thiopental and Pseudotumor-Cerebri

Topics: Anesthesia; Humans; Hydroxybutyrates; Intracranial Pressure; Pseudotumor Cerebri; Respiration, Artificial; Thiopental

Thiopentone is administered as a racemate (rac-thiopentone) for induction of anaesthesia as well as for neurological and neurosurgical emergencies. The pharmacokinetics and pharmacodynamics of rac-thiopentone have been extensively studied but the component R-(+)- and S-(-)- enantiomers, until very recently, have been largely ignored.. The present study analyses the pharmacokinetics of R-(+)- and S-(-)-thiopentone in 12 patients given rac-thiopentone intravenously for induction of anaesthesia and five patients given a prolonged infusion of rac-thiopentone used for treatment of intracranial hypertension.. The mean total body clearance (CLT) and apparent volume of distribution at steady-state (Vss) showed trends towards higher values for R-(+)- than for S-(-)-thiopentone in both patient groups; CLT and Vss of unbound fractions of R-(+)- and S-(-)-thiopentone, however, did not show these trends. The time courses of R-(+)- and S-(-)- thiopentone serum concentrations were so similar that EEG effect could not be attributed to one or other enantiomer. Serum protein binding for S-(-)-thiopentone was greater than for R-(+)-thiopentone (P = 0.02) and 24 h urinary excretion of R-(+)-thiopentone was greater than for S-(-)-thiopentone (P = 0.03). In one patient, concomitant measurement of CSF and serum thiopentone concentrations found that serum: CSF equilibration of unbound fractions of both enantiomers was essentially complete.. The study was unable to determine any pharmacokinetic difference of clinical significance between the R-(+)- and S-(-)-thiopentone enantiomers and concludes that minor differences in CLT and Vss could be explained by enantioselective difference found in serum protein binding.

Topics: Adult; Aged; Aged, 80 and over; Anesthesia; Anesthetics, Intravenous; Blood Proteins; Electroencephalography; Female; Humans; Infusions, Intravenous; Injections, Intravenous; Male; Middle Aged; Protein Binding; Pseudotumor Cerebri; Stereoisomerism; Thiopental

Treatment resistant intracranial hypertension after severe head injury has a very high mortality with conventional therapy such as hyperventilation and mannitol infusions. In this report, we describe the use of large doses of thiopental as a means of treating such swelling. From a consecutive series of 107 severe head injuries with a Glasgow Coma Score (GCS) of 6 or below, we selected all patients below 40 years age with a progressive increase in intracranial pressure (ICP) to 40 mm Hg. The first 16 patients (mean age 20 years, mean GCS 4.3) were treated with deep barbiturate coma and hypothermia (32-35 degrees Celsius) until stable lowering of ICP was achieved. The next 15 patients received conventional intensive care and were in other respects very similar to the barbiturate group (mean age 26, mean GCS 5.2). After 9-12 months the outcome was classified according to the Glasgow Outcome Scale (GOS). Therapy with barbiturate coma resulted in 6 good/moderate outcomes, 3 severe and 7 dead/vegetative. Conventional treatment resulted in 2 good/moderate outcomes and 13 dead/vegetative. This is a highly significant difference and cannot easily be explained by more severe injuries or complications in the conventional group. Superior control of ICP was achieved by large doses of thiopental and the final outcome was better.

Topics: Adolescent; Adult; Brain Concussion; Brain Edema; Brain Injuries; Child; Child, Preschool; Clinical Trials as Topic; Dose-Response Relationship, Drug; Hematoma, Subdural; Humans; Intracranial Pressure; Prognosis; Pseudotumor Cerebri; Thiopental

The effect of indomethacin, a cyclooxygenase inhibitor, was studied in the treatment of 10 patients with head injury and one patient with spontaneous subarachnoid hemorrhage, each of whom presented with high intracranial pressure (ICP) (34.4 +/- 13.1 mm Hg) and cerebral perfusion pressure (CPP) impairment (67.0 +/- 15.4 mm Hg), which did not improve with standard therapy using mannitol, hyperventilation, and barbiturates. The patient had Glasgow Coma Scale scores of 8 or less. Recordings were made of the patients' ICP and mean arterial blood pressure from the nurse's end-hour recording at the bedside, as well as of their CPP, rectal temperature, and standard therapy regimens. The authors assessed the effects of an indomethacin bolus (50 mg in 20 minutes) on ICP and CPP; an indomethacin infusion (21.5 +/- 11 mg/hour over 30 +/- 9 hours) on ICP, CPP, rectal temperature, and standard therapy regimens (matching the values before and during infusion in a similar time interval); and discontinuation of indomethacin treatment on ICP, CPP, and rectal temperature. The indomethacin bolus was very effective in lowering ICP (p < 0.0005) and improving CPP (p < 0.006). The indomethacin infusion decreased ICP (p < 0.02), but did not improve CPP and rectal temperature. The effects of standard therapy regimens before and during indomethacin infusion showed no significant changes, except in three patients in whom mannitol reestablished its action on ICP and CPP. Sudden discontinuation of indomethacin treatment was followed by significant ICP rebound. The authors suggest that indomethacin may be considered one of the frontline agents for raised ICP and CPP impairment.

Topics: Adolescent; Adult; Blood Pressure; Body Temperature; Brain Injuries; Carbon Dioxide; Cerebrovascular Circulation; Child; Cyclooxygenase Inhibitors; Female; Glasgow Coma Scale; Humans; Hyperventilation; Indomethacin; Infusions, Intravenous; Injections, Intravenous; Intracranial Pressure; Male; Mannitol; Pseudotumor Cerebri; Rectum; Subarachnoid Hemorrhage; Thiopental

A patient with sinus thrombosis and characteristic magnetic resonance imaging (MRI) findings, who was managed successfully by barbiturate therapy is reported. MRI showed massive high intensity lesions on T2-weighted image which indicated venous cerebral infarction and brain oedema. Intravenous infusion of thiopental decreased increased intracranial pressure (ICP). The effectiveness of barbiturate therapy is discussed in terms of the similarity between this case and experimental sinus thrombosis. Barbiturate therapy should be considered in cases of severe sinus thrombosis with elevated ICP.

Topics: Adult; Dose-Response Relationship, Drug; Female; Follow-Up Studies; Glycerol; Humans; Intracranial Pressure; Magnetic Resonance Imaging; Mannitol; Neurologic Examination; Pseudotumor Cerebri; Sinus Thrombosis, Intracranial; Thiopental

The effects on intracranial pressure (ICP), cerebral perfusion pressure (CPP) and EEG monitored by Cerebral Function Monitor (CFM) were compared after bolus administration of mannitol (n = 55) and thiopentone (n = 67) to control intracranial hypertension in 18 severely head injured patients. Mannitol increased CPP in 89% of occasions and thiopentone in only 54% (p < 0.001). Thiopentone caused a mean increase in CPP +0.6 kPa (+5.0 +/- 1.6 mmHg) when the minimum pre-bolus voltage of CFM was above 4 microV and a fall in CPP -0.5 kPa (-4.1 +/- 1.6 mmHg) when cortical electrical activity was already severely depressed (p < 0.0002). When pre-bolus CFM was below 4 microV mannitol was superior to thiopentone. This different effect on CPP was due to a significantly greater fall in mean arterial pressure in the thiopentone sub-group -1.6 versus -0.3 kPa (-12.4 +/- 1.5 mmHg, -2.8 +/- 1.2 mmHg; p < 0.001). Severe and unpredictable hypotension occurred, particularly in the thiopentone low CFM sub-group. This symptomatic therapy seems inadequate but a targeted treatment of intracranial hypertension could be possible only with a more sophisticated monitoring, including continuous data on cerebral blood flow and adequacy to metabolic demand.

Topics: Adolescent; Adult; Brain Injuries; Child; Electroencephalography; Female; Humans; Intracranial Pressure; Male; Mannitol; Middle Aged; Monitoring, Physiologic; Pseudotumor Cerebri; Thiopental

The effects of antihypertensive drugs, such as nifedipine, chlorpromazine, reserpine and thiopental on mean arterial blood pressure (ABP), mean intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were studied in 43 patients with systemic hypertension and intracranial hypertension due to hemorrhagic cerebrovascular diseases and other causes. These drugs are commonly used in neurosurgical practice for the treatment of systemic hypertension. Nifedipine, chlorpromazine and reserpine reduced the mean ABP, raised the mean ICP and decreased the CPP. The effects of these drugs on mean ICP and CPP were more pronounced in patients with severely increased ICP (more than 40 mmHg) than in patients with moderately increased ICP (20-40 mmHg). Thiopental reduced both mean ABP and ICP, whereas the CPP was unchanged from the preadministration level. During thiopental administration, however, respiratory depression was observed, and hence, intubation and ventilation were required. We suggest that, in the treatment of systemic hypertension in patients with increased ICP, barbiturates are more desirable than agents with calcium channel or alpha-adrenergic blocking actions, despite the problem of respiratory control.

Topics: Adult; Aged; Antihypertensive Agents; Blood Pressure; Brain Edema; Cerebral Hemorrhage; Cerebrospinal Fluid Pressure; Chlorpromazine; Female; Humans; Hypertension; Intracranial Pressure; Male; Middle Aged; Nifedipine; Pseudotumor Cerebri; Reserpine; Thiopental

Intracranial hypertension complicating fulminant hepatic failure has a mortality in excess of 90% in the presence of renal failure if not rapidly responsive to mannitol and ultrafiltration. Based on data which suggest that barbiturates can be of value in controlling the intracranial hypertension of head injury, intravenous thiopental was assessed in 13 patients with fulminant hepatic failure. All had developed acute renal failure complicated by intracranial hypertension unresponsive to other modes of therapy and were likely by all published criteria to have little chance of survival. The dosage of thiopental was adjusted incrementally until intracranial pressure, measured by extradural transducers, fell to within normal limits or adverse hemodynamic changes occurred. The intracranial pressure was reduced, in each case, by 185 to 500 mg (median: 250 mg) thiopental given over 15 min, and in eight cases continuing infusion achieved stable normal intracranial pressure and cerebral perfusion pressure. Five of the patients made a complete recovery and there were only three deaths from intracranial hypertension. Side effects were few and included minor hypotension controlled by dose reduction. The response of otherwise intractable intracranial hypertension and the 38% survival rate was remarkable for a group of patients with such a poor prognosis.

Topics: Adult; Female; Hepatic Encephalopathy; Humans; Hypotension; Infusions, Intravenous; Intracranial Pressure; Male; Middle Aged; Pseudotumor Cerebri; Thiopental

Topics: Adolescent; Brain Injuries; Child; Child, Preschool; Coma; Female; Humans; Male; Pseudotumor Cerebri; Thiopental

The effects and indications of barbiturate therapy for brain protection, and prevention and reduction of the intracranial hypertension were investigated using an ultrashort acting barbiturate, thiamylal, in sixteen cases with intracranial lesions. Final outcome of the treatment revealed 8 good recoveries which were actively administered thiamylal during operation or immediately after. On the other hand, four cases, whose intracranial pressures (ICPS) of over 40 mmHg could not be controlled suffered brain death. Barbiturate therapy was not effective for brain protection of primary damaged lesions. It is concluded that barbiturate therapy may provide a satisfactory reduction of the intracranial hypertension in cases during the early postoperative stage or of under 40 mmHg initial ICP.

Topics: Adolescent; Adult; Aged; Brain Edema; Brain Injuries; Brain Neoplasms; Cerebral Hemorrhage; Child, Preschool; Female; Humans; Intracranial Aneurysm; Intracranial Arteriovenous Malformations; Male; Middle Aged; Postoperative Complications; Pseudotumor Cerebri; Thiamylal; Thiopental

A patient with Reye syndrome is described in whom cerebral perfusion pressure was reduced to less than 5 mmHg with loss of EEG activity. The intravenous administration of thiopentone reduced intracranial pressure and improved cerebral perfusion pressure with restoration of EEG and full recovery.

Topics: Electroencephalography; Humans; Infant; Injections, Intravenous; Intracranial Pressure; Male; Pseudotumor Cerebri; Reye Syndrome; Thiopental

We report two cases of children, 7 and 14 yr old, in whom prolonged infusion of thiopental sodium (TS) was used to control intracranial hypertension previously unresponsive to conventional therapy. Intracranial hypertension followed removal of a large tumor in 1 case, and trauma in the other. TS was administered at a rate of up to 7 mg/kg . h for 8 days in 1 patient, and up to 12 mg/kg . h for 10 days in the other. Both children regained consciousness and made significant recovery of neurological function. The advantage and the side-effects of the prolonged use of TS for intracranial hypertension are discussed.

Topics: Adolescent; Brain Neoplasms; Cerebral Hemorrhage; Child; Female; Hematoma, Subdural; Humans; Infusions, Parenteral; Lymphoma; Male; Postoperative Complications; Pseudotumor Cerebri; Thiopental; Time Factors

EEGs and somatosensory evoked responses from the brachial plexus, neck and scalp were recorded in seven comatose patients on continuous thiopentone infusion. Although pathological in five of the patients, the evoked responses were present in all. Additional amounts of thiopentone producing a full suppression of all spontaneous EEG activity had no effects either on the configuration of the evoked responses or on the central conduction times. This resistance of the somatosensory evoked responses to a deep and sustained thiopentone narcosis makes it a useful test in comatose patients receiving this treatment.

Topics: Adolescent; Adult; Child; Coma; Delta Rhythm; Electroencephalography; Evoked Potentials, Somatosensory; Humans; Prognosis; Pseudotumor Cerebri; Reaction Time; Theta Rhythm; Thiopental

We present an electroclinical study of 4 severe pneumococcal meningitis cases with intracranial hypertension. In addition to classical anticerebral edema therapy thiopental infusion was used. The plasma thiopental level seems to be only an incomplete indicator of cerebral drug effect, but must be measured to avoid accumulation. EEG monitoring appears to be better in evaluating the clinical status and barbituric impregnation. The burst suppression in EEG recording is noted at variable periods (9-48 h) after the start of the treatment and disappears on discontinuation of infusion while the plasma drug levels remain high. Further, in two cases EEG changes preceded clinical deficits. Evolution of clinical and EEG status was good in the 4 children.

Topics: Child; Child, Preschool; Dominance, Cerebral; Electroencephalography; Evoked Potentials; Female; Humans; Intracranial Pressure; Male; Meningitis, Pneumococcal; Prognosis; Pseudotumor Cerebri; Thiopental

The effectiveness of intravenously administered lidocaine for rapid control of acute intracranial hypertension was compared to the effectiveness of thiopental in 20 patients with brain tumors undergoing craniotomy. Despite normal radial arterial and intracranial pressures (ICP) after induction of N2O-O2-morphine anesthesia, mean ICP increased from 13.8 torr +/- 1.5 SE to 31 torr +/- 2.3 SE (p less than 0.001) in response to application of a pin-holder or scalp incision. To treat the elevated ICP a bolus injection of lidocaine, 1.5 mg/kg IV, was given to 10 patients, whereas the other 10 received thiopental, 3 mg/kg IV. Lidocaine reduced ICP 15.7 torr +/- 5.6 SE (p less than 0.025) did not significantly affect mean arterial pressure. In contrast, thiopental lowered ICP 18.4 torr +/- 9.6 SE (p less than 0.02) and also lowered mean arterial pressure by 26.1 torr +/- 9.6 SE (p less than 0.025). Mean time for injection of medication to ICP nadir was 66 seconds +/- 10 SE after lidocaine versus 48 seconds +/- 9 SE after thiopental (p greater than 0.20). It is concluded that lidocaine is as effective as thiopental for rapid reduction of intraoperative intracranial hypertension but that it causes less cardiovascular depression. Lidocaine may be of particular benefit to patients with both intracranial hypertension and marginal circulatory function.

Topics: Brain Neoplasms; Humans; Injections, Intravenous; Intracranial Pressure; Lidocaine; Middle Aged; Pseudotumor Cerebri; Thiopental

Topics: Animals; Barbiturates; Brain Ischemia; Cats; Cerebral Infarction; Dogs; Haplorhini; Humans; Hypoxia, Brain; Intracranial Pressure; Pentobarbital; Postoperative Complications; Pseudotumor Cerebri; Rats; Thiopental

Topics: Adult; Anesthesia, Intravenous; Cerebrospinal Fluid Shunts; Coma; Diazepam; Humans; Male; Nitrous Oxide; Pseudotumor Cerebri; Thiopental