, and others.

Diagnosis

Diagnosis is usually suspected based on the postural dependency of the headache, although in many cases the diagnosis of intracranial hypotension is not considered for some time.

A contrast-enhanced brain magnetic response imaging (MRI) scan typically shows thickened and brightly enhancing meninges (pachymeningeal enhancement). Other findings include descent of the thalamus and cerebellar tonsils.

MRI signs are highly specific, but the imaging strategy to search for spinal cerebrospinal fluid leaks (none, computed tomography myelography, magnetic resonance myelography with gadolinium, digital subtraction myelography) is a matter of debate 1).

Continuous intracranial pressure monitoring is definitive for documenting abnormally negative intracranial pressures.

The identification of the site of CSF leak in the spinal canal can be very challenging. In some cases, the site cannot be identified. Methods include:

Dynamic myelography with fluoroscopy and computed tomography (CT).

Radioisotope cisternography.

Spinal MRI.

Treatment

If the site of the spinal CSF leak can be identified, then options include:

Epidural blood patch, performed by an anesthesiologist pain management specialist.

Surgical repair of the defect.

Over-draining CSF shunts are managed by replacing the valve with one that drains less.

Lumboperitoneal shunts may have to be removed or ligated.

Outcome

If the cause of the intracranial hypotension can be identified, the outcome following treatment is typically excellent.

1) Urbach H. Intracranial hypotension: clinical presentation, imaging findings, and imaging-guided therapy. Curr Opin Neurol. 2014 Aug;27(4):414-24. doi: 10.1097/WCO.0000000000000105. PubMed PMID: 24978633.

Standardization of practice of a routine repeat head CT

Traumatic intracranial hemorrhage

A definitive consensus on the standardization of practice of a routine repeat head CT (RHCT) scan in patients with traumatic intracranial hemorrhage is lacking.

In a 3-year prospective cohort analysis of patients aged 18 years and older, without antiplatelet or anticoagulation therapy, presenting to a level 1 trauma center with intracranial hemorrhage on initial head CT and a follow-up RHCT. Neurosurgical intervention was defined by craniotomy/craniectomy. Neurologic deterioration was defined as altered mental status, focal neurologic deficits, and/or pupillary changes.

A total of 1,129 patients were included. Routine RHCT was performed in 1,099 patients. The progression rate was 19.7% (216 of 1,099), with subsequent neurosurgical intervention in 4 patients. Four patients had an abnormal neurologic examination, with a Glasgow Coma Scale (GCS) of ≤8 requiring intubation. Thirty patients had an RHCT secondary to neurologic deterioration; 53% (16 of 30) had progression on RHCT, of which 75% (12 of 16) required neurosurgical intervention. There was an association between deterioration in neurologic examination and need for neurosurgical intervention (odds ratio 3.98; 95% CI 1.7 to 9.1). The negative predictive value of a deteriorating neurologic examination in predicting the need for neurosurgical intervention was 100% in patients with GCS > 8.

Routine repeat head CT scan is not warranted in patients with normal neurologic examination. Routine repeat head CT scan does not supplement the need for neurologic examination for determining management in patients with traumatic brain injury 1).

1) Joseph B, Aziz H, Pandit V, Kulvatunyou N, Hashmi A, Tang A, Sadoun M, O’Keeffe T, Vercruysse G, Green DJ, Friese RS, Rhee P. A three-year prospective study of repeat head computed tomography in patients with traumatic brain injury. J Am Coll Surg. 2014 Jul;219(1):45-51. doi: 10.1016/j.jamcollsurg.2013.12.062. Epub 2014 Mar 1. PubMed PMID: 24745622.