BACKGROUND: During gynecological laparoscopic surgery, pneumoperitoneum and the Trendelenburg position (TP) can lead to increased intracranial pressure (ICP). However, it remains unclear whether perioperative fluid therapy impacts ICP. The purpose of this research was to evaluate the impact of restrictive fluid (RF) therapy versus conventional fluid (CF) therapy on ICP in gynecological laparoscopic surgery patients by measuring the ratio of the optic nerve sheath diameter (ONSD) to the eyeball transverse diameter (ETD) using ultrasound.
METHODS: Sixty-four patients who were scheduled for laparoscopic gynecological surgery were randomly assigned to the CF group or the RF group. The main outcomes were differences in the ONSD/ETD ratios between the groups at predetermined time points. The secondary outcomes were intraoperative circulatory parameters (including mean arterial pressure, heart rate, and urine volume changes) and postoperative recovery indicators (including extubation time, length of post-anaesthesia care unit stay, postoperative complications, and length of hospital stay).
RESULTS: There were no statistically significant differences in the ONSD/ETD ratio and the ONSD over time between the two groups (all p > 0.05). From T2 to T4, the ONSD/ETD ratio and the ONSD in both groups were higher than T1 (all p < 0.001). From T1 to T2, the ONSD/ETD ratio in both groups increased by 14.3%. However, the extubation time in the RF group was shorter than in the CF group [median difference (95% CI) -11(-21 to -2) min, p = 0.027]. There were no differences in the other secondary outcomes.
CONCLUSIONS: In patients undergoing laparoscopic gynecological surgery, RF did not significantly lower the ONSD/ETD ratio but did shorten the tracheal extubation time, when compared to CF.
BACKGROUND: ChiCTR2300079284. Registered on December 29, 2023.

Intracranial pressure monitoring enables the detection and treatment of intracranial hypertension, a potentially lethal insult after traumatic brain injury. Despite its widespread use, robust evidence supporting intracranial pressure monitoring and treatment remains sparse. International studies have shown large variations between centres regarding the indications for intracranial pressure monitoring and treatment of intracranial hypertension. Experts have reviewed these two aspects and, by consensus, provided practical approaches for monitoring and treatment. Advances have occurred in methods for non-invasive estimation of intracranial pressure although, for now, a reliable way to non-invasively and continuously measure intracranial pressure remains aspirational. Analysis of the intracranial pressure signal can provide information on brain compliance (ie, the ability of the cranium to tolerate volume changes) and on cerebral autoregulation (ie, the ability of cerebral blood vessels to react to changes in blood pressure). The information derived from the intracranial pressure signal might allow for more individualised patient management. Machine learning and artificial intelligence approaches are being increasingly applied to intracranial pressure monitoring, but many obstacles need to be overcome before their use in clinical practice could be attempted. Robust clinical trials are needed to support indications for intracranial pressure monitoring and treatment. Progress in non-invasive assessment of intracranial pressure and in signal analysis (for targeted treatment) will also be crucial.

BACKGROUND: The etiological diagnosis of intracranial hypertension is quite complicated but important in clinical practice. Some common causes are craniocerebral injury, intracranial space-occupying lesion, subarachnoid hemorrhage, and hydrocephalus. When a patient presents with intracranial hypertension, the common causes are to be considered first so that other causes would be dismissed. With the morbidity lower than 9%, neuromelanin is very rare. Common symptoms include nerve damage symptoms, epilepsy, psychiatric symptoms, and cognitive disorders.
METHODS: We present a patient with melanoma which manifested with isolated intracranial hypertension without any other neurological signs. A 22-year-old male had repeated nausea and vomiting for 2 mo with Babinski sign (+) on both sides, nuchal rigidity, and subarachnoid hemorrhage. He had been diagnosed with melanoma and was given surgery and whole-brain radiation. Ultimately, the patient died 2 mo later.
CONCLUSIONS: Malignant melanoma should be taken into consideration in the differential diagnosis of intracranial hypertension.

Objective:To investigate the clinical features, imaging findings, surgical methods， diagnostic and treatment experience of spontaneous cerebrospinal fluid otorrhoea. Methods:The clinical data of 11 patients with spontaneous cerebrospinal fluid otorrhoea treated surgically at our hospital from May 2018 to May 2023 were retrospectively analyzed. The medical data included medical history, imaging data, leak location, surgical repair method, treatment effect and postoperative follow-up. Results:Among the 11 surgical patients, 4 patients were initially diagnosed with secretory otitis media, 1 was initially diagnosed with purulent otitis media, and 5 patients had a history of meningitis or presented because meningitis as the initial diagnosis. There were 2 cases of cerebrospinal fluid leakage repaired through the ear canal pathway and 9 cases of cerebrospinal fluid leakage repaired through the mastoid pathway. During the operation, leaks were located in the stapes floor plate in 4 cases, sinus meningeal angle in 1 case, posterior cranial fossa combined with middle cranial fossa in 1 case, middle cranial fossa in 4 cases, and labyrinthine segment of the internal auditory canal and facial nerve canal in 1 case. Ten patient was successfully repaired, and another patient developed intracranial hypertension after surgery, with symptoms alleviated by a lateral ventriculoperitoneal shunt. Postoperative follow-up ranged from 6 months to 4 years, and there was no CSF otorrhoea and meningitis recurrence. Conclusion:The incidence of spontaneous cerebrospinal fluid otorrhea is low, the clinical symptoms are atypical, and the rate of delayed diagnosis or missed diagnosis and misdiagnosis is high. Surgery is currently the preferred treatment for spontaneous cerebrospinal fluid otorrhoea, and satisfactory results are usually achieved; During diagnosis and treatment, it is crucial to be vigilant for intracranial hypertension to prevent serious complications and irreversible damage.
目的：探讨自发性脑脊液耳漏的临床特点、影像学表现、手术方法及诊治经验。 方法：回顾性分析2018年5月至2023年5月手术治疗的11例自发性脑脊液耳漏患者的临床资料，包括既往病史，影像学资料、漏口位置、手术修补方法、治疗效果及术后随访情况等。 结果：11例手术患者，其中4例患者首诊为分泌性中耳炎，1例患者首诊为化脓性中耳炎，5例患者既往有脑膜炎病史或因脑膜炎为初次诊断而就诊；经耳道径路修补脑脊液漏2例，经乳突径路修补脑脊液漏9例；术中发现漏口位于镫骨底板4例，窦脑膜角1例，颅后窝合并颅中窝1例，颅中窝4例，内听道底及面神经管迷路段1例；10例患者1次修补成功，另1例患者术后出现颅内高压，最终行侧脑室腹腔分流术后症状解除。术后随访6个月～4年，无脑脊液耳漏及脑膜炎复发。 结论：自发性脑脊液耳漏发病率低，临床症状不典型，延迟诊断或漏诊误诊率高；手术是目前治疗自发性脑脊液耳漏首选方法，通常可以取得满意的效果；诊疗过程中要警惕并重视颅内高压的存在，防止发生严重并发症及不可逆损伤。.

OBJECTIVE: To describe the potential effects of Intracranial pressure monitoring on the outcome of patients with spontaneous intracerebral hemorrhage (ICH).
METHODS: This study is a systematic review with meta-analysis. Patients with spontaneous ICH treated with intracranial pressure monitoring were included. The primary outcome was mortality at 6 months and in-hospital mortality. The secondary outcome was poor neurological function outcome at 6 months.
RESULTS: This analysis compares in-hospital and 6-month mortality rates between patients with intracranial pressure monitoring (ICPm) and those without (no ICPm). Although the ICPm group had a lower in-hospital mortality rate, it was not statistically significant (24.9% vs. 34.1%; OR 0.51, 95% CI 0.20 to 1.31, P = 0.16). Excluding patients with intraventricular hemorrhage revealed a significant reduction in in-hospital mortality for the ICPm group (23.5% vs. 43%; OR 0.39, 95% CI 0.29 to 0.53, P < 0.00001). For 6-month mortality, the ICPm group showed a significant reduction (32% vs. 39.6%; OR 0.76, 95% CI 0.61 to 0.94, P = 0.01), with the effect being more pronounced after excluding intraventricular hemorrhage patients (29.1% vs. 47.2%; OR 0.45, 95% CI 0.34 to 0.60, P < 0.0001). However, there were no statistically significant differences in 6-month functional outcomes between the groups. Increased ICP was associated with higher 3-month mortality (OR 1.12, 95% CI 1.07 to 1.18, P < 0.00001) and lower likelihood of good functional outcomes (OR 1.11, 95% CI 1.04 to 1.18, P < 0.00001).
CONCLUSIONS: Elevated ICP is associated with increased mortality and poor prognosis in ICH patients. Although continuous intracranial pressure monitoring may reduce short-term mortality rates in specific subgroups of ICH patients, it does not improve neurological functional outcomes. While potential patient populations may benefit from ICP monitoring, more research is needed to screen suitable populations for ICP monitoring.

BACKGROUND: Treatment and prevention of intracranial hypertension (IH) to minimize secondary brain injury are central to the neurocritical care management of traumatic brain injury (TBI). Predicting the onset of IH in advance allows for a more aggressive prophylactic treatment. This study aimed to develop random forest (RF) models for predicting IH events in TBI patients.
METHODS: We analyzed prospectively collected data from patients admitted to the intensive care unit with invasive intracranial pressure (ICP) monitoring. Patients with persistent ICP > 22 mmHg in the early postoperative period (first 6 h) were excluded to focus on IH events that had not yet occurred. ICP-related data from the initial 6 h were used to extract linear (ICP, cerebral perfusion pressure, pressure reactivity index, and cerebrospinal fluid compensatory reserve index) and nonlinear features (complexity of ICP and cerebral perfusion pressure). IH was defined as ICP > 22 mmHg for > 5 min, and severe IH (SIH) as ICP > 22 mmHg for > 1 h during the subsequent ICP monitoring period. RF models were then developed using baseline characteristics (age, sex, and initial Glasgow Coma Scale score) along with linear and nonlinear features. Fivefold cross-validation was performed to avoid overfitting.
RESULTS: The study included 69 patients. Forty-three patients (62.3%) experienced an IH event, of whom 30 (43%) progressed to SIH. The median time to IH events was 9.83 h, and to SIH events, it was 11.22 h. The RF model showed acceptable performance in predicting IH with an area under the curve (AUC) of 0.76 and excellent performance in predicting SIH (AUC = 0.84). Cross-validation analysis confirmed the stability of the results.
CONCLUSIONS: The presented RF model can forecast subsequent IH events, particularly severe ones, in TBI patients using ICP data from the early postoperative period. It provides researchers and clinicians with a potentially predictive pathway and framework that could help triage patients requiring more intensive neurological treatment at an early stage.

The rapid perfusion of cerebral arteries leads to a significant increase in intracranial blood volume, exposing patients with traumatic brain injury to the risk of diffuse brain swelling or malignant brain herniation during decompressive craniectomy. The microcirculation and venous system are also involved in this process, but the precise mechanisms remain unclear. A physiological model of extremely high intracranial pressure was created in rats. This development triggered the TNF-α/NF-κB/iNOS axis in microglia, and released many inflammatory factors and reactive oxygen species/reactive nitrogen species, generating an excessive amount of peroxynitrite. Subsequently, the capillary wall cells especially pericytes exhibited severe degeneration and injury, the blood-brain barrier was disrupted, and a large number of blood cells were deposited within the microcirculation, resulting in a significant delay in the recovery of the microcirculation and venous blood flow compared to arterial flow, and this still persisted after decompressive craniectomy. Infliximab is a monoclonal antibody bound to TNF-α that effectively reduces the activity of TNF-α/NF-κB/iNOS axis. Treatment with Infliximab resulted in downregulation of inflammatory and oxidative-nitrative stress related factors, attenuation of capillary wall cells injury, and relative reduction of capillary hemostasis. These improved the delay in recovery of microcirculation and venous blood flow.

Elevated intracranial pressure (ICP) in patients with cerebral lesions has garnered considerable attention in research. It often manifests as a common symptom in conditions such as intracranial tumors, intracerebral hemorrhage, and cerebral edema. This paper provides an overview of ICP concepts, discusses the advantages and disadvantages of traditional monitoring methods, explores the physiological and anatomical aspects of the optic nerve sheath, examines the utility of ultrasound measurement of optic nerve sheath diameter (ONSD) in both nervous system and nonnervous system disorders, and outlines the cutoff values and normal ranges for assessing elevated ICP using ultrasound measurement of ONSD. The review underscores ultrasound measurement of ONSD as a promising noninvasive, safe, straightforward, and repeatable examination technique for various diseases. Nevertheless, the lack of standardized cutoff values for elevated ICP remains a challenge. Summarizing studies on optic nerve sheaths is crucial for enhancing the efficacy of ultrasound measurement of ONSD in assessing ICP.

OBJECTIVE: To investigate the effects of different ventilation strategies on intraocular pressure (IOP) and intracranial pressure in patients undergoing spinal surgery in the prone position under general anesthesia.
METHODS: Seventy-two patients undergoing prone spinal surgery under general anesthesia between November, 2022 and June, 2023 were equally randomized into two groups to receive routine ventilation (with Vt of 8mL/kg, Fr of 12-15/min, and etCO2 maintained at 35-40 mmHg) or small tidal volume hyperventilation (Vt of 6 mL/kg, Fr of18-20/min, and etCO2 maintained at 30-35 mmHg) during the surgery. IOP of both eyes (measured with a handheld tonometer), optic nerve sheath diameter (ONSD; measured at 3 mm behind the eyeball with bedside real-time ultrasound), circulatory and respiratory parameters of the patients were recorded before anesthesia (T0), immediately after anesthesia induction (T1), immediately after prone positioning (T2), at 2 h during operation (T3), immediately after supine positioning after surgery (T4) and 30 min after the operation (T5).
RESULTS: Compared with those at T1, IOP and ONSD in both groups increased significantly at T3 and T4(P < 0.05). IOP was significantly lower in hyperventilation group than in routine ventilation group at T3 and T4(P < 0.05), and ONSD was significantly lower in hyperventilation group at T4(P < 0.05). IOP was positively correlated with the length of operative time (r=0.779, P < 0.001) and inversely with intraoperative etCO2 at T3(r=-0.248, P < 0.001) and T4(r=-0.251, P < 0.001).ONSD was correlated only with operation time (r=0.561, P < 0.05) and not with IOP (r=0.178, P>0.05 at T3; r=0.165, P>0.05 at T4).
CONCLUSIONS: Small tidal volume hyperventilation can relieve the increase of IOP and ONSD during prone spinal surgery under general anesthesia.

BACKGROUND: Decompressive craniectomy (DC), a surgery to remove part of the skull and open the dura mater, maybe an effective treatment for controlling intracranial hypertension. It remains great interest to elucidate whether DC is beneficial to intracerebral hemorrhage (ICH) patients who warrant clot removal (CR) to prevent intracranial hypertension.
METHODS: The trial was a prospective, pragmatic, controlled trial involving adult patients with ICH who were undergoing removal of hematoma. ICH patients were randomly assigned at a 1:1 ratioto undergo CR with or without DC under the monitoring of intracranial pressure. The primary outcome was the proportion of unfavorable functional outcome (modified Rankin Scale 3-6) at 3 months. Secondary outcomes included the mortality at 3 months and the occurrence of reoperation.
RESULTS: A total of 102 patients were assigned to the CR with DC group and 102 to the CR group. Median hematoma volume was 54.0 ml (range 30-80 ml) and median preoperative Glasgow Coma Scale was 10 (range 5-15). At 3 months, 94 patients (92.2%) in CR with DC group and 83 patients (81.4%) in the CR group had unfavorable functional outcome ( P =0.023). Fourteen patients (13.7%) in the CR with DC group died versus five patients (4.9%) in the CR group ( P =0.030). The number of patients with reoperation was similar between the CR with DC group and CR group (5.9 vs. 3.9%; P =0.517). Postoperative intracranial pressure values were not significantly different between two groups and the mean values were less than 20 mmHg.
CONCLUSIONS: CR without DC decreased the rate of modified Rankin Scale score of 3-6 and mortality in patients with ICH, compared with CR with DC.