No full-text available
To read the full-text of this research,
you can request a copy directly from the author.
Intracranial pressure in Infants
Abstract
In infancy, the intracranial pressure (ICP) is normally maintained at a level that is very low by standards that apply later in life. There is little or no overlap of normal pressure and the pressure in infantile hydrocephalus. Knowledge of the normal pressure may allow expectant management of milder instances of infantile hydrocephalus.
During the first few days after birth, as the volume of the brain decreases so does its turgor, and subatmospheric ICP is common. Hydrocephalus may be masked or attenuated in severity during that time or may be incorrectly suspected in a normal child because of the increase in circumference of the head accompanying the restitution of volume. The postnatal decrease in ICP may be responsible for ventricular hemorrhage in the newborn.
... ICP is referenced at the level of the foramen of Monro. The normal suggested reference values for ICP vary with age (Table 1) [68][69][70][71][72]. It is currently accepted that physiologic mean ICP boundaries in healthy adult subjects resting in the horizontal position are 7-15 and −10 mm Hg but not exceeding −15 mm Hg in the vertical position. ...
... It is currently accepted that physiologic mean ICP boundaries in healthy adult subjects resting in the horizontal position are 7-15 and −10 mm Hg but not exceeding −15 mm Hg in the vertical position. Normal mean ICP values are reported to be within the range of 3-7 mm Hg in young children and 1.5-6 mm Hg in term infants [68][69][70][71][72]. ...
Early diagnosis of increased intracranial pressure (ICP) is crucial for prompt diagnosis and treatment of intracranial hypertension in critically ill pediatric patients, preventing secondary brain damage and mortality. Although the placement of an external ventricular drain coupled to an external fluid-filled transducer remains the gold standard for continuous ICP monitoring, other non-invasive approaches are constantly being improved and can provide reliable estimates. The use of point-of-care ultrasound (POCUS) for the assessment of ICP has recently become widespread in pediatric emergency and critical care settings, representing a valuable extension of the physical examination. The aim of this manuscript is to review and discuss the basic principles of ultra-sound measurement of the optic nerve sheath diameter (ONSD) and summarize current evidence on its diagnostic value in pediatric patients with ICP. There is increasing evidence that POCUS measurement of the ONSD correlates with ICP, thus appearing as a useful extension of the physical examination in pediatrics, especially in emergency medicine and critical care settings for the initial non-invasive assessment of patients with suspected raised ICP. Its role could be of value even to assess the response to therapy and in the follow-up of patients with diagnosed intracranial hypertension if invasive ICP monitoring is not available. Further studies on more homogeneous and extensive study populations should be performed to establish ONSD reference ranges in the different pediatric ages and to define cut-off values in predicting elevated ICP compared to invasive ICP measurement.
... I valori normali della PIC sono misurati nel liquido cerebrospinale (LCS) [5] . Solitamente espressi in mmHg (10 cmH 2 O = 7,35 mmHg; 10 mmHg = 13,6 cmH 2 O), variano in base all'età: dai 10 ai 15 mmHg per adulti e bambini più grandi, oscillando, a volte, fino a 20 mmHg, da 3 a 7 mmHg per i bambini piccoli e da 1 a 6 mmHg nel periodo neonatale [14,15] . In uno stato fisiologico stabile, la PIC è stabile nonostante i disturbi transitori, che possono essere indotti da tosse, starnuti o sforzi a glottide chiusa, grazie ai sistemi di compenso offerti dai diversi settori. ...
... Il settore SVSA, con un volume di 150 ml, è diviso in volume ventricolare di 30 ml, volume cisternale di 40 ml e volume spinale di 80 ml [11] . Nei bambini, il valore relativo di questo volume sarebbe ridotto rispetto agli adulti [14] . Il LCS, ultrafiltrato plasmatico, occupa un volume che dipende dalla sua produzione, dal suo volume di stoccaggio o compliance e, infine, dalle sue capacità di riassorbimento. ...
Riassunto
L’ipertensione intracranica (HIC) si riferisce all’impatto clinico di una pressione intracranica (PIC) superiore a 20 mmHg e costituisce una base comune di molteplici patologie neurologiche. La comparsa di un’HIC è la conseguenza biomeccanica ed emodinamica del superamento dei processi fisiologici di compenso di una PIC elevata. Esiste un continuum patogenetico tra HIC espansiva (tumore, trauma cerebrale, idrocefalo), HIC lesionale (tromboflebite cerebrale, tumore gigante della cauda equina, fistola durale, ecc.) e HIC benigna (endocrinopatie, farmaci, apnea del sonno, idiopatica, ecc.). Questa sindrome clinica, il cui nocciolo duro associa cefalea e manifestazioni oculari, espone a uno scompenso clinico per ernia cerebrale attraverso gli orifizi che separano i compartimenti dello spazio craniospinale. L’iter diagnostico, guidato dal rischio di scompenso clinico per ernia cerebrale a cui espone l’HIC espansiva, richiede la realizzazione in urgenza di una neuroradiologia mediante tomografia computerizzata e risonanza magnetica cranioencefalica. Le cause lesionali e le HIC benigne sono diagnosticate utilizzando una neuroradiologia convenzionale, che esplora gli assi vascolari e la perfusione parenchimale, ma anche studiando il liquido cerebrospinale in assenza di qualsiasi processo. La misurazione della PIC permette di ottenere un valore medio e una curva di registrazione continua. Pertanto, la registrazione della PIC disegna un’onda di pressione legata al compartimento vascolare, in relazione diretta con l’attività del vaso cerebrale per l’onda di polso e le onde lente, e indiretta attraverso i grandi vasi intratoracici per le onde respiratorie. Inoltre, la sua analisi permette il calcolo di due indici che sono la riserva di compenso pressione-volume e la reattività cerebrovascolare. Il trattamento dell’HIC, mediante trattamento chirurgico preliminare all’instaurazione di un trattamento medico, cerca di preservare una normale pressione di perfusione cerebrale e una circolazione idrodinamica cefalo-oculare normale.
... On the other hand, we also suggest that expansion of a cranium with complete or nearly complete sutural closure would be difficult due to the increased ICP. The normal range for ICP based on age may be variable and apt to be affected by medical conditions, and the normal range of ICP may be variable in each age group [10, 23,24]. Welch [24] documented that the relationship between age and ICP in infants had a slightly positive slope even if the result was not significant, while Avery et al. [23] reported that an abnormal opening pressure was above 28 cm of water in their LPP study of 197 children aged between 1 and 18 years. ...
... The normal range for ICP based on age may be variable and apt to be affected by medical conditions, and the normal range of ICP may be variable in each age group [10, 23,24]. Welch [24] documented that the relationship between age and ICP in infants had a slightly positive slope even if the result was not significant, while Avery et al. [23] reported that an abnormal opening pressure was above 28 cm of water in their LPP study of 197 children aged between 1 and 18 years. In close agreement with their reports, our result showed a significantly positive correlation between age and LPP only in the infant group (Fig. 1a). ...
Background:
The aim of this study was to retrospectively evaluate and analyze the relationships between head circumference percentile (HCP), lumbar puncture pressure (LPP), and cerebrospinal fluid (CSF) space.
Methods:
The 88 patients were divided into 3 age groups (group 1, up to 12 months; group 2, 12-36 months; group 3, 36-72 months).
Results:
In group 1 (n = 40), there was a significant positive correlation of the HCP with the LPP (r =0.414, p =0.008), Evans ratio (r =0.365, p =0.021), and thickness of subdural hygroma (SDHG; r =0.403, p =0.010). Group 2 (n = 29) revealed a significant positive correlation between the LPP and the thickness of SDHG (r =0.459, p =0.012). Group 3 (n = 19) showed no significant correlation among these factors. Overall, age was related with SDHG thickness both in infants and toddlers, while HCP was related with LPP, Evans ratio, and SDHG thickness only in infants, and LPP was related with SDHG thickness only in toddlers.
Conclusion:
We suggest that increased cerebrospinal space and pressure may result in compensatory enlargement of head circumference only in the infant period, and the SDHG thickness decreases with age during the infant and toddler phases.
... There is associated loss of volume and turgor of the brain, but the level at which this happens is uncertain. Thus, as a physiological adaptation, there is a physiological hydrocephalus seen in neonates compensating the loss in brain volume (Welch, 1980). As a buffer system, in neonates and even in infants, till the AF closes physiologically between the ages of 9 months to 18 months, elevated intracranial pressure is dissipated due to an open fontanelle and sutures. ...
... In an infant below 1 year of age, a normal ICP averages 3.7 mmHg [20]. In 16 infants with active hydrocephalus, the mean ICP was 11.7 mmHg [21]. ...
Background:
Symptomatic or active hydrocephalus in children is linked to an elevation in intracranial pressure (ICP), which is likely to be multifactorial in origin. The CSF outflow resistance, venous sinus resistance and total cerebral blood flow are likely factors in the ICP elevation. The purpose of this paper is to define the incidence, site and significance of venous sinus stenosis and/or cerebral hyperemia in a cohort of children diagnosed with hydrocephalus at a tertiary referral hospital.
Methods:
The imaging database was reviewed over a 10 year period and the index MRI of all children between the ages of 4 months and 15 years, who were diagnosed with treatment naive hydrocephalus of any type (excluding secondary to tumor) and had magnetic resonance venography (MRV) and flow quantification were selected. Patients were compared with children undergoing an MRI with MRV and flow quantification who were subsequently shown to have no abnormality. The cross-sectional area and circumference of the sinuses were measured at 4 levels. The hydraulic and effective diameters were calculated. An area stenosis of 65% or greater was deemed significant. A total cerebral blood flow greater than two standard deviations above the mean for controls was taken to be abnormal.
Results:
There were a total of 55 children with hydrocephalus compared to 118 age matched control MRV's and 35 control flow quantification studies. A high grade stenosis occurred in 56% of patients but in none of the controls (p < 0.0001). The commonest site of narrowing was in the distal sigmoid sinus. Cerebral hyperemia occurred in 13% of patients but did not occur in the controls.
Conclusions:
The elevation in ICP in symptomatic hydrocephalus is multifactorial. Both high grade venous stenosis and cerebral hyperemia are common in childhood hydrocephalus. High grade stenosis was noted to be a risk factor for conservative management failure. Hyperemia was a good prognostic indicator.
... CSF fluid loss and shifting of the cerebellum downward leading to stretching and tearing of veins, is the theory postulated by Yoshida et al [8] . In contrast, Konig et al [6] theorized that increased pressure gradients across veins generated after removal of space occupying lesions such as tumors is a possible mechanism by which RCH develops, a theory based on studies by Welch [11] and Courten et al [12] . ...
Remote Cerebellar Hemorrhage is a rare entity that manifests spontaneously after supratentorial craniotomy and spinal surgeries. We present a 53-year-old male who was admitted due to subdural hematoma along the left frontoparietotemporal convexity. After treatment of the subdural hematoma with craniotomy and evacuation, he developed remote cerebellar hemorrhage 1 week later. Brain computed tomography demonstrated the zebra sign. Follow-up imaging showed complete recovery without any neurologic symptoms or signs.
... ICP varies with age: 8.2 cm H2O represents a normal opening pressure in infants, slowly increasing to 18 cm H 2 O in children aged 8 years, eventually reaching an upper limit of 20 cm H 2 O in children >8 years old. 68,69 In 2010, a diagnostic ICP for IIH was proposed: an opening pressure of >20 cm H 2 O in children <8 years old and >25 cm H 2 O in those >8 years old. 55 Nonetheless, a false high opening pressure may be observed in crying children or anxious patients. ...
Epidemiology Idiopathic intracranial hypertension (IIH) can occur at all stages of life irrespective of sex but has a predilection Abstract Idiopathic intracranial hypertension (IIH), also known as benign intracranial hypertension or pseudotumor cerebri, is characterized by increased intracranial pressure secondary to unknown causes. IIH affects both adults and children but predominately young obese females of child-bearing age. IIH gives rise to headache, visual disturbances, and symptoms of raised intracranial pressure. The pathophysiology of IIH remains elusive; postulations include obesity-related hormonal changes, obstruction of the central venous sinus, and hereditary causes. Diagnosing IIH is based on modified Dandy criteria. Diagnosis in children is challenging as symptoms and presentations vary; atypical and delayed presentations are not uncommon. Treatment for IIH includes oral acetazolamide or lumbar puncture; surgical treatment with shunts and optic nerve sheath fenestration is reserved for complicated and recurring cases. Treatment options for children are limited and associated with considerable risks and side effects. Vision loss is debilitating and occurs in 10% of IIH patients. A thorough and collaborative approach in managing IIH is needed. This study reviews the epidemiology, clinical presentation, diagnosis, and management of IIH in adults and pediatric patients. towards obese females. 1 The annual incidence of IIH is 0.9 cases per 100,000 people and 3.5 cases per 100,000 obese females of child-bearing age. 2 The incidence of IIH in Asians is lower. In a Japanese cohort, the incidence of IIH was 0.3 cases per 100,000 people per year. 3 The incidence in Chinese is not well studied but is believed to be infrequent. 4 Observational studies have shown a direct relationship between increased body mass index and the risk of IIH. 5 The incidence is expected to increase with the global obesity epidemic. Patients with recent weight gain of 5% to 15% have a higher risk of developing IIH than those with stable weight. 5 About 10% of IIH patients are men who are usually diagnosed a decade older than women. 6 Black patients seem to have a worse vision prognosis than whites. It is unknown whether Asians have the same risks of developing IIH as other races. 7,8 Childhood IIH occurs most frequently after puberty. 9 Pre-pubertal IIH is uncommon and is rare in neonates and preschool children. The estimated incidence of childhood IIH is 0.8 cases per 100,000 children. In Hong Kong, the incidence was 0.78 case per 100,000. 10 These figures are probably underestimated because of selection bias and diagnostic problems. Post-pubertal IIH patients are mostly obese females, whereas pre-pubertal IIH patients are usually non-obese, with males and females equally affected. 11,12 A retrospective multicenter study of pediatric IIH using anthropometric parameters identified 3 subgroups of patients: young children (girls aged <7 years and boys aged <8.5 years) who were not overweight; early adolescents (boys and girls aged 7-12 years) who were taller and overweight; and late adolescents (boys and girls aged ≥12.5 years) who were overweight. 13 It is unclear whether these 3 subgroups represent natural progression of pediatric IIH or distinct subgroups of disease with different pathophysiology. The association of adiposity and increased linear growth acceleration in post-pubertal, early and late adolescent
... Communicating type which is secondary to the decreased absorption over the surface of brain. (1) There are various ways of managing hydrocephalous which ranges from medical management for low pressure system to surgical intervention in high pressure system. Surgical procedures available for the treatment of hydrocephalous include endoscopic third ventriculostomy and shunt surgery. ...
... However, some data suggest that this ICP threshold should be lower in young children. Physiologically, ICP and CPP are reduced in proportion to the children age while comparable values to adults are observed after 6-8 years of age [292]. This supports strategies considering age-related ICP values [163,266,273,290]. ...
The latest French Guidelines for the management in the first 24hours of patients with severe traumatic brain injury (TBI) were published in 1998. Due to recent changes (intracerebral monitoring, cerebral perfusion pressure management, treatment of raised intracranial pressure), an update was required. Our objective has been to specify the significant developments since 1998. These guidelines were conducted by a group of experts for the French Society of Anesthesia and Intensive Care Medicine (Société Francaise d'Anesthésie Réanimation (SFAR)) in partnership with the Association de Neuro-Anesthésie-Réanimation de Langue Française (ANARLF), the Société Française de Neurochirurgie (SFN), the Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP) and the Association des Anesthésistes-Réanimateurs Pédiatriques d'Expression Française (ADARPEF). The method used to elaborate these guidelines was the GRADE® method. After two Delphi rounds, 32 recommendations were formally developed by the experts focusing on the evaluation the initial severity of traumatic brain injury, the modalities of prehospital management, imaging strategies, indications for neurosurgical interventions, sedation and analgesia, indications and modalities of cerebral monitoring, medical management of raised intracranial pressure, management of multiple trauma with severe traumatic brain injury, detection and prevention of post-traumatic epilepsia, biological homeostasis (osmolarity, glycaemia, adrenal axis) and paediatric specificities.
... [5][6][7][8][9] DEFINITIONS Normal ICP varies with age, body position, and clinical condition. 1,10 In healthy individuals in supine position it is between 7 and 15 mm Hg; while standing, it becomes negative with an average of about 10 mm Hg. 1,2,10 In term infants, 1.5 to 6 mm Hg is considered normal, whereas in children these values range between 3 and 7 mm Hg. 11 ICP can be increased transiently in physiologic situations such as a coughing or sneezing. Critically ill patients, occasional increases can be observed with changes in position, aspiration of secretions, asynchrony with mechanical ventilation, and physiotherapy. ...
Intracranial hypertension is one of leading causes of mortality after acute brain injury. Its causes and origins are multiple. The approach should be based on the underlying pathophysiology. There are different therapeutic modalities to control increased intracranial pressure (ICP), but all share the objective of normalizing basic physiologic variables. ICP control should be combined with adequate cerebral perfusion pressure. The classic approach to ICP control is unidirectional and sequential escalation of therapy. The nonresponse to classic therapy signaled a refractory condition. Multimodal monitoring has emerged as a useful tool, taking into account the analysis of ICP, oxygenation, and cerebral metabolism.
... In the current experiments we used a pressure of 30 mmHg to ensure pathological pressure against the 3D cell culture construct. This pressure is considered pathologic by many published studies although lower magnitude pathologic pressure, when sustained without relief, may be injurious as well (Welch, 1980;Wiegand and Richards, 2007). ...
Background:
Elevated intracranial pressure (ICP) accompanying a number of neurological emergencies is poorly understood, and lacks a model to determine cellular pathophysiology. This limits our ability to identify cellular and molecular biomarkers associated with the pathological progression from physiologic to pathologic ICP.
New method:
We developed an ex vivo model of pressure-induced brain injury, which combines 3D neural cell cultures and a newly developed Pressure Controlled Cell Culture Incubator (PC(3)I). Human astrocytes and neurons maintained in 3D peptide-conjugated alginate hydrogels were subjected to pressures that mimic both physiologic and pathologic levels of ICP for up to 48hours to evaluate the earliest impacts of isolated pressure on cellular viability and quantify early indicators of pressure-induced cellular injury.
Results:
Compared to control cell cultures grown under physiologic pressure, sustained pathologic pressure exposure increased the release of intracellular ATP in a cell-specific manner. Eighteen hours of sustained pressure resulted in increased ATP release from neurons but not astrocytes.
Comparison with existing methods:
Cell culture incubators maintain cultures at normal atmospheric pressure. Based on multiple literature searches, we are not aware of any other cell culture incubator systems that modify the pressure at which primary CNS cells are maintained.
Conclusion:
This model simulates the clinical features of elevated ICP encountered in patients with hydrocephalus, and provides a first estimate of the pathological signaling encountered during the earliest perid of progression in neonatal hydrocephalus. This model should provide a means to better understand the pathological biomarkers associated with the earliest stages of elevated ICP.
... Even though the general view is that both normative and pathological ICP should be a function of age, there are little data to guide us, so the 20 mmHg threshold for treatment remains widely used [39]. Historical data from lumbar pressure measurements in normal children ranged from 3 to 8 cm H 2 0 in infants and 4-10 cm H 2 0 in children [74]. More recently, Avery et al. studied lumbar cerebrospinal fluid (CSF) opening pressures in children and suggested that the upper threshold for normal was around 20 mmHg (28 cm H 2 O to be precise) [5]. ...
In recent years, much progress has been made in our understanding of traumatic brain injury (TBI). Clinical outcomes have progressively improved, but evidence-based guidelines for how we manage patients remain surprisingly weak. The problem is that the many interventions and strategies that have been investigated in randomized controlled trials have all disappointed. These include many concepts that had become standard care in TBI. And that is just for adult TBI; in children, the situation is even worse. Not only is pediatric care more difficult than adult care because physiological norms change with age, but also there is less evidence for clinical practice. In this article, we discuss the heterogeneity inherent in TBI and why so many clinical trials have failed. We submit that a key goal for the future is to appreciate important clinical differences between patients in their pathophysiology and their responses to treatment. The challenge that faces us is how to rationally apply therapies based on the specific needs of an individual patient. In doing so, we may be able to apply the principles of precision medicine approaches to the patients we treat.
... Previous studies with fontanometry and invasive monitoring defined as normal values of ICP: children under 1 year from 1.5 to 6 mmHg; preschool children from 3 to 7 mmHg; older children and adults from 10 to 15 mmHg. Newborns may present very low and even negative values, possibly affected by the presence of open and wide fontanelle [28,32]. For the monitoring of children with an open fontanelle, besides the clinical information from the physical examination and palpation of the bregmatic fontanelle [15], Doppler ultrasonography can provide accurate and NI information [12]. ...
Purpose:
The purpose of this study is to evaluate a noninvasive device to assess intracranial pressure wave form in children with hydrocephalus.
Methods:
A prospective and non-experimental descriptive-analytic study was performed. Fifty-six patients were enrolled in this study. They were divided in four groups: group A, children with clinically compensated hydrocephalus; B, surgically treated hydrocephalus; C, patients with acute intracranial hypertension due to hydrocephalus; and D, children without neurological disease (control). Data were collected through the installation of an extracranial deformation sensor, coupled to the children's scalp, which allowed registration of noninvasive intracranial pressure curves. Parameters obtained were analyzed: P2/P1 ratio, "classification P1 and P2 and P1 slope.
Results:
P2/P1 index and "classification of P1 and P2" had a sensitivity of 80% and specificity of 100% for predicting intracranial hypertension. "P1 slope" presented no statistical difference.
Conclusion:
This study showed a useful and noninvasive method for monitoring intracranial pressure, which was able to indicate the intracranial hypertension in children with hydrocephalus and, thus, should be further investigated for clinical applications.
... Cependant, certaines données suggèrent que le seuil de traitement pourrait être abaissé dans les tranches d'âge les plus jeunes. Physiologiquement, PIC et PPC sont d'autant plus basses que l'enfant est jeune, avec des valeurs atteignant les valeurs adultes au-delà de 6 à 8 ans [289], ce qui plaide en faveur de seuils variables selon l'âge. Plusieurs études rétrospectives vont dans ce sens, [162,263,270,287] mais avec des seuils thérapeutiques prédéfinis variables selon les auteurs : objectif de PIC < 15 mmHg uniquement pour les moins de 2 ans pour certains auteurs, PIC < 15 mmHg pour l'ensemble de la population pédiatrique pour d'autres. ...
The incidence of traumatic brain injury (TBI) has been increasing globally and is estimated at 27–69 million of new cases per year. It remains the main single cause of death in young people below 40 years of age. The ultimate extent of brain injury and the patient’s outcome result from the degree of primary damage to the central nervous system at the time of impact and the subsequent, pathophysiological sequelae of injury expansion over following hours and days. Clinical management of TBI aims to interrupt the pathological cascade of events and minimise development of secondary damage. Although the entire spectrum of complex, multilevel processes occurring in injured regions of the brain and the peri-lesional penumbra are not fully studied and understood, important part of treatment protocols constitutes invasive monitoring of brain physiology. Intracranial pressure (ICP) measurement plays a key role as a diagnostic tool in critical care of TBI patients. ICP and its derivates are indirect source of data on status of brain autoregulation, intracranial compliance, and compensatory reserve. The pressure reactivity index reflects the condition of cerebrovascular reactivity and indicates an individual, optimal cerebral perfusion pressure. Moreover, the real-time observation of continuous ICP waveform does not only alert clinicians of intracranial hypertension but delivers prognostic information.
Çocuk Yoğun Bakım Ünitesi ve Ekibi Süleyman BAYRAKTAR Kritik Çocuk Hastaya Yaklaşım Metin KARABÖCÜOĞLU Yoğun Bakım Hastasında Sıvı ve Elektrolit Tedavisi Ahmet NAYIR, Zeynep YÜRÜK YILDIRI Çocuk Yoğun Bakım Hastalarında Beslenme Bülent KARAPINAR, Pınar YAZICI İmmün Beslenme Hasan AĞIN, Gökhan CEYLAN Kalp Akciğer Etkileşimi Agop ÇITAK Hemodinamik Monitörizasyon Sultan GÖNCÜ, Benan BAYRAKCI Şok ve Dolaşım Desteği Nilgün ERKEK Septik Şok ve Tedavisi Esra ŞEVKETOĞLU Çoğul Organ Yetmezliği Sendromu Nilüfer YALINDAĞ Yoğun Bakımda Disritmilerin Tedavisi Arda SAYGILI Akut Konjestif Kalp Yetersizliği Oğuz DURSUN Çocuk Kalp Cerrahisi Sonrası Yoğun Bakım Arda SAYGILI Akut Solunum Yetmezliği ve Tedavisi Tanıl KENDİRLİ Yoğun Bakım Ünitelerinde Hastane Enfeksiyonları Tanıl KENDİRLİ İmmünkompromize Hastanın Çocuk Yoğun Bakım Ünitesinde Değerlendirilmesi Hasan AĞIN, Rana İŞGÜDER Komadaki Hastaya Yaklaşım Agop ÇITAK Kafa İçi Basınç Artışı Sendromu Ali Ertuğ ARSLANKÖYLÜ Status Epileptikus ve Tedavisi Murat DUMAN, Emel ULUSOY Kardiyopulmoner Arrest Sonrası Hipoksik İskemik Ensefalopati Damla HANALİOĞLU, Pelin CENGİZ Beyin Ölümü ve Donör Yönetimi Zeynelabidin ÖZTÜRK, Benan BAYRAKCI Kritik Hasta Çocuklarda Akut Böbrek Yetersizliği ve Renal Destek Sistemleri Demet DEMİRKOL Akut Karaciğer Yetmezliği ve Tedavisi Nurettin Onur KUTLU Mekanik Ventilasyon Temel İlkeleri Tolga F. KÖROĞLU Mekanik Ventilasyon Endikasyonları, Yönetimi ve Uygulamaları Dinçer YILDIZDAŞ, Faruk EKİNCİ Hipoksik Solunum Yetersizliğinde Mekanik Ventilasyon Tolga F. KÖROĞLU Hiperkapneik Solunum Yetersizliği ve Tedavisi Demet DEMİRKOL Mekanik Ventilasyon Sırasında Monitorizasyon Başak Nur AKYILDIZ Mekanik Ventilasyondan Ayırma Tanıl KENDİRLİ Noninvazif Mekanik Ventilasyon Bülent KARAPINAR, Pınar YAZICI Çocuk Yoğun Bakım Ünitelerinde Sedasyon ve Analjezi Dinçer YILDIZDAŞ Çoğul Travmalı Hastaya Yaklaşım Murat DUMAN, Hale ÇİTLENBİK İnhalasyon Yaralanmaları Ayşe Berna ANIL Yanık Ayşe Berna ANIL Çocukluk Döneminde Zehirlenme Olgularına Genel Yaklaşım Hayri Levent YILMAZ Sık Görülen Özgül Zehirlenmelere Yaklaşım Hayri Levent YILMAZ Çocuklarda İntraabdominal Hipertansiyon ve Abdominal Kompartman Sendromu Özden ÖZGÜR HOROZ
Measurement of cerebrospinal fluid pressure through lumbar puncture (LP) manometry is an essential practical skill all paediatricians should possess competency in. The ability to perform manometry is crucial in the diagnosis of idiopathic intracranial hypertension and can provide critical information on raised (or lowered) intracranial pressure in other clinical scenarios. Practitioners should be familiar with the procedure and in particular with equipment available to them locally. In this article, we will describe an approach to LP manometry. The online supplemental material includes an instructional video as well as supporting practical information.
Neurosurgery in neonates presents a set of major challenges to the anaesthesiologist. The surgeries are mostly high-end and the neonatal population precarious and delicate due to the presence of unique multi-system anatomical and physiological attributes and concomitant congenital anomalies. The neonatal central nervous system (CNS) is particularly vulnerable to perioperative injury due to a still-developing brain and spinal cord, and a different and evolving neurophysiology that is responsible for the variable and unpredictable responses to surgery and anesthesia. A different subset of neurosurgical lesions with distinct pathophysiologies, manifestations, and management techniques add to the challenges. A further shortcoming is the lack of diagnostic and management facilities for neonates at routine medical centers, and hence, babies with neurosurgical problems require to be transferred soon after birth to neurocenters that have the advanced equipment and expertise for diagnostic neuroradiology, neurosurgery and neonatal intensive care. It requires a healthy involvement of neonatologists, neonatal neurosurgeons, neonatal neuroanesthesiologists, and specialised nursing and technical staff for comprehensive evaluation and further management. A good understanding of these interrelated factors is vital to a favourable outcome after neurosurgery in the neonatal age. This chapter will discuss neuroembryology, physiology of cerebral circulation, various neurosurgical procedures a neonate might undergo, anesthetic implications and management of craniotomy for various CNS conditions, VP shunt placement, and for neuro-endoscopy.
Numerous studies indicate that outcomes for pediatric patients are improved when the anesthesia caregiver has advanced training and knowledge of pediatric anesthesiology. Essentials of Pediatric Anesthesiology is a unique new handbook, providing a clinically relevant and easy-to-read review of all key topics in this important field. Written and edited by leading pediatric anesthesia physicians, each chapter takes a consistent approach, guaranteeing this book is user-friendly and authoritative throughout. Topics include physiology, anatomy, equipment, a comprehensive overview of relevant disease states, and special topics such as regional anesthesia, complications, and anesthesia for remote locations. Numerous diagrams, tables and figures help to organize the information for easy reference. Whether you choose to dip into a particular chapter or read the book cover to cover, Essentials of Pediatric Anesthesiology is a valuable review book for all residents, fellows and clinical practitioners needing to improve or refresh their understanding of pediatric anesthesia management.
Numerous studies indicate that outcomes for pediatric patients are improved when the anesthesia caregiver has advanced training and knowledge of pediatric anesthesiology. Essentials of Pediatric Anesthesiology is a unique new handbook, providing a clinically relevant and easy-to-read review of all key topics in this important field. Written and edited by leading pediatric anesthesia physicians, each chapter takes a consistent approach, guaranteeing this book is user-friendly and authoritative throughout. Topics include physiology, anatomy, equipment, a comprehensive overview of relevant disease states, and special topics such as regional anesthesia, complications, and anesthesia for remote locations. Numerous diagrams, tables and figures help to organize the information for easy reference. Whether you choose to dip into a particular chapter or read the book cover to cover, Essentials of Pediatric Anesthesiology is a valuable review book for all residents, fellows and clinical practitioners needing to improve or refresh their understanding of pediatric anesthesia management.
Numerous studies indicate that outcomes for pediatric patients are improved when the anesthesia caregiver has advanced training and knowledge of pediatric anesthesiology. Essentials of Pediatric Anesthesiology is a unique new handbook, providing a clinically relevant and easy-to-read review of all key topics in this important field. Written and edited by leading pediatric anesthesia physicians, each chapter takes a consistent approach, guaranteeing this book is user-friendly and authoritative throughout. Topics include physiology, anatomy, equipment, a comprehensive overview of relevant disease states, and special topics such as regional anesthesia, complications, and anesthesia for remote locations. Numerous diagrams, tables and figures help to organize the information for easy reference. Whether you choose to dip into a particular chapter or read the book cover to cover, Essentials of Pediatric Anesthesiology is a valuable review book for all residents, fellows and clinical practitioners needing to improve or refresh their understanding of pediatric anesthesia management.
Numerous studies indicate that outcomes for pediatric patients are improved when the anesthesia caregiver has advanced training and knowledge of pediatric anesthesiology. Essentials of Pediatric Anesthesiology is a unique new handbook, providing a clinically relevant and easy-to-read review of all key topics in this important field. Written and edited by leading pediatric anesthesia physicians, each chapter takes a consistent approach, guaranteeing this book is user-friendly and authoritative throughout. Topics include physiology, anatomy, equipment, a comprehensive overview of relevant disease states, and special topics such as regional anesthesia, complications, and anesthesia for remote locations. Numerous diagrams, tables and figures help to organize the information for easy reference. Whether you choose to dip into a particular chapter or read the book cover to cover, Essentials of Pediatric Anesthesiology is a valuable review book for all residents, fellows and clinical practitioners needing to improve or refresh their understanding of pediatric anesthesia management.
Numerous studies indicate that outcomes for pediatric patients are improved when the anesthesia caregiver has advanced training and knowledge of pediatric anesthesiology. Essentials of Pediatric Anesthesiology is a unique new handbook, providing a clinically relevant and easy-to-read review of all key topics in this important field. Written and edited by leading pediatric anesthesia physicians, each chapter takes a consistent approach, guaranteeing this book is user-friendly and authoritative throughout. Topics include physiology, anatomy, equipment, a comprehensive overview of relevant disease states, and special topics such as regional anesthesia, complications, and anesthesia for remote locations. Numerous diagrams, tables and figures help to organize the information for easy reference. Whether you choose to dip into a particular chapter or read the book cover to cover, Essentials of Pediatric Anesthesiology is a valuable review book for all residents, fellows and clinical practitioners needing to improve or refresh their understanding of pediatric anesthesia management.
Numerous studies indicate that outcomes for pediatric patients are improved when the anesthesia caregiver has advanced training and knowledge of pediatric anesthesiology. Essentials of Pediatric Anesthesiology is a unique new handbook, providing a clinically relevant and easy-to-read review of all key topics in this important field. Written and edited by leading pediatric anesthesia physicians, each chapter takes a consistent approach, guaranteeing this book is user-friendly and authoritative throughout. Topics include physiology, anatomy, equipment, a comprehensive overview of relevant disease states, and special topics such as regional anesthesia, complications, and anesthesia for remote locations. Numerous diagrams, tables and figures help to organize the information for easy reference. Whether you choose to dip into a particular chapter or read the book cover to cover, Essentials of Pediatric Anesthesiology is a valuable review book for all residents, fellows and clinical practitioners needing to improve or refresh their understanding of pediatric anesthesia management.
Numerous studies indicate that outcomes for pediatric patients are improved when the anesthesia caregiver has advanced training and knowledge of pediatric anesthesiology. Essentials of Pediatric Anesthesiology is a unique new handbook, providing a clinically relevant and easy-to-read review of all key topics in this important field. Written and edited by leading pediatric anesthesia physicians, each chapter takes a consistent approach, guaranteeing this book is user-friendly and authoritative throughout. Topics include physiology, anatomy, equipment, a comprehensive overview of relevant disease states, and special topics such as regional anesthesia, complications, and anesthesia for remote locations. Numerous diagrams, tables and figures help to organize the information for easy reference. Whether you choose to dip into a particular chapter or read the book cover to cover, Essentials of Pediatric Anesthesiology is a valuable review book for all residents, fellows and clinical practitioners needing to improve or refresh their understanding of pediatric anesthesia management.
Numerous studies indicate that outcomes for pediatric patients are improved when the anesthesia caregiver has advanced training and knowledge of pediatric anesthesiology. Essentials of Pediatric Anesthesiology is a unique new handbook, providing a clinically relevant and easy-to-read review of all key topics in this important field. Written and edited by leading pediatric anesthesia physicians, each chapter takes a consistent approach, guaranteeing this book is user-friendly and authoritative throughout. Topics include physiology, anatomy, equipment, a comprehensive overview of relevant disease states, and special topics such as regional anesthesia, complications, and anesthesia for remote locations. Numerous diagrams, tables and figures help to organize the information for easy reference. Whether you choose to dip into a particular chapter or read the book cover to cover, Essentials of Pediatric Anesthesiology is a valuable review book for all residents, fellows and clinical practitioners needing to improve or refresh their understanding of pediatric anesthesia management.
Numerous studies indicate that outcomes for pediatric patients are improved when the anesthesia caregiver has advanced training and knowledge of pediatric anesthesiology. Essentials of Pediatric Anesthesiology is a unique new handbook, providing a clinically relevant and easy-to-read review of all key topics in this important field. Written and edited by leading pediatric anesthesia physicians, each chapter takes a consistent approach, guaranteeing this book is user-friendly and authoritative throughout. Topics include physiology, anatomy, equipment, a comprehensive overview of relevant disease states, and special topics such as regional anesthesia, complications, and anesthesia for remote locations. Numerous diagrams, tables and figures help to organize the information for easy reference. Whether you choose to dip into a particular chapter or read the book cover to cover, Essentials of Pediatric Anesthesiology is a valuable review book for all residents, fellows and clinical practitioners needing to improve or refresh their understanding of pediatric anesthesia management.
Numerous studies indicate that outcomes for pediatric patients are improved when the anesthesia caregiver has advanced training and knowledge of pediatric anesthesiology. Essentials of Pediatric Anesthesiology is a unique new handbook, providing a clinically relevant and easy-to-read review of all key topics in this important field. Written and edited by leading pediatric anesthesia physicians, each chapter takes a consistent approach, guaranteeing this book is user-friendly and authoritative throughout. Topics include physiology, anatomy, equipment, a comprehensive overview of relevant disease states, and special topics such as regional anesthesia, complications, and anesthesia for remote locations. Numerous diagrams, tables and figures help to organize the information for easy reference. Whether you choose to dip into a particular chapter or read the book cover to cover, Essentials of Pediatric Anesthesiology is a valuable review book for all residents, fellows and clinical practitioners needing to improve or refresh their understanding of pediatric anesthesia management.
Numerous studies indicate that outcomes for pediatric patients are improved when the anesthesia caregiver has advanced training and knowledge of pediatric anesthesiology. Essentials of Pediatric Anesthesiology is a unique new handbook, providing a clinically relevant and easy-to-read review of all key topics in this important field. Written and edited by leading pediatric anesthesia physicians, each chapter takes a consistent approach, guaranteeing this book is user-friendly and authoritative throughout. Topics include physiology, anatomy, equipment, a comprehensive overview of relevant disease states, and special topics such as regional anesthesia, complications, and anesthesia for remote locations. Numerous diagrams, tables and figures help to organize the information for easy reference. Whether you choose to dip into a particular chapter or read the book cover to cover, Essentials of Pediatric Anesthesiology is a valuable review book for all residents, fellows and clinical practitioners needing to improve or refresh their understanding of pediatric anesthesia management.
Numerous studies indicate that outcomes for pediatric patients are improved when the anesthesia caregiver has advanced training and knowledge of pediatric anesthesiology. Essentials of Pediatric Anesthesiology is a unique new handbook, providing a clinically relevant and easy-to-read review of all key topics in this important field. Written and edited by leading pediatric anesthesia physicians, each chapter takes a consistent approach, guaranteeing this book is user-friendly and authoritative throughout. Topics include physiology, anatomy, equipment, a comprehensive overview of relevant disease states, and special topics such as regional anesthesia, complications, and anesthesia for remote locations. Numerous diagrams, tables and figures help to organize the information for easy reference. Whether you choose to dip into a particular chapter or read the book cover to cover, Essentials of Pediatric Anesthesiology is a valuable review book for all residents, fellows and clinical practitioners needing to improve or refresh their understanding of pediatric anesthesia management.
Numerous studies indicate that outcomes for pediatric patients are improved when the anesthesia caregiver has advanced training and knowledge of pediatric anesthesiology. Essentials of Pediatric Anesthesiology is a unique new handbook, providing a clinically relevant and easy-to-read review of all key topics in this important field. Written and edited by leading pediatric anesthesia physicians, each chapter takes a consistent approach, guaranteeing this book is user-friendly and authoritative throughout. Topics include physiology, anatomy, equipment, a comprehensive overview of relevant disease states, and special topics such as regional anesthesia, complications, and anesthesia for remote locations. Numerous diagrams, tables and figures help to organize the information for easy reference. Whether you choose to dip into a particular chapter or read the book cover to cover, Essentials of Pediatric Anesthesiology is a valuable review book for all residents, fellows and clinical practitioners needing to improve or refresh their understanding of pediatric anesthesia management.
Numerous studies indicate that outcomes for pediatric patients are improved when the anesthesia caregiver has advanced training and knowledge of pediatric anesthesiology. Essentials of Pediatric Anesthesiology is a unique new handbook, providing a clinically relevant and easy-to-read review of all key topics in this important field. Written and edited by leading pediatric anesthesia physicians, each chapter takes a consistent approach, guaranteeing this book is user-friendly and authoritative throughout. Topics include physiology, anatomy, equipment, a comprehensive overview of relevant disease states, and special topics such as regional anesthesia, complications, and anesthesia for remote locations. Numerous diagrams, tables and figures help to organize the information for easy reference. Whether you choose to dip into a particular chapter or read the book cover to cover, Essentials of Pediatric Anesthesiology is a valuable review book for all residents, fellows and clinical practitioners needing to improve or refresh their understanding of pediatric anesthesia management.
Numerous studies indicate that outcomes for pediatric patients are improved when the anesthesia caregiver has advanced training and knowledge of pediatric anesthesiology. Essentials of Pediatric Anesthesiology is a unique new handbook, providing a clinically relevant and easy-to-read review of all key topics in this important field. Written and edited by leading pediatric anesthesia physicians, each chapter takes a consistent approach, guaranteeing this book is user-friendly and authoritative throughout. Topics include physiology, anatomy, equipment, a comprehensive overview of relevant disease states, and special topics such as regional anesthesia, complications, and anesthesia for remote locations. Numerous diagrams, tables and figures help to organize the information for easy reference. Whether you choose to dip into a particular chapter or read the book cover to cover, Essentials of Pediatric Anesthesiology is a valuable review book for all residents, fellows and clinical practitioners needing to improve or refresh their understanding of pediatric anesthesia management.
Numerous studies indicate that outcomes for pediatric patients are improved when the anesthesia caregiver has advanced training and knowledge of pediatric anesthesiology. Essentials of Pediatric Anesthesiology is a unique new handbook, providing a clinically relevant and easy-to-read review of all key topics in this important field. Written and edited by leading pediatric anesthesia physicians, each chapter takes a consistent approach, guaranteeing this book is user-friendly and authoritative throughout. Topics include physiology, anatomy, equipment, a comprehensive overview of relevant disease states, and special topics such as regional anesthesia, complications, and anesthesia for remote locations. Numerous diagrams, tables and figures help to organize the information for easy reference. Whether you choose to dip into a particular chapter or read the book cover to cover, Essentials of Pediatric Anesthesiology is a valuable review book for all residents, fellows and clinical practitioners needing to improve or refresh their understanding of pediatric anesthesia management.
Numerous studies indicate that outcomes for pediatric patients are improved when the anesthesia caregiver has advanced training and knowledge of pediatric anesthesiology. Essentials of Pediatric Anesthesiology is a unique new handbook, providing a clinically relevant and easy-to-read review of all key topics in this important field. Written and edited by leading pediatric anesthesia physicians, each chapter takes a consistent approach, guaranteeing this book is user-friendly and authoritative throughout. Topics include physiology, anatomy, equipment, a comprehensive overview of relevant disease states, and special topics such as regional anesthesia, complications, and anesthesia for remote locations. Numerous diagrams, tables and figures help to organize the information for easy reference. Whether you choose to dip into a particular chapter or read the book cover to cover, Essentials of Pediatric Anesthesiology is a valuable review book for all residents, fellows and clinical practitioners needing to improve or refresh their understanding of pediatric anesthesia management.
Numerous studies indicate that outcomes for pediatric patients are improved when the anesthesia caregiver has advanced training and knowledge of pediatric anesthesiology. Essentials of Pediatric Anesthesiology is a unique new handbook, providing a clinically relevant and easy-to-read review of all key topics in this important field. Written and edited by leading pediatric anesthesia physicians, each chapter takes a consistent approach, guaranteeing this book is user-friendly and authoritative throughout. Topics include physiology, anatomy, equipment, a comprehensive overview of relevant disease states, and special topics such as regional anesthesia, complications, and anesthesia for remote locations. Numerous diagrams, tables and figures help to organize the information for easy reference. Whether you choose to dip into a particular chapter or read the book cover to cover, Essentials of Pediatric Anesthesiology is a valuable review book for all residents, fellows and clinical practitioners needing to improve or refresh their understanding of pediatric anesthesia management.
Numerous studies indicate that outcomes for pediatric patients are improved when the anesthesia caregiver has advanced training and knowledge of pediatric anesthesiology. Essentials of Pediatric Anesthesiology is a unique new handbook, providing a clinically relevant and easy-to-read review of all key topics in this important field. Written and edited by leading pediatric anesthesia physicians, each chapter takes a consistent approach, guaranteeing this book is user-friendly and authoritative throughout. Topics include physiology, anatomy, equipment, a comprehensive overview of relevant disease states, and special topics such as regional anesthesia, complications, and anesthesia for remote locations. Numerous diagrams, tables and figures help to organize the information for easy reference. Whether you choose to dip into a particular chapter or read the book cover to cover, Essentials of Pediatric Anesthesiology is a valuable review book for all residents, fellows and clinical practitioners needing to improve or refresh their understanding of pediatric anesthesia management.
Acute paediatric brain injury is a major cause of mortality and morbidity worldwide. Historically raised intracranial pressure (ICP) has been the hallmark for escalating management in acute brain injuries, however there is limited evidence behind this, and no UK approved guidance advocating its use. This article summarises the current role of ICP monitoring within traumatic and non-traumatic paediatric brain injury and discusses the evidence base for different modalities and their uses.
The pediatric age group includes a wide spectrum ranging from neonates, infants to adolescents, each group having unique physiology to understand. Due to the anatomical, physiological, and pathological differences, children present as a heterogeneous group, especially during the first 8 years of life. The nervous system of children is profoundly different during the various stages of childhood and from adults. The central nervous system (CNS) is incompletely developed at birth and continues to grow and mature till the second year of life. The proportion of cerebral blood flow is highest in children between 1 and 3 years, about 40–50% of the cardiac output, increasing their vulnerability to cerebral ischemia during periods of systemic hypotension. Though cerebral autoregulation and CO2 reactivity are preserved even in preterm and term neonates, their immature neurons are extremely vulnerable to adverse events like sudden physiological perturbations and the influences of toxic substances. This warrants the need to maintain homeostasis as closely as possible and the institution of neuroprotective strategies and treatment. Sound knowledge of the unique neurodevelopmental events and neurophysiological principles applicable to the pediatric population is paramount for the safe and effective perioperative care of infants and children at risk for neurological injury.
In this paper, we review the incidence of increased intracranial pressure in children with single-suture craniosynostosis. The major studies in this area are presented, along with their limitations. A rational treatment plan including multidisciplinary team management is recommended. All patients with proven synostosis should be followed closely, whether or not surgery is chosen. Continued clinical and basic science research are necessary to further clarify the ramifications of asymptomatic elevations of intracranial pressure in these patients.
A 28 Y/M, presented in emergency room with a severe traumatic head injury after being in a motorcycle accident without wearing a helmet. The physical examination revealed a Glasgow Coma Scale of 6, decerebrate posturing, pupils bilaterally fixed and 4 mm in size, and cerebral spinal fluid otorrhea on the right side. Computed tomography of the head showed left frontal and temporal subdural haemorrhage and underlying contusion with 8-mm midline shift, effacement of the suprasellar cisterns and effacement of the 3rdand 4th ventricles. Systemic examination revealed bradycardia, and hypertension with an initial blood pressure of 221/105 mm Hg.
Preterm infants commonly present with a hemodynamically significant patent ductus arteriosus (hsPDA). The authors describe the case of a preterm infant with posthemorrhagic ventricular dilation, which resolved in a temporally coincident fashion to repair of hsPDA. The presence of a PDA with left-to-right shunting was confirmed at birth on echocardiogram and was unresponsive to repeated medical intervention. Initial cranial ultrasound revealed periventricular-intraventricular hemorrhage. Follow-up serial ultrasound showed resolving intraventricular hemorrhage and progressive bilateral hydrocephalus. At 5 weeks, the ductus was ligated with the goal of improving hemodynamic stability prior to CSF diversion. However, neurosurgical intervention was not required due to improvement of ventriculomegaly occurring immediately after PDA ligation. No further ventricular dilation was observed at the 6-month follow-up.
Systemic venous flow disruption and abnormal patterns of cerebral blood circulation have been previously associated with hsPDA. Systemic hemodynamic change has been reported to follow hsPDA ligation, although association with ventricular normalization has not. This case suggests that the unstable hemodynamic environment due to left-to-right shunting may also impede CSF outflow and contribute to ventriculomegaly. The authors review the literature surrounding pressure transmission between a PDA and the cerebral vessels and present a mechanism by which PDA may contribute to posthemorrhagic ventricular dilation.
Pregnancy is a special event in a woman’s life. During pregnancy, there are major physiologic changes in nearly every maternal organ system. These alterations are mainly initiated by hormones (progesterone and estrogen) secreted by the corpus luteum and placenta. The most relevant changes involve cardiovascular, hematologic, respiratory, metabolic, and gastrointestinal functions. Data suggest that the incidence of idiopathic intracranial hypertension in pregnancy is rising which correlates with an increase in prevalence of obesity during pregnancy.
Optic nerve head drusen are benign acellular calcium concretions that usually form early in life, just anterior to the lamina cribrosa. Improving imaging using optical coherence tomography suggests they are common and may be present in many clinically normal discs. These drusen may change in appearance in early life, but are generally stable in adulthood, and may be associated with visual field defects, anterior ischaemic optic neuropathy, or rarer complications. Based on long-term clinical data and optical coherence tomography, we propose a refined hypothesis as to the cause of optic disc drusen. Here we summarise recent findings and suggest future studies to better understand the forces involved.
The detection of the onset of intraventricular haemorrhage (IVH) during life is a necessary preliminary to understanding the cause of this condition. In 10 infants of very low birthweight treated with serial transfusions of adult blood the proportions of transfused cells circulating after each transfusion were compared with the proportion of transfused cells found in the intraventricular clot at necropsy. This allowed the timing of IVH to be restricted retrospectively to the period between consecutive blood transfusions. In addition, the proportional changes of transfused cells produced by infusion of a known red cell mass allow changes in the babies' original red cell mass to be followed during life. A fall in this value occurred in 8 infants dying with IVH and was taken to indicate haemorrhage. Comparison of the two methods in 9 infants suggested that, while in some cases intraventricular bleeding occurs rapidly, in others it takes place over a period of time. The interval between birth and the onset of haemorrhage was directly proportional to the gestational age of the infant.
Since the advent of modern methods of neonatal care, intracranial hemorrhage in premature infants, which is usually intraventricular, is probably not as uniformly fatal as generally admitted and the survivors are likely to develop post-hemorrhagic hydrocephalus.
This paper is a retrospective study of 11 premature babies born between 1968 and 1972 and diagnosed as haying hydrocephalus secondary to neonatal intracranial hemorrhage. Nine of these are still alive and two have died, one at 3 and one at 17 months of age. Eight underwent permanant surgical drainage of hydrocephalus.
The perinatal history, laboratory data, clinical evolution, and neurological outcome were studied. Two groups of infants were identified: those with signs of acute neurological deterioration in the neonatal period who had the most severe neurological sequellae (in four cases, periventricular lesions in addition to hydrocephalus were seen on the air study and in one case confirmed at autopsy) and those showing no obvious neurological signs in the neonatal period. Of this latter group, two appear to be developing normally. The therapeutic implications of the findings are discussed.
In infantile hydrocephalus the intracranial pressure is sometimes at a level that would be considered normal by standards applicable to adults. But the pressure normal to infants and children is exceeded in those with hydrocephalus.
Although many authors have suggested vascular congestion of venous system under increased intracranial pressure as a cause of CBF reduction, the exact site and mechanism of compression has remained obscure. The results of our previous investigations in dogs are summarized in Fig. 1. Cortical venous pressure (CVP), bridging venous pressure (bridging VP), and lateral lacunar pressure (lat lacuna P) were constantly 4–18 mmHg higher than ICP, regardless of the level of ICP, while superior sagittal sinus pressure (SSSP) is quite stable at low levels (4–6 mmHg). Thus, pressure gradients between the cortical arterial pressure and the CVP, gradually decrease as ICP is elevated, while the pressure gradient between the CVP and the SSSP continuously increases as ICP is elevated. These evidences indicate that vascular stenosis is taking place in the lateral lacuna of superior sagittal sinus.
In hydrocephalus, the relationship between cerebrospinal fluid (CSF) production and absorption is unbalanced, and the result is an abnormally enlarged ventricular system. In neonatal hydrocephalus, concomitant with ventricular enlargement, is an abnormal head growth. Hydrocephalus is treated surgically with a device that shunts the CSF into another body cavity. The aim of this treatment is to reduce ventricular volume and restore cortical mantle thickness to normal. Although this treatment if often initially successful, complications such as infection and shunt obstruction frequently develop, and periodic revisions to accommodate normal growth of the child are required. When a shunt becomes obstructed, a shunt-dependent patient develops rapidly increasing intracranial pressure (ICP) and prompt surgical intervention is required. Although shunting has proven to be a beneficial and simple treatment, it is essentially a non-physiological remedy. Therefore, other modes of treatment for neonatal hydrocephalus need to be considered.
When lumbar or cisternal pneumoencephalography is carried out on children with nonprogressive brain lesions causing mental deficiency, cerebral palsy or epilepsy, air is seen in the subdural space in at least a third of cases. This proportion is much larger in children 2 years of age or under.
The roentgenographic appearances of subdural air are described and the importance of not attributing these appearances to cerebral atrophy or hypoplasia is emphasized.
In approximately one third of cases in which air enters the subdural space, that is, in from 10% to 15% of all cases, recovery from pneumoencephalography is delayed by the development of signs and symptoms suggesting a rise in intracranial pressure.
In such cases fluid can usually be found by needling the subdural space. Typically this fluid is characteristic of that found in subdural hematoma. There is no evidence that such a collection of fluid was present before pneumoencephalography.
It is therefore suggested that as air enters the subdural space and the brain falls away from the dura, vessels may be torn as they cross this space to reach the superior longitudinal sinus, with the formation of what may be termed subdural hematoma artefacta.
Although the incidence of this complication is moderately high, its effects are seldom serious, provided the situation is appreciated and suitable treatment given. The length of time the child spends in the hospital is, however, often greatly prolonged and occasionally operation proves necessary for removal of a subdural membrane.
Since the subdural hematoma is an artefact occurring in the course of treatment, its removal does not influence the ultimate prognosis.
• Birth and perinatal records from all medical facilities serving the Rochester, Minn population from 1965 through 1974 were reviewed for cases of intracranial hemorrhage. Among a total of 10,850 live births, 12 documented cases of hemorrhage were found, yielding an average rate of occurrence of 1.1/1,000 live births. To investigate the role of some 30 potential risk factors, a case-control study was undertaken. Only prematurity and respiratory distress syndrome (RDS) were significantly associated with intracranial hemorrhage. This study demonstrates that neonatal intracranial hemorrhage is relatively common, associated with prematurity and RDS, difficult to recognize clinically, and characterized by poor prognosis.
THE INTRAVENOUS ADMINISTRATION of hypertonic urea solution has been advocated by Stamey in the diagnosis of unilateral renal disease by differential renal function studies. Its purpose is to promote maximal relative reabsorption of water in the ischmic kidney, and it also serves as an osmotic diuretic to assure satisfactory flow rates for the procedure.
However, an additional effect of the infusion of urea solution is the decrease in cellular volume. When this occurs in the brain, intracranial hemorrhage may be precipitated.
Report of a Case
A 54-year-old male with known hypertension of many years duration, suffered a cerebrovascular accident in 1954 with resultant right hemiparesis. His hypertension was unsatisfactorily controlled by medical therapy. Physical examination revealed a blood pressure of 230/120 mm. Hg and a right hemiparesis marked by muscle atrophy and spasticity of the extremities on that side. A positive Babinski sign was noted on the right side. The
Es wurde der ventrikuläre Druck in 17 Fällen von Hydrocephalus im Säuglingsalter fortlaufend registriert. Bei 2 Kranken konnten typische Plateau-Wellen, bei 10 Kranken an Plateau-Wellen erinnernde, langdauernde hohe Druckperioden beobachtet werden. Die charakteristischen Merkmale dieser hypertensiven Wellen wurden beschrieben und als Varianten der Plateau-Wellen bewertet. In Zusammenhang mit der Erhöhung des intraventrikulären Druckes wurde die Zunahme der Amplituden der Pulsationswellen und der B-Wellen wie auch die Abnahme des durch die Atmung verursachten dynamischen Einflusses festgestellt.
Summary
The ventricular pressure was continous recorded in 17 infantile hydrocephalus cases. Two patients long periods of high pressure occurred of these hypertensive waves are described and reminiscent of plateau waves. The characteristics evaluated as variants of the plateau waves. Parallel to the increase of the intraventricular pressure was noted to raise the amplitude of the pulse – and B – waves, and decreased dynamic influencse caused by breathing.
Résumé
Enrégistrement continu des ondes de pression intraventriculaire chez des nourrissons hydrocéphales
La pression intraventriculaire a été enrégistrée d'une façon continue dans 14 cas d'hydrocéphalie du nourrisson. On peut observer des ondes en plateau typiques chez 2 malades, et leur ressemblant, des périodes de haute pression de longue durée chez 10 autres. Interprétées comme une variante, leurs caractéristiques sont décrites. On releva, en corrélation avec l'élévation de la pression intraventriculaire, une augmentation de l'amplitude des ondes pulsatiles et des ondes B ainsi qu'une atténuation de la répercussion dynamique de la respiration.
The data relative to cerebrospinal fluid pressure in the new-born presented in this paper have been accumulated during the past seven years. They have been compiled from a series of 117 cases of cranial and intracranial injury. Fifty-six of the babies included in this series died while in the hospital. Of these, forty-five came to autopsy, the postmortem material being subjected to both gross and microscopic examination in twenty-three instances. Fifty-eight patients were discharged relieved. Of these, forty-eight were followed for from less than six months to more than six years. Three were duplicate entries. A detailed study of the end-results in these cases has been presented before the Southern Surgical Association1 and need not be considered further at this time.METHODS OF MEASUREMENT
Measurements of cerebrospinal fluid pressure were made during ventricular and lumbar punctures. A mercury manometer was used in every instance. The lowest figure read on
In the first known incidence of a mass salt poisoning of infants, the case fatality rate was 6 of 14 exposed. Five died before the situation was recognized. All five whose brains were examined at autopsy showed hemorrhagic encephalopathy consistent with previous reports of salt poisoning in humans and animals. Eleven of 14 of these infants manifested neurological symptoms. Peritoneal dialysis was attempted in four patients, three of whom survived despite severe illness in two of them. The technique proved feasible under ordinary hospital conditions and may be instrumental in the recovery of patients. Some suggestions for improvement have come from the experience.
Following a prolonged and difficult labour, full- term and post-mature infants have been found to show some or all of the following abnormalities: (a) An increased destruction of body protein during the first 48 hours of life; (b) a reduced glomerular filtration rate, a poor urea clearance and a low urine volume; (c) a high ratio of nitrogen/ potassium in the urine; (d) a large excretion of inorganic phosphate during and immediately after birth. All the characteristic features may not be found in each case and the complete 'syndrome' may be due to multiple causes.
Die Frage nach dem Verhltnis von Subduralhaematom und Haematoma durae matris zur intracraniellen Hypotension wird unter Mitteilung eines klinisch bemerkenswerten Falles errtert. Zur Behandlung intracranieller Druckerniedrigung wird gleichzeitige Flssigkeitszufuhr und Gabe von Hypophysenhinterlappenextrakt vorgeschlagen.
Continuous 24-hour recordings of intracranial pressure and electroencephalographic activity were made on five hydrocephalic children in whom, in the resting wakefulness state, the intracranial pressure (ICP) was considered normal. An increase in both the mean ICP and its oscillations related to cardiac systole was recorded during slow-wave sleep. Further episodic increases, up to a factor of 7 compared to wakefulness values, occurred during sleep. In three patients it was possible to correlate such episodic increases to the rapid eye movement phases of sleep. The authors discuss these phenomena and their possible implication in the progression of hydrocephalus.
• We describe two patients in whom ventricular dilation began within a week of neonatal intraventricular hemorrhage and preceded rapid head growth and clinical signs of increased intracranial pressure by days to weeks. The posthemorrhagic ventricular dilation is readily demonstrated in the neonatal period by computerized tomography of the cranium. These data indicate the importance of careful follow-up of survivors of intraventricular hemorrhage, early demonstration of ventricular dilation, and prompt therapeutic intervention to prevent brain injury.
(Am J Dis Child 131:1212-1215, 1977)
A series of topics relating to hydrocephalus was selected and the pertinent literature was reviewed. First a discussion of cerebrospinal fluid production and absorption in hydrocephalus is given. Then a brief presentation of the various causes of hydrocephalus, such as viral infections and achondroplasia, is made. Under the heading of normal pressure hydrocephalus, the following subjects are discussed: clinical features, pneumocephalography, computed tomography, cisternography, infusion tests, perfusion of the system, cerebral blood flow, long term measurements of pressure, and normal pressure hydrocephalus in infants and children. The last portion of this paper deals with both the conservative and surgical treatment of this disease, the problems of shunt malfunctions and infections, and the results of treatment.
Hemorrhage into the subependymal germinal matrix with rupture into the cerebral ventricles causes significant morbidity and mortality in premature infants. CT brain scanning was performed on eight premature infants on whom autopsy confirmation was obtained. Excellent sensitivity and accuracy in detecting germinal matrix hemorrhage and intraventricular hemorrhage were found. Germinal matrix hemorrhage appears as a parenchymal collection of blood adjacent to the foramen of Monroe and has a convex margin laterally. CT scanning of living premature infants is feasible in diagnosing nonfatal episodes of germinal matrix and intraventricular hemorrhage as well as subsequent development of hydrocephalus and porencephaly.
The aplanation principle has been proposed as a basis for a non‐invasive method of measuring intracranial pressure in infants with patent anterior fontanelles. With minor adjustments, the method was found to give reproduceable results over the range 5 to 60cm H 2 O. The mean (± 1 SD) intracranial pressure of 91 infants born at term was 10.7 ± 3.1cm H 2 O. Babies who had had complicated deliveries were found to have a higher mean intracranial pressure on the first day of life. We suggest this difference is caused by post‐hypoxic cerebral oedema.
RÉSUMÉ
Mesures non agressives de la pression intra‐crânienne chez íes nouveaux‐nŕs normaux
Le principe de 'aplatissement a ŕtŕ proposŕ à la base d̂une mŕthode non agressive de la pression intra‐crânienne chez les nourrissons avec fontanelles antŕrieures apparentes. Avec quelques ajustements minimes, il a ŕtŕ trouvŕ que la mŕthode donnait des rŕsultats reproductibles sur une ŕtendue de pression de 5–60cm d̂eau. La moyenne à ± 1 SD chez 91 nourrissons nŕs à terme a ŕtŕ trouvŕe de 10,7 ± 3,1cm d̂eau. Chez les nourrissons nŕs aprŕGs accouchement compliquŕ, il a ŕtŕ trouvŕ une pression intra‐crânienne moyenne plus ŕlevŕe le premier jour de la vie. Il est suggŕrŕ que cette diffŕrence est causŕe par un oedème cŕrŕbral post‐hypoxique.
ZUSAMMENFASSUNG
Eine nicht eingreifende Methode zur intracraniellen Druckmessung bei Neugeborenen
Bei Kindern mit offener großer Fontanelle wurde das Prinzip der Abflachung als Basis für eine nicht eingreifende Methode zur intracraniellen Druckmessung vorgeschlagen. Mit geringen Angleichungen ergab die Methode reproduzierbare Ergebnisse im Bereich von fünf bis 60cm H 2 O. Der mittlere intracranielle Druck war bei 91 reifen Neugeborenen 10.7 mit einer ersten Standardabweichung von ± 3.cm H 2 O. Neugeborene mit komplizierter Geburt hatten am ersten Lebenstag einen höheren intracraniellen Druck. Es wird angenommen, daß diese Druckdifferenz durch ein aufgrund einer Hypoxie entstandenes cerebrales Ödem hervorgerufen wird.
RESUMEN
Mediciones de la presión intracraneal no‐invasivas en reciŕn nacidos normales
El principio de la aplanación ha sido propuesto como una base para un mŕtodo no invasivo de medición de la presiŕn intracraneal en lactantes con fontanelas anteriores patentes. Con ajustes menores se ha hallado que el mŕtodo da resultados reproducibles sobre un margen de 5 – 60cm H 2 O. El promedio ± 1 SD de la presión intracraneal de 91 lactantes nacidos a tŕrmino fue de 10,7 ± 3,1cm H 2 O. Se halló que en niños nacidos de partos complicados existía una presibn intracraneal media mayor en el primer dia de vida. Se sugiere que está diferencia está causada por un edema cerebral post‐hipóxico.
A noninvasive approach to measuring intracranial pressure in newborns based on optical principles and devoid of electrical hazards is described. This monitoring technique can be used to detail subtle changes in measurements in ill newborns and to predict hydrocephalus. The mean anterior fontanel pressure in normal infants was 10.14 +/- 0.39 cm H2O. Increased pressure was noted in sick neonates and in infants with hydrocephalus. Good correlation was noted between anterior fontanel pressure and CSF pressure. Pediatrics, 59:957-961, 1977, INTRACRANIAL PRESSURE, ANTERIOR FONTANEL PRESSURE, HYDROCEPHALUS, MONITORING DEVICE.
A retrocerebellar cyst was excised from a 17-day-old infant with hydrocephalus. The cyst wall contained not only ependyma-like epithelium, choroid plexus tufts, and glial rests, but also prominent areas of immature neural tissue.
Noninvasive measurement of intracranial pressure is now available via the anterior fontanel in newborn infants. We measured intracranial pressure during the first week of life in 18 preterm infants and found a statistically significant increase from birth to age 24 hours and a significant decrease by 48 hours (13.8 vs. 24.4 vs. 14.3 cm H2O). This did not seem to be the result of postnatal head shrinkage. There were no other apparent correlations. We suspect that hypoxia may play an important role in the etiology of increased intracranial pressure. We believe that these findings may have important implications for intracranial hemorrhage in preterm infants.
Although the syndrome of normal pressure hydrocephalus (NPH) was described in the adult as early as 1964, it has only recently been recognized in the child. In this preliminary report, eight myelomeningocele patients with presumed NPH were evaluated before and after ventricular shunting procedures. Cranial computed tomography and serial psychological testing have proved to be particularly valuable both in the pre‐operative and postoperative assessment of these patients and have the distinct advantage of being simple, non‐invasive diagnostic measures. Continuous intra‐ventricular pressure monitoring has shown what promises to be characteristic elevated pressure plateaux imposed on normal baseline cerebrospinal fluid (CSF) pressures in so‐called NPH but is a more difficult clinical procedure, necessarily associated with potential complications. Although decreasing response to growth‐stimulating hormone can be demonstrated in patients with longstanding hydrocephalus, this endocrine malfunction cannot be considered an early indicator of intracranial pathology.
Single IQ scores are inadequate measures of intellectural function in children with NPH and serial examinations should be carried out. Detailed neuropsychological testing will document performance IQ scores well below verbal IQ scores and will generally show failure of psychomotor development to keep pace with chronological ageing. Initial studies indicate that improved performance scores can be expected within 11/2 to 3 months following successful ventricular shunting operations, and that any downward trend in pre‐operative test scoring can at least be reversed. Statistically significant improvements in full‐scale IQ scores have not been seen, however, before the end of the first post‐operative year. Clinically, improved attentiveness and sociability, and decreased spasticity (if present prior to surgery) can be expected following shunting.
Over‐all, ventriculomegaly, normal CSF pressure, stable head size, and non‐progressive neurological symptoms cannot be regarded as sufficient criteria for the diagnosis of an arrested state of hydrocephalus, and should suggest NPH, especially in those children who demonstrate a discrepancy between performance and verbal IQ scores and who fail to exhibit continuing psychomotor development with advancing age.
RÉSUMÉ
Hydrocéphalic à pression normale chez des sujets avec myéloméningocèle Bien que le syndrome d'hydrocéphalie à pression normale (HPN) ait été décrit chez l'adulte dès 1964, il n'a été reconnu que récemment chez l'enfant. Dans ce rapport préliminaire, huit sujets porteurs de myéloméningocèle avec HPN présumée ont été examinés avant et après la mise en place de shunt ventriculaire. Les tomo‐densitométries crâniennes et les tests psychologiques en série se sont montrés de grande valeur à la fois dans l'appréciation préopératoire et postopératoire de ces sujets, ayant l'avantage particulier d'être des méthodes de diagnostic simples, non traumatisantes. Le contrôle continu de la pression intraventriculaire a montré ce qui promettait d'être des plateaux caractéristiques de pression élévee se surimposant sur une ligne de base normale de pression du liquide céphalo‐rachidien (LCR) dans ce qu'il est convenu d'appeler une HPN mais il s'agit d'un procédé plus difficile et cliniquement plus hasardeux. Quoique une réponse affaiblie à la stimulation par l'hormone de croissance ait pu être démontrée chez les sujets porteurs d'hydrocéphalie de longue date, ce disfonctionnement endocrinient ne peut être considéré comme un indicateur précoce de la pathologie intra‐crânienne.
Les simples notations de QI globaux constituent des mesures inadéquates de la fonction intellectuelle des enfants avec HPN et des examens en série doivent être entrepris. Des tests neuropsychologiques détaillés montreront des QI de performance bien en‐dessous des QI verbaux et révèleront des insuffisances du développement psychomoteur en fonction de l'âge chronologique. Les premiéres études indiquent qu'il est possible d'espérer des scores de performance meilleurs au bout de un et demi à trois mois après une intervention réussie de shunt ventriculaire et que toute tendance à un abaissement préopératoire aux tests peut au moins être inversée. Des améliorations statistiquement significatives à l'échelle globale du test n'ont cependant pas été notées avant la fin de la première année après intervention. Cliniquement, une amélioration de l'attention et de la sociabilité, une diminution de la spasticité si elle existait avant l'intervention, peuvent être espérées après le shunt.
En résumé, de gros ventricules, une pression de LCR normale, un tour de tête stable et des symptômes neurologiques non évolutifs ne peuvent être considérés comme des critères suffisants au diagnostic d'une hydrocéphalic stabilisée; il faut penser également à une HPN spécialement chez les enfants qui présentent une différence entre les QI performance et verbaux et qui ne font pas preuve d'un développement psychomoteur continu en vieillissant.
ZUSAMMENFASSUNG
Normotoner Hydrocephalus bei Patienten mit Myelomeningocele Obwohl das Syndrom des normotonen Hydrocephalus (NPH) beim Erwachsenen bereits 1964 beschrieben wurde, ist es beim Kind erst kürzlich erkannt worden. In diesem vorläufigen Bericht wurden acht Patienten mit Myelomeningocele und dem Verdacht auf NPH vor und nach Ventiloperationen untersucht. Schädeltomographie und wiederholte psychologische Untersuchungen haben sich als aussagekräftig sowohl zur prae‐ als auch postoperativen Beurteilung der Patienten erwiesen. Sie haben den Vorteil, daß sie einfache und nicht eingreifende diagnostische Mittel darstellen. Kontinuierliche intracranielle Druckregistrierung hat charakteristisch erhöhte Druckplateaus gezeigt, die sich beim sogenannten NPH auf den Basisdruck des Liquors aufpflanzen, jedoch ist dies eine schwierigere und gefährlichere Methode. Obwohl bei Patienten mit lange bestehendem Hydrocephalus eine nachlassende Ansprechbarkeit auf die Stimulierung mit Wachstumshormon nachgewiesen werden konnte, kann diese endokrine Funktionsstörung nicht als Friih‐symptom für ein intracranielles pathologisches Geschehen angesehen werden.
Einzelne IQ‐Bestimmungen sind zur Beurteilung der intellektuellen Fähigkeiten der Kinder mit NPH unzureichend und es sollten Serienuntersuchungen vorgenommen werden. Genaue neuro‐psychologische Untersuchungen zeigen niedrigere IQ‐Scores in der praktischen Ausführung als im mündlichen Teil und im allgemeinen auch eine zum chronologischen Alter verzögerte psychomotorische Entwicklung. Erste Untersuchungen haben ergeben, daß innerhalb von eineinhalb bis drei Monaten nach erfolgreicher Ventiloperation die Scores für die Ausführung verbessert werden konnten und daß jede negative Tendenz in praeoperativen Tests zumindestens eine Umkehr erfuhr. Verbesserungen des Gesamt‐iQ wurden jedoch nicht vor Ablauf des ersten postoperativen Jahres beobachtet. Klinisch können nach der Ventiloperation eine bessere Aufmerksamkeit und Geselligkeit und geringere Spastizität, falls vor der Operation vorhanden, erwartet werden.
Zusammenfassend kann gesagt werden, daß Ventrikulomegalie, normaler Liquordruck, gleichbleibendes Kopfwachstum und nicht progrediente neurologische Symptome unzureichende Kriterien für die Diagnose: stationärer Hydrocephalus sind und es wird der Begriff NPH vorgeschlagen, insbesondere bei den Kindern, die eine Diskrepanz in den IQ‐Scores für praktische Ausführung und den verbalen Teil haben und deren psychomotorische Entwicklung nicht dem Alter entspricht.
RESUMEN
Hidrocefalia con presión normal en pacientes con mielomeningocele Aunque el síndrome de hidrocefalia con presión normal (HPN) fue descrita en el adulto ya en 1964, sólo recientemente ha sido reconocida en el niño. En esta comunicación previa, ocho pacientes con mielomeningocele y presunto HPN fueron evaluados antes y después de aplicar una derivatión ventricular. La tonografía craneal computadorizada y los tests psicológicos seriados se han mostrado como particularmente valiosos en la valoración pre y postoperatoria de estos pacientes y tienen la ventaja de ser unas medidas diagnósticas simples y no cruentas. La monitorización contínua de la presión intraventricular ha mostrado lo que promete ser una meseta característica de presión elevada en comparación con la linea basal de presión normal del líquido céfalo‐raquideo en la llamada HPN, pero se trata de un procedimiento más difícil y expuesto. Aunque se puede demostrar una respuesta decreciente a la hormona de crecimiento en pacientes con hidrocefalia de larga duratión, esta disfunción endocrina no puede ser considerada como un indicador precoz de anemia intracraneal.
Los puntajes simples de ci constituyen mediciones inadecuadas de la función intelectual en niños con (HPN) y deben ser realizados exámenes seriados. Los tests detallados neuropsicológicos mostrarán puntajes de CI por debajo de puntajes de IC verbal y en general mostrarán que el desarrollo psicomotor no sigue la marcha de la edad cronológica. Los estudios iniciales indican que pueden esperarse mejorias en los puntajes de realizatión dentro de uno y medio y tres meses de aplicada una derivatión ventricular con éxito y puede por los menos invertirse la tendencia hacia abajo de los puntajes en los tests preoperatorios.
Sin embargo no se han visto mejorias significativas en puntajes de escala completa de CI antes del final del primer año del postoperatorio. Clínicamente si existia antes de la interventión una mejoria en la atención y sociabilidad y disminución en la espasticidad puede esperarse que continuará después de la misma.
En conjunto, la ventriculomegalia, la presión normal en el LCR, una dimensión de la cabeza estable y unos signos neurológicos no progresivos, pueden ser tornados como criterios suficientes en aquellos niños que tienen una discrepancia entre los puntajes de CI de realizatión y los verbales y que dejan de presentar un desarrollo psicomotor continuado con la edad.
The fronto-occipital circumference, fronto-occipital and biparietal diameters, degree of suture overriding, and weight were measured daily during the first week of life in 50 infants of birth weight under 2,000 gm. In a second similar group of 21 infants, fronto-occipital circumference, weight, and sodium balance were measured daily during the first week of life. Head volumes were estimated from the circumference and diameters of the head.
The parameters of head size and derived volumes changed maximally and significantly in the direction of intracranial shrinkage around 3 days of age. The degree of shrinkage was significantly correlated (P < .005) with the degree of weight and cumulative sodium losses, and decreasing gestational age.
We postulate that postnatal head shrinkage results from shift of sodium and water outward from the intracranial cavity as a transient phenomenon during the first week of life. The significance of head shrinkage is discussed.
Birth and perinatal records from all medical facilities serving the Rochester, Minn population from 1965 through 1974 were reviewed for cases of intracranial hemorrhage. Among a total of 10,850 live births, 12 documented cases of hemorrhage were found, yielding an average rate of occurrence of 1.1/1,000 live births. To investigate the role of some 30 potential risk factors, a case-control study was undertaken. Only prematurity and respiratory distress syndrome (RDS) were significantly associated with intracranial hemorrhage. This study demonstrates that neonatal intracranial hemorrhage is relatively common, associated with prematurity and RDS, difficult to recognize clinically, and characterized by poor prognosis.
The applanation transducer was used to measure intracranial pressure (ICP) through the intact fontanel. The method is painless, rapid, and accurate. The pressures recorded with this fontogram were correlated with direct measurements of ICP. The correlation coefficient of the 21 paired determinations was .98—a very good correlation.
Fontanel pressure was determined in 35 normal newborn infants. The mean pressure was 7.37 mm Hg with an SD of ± 1.45 (range, 3.5 to 9.5 mm Hg). Three clinical cases are presented to illustrate the usefulness of this apparatus in the detection of increased ICP and in monitoring the effectiveness of treatment.
Hemorrhage into the ventricles of the brain in infants, especially those of low birth weight, occurring either without known predisposition or more commonly with respiratory distress, is an important and sometimes devastating event in early life and its recognition and treatment are assuming practical importance because the chance for survival in the more severe cases is better than it was formerly. The bleeding takes place as a rule within the first several days after birth and its clinical recognition depends on deterioration in the condition of the child with seizures, fall in hematocrit reading, disturbance of breathing, and other signs.1 The event, however, may go unrecognized.
Computerized tomography of the head is ideally suited to establishing the diagnosis of the condition and to the assessment of its extent and the degree of complicating hydrocephalus.2 Volpe, Pasternak, and Allan in this issue of the Journal (see p 1212) describe
Alterations of head shape in preterm, small-for-dates, and term normal infants were studied by measuring occipitofrontal circumference (OFC), biparietal diameter (BPD), and occipitofrontal diameter (OFD) at intervals after birth. In 9 preterm infants born by elective caesarean section ther was a 5-2% reduction in BPD and 2-0% reduction in OFC at the age of 7 days. In 18 term infants born by elective caesarean section these changes were 2-4% and 0% respectively in BPD and OFC. In 25 preterm infants born by vertex vaginal delivery there was a significant fall in OFC of 0-7% at the age of 7 days and of 2-4% in BPD, but no significant change in OFD. In 19 small-for-dates infants born vaginally OFC increased 1-0% and OFD 2-7% at 7 days, but BPD decreased 2-5%. After the first week all three measurements increased in both groups of vaginal deliveries. The results show that shrinkage and biparietal flattening of the skull occur during the first week of life in preterm and term infants born by caesarean section and in preterm infants born vaginally. This fact should be borne in mind when comparing the measurements of an infant's head size with published norms.
Rapidly enlarging head circumference is a standard clinical sign of progressive hydrocephalus in an infant. Six neonates 29 to 36 weeks gestational age, with intraventricular hemorrhage, confirmed by ventricular tap, had head circumferences measured at intervals from birth. The sudden appearance of rapidly expanding head size, not associated with changing clinical status, occurred 9 to 20 days after the estimated time of hemorrhage in all of the infants. Air ventriculography within three days of abnormal acceleration of head circumference growth demonstrated moderately to severely dilated ventricles. The ventricles were probably enlarging slowing from the time of hemorrhage because there was no associated clinical deterioration in the infants coincident with the rapid increase in head circumference. After intraventricular hemorrhage, enlarging head circumference appears to be an insensitive sign of hydrocephalus in premature infants.
Ten infants with spina bifida cystica were investigated during life by simultaneous ventricular and intraspinal CSF pressure recordings, and 11 post‐mortem specimens were studied by means of crystic resin castings of the ventricles.
The results indicate marked pressure differentials between the lateral ventricles and intraspinal CSF pathways, which contribute to the moulding of the Arnold‐Chiari malformation as a sliding hernia. Similar pressure differentials may exist at the incisura, with moulding of tissues producing blockage of the aqueduct and the subarachnoid pathways. A valvular action was demonstrated, in which baseline pressure differences were exaggerated by the infant's straining ( e.g. crying, sucking), and it seems that complete dissociation between the two pressures may develop as a result of periods of partial dissociation. Removal of the meningocele sac increased the peaks in recordings of intraspinal pressure produced by straining. If it is carried out when there is a valvular effect, it seems that it will hasten the onset of established ventriculo‐spinal pressure dissociation and uncompensated hydrocephalus by leading to impaction of the Arnold‐Chiari malformation in the foramen magnum.
The results indicate that even after birth the CSF pathways of babies with spina bifida cystica are in a plastic and changeable condition, with competition between constricting and distending forces. The demonstration that pressures tend to be low in the spine and to become lower before exacerbation of hydrocephalus suggests that all the intracranial manifestations of spina bifida cystica may be due to low intraspinal pressure, which results from initial failure of the neural tube to close during embryogenesis.
ZUSAMMENFASSUNG
Liquordruckgradienten bei Spina bifida cystica: mit besonderem Hinweis auf die Arnold‐Chiarische Deformität und die Aquaeduktstenose
Zehn Kinder mit Spina bifida cystica wurden zu Lebzeiten anhand simultaner ventrikulärer und intraspinaler Liquordruckmessungen untersucht und elf post mortem Untersuchungen wurden an Harzabdrücken der Ventrikel durchgeführt.
Die Ergebnisse sprechen für deutliche Druckdifferenzen zwischen den Seitenventrikeln und den intraspinalen Liquorbahnen, was die Bildung der Arnold‐Chiarischen Deformität als eine Gleithernie unterstützt. Ähnliche Druckdifferenzen gibt es möglicherweise auch an der Incisur, wodurch Gewebsausstülpungen hervorgerufen werden, die zur Verlegung des Aquaeduktes und der Subarachnoidalräume führen.
Es konnte eine Klappenfunktion nachgewiesen werden, bei der die basalen Druckdifferenzen durch Anstrengungen des Kindes (z.B. Schreien, Saugen) verstärkt wurden und es scheint, daß eine vollständige Dissoziation zwischen den beiden Drucken das Ergebnis von Perioden partieller Dissoziation ist. Die Abtragung des Meningocelensackes verstärkte die Ausschläge bei den Aufzeichnungen des durch Anstrengung ausgelösten intraspinalen Druckes. Wenn dies bei Vorhandensein eines Klappeneffektes durchgeführt wird, scheint die Abtragung den Beginn der konstanten ventrikulo‐spinalen Druck‐dissoziation und des nicht kompensierten Hydrocephalus zu beschleunigen, indem es zur Einklemmung der Arnold‐Chiarischen Deformität in das Foramen magnum führt.
Die Ergebnisse zeigen daß auch nach der Geburt die Liquorbahnen der Säuglinge mit Spina bifida cystica noch formbar und zu verändern sind und unter dem Einfluß konstringierender und distendierender Kräfte stehen. Der Nachweis, daß die Drucke im Rückenmarkskanal meistens niedrig sind und vor der Verschlechterung eines Hydrocephalus abfallen, läßt vermuten, daß alle intrakraniellen Veränderungen bei Spina bifida cystica möglicherweise durch den niedrigen intraspinalen Druck bedingt sind, der daraus resultiert, daß sich das Neuralrohr während der Embryogenese nicht geschlossen hat.
RESUMEN
Gradientes de presión del liquido cefalorraquídeo en la espina bífida cística con especial referencia a la malformación de Arnold‐Chiari y estenosis de acueducto
Diez lactantes con espina bífida cística fueron estudiados en vida practicando inscripciones simultáneas de la presión ventricular e intraspinal y 11 piezas anatómicas postmortem fueron estudiadas a partir de moldes con resina crística de los ventrículos.
Los resultados indican unos diferenciales de presión marcados entre los ventrículos laterales y las vías intraspinales del LCR, lo cual contribuye a moldear la malformación de Arnold‐Chiari en forma de hernia deslizante. Unos diferenciales de presión similares pueden existir en la incisura con moldeado de los tejidos produciendo bloqueo del acueducto y de las vías subaracnoideas. Fué demostrada una acción paravalvular en la cual los diferenciales de presión basales estaban exageradoscuando el niñorealizabaesfuerzo (por ejemplo, succionar o Ilorar) y parece que puede desarrollarse una disociación completa entre ambas presiones como resultado de periodos de disociación parcial. La extirpación del saco del meningocele aumentaba los picos en las inscripcionnes de la presión intraespinal producida por el esfuerzo. Si la extirpación se Ileva a cabo cuando hay un efecto valvular, parece que puede acelerar el inicio del establecimiento de una disociación de presiones ventrículo‐espinales y de una hidrocefalia no compensada al conducir al impacto de la malformación de Arnold‐Chiari en el foramen magnum.
Los resultados indican que, incluso después del nacimiento, las vías del LCR de lactantes con espina bífida cística se hallan en una condición plástica y cambiable, con una competición entre fuerzas constrictivas y distensoras. La demostración de que las presionnes tienden a estar bajas en el raquis y hacerse más bajas antes de la exacerbación de la hidrocefalia sugiere que todas las manifestaciones intracraneales de la espina bífida cística pueden ser debidas a una presión intraespinal baja, la cual resulta del fallo inicial del tubo neural para cerrarse durante la embriogenesis.
Lumbar cerebrospinal fluid (CSF) pressure was recorded in 116 adult neurosurgical patients in the lateral and sitting positions. The level of zero CSF pressure while in the sitting position (ZPS) and hydrostatic indifferent point (HIP) for lateral and sitting positions were determined and referred to the craniospinal axis. In control patients ZPS was located mainly at the upper cervical region, and showed nearly the same variation and frequency distribution as CSF pressure in the lateral position when efforts were made to reduce sources of error and there was no orthostatic change in CSF filling pressure. Under these circumstances ZPS may be used as a variable comparable from one subject to another. In control patients the HIP was located between C-6 and T-5. In 25 hydrocephalic patients, shunting resulted in a mean caudal shift of ZPS of 244 mm, and a mean pressure fall of 126 mm H2O in the lateral position. This difference was due to a caudal shift of HIP on shunting. A caudally located ZPS was found in patients with complete cervical subarachnoid block. Prevention and treatment of CSF leakage cranial to HIP is discussed.
Intraventricular hemorrhage is a frequent postmortem finding in the preterm infant with severe perinatal problems, often with respiratory distress. It is a late event, most probably secondary to perinatal circulatory disturbances related to central cerebral infarction. The bleeding occurs generally during the second or third day of life. Except for characteristic seizures, individual clinical signs and symptoms are of limited value for the timing of the bleeding, although in most instances the general clinical picture may accurately indicate the diagnosis of intraventricular hemorrhage.
The ventricular CSF of a group of preterm infants dying in the newborn period contained a large excess of protein which appeared to be a plasma filtrate. This excess was found whether or not an intraventricular haemorrhage (IVH) was also present. After consideration of the clinical features of the infants, their coagulation status, and the findings at necropsy, we suggest that increased cerebral venous and capillary pressure, usually caused by heart failure resulting from hypoxia and acidosis, was responsible both for the IVH, by rupturing the terminal veins, and for promoting the filtration of plasma proteins into the CSF. Abnormalities of haemostasis, though very common, did not seem to provide an adequate explanation for the initiation of intraventricular bleeding, though they may have exacerbated it.
The clinical features, investigations, and results of treatment are described in a series of 47 infants with posthaemorrhagic hydrocephalus. 7 were unfit for treatment; 3 had medical (isosorbide) treatment alone, 2 of whom made a good recovery; the remaining 37 were surgically treated. 32 (68%) survived for 18 months to 16 years, but 12 of them are severely affected mentally and/or physically. The results can be considered satisfactory in 19 (40%), though there are only 9 (19%) without detectable sequelae. The most serious adverse prognostic features on admission were acute illness with active bleeding or neurological signs such as spasticity, fits, visual defects, or subdural effusions, and such infants did not recover without severe sequelae. The degree of hydrocephalus was also of prognostic value. Since results could have been far better with better management, it is hoped that the publication of this series will lead to better care and prognosis.
1. Samples of cisternal cerebrospinal fluid (c.s.f.) and blood plasma have been obtained nearly simultaneously from foetal sheep of different ages, the foetus having been exteriorized and maintained in a normal state with respect to its blood gases and arterial pH. The brains were removed from these foetuses and also from foetal guinea‐pigs after exsanguination.
2. A comprehensive study has been made of the concentrations of water, chloride, sodium, potassium, calcium and magnesium in blood plasma, c.s.f. and brain from foetal sheep and in brain from foetal guinea‐pigs during development in utero . Maternal arterial blood plasma, cisternal c.s.f. and brain from the sheep and brain from the guinea‐pig have been analysed for comparison.
3. Concentrations of the ions analysed in foetal blood plasma are similar to those found by others in the sheep and other species. In the case of calcium, the results suggest an active maintenance of the concentration of this ion in foetal plasma by the placenta.
4. The chloride concentration in c.s.f. at ages between 65 days and term (147 days) averaged 1·19 times that in foetal plasma, but only 1·08 at 45–50 days; the sodium concentration in c.s.f. was also slightly reduced at this time. The increase in the c.s.f./plasma ratios for chloride and sodium appears to coincide with the first development of the blood—brain and blood—c.s.f. barriers to non‐electrolytes.
5. Magnesium was at a slightly higher concentration in c.s.f. than in plasma at all foetal ages and did not vary with age. The concentrations of potassium and calcium in c.s.f. were high at early ages and fell to reach adult concentrations after birth: the mechanisms determining the concentrations of the various ions in c.s.f. develop at very different, largely independent, rates.
6. The water content of the cerebral hemispheres of the foetal sheep was stable at 90% of the wet weight till 105 days and fell thereafter. The contents of chloride, sodium and potassium followed paraboloid relations with age. Chloride and sodium reached a peak of 62 and 81 m‐equiv/kg respectively between 89 and 105 days in the sheep. Potassium was at a minimum of 65 m‐equiv/kg at the same time. The content of water and these electrolytes in the cerebral hemispheres of the foetal guinea‐pig underwent similar changes, the maxima and minimum occurring as in the sheep at two‐thirds of the total length of the pregnancy, namely 65 days in the guinea‐pig. At 46 days in the guinea‐pig, chloride in brain reached 53 m‐equiv/kg, sodium was 68 m‐equiv/kg and potassium was 75 m‐equiv/kg. In contrast to the sheep, no reversal of the sodium‐potassium ratio occurred. These changes in water and electrolytes probably represent a rise, a peak and a decrease in the volume of the extracellular space of cerebral cortex, but changes in the volume occupied by a cell‐type, containing much intracellular chloride and sodium, could also contribute to this phenomenon.
7. The calcium content in the cerebral hemispheres of the foetal sheep remained at about 3·0 m‐equiv/kg throughout pregnancy. Magnesium in the cerebral hemispheres of both the foetal sheep and the guinea‐pig showed a trough in concentration during pregnancy which corresponded approximately in position to the minimum in potassium content and the maxima in chloride and sodium contents. Lowest values were 9·6 m‐equiv/kg at 105 days in the sheep and 9·5 m‐equiv/kg at 51 days in the guinea‐pig.
It is suggested that non-invasive techniques for measuring intracranial pressure should be suitable for use in the unsedated infant and should be capable of measuring pressure continuously. Methods described by other authors are reviewed. After investigation of 18 patients the technique relying upon the pulsation of the fontanelle described by Purin was rejected as being difficult to perform and applicable only in certain patients with large fontanelles. The technique of using a modified Schiotz tonometer was examined but rejected on grounds of inaccuracy, the need to perform the measurement with the infant in a vertical position, and the varying compressibility of the fontanelle. A method for indirectly estimating intracranial pressure using a modified aplanation principle is described, and a comparison of the pressures so measured and needle pressures is reported. The possible uses of a `fontanometer' using the aplanation principle are discussed and a preliminary report given of its use to monitor the changes of intracranial pressure caused by drugs.
The occurrence of symptomatic normal pressure hydrocephalus in children as a complication of posterior fossa surgery is recorded here.
Diagnosis of this exceedingly treatable condition is essential since its syndrome can be confused with brain stem or cortical injury attributed to surgery.
All cases responded to shunting with marked improvement.
N A previous paper the technical measures necessary for ideal placement of the Holter valve-controlled shunt from ventricle to venous system were described. 16 Our accumulated experience with 140 venous shunts for progressive hydrocephalus in infancy from 1956 to 1966 now provides a basis for understanding and preventing shunt dysfunction or infection which often necessitate shunt removal. Cases in which shunts were used in the management of a known neoplasm are not included in this series. Prior experience with simple check valves for venous shunts first performed in 1949 had pointed up the problems resulting from overdrainage of ventricular fluid? s Check valves of proper resistance were simultaneously developed by Pudenz, et al., 2~ and SpitzY In considering this artificial but mechanically effective method for controlling ventricular pressure and size, three principles have gradually established themselves and now form the basis of our philosophy and plan of management. First, severe uncomplicated infantile hydrocephalus, when properly treated, clearly can be followed by normal brain development much more frequently than has been taught in the past. 6a4,15 Second, the ultimate result, although related in part to the original cause and severity of the hydrocephalus, is strongly affected by the adequacy of continued mechanical palliation. Even children who are apparently tolerating a shunt blockade will often be found to have re-enlarged ventricles with sufficient elevation of pressure to prevent optimal development, a,5 Third, the many technical problems posed by continuous maintenance of shunt function in the rapidly growing infant can be minimized by expert planning. In this paper we will deal primarily with