Intracranial pressure waveform indices in transient and refractory intracranial hypertension

doi:10.1016/0165-0270(94)00106-Q

Journal of Neuroscience Methods

Volume 57, Issue 1, March 1995, Pages 15-25

https://doi.org/10.1016/0165-0270(94)00106-Q Get rights and content

Abstract

Analysis of data obtained by continuous computerized monitoring of intracranial pressure (ICP) in 109 adult patients with severe head trauma was performed to examine the patterns of change in indices of the ICP waveform. Indices derived from direct measurement of the ICP wave and obtained from a Fast Fourier Transform (FFT) were examined. Concurrent physiologic measurements were made. Two types of intracranial hypertension (ICH) were defined for comparison. ‘Transient intracranial hypertension’ occurred when an abrupt rise in ICP was followed by a return to below 25 mm Hg (n = 63). Increases in ICP that were progressive and led to neurologic deterioration and death were termed ‘refractory intracranial hypertension’ (n = 18). During transient ICH heart rate, arterial pressure, end-tidal carbon dioxide and jugular venous oxygen saturation all increased, while these measures either were unchanged or decreased during refractory ICH. The pulse amplitude of the ICP wave increased in both types of ICHtn. Other changes in the waveform indices were consistent with this change in pulse amplitude. HFC responded differently to the two types of changes, with an increase during the transient changes and a decrease during the refractory changes. The differences in changes in physiologic measurements as ICH occurred in the 2 groups suggest that in refractory ICH cerebral blood flow is maintained against the mounting ICP, while in transient ICH the hypertension is caused by an increase in cerebral blood flow. The waveform indices do not discriminate between the two types of changes.

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Despite recent research that has been equivocal, intracranial pressure (ICP) monitoring is invaluable in the management of neurocritical care patients, including head injury, poor grade subarachnoid hemorrhage, stroke, intracerebral hematoma, meningitis, acute liver failure, hydrocephalus, benign intracranial hypertension, etc. Monitoring of ICP requires an invasive transducer, and an intraventricular drain connected to an external pressure transducer is still considered to be the ‘‘gold standard’’ method.
However, some attempts have been made to measure ICP noninvasively, with promising results.
Information can be derived from ICP and its waveforms, including cerebral perfusion pressure, brain compensatory reserve, regulation of cerebral blood flow and volume, and content of vasogenic events. There are many possible conditions that can lead to elevated intracranial pressure, for acute, chronic, and both intracranial or extracranial causes. Since increased intracranial pressure is associated with increased morbidity and mortality, it should be promptly detected, and treatment must be immediately started with appropriate intensive care.
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As a consequence, their analysis did not explore frequencies above 0.2 Hz. Several indexes that quantify the signal spectrum waveform were analysed in [19] to explore the differences in the shape of the waveform for different conditions. A continuous monitoring of ICP was required to obtain the recordings.
Hydrocephalus includes a number of disorders characterised by clinical symptoms, enlarged ventricles (observable using neuroimaging techniques) and altered cerebrospinal fluid (CSF) dynamics. Infusion tests are one of the available procedures to study CSF circulation in patients with clinical and radiological features of hydrocephalus. In them, intracranial pressure (ICP) is deliberately raised and CSF circulation disorders evaluated through measurements of the resulting ICP. In this study, we analysed seventy-seven ICP signals recorded during infusion tests using four spectral-based parameters: median frequency (MF) and relative power (RP) in three frequency bands. These measures provide a novel perspective for the analysis of ICP signals in the frequency domain. Each signal was divided into four artefact-free epochs (corresponding to the basal, early infusion, plateau and recovery phases of the infusion study). The four spectral parameters were calculated for each epoch. We analysed differences between epochs of the infusion test and correlations between these epochs and patient data. Statistically significant differences (p < 1.7 × 10⁻³, Bonferroni-corrected Wilcoxon signed-rank tests) were found between epochs of the infusion test using MF and RP. Furthermore, some spectral parameters (MF in the basal phase, RP for the first frequency band and in the early infusion phase, RP for the second frequency band and in all phases of the infusion study and RP in the third frequency band and in the basal phase) revealed significant correlations (p < 0.01) between epochs of the infusion test and signal amplitude in the basal and plateau phases. Our results suggest that spectral analysis of ICP signals could be useful for understanding CSF dynamics in hydrocephalus.
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2012, Artificial Intelligence in Medicine
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While current clinical protocols generally rely on the continuous measurement of the mean ICP, recent works have demonstrated that the morphology of ICP waveform also holds essential informations about the intracranial adaptive capacity, and even the outcome of head injured patients [2,3]. For example, it has been shown that variations of the ICP pulse morphology are linked to the development of intracranial hypertension [4,5] and cerebral vasospasm [6], acute changes in the cerebral blood carbon dioxide (CO2) levels [7,8], changes in the craniospinal compliance [9], decreased cerebral blood flow [10], and elevated ICP [11]. Therefore, the extraction of morphological features may provide insight to monitor and to understand ICP in an automatic fashion with the ultimate goal of improving the treatment of pathophysiological intracranial and cerebrovascular dynamics.
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Experiments demonstrate the effectiveness of the tracking framework on real ICP pulses and its robustness to occlusion and missing peaks. On artificialy distorted ICP sequences, the average error in latency in comparision with MOCAIP detector was reduced as follows: 11.88–8.09 ms, 11.80–6.90 ms, and 11.76–7.46 ms for the first, second, and third peak, respectively.
The proposed tracking algorithm sucessfuly increases the temporal resolution of detecting ICP pulse morphological changes from the minute-level to the beat-level.
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Research paperIntracranial pressure waveform indices in transient and refractory intracranial hypertension

Abstract

Surg. Neurol.

Cerebrospinal fluid pulse pressure and intracranial volume-pressure relationships

J. Neurol. Neurosurg. Psych.

Development of a clinical monitoring system by means of ICP waveform analysis

Systems analysis of intracranial pressure. Comparison with volume-pressure test and CSF-pulse amplitude analysis

J. Neurosurg.

Effects of heart rate on the shape of the intracranial pressure wave and related parameters

Cerebrospinal fluid pressure and pulsatility. An experimental study of circulatory and respiratory influences in normal and hydrocephalic dogs

Eur. Neurol.

Intracranial pressure monitoring

Care Crit.

A study of the cerebrospinal fluid pulse wave

Arch. Neurol.

Infuence of systemic and cerebral vascular factors on the cerebrospinal fluid pulse waves

J. Neurosurg.

Research paper
Intracranial pressure waveform indices in transient and refractory intracranial hypertension