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Noninvasive Intracranial Pressure Assessment in Acute Liver Failure.
Neurocrit Care. 2018 10; 29(2):280-290.NC

Abstract

BACKGROUND

Elevated intracranial pressure (ICP) is an important cause of death following acute liver failure (ALF). While invasive ICP monitoring (IICPM) is most accurate, the presence of coagulopathy increases bleeding risk in ALF. Our objective was to evaluate the accuracy of three noninvasive ultrasound-based measures for the detection of concurrent ICP elevation in ALF-optic nerve sheath diameter (ONSD) using optic nerve ultrasound (ONUS); middle cerebral artery pulsatility index (PI) on transcranial Doppler (TCD); and ICP calculated from TCD flow velocities (ICPtcd) using the estimated cerebral perfusion pressure (CPPe) technique.

METHODS

In this retrospective study, consecutive ALF patients admitted over a 6-year period who underwent IICPM as well as measurement of ONSD, TCD-PI or ICPtcd were included. ONSD was measured offline by a blinded investigator from deidentified videos. The ability of highest ONSD, TCD-PI, and ICPtcd to detect concurrent invasive ICP > 20 mmHg was assessed using receiver operating characteristic (ROC) curves. The ROC area under the curve (AUC) was calculated with 95% confidence interval (95% CI) and evaluated against the null hypothesis of AUC = 0.5. Noninvasive measures were also evaluated as predictors of in-hospital death.

RESULTS

Forty-one ALF patients were admitted during the study period. In total, 27 (66%) underwent IICPM, of these, 23 underwent ONUS and 21 underwent TCD. Eleven out of 23 (48%) patients died (two from intracranial hypertension). Results of ROC analysis for detection of concurrent ICP > 20 mmHg were as follows: ONSD AUC = 0.59 (95% CI 0.37-0.79, p = 0.54); TCD-PI AUC = 0.55 (95% CI 0.34-0.75, p = 0.70); and ICPtcd AUC = 0.90 (0.72-0.98, p < 0.0001). None of the noninvasive measures were significant predictors of death.

CONCLUSIONS

In patients with ALF, neither ONSD nor TCD-PI reliably detected concurrent ICP elevation on invasive monitoring. Estimation of ICP (ICPtcd) using the TCD CPPe technique was associated with concurrent ICP elevation. Additional studies of TCD CPPe in larger numbers of ALF patients may prove worthwhile.

Authors+Show Affiliations

Department of Neurosurgery, University of Michigan, Taubman Health Care Center 3522, SPC 5338, 1500 East Medical Center Drive, Ann Arbor, MI, 48109-5338, USA. vrajajee@yahoo.com. Department of Neurology, University of Michigan, Ann Arbor, MI, USA. vrajajee@yahoo.com.Department of Neurosurgery, University of Michigan, Taubman Health Care Center 3522, SPC 5338, 1500 East Medical Center Drive, Ann Arbor, MI, 48109-5338, USA. Department of Neurology, University of Michigan, Ann Arbor, MI, USA.Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.Department of Neurosurgery, University of Michigan, Taubman Health Care Center 3522, SPC 5338, 1500 East Medical Center Drive, Ann Arbor, MI, 48109-5338, USA.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

29948998

Citation

Rajajee, Venkatakrishna, et al. "Noninvasive Intracranial Pressure Assessment in Acute Liver Failure." Neurocritical Care, vol. 29, no. 2, 2018, pp. 280-290.
Rajajee V, Williamson CA, Fontana RJ, et al. Noninvasive Intracranial Pressure Assessment in Acute Liver Failure. Neurocrit Care. 2018;29(2):280-290.
Rajajee, V., Williamson, C. A., Fontana, R. J., Courey, A. J., & Patil, P. G. (2018). Noninvasive Intracranial Pressure Assessment in Acute Liver Failure. Neurocritical Care, 29(2), 280-290. https://doi.org/10.1007/s12028-018-0540-x
Rajajee V, et al. Noninvasive Intracranial Pressure Assessment in Acute Liver Failure. Neurocrit Care. 2018;29(2):280-290. PubMed PMID: 29948998.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Noninvasive Intracranial Pressure Assessment in Acute Liver Failure. AU - Rajajee,Venkatakrishna, AU - Williamson,Craig A, AU - Fontana,Robert J, AU - Courey,Anthony J, AU - Patil,Parag G, PY - 2018/6/28/pubmed PY - 2019/10/8/medline PY - 2018/6/28/entrez KW - Cerebral edema KW - Fulminant hepatic failure KW - Intracranial hypertension KW - Transcranial Doppler ultrasonography KW - Ultrasonography SP - 280 EP - 290 JF - Neurocritical care JO - Neurocrit Care VL - 29 IS - 2 N2 - BACKGROUND: Elevated intracranial pressure (ICP) is an important cause of death following acute liver failure (ALF). While invasive ICP monitoring (IICPM) is most accurate, the presence of coagulopathy increases bleeding risk in ALF. Our objective was to evaluate the accuracy of three noninvasive ultrasound-based measures for the detection of concurrent ICP elevation in ALF-optic nerve sheath diameter (ONSD) using optic nerve ultrasound (ONUS); middle cerebral artery pulsatility index (PI) on transcranial Doppler (TCD); and ICP calculated from TCD flow velocities (ICPtcd) using the estimated cerebral perfusion pressure (CPPe) technique. METHODS: In this retrospective study, consecutive ALF patients admitted over a 6-year period who underwent IICPM as well as measurement of ONSD, TCD-PI or ICPtcd were included. ONSD was measured offline by a blinded investigator from deidentified videos. The ability of highest ONSD, TCD-PI, and ICPtcd to detect concurrent invasive ICP > 20 mmHg was assessed using receiver operating characteristic (ROC) curves. The ROC area under the curve (AUC) was calculated with 95% confidence interval (95% CI) and evaluated against the null hypothesis of AUC = 0.5. Noninvasive measures were also evaluated as predictors of in-hospital death. RESULTS: Forty-one ALF patients were admitted during the study period. In total, 27 (66%) underwent IICPM, of these, 23 underwent ONUS and 21 underwent TCD. Eleven out of 23 (48%) patients died (two from intracranial hypertension). Results of ROC analysis for detection of concurrent ICP > 20 mmHg were as follows: ONSD AUC = 0.59 (95% CI 0.37-0.79, p = 0.54); TCD-PI AUC = 0.55 (95% CI 0.34-0.75, p = 0.70); and ICPtcd AUC = 0.90 (0.72-0.98, p < 0.0001). None of the noninvasive measures were significant predictors of death. CONCLUSIONS: In patients with ALF, neither ONSD nor TCD-PI reliably detected concurrent ICP elevation on invasive monitoring. Estimation of ICP (ICPtcd) using the TCD CPPe technique was associated with concurrent ICP elevation. Additional studies of TCD CPPe in larger numbers of ALF patients may prove worthwhile. SN - 1556-0961 UR - https://www.unboundmedicine.com/medline/citation/29948998/Noninvasive_Intracranial_Pressure_Assessment_in_Acute_Liver_Failure_ L2 - https://dx.doi.org/10.1007/s12028-018-0540-x DB - PRIME DP - Unbound Medicine ER -