There is very little data correlating lumbar puncture pressures to formal intracranial pressure monitoring despite the widespread use of both procedures. The hypothesis was that lumbar puncture is a single-point measurement and hence it may not be a reliable evaluation of intracranial pressure. The study was therefore carried out to compare lumbar puncture opening pressures with the Camino bolt intracranial pressure monitor in children. Twelve children with a mean age of 8.5 years who had both lumbar puncture and intracranial pressure monitoring were analyzed. The mean lumbar puncture opening pressure was 22.4 mm Hg versus a mean Camino bolt intracranial pressure of 7.8 mm Hg (P < .0001). Lumbar puncture therefore significantly overestimates the intracranial pressure in children. There were no complications from the intracranial pressure monitoring, and the procedure changed the treatment of all 12 children avoiding invasive operative procedures in most of the patients.
When an emergent ventriculostomy is required for relief of increased intracranial pressure, it is critical that participating physicians and nurses work as an efficient team for optimal outcomes. From our experience, problems in ventriculostomy insertion have occurred because of delays in obtaining correct supplies and lack of skill in assembling the drainage system. The goals of this study were to (a) decrease the response time and (b) increase competency for successful insertion and setup of a ventriculostomy by using a "mock herniation" scenario. Three different nursing shifts in the pediatric intensive care unit at the University of Missouri Health Care were presented with a mock scenario of a child with increased intracranial pressure and impending herniation. Each group was timed on its ability to gather the correct supplies and scored on accuracy in setting up the drainage system. Subsequently, all pediatric intensive care unit nurses underwent skills laboratory training on correct assembly of the drainage system. After training, three different groups of nurses were tested again using the mock herniation scenario. This time, there was improvement in all areas tested, particularly in the mean time taken for accurate assembly and setup of the emergency ventriculostomy drainage system. We conclude that skills laboratory training reinforced by periodic mock herniations significantly decreases response time and increases accuracy of assembling supplies and setting up the drainage system for ventriculostomy insertion.
Abstract INTRODUCTION Metopic craniosynostosis lacks a defined threshold for surgery. We conducted a short online survey to determine if surgeon opinions reflected the current conflicting evidence in the literature. METHODS The survey was conducted using SurveyMonkey and recipients included members of the International Society for Pediatric Neurosurgery (N = 212). The survey consisted of 2 clinical vignettes of children with metopic craniosynostosis with 5 questions each. The first vignette featured a 1 year old girl presenting with a persistent metopic ridge with otherwise normal development and no signs of raised ICP. The second vignette featured a 1 month old boy with metopic synostosis but otherwise normal exam with soft anterior fontanelle and no raised ICP. The respondents were asked if surgery should be advised, reason for surgery (if advised), type of procedure recommended (if advised), likelihood of increased ICP in the future, and predicted prognosis in 10 years if no surgery performed. RESULTS >We received 75 responses from pediatric neurosurgeons, with the majority (41.4%) having 20 + years in practice. For vignette #1, the majority (94.5%) did not suggest surgery and 67.6% of them were not concerned about increased ICP in the future. However, only 46.5% of respondents against surgery believed the ridge would improve in 10 years, whereas 49.3% thought it would remain unchanged. In vignette #2, 93.0% of surgeons advised surgery and the reasons for advising surgery varied: appearance (60.6%), developmental delay concern (15.2%), and increased ICP (10.6%). Most surgeons suggested an open procedure (71.2%) over endoscopy assisted strip craniectomy (28.8%). The majority rated the likelihood of raised ICP as <10% (37.1%), with the minority suggesting 10–24% (25.7%), 25–50% (15.7%), and 51–100% (4.3%). CONCLUSION While the majority of surgeons agreed upon surgery versus non-surgery in each case, we observed significant variations in opinions regarding reasons for proceeding with surgery, surgical approach, and patient prognosis.
Stroke is devastating and a common cause of death. Early recognition and treatment of stroke reduces the risk of death and disability. The initial screening CT initiates the pathway of care for the patient hence it is important for frontline doctors to appreciate the subtle changes that occur in a brain CT scan in stroke. Prompt recognition of stroke is covered extensively in this chapter because of the eminently treatable nature of this disease. In addition, the subtle changes in density in ischemic stroke are clearly discussed while emphasizing and illustrating the time dependent nature of this observation. Although outside the scope of this book, the uses of CT angiogram to further investigate these patients (advanced imaging) is mentioned for the curious reader.
Object. Photofrin is widely distributed in the body after intravenous injection. This study was designed to quantify the preferential uptake of Photofrin by pituitary adenoma tissue for intraoperative photodynamic therapy. Methods. Eight patients (seven men) with recurrent pituitary adenomas who had undergone previous surgery and radiation therapy were recruited for a Phase I/II feasibility study of the application of photodynamic therapy to pituitary tumors. Photofrin was administered intravenously at a dose of 2 mg/kg body weight 48 hours before repeated transsphenoidal hypophysectomy was performed. At the time of the operation, pituitary adenoma tissue, muscle, fat, skin, and plasma were obtained for measurement of Photofrin content by fluorometric assay. The mean Photofrin level in pituitary adenoma tissue was 6.87 ng/mg (95% confidence interval [CI] 3.99–9.75), which was significantly higher than the uptake by skeletal muscle (2.24 ng/mg, 95% CI 1.28–3.2; p = 0.008), or fat (2.54 ng/mg, 95% CI 0.66–4.42; p = 0.007). Nevertheless, the mean drug concentration in pituitary adenoma tissue was not significantly different from the level in plasma (7.65 µg/ml, 95% CI 5.38–9.90; p = 0.558). Skin specimens were available in four patients, and these showed a mean uptake of 2.19 ng/mg. Conclusions. Photofrin is preferentially retained by pituitary adenoma tissue to levels both adequate for intraoperative photodynamic therapy and approximately 50% higher than those reported for gliomas.
The techniques covered in the preceding chapters are reviewed with more complex examples to illustrate the point that advanced inference is a function of carefully applying the basic principles we have learnt. The examples include a case of severe traumatic hematoma with herniation that has superimposed imaging artefacts. Aptly titled "when chaos becomes a concept", it illustrates the reliability of the basic principles even in complicated situations. Advanced imaging techniques are mentioned for the advanced reader to explore independently. CT angiography and CT venography with 3D rendition is widespread but functional imaging modalities such as CT perfusion are less common. A brief mention is made of the principles CT scanning in this section rather than at the beginning to emphasize that this knowledge is not required to interpret a brain CT scan just as you do not need to be an automotive engineer to drive a car.
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