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N Stocchetti

Publications and source records attributed to N Stocchetti.

At least 37 records · Page 2Linked to original sources
PubMed2000

Neuro-Link, a computer-assisted database for head injury in intensive care.

Reliable information is vital for clinical trials, so we developed a database, for head trauma victims admitted to neuro-intensive care units (NICU). This database, first step in a sequential project, comprises 176 selected fields mainly focused on the early post-traumatic phase and has a user-friendly computerized interface. The software was tested for a trimester in 18 Italian neuro-intensive care units. The paper describes the main features of the database, the results of a three months' data collection test, its limitations and its potential improvements. A description of the database fields and a brief summary of the 282 patients included so far are also presented.

Adolescent↗
PubMed2000

The value of the "worst" computed tomographic scan in clinical studies of moderate and severe head injury. European Brain Injury Consortium.

OBJECTIVE: Computed tomographic (CT) scanning can reveal the pattern and severity of structural brain damage after head injury. With the proliferation of CT scanners in general hospitals, and with improvements in patient transport, the interval from injury to the first CT scan is decreasing. The potential result is an "admission" scan missing an evolving and potentially operable lesion. Furthermore, the literature is confusing regarding the timing and coding of CT findings. We sought to establish the frequency of deterioration in CT appearance from an admission scan to subsequent scans and the prognostic significance of such deterioration. METHODS: In a survey organized by the European Brain Injury Consortium, data on initial severity, management, and subsequent outcome were gathered prospectively for 1005 patients with moderate or severe head injury admitted to one of 67 European neurosurgical units during a 3-month period in 1995. The findings of the initial and the final ("worst") CT scan were classified according to the Traumatic Coma Data Bank system and were related to outcome as assessed using the Glasgow Outcome Scale 6 months after injury. RESULTS: Data on an initial and a final CT scan were available for 897 patients; of these, 724 patients were assessed using the Glasgow Outcome Scale at 6 months. The initial CT findings were classified as a diffuse injury for 53% of the cohort, with 16% of these diffuse injuries demonstrating deterioration on a subsequent scan. In 56 (74%) of 76 deteriorations, the change was from a diffuse injury to a mass lesion. When the initial CT scan demonstrated a diffuse injury without swelling or shift, evolution to a mass lesion was associated with a statistically significant increase in the risk of an unfavorable outcome (62% versus 38%). When the initial scan demonstrated evidence of swelling or shift, there was a nonsignificant trend in the opposite direction, although the numbers were limited. CONCLUSION: When an admission CT scan demonstrates evidence of a diffuse injury, follow-up scans should be performed, because approximately one in six such patients will demonstrate significant CT evolution. In studies comparing series of head-injured patients, correspondence of timing of CT scans is necessary for valid comparison.

Brain Injuries↗
PubMed2000

Neurophysiological consequences of three tracheostomy techniques: a randomized study in neurosurgical patients.

We describe the effects of different tracheostomy techniques on intracranial pressure (ICP), cerebral perfusion pressure (CPP), and cerebral extraction of oxygen. We attempted to identify the main mechanisms affecting intracranial pressure during tracheostomy. To do so we conducted a prospective, block-randomized, clinical study which took place in a neurosurgical intensive care unit in a teaching hospital. The patients studied consisted of thirty comatose patients admitted to the intensive care unit because of head injury, subarachnoid hemorrhage, or brain tumor. Ten patients per group were submitted to standard surgical tracheostomy, percutaneous dilatational tracheostomy or translaryngeal tracheostomy. In every technique a significant increase of ICP (P < .05) was observed at the time of cannula placement. Intracranial hypertension (ICP > 20 mm Hg) was more frequent in the percutaneous dilatational tracheostomy group (P < .05). Cerebral perfusion pressure dropped below 60 mm Hg in eleven cases, more frequently during surgical tracheostomy. Arterial tension of CO2 significantly increased in all three groups during cannula placement. No other major complications were recorded during the procedures. At follow-up no severe anatomic or functional damage was detected. We conclude that the three tracheostomy techniques, performed in selected patients where the risk of intracranial hypertension was reduced to the minimum, were reasonably tolerated but caused an intracranial pressure rise and cerebral perfusion pressure reduction in some cases.

Adult↗
PubMed2000

Mass volume measurement in severe head injury: accuracy and feasibility of two pragmatic methods.

OBJECTIVE: To assess the clinical feasibility and the accuracy of two pragmatic methods in comparison with a conventional computer based method of measurement of masses from CT. METHODS: Nineteen CT scans of 11 patients with severe head injury, showing 34 traumatic lesions, were examined. The volume of every lesion was digitally measured, then a panel of three examiners independently repeated the measurement using the ellipsoid and the Cavalieri method in random order. RESULTS: All the lesions were identified by all the readers and the mean volume measured by each examiner differed by less than 1.5 ml. The average reading time for each scan was 4 minutes for the ellipsoid and 7 minutes for the Cavalieri method. The average volume of the lesions was 34.2 (SD 35) ml with the digital system, and 38.4 (SD 41) ml and 34.8 (SD 36) ml for the ellipsoid and the Cavalieri readings respectively. The average difference between the applied technique and the digital system was 0.57 (SD 9.99) ml for the Cavalieri direct estimator and 0.20 (SD 15.48) ml for the ellipsoid method. The 95% confidence interval for this difference fell between -2.75 and 3.89 ml for the Cavalieri, and between -4.94 and 5.35 ml for the ellipsoid method. There were 19 lesions >25 ml; the ellipsoid method identified 16 of them, whereas 17 were classified with the Cavalieri method. When considering individual lesions rather than the average volume, discrepancies were detected with both methods. The ellipsoid method was less precise, especially when extracerebral lesions were measured. CONCLUSIONS: Both pragmatic methods are inferior to computer based reading, which is the choice when accurate volume estimation is necessary. However, if a digital volumetric determination of the lesions using a CT computer is not possible, the two pragmatic methods offer an alternative.

Analysis of Variance↗
PubMed2000

Guidelines for the treatment of adults with severe head trauma (part I). Initial assessment; evaluation and pre-hospital treatment; current criteria for hospital admission; systemic and cerebral monitoring.

If pragmatic recommendations for treatment of severely head-injured patients could really be applied, they would probably have a considerable impact in terms of reduction in mortality and disability. Since 1995 a Group of Italian Neurointensivists and Neurosurgeons belonging to the Italian Societies of Neurosurgery (SINch) and Anesthesiology & Intensive Care (SIAARTI) has produced this first part of recommendations that are completed by Medical treatment (Part II) and Surgical treatment criteria (Part III). These recommendations reflect a multidisciplinary consent but are based on scientific evidence, when available, and take origin mainly from expert opinions and the current clinical and organizational situation. For this aspect they differ from other American and European guidelines, which are strictly based on criteria of proven efficacy. These recommendations aim at providing a practical reference for all those dealing with severe head injuries from first-aid to intensive care units, setting out the minimal goals of management to be reached throughout the country. For these reasons they need continual critical review and updating. Main clinical aims are: 1) to prevent secondary cerebral damage by continuous and meticulous maintenance of systemic homeostasis 2) to standardize methods of neurological evaluation and CT scan classification and scheduling; 3) to give simple indications for systemic and cerebral monitoring 4) to pragmatically discuss the organizational scenarios and specify the minimal safe clinical approach when patients are treated in non-specialized settings. Briefly, smooth tracheal intubation and ventilation in all comatose patients, administration of rapidly metabolized sedative and analgesic drugs to permit frequent neurological evaluation, restoration of volemia and systolic blood pressure above 110 mm Hg, oxygen saturation >95% and normocapnia, are all recommended from the very early treatment and transport. Homogeneity of language, reliable and correctly tested Glasgow Coma Score and pupillary reflexes, and a simple CT scan classification are recommended to improve communications and clinical decisions in the multidisciplinary setting of management. In comatose patients, cerebral perfusion pressure, intracranial pressure and oxygen jugular saturation must be monitored according to specific criteria, which are described. Therapy with hyperventilation and mannitol should be used only in case of clinical deterioration and uncal herniation. This therapy could be useful to gain time to reach neurosurgery. The aim of these recommendations is to achieve safer management of severely brain injured patients, immediate diagnosis of clinical deterioration and successful identification and treatment of surgical lesions. The impact of these guidelines requires further verification.

Adult↗
PubMed2000

Guidelines for the treatment of adults with severe head trauma (part II). Criteria for medical treatment.

Since 1995 a Group of Italian Neurointensivists and Neurosurgeons belonging to the Italian Societies of Neurosurgery (SINch) and Anesthesia & Intensive Care (SIAARTI) has produced some recommendations for treatment of adults with severe head trauma. They have been published in 3 parts: Part I (Initial assessment, Evaluation and pre-hospital treatment, Criteria for hospital admission, Systemic and cerebral monitoring), Part II (Medical treatment) and Part III (Surgical treatment criteria). These recommendations reflect a multidisciplinary consent and are mostly based on expert opinion. The main aim is to provide a practical reference for all those dealing with severe head injuries from first-aid to intensive care units, setting out the minimal goals of management to be reached throughout the Country. These recommendations need a continuous critical review and updating. Medical treatment is aimed at preventing or minimizing secondary brain damage following acute brain injury, provided that surgical masses have been promptly identified and removed. In order to assure cerebral perfusion, systemic hemodynamics and respiratory exchanges should be normal. Volemia is crucial, and mean arterial pressure should remain above 90 mmHg. Good general intensive care, including gastroprotection, water-electrolyte balance, infection control, nutrition and physiotherapy, is assumed as the basis for brain-oriented therapy. Intracranial hypertension requires an approach based on various steps. First, factors that can directly rise intracranial pressure (ICP) such as venous outflow obstruction, fever, pain etc. should be checked and corrected. Second, Mannitol, CSF withdrawal, sedation and moderate hyperventilation should be applied. This can be done by targeting specific problems with specific treatment (which is possible when the cause of ICP rise is known) or in a step-wise approach, by using less aggressive interventions before than more aggressive ones, with a higher risk of complications. Third, extreme treatment, such as barbiturates, should be reserved to cases with refractory intracranial hypertension. The main goal of ICP treatment is not simply ICP reduction, but the maintenance of adequate cerebral perfusion pressure.

Adult↗
PubMed2000

Guidelines for the treatment of adults with severe head trauma (part III). Criteria for surgical treatment.

The Guidelines of the surgical management of severe head injury in adults, as evolved by the Neurotraumatology Group of the Italian Neurosurgery Society and the Italian Society for Anaesthesia, Analgesia, Reanimation and Intensive Care are presented and briefly discussed. Guidelines presented here are of a pragmatic nature, based on consensus and expert opinion. Aspects pertaining to specific indications to surgery and/or to the possibility of conservative management of different traumatic intracranial lesions are highlighted. The importance of surgery in preventing secondary insults to the traumatised brain is emphasised.

Adult↗
PubMed1999

Intracranial hypertension in head injury: management and results.

OBJECTIVE: (1) To describe the pattern of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in a group of severe head-injured patients, (2) to quantify complications of ICP monitoring, and (3) to describe a management protocol and its results. DESIGN: Prospective observational study. SETTING: General intensive care unit in a teaching hospital. PATIENTS: 138 comatose patients, selected according to the following criteria: age > 16 years, coma [Glasgow Coma Scale (GCS) < or = 8] with at least one pupil reactive after resuscitation, digital recording of intracranial and arterial pressure, and jugular saturation measurements. MEASUREMENTS AND RESULTS: Median GCS was 5, and 62 patients had significant extracranial injuries; 71 had intracranial hematomas, which were urgently evacuated. Mean ICP was 20.5 mmHg (SD 8.34), mean CPP was 71.86 mmHg (SD 11.22); cerebral extraction of oxygen averaged 29 %. Medical therapy was used to control ICP in 130 cases; 93 patients required hyperventilation. Vasopressors were infused in 16 cases; in 14 cases a barbiturate infusion was started. In 6 patients all pharmacological treatments failed and surgical decompression was done. The only complication of ICP monitoring was meningitis in 3 patients. Outcome at 6 months was a good recovery and moderate disability for 82 patients (59.4%), severe disability and vegetative status for 37 (26.8%), and 19 patients died (13.7%). The severity of intracranial hypertension was related to poorer results at 6 months. CONCLUSIONS: Intracranial hypertension is very frequent in severe head injury but can be reasonably well controlled by combined surgical and medical therapy.

Adolescent↗
PubMed1999

The European Brain Injury Consortium survey of head injuries.

To provide a picture of contemporary practice, a survey was carried out of severely and moderately head injured patients admitted to 67 'neuro' centres in 12 European countries. 1,005 adult head injuries were recruited over a three month period. Sixty items of information on demography, clinical features, investigations, management and early complications were captured on a simple, two-page questionnaire and, information on outcome at six months on a third page. The median age of the subjects was 38 years, 74% were male and 51% injured in road traffic accidents; 57% of patients were transferred to the 'neuro' centre from another hospital. Assessment of clinical responsiveness was limited by the use of sedation and intubation and information from four early time points (pre-hospital, arrival at the Accident and Emergency department, post-resuscitation, and arrival at the 'neuro' unit) was combined to stratify the subjects as severe (58%), moderate (17%) or intermediate (19%). In 48% of patients classified the CT scan showed features of a 'mass lesion' and in 40% showed a subarachnoid haemorrhage. Fifty-five centres provided the data on outcome for 94% of the cases recruited in these centres six months after injury. 31% died, 3% were vegetative, 16% severely disabled, 20% moderately disabled and 31% had made a good recovery. Comparison of the data from different parts of Europe showed differences in the frequency of secondary transfer, cause of injury, occurrence of major extracranial injury, CT scan findings, intracranial operation, clinical severity of injury and utilisation of the components of intensive care and the occurrence of a favourable outcome, although the latter difference was not statistically significant when variations in the initial severity of injury were taken into account. The findings in the present survey are compared with newly analysed information for three previous large series: the International Data Bank involving the UK, the Netherlands and the USA, the North American Traumatic Coma Data Bank, and data from four centres in the UK. The comparisons showed substantial similarities and also differences that may reflect variations in policy for admission of the head injury to 'neuro' units, and evolution in methods of assessment, investigation and management. The effects of these differences on outcome requires further, rigorous prospective study.

Adolescent↗
PubMed1999

[Cerebral tissue oxygen monitoring: a useful thing?].

Monitoring cerebral oxygenation has been one of the main fields of interest in neurointensive care during the past few years. In fact it is strongly believed that restoring adequate cerebral oxygenation is the premise to maintaining the viability and restoring the function of the damaged CNS. Global monitoring provides an indirect estimation of adequacy of substrates supply to the brain. Local measurement of brain oxygen tension (ptiO2) is possible through a Clark electrode implanted into the cerebral parenchyma. The paper describes the physical basis of the monitoring, the pathophysiology of ptiO2 and its clinical use.

Brain Chemistry↗
PubMed1999

[Cranial trauma and multiple trauma: from the street to the operating room].

Brain injury occurs with a range of severity: even less severe cases should be carefully observed since they may deteriorate. By definition severe head injury has a Glasgow Coma Scale score of 8 or less; comatose patients are defined as cases who do not obey commands, do not open their eyes and do not speak. Very often (50% of case in our series) brain injury is associated with relevant extracranial injuries that may add to the severity of cases and may worsen outcome. The conceptual framework for treating head injury is based on the evidence that after the impact, the initial damage may be exacerbated by insults capable of further disturbing cerebral metabolism, leading to a final damage defined as secondary damage. Secondary damage represents the final end of many pathways that can be studied at the biochemical level and are centered in a calcium influx into the neuronal cell. Most probably there is a genetic susceptibility to secondary damage leading to a range of cellular dysfunctions for any given level of insult. The management of traumatic brain injury is aimed at interrupting the chain of events leading to secondary brain damage and from this perspective the fact that damage may develop over time can be seen as a window of opportunity for timely treatment. The milestone of treatment is the removal of surgical masses. This surgical treatment can be performed only in a brain that is properly perfused and once coagulation is preserved. Therefore the organization of treatment from rescue to neuro-traumatological centers should provide appropriate restoration of the volume and a normal oxygen delivery to the brain and to the overall organism.

Craniocerebral Trauma↗
PubMed1998

Complications and safety associated with ICP monitoring: a study of 542 patients.

In our institution ICP was monitored in patients with GCS < or = 8 and abnormal CT scan: 362 severely head injured and 180 subarachnoid hemorrhage. Mean duration of monitoring was 103.6 hours (SD 74.96). Among 542 patients, 440 showed at least one episode of ICP above the threshold of 20 mm Hg. Among 362 head injured patients only 71 (19.3%) had an ICP lower than 20 mm Hg. In the remaining 289 (81.7%) at least one episode > or = 20 mm Hg was measured. In 13 cases (2.2%) a ventricular infection has been diagnosed. In 1 case an intraparenchimal hemorrhage related to the presence of the catheter was detected. Elevated risk of HICP and low incidence of complications have been shown in this series.

Adolescent↗
PubMed1998

Effects of cerebral perfusion pressure on brain tissue PO2 in patients with severe head injury.

Ischemia causes secondary brain damage after severe head injury (SHI). Cerebral perfusion is commonly estimated by monitoring CPP, but the adequacy of cerebral oxygenation requires further measurements, such as jugular oxygen saturation or, more recently, PtiO2 monitoring. In 7 patients with severe head injury, ICP, MAP, CPP, SjO2 and PtiO2 were monitored for a mean time of 9.0 +/- 2.2 days. Most of the data were in a "normal" range. Focusing on values under the thresholds of 60 mm Hg for CPP and 20 mm Hg for PtiO2, we found a relationship between CPP and PtiO2. Looking at the PtiO2 time-course, we observed a quite constant increasing trend during the first 48 hours of monitoring, then the values remained relatively constant within a normal range. Our data show that decreases of PtiO2 are not uncommon after severe head injury and therefore it seems that monitoring of PtiO2 in SHI may be useful in order to minimize secondary insults.

Adolescent↗
PubMed1998

High cerebral perfusion pressure improves low values of local brain tissue O2 tension (PtiO2) in focal lesions.

Arterial hypertension is widely applied to improve regional cerebral blood flow (rCBF). We measured local brain tissue O2 pressure (PtiO2) in low density lesions at computerized tomography (CT) of the head before and after manipulation of mean arterial pressure (MAP) in order to increase cerebral perfusion pressure (CPP). Nine patients, 7 subarachnoid hemorrhage (SAH), 1 severe head injury, 1 meningeoma, were included in our study. A flexible polarographic microcatheter for PtiO2 measurement was placed at the border of the low density area found at CT. PtiO2 was continuously measured for 615 hours. Hypoperfusion in low density areas was detected by perfusional single photon emission computed tomography (SPECT). We recorded 22 episodes of induced or spontaneous increase of MAP. Initial PtiO2 regularly improved after the CPP increase (r2 0.74 in induced episodes). Low PtiO2 showed a greater percent increase for unitary changes of CPP than normal-high PtiO2. Baseline PtiO2 below 20 mm Hg was associated with normal CPPs; 5 readings of PtiO2 below 20 mm Hg normalized when a higher CPP was obtained. Our results show that in ischemic areas PtiO2 is dependent on CPP suggesting both a derangement of pressure autoregulation and high regional cerebrovascular resistences (CVRs). Low PtiO2 was associated with normal CPP, thus indicating that CPP could be an inadequate estimate of rCBF in focal ischemic areas. Arterial hypertension, capable of increasing CPP above normal values, appeared useful in normalizing tissue oxygenation in ischemic areas.

Adult↗