Biomechanical properties of the human cranium: aging aspects

Biomechanical properties of the human skull affect its dynamic tensility (pliability, compliance) by changes of intracranial volume and pressure (deltaV/deltaP). The goal of this study is to substantiate a possibility of noninvasive and dynamic evaluation of cranial compliance. The transcranial dopplerogram of middle cerebral artery and hemispheric bioimpedance were synchronously recorded, which represent information about pulsative changes of intracranial pressure and volume, respectively. The parameters were recorded at rest and during adequate hemo- and liquorodynamic tests in different age groups--20-30, 40-50, and 70-85 years. As compared with the young group, a decrease of the cranial compliance in the intermediate age group was revealed due to an observed increase if rigidity of skull bones and ligaments, which indicates a decrease of stability of the intracranial circulatory system. However, in the group of 70-85 years the compliance rose again due to an enlargement of intracranial liquor spaces and facilitation of liquor circulation inside the intracranial cavity; this can be suggested to be a compensatory mechanism for supporting the adequate brain circulatory-metabolic state.     

The effects of raising intracranial pressure on breathing movements, eye movements and electrocortical activity in fetal sheep

Extra-dural or cerebroventricular intracranial pressure was measured in 7 unanaesthetized fetal sheep (123-137 days gestation). Basal intracranial pressure was 6.7 +/- 1.7 mmHg, but there were many transient increases of pressure in association with spontaneous changes of amniotic pressure, fetal intrathoracic pressure, and particularly when the fetal nuchal muscles were active. These spontaneous increases of intracranial pressure were often associated with cessation of breathing movements and change of the electrocorticogram from low to high voltage activity. To test whether increased intracranial pressure influenced breathing movements and electrocortical activity, intracranial pressure was raised either by occluding the superior vena cava for 1 min with an implanted extravascular cuff, or by extra-dural injection of 0.3-1.0 ml of 0.9% NaCl. Increasing the intracranial pressure 5-15 mmHg by either method during low voltage electrocortical activity caused cessation of breathing movements, electro-ocular activity, and change of the electrocorticogram from low to high voltage in a significant proportion of trials. We propose that natural fluctuations of intracranial pressure caused by compression of the fetal body or skull, by body movements or by uterine activity, may cause changes in electrocortical activity and breathing movements.     

Biomechanical properties of human cranium: Age-relayed aspects

Biomechanical properties of the human skull affect its dynamic tensility (pliability or compliance) at changes of intracranial volume and pressure (ΔV/ΔP). The work substantiates a possibility of noninvasive and dynamic evaluation of cranial compliance by synchronous recording of transcranial dopplerogram of middle cerebral artery and cranial bioimpedance that provides information about pulsative changes of intracranial pressure and volume, respectively, with subsequent computer pattern and phasic analysis of these processes. The characteristic peculiarities of the cranial compliance at rest and during action of functional hemo- and liquorodynamic tests were traced in people of the middle (40–50 years) and elderly (70–85 years) age groups as compared with the young group (20–30 years). A relative decrease of this parameter has been revealed in the middle age group due to an increase of rigidity of skull bones and ligaments, which indicates a decrease of tolerance of the intracranial circulatory system. However, in the group of 70–85 years the compliance parameters rose due to an increase of intracranial liquor volume and activation of liquor circulation inside the craniospinal space, which is a compensatory mechanism for maintenance of the adequate brain circulatory-metabolic activity.     

Age-related characteristics of relationships between brain blood flow, liquor dynamics and biomechanical properties of human cranium

The peculiarities of relationships between changes of cerebral blood flow, intracranial liquor dynamics and skull biomechanics in humans were studied in an age aspect. For this aim, a non-invasive method was proposed based on concomitant registration of rheoencephalogram and transcranial dopplerogram and evaluation of relationships between intracranial volume and pulse pressure changes (P-V index). The data obtained were analyzed by pattern-phase computer processing and compared with the blood flow parameters. The investigation was carried out on healthy volunteers of 18-25, 40-50 and 65-75 years of age. It was shown that circulatory-metabolic supplying of human brain was supported by such factors as volume brain blood flow, intracranial liquor dynamics in cooperation with skull biomechanics. The cerebral blood flow decrease at aging could be compensated by increase of the reserve-compensatory abilities of the system of cranial-spinal liquor dynamics.     

Mechanism of the decrease in intracranial pressure as affected by furosemide

The correlation was established between the increase in diuresis and natriuresis and fall of CSF pressure after intravenous injection of 10 mg/kg furosemide into dogs. Osmolarity and ion concentration in the serum and CSF did not change in these experiments. In nephrectomized dogs, furosemide did not changes CSF pressure. Furosemide dehydrated brain with traumatic edema, reduced brain Fe content probably due to diminishing brain blood content. The mechanism of intracranial pressure fall after furosemide injection can be explained by acute excretion of a large volume of fluid by the kidneys, leading to a decrease in the blood content of the skull cavity.     

Ultrasound measurement of transcranial distance during head-down tilt

Exposure to microgravity elevates blood pressure and flow in the head, which may increase intracranial volume (ICV) and intracranial pressure (ICP). Rhesus monkeys exposed to simulated microgravity in the form of 6 degrees head-down tilt (HDT) experience elevated ICP. With humans, twenty-four hours of 6 degrees HDT bed rest increases cerebral blood flow velocity relative to pre-HDT upright posture. Humans exposed to acute 6 degrees HDT experience increased ICP, measured with the tympanic membrane displacement (TMD) technique. Other studies suggest that increased ICP in humans and cats causes measurable cranial bone movement across the sagittal suture. Due to the slightly compliant nature of the cranium, elevation of ICP will increase ICV and transcranial distance. Currently, several non-invasive approaches to monitor ICP are being investigated. Such techniques include TMD and modal analysis of the skull. TMD may not be reliable over a large range of ICP and neither method is capable of measuring the small changes in intracranial volume that accompany changes in pressure. Ultrasound, however, may reliably measure small distance changes that accompany ICP fluctuations. The purpose of our study was to develop and evaluate an ultrasound technique to measure transcranial distance changes during HDT.     

Ophthalmodynamometry for ICP prediction and pilot test on Mt. Everest

Background  

A recent development in non-invasive techniques to predict intracranial pressure (ICP) termed venous ophthalmodynamometry (vODM) has made measurements in absolute units possible. However, there has been little progress to show utility in the clinic or field. One important application would be to predict changes in actual ICP during adaptive responses to physiologic stress such as hypoxia. A causal relationship between raised intracranial pressure and acute mountain sickness (AMS) is suspected. Several MRI studies report that modest physiologic increases in cerebral volume, from swelling, normally accompany subacute ascent to simulated high altitudes.     

Klinik und Genetik syndromaler und nichtsyndromaler Kraniosynostosen

With an incidence of 1:2000–1:3000 births, craniosynostoses are among the most common craniofacial anomalies. Growth inhibition caused by premature fusion of one or more cranial sutures can lead to severe deformities of the skull and facial skeleton. Besides the severe aesthetic problems for the patient, it also has important clinical consequences. These may include raised intracranial pressure, optic nerve atrophy, respiratory, and developmental disorders. Despite major efforts, causative genes (e.g., FGFR1-3, TWIST1) have been detected for only a portion of the autosomal dominantly inherited craniosynostosis syndromes. The etiology of non-syndromic craniosynostosis still remains unclear. The application of next generation sequencing technologies will probably lead to the identification of additional causative genes underlying at the least syndromic forms of craniosynostosis in upcoming years. Due to their clinical complexity, particularly the syndromic forms of craniosynostosis require interdisciplinary care. The only treatment option currently available is craniofacial surgery, which in the long term often fails to remedy the genetically determined pathological growth pattern of complex syndromic craniosynostoses.     

Electrocardiographic abnormalities associated with raised intracranial pressure.

Serial electrocardiographic (E.C.G.) recordings were taken in seven patients suffering from intracranial conditions, for which their intracranial pressure was directly and continuously monitored with a Konigsberg extradural transducer. The E.C.G. changes observed in patients with raised intracranial pressure were prominent U waves, ST-T segment changes, notched T waves, and shortening and prolongation of Q-T intervals. Two patients with normal intracranial pressure showed no E.C.G. abnormalities but also establish a relationship between E.C.G. abnormalities and changing intracranial pressure.     

Volume reduction of the jugular foramina in Cavalier King Charles Spaniels with syringomyelia

ABSTRACT: BACKGROUND: Understanding the pathogenesis of the chiari-like malformation in the Cavalier King Charles Spaniel (CKCS) is incomplete, and current hypotheses do not fully explain the development of syringomyelia (SM) in the spinal cords of affected dogs. This study investigates an unconventional pathogenetic theory for the development of cerebrospinal fluid (CSF) pressure waves in the subarachnoid space in CKCS with SM, by analogy with human diseases. In children with achondroplasia the shortening of the skull base can lead to a narrowing of the jugular foramina (JF) between the cranial base synchondroses. This in turn has been reported to cause a congestion of the major venous outflow tracts of the skull and consequently to an increase in the intracranial pressure (ICP). Amongst brachycephalic dog breeds the CKCS has been identified as having an extremely short and wide braincase. A stenosis of the JF and a consequential vascular compromise in this opening could contribute to venous hypertension, raising ICP and causing CSF jets in the spinal subarachnoid space of the CKCS. In this study, JF volumes in CKCSs with and without SM were compared to assess a possible role of this pathologic mechanism in the development of SM in this breed. RESULTS: Computed tomography (CT) scans of 40 CKCSs > 4 years of age were used to create three-dimensional (3D) models of the skull and the JF. Weight matched groups (7--10 kg) of 20 CKCSs with SM and 20 CKCSs without SM were compared. CKCSs without SM presented significantly larger JF -volumes (median left JF: 0.0633 cm3; median right JF: 0.0703 cm3; p < 0.0001) when compared with CKCSs with SM (median left JF: 0.0382 cm3; median right JF: 0.0434 cm3; p < 0.0001). There was no significant difference between the left and right JF within each group. Bland-Altman analysis revealed excellent reproducibility of all volume measurements. CONCLUSION: A stenosis of the JF and consecutive venous congestion may explain the aetiology of CSF pressure waves in the subarachnoid space, independent of cerebellar herniation, as an additional pathogenetic factor for the development of SM in this breed.     

Lumbar Puncture in the Presence of Raised Intracranial Pressure

Study of 30 patients with raised intracranial pressure whose condition worsened after lumbar puncture emphasizes the danger of carrying this out in the presence of raised intracranial pressure. In half the cases deterioration was immediate and dramatic, and in the other half it occurred within 12 hours. Probably a tentorial or cerebellar pressure cone, or both, had formed before lumbar puncture, and the procedure made this worse and caused the clinical deterioration.A history of progressive headache associated with mental changes, and the development and progression of localizing neurological signs were the two features suggestive of varied intracranial pressure found most constantly in this series. A good quality plain x-ray film is important in the diagnosis of this condition.     

Risks of acute traumatic intracranial haematoma in children and adults: implications for managing head injuries.

OBJECTIVE--To determine the factors influencing the risk of an acute traumatic intracranial haematoma in children and adults with a recent head injury. DESIGN--Prospective study of incidence of risk factors in samples of patients attending accident and emergency departments and in all patients having an acute traumatic intracranial haematoma evacuated in one regional neurosurgical unit during 11 years. SETTING--Accident and emergency departments in Scotland or Teesside and regional neurosurgical centre in Glasgow. PATIENTS--8406 Adults and children (less than or equal to 14 years) who attended accident and emergency departments and 1007 consecutive patients who had an operation for an acute traumatic intracranial haematoma. Data were complete in 8366 and 960 patients respectively. RESULTS--Overall, children were less at risk than adults (one in 2100 v one in 348 respectively). In both age groups the presence of a skull fracture and changes in conscious level permitted identification of subgroups of patients with widely differing degrees of risk. In children the absolute risk ranged from one in almost 13,000 without a fracture or altered conscious level to one in 12 for a child in a coma and with a fracture; the pattern was similar in adults, the risks in corresponding groups ranging from one in almost 7900 to one in four. CONCLUSIONS--Although children attending hospital after a head injury have a lower overall risk of a traumatic haematoma, the main indicators of risk, a skull fracture and conscious level, are the same as in adults, and the pattern of their combined effect is similar. Guidelines for managing adults with recent head injury may therefore be applied safely to children; with the increasing provision of facilities for computed tomography they should be revised to ensure early scanning of more patients with head injury.     

Probable destructive meningioma in an archaeological adult male skull from Alaska

Several intracranial pathological conditions can affect the bones of the skull. The most common cause of these conditions is tumor, but infection and other diseases are also known to affect the bones of the skull. Distinguishing between the various causes of intracranial skeletal pathology in archaeological human remains is usually a challenging exercise, and a specific diagnosis will often be impossible. Meningiomas are tumors that arise in arachnoid tissues embedded in the outer layer of the dura. Because of this association, they occur almost exclusively in the skull and vertebral column. Usually meningiomas are slow-growing tumors that do not metastasize to other organs and tissues of the body. However, rare cases can be malignant and, even when meningiomas are benign, their presence and growth can adversely affect the nervous and vascular supply to other tissues in the skull and vertebral column. Their effect on adjacent bone tissue varies from stimulating bone-forming lesions to causing highly destructive lesions. A few examples of meningioma have been described in the paleopathological literature. Most of these cases are bone-stimulating meningiomas. The case presented here is a probable example of a highly destructive meningioma of the skull base, with unilateral extension into the left side of the cranium. This case is compared with a modern clinical case of destructive intracranial meningioma that was documented both radiographically and pathologically. Destructive meningiomas can be confused with other pathological conditions, including benign and malignant tumors. Criteria for differentiating the diagnostic options are reviewed.     

Use of the free vastus lateralis flap in skull base reconstruction

Free flaps in skull base reconstruction are indicated for providing an effective separation of the intracranial cavity from the oronasal space, for eliminating a dead space, and for the treatment of established wound complications such as dural exposures and cerebrospinal fluid leaks. Seven patients with cranial base defects underwent reconstructions using a free vastus lateralis muscle flap. In two cases, a vastus lateralis flap was raised to incorporate the anterolateral thigh skin as a myocutaneous flap. In four cases, a free flap was indicated for reconstruction following tumor ablation, and in three cases, for the resolution of wound or cerebrospinal fluid leak complications following previous cranial base surgery. All flaps were successful, with no partial failures. In those patients undergoing tumor ablative surgery, the cranial cavity was effectively sealed from the oronasal cavity. Patients with established wound complications following previous cranial base surgery had a complete resolution of their symptoms. This report discusses the suitability of the vastus lateralis flap for skull base reconstruction in terms of the availability of adequate muscle volume to fill dead space, vascularized fascia to augment dural repairs, and the freedom to use skin if required for internal lining or external skin cover. This flap also provides an extremely long pedicle, allows simultaneous flap harvest, and has low donor site morbidity.     

Two massive congenital intracranial immature teratomas with neck extension

In this report we detail two congenital intracranial immature teratomas, noteworthy for their massive intracranial growth and extension through the skull with compromise of neck structures. Cytogenetic studies were done in both cases on the fetuses and their tumors and are the first in the literature. Few previously reported congenital intracranial teratomas have been described with neck extension. In both cases, polyhydramnios was detected by prenatal ultrasonography and was possibly caused by the laryngoesophageal and/or brainstem distortion by neoplasm. Possible reasons for such excessive, unchecked growth of teratomas in the fetal period are discussed.     

Interhemisphere asymmetry of the CSF dynamics and biomechanical properties of the skull

This investigation shows that both intracranial liquor circulation and skull biomechanical properties evaluated by its pliability (compliance) to intracranial pressure are characterised by marked interhemisphere asymmetry. The interhemisphere differences of cerebrospinal fluid mobility were evaluated by means of asymmetry coefficient (right/left ratio of liquor mobility) which was found to be 1.25-1.45 in healthy middle-age persons. For the skull pliability (compliance) the coefficient of hemispheric asymmetry was 0.75-0.95. These two hemisphere asymmetry coefficients are characterized by reciprocal relationships. These coefficients demonstrated no dominancy related to right/left hemisphere as well as no correlation with neurophysiological parameter. Functional tests (apnoea, hyperventilation, Stookey test) gave rise to significant changes of these coefficient values. At ageing, the magnitudes of these coefficients decreased. The spectral analysis of pulse waves of dopplerogram and rheoencephalogram reveals hemisphere asymmetry, too. It should be suggested that the interhemisphere asymmetry of the CSF dynamics and skull biomechanical properties is a special mechanism which contributes in the process of circulatory-metabolic support of brain activity.     

Nocturnal ultrasound measurements of optic nerve sheath diameter correlate with intracranial pressure in children with craniosynostosis

Children with craniosynostosis are at risk for increased intracranial pressure, and additional possibilities to screen for increased intracranial pressure are required. The authors' aim was to use ultrasound measurements of the optic nerve sheath to understand and express the variability of intracranial pressure in syndromic craniosynostosis. Therefore, five pediatric patients with craniosynostosis underwent invasive 24-hour intracranial pressure monitoring and simultaneous optic nerve sheath measurements. In three patients, the intracranial pressure was abnormal, and during the second half of the night, the optic nerve sheath was increased in all three patients. The optic nerve sheath diameter changes during the night and is as dynamic as the intracranial pressure. To the best of their knowledge, the authors are the first to describe a real-time relationship of the optic nerve sheath with increased intracranial pressure in children.     

A Study on the Finite Element Model for Head Injury in Facial Collision Accident

In order to predict and evaluate injury mechanism and biomechanical response of the facial impact on head injury in a crash accident. With the combined modern medical imaging technologies, namely computed tomography (CT) and magnetic resonance imaging (MRI), both geometric and finite element (FE) models for human head-neck with detailed cranio-facial structure were developed. The cadaveric head impact tests were conducted to validate the headneck finite element model. The intracranial pressure, skull dynamic response and skull-brain relative displacement of the whole head-neck model were compared with experimental data. Nine typical cases of facial traffic accidents were simulated, with the individual stress wave propagation paths to the intracranial contents through the facial and cranial skeleton being discussed thoroughly. Intracranial pressure, von Mises stress and shear stress distribution were achieved. It is proved that facial structure dissipates a large amount of impact energy to protect the brain in its most natural way. The propagation path and distribution of stress wave in the skull and brain determine the mechanism of brain impact injury, which provides a theoretic basis for the diagnosis, treatment and protection of craniocerebral injury caused by facial impact.